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Disclosures : 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

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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

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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/ 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

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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

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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

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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, 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

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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 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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Roadmap Medications and Surgical Procedures

 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  Consequences  Kyphosis progression reduced over 3 years in studies of strontium ranelate versus placebo among post-  Exercise and therapeutic interventions menopausal women with osteoporosis (Roux, C, 2010)  Recommendations for clinical practice  and future research 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 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Exercise for Improving Age-Related Hyperkyphotic Posture: A Systematic Review Bansal, et al., in review Author Population Intervention Results Abreu, et al., Elderly women with Strengthening quads, triceps, No significant within or between group 2012 osteoporosis, N=20 paravertebral and abdominal muscles; difference Spinal Flexion and Vertebral Fracture 2x/week x 12 weeks Bautmans et Post-menopausal Thoracic extension, stretching, erector Significant improvement within Extension al., 2010 women receiving 3- spinae strengthening, manual intervention group, p<0.01 monthly IV mobilization and postural exercise; exercise pamidronate , N=48 daily for 10 weeks Men and women 65 Active spinal extensor strengthening Significant improvement within years and older with and postural alignment compared to intervention group occiput to wall, Benedetti, MG, flexed posture, N=34 non-specific physical; 2-3 times weekly p=0.001 et al., 2008 for 3 months Men and women >50 Spinal mobilization, low intensity No significant within or between group Bennell, K, et years old with painful spinal strengthening, postural training difference al., 2010 osteoporotic vertebral compared to no treatment; once a fracture, N=19 week for 10 weeks Flexion Men and women 65 Modified yoga compared to monthly Significant between group difference in exercise Greendale, G, years and older with luncheon; 3 times weekly for 24 weeks flexicurve index, p=0.004 and flexicurve et al., 2009 kyphosis ≥ 40 degrees, angle, p=0.005; no significant between N=118 group difference in kyphometer, p=0.44 Post-menopausal Prone trunk extension compared to Significant within group difference Itoi, E, et women, 49-65 years usual activity; 30% 1 repetition max among those with baseline kyphosis; Sinaki & Mikkelsen, 1984 al.,1994 old, N=60 for 10 repetitions; 5 times weekly for 2 >34 degrees; significant between group years difference, p=0.016 Scheurman et Post-menopausal Postural exercises (shoulder flexion, No significant within or between group al., 1998 women with wall pushups, scapular adduction); differences UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care osteoporosis, N=60 daily for 12 weeks

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Spinal Extensor Strengthening May Current/Future Studies Reduce Incident Vertebral Fractures National Institute of Aging (NIA): RCT of a 6-month multimodal Prospective study 50 postmenopausal women exercise intervention to determine the effects on kyphosis  Spinal strengthening exercises 5x/wk for 2 years  Fewer fractures at 10-year follow-up in exercise group Office of Research on Women’s Health and National Institute of (Sinaki, 2002) Arthritis and Musculoskeletal and Skin Diseases (NIAMS): Retrospective study 57 patients, adults 55 years and older Specialized Center of Research to investigate sex differences in with osteoporosis and vertebral compression fracture musculoskeletal issues across the lifespan – Kyphosis Project  Compared refracture rates Canadian Institutes of Health Research (CIHR), U of Waterloo: and time before refracture Pilot RCT to test the feasibility of a large multicentre study to after targeted exercise (ROPE) evaluate whether tailored home exercise can prevent fractures vs. vertebroplasty (PVP) vs. (primary outcome) in high-risk individuals. combined ROPE and PVP  Lowest rate in non-surgical National Taiwan University Hospital – RCT to determine the effects exercise ROPE group (Huntoon, 2008) 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 “Neutral Spine ”  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

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Best Posture and Movement Best Posture and Lifting in Daily Activity Bend and lift with the spine in “neutral”

Bending and reaching with a round back

increases spinal fracture risk if you have

 Osteoporosis Avoid bending and twisting  History of spinal fracture 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 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Best Posture and Exercise Spinal Extension Strengthening Exercises

THESE : neutral or extended spine 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 Next steps  Age-related hyperkyphosis is easily recognized yet rarely  Screen patients and identify those with treated geriatric syndrome, common among older adults and associated with poor health outcomes. hyperkyphosis  Few well-controlled, high quality randomized controlled trials  Best posture and body mechanics training to have investigated the effects of exercise on kyphosis. improve sagittal plane alignment  Results from several trials suggest that back extensor strengthening may be effective in improving kyphosis.  Targeted spinal strengthening exercise to reduce

 Hyperkyphosis and spinal flexion increase spinal load that in excessive thoracic kyphosis turn increases risk for vertebral fractures.  Randomized controlled trials of exercise  Best posture, neutral body mechanics and targeted back interventions with kyphosis and fracture extension strengthening interventions may reduce spinal load and risk for fractures. outcomes

UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care

Let’s practice! • Neutral spine • Hip hinge • Alphabets

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