Kyphosis: Causes, Consequences and Treatments Are we doomed to - - PowerPoint PPT Presentation

7/24/2014 1

Kyphosis: Causes, Consequences and Treatments

Are we doomed to stoop with aging?

Wendy Katzman, PT, DPTSc Associate Professor UCSF Department of Physical Therapy & Rehab Science

Disclosures

• None

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Roadmap

Age-related hyperkyphosis

Background and significance Causes, correlates, consequences Exercise and therapeutic interventions Recommendations for clinical practice and future research

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Background and Significance

• Life expectancy increasing
• Physical disability is not inevitable
• Identify new, potentially modifiable factors
• Develop targeted interventions to maximize

function and minimize disability

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

7/24/2014 2 Hyperkyphosis Definition

• Hyperkyphosis is an excessive

curvature in the thoracic spine

• Alters sagittal plane alignment
• Associated with faulty movement

patterns that increase flexion stress

• n the spine

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Epidemiology of Hyperkyphosis

• Kyphosis increases with age1,2,3,4,5
• Affects 20-40% of older adults7, 8, 9
• More common in older women7,8

1Ball, 2009; 2Ensrud, 1997; 3Ettinger, 1994; 4Kado, 2012; 5Fon, 1980, 6Voutsinas, 1986, 7Katzman, 2011; 8Schneider, 2004; 9Takahashi, 2005

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Measurement of Hyperkyphosis

Radiographic Flexible ruler Occiput-to-wall Cobb angle Block method Kyphometer

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Primary Correlates of Hyperkyphosis

• Vertebral fractures1,2
• Osteoporosis3, 4, 5
• Degenerative discs5
• Diffuse idiopathic skeletal hyperostosis (DISH)6
• Genetics7,8

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

1Ensrud, 1997; 2Kado, 1999,

2013; 3Fon, 1980;

4Ettinger, 1994; 5Schneider, 2004; 6Nardo, in review; 7Kado, 2005; 8Huang, 2006

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Hyperkyphosis Associated With Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Among 1172 men and

women mean age 74 years in the Health Aging and Body Composition Study

• DISH in the thoracic

spine is associated with greater Cobb angle of kyphosis

• 11 degrees (95% CI:7,15)

greater kyphosis in blacks

• 4 degrees (95% CI:1,6)

greater kyphosis in whites with DISH compared to no DISH.

Lateral scout CT images. At the middle and lower thoracic spine, abnormal confluent hyperostosis (arrow) is noted in the anterior longitudinal ligament (a); this finding is not present in lumbar segments of the spine (b). The intervertebral disc spaces are relatively maintained (double arrows) in both lumbar and thoracic spine.

(Nardo, et al., in review)

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Other Correlates of Hyperkyphosis

Fat accumulation in the spinal extensor muscles

L4 computed tomography image Cross-sectional study of predictors of hyperkyphosis in 1172 community-dwelling men and women 70-80 years old in the Health, Aging and Body Composition Study

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Katzman, et al., 2011

Other Correlates of Hyperkyphosis

Sinaki, 1996

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Other Correlates of Hyperkyphosis

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Reduced spinal, shoulder and hip mobility

• Older women less able to

stand erect and actively reduce their kyphosis.1

• Decreased functional axial

rotation occurs with age, reduces physical performance and is associated with greater kyphosis.2

• Hyperkyphosis is associated

with shorter pectoral and hip flexor muscles.3

1Hinman, 2004; 2Schenkman, 1996; 3Balzini, 2003

7/24/2014 4 Other Correlates of Hyperkyphosis

Cross-sectional comparison

• f thoracic kyphosis degree,

trunk muscle strength and trunk proprioception among 20 healthy and osteoporotic elderly women.

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Poor trunk proprioception

Granito, et al., 2012

Consequences of Hyperkyphosis

Impaired physical function,2,4,6,7,10,11,14 quality of life,12,16 and increased risk of early mortality6 –Slower gait speed, stair climbing, functional reach2,14,16 –May affect balance and risk for falls1,6,7,15 –Pulmonary, gastrointestinal and gynecologic dysfunction3,8, 9,10,11,13,14 –Fracture risk5,6

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

1Arnold, 2005; 2Balzini, 2003; 3Di

Bari, 2004;

4Hirose 2004; 5Huang, 2006; 6Kado, ‘99, ‘02,

‘04, ‘05, ‘07;

7Katzman, 2011; 8Kusano, 2008; 9Leech,1990; 10Lind, 1996; 11Lombardi 2004; 12Martin 2002; 13Mattox, 2000; 14Ryan 1997; 14Schlaich, 1998; 15Sinaki,1997; 16Takahashi 2005

Consequences of Hyperkyphosis

Increased risk for future fractures

• Prospective cohort studies
• 596 community-dwelling women 47–92 years

(Rancho Bernardo) over 4 years1

• Approximately 75% increased risk of fracture,

independent of age, baseline fracture, BMD

• 994 community-dwelling women aged 65 at

baseline (SOF) over 15 years2

• 31% increased risk of non-spine fracture (95%

CI, 1.1-1.6) after adjusting for BMD, prevalent vertebral fractures, prior history of fractures, and

• ther fracture risk factors

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

1Huang, et al., 2006; 2Kado, et al., 2013

Consequences of Hyperkyphosis

Hyperkyphosis increases risk of injurious falls.1

1.5 fold increased risk (95% CI:1.05,1.9) with ≥2 blocks versus ≤1 blocks (95% CI:1.1, 2.0)

Greater kyphosis predicts worsening performance times on the Timed Up and Go test, a strong indicator of increased fall risk.2 Balance impairments in women with kyphosis compared to healthy controls.3

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

1Kado, 2007; 2Katzman, 2011; 3Sinaki, 2005

7/24/2014 5 Consequences of Hyperkyphosis

Balance and falls conundrum:

Kyphosis condition improved balance tests, especially in backward movement. Trunk muscle strength and composition is associated with balance, functional performance, and falls in older adults. Decreased back extension strength/endurance and lumbar kyphosis (not thoracic)….. are related to postural instability and falls in elderly individuals.

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Choi, 2011; Granacher, 2013; Isahikawa, 2009, Kasakawa, 2010; Thomas, JC, 2014

Briggs, et al., 2007

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Spinal Load and Vertebral Fracture

• 51% body weight (BW) at L3 in standing
• 173% BW at L3 sit to stand
• 319% BW at L3 lifting 33# from floor

Bone fails sooner at the same load with low BMD Predicted load in lumbar spine varies with activity

Bouxsein, 2006; Myers, Wilson, Bouxsein, 1997

Consequences of Hyperkyphosis

Greater spinal load among high kyphosis group

• 44 subjects mean age 62 years dichotomized into high/low kyphosis
• Standing lateral radiographs captured and digitized
• Biomechanical models estimated multi-segmental load T2-L5

Briggs, et al., 2007 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

7/24/2014 6 Consequences of Hyperkyphosis

Kyphosis increases spinal load. Spinal load varies with sagittal plane alignment.

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Bruno, AG, et al., 2012

Safe Functional Motion (SFM) Test Predicts Incident Vertebral Compression Fracture

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

For every 10 point increase in SFM test, the odds of future vertebral fracture decreased 18% (n=878) at 1 year and 27% (n=503) at 3 years after adjusting for covariates.

Assesses movement strategies during ADLs; 60% includes spinal loading and balance domains; 40% upper and lower body strength and flexibility

• Sit to floor
• Climb-carry
• Night walk
• Sweep
• Washer/dryer load

MacIntyre, N, et al., 2014

Translation to activities of daily living

Compression loads on the L3 vertebrae increase with 30º of trunk flexion. – 2610 N with arms in front, holding 2 kg in each hand – 300 to 1200 N enough to fracture an osteoporotic vertebra

Practical Application - bend and lift in everyday life with the trunk in relative neutral!

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Schultz, 1982; Edmondston, 1997; adapted from Bookstein and Lindsey, “Osteoporosis – What You Should Know” powerpoint

Spinal Flexion and Vertebral Fracture

Sinaki & Mikkelsen, 1984

7/24/2014 7 Spinal Extensor Strengthening May Reduce Incident Vertebral Fractures

Prospective study 50 postmenopausal women1

– RCT spinal strengthening exercises 5x/wk for 2 years – Fewer fractures at 10-year follow-up in exercise group

Retrospective study 57 patients, adults 55 years and older with osteoporosis and vertebral compression fracture2

– Compared refracture rates and time before refracture after targeted exercise (ROPE)

• vs. vertebroplasty (PVP) vs.

combined ROPE and PVP – Lowest rate in non-surgical exercise ROPE group

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

1Sinaki, 2002; 2Huntoon, 2008

Current/Future Studies

Canadian Institutes of Health Research (CIHR), U of Waterloo: Pilot RCT to test the feasibility of a large multicenter study to evaluate whether tailored home exercise can prevent fractures (primary outcome) in high-risk individuals with vertebral fracture. National Institute of Aging (NIA): Study of hyperkyphosis, function and exercise (SHEAF) RCT of a 6-month multimodal exercise intervention (spine strength, functional mobility) to determine effects on kyphosis Office of Research on Women’s Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): Specialized Center of Research (SCOR) to investigate sex differences in musculoskeletal issues across the lifespan

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Spinal Extension and Functional Strengthening Exercises

“Too Fit to Fracture” Consensus

For individuals with osteoporosis Engage in multicomponent exercise program: Resistance and balance training postural muscles (spinal extensor muscles) functional movements (squats, sit to stand)

• Aerobic training

Proper posture during exercise, everyday activity For individuals with osteoporotic vertebral fx Consultation with a physical therapist to ensure safe and appropriate exercise

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Giangregorio, L, et al., 2014

7/24/2014 8 National Osteoporosis Foundation (NOF) Rehabilitation guide

• Based on the initial condition of the patient,

provide exercise recommendations that includes weight-bearing aerobic activities for the skeleton,

postural training, progressive resistance training

for muscle and bone strengthening, stretching for tight soft tissues and joints and balance training.

• Provide training for the performance of safe

movement and safe activities of daily living, including posture, transfers, lifting and

ambulation in populations with or at high risk for

• steoporosis.
• Advise patients to avoid forward bending and

exercising with trunk in flexion, especially in combination with twisting.

29

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

NOF Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010

Best Posture and Body Mechanics “Neutral Spine”

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Best Posture and Movement in ADLs

Photos: Do It Right, American Bone Health, Sherri Betz, PT,GCS UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Best Posture and Exercise

THESE:

neutral or extended spine

AVOID:

flexion, rounding, twisting

Photos: Do It Right, American Bone Health, Sherri Betz, PT, GCS UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

7/24/2014 9 Summary

• Age-related hyperkyphosis is easily

recognized yet rarely treated geriatric syndrome, common among older adults and associated with poor health outcomes.

• Hyperkyphosis and spinal flexion increase

spinal load that in turn increases risk for vertebral fractures.

• Recent consensus guidelines include training

in proper posture and safe movement.

• Best posture, safe body mechanics and

targeted back extension strengthening interventions may reduce kyphosis, spinal load and risk for fractures.

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Next steps

Screen patients and identify those with hyperkyphosis Best posture and body mechanics training to improve sagittal plane alignment Targeted spinal strengthening exercise to reduce excessive thoracic kyphosis Randomized controlled trials of exercise interventions with kyphosis and fracture

• utcomes

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

• Neutral spine
• Hip hinge
• Spine extension strengthening

UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Let’s practice!