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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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