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Prosthetics and Orthotics International, 1989,13, 6-13

Cervical orthoses

Oxford Orthopaedic Engineering Centre, Oxford

Abstract as neck injuries result from about 20 per cent of

A biomechanical study is presented to compare all vehicle accidents (Mealy et al, 1986). These
the effectiveness of three types of off-the-shelf collars are available through the United
cervical orthoses and one custom-fit collar in Kingdom National Health Service as stock
restricting cervical spine motion. A group of 10 items. Almost an equal number are made from
normal subjects was studied. The sheet material by therapists in outpatient
measurements of flexion and extension, lateral departments for conditions, such as cervical
side flexion and axial rotation were recorded spondylosis and rheumatoid arthritis
using various measurement techniques. (Dudgeon, 1984).
Interface pressures at the chin and occiput were There are several categories of cervical
also measured, along with the warming effect of orthoses. Johnson (1977), divided them into
the collars. four groups, namely, the simple collar
The results indicated that all the collars extending from head to the upper part of the
restricted neck movements, for example, the thorax, the "poster brace" with mandibular and
Plastazote collar by 50% of flexion and occipital supports, the cervicothoracic brace
extension, and that there was no significant extending over the trunk, and the halo brace
difference between off-the-shelf Plastazote and involving skeletal fixation. When cervical
custom-fit collars in restricting movement. instability due to trauma or disease is not
Significantly high interface pressures were apparent, then the simple collar is prescribed.
recorded at the chin, with the subjects wearing What is the basic rationale of prescription of
the hard and Plastazote orthoses. The warming these simple collars? Lusskin and Berger (1975)
effect of the soft collar was equal to that of a stated that collars should act as a reminder to
wool scarf. restrict head and neck motions, to mechanically
The study was aimed at improving limit flexion, extension, lateral flexion and
prescription and although the subjective rotation of the head and cervical spine, and to
observations were not validated, the subjects partially relieve gravitational stress by weight
concluded that the custom-fit collars were more transfer. Since the collar supports a portion of
comfortable; an important point with such a head weight, the cervical spine is partially
high rejection rate. unloaded. Caillet (1981) stated that whether the
problems are acute or chronic, treatment of the
Introduction painful neck, or of problems related to the
Cervical orthoses are prescribed for a wide neck, employs basic concepts. One such is that
spectrum of clinical problems ranging from a collar, properly made and fitted, and correctly
muscle spasm to serious instability. The main used, should be beneficial. In this context
objectives are to rest the neck and give support, "properly fitted" implies that the collar is made
to allow muscles to relax and to permit any specially for or matched to an individual.
inflammation to subside. A large number are Caillet (1981) advocated that the neck should
used as standard treatment in accident and be held in a slightly flexed position so
emergency departments for initial separating the posterior facet joints and
immobilization following trauma of soft tissues, opening the foraminae. This position minimizes
the need for muscle "splinting", restricts
All correspondence to be addressed to Dr. A.
Turner-Smith, Oxford Orthopaedic Engineering *Present address: Mrs. A. Beavis, Child Development
Centre, Nuffield Orthopaedic Centre, Headington Centre, Charing Cross Hospital, London, United
Oxford OX3 7LD. Kingdom.
Cervical orthoses 7

excessive motion, and gives sensory cutaneous movements measured were flexion/extension,
stimulation and warmth to the neck lateral side flexion and axial rotation.
musculature causing a decrease in pain A description of the different cervical
impulses. Since immobilization is not complete, orthoses tested is detailed in Table 1 and the
the neck muscles are allowed to contract orthoses shown in Figure 1.
isometrically within the collars and atrophy and
disuse are thus prevented. However these Measurements of cervical spine movements
orthoses may not always match these The movements were measured using the
specifications and Lusskin and Berger (1974) vector stereograph, an instrument with three
have suggested problems involving, extensible strings mounted on bobbins in one
1. Muscle atrophy and weakness. plane and joined at an attachment point, as
2. Tightness and contracture of tissues. described by Grew and Harris (1979). In the
3. Psychological dependence. present study the vector stereograph strings
4. Symptoms aggravated and undiagnosed were arranged to intersect at a central anterior
disorders progressing. position on the head with an attachment to a
headband, thus allowing for positioning with or
In this study, the possible effects of the "simple without an orthosis (Gant, 1985). For the first
collar" and custom-fit cervical orthoses, were combined movement of flexion and extension
examined in terms of: the subjects were instructed to look forwards
1. Limitation of movement. and follow a taped line marked on the wall,
2. Interface pressures at the occiput and chin. from the ceiling down to the floor. When
3. Warming of the skin. completing the second movement of combined
Bearing in mind the prescription specifications lateral side flexion the subjects were instructed
and rationale for use. to look forwards to a mirror, and bring their ear
down to their shoulder, following an arcshaped
Materials and methods
wall marker. The movement was reversed so
The study group comprised ten adults (5 men
that the opposite ear was brought down to the
and 5 women), aged 25-65 years, with no
contralateral shoulder. This method with straps
history of neck trauma. The subjects were
pulling downwards over the shoulders helped to
seated in a geriatric chair with the torso held by
limit rotation and involvement of the shoulder
diagonal straps to eliminate unnecessary
and thorax. The stereograph outputs were fed
movement of the thoracic and lumbar spines.
into a minicomputer for subsequent analysis of
The cervical spine movements of each subject
movement patterns. A goniometer or builders
were measured when moving freely without an
inclinometer, as described by Pearcy (1986),
orthosis and repeated when each of the four
was also used to measure cervical movements of
types of collars were worn. The cervical spine
flexion, extension and lateral side flexion. The
Table 1. Description of cervical orthoses tested subjects wore a headband with the inclinometer
attached, while strapped into the geriatric
chair. All the movements of flexion, extension
and lateral side flexion to the right and to the
left, were measured in degrees and taken as
separate motions. Axial rotation could not be
measured satisfactorily using the vector
stereograph, and this was measured using two
different goniometers. One inclinometer-type
goniometer was attached to the top of the
subject's head by a headband with the subject
in the supine position, while the other
horizontal goniometer, the mortar board type,
measured head rotation about a vertical axis
with the subject seated in the test position (Fig.
2). All movements were repeated on six
occasions for each subject.
s A Beavii

Fig. 1. Types of cervical orthoses used in the trial. T o p left, soft collar; t o p right, h a r d collar; b o t t o m left,
Plastazote collar; b o t t o m right, custom-fit collar.

Skin temperature
Interface pressures measurements at the chin and To assess the warming effect of each collar,
occiput skin temperatures were measured at two sites,
The interface pressures were recorded using one in the mid-cervical spine area under the
the Oxford Pressure Monitor (Bader and collar, and a second in the mid-thoracic T7
Hawken, 1986) as the subjects were seated in area. This latter site was at a distance from the
the test position wearing the different collars. area of influence of the collar and therefore
Two pressure matrices, each incorporating a used as a control, Grew and Deane (1982). The
row of six pneumatic cells, were employed at three thermistors (Technoterm 1100) were
the interfaces between the chin and collar and taped to the skin with porous tape (Micropore
the occiput and the collar The pressures in 3M) and the electronic thermometer recorded
millimetres Hg were recorded at rest and at the the three temperatures, namely,
extremes of the movements of flexion and 1. Skin temperature under the collar
extension, as recommended by Fisher (1977). 2. Skin temperature at the thoracic spine
The subject was required to flex the neck to a under normal clothing
position which could enable normal reading at 3. The ambient temperature
lap level. Then an extended neck position was
attained with no extreme level of force or A pilot study indicated that the thermometer
movement. registered the change of skin temperature
Cervical orthoses 9

and with and without a wool neck scarf. Also

the subjects skin temperatures were registered
indoors and outdoors, in different weather
conditions, specifically on a cold January day
and a damp May day.
Cervical spine movements
The mean results of movement using the
vector stereograph and the inclinometer
goniometer are detailed in Tables 2 and 3,
respectively. The percentage limitation of
movements, as assessed by the vector
stereograph and the goniometer, can also be
represented in histogram form (Fig. 3). The
differences between the two measuring
techniques, namely the vector stereograph and
the goniometer (inclinometer), for both types
of movements were not found to be statistically
significant. The results of the rotation
measurements by the two different goniometers
are indicated in Table 4.
There was no significant difference between
Fig. 2. Subject seated in test position for h e a d using the goniometer (inclinometer) and
rotation m e a s u r e m e n t using a horizontal g o n i o m e t e r . horizontal goniometer (mortar board type) for
under the collars and clothing to within 0.2° of measuring rotation in the supine or sitting
the final temperature within 1 minute 40 positions.
seconds. A specific comparison was also performed
The subjects had the thermistors taped to between two Plastazote collars. The restriction
their skin in the appropriate areas and with all three types of movement is shown in
recordings made with and without the collars, histogram form (Fig. 4).
Table 2. T h e m e a n distance of motion m e a s u r e d by the vector stereograph
and p e r c e n t a g e reduction of motion from unrestrained normal m o v e m e n t .
10 A. Beavis

Skin temperatures
In both Winter and Spring climatic conditions
the thoracic sensors recorded a constant skin
temperature of 35.3°C, and this was taken as
the control sensor, as recommended by Grew
and Deane (1982). As the subjects moved from
indoors with an ambient temperature of 20°C,
to outside at an ambient temperature of — 1°C,
on a January day, the skin in the uncovered
cervical area decreased by 8.1°C from 34.1°C to
26°C. However, when either the soft collar or a
wool neck scarf was worn on the same day a
decrease of only 1.5°C in skin temperature was
recorded in the cervical area.
Repeating the same measurement on a May
day, when the ambient temperature inside was
27.5°C and outside was 10.5°C, and the control
thoracic skin temperature was 35.1°C, the skin
temperature in the uncovered cervical area
decreased 5°C from 35°C to 30°C. However
when either the soft collar or a wool neck scarf
was worn a decrease of only 1°C in skin
temperature was recorded in the cervical area.
It thus appeared that both the soft cervical
orthosis and the wool scarf were equally
effective in maintaining neck skin temperature
at a comfortable level.
Fig. 3. Top, restriction of movement with different
orthoses using the vector stereograph. Bottom,
restriction of movement with different orthoses using Discussion
the goniometer. The anatomy and movements of the cervical
spine are complex, but normally there is a
Interface pressures gradual intersegmental flow of movement,
Table 5 gives the mean values of the maximum which is greatest in the upper part of the neck.
pressures recorded at the two interface areas. There is also a gliding motion at the facet joints,
Even at rest, the hard, Plastazote and custom- while the discs deform. The amount of anterior
fit collars produced considerable maximum shift depends on the obliquity of the articular
pressures, which increased by greater than 100 processes (Fielding, 1964). So in this study, the
per cent when the subject went into flexion. combined anterior posterior movement
The occipital pressures were negligible at rest measured in the sagittal plane by the vector
but increased to significant interface pressures stereograph was not 'true' flexion/extension of
during full extension of the cervical spine. the cervical spine, Kaufman et al (1986). Again,
Table 4. The mean rotation measured by the goniometer inclinometer and the horizontal goniometer, showing
percentage restriction of movement from unrestrained rotation.
Cervical orthoses 11

Fig. 4. Restriction of m o v e m e n t of off-the-shelf and c u s t o m fitted Plasatzote collars in all t h r e e types of m o v e m e n t .

lateral side flexion is not a 'true' movement of collar to an individual is of paramount

side bending, as it is always associated with importance. The 'nodding' and 'chin poking'
rotation (Caillet, 1981). However, for the movements must be considered, as the cervical
purpose of the present study, each subject was spine movements of flexion and extension occur
instructed to exert a conscious effort to about many axes (Kaufman et al, 1980).
eliminate unwanted movements, as In spite of movement complexities, the ten
recommended by other researchers (Hartman subjects fitted with the different collars showed
et al, 1975; Kaufman et al, 1986). limitation of movement in all ranges. The soft
Two other clinical factors make bracing the collar limited flexion/extension and lateral side
neck with a 'simple' type collar even more flexion by approximately 14 per cent, whilst the
complicated. Firstly, Caillet (1981) found hard, Plastazote, and custom-fit collars limited
clinically that 'nodding' first will result in a the movements of flexion/extension and lateral
greater degree of total flexion, so the sequence side flexion by between 43 and 51 per cent.
of acts alters the degree of movement. If the In the rotation of the cervical spine, 50 per
neck is fully flexed first and then the chin is cent takes place at the atlanto-axial joint
brought into flexion as a second phase, total (Fielding 1964). However, it may be surprising
neck movement is less than if the chin is flexed that the soft collar restricted axial rotation by as
first ('nod') and then followed by bending the much as between 13 and 20 per cent and the
rest of the neck. In addition, when the subjects three other collars restricted rotation by
were restricted by a chin-piece and attempted between 42 and 66 per cent.
to flex against it the upper part of the cervical Bearing in mind the biomechanics of the
spine extended while the lower part flexed. neck, the study found, using the analysis of
Fisher (1978) an Colachis et al, (1973) also variance, three subjects which stood out as
found that the chin-piece on the collar having higher than normal variance in their
produced straightening of the upper cervical range of movements. One female subject had a
spine. Caillet (1981) also stated that fitting the long slender neck and the other two male
Table 5. M a x i m u m interface pressures during flexion extension.
12 A. Beavis

subjects were of a short stocky build. These Appendix

anomalies did not alter the overall readings in *Soft Collar: Manufactured by Camp
the study, but as already noted the clinical Ltd.
factor of sequence of movement the 'nod' factor Northgate House
and the 'poking chin' factor, i.e. gliding Staple Gardens
motions of the facet joints may play a part in Winchester SO23 8ST
the anomalous findings with regard to these UK
three subjects in the study.
There was no significant difference between Hard Collar: Supplied by OEC
the methods of measuring the movements of Orthopaedic Ltd
the cervical spine, using either the vector Waterton Industrial Estate
stereograph or the different goniometers. Bridgend
The interface pressures recorded at the chin South Glamorgan CF31
area were high, especially on flexion, but did 3YN
not cause discomfort to the subjects. This Wales
increase of pressure could act as a reminder to
restrict movements to a subject's injured neck. Plastazote Collar: Manufactured by Camp
The pressures recorded, especially at rest, do Ltd.
indicate that the collars partially relieve
gravitational stress to the neck muscles Custom-fit collar: BXL Plastics
(Lusskin and Berger, 1975). ERP Division
All collars had a satisfactory result in keeping Mitcham Road
the neck warm, but interestingly a wool scarf Croydon
had an equal warming effect. Surrey
All the subjects stated that their custom-
made Plastazote collars were very comfortable Velcro: UK Manufacturer
immediately on donning, and all subjects were Selectus Ltd.
convinced that the limitation of movement was
greater and the pressures at the chin and
occiput were less with these than with the off-
the-shelf type of Plastozote collar. However,
these subjective observations were not
validated. Nevertheless, since the custom-made
collars are more comfortable, and the rejection B A D E R , D . L . , H A W K E N , M . B . (1986). Pressure
distribution u n d e r the ischium of n o r m a l subject. J.
rate of orthoses is always high, subjective Biomed. Eng. 8 , 353-357.
feeling of comfort should not be disregarded.
In conclusion, all the cervical collars in the CAILLET, R . (1981). Neck and arm pain 2nd edition.
Philadelphia P A : F . A . Davis, p p 118-123.
study both off-the-shelf and custom-made,
limited the movements of flexion/extension, Classification of O r t h o s e s (1980). D H S S Training
lateral side flexion and rotation, and the Council of Orthotists — L o n d o n : H M S O .
goniometer proved to be a reliable non-invasive COLACHIS, S. C, STROHM, B . R., GANTER, E. L.
clinical tool. (1973). Cervical spine m o t i o n in n o r m a l w o m e n :
radiographic study of effect of cervical collars.
Arch. Phys. Med. Rehabil. 5 4 , 1 6 1 - 1 6 9 .
My acknowledgement and thanks to Mrs D U D G E O N , P . (1984). T h e effectiveness of cervical
orthoses; t h e p a t i e n t s ' viewpoint. Br. J. Occup.
Elizabeth Crowther MCSP, Deputy Ther. 4 7 , 242-250.
Superintendant, Aftercare Department,
Nuffield Orthopaedic Centre, Oxford, for FIELDING, J . W . (1964). N o r m a l and selected
a b n o r m a l m o t i o n of the cervical spine from the
making and fitting the custom-fit Plastazote second cervical vertebra to the seventh cervical
collars. vertebra based o n c i n e r o e n t g e n o g r a p h y . J. Bone
Joint. Sur. 4 6 - A , 1779-1781.

FISHER, S. (1978). P r o p e r fitting of cervical orthosis

Arch. Phys. Med. Rehabil. 5 9 , 505-507.
Cervical orthoses 13

FISHER, S V., BOWAR, J. F., AwAD, E. A., J O H N S O N , R . M , , H A R T , D . L . , SIMMONS, E . F . ,

G u L L i c K s o N , G . (1977). Cervical orthoses effect R A M S B Y , G . R , , SOUTHWICK, W . O . (1977).
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goniometric m e t h o d of study, Arch. Phys. Med. effectiveness in restricting cervical m o t i o n in
Rehabil. 5 8 , 109-115. normal subjects. J. Bone. Joint. Surg. 5 9 - A , 3 3 2 -
G A N T , C . (1985). A n evaluation of the effectiveness
of cervical orthoses using vector stereograph. KAUFMAN, W. A . , LUNSFORD, T. R . , LUNSFORD, B .
A n n u a l R e p o r t Oxford O r t h o p a e d i c Engineering R . , L A N C E , L . L . ( 1 9 8 6 ) . C o m p a r i s o n of t h r e e
Centre. 6 3 - 6 4 . prefabricated cervical collars. Orthot. Prosthet. 3 9
(4), 2 1 - 2 8 .

G R E W , N . D . , D E A N E , G . (1982). T h e physical effect

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