7/24/2014 Disclosures • None 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 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Background and Significance Roadmap • Life expectancy increasing � Age-related hyperkyphosis • Physical disability is not inevitable � Background and significance • Identify new, potentially modifiable factors � Causes, correlates, consequences • Develop targeted interventions to maximize � Exercise and therapeutic interventions function and minimize disability � Recommendations for clinical practice and future research UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 1
7/24/2014 Hyperkyphosis Definition Epidemiology of Hyperkyphosis • Hyperkyphosis is an excessive • Kyphosis increases with age 1,2,3,4,5 curvature in the thoracic spine • Affects 20-40% of older adults 7, 8, 9 • Alters sagittal plane alignment • Associated with faulty movement • More common in older women 7,8 patterns that increase flexion stress on the spine 1 Ball, 2009; 2 Ensrud, 1997; 3 Ettinger, 1994; 4 Kado, 2012; 5 Fon, 1980, 6 Voutsinas, 1986, 7 Katzman, 2011; 8 Schneider, 2004; 9 Takahashi, 2005 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Measurement of Hyperkyphosis Primary Correlates of Hyperkyphosis Radiographic Flexible ruler Occiput-to-wall • Vertebral fractures 1,2 Cobb angle • Osteoporosis 3, 4, 5 • Degenerative discs 5 • Diffuse idiopathic skeletal hyperostosis (DISH) 6 • Genetics 7,8 Kyphometer Block method 1 Ensrud, 1997; 2 Kado, 1999, 2013; 3 Fon, 1980; 4 Ettinger, 1994; 5 Schneider, 2004; 6 Nardo, in review; 7 Kado, 2005; 8 Huang, 2006 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 2
7/24/2014 Hyperkyphosis Associated With Diffuse Other Correlates of Hyperkyphosis Idiopathic Skeletal Hyperostosis (DISH) Fat accumulation in the spinal extensor muscles • 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 Lateral scout CT images. At the middle and lower thoracic spine, abnormal confluent • 11 degrees (95% CI:7,15) hyperostosis (arrow) is noted in the anterior greater kyphosis in blacks longitudinal ligament (a); this finding is not present in lumbar segments of the spine L4 computed tomography image • 4 degrees (95% CI:1,6) (b). The intervertebral disc spaces are greater kyphosis in whites Cross-sectional study of predictors of hyperkyphosis in 1172 relatively maintained (double arrows) in with DISH compared to no community-dwelling men and women 70-80 years old in the both lumbar and thoracic spine. (Nardo, et al., DISH. Health, Aging and Body Composition Study in review) Katzman, et al., UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 2011 Other Correlates of Hyperkyphosis Other Correlates of Hyperkyphosis 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 1 Hinman, 2004; 2 Schenkman, 1996; UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 3 Balzini, 2003 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Sinaki, 1996 3
7/24/2014 Consequences of Hyperkyphosis Other Correlates of Hyperkyphosis Impaired physical function, 2,4,6,7,10,11,14 quality of Poor trunk proprioception life, 12,16 and increased risk of early mortality 6 Cross-sectional comparison 1 Arnold, 2005; –Slower gait speed, stair climbing, functional 2 Balzini, 2003; 3 Di of thoracic kyphosis degree, Bari, 2004; reach 2,14,16 trunk muscle strength and 4 Hirose 2004; 5 Huang, 2006; trunk proprioception among 6 Kado, ‘99, ‘02, –May affect balance and risk for falls 1,6,7,15 20 healthy and osteoporotic ‘04, ‘05, ‘07; 7 Katzman, 2011; elderly women. –Pulmonary, gastrointestinal and gynecologic 8 Kusano, 2008; 9 Leech,1990; dysfunction 3,8, 9,10,11,13,14 10 Lind, 1996; 11 Lombardi 2004; –Fracture risk 5,6 12 Martin 2002; 13 Mattox, 2000; 14 Ryan 1997; 14 Schlaich, 1998; 15 Sinaki,1997; Granito, et al., 2012 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 16 Takahashi 2005 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Consequences of Hyperkyphosis Consequences of Hyperkyphosis Increased risk for future fractures � Hyperkyphosis increases risk of injurious falls . 1 •Prospective cohort studies � 1.5 fold increased risk (95% CI:1.05,1.9) with ≥ 2 blocks versus ≤ 1 blocks (95% CI:1.1, 2.0) • 596 community-dwelling women 47–92 years (Rancho Bernardo) over 4 years 1 � Greater kyphosis predicts worsening performance times on the Timed Up and Go • Approximately 75% increased risk of fracture, test, a strong indicator of increased fall risk. 2 independent of age, baseline fracture, BMD • 994 community-dwelling women aged 65 at � Balance impairments in women with baseline (SOF) over 15 years 2 kyphosis compared to healthy controls. 3 • 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 other fracture risk factors 1 Kado, 2007; 2 Katzman, 2011; 1 Huang, et al., 2006; 3 Sinaki, 2005 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 2 Kado, et al., 2013 4
7/24/2014 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. Choi, 2011; Granacher, 2013; Isahikawa, 2009, Kasakawa, 2010; Briggs, et al., Thomas, JC, 2014 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 2007 Consequences of Hyperkyphosis Spinal Load and Vertebral Fracture Greater spinal load among high kyphosis group Predicted load in lumbar spine varies with activity • 44 subjects mean age 62 years dichotomized into high/low kyphosis • Standing lateral radiographs captured and digitized • 51% body weight (BW) at L3 in standing • Biomechanical models estimated multi-segmental load T2-L5 • 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 Bouxsein, 2006; Myers, Wilson, Briggs, et al., 2007 UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Bouxsein, 1997 5
7/24/2014 Safe Functional Motion (SFM) Test Predicts Consequences of Hyperkyphosis Incident Vertebral Compression Fracture Kyphosis increases spinal load. Spinal load Assesses movement strategies varies with sagittal plane alignment . 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 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. MacIntyre, N, et Bruno, AG, et al., UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care al., 2014 2012 Translation to activities of daily living Spinal Flexion and Vertebral Fracture � 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! Schultz, 1982; Edmondston, 1997; adapted “ Osteoporosis – from Bookstein and Lindsey, Sinaki & What You Should UCSF 11th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Know” powerpoint Mikkelsen, 1984 6
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