7/6/2016 Disclosures Age-related Hyperkyphosis: Stand Tall ™ license and exercise DVD Are we destined to stoop with aging? 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 Wendy Katzman, PT, DPTSc, OCS Associate Professor Department of Physical Therapy & Rehabilitation Science University of California San Francisco UCSF 13 th Annual Osteoporosis Update – 7/21/16 Background and Significance Roadmap • Age-related thoracic hyperkyphosis is common, • Causes and consequences of age-related affects up to 40% older adults, and is associated with hyperkyphosis adverse health outcomes. • Hyperkyphosis, spinal load and fractures • Research in exercise for hyperkyphosis • Identifying and treating hyperkyphosis may improve health status. • Clinical recognition and treatment of hyperkyphosis Kado, et al., J Amer Geriatr Soc, 2004; Takahashi, et al., Osteoporos Int, 2005; Crimmins & Beltrán-Sánchez, J Gerontol Soc Sci, 2010 1
7/6/2016 Cobb Angle of Kyphosis Thoracic Kyphosis Progresses With Age Kyphosis is a normal sagittal plane • Birth to 30 years kyphosis is 20 ° to 30 ° convexity of the thoracic spine. • Progresses after age 40 • more rapidly in women Cobb angle greater than 40 ° -- the • 5 ° per decade after age 50 95th percentile of normal for young adults -- is commonly defined as hyperkyphosis. 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 Measurement of Thoracic Kyphosis Flexed Posture Radiographic Flexible ruler Occiput-to-wall Kyphometer Block method Other tools… 2
7/6/2016 Vertebral Fractures, Osteoporosis and Prevalence of Cobb Angle Hyperkyphosis Kyphosis are Linked But Not Synonymous 20-40% prevalence in older adults, varies by: • Older women with higher Cobb angles more likely to • Age have osteoporosis and vertebral fractures (SOF, FIT) • Race • Sex • However, 2/3 of men and women with most severe • Measurement tool kyphosis had no evidence of underlying osteoporosis • Position or vertebral fractures (Rancho Bernardo) • Degenerative disc disease, not vertebral fractures, was the most common finding associated with kyphosis 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 Ettinger, et al., Osteoporos Int, 1994; Ensrud, et al., J Amer Geriatr Soc, Med Sci, 2005; Kado, et al., Spine, 2006 1997; 1997Schneider, et al., J Rheumatol, 2004 Vertebral Fractures, Osteoporosis and Hyperkyphosis: Impaired Neuromuscular Impairments Kyphosis are Linked But Not Synonymous Poor spinal extensor muscle strength and quality • Vertebral fractures (FIT, SOF) Loss of flexibility: • Low bone mineral density (FIT) • spinal extension • Degenerative disc disease (Rancho Bernardo, SOF) • functional axial rotation • Diffuse idiopathic skeletal hyperostosis (Health ABC) • shoulders, hips • hamstrings • Poor paraspinal extensor muscle strength (Sinaki) and quality (Health ABC) Flexed posture • sway-back posture Poor trunk proprioception Hinman, et al. Spine J, 2004; Schenkman, et al. Phys Ther, 1996; Balzini, et al. J Schneider, et al., J Rheumatol, 2004; Nardo, et al., Spine, 2014, Sinaki, et al., Am Geriatr Soc 2003; Kendall, et al. 2005; Sahrmann, 2002; Granito, et al., Am J Phys Med Rehabil, 1996, Katzman, et al., J Gerontol Med Sci, 2011 Arch Gerontol Geriatr, 2012 3
7/6/2016 Sex Differences in Phenotypes of Kyphosis Hyperkyphosis: Functional Impairments • Women • Gait speed – low bone mineral and muscle density • Timed Up and Go – vertebral fractures • Chair stand • Balance – paraspinal muscle weakness • Stair climbing • Functional reach • Men • Vital capacity – degenerative disc disease – diffuse idiopathic skeletal hyperostosis (DISH) – Scheurmann’s kyphosis 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., Ensrud, et al., JAGS, 1997; Ettinger, et al., Osteopros Int, 1994; Kado, et al., JBMR, 2014; Osteo Int, 2004; Kado, et al.,2005 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: A Risk Factor for Fracture Hyperkyphosis: Reduced Quality of Life All Fracture Risk • Physical difficulty, more adaptations • Community-dwelling women 47–92 years, • Greater generalized fears N= 596 (Rancho Bernardo), prospectively over 4 years • Less satisfaction with subjective health, family relationships and their lives in general • 75% increased all fracture risk • Qualitative decrease in self-confidence Non-spine Fracture Risk • Body image/appearance • Community-dwelling women aged 65 at baseline, • Sleep N= 994 (SOF), prospectively over 15 years, • 31% increased non-spine fracture risk (hip, pelvis, extremities) Sangtarash F, et al., Osteoporos, Int, 2015; Martin, et al., Bone, Huang, et al., J Bone Min Res, 2006 ; Kado, et al., J Bone Min Res, 2014 2002; Takahashi, et al., Osteoporos Int, 2005; Kado, et al., 2015 4
7/6/2016 Hyperkyphosis: A Risk Factor for Falls Mechanisms • Increased risk of injurious falls retrospectively • Falls? • 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? • Other factors? Van der Jagt-Willems, et al., BMC Geriatrics, 2015; Kado, et al., J Gerontol Med Sci, 2007; Granacher, et al., Sports Med, 2013 Hyperkyphosis: Increases Spinal Load in Standing Briggs, et al., Phys Ther, 2007 • 44 subjects mean 62 years with standing lateral spine Hyperkyphosis, spinal load and fractures radiographs dichotomized high/low thoracic kyphosis Compression Forces Shear Forces 5
7/6/2016 Hyperkyphosis: Increases Spinal Load in Forces on Vertebral Bodies Depend Upon Flexed Posture Load and Position Bruno, et al., J Bone Min Res, 2012 Iyer, et al., Clin Biomech, 2010 Mechanical model of relaxed standing and standing • Predicted compressive forces in the spine T6 with 5 kg weight in each hand to estimate spinal load through L5 with functional tasks Load increased with kyphosis and holding 5 kg • Five conditions: standing, standing with 10 kg (5 kg Loads mitigated in compensated and congruent posture on each arm), lifting 10 kg with elbows bent, 30° trunk flexion with 10 kg, and 15° of extension Forces on Vertebral Bodies Depend Upon Flexion Moment, Compression and Shear Load and Position After Vertebral Fracture Iyer, et al., Clin Biomech, 2010 • Flexion moment, compression and shear forces are higher in the spine after vertebral fracture Flexion, 30 deg, 10kg • Level above, fractured level, level below Elbows bent, 10kg Extension, 15deg Standing, 10kg Standing Briggs, A, et al., Euro Spine, 2006 6
7/6/2016 Good Movement Strategies Summary of Evidence Reduce Risk of Vertebral Fracture Safe Functional Motion (SFM) test assesses body • Hyperkyphosis is a risk factor for adverse health mechanics during activities of daily living (ADLs) in outcomes adults 50 years and older with osteoporosis, N=878. • Clinically useful marker for possible prevalent vertebral • Scoring assesses spinal loading, balance, strength and flexibility fracture (VF) during ADLs • May not have prior clinical or radiographic VF • ADLs: Sit-floor, climb-carry, sweep, load washer/dryer, night walk • Increases risk for fractures • Results: Better SFM score associated with fewer prevalent and incident vertebral fracture (VF) • Increases risk for falls • 18% - 27% lower odds of VF at 1 and 3 years respectively • Increases spinal load • Best posture and movement during everyday activity reduces risk for vertebral fracture MacIntyre, N, et al., Osteoporos Int, 2014; Macintyre, et al., Physiotherapy Canada, 2013 Change in Flexed Posture, Musculoskeletal Impairments and Physical Performance After Exercise Katzman, et al., Arch Phys Med & Rehabil, 2007 Research in exercise for hyperkyphosis • 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%) • 7
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