Aspen® TX

Solving the Problem of Pressure Ulcers Resulting from Cervical Collars: A Step-By-Step Approach

Blaylock, B
ET Nursing Department, St. Vincent Medical Center, Toledo, Ohio
Published in Ostomy Wound Management, 1996 May, Vol. 42 (4), 26-33.

Abstract

Cervical Orthotic devices (cervical collars) are integral to the treatment of patients with suspected or confirmed fracture of the cervical spine. Pressure ulcers can develop under the cervical collar on the occipital protuberance and on the chin due to both prolonged immobilization and the collar construction. A multidisciplinary team at a Northwest Ohio trauma center led an investigation of this problem when a one-day study of pressure ulcer prevalence revealed that 4% of nosocomial pressure ulcers, 2% were attributed to cervical collars.

Selected Quotations

“… in 1993 an average of 6 cases per quarter were seen.”

(Pg. 27)

“At this trauma center, we had been using a closed cell foam collar for many years.”

(Pg. 28)

“We discovered that another hard cervical collar had been brought into the institution in March 1993, just prior to the development of some of the most severe occipital ulcers.”

(Pg. 28)

“After the educational programs were conducted, … We again concluded/hypothesized that the main contributing factor in the development of pressure ulcers was the type of collar itself, and not the care provided for the patient.”

(Pg. 29)

“The product trial resulted in zero skin breakdown for the 20 patients involved.”

(Pg. 26)

“Repeated CQI studies have demonstrated that the problem of pressure ulcers resulting from cervical collars has been eliminated at this institution.”

(Pg. 32)

A Multidisciplinary Approach to Occipital  Pressure Ulcers Related to Cervical Collars

Powers, J
Wishard Memorial Hospital, Indianapolis, Indiana
Published in Journal of Nursing Care Quality, 1997 Oct., Vol. 12, No. 1.

Abstract

Pressure ulcers related to cervical collars are a common difficult-to-manage complication of cervical immobilization in the trauma patient. After many cases of occipital pressure ulcers occurred at our institution, a multidisciplinary task force was formed to look at this issue. The group was to identify causes for this problem and develop a plan to decrease the occurrence of pressure ulcers related to cervical immobilization. The problem involved three areas that needed improvement. These were: nursing care, the type of collar used, and the lengthy process of clearing C-spines.

Selected Quotations

“Occipital pressure ulcers are largely preventable and in the early stages are readily responsive to the appropriate therapies.”

(Pg. 47)

“At our institution we noticed an increase in occipital breakdown related to the presence of cervical collars. We observed 19 documented cases of skin breakdown in a one-year period.”

(Pg. 285)

“We began official implementation of the collars [sic. Aspen], in January of 1996. After one year and 76 patients in collars we had only one case of skin breakdown and this was attributed to the patient not being placed in the appropriate sized collar.”

(Pg. 50)

“The cost of treating just one occipital breakdown was calculated to be $4,323.00.”

(Pg. 50)

“The cost of treating just one occipital breakdown was calculated to be $4,323.00.”

(Pgs. 50-52)

Biomechanical Analysis of Cervical Orthoses in Flexion  and Extension: A Comparison of Cervical Collars and Cervical Thoracic Orthoses

Gavin, T; Carandang, G; Havey, R; Flanagan, P; Ghanayem, A; Patwardhan, A
Musculosketal Biomechanics Laboratory, Edward Hines Jr., Department of Veterans Affairs Hospital, Maywood, Illinois
Published in J of Rehabilitation Research and Development, 2003 Nov./Dec., Vol. 40, No. 6, 527-538

Abstract

The analysis of current cervical collars (Aspen and Miami J collars) and cervical thoracic orthoses (Aspen 2-post and Aspen 4-post) in reducing cervical intervertebral and gross range of motion in flexion and extension was performed using 20 normal volunteer subjects.

Selected Quotations

“It is important that the prescribing physician recognizes the differences between the function of cervical orthoses, so they may make informed decisions as to which orthosis is most appropriate for a specific condition.”

(Pg. 527)

Gross Head Motion Restriction
“Flexion motion allowed in the Miami J collar was significantly greater than that allowed in the Aspen collar. No significant difference was found between the two collars in extension.”

(Pg. 531)

Neck (CO to C7) Motion Restriction
“When measuring angular motion of CO relative to C7 using VF images, we found no statistically significant differences in angular motion allowed between the Miami J and Aspen collars in either flexion or extension.”

(Pg. 531)

Intervertebral Angular Motion Restriction
“No significant differences in flexion were allowed at any intervertebral segment between the Aspen or Miami J collars except at C5-6, where the Miami J allowed more motion.”

(Pg. 532)

“In restricting angular motion in flexion, the CTO’s were significantly better than the collars at C3-4, C5-6 and C6-7 segments.”

(Pg. 532)

Discussion
“The capability of the 4-post CTO to effectively restrict extension motion seems to contradict the current thinking that the halo may be the only effective orthosis for reducing motion in extension.”

(Pg. 536)

Conclusion
“Our findings suggest that either of the two collars could be used to treat similar cervical pathologies or injuries except those involving the C5-6 segment, where the Aspen collar may provide better motion restriction.”

(Pg. 537)

The Effects of Lumbar Orthoses on the Range of Motion of the Lumbar Spine
During Fifteen Activities of Dail Living

Christopher Miller, MD; Jesse Bible, MD; Debdut Biswas; Peter Whang, MD; Jonathan Grauer, MD
Yale University School of Medicine, New Have, CT, USA
Poster Presented at NASS 24^th Annual meeting. Published in The Spine Journal 9 (2009) 200S.

Abstract

BACKGROUND CONTEXT: Lumbar braces are fequently considered for patients suffering from acute and chronic low back pain, postoperatively, and in other situations. There are a variety of options for lumbar braces ranging from generic, soft corsets to rigid, custom fit orthoses. Previous studies have demonstrated that the range of motion (ROM) reduction from lumbar braces varies greatly from subject to subject based on body habitus and type of brace. They also have shown that the overall reduction in full, active motion is often quite modest. However, there has been little date to date exploring how lumbar braces affect the ROM used during activities of daily living (ADLs).

PURPOSE: The purpose of this study was to evaluate the relative efficacies of a soft corset, a semi-rigid off the shelf LSO, and a rigid, custom molded LSO for restricting both the full, active and functional ranges of motion (ROM) of the lumbar spine during 15 activities of daily living (ADLs).

STUDY DESIGN/SETTING: Prospective cohort study. PATIENT SAMPLE: Ten subjects with no history of lumbar spine pathology and no current back pain or disability.

OUTCOME MEASURES: Full, active functional ROM of the lumbar spine.

METHODS: In this investigation, a previously validated electrogoniometer device was employed to quantify both the full, active ROM of ten subjects as well as the functional ROM during a series of 15 ADLs in the sagittal and coronal planes. For each individual, these ROM measurements were repeated without a brace (No Brace) and after the application of a soft corset (Corset), a semi-rigid off the shelf brace (Semi-Rigid), a custom LSO brace (Custom).

RESULTS: The Corset, Semi-Rigid and Custom braces restricted mean (± 95% CI) full, active motion in the sagittal plane by 24.1 ± 7.9%, 46.8 ± 7.1%, and 64.7 ± 8% compared to No Brace (p < 0.008 for each), respectively. In the lateral plane, they restricted full, active motion by 33.9 ± 8.8%, 51 ± 9.4%, and 49.1 ± 11.8% compared to No Brace (p < 0.008 for each), respectively. There was no difference in ROM between No Brace and any of the braces for seven of the ADLs in the sagittal plane and nine of the ADLs in the lateral plane. In the sagittal plane, there was a greater restriction of full, active motion with the Custom compared to the Semirigid brace (p < 0.01). However, there was no difference between these two braces for the ROM used during any of the ADLs (pO0.325 for all activities). There were 4 ADLs for the Custom brace and 1 ADL for the Semi-rigid brace for which the respective brace provided better sagittal motion than the soft Corset (p < 0.021 for all). In the lateral plane, there were no differences observed in motion restriction between any of the braces (pO0.116 for all).

CONCLUSIONS: We found that all fo the braces provided some restriction of full, active ROM. The custom brace provided the most restriction followed by the Semi-Rigid brace and then the Corset. For functional ROM, we found that the Custom and Semi-Rigid braces provided significantly better restriction during some of the ADLs compared to the Corset. However, there were no differences between these two braces for ROM during any of the ADLs. Thus, depending on the clinical goal of bracing, this study suggests that the Custom LSO may no always be superior to less expensive generic models, which may suffice for providing restriction during many daily activities.

Selected Quotations

Summary: Functional ROM
“…[There was] no difference in functional ROM for Semi-Rigid LSO (Contour^™ by Aspen) and Custom LSO braces for any ADLs in any plane.”

Clinical Significance
“…For Trauma, the Semi-Rigid LSO (Contour^™ by Aspen) and Custom braces provide excellent reductions in full, active and functional ROM.”

Absorption and Transfer Characteristics of Cervical Collar Padding

Technical Report

OVERVIEW: Patients with moist skin are four times more likely to suffer skin breakdown than those who are kep dry.¹ Cervical collars with replaceable padding, such as the Aspen^® and Miami J^®, utilize open cell foam for comfort, and to control perspiration or other fluids at the skin surface. The padding in these two collars differs in the type of foam used² and lining material adhered to the foam. Since the lining material comes into direct contact with the skin, fluid absorption and transfer characteristics of the pads may significantly impact patient care.

This report evaluates the effectiveness of both Aspen^® and Miami J^® pads in keeping moisture away from a patient's skin. The results indicate that Aspe^® Collar Pads absorb more readily, and move fluid away from the skin contact surface much more effectively.

MATERIALS & METHODS: The pads tested were obtained from currently available Aspen^® and Miami J^® Collars. Two small pools of fluid (~.23 cc) were placed on a glass surface. The cotton side of the Aspen^® pad, and the smooth nylon side (referred to by the manufacturer as "Sorbatex^™"³) of the Miami J^® pad were placed flat, without pressure, over the fluid.

After eight seconds the pads were lifted off of the surface, and turned over so the wetted "skin contact" surface faced up. The fluid remaining on the surface was then observed.

A sheet of tissue paper was placed over both pads for 30 seconds.

Moisture on the skin contact surface was absorbed by the tissue and the wetted area was measured. The test was repeated three times and then averaged.

RESULTS: The Aspen^® pad appeared to be more effective in absorption. Significantly more fluid was observed on the glass surface under the Miami J^® pad. The area of the tissue that became wet when placed over the Aspen^® pad measured 24 (± .5) sq. mm., while the wetted are of the tissue placed over the Miami J^® pad measured 860 (±.5) sq. mm. When comparing the wetted ares, the Aspen^® pad transferred more fluid away from the surface. The Miami J^® pad produced a moist skin contact surface area that was 35 times larger than that produced by the Aspen^® pad.

DISCUSSION: Differences in materials used in cervical collar padding may result in significant differences in the ability of the pads to keep patients dry. Synthetic materials have been shown to offer advantages in cooling (i.e-athletic apparel) by dispersing perspiration for increased evaporation when there is substantial airflow.⁴ When assessing evaporation in cervical collar padding, however, there is no significant airflow, so evaporative cooling is not an important factor. The results of this evaluation show that the Aspen^® pads readily absorb and move fluid away from the patient's skin surface. Miami J^® pads proved to be less effective in absorbing fluid and substantially worse in transferring moisture away from the skin contact surface.

CONCLUSIONS: Aspen^® Collar Pads, absorbed moisture and transferred it away from the contact surface more effectively than the synthetic-lined padding used in the Miami J^® Collar. By minimizing the moist contact area and by transfering fluid away from the skin contact surface, Aspen^® Collar Pads keep patients comfortable and may reduce the likelihood of collar related skin breakdown.

ACKNOWLEDGMENT: Experiments were performed and data was collected by Orange County Materials Test Laboratories, Anaheim, California.

REFERENCES
1. Kosiak M: Etiology of decubitus ulcers. Arch Phys Med Rehabil 42:19, 1961.

2. Albero, Marc J., Foamex International Inc., personal correspondence, Feb. 28, 2002.

3. Spingarm, Neil E., Report of Spectrographic Analysis, SN Labs, Santa Ana, CA. Mar. 28, 2002.

4. Dupont Data website: www.dupont.com/coolmax/html/diagrams.html

Evaluation of the Cushioning Characteristics of Padding in Cervical Orthoses

Technical Report

OVERVIEW: Clinicians agree that sustained pressure greater than 32 mmHg can cause irreversible skin damage in as little as two hours.¹ Manufacturers of cervical orthoses must consider these parameters in their selection of padding materials, since the effectiveness of the padding can influence pressure at the skin surface.

Research sugggests that when properly fitted, both the Miami J^® Cervical Collar and the Aspe^® Cervical Collar generate a maximum average pressure of less than 25 mmHg.² While this is below the capillary closing pressure of healthy tissue, not all patients have healthy tissue.

In this report, the cushioning characteristics of the padding material used in the Aspen^® Collar and the Miami J^® Collar are evaluated. The results demonstrate that at pressures of ~25 mmHg the foam used in the Aspe^® pads provides cushioning that is approximately twice as effective as the pads used in the Miami J^® Collar.

MATERIALS & METHODS: Replacement pads were obtained from currently available Aspen^® and Miami J^® Cervical Collars. Analysis showed that the Miami J^® pads are manufactured from a "non-clickable" foam with a density of 1.6 lbs. "Non-clickable" foam does not readily spring back after it is die cut, so the edges appear to be sealed. Aspen^® pads are manufactured from 1.6 lbs foam tha is "clickable." Clickable foam is desigend to have superior resilency so that edges do spring back and do not stay compressed after it is die cut.³

The thickness of each pad was measured. A 1 Kg weight, fitted with a base plate designed to yield a pressure of ~25 mmHg was pressed into both pads and allowed to rebound. After 60 seconds, with the weight in place, the thickness of each pad was again measured.

RESULTS: The Miami J^® pad averaged an initial, uncompressed thickness of .4015 inches and showed an average compressed thickness of .1860 inches after 60 seconds. The Aspen^® pad had an average, uncompressed thickness of .4280 inches and rebounded to an average compressed thickness of .3180 after 60 seconds.

DISCUSSION: While the Aspen^® padding rebounded to 75% of its original cushioning height, the Miami J^® padding rebounded to less than half (46%) of its original height. These differences in performance may explain why using Aspen^® Cervical Collars, in conjunction with comprehensive protocols, can significantly reduce the incidence of skin breakdown commonly seen when other cervical collars are used.^4,5

CONCLUSIONS: The results of this evaluation demonstrate that there are clear differences in the cushioning ability of the pads used in the Miami J^® and Aspen^® Collars. The clickable foam used in Aspen^® Cervical Collars offers superior cushioning to the non-clickable foam used in Miami J^® Collars. The padding material used in Miami J^® Collars lost significantly below capillary closing pressure.

ACKNOWLEDGMENT: This report data was generated by Orange County Materials Test Laboratories, Anaheim, California.

REFERENCES
1. Kosiak M: Etiology of decubitus ulcers. Archives of Physical Medicine and Rehabilitation 42:19, 1961.

2. Plaisier, B., Gabram, S.G., Schwartz, R.J., and Jacobs, I.M. "Prospective Evaluation of Craniofacial Pressure in Four Different Cervical Orthoses."
Journal of Trauma 37 (1994):714-720.

3. Foamex Report

4. Powers, Jan. "A Multidisciplinary Approach to Occipital Pressure Ulcers Related to Cervical Collars." Journal of Nursing Care Quality 1997;12(1), 46-52.

5. Blaylock, Barbara. "Solving the Problem of Pressure Ulcers Resulting from Cervical Collar: A Step-by-Step Approach" Ostomy Wound Management.
May 1996;42(4):26-33.