Principles of Bracing in the Rehabilitation of the Paraplegic

W I T H I N recent years it has been c o m m o n l y accepted that crutch-and-brace ambulation forms an integral part of the rehabilitation of the paraplegic. It is necessary to develop a proper orientation to the subject as a whole and specifically to discuss the methods of attainment of maximal function with minimal brac­ ing. Four points of view have developed, concerning the degree to which this ambulation can be carried out. There are those who believe that the para­ plegic must develop the use of crutch­ es and braces to the point of total ambulation. Some think that the use of the wheelchair as the sole means of locomotion is sufficient. A third group feels that a combination of both of these methods is best. The fourth group, which fortunately has not put its concepts into practice, has suggest­ ed that paraplegics would be better off and more adept at handling them­ selves if both legs were amputated. It would be well, at this point, to ana­ lyze all these opinions and to under­ stand the advantages and disadvan­ tages of each. The last group can be quickly dis­ posed of. It has been the experience of almost all who have worked with paraplegics that in most cases the retention of the lower extremities does not form an insurmountable bar­ rier to the ability of the paraplegic to become self-sufficient. Furthermore, those paraplegics that we have seen, in whom the lower extremities had to be amputated for other rea­ sons, did poorly in comparison to those with similar neurologic lesions who retained their lower extremities. Ambulation by means of crutches and braces as the sole method of getting around, has proven feasible in a limited number of cases. Generally, these people are slim, athletic and have either conus or cauda equina lesions. This lower motor neuron type of lesion spares the abdominal and back muscles and permits the legs to remain flaccid following spinal shock. There is also a large loss of weight, due to the almost total muscle atrophy occurring in the lower ex­ tremities. However, in heavy, spastic individuals who have high lesions there is a limit to the development of muscle power in the upper normal part of the body, and the lower ex­ tremities remain heavy and bulky. Crutch-and-brace walking as a total means of ambulation in these cases become a goal almost impossible to attain with any any great degree of efficiency, and is usually accompan­ ied by frustration.