Kyphosis Causes Consequences Treatment

7/26/2012
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 9th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care
Roadmap
Sagittal Plane Alignment
Age-related thoracic hyperkyphosis

Causes and consequences
Relation to spinal load and vertebral
fractures
Exercise and therapeutic interventions for
reducing hyperkyphosis, spinal load and
associated vertebral fracture risk
7/26/2012
Measurement of Thoracic Kyphosis

Radiographic
Cobb angle
Epidemiology of Kyphosis
Clinical tools
Flexible ruler
Occiput-to-wall
Kyphosis increases with age1,2,3,6

Defined as >40 degrees4, 9
20-40% of older adults5, 7, 8
More common in women6, 7
Block method
Block method
1Ball,
2009; 2Ensrud, 1997; 3Ettinger, 1994; 4Fon, 1980; 5Kado, 2004; 6Katzman, 2011;
2004; 8Takahashi, 2005; 9Voutsinas, 1986
7Schneider,
Kyphosis Cobb Angle (degrees))
Kyphosis Progression in Older Women

Over 15 Years
Correlates of Hyperkyphosis
61
Age and heredity1, 3, 4,, 5, 10
59
With prevalent
vertebral fracture
57
Vertebral fractures, low bone mineral density,
disc degeneration
55
3, 4, 11,16
Mean Trajectory
53
Decreased shoulder, hip and spinal
51
mobility/spinal proprioception
Without prevalent
vertebral fracture
47
2, 6, 8, 10
Spinal muscle weakness
49
9, 15, 17
Spinal muscle attenuation
45
12
43
0
10
12
14
Time (years)
16
1Axenovich, 2001; 2Balzini, 2002; 3Ensrud, 1997; 4Ettinger, 1994; 5Fon, 1980; 6Granito,
2012; 8Hinman, 2004; 9Hongo, 2012; 10Kado, 1999; 11Kado, 2005; 12Katzman, 2011;
13Kendall, 1993; 14Manns, 1996; 15Mika, 2009; 16Schneider, 2004; 17Sinaki, 1996
Kado, in review
7/26/2012
Spinal Muscle Strength and Kyphosis
(Sinaki, 1996)
Back Extensor Strength Declines With Age
Sinaki M, 2001
Clinical Consequences of Hyperkyphosis

Impaired quality of life,12,16 physical function,2,4,6,7,10,11,14
and increased risk of early mortality6

Vertebral fracture risk5,6
May affect balance and risk for falls1,6,7,15
Slower gait speed, stair climbing, functional reach2,14, 16
Pulmonary, gastrointestinal and gynecologic
dysfunction3,8, 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; 10Lind, 1996; 11Lombardi 2004;
12Martin 2002; 13Mattox, 2000; 14Ryan 1997; 14Schlaich, 1998; 15Sinaki , 1997; 16Takahashi
2005
Falls and Kyphosis

Hyperkyphosis increases risk of an injurious fall overall
1.38-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 on
the Timed Up and Go test, a strong indicator of

increased fall risk
(Katzman, 2011)
Balance impairments among osteoporotic-kyphotic
women; exercise improved balance and reduced risk

for falls
(Sinaki, 2005)
Balance impairment is related to vertebral fracture not
kyphosis among individuals with osteoporosis
(Greig, 2007)
7/26/2012
Fracture Risk and Kyphosis
Factors Influencing the Vertebral Fracture Cascade
Hyperkyphosis increased risk for future
fractures approximately 75% (Huang, 2006)

independent of age, baseline fracture, bone mineral
density
prospective cohort study among 596 communitydwelling women 4792 years
Possible mechanisms
falls or spinal loading

Briggs, 2007
Predicted Loads on the Lumbar Spine

Predicted load at L3 vertebrae
% body weight (BW) for
average sized woman
51% standing
173 % sit to stand
319% lifting 33# from floor
vertebrae occurs
sooner at the same
load with low BMD
Loads vary with
activities of daily living
kyphosis and sagittal plane

alignment Bruno, AG, 2012
BMD, Activity and Load Modify Risk

of Bone Failure
Failure in the L2
Loads can increase during

Spinal load varies with thoracic
Buoxsein, 2006
common activities of
daily living
(Myers, Wilson, Bouxsein, 1997)
7/26/2012
Spinal Load and Disc Degeneration
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
Compressive force
Shear force
Disc degeneration
predisposes
vertebrae to anterior
fracture when
spine is flexed stress shielding
Pollintine, 2004
Briggs, 2007
Spinal Flexion and Vertebral Fracture

Extension
exercise
Compression loads on the L3 vertebrae
increase with 30 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
Flexion
exercise
everyday life with the trunk in relative

neutral! (adapted from Bookstein and Lindsey,
Osteoporosis What You Should Know powerpoint)
Sinaki & Mikkelsen, 1984
7/26/2012

Case series of 3 healthy persons with low bone mass

developed 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
Sinaki, 2012
Exercise and Kyphosis

RCT 118 men and women with kyphosis >40
Modified yoga versus monthly luncheon for 6 mos.
4-5% improvement in flexible ruler measures of
kyphosis
No significant change in radiographic Cobb angle
or physical function
Greendale, 2009
Exercise, Physical Function and Kyphosis
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 significantly
among those with Cobb angle >34and significant

spinal weakness at baseline
(Itoi & Sinaki, 1994)
Uncontrolled trial 21 women
72 4.3 years with kyphosis >50

High intensity spinal muscle
strengthening, stretching and

postural training for 3 mos.
Kyphosis improved 6,
physical function improved and

improvements maintained at 1 year
Katzman, 2007
7/26/2012
Mobilization, Exercise and Kyphosis

RCT 20 men/women over 50 with painful vertebral fracture
Mobilization, Taping, Exercise and Kyphosis

RCT 48 women with
osteoporosis (age 76 7 years)

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 Standing
Pain reduced and health-related QoL improved
Bennell, 2010
3 months rehabilitation manual
mobilization, taping and low

intensity exercises vs. waitlist
control
Kyphosis reduced 7 (spinal
mouse); no change in secondary

outcomes of pain, QoL
Proprioception and Kyphosis

Joint position sense is
correlated with degree of

kyphosis (Granito, 2012)
Spinal taping
Thoracolumbar orthosis
Spinal taping improves kyphosis

Weighted kypho-orthosis
Thoracolumbar orthosis
Medications, Surgical Procedures and Kyphosis

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 of
(Bautmans, 2010; Greig, 2007)
reduces kyphosis, improves

balance (Sinaki, M, 1995)
Bautmans, 2010
strontium ranelate versus placebo among

postmenopausal women with osteoporosis (Roux, C, 2010)
Weighted kypho-orthosis
reduces kyphosis, improves

strength and physical function
(Pfeifer, M, 2004)
Reduction of radiographic Cobb angle after
vertebroplasty and balloon kyphoplasty for vertebral

fracture (Theodorou DJ, 2002; Teng, 2003)
7/26/2012
Exercise and Vertebral Fractures
Exercise and Vertebral Fracture
Retrospective 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)
Best Posture and Body Mechanics
Survival plot showing the percentage of patients in each group with no

refracture at various time points (P<.001) ; median time to refracture PVP: 4.5
months (95% CI, 1.4-9.3); PVP-ROPE, 20.4 mos (95% CI, 2.8 undefined); ROPE
only: 60.4 mos (95% CI, 27.6 -undefined) (P<.001)
(Huntoon, 2008)
Best Posture and Movement

in Daily Activity
Neutral Spine
Photos: Do It Right, American Bone Health, Sherri Betz, PT,GCS

7/26/2012
Best Posture and Lifting
Best Posture and Exercise
Bend and lift with the spine in neutral

Bending and reaching with a round back
THESE: neutral or extended spine
AVOID: flexion, rounding, twisting
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
Hinge at the hip
Strengthen spinal extensors and stabilizers

Photos: Do It Right, American Bone Health, Sherri Betz, PT, GCS
Summary
Hyperkyphosis and spinal flexion increase spinal load
that in turn increases risk for vertebral fractures
Best posture, neutral body mechanics and targeted
interventions reduce excessive thoracic kyphosis
High-intensity spinal strengthening
exercise appears more effective and

may have additional benefits
Next steps
Screen patients and identify those with thoracic
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
7/26/2012
Lets practice!!!!!
Neutral spine
Hip hinge
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Kyphosis Causes Consequences Treatment

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7/26/2012

Kyphosis: Causes, Consequences

Sagittal Plane Alignment

Age-related thoracic hyperkyphosis

Relation to spinal load and vertebral

Measurement of Thoracic Kyphosis

Kyphosis increases with age1,2,3,6

Kyphosis Cobb Angle (degrees))

Kyphosis Progression in Older Women

Age and heredity1, 3, 4,, 5, 10

Vertebral fractures, low bone mineral density,

Decreased shoulder, hip and spinal

Spinal muscle weakness

Spinal muscle attenuation

Spinal Muscle Strength and Kyphosis

Back Extensor Strength Declines With Age

Clinical Consequences of Hyperkyphosis

and increased risk of early mortality6

Falls and Kyphosis

1.38-fold (CI: 1.051.9); 1.48-fold (CI: 1.102.00)

Greater kyphosis predicts worse performance times on

the Timed Up and Go test, a strong indicator of

Balance impairments among osteoporotic-kyphotic

women; exercise improved balance and reduced risk

Balance impairment is related to vertebral fracture not

kyphosis among individuals with osteoporosis

Fracture Risk and Kyphosis

Factors Influencing the Vertebral Fracture Cascade

Hyperkyphosis increased risk for future

fractures approximately 75% (Huang, 2006)

falls or spinal loading

Predicted Loads on the Lumbar Spine

activities of daily living

kyphosis and sagittal plane

BMD, Activity and Load Modify Risk

Loads can increase during

(Myers, Wilson, Bouxsein, 1997)

Spinal Load and Disc Degeneration

Spinal Load and Kyphosis

Spinal Flexion and Vertebral Fracture

Spinal Flexion and Vertebral Fracture

Compression loads on the L3 vertebrae

increase with 30 of trunk flexion.

Practical Application - bend and lift in

everyday life with the trunk in relative

Sinaki & Mikkelsen, 1984

Spinal Flexion and Vertebral Fracture

Case series of 3 healthy persons with low bone mass

87 year-old woman L2 fracture after exercise a

Exercise and Kyphosis

Exercise, Physical Function and Kyphosis

Exercise and Kyphosis

among those with Cobb angle >34and significant

Uncontrolled trial 21 women

72 4.3 years with kyphosis >50

strengthening, stretching and

physical function improved and

Mobilization, Exercise and Kyphosis

Mobilization, Taping, Exercise and Kyphosis

osteoporosis (age 76 7 years)

postural training versus no treatment for 10 weeks

3 months rehabilitation manual

mobilization, taping and low

mouse); no change in secondary