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The Thoracic Suspension Jacket-
Review of Principles and Fabrication
Orthotics and Prosthetics, Volume 38, Number 1, Spring,
1984, pp. 36-44. ©The American Orthotic and Prosthetic Association. All
rights reserved.
Carlton E. Fillauer, C.P.O.
Charles H. Pritham, C.P.O.
Apparently, the first reference to the Thoracic Suspension
Jacket was in an article by Siebens in 1972. Since then, considerable
experience with it has been amassed at Newington Children’s Hospital and
other localities as described by Siegfried Paul, C.P.O., (E), 2 3 James
C. Drennan, M.D. 4 5 6 and others. Durr-Fillauer’s involvement began in
1974, and over the years, simplified fabrication procedures using prefabricated
components adaptable to wheelchair use or other sitting accommodations
have been developed.
There have been frequent requests from orthotists for
information relating to it. It is hoped that this article will at least
partially fulfill the need.
DESCRIPTION
The Thoracic Suspension Jacket is a custom molded Thoraco-Lumbo Sacral
Orthosis with an anterior opening and a PELITE* lining. The portions under
the antero-lateral aspect of the costal margins are indented to provide
shelves on which the ribs rest and the inferior edge is trimmed higher
than usual for sitting comfort. Suspension lugs are secured to the right
and left sides of the jacket and hangers are secured to the back uprights
of the wheelchair on which the jacket is suspended. Adjusting the height
of the hangers and clamps permits the amount of weight borne by the thorax
to be increased or decreased. By this means, the distractive effect of
the lower portion of the body can be used to extend the spine and/or the
buttocks, and other pressure sensitive areas can be relieved of superincumbent
weight.
INDICATIONS AND CONTRAINDICATIONS
Drennan 4 5 has described the orthosis as being indicated for individuals
with paralytic spinal deformity for whom surgery, for whatever reason,
(immature skeletal growth, life threatening complications, etc.) is not
contemplated. He has described the objectives as:
- Arrest or correction of spinal deformity
- Improvement of sitting balance
- Freeing of the arms from the role of trunk supports
- Improved appearance and body language
- Increased independence and mobility
- Improvement of respiratory function
- Relief of pressure and decubiti over the ischial
tuberosities and sacrum
- Relief of back pain
He cited prerequisites to success as being:
- Willing patient and family cooperation
- Presence of a skilled and experienced team including
orthotist, physician, therapists, and nursing staff
Surprisingly enough, Drennan stated that anesthetic
skin, with appropriate attention to detail and follow up, had not been
a problem and that patients without sensation had developed tolerance
of up to 10-12 hours. While adequate hip flexion for sitting is essential,
it was found that fixed pelvic obliquities and dislocated hips could be
accommodated.
Relative contraindications creating problems (and in
some case failure) were listed as:
- Uncooperative family and patients.
- Hip joint stiffness wit inability to sit.
- Severe athetoid cerebral palsy or severe involuntary
movements.
- Gross obesity, as the underlying structures are
difficult to grasp and the load imposed may be more than the skin can
tolerate.
- Cachexia (condition of general wasting marked
by extreme thinness and muscular atrophy). Patients tended to “slip
through” the orthosis, especially those with muscular diseases and progressive
weight loss and atrophy.
In a similar vein, Robin Black7 has listed as complicating
factors:
- Severe spinal deformity leading to unequal loading
on the rib cage and reduced tolerance time.
- Obese individuals.
- Patients with ileostomies.
- Poorly motivated patients.
FABRICATION
The negative impression is made in the usual fashion.
The patient may either be positioned supine on a Risser table and wrapped
circumferentially or positioned prone on the end of an ordinary fitting
table with the knees flexed for casting in two steps with splints. In
this latter instance, use of the Durr-Fillauer Pelvic Casting Fixture
may prove helpful. Whatever technique is used, flexible curves should
be corrected, and the space superior to the iliac crests and inferior
to the costal margins should be indented in the usual manner. Before removal
of the negative impression, the patient should be positioned straight,
keeping in mind the eventual sitting posture, and anterior and lateral
center lines drawn.
Following removal of the negative impression from the
patient and closure, the suspension points are identified. While the method
of clamping the hanger rods to the wheelchair gives considerable adjustability,
the suspension points should be located as accurately as possible, taking
into account such things as decompensated curves and eventual sitting
position. Once the suspension points are located, _” holes are cut in
the negative impression and the lubricated casting rod is positioned in
them (Figures 1, 2). The negative impression is poured in the usual fashion,
the rod is then removed (leaving a clear channel through the positive
model), and the cast is removed from the positive model.
The positive model is smoothed and modified in the usual
manner. Drennan4 has recommended building up the areas superior to the
costal margins to give room for chest expansion and respiration. Similarly,
he has advised removal of plaster in the upper abdominal area to provide
hydraulic resistance to contraction of the diaphragm and thus again aid
chest expansion and respiration.
The modified positive model is prepared for vacuum forming
and covered with a layer of 5mm A8 ventilated medium density PE-LITE (Figure
3) with an anterior opening. For several years the suspension lugs were
mounted on anchor cups fabricated of aluminum and rigid polyurethane foam.
Recently a quicker and more efficient means of mounting the suspension
lugs has been developed.
The PE-LITE cup, adapter nut, and the rest of the components
of the lug mount are assembled on the alignment rod.
The alignment rod is inserted in the hole previously
provided by the casting rod (Figure 4) and the amount of PE-LITE to be
removed is identified by measurement (Figure 5).
The PE-LITE cup is trimmed so that it makes even contact
with the surface of the positive model and protrudes no more than _”.
When properly contoured, the PE-LITE cup (Figures 6, 7) is filled with
Rapidcuret and repositioned on the positive model in proper alignment
(Figure 8). Once the acrylic compound reaches a stiff dough-like consistency,
it is faired into the surface of the PE-LITE using a fingertip dipped
in the methylmethacrylate catalyst. Once the lug mounts are properly shaped
and secured in place, the alignment rod is removed (Figure 9) and the
positive model is vacuum formed with 3/16” polyethylene.
When the polyethylene has cooled, the threaded holes
in the lug mounts are exposed using a 3/8” drill (Figure 10) and
a 5/16”-18 tap is used to clear the threads and properly align the
hole (Figure 11) in the polyethylene.
The areas about the holes are heated (Figure 12) and
the suspension lugs securely screwed into position (Figure 13) so that
the plastic forms flat seats about them. Trimlines are drawn on the orthosis
(Figure 14) and it is removed from the positive model and finished as
usual.
The clamp assemblies and hanger rods are secured to
the chair horizontally (Figures 15, 16, 17) to provide appropriate positioning
of the orthosis in the wheelchair. While rotation of the clamp assemblies
on the uprights of the wheelchair provides considerable adjustability,
modification of the hanger rods may be necessary. Although the thoracic
suspension orthosis is generally adjusted so as to relive the buttocks
of the patient’s weight, it may also be used for stabilization of
the torso without weight-bearing.
BREAK-IN
PERIOD AND FOLLOW UP
Drennan and Black4 5 6 7 agree that wearing tolerance should be built
up very gradually over a period of several weeks. The goal is that in
2-3 weeks time, the patient can use it for a full day with periods of
relief from suspension. Drennan recommends hospitalization for this period
of tolerance building and discharge once the patient can tolerate suspension
for two hours out of four. Obviously, success depends on willing, intelligent
cooperation of the patient and family.
The orthosis should be used daily to maintain tolerance,
the skin should be inspected daily, and care should be taken to avoid
wrinkles in undergarments worn. Areas of redness that do not clear after
20 minutes should be brought to the attention of the orthotist for appropriate
action. Patients should not be transported in suspension, as the jarring
motion can cause discomfort and skin breakdown. Drennan 4 5 has reported
that new orthoses were necessary on the average of 15 months after initial
fitting, with a readmission to the hospital of about three days.
RESULTS
In 1979, Drennan 4 reported the results of 62 patients fit since 1972.
The suspension orthosis was prescribed most frequently for spina bifida,
cerebral palsy, Duchenne muscular dystrophy, spinal muscular atrophy,
trauma, and various other conditions. Patients ranged in age from 14 months
to 26 years. Five instances of failure were described and attributed to:
lack of cooperation, obesity, hip joint stiffness, severe athetoid cerebral
palsy, and extreme and progressive cachexia.
Similarly in 1975, Robin Black7 described the results
of fitting over a dozen children with spina bifida with suspension jackets
over a period of two and one half years. Eight patients were identified
as having benefited from use of the jacket, five of them remaining free
of pressure sores for more than one year.
In addition, Karl Fillauer, CPO has fitted several patients
with hemicorporectomy amputations with suspension orthoses and achieved
good results.
CONCLUSION
The thoracic Suspension Jacket has proven itself to be an efficient and
practical means of handling individuals with severe scoliosis and decubitus
ulcers. For the benefit of those who may not be familiar with the orthosis,
indications, contraindications, fabricatino, and follow up procedures
are reviewed. It is hoped that this information will be of some assistance
in meeting the needs of the severely deformed.
REFERENCES
- Sibens, A.A.; Hohf, J.P.; Engel, W.F.; and Scribner,
N., “Suspension of Certain Patients from their Ribs,’ ÔJohn Hopkins
Med. J. 130:26, 1972.
- Paul, Siegried, W., “Current Principles in Spinal
Orthotics for Children,” Inter-Clinic Information Bulletin, Vol. XIII,
1973, pp. 1-12, 16.
- Paul, Siegfried, W., “Thoraic Suspension Orthosis
in the Management of Neuromuscular Spinal Deformity,” Orthopaedic Technic,
6-80.
- Drennan, J.C.; Renshaw, T.S.; and Curtis,B.H.,
“The Thoracic Suspension Orthosis,” Clinical Orthopaedics and Related
Research, No. 39, March/April 1979, pp. 33-39.
- Drennan, J.C., “The Role of the Thoracic Suspension
Orthosis in the Management of Myelomeningocele Spinal Deformities,”
Inter-Clinic Information Bulletin, Vol. XVII, No. 6, Dec. 1979, pp.
1-4.
- Drennan, J.C., Orthopedic Management of Neuromuscular
Disorders, J.B. ippincott Co., Philadelphia, 1983.
- Black, R. “Suspension Seating.” Ortho pros., Summer
1975, pp. 13-14
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