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 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 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 1 6/14/2013 Hyperkyphosis Definition • Hyperkyphosis is an excessive curvature in the thoracic spine • Alters sagittal plane alignment Epidemiology of Hyperkyphosis • Kyphosis increases with age 1,2,3,4,5 • Affects 20-40% of older adults ,7, 8, 9 • More common in older women 7,8 1Ball, 2009; 2Ensrud, 1997; 3Ettinger, 1994; 4Kado, 2012; 5Fon, 1980, 1986, 7Katzman, 2011; 8Schneider, 2004, 9 Takahashi, 2005 6Voutsinas,, UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 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 Roadmap Age-related hyperkyphosis Background and significance Causes and correlates Consequences Kyphometer Block method UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Exercise and therapeutic interventions Recommendations for clinical practice and future research UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 2 6/14/2013 Vertebral fractures1,2 Osteoporosis3, 4, 5 Degenerative discs5 Family history6,7 1Ensrud, 6Kado, 1997; 2Kado, 2013; 3Fon, 1980; 4Ettinger, 1994; 5Schneider, 2004; 2005; 7Huang, 2006 Kyphosis Cobb Angle (degrees)) Primary Correlates of Hyperkyphosis Kyphosis Progression in Older Women Over 15 Years (Kado, et.al, 2013) 61 59 With prevalent vertebral fracture 57 55 Mean Trajectory 53 7 degree increase in kyphosis over 15 years 51 49 Without prevalent vertebral fracture 47 45 43 0 2 4 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Progression of Kyphosis 47 degrees versus 54 degrees 6 8 10 12 Kado, 2012 16 14 Time (years) 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); 2004; 11 Granito, 2012 10 Hinman, UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 3 6/14/2013 Primary Correlates of Hyperkyphosis Primary Correlates of Hyperkyphosis Fat accumulation in the paraspinal extensor muscles (Sinaki, 1996) UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Primary Correlates of Hyperkyphosis Reduced spinal, shoulder and hip mobility Older women are 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 degree of kyphosis.2 Flexed posture (hyperkyphosis) associated with shorter pectoral and hip flexor muscles.3 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 Greater kyphosis is associated with poor trunk proprioception. Cross-sectional comparison of thoracic kyphosis degree, trunk muscle strength and trunk proprioception among 20 healthy and osteoporotic elderly women. (Granito, 2012) 1Hinman, 2004; 2Schenkman, 1996; 3Balzini, 2003 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 4 6/14/2013 Roadmap Age-related hyperkyphosis Background and significance Causes and correlates Consequences 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 Exercise and therapeutic interventions Recommendations for clinical practice and future research – 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) • 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 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 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 5 6/14/2013 Clinical Consequences of Hyperkyphosis Clinical Consequences of Hyperkyphosis Hyperkyphosis increases risk of injurious falls. Balance and falls conundrum: 1.4 fold increased risk (95% CI:1.05,1.91) that increased to 1.5 Kyphosis condition improved balance tests, especially in backward movement.(Choi, 2011) 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. 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) (Sinaki, 2005) UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Clinical Consequences of Hyperkyphosis UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Spinal Flexion and Vertebral Fracture Flexion increases spinal load during activities of daily living. 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) Briggs, 2007 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF/SFSU Graduate Program in Physical Therapy Spring Symposium 2013 2 6 6/14/2013 Scores on the Safe Functional Motion Test (SFM) Predict Incident Vertebral Compression Fracture 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 Compressive force Shear force 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) UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 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) Briggs, et al., 2007 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 osteoporotic 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 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 7 6/14/2013 Medications and Surgical Procedures Roadmap Age-related hyperkyphosis No effect on kyphosis progression over 4 years in the Background and significance Fracture Intervention Trial study of the effects of alendronate on fracture reduction (Kado, DM, 2008) Causes and correlates Kyphosis progression reduced over 3 years in studies Consequences Exercise and therapeutic interventions Recommendations for clinical practice and future research UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care of strontium ranelate versus placebo among postmenopausal 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 Author Abreu, et al., 2012 Population Elderly women with osteoporosis, N=20 Bautmans et al., 2010 Post-menopausal women receiving 3monthly IV pamidronate , N=48 Benedetti, MG, et al., 2008 Bennell, K, et al., 2010 Greendale, G, et al., 2009 Itoi, E, et al.,1994 Scheurman et al., 1998 Men and women 65 years and older with flexed posture, N=34 Men and women >50 years old with painful osteoporotic vertebral fracture, N=19 Men and women 65 years and older with kyphosis ≥ 40 degrees, N=118 Post-menopausal women, 49-65 years old, N=60 Post-menopausal women with osteoporosis, N=60 Intervention Strengthening quads, triceps, paravertebral and abdominal muscles; 2x/week x 12 weeks Thoracic extension, stretching, erector spinae strengthening, manual mobilization and postural exercise; daily for 10 weeks Active spinal extensor strengthening and postural alignment compared to non-specific physical; 2-3 times weekly for 3 months Spinal mobilization, low intensity spinal strengthening, postural training compared to no treatment; once a week for 10 weeks Bansal, et al., in review Results No significant within or between group difference Significant improvement within intervention group, p<0.01 Extension exercise Significant improvement within intervention group occiput to wall, p=0.001 No significant within or between group difference Modified yoga compared to monthly Significant between group difference in luncheon; 3 times weekly for 24 weeks flexicurve index, p=0.004 and flexicurve angle, p=0.005; no significant between group difference in kyphometer, p=0.44 Prone trunk extension compared to Significant within group difference usual activity; 30% 1 repetition max among those with baseline kyphosis; for 10 repetitions; 5 times weekly for 2 >34 degrees; significant between group years difference, p=0.016 Postural exercises (shoulder flexion, wall pushups, scapular adduction); daily for 12 weeks Spinal Flexion and Vertebral Fracture No significant within or between group differences Flexion exercise Sinaki & Mikkelsen, 1984 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 8 6/14/2013 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) 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 of core muscle training with EMG biofeedback on kyphosis. UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Roadmap Best Posture and Body Mechanics Age-related hyperkyphosis “Neutral Spine” 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 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care 9 6/14/2013 Best Posture and Movement in Daily Activity 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 Avoid bending and twisting with a rounded spine Hyperkyphosis Hip hinge during all activity and movements Neutral spine Increase extension in upper spine 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 Exercise THESE: neutral or extended spine Hinge at the hip Strengthen spinal extensors and stabilizers UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Spinal Extension Strengthening Exercises 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 10 6/14/2013 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 outcomes 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 11
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