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Year : 2022  |  Volume : 70  |  Issue : 2  |  Page : 618--622

Compliance with Long-Term Use of Orthoses Following Spinal Cord Injury

Oya U Yemisci, Selin Ozen, Sacide N Saracgil Cosar, Sevgi I Afsar 
 Department of Physical Medicine and Rehabilitation, Başkent University Medical School Hospital, Ankara, Turkey

Correspondence Address:
Dr. Selin Ozen
Yukari Bahçelievler, Maresal Fevzi Çakmak Cd. No: 45, 06490 Çankaya, Ankara


Background: Prescription of orthoses and assistive devices that facilitate physical function is a major component of the rehabilitation process in spinal cord injury (SCI). Objective: To evaluate the long-term use of orthoses prescribed during inpatient rehabilitation in people with SCI and investigate the factors related to discarding the device. Materials and Methods: Medical records of 202 SCI patients who were included in an inpatient rehabilitation program of a tertiary research hospital were reviewed retrospectively. Patients' demographic data, neurological level of spinal cord injury functional state and use of assistive devices for ambulation (orthoses, walkers, etc.) at discharge were recorded. At follow-up, study participants were contacted by telephone and queried regarding the frequency and duration of use of orthoses; if the individual had discontinued using the orthoses, the reasons for discarding the device were sought. Results: The majority of the study participants (62.7%) had been prescribed a knee-ankle-foot orthosis during their inpatient stay. At follow-up, the regular use of orthoses was ongoing in 67.6% of the participants, and nonuse was determined in 32.4%. The most common cited reasons for discarding the device were difficulty in donning and doffing, functional improvement, and mechanical problems of the orthoses. Conclusions: A significant number of patients had discarded their orthoses at the long-term follow-up and the main reasons for discarding the devices were orthotic factors. Timely reevaluation of the patient and orthosis modification according to patients' needs is necessary to achieve long-term compliance.

How to cite this article:
Yemisci OU, Ozen S, Saracgil Cosar SN, Afsar SI. Compliance with Long-Term Use of Orthoses Following Spinal Cord Injury.Neurol India 2022;70:618-622

How to cite this URL:
Yemisci OU, Ozen S, Saracgil Cosar SN, Afsar SI. Compliance with Long-Term Use of Orthoses Following Spinal Cord Injury. Neurol India [serial online] 2022 [cited 2022 Aug 16 ];70:618-622
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Full Text

Orthoses and assistive devices are a major component of an effective rehabilitation program. Following spinal cord injury (SCI), achieving a sufficient level of mobility is imperative to maintaining patients' participation in activities of daily living and social activities.[1],[2] Gait training with orthoses has been shown to have a positive effect on both kinematics and temporal-spatial awareness of gait parameters,[3],[4] improving the biomechanics of both standing and walking.[5] Prescription of orthoses and assistive devices following SCI is very common and many different orthotic devices, such as contemporary lightweight mechanical orthoses, functional electrical systems, hybrid and robotic systems, have been developed to aid standing and walking in SCI patients.[6],[7],[8],[9] Long-term follow-up of SCI patients has shown that approximately 96% of patients use an assistive device of some sort, mostly in the form of a wheelchair, in their day-to-day activities.[10] However, the disadvantages of orthosis use, such as high-energy consumption during ambulation, slow walking speed, the impracticalities of donning and doffing the device, can result in patients terminating their use following discharge from hospital. Previous studies have shown that up to 65% of patients with paraplegia abandon orthosis use, mostly due to lack of functionality of the orthosis, psychological factors, and the need for support when donning and doffing.[11],[12] To the contrary, some studies have found that there are no factors that can predict use/rejection of orthoses.[13],[14] To date, there is no consensus regarding the factors affecting ongoing orthosis use following discharge from the rehabilitation unit.

The aim of this study was to evaluate the long-term use of orthoses/assistive devices prescribed during inpatient rehabilitation of SCI patients and investigate the factors related to discarding the device.


Medical records of 202 individuals with chronic SCI (≥3 months after SCI with no new neurological changes[15]), who were included in an inpatient rehabilitation programme at a tertiary level rehabilitation centre affiliated with a university hospital from 2005 to 2012, were retrospectively reviewed in June 2012. Those undergoing their initial course of inpatient rehabilitation after sustaining a SCI were included in the study. Patients with poor cognitive function, those under the age of 18, and those who had been repeatedly hospitalized were excluded from the study. Demographic data, gender, etiology of SCI, level of injury, time since SCI, length of inpatient rehabilitation, and ambulation level of patients at the end of the rehabilitation programme right before discharge were recorded from the medical notes. In addition, the neurological level of SCI according to the American Spinal Injury Association Impairment Scale (AIS),[16] adapted to the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury, was used to classify the neurological level of SCI. The type of orthoses and assistive device (metal knee-ankle-foot, metal/plastic ankle-foot orthoses, walkers, canes, etc.) prescribed prior to discharge were recorded. All study participants had been included in an inpatient rehabilitation program 2 hours per day for 6 days a week including range of motion and progressive resistance exercises, balance and coordination training, and occupational therapy. Assistive devices appropriate to the participants' level of mobility in the form of walking aids and orthoses were planned and prescribed by the physiatrist accordingly. Verbal informed consent was provided from all participants. Study participants were contacted by follow-up telephone calls between June 2012 and August 2012, and those who were available were questioned regarding their orthoses and assistive devices. The information specifically recorded included: whether the study participants had continued to use orthoses or assistive devices at home, frequency and duration of use of orthoses, and if they had discontinued using an orthoses the reasons for discarding the device. Ethical approval was granted on 18.12.2012.

This study was approved by the University Institutional Review Board and Ethics Committee (KA12/265) of Baskent University and carried out according to the institutional guidelines and the principles of the Declaration of Helsinki.

Statistical analysis

Statistical analyses were performed using the SPSS software version 22. The Kolmogorov–Smirnov test was used to test the normal distribution of each of the variables. Descriptive statistics were used to calculate mean, standard deviation, and median values. The Chi-square test was used for the comparison of dichotomous variables between patients who continued to use orthoses postdischarge and those who stopped using them (nonusers) (gender, presence of sacral sparing, etiology, neurological level of SCI, ambulation status). The Mann–Whitney U test was used for intergroup comparison of the nonnormally distributed data including patient age, time since trauma, and length of hospital stay. Association between nonnormally distributed and/or ordinal variables was assessed using the Spearman test.


Out of 202 individuals with a new diagnosis of SCI, 102 [62 males (60.8%), 40 females (39.2%)] were available for telephone interview. Eighty of the study participants whose medical records were initially reviewed were uncontactable via telephone and 20 of the study participants refused to participate in the study. Demographic characteristics of participants are given in [Table 1]. Mean age of participants was 38.2 ± 1.6 years. Etiology of SCI was traumatic in the majority of the participants (81.4%) of which 57.8% was due to traffic accidents. According to the AIS classification, 64 (62.7%) of the participants had a complete lesion, AIS impairment A. Tetraplegia (neurological level of injury C4-T1) was present in 19 (18.6%) participants, while paraplegia (neurological level of injury T2-T12) was present in 61 (59.8%). The average duration of inpatient rehabilitation was 83.3 ± 6.1 days. On discharge, 30 (29.4%) of the patients were community ambulators. The majority of the study participants (n = 65, 63.7%) had been prescribed a metal knee-ankle-foot orthoses (KAFO) during the rehabilitation period and were recommended continued use of their orthoses after discharge. The second most common orthoses prescribed was metal ankle-foot orthoses (17.6%). In addition to orthoses, 44 (43.1%) patients were using bilateral lofstrand crutches on discharge [Table 2]. At the follow-up time (at the time of telephone interview), the average time since discharge from the rehabilitation unit was 53.9 ± 27.6 months (range 5–84 months). The same 30 (29.4%) study participants remained community ambulators. Participants who continued to use their orthoses was 67.6% (n = 69), while 32.4% (n = 33) had discontinued orthosis use. There was no significant difference in orthosis type between those study participants who continued orthosis use and those who did not (P' =0.671). Similarly, there was no significant difference in the type of ambulatory aid used between study participants who continued orthosis use and those who did not (P = 0.132).{Table 1}{Table 2}

The most common reasons for discarding the device were difficulty in donning and doffing (75.8%), functional improvement (21.2%), and wear and tear of orthoses (3%). Of those who continued to use their orthoses, 24 (35%) used their orthoses daily and the majority (32%) were walking for greater than 3 hours a day using their orthoses [Table 3]. Overall, there was no statistically significant correlation between SCI etiology, level of injury, AIS grading, level of ambulation, and termination of orthosis use [Table 4]. Similarly, age, time since SCI on hospital admission, and length of hospital stay did not significantly affect orthoses compliance, P = 0.764, P = 0.530, and P = 0.136, respectively. There was also no significant correlation between follow-up time and orthoses compliance (r = 0.142, P = 0.681) and levels of ambulation (r = 0.241, P = 0.536).{Table 3}{Table 4}


To the best of our knowledge, this is the first study detailing long-term orthosis compliance in SCI patients with both tetraplegia and paraplegia who underwent a comprehensive inpatient rehabilitation program. All patients received a supervised rehabilitation program, including balance and coordination training and walking exercises appropriate to the level of SCI, training, and support to adapt to their customized orthoses. At follow-up, almost a third of the patients discontinued orthosis use. Even though the data on which this study was based was gathered in 2012, the results were consistent with other studies in the literature. In addition, as the same types of orthoses continue to be used widely in developing countries even today, this indicates that long-term orthosis noncompliance in following SCI is still a contemporary problem, which needs to be addressed and resolved. In previous studies, the rate of abandonment of gait orthoses has been reported as 27–65%.[12],[17] Furthermore, abandonment of orthosis use seems to increase as the time since SCI and time since prescription of orthosis increases.[17] Our study revealed that 76.7% of patients who continued orthotic use were community ambulators, and that the majority of these compliant patients used their orthoses every day (34.8%), with 31.9% making use of their orthoses for greater than 3 h per day. The most common reason for orthoses abandonment was difficulty in using the orthoses, especially independent donning and doffing, discomfort, and energy expenditure. Such reasons for orthoses abandonment have also been highlighted in previous studies.[12],[17],[18],[19] The high rate of traditional KAFO use with a swing-through gait style in this study (63.7% of the total) would make this even more of an issue. The simplest and most traditional approach to enabling standing and ambulation in SCI patients is use of a purely mechanical orthoses, such as those used by the patients of this study. Although the data in this study was collected nine years ago, the results of the study remain relevant as similar orthoses are still used in most developing countries to this day. It has been shown that energy expenditure during ambulation is more with a conventional KAFO when compared to the advanced reciprocating gait orthoses.[20] More advanced medial linkage orthoses, such as the walkabout orthoses, have been shown to have a simpler function and to be more user friendly for those with SCI.[19] However, in most developing countries, the economic burden of orthoses means that the government only subsidizes the recommended orthoses by a certain amount. Therefore, even to the present day, the price of more advanced technology, lightweight orthoses mostly, exceeds the patients' budget and the majority of the prescribed orthoses are conventional metal orthoses. We agree with authors that policies regarding equipment prescription are primarily driven by the socioeconomic status of the country.[21]

Seven (21.2%) of the patients terminated orthosis use as they felt that they were able to walk without their orthoses. Motor recovery can continue in the long term following SCI; a study by Katoh et al.[22] in which patients with cervical SCI and complete paralysis were followed up with regard to motor recovery showed that 33% of the patients were able to walk at the end of 1 year. However, in the present study, the reason for terminating orthosis use was subjective since the data collated regarding utilization of devices were based on self-report via telephone calls; study participants were not questioned face to face nor was follow-up examination and evaluation performed to determine the level of neurological recovery. The reliability of the telephone conversations, and inferences drawn based solely on this information, is a major limitation of the study. Periodic reevaluation of functional recovery status of the patients by a physician working in this field is important to determine the continued need for orthoses use and to reorganize and modify the orthoses according to the patients' needs where necessary. In this study, we found that wear and tear of orthoses was a rare cause of noncompliance with only one (3%) study participant abandoning orthosis use for this reason. On the other hand, all of these reasons for termination of orthosis use may emphasize inadequate instruction and demonstration of orthosis utilization to the patients and the necessity for regular follow-up of these patients by a rehabilitation physiatrist soon after discharge or at their first postdischarge encounter. Wear and tear issues could be addressed and the ability of the patient to walk without an orthosis could be evaluated by a rehabilitation specialist and a physiotherapist, thus avoiding long-term musculoskeletal problems arising from inappropriate ambulation. Furthermore, discarding the device may also cause reduced patient mobility, which can result in an increased risk of development of both local and systemic complications, such as pressures ulcers and anemia of immobility,[23],[24] which would have a negative knock-on effect on the patients' outcome. These issues may be important areas of investigation in future studies. This study showed no significant correlation between age and time since SCI on admission and length of hospital stay between those who carried on using their orthoses when compared to those who stopped. In our study, the level of SCI and the presence of complete/incomplete SCI did not affect patient compliance to orthoses use. Similarly, in the study by Koyuncu et al.,[12] and Alemdaroglu et al.,[17] lesion level did not affect orthosis compliance. To the contrary, in the study by Alemdaroglu et al.,[17] termination of orthosis use was significantly higher in those with incomplete SCI and sacral sparing. The potential for motor recovery in those with a lower neurological level of injury and preserved muscle strength were provided as the reasons behind these findings. In addition, although the study participants were followed-up over a long period of time (5–-84 months), at the time of the calls, we did not find any association between follow-up time and compliance nor follow-up time and ambulation levels. Previous studies have also shown that continued orthosis use following SCI is not influenced by inpatient/outpatient prescription nor length of inpatient rehabilitation.[25] Nevertheless, the current study showed that the proportion of those who continued orthosis use was greater than the proportion of those who discontinued their use.

Study limitations

Relatively small sample size with no comparison group is one limitation of the study. Drawing inferences based on a telephone conversation during the patient follow-up rather than a face-to-face consultation is an important limitation of the study due to the subjectivity of the information obtained from the patient. Performing patient follow-up remotely via a telephone meant that the evaluation of functional status of the study participants and follow-up examination performed to determine the level of neurological recovery and psychological status after discharge could not be established. All of these factors can compromise the reliability of the information obtained regarding orthosis/assistive device compliance.


This study highlights that although the majority of the study participants continued to use their prescribed orthoses, a significant number of orthoses were discarded at the long-time follow-up. The main reasons for discarding the devices were orthotic factors such as impracticality in orthosis use and discomfort. To truly understand factors associated with orthoses abandonment, good knowledge and thorough understanding of patient preferences, physical, psychological, and environmental needs, and timely neurological reevaluation of each patient is essential.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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