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To brace or not to brace? This is a question that I am often asked, and the answer is always: "it depends on whether one wishes to provide comfort, stability or edema control." But what should effective bracing look like in any of these circumstances? Read on to find out.
What is a Brace?
The online Merriam-Webster dictionary defines a brace (noun) as "something that transmits, directs, resists, or supports weight or pressure." It goes on to give a medical definition: "an appliance for supporting a body part."
Simply put, a brace must transmit force. However, the material, body part supported, or whether the brace resists or applies force are left undetermined. As a result, braces come in many forms, with many designs, and are used for specific purposes.
Reasons to Brace
So, you think you want a brace. The first question you have to ask yourself is, why or for what purpose?
There are three reasons to brace:
Comfort
Stability
Edema Control
Let’s tackle Comfort first.
Suppose you twisted your ankle or tweaked your knee. The area around the injured joint is probably slightly swollen. Swelling can cause pain by virtue of the pressure and stretch it applies to tissue. In this case, your goal is to reduce the swelling that causes pain and thus improve comfort. This is a hybrid example where your choice of brace would be a compressive garment or sleeve surrounding the joint.
Now, let’s assume your wrist hurts every time you bend it in a certain direction and passed a certain point. You might consider a brace that stops your wrist from moving in that direction or passed that point, thus improving comfort. This brace would likely be a stabilizing brace, not a compressive brace as in the first example. If you used a compressive brace in place of a stabilizing brace, you likely wouldn’t improve your comfort as you would still be able to move your wrist into a painful position.
In order to choose the correct brace, you must first know the cause of your discomfort.
Second, Stability.
Stability is simple. Start by asking yourself, "What structure is injured?" or "What movement causes pain?" Once you have that answer, you must choose a brace that protects that structure or limits that movement. The difficult part is in choosing between multiple braces that purport to protect the structure you wish to protect and cost highly variable amounts of money. The ‘Cadillacs’ often have specific use scenarios and are custom fit while the bargain braces often fit poorly and are uncomfortable. Shop around and ask your health care provider for advice before purchasing a brace.
Lastly, Edema Control.
Edema control can be complicated. You always want a compressive garment, and sometimes a graduated compression garment. Non-medical grade garments exert uniform compression and less pressure than medical grade garments. These can be purchased over the counter at drug stores or online. Medical grade graduated compression garments apply varying amounts of pressure from <20 mm Hg (class 1), 20-30 mm Hg (class 2), to >30 mm Hg (class 3), and some medical conditions make use of these garments dangerous. It is typically impossible to purchase a medical grade compression garment without a prescription, and only certain medical supply stores sell these garments.
If you’re healthy and have a swollen knee, a neoprene sleeve may do the trick. Likewise a soft/compressive ankle brace may help after ankle sprain. These options are generally safe as long as they are not tight enough to cut off circulation.
If you’ve had surgery, have any health conditions like diabetes or heart disease, or you don’t know your health status then you should always seek advice from a medical professional, preferably a Family Physician (GP) or your surgical specialist.
An excellent technical review of compressive therapy authored by Chung Sim Lim and Alun H. Davies published in the Canadian Medical Association Journal in 2014 titled Graduated compression stockings (doi: 10.1503/cmaj.131281) details the uses, mechanisms, indications and contraindications surrounding compressive garments.
Types of Braces
There are two main brace types, many sub-types and some hybrids.
1. Stabilizing Braces: Typically made with metal stays, rigid plastic and/or Velcro straps, these braces are designed to restrict joint and bone movement by absorbing force or providing a force to counter the unwanted movement.
Multi-plane Immobilization: These braces cross a joint, do not have a hinge, and are responsible for maintaining joint position to protect muscle, bone or ligament while it heals. They are made with metal stays or thermoplastic and attached with Velcro straps.
Examples: Thumb spica, wrist splint, knee immobilizer.
Uni-plane Immobilization: These braces cross a joint, have a hinge to allow normal joint movement in one plane (direction), and protect muscle, bone or ligament on the side(s) with a hinge. They are made with multiple hinged metal stays and attached with Velcro straps.
Examples: Hinged knee brace for ACL, PCL, LCL, MCL stability, hinged elbow brace for UCL and RCL stability
Unloader Brace: These braces apply a force across a joint and transfer the
force of body weight from one side of the joint to the other. They provide stability in only one direction, but their primary purpose is to unload part of an arthritic joint and reduce pain.
Example: Knee unloader
2. Compressive Braces: Typically cylindrical and made with elastic materials such as neoprene, compressive braces may be slip on or Velcro on and may be open at one end or both ends.
Multi-Joint Compression: Graduated compression garments apply more pressure distally and less proximally, come in below knee/elbow or above knee/elbow varieties and are typically closed at the distal end. Most commonly used to control edema (swelling) in a limb and may or may not reduce pain.
Example: Compression stockings
Single-Joint Compression: Open at both ends, slip-on sleeves or wrap around garments with Velcro that apply limited compression. Predominantly used for comfort and may or may not reduce edema or pain.
Example: Knee sleeve, arm sleeve
3. Hybrid Braces: A combination of compressive and stabilizing brace materials, hybrid braces may get the best or worst qualities of their pure compressive or stabilizing counterparts.
Lace-up Compressive Garments that Stabilize: Pre-stitched, minimally elastic slip-on cloth with laces and a wrap of material that when applied tight enough, creates stability. May or may not have metal stays across a joint.
Examples: Lace-up ankle braces with Velcro wraps around the arch and across the ankle, lace-up wrist braces with Velcro wrap around thumb +/- volar plate
Compressive Garments with Hinged Metal Stays: Typically neoprene sleeves or wrap around, these garments have short metal stays with a hinge on either side of a joint. They are a short version of the hinged stabilizing braces and thus have reduced ability to resist unwanted forces on a joint. Their compression is similar to other neoprene garments, but often causes the metal stays and hinge to dig into skin.
Example: Neoprene hinged knee brace
Final Words
Choosing a brace is complicated. You need to identify the reason for bracing, have an understanding of brace materials and construction and finally ensure that the brace fits well and is safe given your current state of health. Many people have injuries that do not require bracing, and some people have injuries that may get worse if they wear a brace. Before purchasing a brace, it is always recommended that you consult with a health care provider who is familiar with your injury and familiar with the braces that are available.
Stephen Baker graduated from Western University with a Masters of Physical Therapy. He has a passion for helping those with neck, hand or knee injuries return to their daily adventures. Book with Stephen today.