An interview with OSNC's Dr. Mark Galland in PainPathways, a quarterly pain management magazine

Next to aspirin, braces may be one of the simplest solutions in all of pain management medicine.

Carl Macchia, CO (certified orthotist) at brace manufacturer VQ OrthoCare in Irvine, California, easily reels off a few of the benefits of braces. "They are non-pharmaceutical, non-invasive, economical and extremely effective," he says. "The cost of pain medication itself and the associated costs of its side effects are staggering."

Doctors may prescribe braces for both acute and chronic pain. "Braces provide stability to a swollen, unstable or painful joint," says Dr. Mark Galland, an orthopedic surgeon in the Triangle region of North Carolina who regularly prescribes braces for his patients. "No matter what joint you're bracing, braces can decrease pain, diminish swelling and—in some cases—improve function."

They may be recommended for conditions that range from osteoarthritis (OA) to fractures to sprains. "Any acute injury that results in pain from movement could be treated with a brace," says Dr. Galland.

So, how effective is this workhorse of the health care field? That depends.

One part of the plan

Dr. Galland says, "In some cases, bracing will completely alleviate pain, but it's very individualized. Patients could experience anything from complete relief to nil, to something intermediate. You could call it ‘dealer's choice' because the results can vary so widely. But, there are some patients who think of bracing as almost a miracle."

Dr. Galland refers to bracing as an "adjunctive therapy," meaning he uses braces in conjunction with other treatments, which might include massage therapy, topical ointments and oral pain medications. While bracing is just one of the treatments he recommends, he says, "If you're not considering bracing for pain, then you're not using all the tools at your disposal."

But again, braces are just one tool in the toolbox. Other tools might be administered by massage therapists, physical therapists and chiropractors, since Dr. Galland likes to take a team approach with his patients.

And just as there may be a variety of professionals involved in treating patients, there may also be a variety of treatments. Each one has its place, says Dr. Galland. "No one modality is likely to do everything," he says. "Each modality does its part. For example, maybe taking ibuprofen every day gets you 10 percent better. And then, physical therapy might get you another 20 percent better. A brace can play a role in the process by getting you another certain percentage better. So, why not use everything you have?"

While easy and cost-effective, braces are generally not the first solution a physician reaches for, according to Macchia. "At the first signs of pain, NSAIDs [nonsteroidal anti-inflammatory drugs] or injections may be the approach," he says. "The pain has usually progressed a bit before someone is willing to use a brace." His advice regarding braces is "the earlier, the better," in order to preserve the joint.

Consider your knee

Talking specifically about OA knee pain, Macchia says, "[It] … is degenerative in a compounded sort of way. First there is pain upon walking, so the patient walks less, and gains weight due to their more sedentary tendencies. There can also be disuse muscle atrophy, which … adds to the downward spiral."

For OA patients, surgery may be necessary, but it is often the last resort. Macchia advises, "There are considerations relative to whether patients are surgical candidates. They could be too old or too young. A knee replacement has a life expectancy, and it's best to [surgically replace a knee only] once."

Know when to say when

If you suffer from OA and the pain related to it, how do you know when the time is right for a brace? "It's preferable to catch a patient when their condition is in the early stages so the brace can reduce knee wear and tear to a degree," says Macchia. "Even in the mid-to latter stages, knee replacement surgery is the last option, so trying a brace is a great solution."

"OA braces are generally used when the arthritic changes to the knee joint have progressed to the point where there is pain upon ambulation," says Macchia. "Typically, the cartilage that cushions the knee deteriorates, and that lack of cushion—combined with high pressures inside the joint [while in motion]—can create substantial pain. Some patients may even be fully bone on bone in a joint where there should be cartilage to cushion things."

Ted Ortiz of Pomona, California, didn't waste much time in getting to a doctor when he experienced pain in his knee. About three years ago the veteran of 18 marathons was hunting with his son when he experienced severe pain in his knee. He endured the pain for about three months before going to a sports medicine doctor.

"I asked for a brace early on," he says. "I was diagnosed with arthritis and referred to a physical therapist. That helped, but it didn't take the pain away. And I wanted to keep moving."

Moving is what Ortiz does. He runs, hunts, cycles, camps and fishes. He did not intend to let arthritis slow him down. The brace allows him to participate in all the physical activities he loves.

"I don't use the brace every day," he says. "But, when I feel a pain coming on, I reach for it. For me, it's sufficient. I don't need any pain medication. The brace works for me."

Ortiz no longer runs marathons, but he can and does "bike marathons" and still jogs several times a week.

Bottom line: See your doctor. He or she can help determine if the timing is right to try a brace, along with other pain management therapies.

A permanent fix?

The length of time a patient needs to wear a brace varies depending on the joint being braced, the medical need for bracing and the patient's overall health. For an acute injury, the patient will wear the brace for only a prescribed amount of time.

Someone who suffers from OA may need to wear the brace for a lifetime—or until surgery is warranted. But, Dr. Galland says, "People shouldn't think of this as a life sentence. It's really a ‘get out of jail free' card. The brace is allowing you to enjoy a normal life."

For OA sufferers, Macchia says, "Studies have shown that between 40 and 60 percent of patients were still using OA braces after approximately three years, so long-term usage can be quite good. On a daily basis, patients may wear their brace at all times when they are walking or active, but some opt to use it only when they expect to be involved in a higher-than-normal amount of walking or activity for a period." As an example, he says many patients will deal with their pain on a typical day but use a brace to play golf or go for a walk.

"These braces work incredibly well and can immediately reduce pain, even in severe cases," says Macchia. "For many people, they are life changing."

How it works

In addition to pain, some OA patients experience deterioration of the cartilage on either the inside or the outside of the affected knee. The right kind of brace will treat both conditions.

Besides the most obvious benefit of an OA brace—pain reduction—there are other benefits, as well. A brace can slow the deterioration of the cartilage that cushions the knee joint and reduce the load the joint experiences during the weight-bearing phase of walking.

The knee basically acts as a hinge that can also rotate, to a degree. The knee joint is divided into two "compartments"—medial (inside) and lateral (outside). An average person's weight is somewhat evenly distributed across both compartments, with the medial side taking on a bigger load during the gait cycle. When the axis angle is out of balance, the load bearing is uneven. The side that bears the heaviest load will wear out faster. OA patients generally have either medial or lateral compartment disease. A brace applies a gentle force that reduces the load on the affected compartment.

Easing into it

Dr. Galland says it can be a challenge to get patients used to just the idea of a brace—and then getting used to the brace itself is another challenge. Patient concerns about braces include comfort, limitation of motion, weight and bulkiness, according to Dr. Galland. Even satisfied patients will often tell him it took them a while to adjust to wearing it.

"I'll have patients go through a transition period and work their way into regular usage," he says. "They might wear it for an hour and then have it off for four, for example, until they get comfortable with it."

Braces can be worn either under or over clothes. When a patient opts to wear it under clothes, as most do, no one can even tell a brace is there. "A friend or family member may notice you seem to walking with less pain than before, but that's the only way they will know you're wearing a brace," he says.

A worry about cost should not keep anyone from at least investigating the option of bracing. Macchia says, "Knee bracing is pretty well covered by most insurance, but there's a wide range in the reimbursements from different insurance payers."

While a brace is an easy, affordable approach to managing joint pain, it is not a cure-all. Macchia says, "A brace does not help healing, since nothing replaces cartilage lost. But, it can slow progression of OA to hold off more invasive procedures."

Even a surgeon advises delaying surgery for as long as possible. Dr. Galland says, "As long as the brace is keeping you off the operating table, it's doing its job."

A brace doing its job means someone with joint pain can keep doing whatever it is he loves to do. Wearing a brace doesn't cramp Ted Ortiz's style. In fact, having worn a brace on and off for the past three years, Ortiz says, "When I got my knee back, I got my life back."

• www.arthritis.org
• www.vqorthocare.com/OActive-BioniCare.html
• www.cureathritis.org

Originally Published: Summer 2009, PainPathways.org.