kyphosis causes consequences treatment

8/10/2019 Kyphosis Causes Consequences Treatment

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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


RoadmapAge-related thoracic hyperkyphosis

Causes and consequencesRelation to spinal load and vertebralfracturesExercise and therapeutic interventions forreducing hyperkyphosis, spinal load andassociated vertebral fracture risk


Sagittal Plane Alignment



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Measurement of Thoracic Kyphosis

Block method

Radiographic Clinical toolsCobb angle Flexible ruler Occiput-to-wall

Block method


Epidemiology of Kyphosis


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


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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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


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


Factors Influencing the Vertebral Fracture Cascade


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


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


Compressive force Shear force

Spinal Load and Disc Degeneration

Disc degenerationpredisposesvertebrae to anteriorfracture whenspine is flexed -stress shielding

Pollintine, 2004


.

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


Extensionexercise

Flexionexercise



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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


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


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)


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


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


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


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)


( .001) .

( % , 1. . ) , 20. ( % , 2. ) 0. ( % , 2 . ) ( .001 ( , 200 )

Exercise and Vertebral Fracture


Best Posture and Body MechanicsNeutral Spine


Best Posture and Movementin Daily Activity

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



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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


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


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



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Lets practice!!!!!Neutral spine Hip hinge Alphabets


kyphosis causes consequences treatment

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