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Kyphosis: Causes, Consequences
and Treatments
Wendy Katzman, PT, DPTSc, OCSDepartment of Physical Therapy andRehabilitation ScienceUniversity of California San Francisco
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Disclosures
None
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
RoadmapAge-related thoracic hyperkyphosis
Causes and consequencesRelation to spinal load and vertebralfracturesExercise and therapeutic interventions forreducing hyperkyphosis, spinal load andassociated vertebral fracture risk
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Sagittal Plane Alignment
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Measurement of Thoracic Kyphosis
Block method
Radiographic Clinical toolsCobb angle Flexible ruler Occiput-to-wall
Block method
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Epidemiology of Kyphosis
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Kyphosis increases with age 1,2 ,3,6 Defined as >40 degrees 4, 9 20-40% of older adults 5, 7, 8 More common in women 6, 7
1Ball, 2009; 2Ensrud, 1997; 3Ettinger, 1994; 4Fon, 1980; 5Kado, 2004; 6Katzman, 2011;7Schneider, 2004; 8Takahashi, 20 05; 9Voutsinas, 1986
Kado, in review
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0 2 4 6 8 10 12 14 16
K y p
h o s
i s C o
b b
A n g
l e ( d e g r e e s
) )
Time (years)
Kyphosis Progression in Older WomenOver 15 Years
Mean Trajectory
With prevalentvertebral fracture
Without prevalentvertebral fracture
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Correlates of Hyperkyphosis
Age and heredity 1, 3, 4,, 5, 10
Vertebral fractures, low bone mineral density,disc degeneration 3, 4, 11,16
Decreased shoulder, hip and spinalmobility/spinal proprioception 2, 6, 8, 10
Spinal muscle weakness 9, 15, 17
Spinal muscle attenuation 121Axenovich, 2001; 2Balzini, 2002; 3Ensrud, 1997; 4Ettinger, 1994; 5Fon, 1980; 6Granito,2012; 8Hinman, 2004; 9Hongo, 2012; 10 Kado, 1999; 11Kado, 2005; 12 Katzman, 2011;13 Kendall, 1993; 14 Manns, 1996; 15 Mika, 2009; 16 Schneider, 2004; 17 Sinaki, 1996
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UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Back Extensor S trength Declines With Age
Sinaki M, 2001
Clinical Consequences of Hyperkyphosis
Impaired quality of life, 12,16 physical function, 2,4,6,7,10,11,14and increased risk of early mortality 6
Vertebral fracture risk 5,6
May affect balance and risk for falls 1,6,7,15
Slower gait speed, stair climbing, functional reach 2,14, 16
Pulmonary, gastrointestinal and gynecologicdysfunction 3,8, 9,10,11,13,14
1Arnold, 2005; 2Balzini, 2003; 3Di Bari, 2004; 4Hirose 2004; 5Huang, 2006; 6Kado, 99, 02, 04,05, 07; 7Katzman, 2011; 8Kusano, 2008; 9Leech,1990; 10 Lind, 1996; 11Lombardi 2004;12 Martin 2002; 13 Mattox, 2000; 14 Ryan 1997; 14 Schlaich, 1998; 15 Sinaki , 1997; 16 Takahashi2005
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Falls and KyphosisHyperkyphosis increases risk of an injurious fall overall1.38-fold (CI: 1.051.9); 1.48-fold (CI: 1.102.00)among those with the worst kyphosis (Kado, 2005)
Greater kyphosis predicts worse performance times onthe Timed Up and Go test, a strong indicator ofincreased fall risk (Katzman, 2011)
Balance impairments among osteoporotic-kyphoticwomen; exercise improved balance and reduced riskfor falls (Sinaki, 2005)
Balance impairment is related to vertebral fracture notkyphosis among individuals with osteoporosis
(Greig, 2007)
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Fracture Risk and Kyphosis
Hyperkyphosis increased risk for futurefractures approximately 75% (Huang, 2006) independent of age, baseline fracture, bone mineral
density prospective cohort study among 596 community-
dwelling women 4792 years
Possible mechanisms falls or spinal loading
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Factors Influencing the Vertebral Fracture Cascade
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Predicted Loads on the Lumbar Spine
Predicted load at L3 vertebrae% body weight (BW) foraverage sized woman
51% standing173 % sit to stand319% lifting 33# from floor
Loads can increase duringactivities of daily living
Spinal load varies with thoracickyphosis and sagittal planealignment Bruno, AG, 2012
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
BMD, Activity and Load Modify Riskof Bone Failure
Failure in the L2vertebrae occurssooner at the sameload with low BMD
Loads vary withcommon activities ofdaily living
(Myers, Wilson, Bouxsein, 1997)
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Spinal Load and Kyphosis
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, 2007
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Compressive force Shear force
Spinal Load and Disc Degeneration
Disc degenerationpredisposesvertebrae to anteriorfracture whenspine is flexed -stress shielding
Pollintine, 2004
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
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Spinal Flexion and Vertebral Fracture
Compression loads on the L3 vertebraeincrease with 30 of trunk flexion.
2610 N with arms in front, holding 2kg in each hand (Schultz, 1982)300 to 1200 N enough to fracture anosteoporotic vertebra (Edmondston, 1997)
Practical Application - bend and lift ineveryday life with the trunk in relativeneutral! ( adapted from Bookstein and Lindsey,
Osteoporosis What You Should Know powerpoint)
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clini cal Care
Spinal Flexion and Vertebral Fracture
Extensionexercise
Flexionexercise
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
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Spinal Flexion and Vertebral Fracture
Case series of 3 healthy persons with low bone massdeveloped yoga-induced pain and vertebral fracture
87 year-old woman L2 fracture after exercise a
70 year-old woman T8T9 fractures after a and b
61 year-old woman T4 endplate fracture after a and c
a b cSinaki, 2012
c
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Exercise and KyphosisRCT 118 men and women with kyphosis >40
Modified yoga versus monthly luncheon for 6 mos.
4-5% improvement in flexible ruler measures ofkyphosis
No significant change in radiographic Cobb angleor physical function
Greendale, 2009
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Exercise and Kyphosis
RCT 60 post-menopausal women 49-65 years
High-intensity spinal strengthening vs. usual activity
30% for 10 repetitions; 5 times weekly for 2 years
Post-hoc analysis: kyphosis reduced significantlyamong those with Cobb angle >34and significantspinal weakness at baseline
(Itoi & Sinaki, 1994)
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Exercise, Physical Function and Kyphosis
Uncontrolled trial 21 women72 4.3 years with kyphosis >50
High intensity spinal musclestrengthening, stretching andpostural training for 3 mos.
Kyphosis improved 6,physical function improved andimprovements maintained at 1 year
Katzman, 2007
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Mobilization, Exercise and Kyphosis
RCT 20 men/women over 50 with painful vertebral fracture
Spinal mobilization, low intensity spinal strengthening,postural training versus no treatment for 10 weeks
No significant improvement in kyphosis (5% inclinometer)Physical function improved in Timed Loaded StandingPain reduced and health-related QoL improved
Bennell, 2010
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Mobilization, Taping, Exercise and Kyphosis
RCT 48 women withosteoporosis (age 76 7 years)
3 months rehabilitation manualmobilization, taping and lowintensity exercises vs. waitlistcontrol
Kyphosis reduced 7 (spinalmouse); no change in secondaryoutcomes of pain, QoL
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Proprioception and Kyphosis
Joint position sense iscorrelated with degree ofkyphosis (Granito, 2012)
Spinal taping improves kyphosis(Bautmans, 2010; Greig, 2007)
Weighted kypho-orthosisreduces kyphosis, improvesbalance (Sinaki, M, 1995)
Thoracolumbar orthosisreduces kyphosis, improvesstrength and physical function(Pfeifer, M, 2004)
Spinal taping Thoracolumbar orthosis
Weighted kypho-orthosis
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Medications, Surgical Procedures and Kyphosis
No effect on kyphosis progression over 4 years in theFracture Intervention Trial study of the effects ofalendronate on fracture reduction (Kado, DM, 2008)
Kyphosis progression reduced over 3 years in studies ofstrontium ranelate versus placebo amongpostmenopausal women with osteoporosis (Roux, C, 2010)
Reduction of radiographic Cobb angle aftervertebroplasty and balloon kyphoplasty for vertebralfracture (Theodorou DJ, 2002; Teng, 2003)
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Exercise and Vertebral Fractures
Retrospective study 50 postmenopausal womenSpinal strengthening exercises 5x/wk for 2 yearsFewer fractures at 10-year follow-up in exercise group
(Sinaki, 2002)
Retrospective study 57 patients, adults 55 years and olderwith osteoporosis and vertebral compression fractureCompared refracture rates and time before refracture
after targeted exercise (ROPE) vs. vertebroplasty (PVP)vs. combined ROPE and PVPLowest rate in non-surgical exercise ROPE group
(Huntoon, 2008)
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
( .001) .
( % , 1. . ) , 20. ( % , 2. ) 0. ( % , 2 . ) ( .001 ( , 200 )
Exercise and Vertebral Fracture
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Best Posture and Body MechanicsNeutral Spine
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Best Posture and Movementin Daily Activity
Photos: Do It Right, American Bone Health, Sherri Betz, PT,GCS
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
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Best Posture and LiftingBend 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 twistingwith a rounded spine
UCSF 9th 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 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
SummaryHyperkyphosis and spinal flexion increase spinal loadthat in turn increases risk for vertebral fractures
Best posture, neutral body mechanics and targetedinterventions reduce excessive thoracic kyphosis
High-intensity spinal strengtheningexercise appears more effective andmay have additional benefits
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Next stepsScreen patients and identify those with thoracichyperkyphosis
Best posture and body mechanics training to
improve sagittal plane alignmentTargeted spinal strengthening exercise toreduce excessive thoracic kyphosis
Randomized controlled trials of exerciseinterventions with kyphosis and fractureoutcomes
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
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Lets practice!!!!!Neutral spine Hip hinge Alphabets
UCSF 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care