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 � Develop targeted interventions � E xercise 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 1
6/14/2013 Hyperkyphosis Definition Epidemiology of Hyperkyphosis • Kyphosis increases with age 1,2,3,4,5 • Hyperkyphosis is an excessive curvature • Affects 20-40% of older adults ,7, 8, 9 in the thoracic spine • Alters sagittal plane alignment • More common in older women 7,8 1 Ball, 2009; 2 Ensrud, 1997; 3 Ettinger, 1994; 4 Kado, 2012; 5 Fon, 1980, 6 Voutsinas,, 1986, 7 Katzman, 2011; 8 Schneider, 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 � E xercise and therapeutic interventions Kyphometer Block method � 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 Kyphosis Cobb Angle (degrees)) 59 � Vertebral fractures 1,2 With prevalent vertebral fracture 57 � Osteoporosis 3, 4, 5 55 Mean Trajectory � Degenerative discs 5 53 7 degree increase in kyphosis over 15 years 51 � Family history 6,7 49 Without prevalent vertebral fracture 47 1 Ensrud, 1997; 2 Kado, 2013; 3 Fon, 1980; 4 Ettinger, 1994; 5 Schneider, 2004; � 6 Kado, 2005; 7 Huang, 2006 45 43 Kado, 2012 0 2 4 6 8 10 12 14 16 UCSF 10th Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care Time (years) Primary Correlates of Hyperkyphosis Progression of Kyphosis � Musculoskeletal changes 47 degrees versus 54 degrees Spinal extensor muscle weakness 6, 7, 8 • Spinal extensor muscle attenuation 8, 9 • Postural stiffness 10 • Poor trunk position sense/proprioception 11 • 6 Sinaki, 1996; 7 Mika,2005; 8 Katzman, 2011; 9 Katzman, 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 Study (Katzman, 2011) (Sinaki, 1996) 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 Cross-sectional comparison � Decreased functional axial rotation of thoracic kyphosis degree, occurs with age, reduces physical performance and is associated with trunk muscle strength and greater degree of kyphosis. 2 trunk proprioception among � Flexed posture (hyperkyphosis) 20 healthy and osteoporotic associated with shorter pectoral elderly women. and hip flexor muscles. 3 (Granito, 2012) 1 Hinman, 2004; 2 Schenkman, 1996; 3 Balzini, 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 Clinical Consequences of Hyperkyphosis Roadmap � Impaired physical function, 2,4,6,7,10,11,14 quality of life, 12,16 � Age-related hyperkyphosis and increased risk of early mortality 6 � Background and significance – Slower gait speed, stair climbing, functional reach 2,14,16 � Causes and correlates � Consequences – May affect balance and risk for falls 1,6,7,15 � E xercise and therapeutic interventions – Pulmonary, gastrointestinal and gynecologic dysfunction 3,8, 9,10,11,13,14 � Recommendations for clinical practice and future research – Fracture risk 5,6 1 Arnold, 2005; 2 Balzini, 2003; 3 Di Bari, 2004; 4 Hirose 2004; 5 Huang, 2006; 6 Kado, ‘99, ‘02, ‘04, ‘05, ‘07; 7 Katzman, 2011; 8 Kusano, 2008; 9 Leech,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 falls • Prospective cohort studies • spinal loading • 596 community-dwelling women 47–92 years • (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 Balance and falls conundrum: Hyperkyphosis increases risk of injurious falls. Kyphosis condition improved balance tests, � 1.4 fold increased risk (95% CI:1.05,1.91) that increased to 1.5 especially in backward movement. (Choi, 2011) using a cutoff of ≥ 2 blocks versus ≤ 1 blocks (95% CI:1.10, 2.00) (Kado, 2007) Trunk muscle strength and composition is Greater kyphosis predicts worsening performance 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 kyphosis (not thoracic)….. are related to postural Balance impairments in women with 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
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