Kyphosis: Causes, Consequences None and Treatments Wendy Katzman, - - PowerPoint PPT Presentation

▶
kyphosis causes consequences
SMART_READER_LITE
LIVE PREVIEW

Kyphosis: Causes, Consequences None and Treatments Wendy Katzman, - - PowerPoint PPT Presentation

Jan 18, 2024 118 likes •237 views

6/14/2013 Disclosures Kyphosis: Causes, Consequences None and Treatments Wendy Katzman, PT, DPTSc, OCS Department of Physical Therapy and Rehabilitation Science University of California San Francisco UCSF 10th Annual Osteoporosis: New

slide-1
SLIDE 1

6/14/2013 1

Kyphosis: Causes, Consequences and Treatments

Wendy Katzman, PT, DPTSc, OCS Department of Physical Therapy and Rehabilitation Science University of California San Francisco

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Disclosures

None

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Roadmap

Age-related hyperkyphosis Background and significance Causes and correlates Consequences

Exercise and therapeutic interventions

Recommendations for clinical practice

and future research

UCSF 10th 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

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-2
SLIDE 2

6/14/2013 2

Hyperkyphosis Definition

  • Hyperkyphosis is an excessive curvature

in the thoracic spine

  • Alters sagittal plane alignment

UCSF 10th 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 adults,7, 8, 9
  • More common in older women7,8

1Ball, 2009; 2Ensrud, 1997; 3Ettinger, 1994; 4Kado, 2012; 5Fon, 1980, 6Voutsinas,, 1986, 7Katzman, 2011; 8Schneider, 2004, 9 Takahashi, 2005 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Measurement of Sagittal Plane Alignment

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

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Roadmap

Age-related hyperkyphosis Background and significance Causes and correlates Consequences

Exercise and therapeutic interventions

Recommendations for clinical practice

and future research

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-3
SLIDE 3

6/14/2013 3

Primary Correlates of Hyperkyphosis

Vertebral fractures1,2

Osteoporosis3, 4, 5 Degenerative discs5 Family history6,7

  • 1Ensrud, 1997; 2Kado, 2013; 3Fon, 1980; 4Ettinger, 1994; 5Schneider, 2004;

6Kado, 2005; 7Huang, 2006 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Kado, 2012

43 45 47 49 51 53 55 57 59 61 2 4 6 8 10 12 14 16

Kyphosis Cobb Angle (degrees))

Time (years)

Kyphosis Progression in Older Women Over 15 Years (Kado, et.al, 2013)

Mean Trajectory With prevalent vertebral fracture Without prevalent vertebral fracture

7 degree increase in kyphosis over 15 years

Progression of Kyphosis

47 degrees versus 54 degrees

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Primary Correlates of Hyperkyphosis

Musculoskeletal changes

  • Spinal extensor muscle weakness6, 7, 8
  • Spinal extensor muscle attenuation8, 9
  • Postural stiffness10
  • Poor trunk position sense/proprioception11

6Sinaki, 1996; 7Mika,2005; 8Katzman, 2011; 9Katzman, 2012 (ASBMR); 10 Hinman, 2004; 11 Granito, 2012 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-4
SLIDE 4

6/14/2013 4 Primary Correlates of Hyperkyphosis

(Sinaki, 1996)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Primary Correlates of Hyperkyphosis

Fat accumulation in the paraspinal extensor muscles

Cross-sectional study of independent predictors of hyperkyphosis in 1172 community-dwelling men and women 70-80 years old in the Health, Aging and Body Composition Study (Katzman, 2011)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Primary Correlates of Hyperkyphosis

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Reduced spinal, shoulder and hip mobility

Older women are less able to stand

erect and actively reduce their kyphosis.1

Decreased functional axial rotation

  • ccurs with age, reduces physical

performance and is associated with greater degree of kyphosis.2

Flexed posture (hyperkyphosis)

associated with shorter pectoral and hip flexor muscles.3

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

Primary Correlates of Hyperkyphosis

Cross-sectional comparison

  • f thoracic kyphosis degree,

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

(Granito, 2012)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Greater kyphosis is associated with poor trunk proprioception.

slide-5
SLIDE 5

6/14/2013 5

Roadmap

Age-related hyperkyphosis Background and significance Causes and correlates Consequences

Exercise and therapeutic interventions

Recommendations for clinical practice

and future research

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Clinical 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

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

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Clinical Consequences of Hyperkyphosis

  • Increased risk for future fractures
  • Prospective cohort studies
  • 596 community-dwelling women 47–92 years

(Rancho Bernardo) over 4 years (Huang, et al., 2006)

  • Approximately 75% increased risk of fracture, independent of age,

baseline fracture, BMD

  • 994 community-dwelling women aged 65 at baseline

(SOF) over 15 years (Kado, et al., 2013)

  • 31% increased risk of non-spine fracture (95% CI, 1.09 -1.59) after

adjusting for BMD, prevalent vertebral fractures, prior history of fractures, and other fracture risk factors

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Clinical Consequences of Hyperkyphosis

  • Possible mechanisms for future fractures
  • falls
  • spinal loading
  • marker for frailty

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-6
SLIDE 6

6/14/2013 6

Clinical Consequences of Hyperkyphosis

Hyperkyphosis increases risk of injurious falls.

1.4 fold increased risk (95% CI:1.05,1.91) that increased to 1.5

using a cutoff of ≥2 blocks versus ≤1 blocks (95% CI:1.10, 2.00) (Kado, 2007)

Greater kyphosis predicts worsening performance times on the Timed Up and Go test, a strong indicator of increased fall risk.(Katzman, 2011) Balance impairments in women with kyphosis compared to healthy controls.

(Sinaki, 2005)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Clinical Consequences of Hyperkyphosis

Balance and falls conundrum: Kyphosis condition improved balance tests, especially in backward movement.(Choi, 2011) Trunk muscle strength and composition is associated with balance, functional performance, and falls in older adults.(Granacher, 2013) Decreased back extension strength and lumbar kyphosis (not thoracic)….. are related to postural instability and falls in elderly individuals.

(Isahikawa, 2009,Kasakawa, 2010)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Clinical Consequences of Hyperkyphosis

Briggs, 2007

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

2

Spinal Flexion and Vertebral Fracture

Predicted load in lumbar spine varies (Bouxsein, 2006)

51% body weight standing 173% sit to stand 319% lifting 33# from floor

Bone fails sooner at the same load with low bone density.

(Myers, Wilson, Bouxsein, 1997)

UCSF/SFSU Graduate Program in Physical Therapy Spring Symposium 2013

Flexion increases spinal load during activities of daily living.

slide-7
SLIDE 7

6/14/2013 7

Scores on the Safe Functional Motion Test (SFM) Predict Incident Vertebral Compression Fracture

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

For every 10 point increase in SFM test, the odds of future VCF decreased at 1 year by 18% (n=878) and 3 years by 27% (n=503) after adjusting for covariates.(MacIntyre, N, et. al , Submitted for publication) Task specific scoring for domains of spine-loading, balance, upper- and lower body strength and flexibility

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

Clinical 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 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Compressive force Shear force

Clinical Consequences of Hyperkyphosis

Kyphosis increases spinal load during activities of daily living. Spinal load varies with thoracic kyphosis and sagittal plane alignment.(Bruno, AG, et al., 2012)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

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 (Schultz, 1982)

300 to 1200 N enough to fracture an

  • steoporotic vertebra (Edmondston, 1997)

Practical Application - bend and lift in

everyday life with the trunk in relative neutral! (adapted from Bookstein and Lindsey,

“Osteoporosis – What You Should Know” powerpoint)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-8
SLIDE 8

6/14/2013 8

Roadmap

Age-related hyperkyphosis Background and significance Causes and correlates Consequences

Exercise and therapeutic interventions

Recommendations for clinical practice

and future research

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Medications and Surgical Procedures

No effect on kyphosis progression over 4 years in the

Fracture Intervention Trial study of the effects of alendronate on fracture reduction (Kado, DM, 2008)

Kyphosis progression reduced over 3 years in studies

  • f strontium ranelate versus placebo among post-

menopausal women with osteoporosis (Roux, C, 2010)

Reduction of radiographic Cobb angle after

vertebroplasty and balloon kyphoplasty for vertebral fracture (Theodorou DJ, 2002; Teng, 2003)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Exercise for Improving Age-Related Hyperkyphotic Posture: A Systematic Review

Bansal, et al., in review Author Population Intervention Results Abreu, et al., 2012 Elderly women with

  • steoporosis, N=20

Strengthening quads, triceps, paravertebral and abdominal muscles; 2x/week x 12 weeks No significant within or between group difference Bautmans et al., 2010 Post-menopausal women receiving 3- monthly IV pamidronate , N=48 Thoracic extension, stretching, erector spinae strengthening, manual mobilization and postural exercise; daily for 10 weeks Significant improvement within intervention group, p<0.01 Benedetti, MG, et al., 2008 Men and women 65 years and older with flexed posture, N=34 Active spinal extensor strengthening and postural alignment compared to non-specific physical; 2-3 times weekly for 3 months Significant improvement within intervention group occiput to wall, p=0.001 Bennell, K, et al., 2010 Men and women >50 years old with painful

  • steoporotic vertebral

fracture, N=19 Spinal mobilization, low intensity spinal strengthening, postural training compared to no treatment; once a week for 10 weeks No significant within or between group difference Greendale, G, et al., 2009 Men and women 65 years and older with kyphosis ≥ 40 degrees, N=118 Modified yoga compared to monthly luncheon; 3 times weekly for 24 weeks Significant between group difference in flexicurve index, p=0.004 and flexicurve angle, p=0.005; no significant between group difference in kyphometer, p=0.44 Itoi, E, et al.,1994 Post-menopausal women, 49-65 years

  • ld, N=60

Prone trunk extension compared to usual activity; 30% 1 repetition max for 10 repetitions; 5 times weekly for 2 years Significant within group difference among those with baseline kyphosis; >34 degrees; significant between group difference, p=0.016 Scheurman et al., 1998 Post-menopausal women with

  • steoporosis, N=60

Postural exercises (shoulder flexion, wall pushups, scapular adduction); daily for 12 weeks No significant within or between group differences

Spinal Flexion and Vertebral Fracture

Sinaki & Mikkelsen, 1984 Extension exercise Flexion exercise

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-9
SLIDE 9

6/14/2013 9

Spinal Extensor Strengthening May Reduce Incident Vertebral Fractures

Prospective study 50 postmenopausal women

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

(Sinaki, 2002)

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

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(Huntoon, 2008)

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Current/Future Studies

National Institute of Aging (NIA): RCT of a 6-month multimodal exercise intervention to determine the 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 to investigate sex differences in musculoskeletal issues across the lifespan – Kyphosis Project Canadian Institutes of Health Research (CIHR), U of Waterloo: Pilot RCT to test the feasibility of a large multicentre study to evaluate whether tailored home exercise can prevent fractures (primary outcome) in high-risk individuals. National Taiwan University Hospital – RCT to determine the effects

  • f core muscle training with EMG biofeedback on kyphosis.

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Roadmap

Age-related hyperkyphosis Background and significance Causes and correlates Consequences

Exercise and therapeutic interventions

Recommendations for clinical practice

and future research

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Best Posture and Body Mechanics

“Neutral Spine”

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

slide-10
SLIDE 10

6/14/2013 10 Best Posture and Movement in Daily Activity

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

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Best Posture and Lifting

Bend and lift with the spine in “neutral”

Bending and reaching with a round back increases spinal fracture risk if you have

Osteoporosis History of spinal fracture Hyperkyphosis

Hip hinge during all activity and movements

Neutral spine Increase extension in upper spine Strengthen spinal extensors and stabilizers

Hinge at the hip Avoid bending and twisting with a rounded spine

UCSF 10th 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 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Spinal Extension Strengthening Exercises

slide-11
SLIDE 11

6/14/2013 11

Summary

Age-related hyperkyphosis is easily recognized yet rarely

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

Few well-controlled, high quality randomized controlled trials

have investigated the effects of exercise on kyphosis.

Results from several trials suggest that back extensor

strengthening may be effective in improving kyphosis.

Hyperkyphosis and spinal flexion increase spinal load that in

turn increases risk for vertebral fractures.

Best posture, neutral body mechanics and targeted back

extension strengthening interventions may reduce spinal load and risk for fractures.

UCSF 10th 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 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Let’s practice!

  • Neutral spine
  • Hip hinge
  • Alphabets

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care