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To Brace, Or Not To Brace?

A cartoon skeleton thinking about whether "to brace or not to brace?" their joints, next to another skeleton wearing a back brace, knee brace and ankle brace.

All Shakespearian jokes aside, when our bodies are hurting and our joints are unstable, pain can make us desperate for relief. Sometimes we turn to bracing as a solution. While braces have been used since before Shakespeare's day, like many other types of technology, they have changed significantly in recent decades.

Braces have evolved over time from simple rigid wooden splints that were tied around an injured limb, to being made from a variety of materials with hinging joints, and movement assisting components. There is a delicate balance to keep between improving stability, without losing too much mobility. (See Ehlers Danlos: Is Stretching Safe?)

But before we get into what kinds of bracing are helpful, it's best to take a step back and evaluate the problem. Why do we want to use braces in the first place? How we approach bracing can vary for the different groups. We'll tackle their individual needs in sections, and then talk about types of bracing.

People who are considering bracing fall into several categories

  1. They have unstable joints that are at risk of dislocating (I.e. Ehlers Danlos)

  2. They have chronic pain with movement (I.e. back pain)

  3. They're interested in injury prevention/protection while performing heavy activities.

  4. They have neurological damage that prevents them from controlling their joints (i.e. after stroke or spinal cord injury)

  5. They are recovering from injury like a surgery, or a broken bone.

Then we'll consider the pros and cons of different types of braces

Unstable Joints & Dislocations

When joints are unstable and have a history of dislocating, bracing can help provide some added stability. It's important however, to first evaluate why the joints are unstable. Joints are held together by ligaments, and muscles. Some level of coordination in our nervous system is also required to use our muscles at the right time to support the joint.

Sometimes instability is due to genetic connective tissue disorders that make the ligaments too loose that are supposed to hold the joints together. People who experience chronic instability in one or more joints may benefit from screening for Ehlers Danlos Syndrome (EDS), or Hypermobility Spectrum Disorder (HSD). Because our bodies have more than one system to hold the joints stable, sometimes working with a physical therapist who specializes in these disorders can train the muscles to better support the joints so that bracing is not necessary.

For other individuals, a past traumatic injury caused a dislocation and weakened the ligaments. As a result the joint has become chronically unstable. Depending on the degree of laxity (or looseness) of the joint ligaments. A physical therapist, and an orthopedic doctor can help determine if the muscles can be taught to compensate, or if surgery or bracing are better options.

There are also temporary causes of unstable joints such as pregnancy. The hormones in the body shift during this time to allow for greater flexibility in the ligaments so that the pelvic bones can shift to accommodate a child as it grows. Bracing can be an attractive option for managing sacroiliac pain, back pain, and other pregnancy related issues especially because many treatment options such as medications are limited during pregnancy.

Chronic Pain with Movement

There are many reasons for persistent pain with movement. For some this is a localized sensitivity in one part of their body, for others it is widespread and affects them globally. In order to treat pain effectively, the treatment has to be aimed at the root cause of the symptoms.

In most of these instances, bracing is intended to help manage pain, but not cure it. The brace may be something that is required for the rest of your life. While this is appropriate for some, it is always good to check first that there is not some underlying cause that can be cured. If a brace is successful in helping manage your pain, then it's likely that the way you are moving is contributing to your pain. If that is the case then there is hope that teaching you how to move differently can help. Managing chronic pain is complex and should involve individualized medical care and solutions.

It's important to work with a team of healthcare providers, and to get multiple opinions. If one physical therapist or one orthopedic surgeon is unable to help with the problem, it may be beneficial to consult two or even three. Different providers may have been trained at different schools, or in different time periods. As a result, they may think differently. While the older provider may have more experience, the younger provider may be up on the newest discoveries in research that could hold the answer to treating your condition. If you live in an area that is more rural, or where the medical community is composed of people who all went to the same university, going out of town for another opinion may also help. Exposure to healthcare providers who were trained at different schools, or lived in a more transient big city where they are exposed to different ideas can provide some new perspective on your case.

Injury Prevention

For those who engage in repetitive sports, high impact sports, heavy weight lifting, or contact sports, the goal of bracing is to prevent an injury.

Repetitive sports like long distance running, or dance can put repeated strain on the same tissues. Minor flaws in technique if repeated over and over can predispose you to overuse related injuries. Braces may help to offload joints during heavy training phases, but it can also become a crutch an athlete is dependent on.

High impact sports like gymnastics can put athletes at risk of injury. This especially true when learning a new skill and frequently making the same error in form and technique. A brace can be temporarily helpful, but may also restrict movement. Weight lifters may use bracing when they are increasing their weight for the first time to protect them if the added weight causes a failure in their form. They might also elect to use braces consistently when lifting very heavy weights. This however is for athletes who are competing at very high levels.

For gymnasts and weight lifters, bracing is most often helpful in the transition phases. Using it constantly however can cause the muscles to become lazy. After all, why should the muscles keep working hard if the brace does their job for them? This can actually make the person more likely to get injured when they aren't using the brace, because the muscles intended to hold them stable have weakened, or gotten used to not needing to work at the right times.

In regards to contact sports athletes, some braces can provide a layer of protection from injury. The same braces however typically restrict your movement and may limit you from moving freely on a regular basis. It can also signal to an opponent a weak point to take advantage of.

Neurological Injury

After injuries like a stroke or a spinal cord injury, the nerves may be damaged to the point that they cannot tell the muscles to contract. If this decrease in muscle tone and voluntary control of the muscles occurs, all of the stress of maintaining stability in the joints is placed on the ligaments. Over time, the ligaments will wear and stretch out from the added strain which can lead to pain and injury.

In light of the fact that the muscles may not be trainable, after physical and occupational therapists have tried to rehabilitate the nervous system as much as possible, a brace may be necessary.

Injury Recovery

Typically individuals recovering after a surgery or a broken bone are using braces under the direction of their doctors. That being said, it is ok to ask questions about the purpose of using the brace.

For example, if an ankle ligament is sprained to the point of a near complete tear, a brace may be appropriate for a period of time while the tissues heal. The risk of the muscles not performing correctly and added strain on the ligament causing a complete rupture of the ligament which would then require surgery may be too high. On the other hand, when using an ankle brace on a more mild ankle sprain where the ligament tearing is minor may be counter productive. It may only weaken the muscles and put the individual at increased risk of injury later when they make the transition out of wearing the brace.

It's best to consult your physician and your doctor of physical therapy to determine the best solution for you.

Types of Braces

Compression/Sleeve Braces

These braces are commonly available at local stores especially for knees and ankles. There are a few benefits to this kind of brace. First, the compression can reduce swelling and improve blood flow. This can be helpful if you are prone to swelling and poor circulation. This can also occur with some endurance athletes like runners who push their cardiovascular system to perform for a long time. People who have dysautonomia conditions like POTS may benefit from this type of brace. It is however important to be cautious about how much compression is being applied. Braces that are ill fitting and too tight can restrict blood flow from your tissues or even cut off circulation. Braces that aren't tight enough may not help at all.

Second, the compression provides added feedback to the nervous system. The compression of the nerves, while mild, can improve the body's awareness of changing positions of the joint. These braces can be helpful for individuals with poor proprioception due to connective tissue disorders like EDS that effect the ligaments. Many of the nerves that sense proprioception are located in the ligaments. See Perfecting Proprioception (Coming Soon). They may also benefit individuals with neurological damage to their sensory system but who have intact motor function. If the nature of a stroke leaves a person with limited feeling in the joint, but they still have the muscular ability to control the joint well, this brace may help give them better sensory input.

Third, there are psychological benefits. Putting on any brace can give you a sense of security in feeling like you've done something to protect yourself. It can also give you a sense of control that you are doing something helpful and be empowering from that perspective.

Some other benefits to these braces are that they are generally inexpensive, easily accessible, can typically be washed, and don't restrict mobility very much.

The downsides to these braces are that they don't provide very much support, and the elastic compression typically wears out over time.

Splinting Braces

These braces restrict movement in varying degrees in order to protect certain tissues from being loaded/stressed. They are most often used after injuries have occurred.

Some of these braces prevent any motion at the joint (such as a plaster cast on a broken arm, or a finger splint on a broken finger). There are others however, which are used after surgeries to allow a joint to move in a controlled range of motion. For example, the surgeon may set the brace to allow your knee to only bend a certain number of degrees while you are recovering.

You may also see these braces commercially available in the form of plantar fasciitis boots that you wear to keep your foot in a good position while sleeping, or a carpal tunnel brace to keep you from balling up your fists at night while you sleep.

The benefits of these braces are that they offer a higher level of protection and stability for the joint. This can be ideal in the presence of significant tissue injuries such as broken bones, surgical tissue repairs, or severe ligament tears. They may also be appropriate for positional support at night.

The negative consequence of that higher level of stability however is that you lose mobility. While this doesn't matter as much at night while you sleep, these braces can limit your ability to perform daily movements. Consequentially, because the braces are providing stability and restricting movement, they can lead to muscle weakness from disuse of the muscles in some cases (especially if worn all the time). Additionally, they may negatively impact surrounding joints. If you are unable to move one particular joint, the body will often compensate by using the joints above or below to help you move.

For example, if you are wearing a walking boot that restricts the movement of your ankle, it will place added stress on your knee, and the uneven height of your shoes between the walking boot and your shoe can cause a leg length discrepancy leading to hip/lower back problems.

Movement Assisting Braces

These braces are designed to help encourage good movement patterns. They might utilize springs to assist movement, specifically woven fabrics, or even electronic components.

These braces can encourage movement patterns more actively. Some of them which are predominantly in a research phase even utilize electrical stimulation to encourage muscles to contract. This can be a great option for people who have lost nerve function and can't perform a movement voluntarily. Unfortunately however, while the Anikin Skywalker mechanical hand replacement is on the horizon, those braces are generally not commercially available and are expensive due to the newness of the technology.

More available forms are spring loaded, to trigger a motion when you apply pressure to the device in a certain position. These braces usually are made and custom fitted by a skilled provider called a prosthetist. They often require some training for you to learn to utilize the braces correctly. These braces are costly, but may be covered by insurance in some situations. They are generally designed for people who are unable to perform a movement voluntarily.

The forms that utilize specifically woven fabrics are designed to facilitate movement with tension. The concept is similar to the utilization of kinesiotape. The tension and pull of the tape/fabric can encourage movement in different directions if the nervous system is intact to be able to feel the pressure/tension. This triggers the muscles to move in a certain way. It is intended as a low grade support. It assists the movement, but cannot completely perform a movement for you. If you aren't sure if this type of bracing is for you, kinesiotape can serve as a trial run. The brace has advantages over the tape if you plan to use it on a regular basis, or if you have adhesive allergies.

Overall, movement assisting braces can be helpful if the muscles are not able to perform a movement independently for neurological reasons. The custom fit braces also have advantages compared to generic in terms of fit and comfort. Depending on the degree of movement assistance, the muscles may still work some, which can prevent muscles weakening due to disuse.

Some drawbacks of movement assisting braces include cost, accessibility, and the tendency of the muscles to become weaker due to disuse. If the brace is performing the movement, the muscles are not required to work to do so.

The above information is intended for educational purposes and is not a replacement for individual medical advice from a licensed provider. If you're looking for specific recommendations for products, message or call our office to set up an evaluation for personalized recommendations.

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