Positioning and spinal bracing for pain relief in metastatic spinal cord compression in adults
This is an updated version of the original Cochrane review published in Issue 3 (Lee 2012) on patient positioning (mobilisation) and bracing for pain relief and spinal stability in adults with metastatic spinal cord compression.
Many patients with metastatic spinal cord compression (MSCC) have spinal instability, but their clinician has determined that due to their advanced disease they are unsuitable for surgical internal fixation. Mobilising may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (whether a patient should be managed with bed rest or allowed to mobilise) and whether spinal bracing is helpful, is contradictory.
To investigate the correct positioning and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC.
For this update, we searched for relevant studies from February 2012 to 31 March 2015. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In Process, EMBASE, AMED, CINAHL, TRIP, SIGN, NICE, UK Clinical Research Network, National Guideline Clearinghouse and PEDro database. We also searched the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov, UK Clinical Trials Gateway (UKCTG), WHO International Clinical Trials Registry Platform (ICTRP) and Australia New Zealand Clinical Trials Registry (ANZCTR).
For the original version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse, and PEDro database, in February 2012.
We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning (mobilisation) and bracing.
Data collection and analysis
Two review authors independently assessed each possible study for inclusion and quality.
For the original version of the review, we screened 1611 potentially relevant studies. No studies met the inclusion criteria. Many papers identified the importance of mobilisation, but no RCTs of bed rest versus mobilisation have been undertaken. We identified no RCTs of bracing in MSCC.
For this update, we identified 347 potential titles. We screened 300 titles and abstracts after removal of duplicates. We did not identify any additional studies for inclusion.
Since publication of the original version of this review, no new studies were found and our conclusions remain unchanged.
There is a lack of evidence‐based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.
Siew Hwa Lee, Robin Grant, Catriona Kennedy, Lynn Kilbride
Plain language summary
Position and spinal bracing for pain relief in adults with metastatic spinal cord compression
Metastatic spinal cord compression (MSCC) is a serious complication of advanced cancer that can cause pain and mobility (movement) problems as well as paralysis. For many patients, a diagnosis of MSCC indicates the final stages of their illness. The spread of cancer to the spinal column can make walking unsafe. However, staying in bed risks deep vein thrombosis or pressure sores. Supporting the spine with spinal bracing (neck, thoracic spine, or lumbar support) may prevent further spinal collapse, but may be uncomfortable or ineffective.
Managing this condition is challenging for healthcare professionals. Some existing guidelines suggest bed rest (avoiding movement) and the use of spinal braces. However, positioning (for example lying flat, sitting up, standing or walking) and the use of spinal braces needs to be balanced against the patient's wishes, ensuring their comfort and individual preferences. If the spine is unstable, movement may cause more pain and risk further spinal cord or nerve root damage. Spinal bracing may be supportive and reduce pain and risk of collapse. However, spinal bracing may not prevent further collapse and spinal cord damage, and may be uncomfortable. If life expectancy is short, then a palliative care approach focusing on patient preferences and priorities is appropriate.
This review update attempted to find the existing evidence on positioning and spinal bracing for adults with MSCC. We ran updated searches in March 2015. We found no randomised clinical trials comparing positioning (bed rest versus mobilisation), or spinal bracing to no bracing, for pain relief. In the absence of clear evidence, healthcare professionals and patients need to discuss the options to decide what is best for the individual patient.
For this update, no new studies were found and our conclusions remain unchanged. There is a need for randomised controlled clinical trials to find out which treatment is most effective.
Siew Hwa Lee, Robin Grant, Catriona Kennedy, Lynn Kilbride
Implications for practice
People with MSCC
There is a lack of evidence available to guide people with MSCC about the effectiveness of spinal bracing, positioning, or mobilisation. Quality of life, including pain relief and being able to mobilise, are important issues for people with MSCC and clinicians to consider when making decisions around the management of MSCC. Fear of doing further damage by mobilising must be balanced against the possible consequences for quality of life and physical health of inappropriate prolonged bed rest. There exists insufficient evidence to support one management plan over another. In the absence of clear evidence, healthcare professionals and people with MSCC need to discuss the options and come to an agreed management plan. Development of an appropriate clinical trial is required.
Since the publication of the original version of this review, we have found no new studies, and therefore the conclusions remain unchanged. Currently there is a lack of quality evidence regarding the effectiveness of spinal bracing for patients with MSCC. Spinal bracing may improve comfort and quality of life for some patients, but we are unable to make broad recommendations for practice based on this review. Consideration should be given to developing a randomised controlled trial.
This review highlights a strong need for future research to provide healthcare professionals with useful guidelines to inform clinical decision making and guidelines.
Research to examine this topic needs to be undertaken to inform future practice. The cost of such a trial would be low as the only intervention with an associated cost is the provision of an appropriate spinal brace for participants randomised to intervention. This is best addressed in the UK through NCRI Supportive and Palliative Care Clinical Studies Group by expanding the remit of the National Cancer Research Institute Brain CSG in collaboration with the Supportive & Palliative Care CSG.
Implications for research
Further research and exploration of best practice in MSCC on positioning, bracing, and spinal stability are required. There are sufficient cases to allow quick recruitment, but cases are spread across many primary cancer sites (lung, breast, colon, prostate, renal, colorectal, etc.). Protocols should most likely stratify by tumour type. There should be multidisciplinary involvement of orthotics, nursing, physiotherapy, and occupational therapy staff along with oncology and palliative care leads.
Randomised controlled trials to measure the efficacy of bracing would be possible.
Change in pain score, gait speed (timed 10‐metre walk), and Barthel Index of Activities of Daily Living, which covers continence and motor function, may be appropriate scales to use in a prospective study along with a patient‐reported quality‐of‐life measure. These measures could be performed at baseline and one month.
Most patients are in the oncology wards before and during treatment for MSCC. By one month, they may be home or still in a hospital for rehabilitation or palliative care. A health economic evaluation would be valuable as part of the trial. Furthermore, descriptive and qualitative studies would be beneficial to clarify mobilisation and positioning from a physician, nursing, and patient point of view.