Disclosures Age-related Hyperkyphosis: Stand Tall license and - - PDF document

7/6/2016 1

Age-related Hyperkyphosis:

Are we destined to stoop with aging?

Wendy Katzman, PT, DPTSc, OCS Associate Professor Department of Physical Therapy & Rehabilitation Science University of California San Francisco UCSF 13th Annual Osteoporosis Update – 7/21/16

Disclosures

Stand Tall™ license and exercise DVD Grant/Research Support: K12 UCSF/NIH BIRCWH RO1 NIH - National Institute of Aging P50 NIH - Office of Research in Women’s Health National Institute of Musculoskeletal and Arthritis and Skin Diseases

Roadmap

• Causes and consequences of age-related

hyperkyphosis

• Hyperkyphosis, spinal load and fractures
• Research in exercise for hyperkyphosis
• Clinical recognition and treatment of hyperkyphosis

Background and Significance

• Age-related thoracic hyperkyphosis is common,

affects up to 40% older adults, and is associated with adverse health outcomes.

• Identifying and treating hyperkyphosis may improve

health status.

Kado, et al., J Amer Geriatr Soc, 2004; Takahashi, et al., Osteoporos Int, 2005; Crimmins & Beltrán-Sánchez, J Gerontol Soc Sci, 2010

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Cobb Angle of Kyphosis

Kyphosis is a normal sagittal plane convexity of the thoracic spine. Cobb angle greater than 40°-- the 95th percentile of normal for young adults -- is commonly defined as hyperkyphosis.

Thoracic Kyphosis Progresses With Age

• Birth to 30 years kyphosis is 20°to 30°
• Progresses after age 40
• more rapidly in women
• 5°per decade after age 50

Fon, et al., Am J Roentgenol, 1980; Ensrud, et al., JAGS, 1997; Kado, et al., J Bone Min Res, 2013; Ball, et al., Osteoporos Int, 2009

Hyperkyphosis, Sagittal Plane Alignment, and Flexed Posture Measurement of Thoracic Kyphosis

Radiographic Flexible ruler Occiput-to-wall Kyphometer Block method

Other tools…

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Prevalence of Cobb Angle Hyperkyphosis

20-40% prevalence in older adults, varies by:

• Age
• Race
• Sex
• Measurement tool
• Position

Takahashi, et al., Osteoporos Int, 2005; Katzman, et al., J Gerontol Med Sci, 2011; Schneider, et al., J Rheumatol, 2004; Kado, et al., J Gerontol Med Sci, 2005; Kado, et al., Spine, 2006

Vertebral Fractures, Osteoporosis and Kyphosis are Linked But Not Synonymous

• Older women with higher Cobb angles more likely to

have osteoporosis and vertebral fractures (SOF, FIT)

• However, 2/3 of men and women with most severe

kyphosis had no evidence of underlying osteoporosis

• r vertebral fractures (Rancho Bernardo)
• Degenerative disc disease, not vertebral fractures, was

the most common finding associated with kyphosis

Ettinger, et al., Osteoporos Int, 1994; Ensrud, et al., J Amer Geriatr Soc, 1997; 1997Schneider, et al., J Rheumatol, 2004

Vertebral Fractures, Osteoporosis and Kyphosis are Linked But Not Synonymous

• Vertebral fractures (FIT, SOF)
• Low bone mineral density (FIT)
• Degenerative disc disease (Rancho Bernardo, SOF)
• Diffuse idiopathic skeletal hyperostosis (Health ABC)
• Poor paraspinal extensor muscle strength (Sinaki) and

quality (Health ABC)

Schneider, et al., J Rheumatol, 2004; Nardo, et al., Spine, 2014, Sinaki, et al., Am J Phys Med Rehabil, 1996, Katzman, et al., J Gerontol Med Sci, 2011

Hyperkyphosis: Impaired Neuromuscular Impairments

Poor spinal extensor muscle strength and quality Loss of flexibility:

• spinal extension
• functional axial rotation
• shoulders, hips
• hamstrings

Flexed posture

• sway-back posture

Poor trunk proprioception

Hinman, et al. Spine J, 2004; Schenkman, et al. Phys Ther, 1996; Balzini, et al. J Am Geriatr Soc 2003; Kendall, et al. 2005; Sahrmann, 2002; Granito, et al., Arch Gerontol Geriatr, 2012

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Sex Differences in Phenotypes of Kyphosis

• Women

– low bone mineral and muscle density – vertebral fractures – paraspinal muscle weakness

• Men

– degenerative disc disease – diffuse idiopathic skeletal hyperostosis (DISH) – Scheurmann’s kyphosis

Ensrud, et al., JAGS, 1997; Ettinger, et al., Osteopros Int, 1994; Kado, et al., JBMR, 2014; Schneider, et al., J Rheumatol, 2004; Kado, et al., J Gerontol Med Sci, 2005; Katzman, W, et al. J Gerontol Med Sci 2011; Nardo, et al., Spine, 2014

Hyperkyphosis: Functional Impairments

• Gait speed
• Timed Up and Go
• Chair stand
• Balance
• Stair climbing
• Functional reach
• Vital capacity

Katzman, et al., 2011, 2014; Hirose, et al., Clin Biomech, 2004; Balzini, et al., J Am Geriatr Soc. 2003; Kado, et al., J Gerontol Med Sci, 2005; Lombardi, et al., Osteo Int, 2004; Kado, et al.,2005

Hyperkyphosis: Reduced Quality of Life

• Physical difficulty, more adaptations
• Greater generalized fears
• Less satisfaction with subjective health, family

relationships and their lives in general

• Qualitative decrease in self-confidence
• Body image/appearance
• Sleep

Sangtarash F, et al., Osteoporos, Int, 2015; Martin, et al., Bone, 2002; Takahashi, et al., Osteoporos Int, 2005; Kado, et al., 2015

Hyperkyphosis: A Risk Factor for Fracture

Huang, et al., J Bone Min Res, 2006 ; Kado, et al., J Bone Min Res, 2014

All Fracture Risk

• Community-dwelling women 47–92 years,

N= 596 (Rancho Bernardo), prospectively over 4 years

• 75% increased all fracture risk

Non-spine Fracture Risk

• Community-dwelling women aged 65 at baseline,

N= 994 (SOF), prospectively over 15 years,

• 31% increased non-spine fracture risk (hip, pelvis,

extremities)

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Hyperkyphosis: A Risk Factor for Falls

• Increased risk of injurious falls retrospectively
• 1.5 fold increased risk (95% CI: 1.1, 2.0) (Rancho

Bernardo)

• Increased risk of incident falls prospectively
• 2 fold increased odds (95% CI: 1.1,4.5) (Out-patient

geriatric clinic)

• Controversy re: kyphosis, balance and falls
• Spinal extensor muscle weakness?

Van der Jagt-Willems, et al., BMC Geriatrics, 2015; Kado, et al., J Gerontol Med Sci, 2007; Granacher, et al., Sports Med, 2013

Mechanisms

• Falls?
• Other factors?

Hyperkyphosis, spinal load and fractures

Hyperkyphosis: Increases Spinal Load in Standing

• 44 subjects mean 62 years with standing lateral spine

radiographs dichotomized high/low thoracic kyphosis

Briggs, et al., Phys Ther, 2007

Compression Forces Shear Forces

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Hyperkyphosis: Increases Spinal Load in Flexed Posture

Bruno, et al., J Bone Min Res, 2012

• Load increased with kyphosis and holding 5 kg
• Loads mitigated in compensated and congruent posture

Mechanical model of relaxed standing and standing with 5 kg weight in each hand to estimate spinal load

• Predicted compressive forces in the spine T6

through L5 with functional tasks

• Five conditions: standing, standing with 10 kg (5 kg
• n each arm), lifting 10 kg with elbows bent, 30°

trunk flexion with 10 kg, and 15° of extension

Forces on Vertebral Bodies Depend Upon Load and Position

Iyer, et al., Clin Biomech, 2010

Forces on Vertebral Bodies Depend Upon Load and Position

Iyer, et al., Clin Biomech, 2010 Flexion, 30 deg, 10kg Elbows bent, 10kg Extension, 15deg Standing, 10kg Standing

Flexion Moment, Compression and Shear After Vertebral Fracture

• Flexion moment, compression and shear forces are

higher in the spine after vertebral fracture

• Level above, fractured level, level below

Briggs, A, et al., Euro Spine, 2006

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Good Movement Strategies Reduce Risk of Vertebral Fracture

Safe Functional Motion (SFM) test assesses body mechanics during activities of daily living (ADLs) in adults 50 years and older with osteoporosis, N=878.

• Scoring assesses spinal loading, balance, strength and flexibility

during ADLs

• ADLs: Sit-floor, climb-carry, sweep, load washer/dryer, night walk
• Results: Better SFM score associated with fewer prevalent and

incident vertebral fracture (VF)

• 18% - 27% lower odds of VF at 1 and 3 years respectively

MacIntyre, N, et al., Osteoporos Int, 2014; Macintyre, et al., Physiotherapy Canada, 2013

Summary of Evidence

• Hyperkyphosis is a risk factor for adverse health
• utcomes
• Clinically useful marker for possible prevalent vertebral

fracture (VF)

• May not have prior clinical or radiographic VF
• Increases risk for fractures
• Increases risk for falls
• Increases spinal load
• Best posture and movement during everyday activity

reduces risk for vertebral fracture

Research in exercise for hyperkyphosis

Change in Flexed Posture, Musculoskeletal Impairments and Physical Performance After Exercise

Katzman, et al., Arch Phys Med & Rehabil, 2007

• Uncontrolled trial; 21 women

72 ± 4.3 years with kyphosis >50°

• High intensity spinal muscle

strengthening, stretching and postural training for 3 months

• Results:
• Kyphosis improved 6° (11%)
• Spinal extensor strength gain (53%)
• Physical performance test improved (7%)

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Study of Hyperkyphosis, Function and Exercise (SHEAF)

• Randomized controlled trial among 100

community-dwelling men and women aged 60 or

• lder with kyphosis ≥40° to determine the effects
• f a multi-modal spine strengthening exercise

program on Cobb angle of kyphosis compared to attentional control

• Secondary measures of clinical kyphosis,

physical function and health-related quality of life

• Funded by the National Institute of Aging
• UCSF and Kaiser

SHEAF Intervention Framework

Intervention group

• Multi-modal group-based kyphosis-specific exercises

taught by physical therapist

• 1-hour class, 3x/week for 6-months

Targets

• Spinal strengthening
• Spinal alignment
• Spinal mobility
• Diaphragmatic breathing
• Postural correction

Increase challenge to neuromuscular system, progress strengthening exercises to high intensity

Katzman, et al., Physical Therapy, 2016

SHEAF Preliminary Results

• N=99, mean age 71 ± 0.6 years with baseline Cobb angle of

kyphosis 57 ± 12.5 degrees.

• ‐3.3 ± 4.9 degrees within‐group change over 6 months in

the active group and ‐0.4 ± 5.3 degrees in the control

• group. There is a significant ‐2.9 (95% CI: 5.2, ‐0.7)

difference in change between groups, p=0.01.

• A targeted multi‐modal spine strengthening exercise

program reduced Cobb angle of kyphosis and prevented kyphosis progression compared to the control.

• Unpublished data

Clinical recognition and treatment of hyperkyphosis

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Next Week In Clinic

• Observe patient and identify excessive kyphosis
• Observe posture during movement (walk, remove

shoes, get out of chair)

• Ask about back pain, falls in the past year
• Note changes in height
• Note fracture history and risk factors for fracture
• Assess musculoskeletal impairments of posture,

spinal strength, endurance, mobility, balance, body mechanics

• Develop appropriate plan of care

Clinical Recommendations

• For individuals with hyperkyphosis
• Postural alignment and kyphosis assessment: flexible

ruler, occiput to wall, block method

• Body mechanics during ADLs and exercise
• Spinal muscle strength, endurance and flexibility
• Fall risk: balance, home safety

Clinical Recommendations

• For individuals with hyperkyphosis
• Best posture during ADLs and exercise
• Advice about risks of spinal flexion (slouched posture

and forward bending)

• Spinal extension strengthening

Clinical Recommendations

• For patients with hyperkyphosis, osteoporosis and prior

vertebral fracture, an individualized plan of care

• Interventions to minimize spinal loads immediately after

vertebral fracture to reduce risk of further fractures

• Instruction in best posture during exercise and ADLs
• Multicomponent exercise program including spinal

extensor strengthening exercise, flexibility in spine and extremities to increase extension

• Balance training

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Training for Best Posture

Align:

• Back of head
• Shoulder blades
• Rib cage
• Buttocks/sacrum
• Feet

Practice best posture throughout the day

Best Posture and Exercise

THESE:

neutral or extended spine

AVOID:

flexion, rounding, twisting

Photos: Do It Right, American Bone Health, Sherri Betz, PT, GCS

Best Posture and Movement in ADLs

Photos: Do It Right, American Bone Health, Sherri Betz, PT,GCS

Stability with Mobility

• Alignment points remain constant during movement
• Torso muscles work hard to stabilize
• Torso is “silent but strong” during functional movements

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Spinal Extension Muscle Strengthening

More demanding positions More complex moves Improve strength & endurance

• Add therabands or weights
• Increase duration or repetitions

Spinal Extensor Muscle Strengthening Spinal Extensor Muscle Strengthening

Shoulder press: an example of an exercise for training spinal extensor endurance

Shoulder, Hip and Spine Flexibility

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• Age-related hyperkyphosis is common, easily

recognized geriatric syndrome

• Hyperkyphosis is associated with poor health
• utcomes
• Hyperkyphosis may indicate underlying vertebral

fracture and increases risk for vertebral fracture

Summary

• Flexion of the spine increases risk of incident

vertebral fractures, if prior fracture and/or low bone mass, irrespective of the degree of kyphosis.

• Best posture and movement during exercise and

everyday activity is recommended for those with hyperkyphosis, osteoporosis and prior vertebral fracture.

• Spinal extensor muscle strengthening improves

hyperkyphosis and prevents progression over time.

Summary

Resources

• National Osteoporosis Foundation

– www.nof.org – Health professionals guide to rehabilitation of the patient with

• steoporosis
• American Bone Health
• https://americanbonehealth.org/what-you-should-

know/exercise

• American Physical Therapy Association

– Stand Tall™ exercise video – Measurement of kyphosis video – www.geriatricspt.org/store/

• UCSF Health and Wellness

– Stand Tall™ revised exercise video – wellness@ptrehab.ucsf.edu (email) – http://ptrehab.ucsf.edu/stand-tall (website link)

Questions?