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Kyphosis: Causes, Consequences and Treatments

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Kyphosis: Causes, Consequences and Treatments 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 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Background and Significance Roadmap Life expectancy increasing Age-related hyperkyphosis Background and significance Physical disability is not inevitable Causes and correlates Identify new, potentially modifiable factors Consequences Exercise and therapeutic interventions Develop targeted 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 1 6/14/2013 Hyperkyphosis Definition Epidemiology of Hyperkyphosis • Kyphosis increases with age 1,2,3,4,5 • Hyperkyphosis is an excessive curvature in the thoracic spine • Affects 20-40% of older adults ,7, 8, 9 • Alters sagittal plane alignment • More common in older women 7,8 1Ball, 2009; 2Ensrud, 1997; 3Ettinger, 1994; 4Kado, 2012; 5Fon, 1980, 6Voutsinas,, 1986, 7Katzman, 2011; 8Schneider, 2004, 9 Takahashi, 2005 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 Roadmap Radiographic Cobb angle Flexible ruler Occiput-to-wall Age-related hyperkyphosis Background and significance Causes and correlates Consequences Kyphometer Block method 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 2 6/14/2013 Kyphosis Progression in Older Women Over 15 Years (Kado, et.al, 2013) Primary Correlates of Hyperkyphosis 61 ) ) 59 Vertebral fractures 1,2 With prevalent 57 vertebral fracture 3, 4, 5 Osteoporosis 55 53 Mean Trajectory 5 Degenerative discs 7 degree increase in kyphosis over 15 years 51 Family history 6,7 49 Kyphosis Cobb Angle (degrees Angle CobbKyphosis Without prevalent 47 vertebral fracture 1Ensrud, 1997; 2Kado, 2013; 3Fon, 1980; 4Ettinger, 1994; 5Schneider, 2004; 6 7 Kado, 2005; Huang, 2006 45 43 0 2 4 6 8 10 12Kado, 14 2012 16 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Time (years) Progression of Kyphosis Primary Correlates of Hyperkyphosis 47 degrees versus 54 degrees Musculoskeletal changes • Spinal extensor muscle weakness 6, 7, 8 • Spinal extensor muscle attenuation 8, 9 • Postural stiffness 10 • Poor trunk position sense/proprioception 11 6Sinaki, 1996; 7Mika,2005; 8Katzman, 2011; 9Katzman, 2012 (ASBMR); 10 Hinman, 2004; 11 Granito, 2012 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 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 (Sinaki, 1996) Study (Katzman, 2011) UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Primary Correlates of Hyperkyphosis Primary Correlates of Hyperkyphosis Reduced spinal, shoulder and hip mobility Greater kyphosis is associated with poor trunk Older women are less able to stand proprioception. erect and actively reduce their kyphosis. 1 Decreased functional axial rotation Cross-sectional comparison occurs with age, reduces physical of thoracic kyphosis degree, performance and is associated with trunk muscle strength and 2 greater degree of kyphosis. trunk proprioception among Flexed posture (hyperkyphosis) associated with shorter pectoral 20 healthy and osteoporotic and hip flexor muscles. 3 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 Clinical Consequences of Hyperkyphosis Age-related hyperkyphosis Impaired physical function, 2,4,6,7,10,11,14 quality of life, 12,16 Background and significance and increased risk of early mortality 6 Causes and correlates – Slower gait speed, stair climbing, functional reach2,14,16 Consequences – May affect balance and risk for falls 1,6,7,15 Exercise and therapeutic interventions – Pulmonary, gastrointestinal and gynecologic Recommendations for clinical practice dysfunction 3,8, 9,10,11,13,14 and future research – Fracture risk 5,6 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; 11 Lombardi 2004; 12 Martin 2002; 13 Mattox, 2000; 14 Ryan 1997; 14 Schlaich, 1998; 15 Sinaki , 1997; 16 Takahashi 2005 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Clinical Consequences of Hyperkyphosis Clinical Consequences of Hyperkyphosis • Increased risk for future fractures • Possible mechanisms for future fractures • Prospective cohort studies • falls • 596 community-dwelling women 47–92 years • spinal loading (Rancho Bernardo) over 4 years (Huang, et al., 2006) • 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, using a cutoff of ≥2 blocks versus ≤1 blocks (95% CI:1.10, especially in backward movement. (Choi, 2011) 2.00) (Kado, 2007) Greater kyphosis predicts worsening performance Trunk muscle strength and composition is associated with balance, functional performance, times on the Timed Up and Go test, a strong and falls in older adults .(Granacher, 2013) indicator of increased fall risk. (Katzman, 2011) Decreased back extension strength and lumbar Balance impairments in women with kyphosis (not thoracic)….. are related to postural instability and falls in elderly individuals. kyphosis compared to healthy controls. (Isahikawa, 2009,Kasakawa, 2010) (Sinaki, 2005) UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Clinical Consequences of Hyperkyphosis 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) Clinical Consequences of Hyperkyphosis Predict Incident Vertebral Compression Fracture • Greater spinal load among high kyphosis group Task specific scoring for domains of • 44 subjects mean age 62 years dichotomized into high/low kyphosis spine-loading, balance, upper- and • Standing lateral radiographs captured and digitized lower body strength and flexibility • Biomechanical models estimated multi-segmental load T2-L5 • Sit to floor Compressive force Shear force • Climb-carry • Night walk • Sweep • Washer/dryer load • Pour 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) Briggs, et al., 2007 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Clinical Consequences of Hyperkyphosis Spinal Flexion and Vertebral Fracture Kyphosis increases spinal load during activities of daily living. Spinal load varies with thoracic kyphosis and sagittal plane Compression loads on the L3 vertebrae alignment .(Bruno, AG, et al., 2012) 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
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