Wendy B. Katzman

Age-Related Hyperkyphosis: Its Causes, Consequences, and Management

SYNOPSISnAge-related hyperkyphosis is an exaggerated anterior curvature in the thoracic spine that occurs commonly with advanced age. This condition is associated with low bone mass, vertebral compression fractures, and degenerative disc disease, and contributes to difficulty performing activities of daily living and decline in physical performance. While there are effective treatments, currently there are no public health approaches to prevent hyperkyphosis among older adults. Our objective is to review the prevalence and natural history of hyperkyphosis, associated health implications, measurement tools, and treatments to prevent this debilitating condition.nnnLEVEL OF EVIDENCEnDiagnosis/prognosis/therapy, level 5.J Orthop Sports Phys Ther 2010;40(6):352-360, Epub 15 April 2010. doi:10.2519/jospt.2010.3099.

Association of Spinal Muscle Composition and Prevalence of Hyperkyphosis in Healthy Community-Dwelling Older Men and Women

BACKGROUNDnOlder adults with hyperkyphosis are at increased risk of falls, fractures, and functional decline. Modifiable risk factors for hyperkyphosis have not been well studied. Our objective was to determine whether spinal muscle area and density are associated with hyperkyphosis, independent of age, race, sex, bone mineral density, and trunk fat.nnnMETHODSnUsing data from the Pittsburgh site of the Health, Aging, and Body Composition study, we performed a baseline cross-sectional analysis. Participants were black and white men and women 70-79 years old (N = 1172), independent in activities of daily living and able to walk ¼ mile and up 10 steps without resting. We measured Cobbs angle of kyphosis from supine lateral scout computed tomography scans, and categorized hyperkyphosis as Cobbs angle >40°. Axial images from lateral scout computed tomography scans assessed spinal extensor muscle cross-sectional area and density (proxy for fat infiltration).nnnRESULTSnIn our sample, 21% had hyperkyphosis. Prevalence in black men was 11%; in white men, 17%; in black women, 26%; and in white women, 30%. In multivariate analysis, each standard deviation increase in muscle density was associated with a 29% reduction in the odds of hyperkyphosis, independent of covariates. Muscle area was not significantly associated with hyperkyphosis.nnnCONCLUSIONSnLower spinal muscle density is associated with hyperkyphosis in healthy community-dwelling older adults. This potentially modifiable risk factor could be targeted in exercise interventions. Randomized trials are needed to determine whether an exercise program targeting spinal muscle density reduces hyperkyphosis and in turn improves health outcomes.

Age-related hyperkyphosis, independent of spinal osteoporosis, is associated with impaired mobility in older community-dwelling women

SummaryWhile many assume hyperkyphosis reflects underlying spinal osteoporosis and vertebral fractures, our results suggest hyperkyphosis is independently associated with decreased mobility. Hyperyphosis is associated with slower Timed Up and Go performance times and may be a useful clinical marker signaling the need for evaluation of vertebral fracture and falling risk.IntroductionWhile multiple studies have demonstrated negative effects of hyperkyphosis on physical function, none have disentangled the relationship between hyperkyphosis, impaired function, and underlying spinal osteoporosis. The purpose of this study is to determine whether kyphosis, independent of spinal osteoporosis, is associated with mobility on the Timed Up and Go, and to quantify effects of other factors contributing to impaired mobility.MethodsWe used data for 3,108 community-dwelling women aged 55-80xa0years in the Fracture Intervention Trial. All participants had measurements of kyphosis, mobility time on the Timed Up and Go test, height, weight, total hip bone mineral density (BMD), grip strength, and vertebral fractures at baseline visits in 1993. Demographic characteristics included age and smoking status. We calculated mean Timed Up and Go time by quartile of kyphosis. Using multivariate linear regression, we estimated the independent association of kyphosis with mobility time, and quantified effects of other covariates on mobility.ResultsMean mobility time increased from 9.3xa0s in the lowest to 10.1xa0s in the highest quartile of kyphosis. In a multivariate-adjusted model, mobility time increased 0.11xa0s (pu2009=u20090.02) for each standard deviation (11.9°) increase in kyphosis. Longer performance times were significantly associated with increasing age, decreasing grip strength, vertebral fractures, body mass index ≥25, and total hip BMD in the osteoporotic range.ConclusionsKyphosis angle is independently associated with decreased mobility on the Timed Up and Go, which is in turn correlated with increased fall risk. Hyperkyphosis may be a useful clinical marker signaling the need for evaluation of vertebral fracture and falling risk.

Factors associated with kyphosis progression in older women: 15 years' experience in the study of osteoporotic fractures.

Age‐related hyperkyphosis is thought to be a result of underlying vertebral fractures, but studies suggest that among the most hyperkyphotic women, only one in three have underlying radiographic vertebral fractures. Although commonly observed, there is no widely accepted definition of hyperkyphosis in older persons, and other than vertebral fracture, no major causes have been identified. To identify important correlates of kyphosis and risk factors for its progression over time, we conducted a 15‐year retrospective cohort study of 1196 women, aged 65 years and older at baseline (1986 to 1988), from four communities across the United States: Baltimore County, MD; Minneapolis, MN; Portland, OR; and the Monongahela Valley, PA. Cobb angle kyphosis was measured from radiographs obtained at baseline and an average of 3.7 and 15 years later. Repeated measures, mixed effects analyses were performed. At baseline, the mean kyphosis angle was 44.7 degrees (SEu2009=u20090.4, SDu2009=u200911.9) and significant correlates included a family history of hyperkyphosis, prevalent vertebral fracture, low bone mineral density, greater body weight, degenerative disc disease, and smoking. Over an average of 15 years, the mean increase in kyphosis was 7.1 degrees (SEu2009=u20090.25). Independent determinants of greater kyphosis progression were prevalent and incident vertebral fractures, low bone mineral density and concurrent bone density loss, low body weight, and concurrent weight loss. Thus, age‐related kyphosis progression may be best prevented by slowing bone density loss and avoiding weight loss.

Increasing Kyphosis Predicts Worsening Mobility in Older Community-Dwelling Women: A Prospective Cohort Study

OBJECTIVES: To determine whether increasing kyphosis angle was independently associated with poorer mobility as measured according to the Timed Up and Go Test (TUG), after controlling for other established risk factors.

Hyperkyphosis, Kyphosis Progression, and Risk of Non-Spine Fractures in Older Community Dwelling Women: The Study of Osteoporotic Fractures (SOF)

While accentuated kyphosis is associated with osteoporosis, it is unknown whether it increases risk of future fractures, independent of bone mineral density (BMD) and vertebral fractures. We examined the associations of baseline Cobb angle kyphosis and 15 year change in kyphosis with incident non‐spine fractures using data from the Study of Osteoporotic Fractures. A total of 994 predominantly white women, aged 65 or older, were randomly sampled from 9704 original participants to have repeated Cobb angle measurements of kyphosis measured from lateral spine radiographs at baseline and an average of 15 years later. Non‐spine fractures, confirmed by radiographic report, were assessed every 4 months for up to 21.3 years. Compared with women in the lower three quartiles of kyphosis, women with kyphosis greater than 53° (top quartile) had a 50% increased risk of non‐spine fracture (95% CI, 1.10–2.06 after adjusting for BMD, prevalent vertebral fractures, prior history of fractures, and other fracture risk factors. Cobb angle kyphosis progressed an average of 7° (SDu2009=u20096.8) over 15 years. Per 1 SD increase in kyphosis change, there was a multivariable adjusted 28% increased risk of fracture (95% CI, 1.06–1.55) that was attenuated by further adjustment for baseline BMD (HR per SD increase in kyphosis change, 1.19; 95% CI 0.99–1.44). Greater kyphosis is associated with an elevated non‐spine fracture risk independent of traditional fracture risk factors in older women. Furthermore, worsening kyphosis is also associated with increased fracture risk that is partially mediated by low baseline BMD that itself is a risk factor for kyphosis progression. These results suggest that randomized controlled fracture intervention trials should consider implementing kyphosis measures to the following: (1) further study kyphosis and kyphosis change as an additional fracture risk factor; and (2) test whether therapies may improve or delay its progression.

Kyphosis and Decline in Physical Function Over 15 Years in Older Community-Dwelling Women: The Study of Osteoporotic Fractures

BACKGROUNDnMaintaining physical function is an important prerequisite for preserving independence in later life. Greater degrees of kyphosis in the thoracic spine are prevalent in older persons and accompanied by reduced physical function in multiple cross-sectional studies. It is unknown whether kyphosis predicts worse physical function over time.nnnMETHODSnWe retrospectively assessed whether greater magnitude of kyphosis is associated with decline in self-reported and objectively measured physical function over 15 years. Digitized Cobb angle kyphosis (T4-T12) was derived from supine lateral thoracic spine radiographs in a cohort of 1,196 women aged 65 and older (mean = 69.3 years [SD = 4.0]). Using regression models, we evaluated associations of baseline kyphosis with both self-reported functional status and objectively measured gait speed, grip strength, and timed chair stands cross-sectionally and as change assessed over 15 years.nnnRESULTSnIn cross-sectional multivariate analyses, with each 10-degree increment of kyphosis, grip strength was 0.24 kg lower (p = .02), but there were no significant associations between kyphosis and functional status, gait speed, or timed chair stand, likely reflecting the high functioning study participants. In multivariate longitudinal analysis, with each 10-degree increment in baseline kyphosis, there was 0.07 point additional decline in functional status (p = .09), 0.01 m/s more decline in gait speed (p = .07), and 0.32 s greater decline in time to complete five chair stands (p = .004), but no association with decline in grip strength.nnnCONCLUSIONSnGreater magnitude of kyphosis may predict worsening lower extremity function over time in older women. Early recognition and preventative measures against kyphosis progression may help preserve physical function over the long term.

Stability of Kyphosis, Strength, and Physical Performance Gains 1 Year After a Group Exercise Program in Community-Dwelling Hyperkyphotic Older Women

OBJECTIVEnTo determine if subjects maintained improvements in kyphosis, spinal extensor strength, and physical performance 1 year after a 12-week multidimensional group exercise program.nnnDESIGNnFollow-up data compared with posttest outcome measures.nnnSETTINGnOutpatient academic medical center.nnnPARTICIPANTSnNineteen of the initial 21 women, ages 65 to 80, with thoracic kyphosis of 50 degrees or greater at the onset of the study completed follow-up testing.nnnINTERVENTIONSnInitial intervention included multidimensional group exercise performed 2 times a week for 12 weeks, consisting of spinal extensor strengthening, flexibility exercises, and integrated spinal proprioception training. Subjects exercised independently during the following year.nnnMAIN OUTCOME MEASURESnPrimary measures at the 1-year follow-up were usual and best kyphosis. Secondary measures included spinal extensor strength, modified Physical Performance Test (PPT), and the Jug Test.nnnRESULTSnSubjects maintained gains at the 1-year follow-up (P>.05). Best kyphosis improved by 3 degrees during the follow-up year (P=.022). There were no significant declines in usual kyphosis (P=.302), spinal extensor strength (P=.999), PPT (P=.087), and the Jug Test (P=.999) at follow-up.nnnCONCLUSIONSnHyperkyphotic women maintained gains in usual kyphosis, spinal extensor strength, and physical performance 1 year after a group exercise program. Improvement in best kyphosis in the year after the intervention was also observed. Detraining effects may be minimized by multidimensional exercises.

Exercise for Improving Age-Related Hyperkyphotic Posture: A Systematic Review

OBJECTIVEnTo evaluate previous research to determine if exercise can improve preexisting hyperkyphosis by decreasing the angle of thoracic kyphosis in adults aged ≥45 years.nnnDATA SOURCESnPubMed, Embase, and the Cumulative Index to Nursing and Allied Health Literature databases were searched for studies related to posture, exercise, and age ≥45 years. Online conference proceedings of the American Society for Bone and Mineral Research, American Physical Therapy Association, and Gerontological Society of America were also searched.nnnSTUDY SELECTIONnTwo independent reviewers screened the titles and abstracts and selected studies that tested the effect of exercise on measures of kyphosis, or forward head posture, in individuals with hyperkyphosis at baseline (defined as angle of kyphosis ≥40°). Reviews, letters, notes, and non-English language studies were excluded.nnnDATA EXTRACTIONnA pilot-tested abstraction form was used by each reviewer to extract data from each study regarding details of exercise intervention, participant characteristics, safety, adherence, and results. The Cochrane Collaborations tool for assessing risk of bias was used to assess methodologic quality. Discrepancies on the abstraction forms between the 2 reviewers were resolved by a third reviewer. A formal meta-analysis was not performed.nnnDATA SYNTHESISnThirteen studies were abstracted and included in the review; of these, 8 studies saw improvements in ≥1 measure of posture. The main sources of bias were related to blinding participants and incomplete outcome data. The adherence reported across studies suggests that exercise is an acceptable intervention for individuals with age-related hyperkyphosis.nnnCONCLUSIONSnThe scarcity and quality of available data did not permit a pooled estimate of the effect of exercise on hyperkyphotic posture; however, the positive effects observed in high-quality studies suggest some benefit and support the need for an adequately designed randomized controlled trial examining the effect of exercise on hyperkyphosis.

Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain

Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and successfully treating MFPP.