Physical function in older men with hyperkyphosis

Relationship of total sagittal spinal alignment index of thoracic kyphosis and lumbar lordosis with physical function in community-dwelling older adults

BACKGROUND

Overall spinal curvature is evaluated by calculating the difference between the angles of lumbar lordosis (LL) and thoracic kyphosis (TK) and is expressed as LL minus TK (LL-TK). It is unclear whether LL-TK is associated with physical function in community-dwelling older adults and whether it is more relevant than TK or LL alone.

OBJECTIVE

This study aimed to identify whether LL-TK is associated with physical function in community-dwelling older adults, and whether it is strongly associated than TK or LL alone.

METHODS

The participants comprised 1,674 community-dwelling older adults who underwent physical assessments (women, n = 1,099; mean age, 67.4 ± 5.3 years). As spinal alignment indices, TK and LL were measured using skin surface methods, and LL-TK was calculated as the difference between them. Decreased LL-TK indicated increased overall spinal curvature. Physical function was determined by measuring single-leg standing, five-times chair-stand, and usual gait speed. Stepwise multiple regression analyses were performed with each physical function as the dependent variable and spinal alignment indices as the independent variables, with adjustments.

RESULTS

Multiple regression analyses showed that single-leg standing (β = 0.092, 95% confidence interval [CI] = 0.071 to 0.214, p < .001) and five-times chair-stand (β=-0.142, 95% CI = -0.037 to -0.019, p < .001) were significantly associated with LL-TK, but not LL. Both LL-TK (β = 0.121, 95% CI = 0.001 to 0.004, p < .001) and LL (β = 0.087, 95% CI = 0.001 to 0.003, p = .003) were significant determinants of usual gait speed.

CONCLUSIONS

This study showed that decreased LL-TK may be associated with poor physical function. This association may be stronger than that observed for TK or LL alone.

Effect of taping on posture of thoracic region in patients with thoracic kyphosis using acceleration

BACKGROUND

In the working environment of modern society, a poor sitting posture for a prolonged time may lead to abnormal spinal alignment such as thoracic kyphosis (TK).

OBJECTIVE

This study aimed to evaluate the efficacy of taping for posture correction of patients with TK, providing theoretical and empirical guidance for clinicians attempting to rectify TK posture.

METHODS

The study included 15 subjects aged 30-60 years, all with a TK angle of ⩾ 40∘. Subjects were required to ascend and descend a set of three steps (a low step, high step, and second low step) under three different conditions: without tape assistance, with taping assistance using 20% elongation, and with taping assistance using 40% elongation. A triaxial accelerometer was employed to measure and compare the anterior-posterior (AP), vertical (VT), and medial-lateral (MIL) movements of the thoracic vertebrae in the different conditions.

RESULTS

There were no significant differences in the MIL (P= 0.903) or AP (P= 0.114) movements between the no tape assistance and 20% elongation taping conditions. However, a significant difference was found in the VT movement (P= 0.017). Comparing the no assistance condition to the 40% elongation taping condition, no significant changes were noted in the MIL movement (P= 0.650), but significant differences were detected in both the VT (P= 0.003) and AP movements (P= 0.016). No significant differences were found in any of the three measurements between 20% and 40% elongation taping.

CONCLUSION

Taping serves as an effective method for immediately improving kyphotic posture. It corrects the position of the scapula and cervicothoracic line and exerts passive retraction on the relevant muscles, thus mitigating trunk imbalance.

Effectiveness of Telerehabilitation for Correcting Posture in Elderly with Thoracic Kyphosis in Urban Thailand

Introduction

Thoracic kyphosis (TK) is an abnormal thoracic spine. Telerehabilitation and conventional physical therapy were compared for correct posture in the thoracic angle, forward head posture, back muscle strength, and cost-effectiveness.

Method

Twenty-two Thai women 60 years of age and over, with thoracic angles over 45 degrees, participated in this study. Participants were randomly allocated into a telerehabilitation group (TG) or a control group (CG). TG and CG underwent a thoracic corrective exercise program for 1 hour each session, three times per week for 8 weeks.

Result

Thoracic angle, forward head posture, and back muscle strength improved (P < .05) in both groups. Furthermore, cost-effectiveness showed the cost of intervention in TG lower than CG, approximately 133.78 US$.

Conclusion

Our study showed no difference in telepractice program efficacy and effectiveness compared to in-person treatment in the clinic. Thus, telerehabilitation may be an alternative treatment for the elderly who cannot travel to the hospital.

Hyperkyphosis and mortality risk in older men: The osteoporotic fractures in men study

INTRODUCTION

Hyperkyphosis commonly affects older people but is not widely acknowledged as a clinically actionable problem, especially in men. There are several techniques to quantify kyphosis including the blocks and Cobb angle measurements. This study includes both kyphosis measures to investigate whether older men with accentuated kyphosis may be at increased mortality risk.

METHODS

Men aged ≥65 years (N = 5994) were recruited to participate in the MrOS prospective cohort study from 2000 to 2002 (baseline). Our primary cohort included 2931 enrollees (mean age 79.3 years; SD 5.2) who underwent blocks-measured kyphosis from 2006 to 2009. Our secondary cohort included 2351 participants who underwent radiographic Cobb angle measurements at baseline. Cox proportional hazards analyses were used to determine association between kyphosis and all-cause mortality while adjusting for prevalent radiographic vertebral fractures, bone mineral density, incident fractures, gait speed, timed chair stands, self-reported health, alcohol use, medical co-morbidities, and physical activity.

RESULTS

During a mean follow-up of 8.3 (SD 3.2) years, 1393 participants died in the primary cohort. In this group, compared to men with 0-1 block kyphosis, increasing blocks-measured kyphosis was associated with increased mortality (HR: 1.26-1.53, p trend <0.001). With addition of prevalent vertebral fracture to adjusted models, the association remained significant in participants with severe kyphosis (3+ blocks-measured). Similarly, with addition of chair stand performance the association remained significant for 4+ blocks kyphosis. Walking speed did not attenuate the association of kyphosis and mortality. In the secondary cohort, there were no significant associations between radiographic Cobb angle kyphosis and mortality.

CONCLUSIONS

Increasing blocks-measured kyphosis was associated with a greater risk of mortality in older men, indicating that hyperkyphosis identified on physical exam should be considered a clinically significant finding that may warrant further evaluation and treatment.

Using the specificity and overload principles to prevent sarcopenia, falls and fractures with exercise

The aim of this narrative review is to discuss the evidence on exercise for fall, fracture and sarcopenia prevention, including evidence that aligns with the specificity and progressive overload principles used in exercise physiology, implementation strategies and future research priorities. We also provide a brief discussion of the influence of protein intake and creatine supplementation as potential effect modifiers. We prioritized evidence from randomized controlled trials and systematic reviews. Resistance training can improve muscle mass, muscle strength and a variety of physical performance measures in older adults. Resistance training may also prevent bone loss or increase bone mass, although whether it needs to be done in combination with impact exercise to be effective is less clear, because many studies use multicomponent interventions. Exercise programs prevent falls, and subgroup and network meta-analyses suggest an emphasis on balance and functional training, or specifically, anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility, to maximize efficacy. Resistance training for major muscle groups at a 6-12 repetitions maximum intensity, and challenging balance exercises should be performed at least twice weekly. Choose resistance training exercises aligned with patient goals or movements done during daily activities (task specificity), alongside balance exercises tailored to ability and aspects of balance that need improvement. Progress the volume, level of difficulty or other aspects to see continuous improvement (progressive overload). A critical future priority will be to address implementation barriers and facilitators to enhance uptake and adherence.

Effects of the "Spinomed active" orthosis on chronic back pain in kyphotic women with osteoporotic vertebral fractures three months and older: A randomized controlled study

Vertebral fractures are frequent clinical consequences of osteoporosis. Considering the demographic change in Europe, the number of vertebral fractures will quite likely increase during the next decades. Apart from pharmaceutic agents and physiotherapy, spinal orthoses are established elements of conservative therapy for vertebral (body) fractures. Recent studies on acute vertebral fractures reported positive effects on back pain, kyphosis and functional disabilities, but the efficacy of active strengthening spinal orthoses in vertebral fractures ≥6 months remains to be established. Eighty hyperkyphotic, community-dwelling women ≥65 years with chronic back pain and vertebral fractures occurred ≥3 months ago were randomly allocated to a group which wore the "Spinomed active" orthoses 2 × 2-3 h/d for 16 weeks (SOG: n = 40) or an untreated control group (CG: n = 40). Study outcomes were back pain intensity, kyphosis angle, trunk strength, back pain induced- and general function and disability, functional ability (chair-rise test) and respiratory function. We applied an intention-to-treat analysis; data were consistently adjusted for baseline values applying an ANCOVA. Observing a compliance of 82 ± 14% with the wearing protocol, we determined large and significant favorable effects for back pain (p = .008), back pain-induced physical disability (p < .001) and kyphosis angle (p < .001). We also demonstrated positive effects on trunk strength (p = .049), functional ability (p = .062) and general function and disability (p = .057), although not all of the parameters reach significance. No relevant changes were observed for respiratory function. After a few further individual adjustments of the orthosis (n = 2), no adverse effects were reported. In summary, the present study provided evidence for the efficacy of an active strengthening spinal orthosis ("Spinomed active") in people with vertebral fractures ≥6 months. Based on our results, we recommend expanding the application of the "Spinomed active" orthosis, which was previously validated for acute vertebral fractures, also to older hyperkyphotic women with osteoporotic vertebral fractures ≥3 months.

The Effect of a Comprehensive Corrective Exercise Program on Kyphosis Angle and Balance in Kyphotic Adolescents

This study aimed to investigate the effects of a comprehensive corrective exercise program on the kyphosis angle and balance in kyphotic adolescents. A total of 62 male adolescents (between the ages of 10 and 18, mean BMI 21.7 kg/m2) with a thoracic kyphosis (TK) angle of ≥ 50° were divided into three groups using the simple randomization method: CCEP (comprehensive corrective exercise program), TEP (thoracic exercise program) and control group. The CCEP program consisted of corrective exercises plus postural perception training (PPT). Exercise programs were applied for 40−50 min, 3 days a week for 12 weeks. The kyphosis angle was measured using a flexible ruler, and balance was assessed using the Romberg index obtained from pedobarography. After training, a highly significant reduction in the kyphosis angle was observed in the CCEP and TEP groups (p < 0.001). Comparison among the groups showed a greater reduction in the kyphosis angle in the CCEP group (p < 0.020). Postural perception improved in the CCEP group versus other groups (p < 0.001). Improvement of the Romberg index (balance) was found only in the CCEP group upon within-group comparison (p < 0.001), with no difference among the groups (p > 0.05). The use of postural perception in combination with corrective exercise programs for thoracic kyphosis represents a comprehensive approach, and PPT can increase the effectiveness of the intervention.

The 7th cervical vertebra wall distance (C7WD) identifies balance control, functional mobility and the risk of multiple falls in elderly community-dwelling women with thoracic hyperkyphosis

BACKGROUND

Thoracic hyperkyphosis is common in the elderly, especially in women, and results in impaired balance control, impaired functional mobility and an increased risk of multiple falls. The 7th cervical vertebra wall distance (C7WD) is a practical method for evaluating thoracic hyperkyphosis.

OBJECTIVE

This study calculated C7WD cut-off scores that may identify impaired balance control, impaired functional mobility and an increased risk of multiple falls in elderly community-dwelling women with thoracic hyperkyphosis. This study also explored the correlation between C7WD, balance control and functional mobility.

METHODS

Sixty participants were assessed for thoracic hyperkyphosis using the C7WD, balance control using the functional reach test (FRT), functional mobility using the timed up-and-go test (TUG) and a history of falls using their personal information.

RESULTS

The data indicated that a C7WD of at least 7.95 cm, 8.1 cm and 8.8 cm had a good to excellent capability of identifying impaired balance control, impaired functional mobility and an increased risk of multiple falls, respectively. The C7WD results were significant and correlated with balance control (rs=-0.68) and functional mobility (rs= 0.41).

CONCLUSIONS

The C7WD may be utilised as a screening tool for these three impairments in this population.

The association between the kyphosis angle and physical performance in community-dwelling older adults

BACKGROUND

We investigated prospectively among community-dwelling older adults aged 65 years and over whether a larger kyphosis angle is associated with poorer physical performance (balance, muscle strength or both), and whether this association is unidirectional.

METHODS

ale and female participants performed a multicomponent physical performance test with subscores for gait, muscle strength and balance at baseline and after 2 years. Hand grip strength was also measured at baseline and at follow-up. The Cobb angle was measured on DXA-based Vertebral Fracture Assessments, made at the baseline and follow-up visit. Through linear and logistic regression analysis, we investigated the association between the kyphosis angle and physical performance and vice versa. We stratified for sex, and tested for effect modification by age and study center.

RESULTS

The mean kyphosis angle was 37° and 15% of the participants (n=1220, mean age 72.9±5.7 years) had hyperkyphosis (Cobb angle ≥50°). A larger kyphosis angle at baseline was independently associated with a poorer total physical performance score in women of the oldest quartile (≥77 years) in both the cross-sectional and longitudinal analyses (baseline B-0.32, 95%CI -0.56--0.08; follow-up B 0.32, 95%CI -0.55--0.10). There was no association between physical performance at baseline and kyphosis progression.

CONCLUSIONS

A larger kyphosis angle is independently associated with a poorer physical performance at baseline and over time, and the direction of this association is unidirectional. These results emphasize the importance of early detection and treatment of hyperkyphosis to prevent further worsening of the kyphosis angle, thereby potentially preserving physical performance.

Association of kyphotic posture with loss of independence and mortality in a community-based prospective cohort study: the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS)

OBJECTIVES

This study aimed to investigate the association between kyphotic posture and future loss of independence (LOI) and mortality in community-dwelling older adults.

DESIGN

Prospective cohort study.

SETTING

Two Japanese municipalities.

PARTICIPANTS

We enrolled 2193 independent community-dwelling older adults aged≥65 years at the time of their baseline health check-up in 2008. Kyphotic posture was evaluated using the wall-occiput test (WOT) and classified into three categories: non-kyphotic, mild (>0 and ≤4 cm) and severe (>4 cm).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality and the secondary outcomes were LOI (new long-term care insurance certification levels 1-5) and a composite of LOI and mortality. A Cox proportional hazards model was used to estimate the adjusted HRs (aHRs).

RESULTS

Of the 2193 subjects enrolled, 1621 were included in the primary analysis. Among these, 272 (17%) and 202 (12%) were diagnosed with mild and severe kyphotic postures, respectively. The median follow-up time was 5.8 years. Compared with the non-kyphotic group, the aHRs for mortality were 1.17 (95% CI 0.70 to 1.96) and 1.99 (95% CI 1.20 to 3.30) in the mild and severe kyphotic posture groups, respectively. In the secondary analysis, a consistent association was observed for LOI (mild: aHR 1.70, 95% CI 1.13 to 2.55; severe: aHR 2.08, 95% CI 1.39 to 3.10) and the LOI-mortality composite (mild: aHR 1.27, 95% CI 0.90 to 1.79; severe: aHR 1.83, 95% CI 1.31 to 2.56).

CONCLUSION

Kyphotic posture was associated with LOI and mortality in community-dwelling older adults. Identifying the population with kyphotic posture using the WOT might help improve community health.

The impact of conservative soft orthotic intervention with strapping on thoracic kyphotic posture and spinal mobility in children with cerebral palsy: a randomized control trial

Background

This study mainly aimed to evaluate the influences of Thera Togs orthotic undergarment with its strapping system on dorsal kyphotic posture and spinal mobility in children with spastic diplegic cerebral palsy. The study also investigated the impact of the modulation of thoracic kyphosis on balance and risk of falls in these children.

Study design

This study was a randomized control trial.

Participants

Forty children with diplegic cerebral palsy, aged from 8 to 10 years were met the inclusion criteria and participated in this study. Only 38 children completed the study.

Methods

The children in the control group received 2 h of conventional exercise protocol aiming for modulating thoracic kyphotic posture. The treatment program was conducted 3 times/week, for 12 successive weeks. Children in the study group wore TheraTogs orthoses with the strapping system for 8 h every day in combination with the conventional exercise program.

Outcome measures

For both groups, the primary outcome measures (thoracic kyphotic angle, and thoracic flexion and extension range of motion), and the secondary outcomes (the overall stability index of fall risk test, and the pediatric balance scale score) were recorded at baseline and after completion of the treatment. T test was used to compare the changes within-and between-groups in all measured variables, at baseline and immediately after 12 weeks of treatment.

Results

Children in the study group showed significant improvements in the scores of all primary and secondary measures post-treatment compared to the control group (P < 0.05).

Conclusion

Conservative treatment composed of TheraTogs orthotic system with conventional exercise treatment is effective in modulating thoracic kyphosis and improving dorsal range of motion in children with spastic diplegic cerebral palsy. This improvement has a positive influence on postural balance performance and reduces the risk of fall in these children.

Trial registration

The ClinicalTrial.gov PRS (NCT05063175). 30 September 2021—retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05063175

The association between hyperkyphosis and fall incidence among community-dwelling older adults

Hyperkyphosis, an increased kyphosis angle of the thoracic spine, was associated with a higher fall incidence in the oldest quartile of a large prospective cohort of community-dwelling older adults. Hyperkyphosis could serve as an indicator of an increased fall risk as well as a treatable condition.

INTRODUCTION

Hyperkyphosis is frequently found in adults aged 65 years and older and may be associated with falls. We aimed to investigate prospectively in community-dwelling older adults whether hyperkyphosis or change in the kyphosis angle is associated with fall incidence.

METHODS

Community-dwelling older adults (n = 1220, mean age 72.9 ± 5.7 years) reported falls weekly over 2 years. We measured thoracic kyphosis through the Cobb angle between the fourth and 12th thoracic vertebra on DXA-based vertebral fracture assessments and defined hyperkyphosis as a Cobb angle ≥ 50°. The change in the Cobb angle during follow-up was dichotomized (< 5 or ≥ 5°). Through multifactorial regression analysis, we investigated the association between the kyphosis angle and falls.

RESULTS

Hyperkyphosis was present in 15% of the participants. During follow-up, 48% of the participants fell at least once. In the total study population, hyperkyphosis was not associated with the number of falls (adjusted IRR 1.12, 95% CI 0.91-1.39). We observed effect modification by age (p = 0.002). In the oldest quartile, aged 77 years and older, hyperkyphosis was prospectively associated with a higher number of falls (adjusted IRR 1.67, 95% CI 1.14-2.45). Change in the kyphosis angle was not associated with fall incidence.

CONCLUSIONS

Hyperkyphosis was associated with a higher fall incidence in the oldest quartile of a large prospective cohort of community-dwelling older adults. Because hyperkyphosis is a partially reversible condition, we recommend investigating whether hyperkyphosis is one of the causes of falls and whether a decrease in the kyphosis angle may contribute to fall prevention.

THORACIC HYPERKYPHOSIS DOES NOT INFLUENCE THE BALANCE IN SEDENTARY ELDERLY

ABSTRACT Objective: Evaluate and correlate balance and thoracic hyperkyphosis in sedentary elderly people. Methods: 61 elderly, 14 men and 47 women, mean age of 78.03 ± 9.34, mean weight of 67.80 kg ± 12.82, and mean height of 1.58 m ± 0.09. Balance assessment was performed using the Berg Balance Scale, Romberg Test, and Functional Reach Test, and the Flexicurve method was used to detect thoracic hyperkyphosis. The correlation between the variables was performed using the Bivariate correlation test. Results: The values obtained in the tests were: Flexicurve (65.73º ± 10.57), Berg Balance Scale (44.05 points ± 7.58), Functional Reach Test (16.29 cm ± 6.36), and Romberg Test (89% positive, 11% negative). There was no correlation between the Flexicurve method and the Berg Balance Scale (r = -0.22, p = 0.08); with the Romberg Test (r = -0.08, p = 0.52); and the Functional Range Test (r = 0.13 p = 0.31). Conclusion: Thoracic hyperkyphosis did not influence the balance variables in the elderly sample studied. Level of evidence I; Diagnostic studies - Investigation of a diagnostic test - Test of previously developed diagnostic criteria in consecutive patients (with “gold” reference standard applied).

Dynamic and static postural control among fighter pilots with spinal sagittal plane deformities

Background

Fighter pilots are at high risk for sagittal deformities because they are exposed to in-flight gravitational forces. These patients have reduced proprioception and are susceptible to imbalance. The present study was conducted to assess the dynamic and static postural control among fighter pilots with kyphosis and lordosis.

Methods

This is a causal-comparative study, which was conducted on 40 employed active fighter pilots during 2019. Our aim was to identify their sagittal plane deformity for complementary medical examinations, determine their flight status and reduce the possible related air accident. First, lordosis and kyphosis angles were measured in the standing position. Then, the static balance was measured using the one-leg standing test with the eyes open and closed. Dynamic balance was measured using the star excursion balance test in eight directions with a total of 16 unilateral squats.

Results

Dynamic balance in the hypo-kyphosis was significantly different in all directions, except for postero-lateral and lateral. No significant difference was obtained between the hyper- and hypo-lordosis in dynamic balance in all directions. The mean static balance scores in the hyper-kyphosis group were significantly more than that in the hypo-kyphosis group. There was no significant difference between the hyper- and hypo-lordosis participants with respect to static balance.

Conclusions

The hypo-kyphosis had a significantly higher dynamic balance in all directions, except for posterolateral and lateral, compared to the hyper-kyphosis group. No significant static and dynamic balance differences were observed between the patients with hyper- and hypo-lordosis. The static balance was higher in the hypo-kyphosis rather than hyper-kyphosis under the eyes open and closed. The patients with hyper-lordosis had a higher static balance, rather than hyper-kyphosis.

Validity and reliability of the block method for measuring thoracic hyperkyphosis

OBJECTIVE

This study aimed to investigate the concurrent validity of the block method as compared with the gold standard (Cobb's method). An additional aim was to examine the intra- and inter-rater reliability of expert and novice assessors using the block method.

METHODS

In a cross-sectional study, we enrolled 62 participants with hyperkyphosis aged ≥10 years, with hyperkyphosis defined as one or more blocks. The participants were stratified by age (<60 years and ≥60 years). To determine concurrent validity, and kyphosis was assessed in all the participants using the block method and Cobb's method. Finally, 15 participants were included in a reliability study. To determine intra- and inter-rater reliability, each participant was assessed twice, 7 days apart, by one expert and one novice using the block method.

RESULTS

The concurrent validity of the block method and gold standard method showed moderate correlation (r_s = 0.53, P < .001). However, after stratifying the participants by age (<60 years and ≥60 years), there was small to moderate correlation (r_s = 0.42, P = .006, and r_s = 0.64, P = .002, respectively). The intra- and inter-rater reliability of the expert and novice assessors was excellent (ICC_3,1 = 0.82-0.97, P < .001).

CONCLUSIONS

The findings showed small correlation in those <60 and moderate correlation in those ≥60 years, and reported excellent reliability. The block method can be used by novices with strong reliability. This method is a practical technique for early screening hyperkyphosis in the elderly.

Long-Term Efficacy of Treatment Effects After a Kyphosis Exercise and Posture Training Intervention in Older Community-Dwelling Adults: A Cohort Study

BACKGROUND AND PURPOSE

Treatments that prevent worsening kyphosis are important due to the progressive nature of kyphosis with aging. We assessed long-term efficacy of treatment effects after a short-term kyphosis exercise and posture training intervention in a cohort study among older adults with hyperkyphosis, and investigated whether long-term treatment effects differ among males and females.

METHODS

In the original kyphosis intervention, 112 older adults enrolled in a waitlist design randomized controlled trial. One hundred three participants, mean age 70.0 (5.7) years and kyphosis 52.0° (7.4°), completed a twice weekly, 3-month, group exercise and posture training intervention, and were eligible to enroll in the follow-up study. We compared (1) change in outcomes pre-/postintervention to change postintervention over the follow-up period, (2) change in outcomes pre-/postintervention and postintervention to follow-up, stratified by sex, and (3) long-term change postintervention to follow-up in males and females. Primary outcome was change in kyphometer-measured thoracic kyphosis. Secondary outcomes were change in lumbar lordosis, objective measures of physical function, self-reported measures of physical activity, and health-related quality of life (HRQoL).

RESULTS AND DISCUSSION

Forty-three participants, 42% of the eligible cohort, returned for follow-up, a mean 3.0 (0.7) years after completing the original intervention. Participants (27 females and 16 males) were 73.8 (6.1) years old, with mean kyphosis 48.9° (11.9°) at follow-up. Kyphosis declined -1.5° (95% confidence interval [CI]: -3.9° to 1.0°) postintervention to follow-up and this was no different than change pre-/postintervention, P = .173. Lordosis improved 8.9° (95% CI: 6.2° to 11.6°), more than change pre-/postintervention, P < .001. Gait speed measure of physical function increased 0.08 (95% CI: 0.02 to 0.14) m/s, Physical Activity Scale for the Elderly (PASE) measure of physical activity increased 4 (95% CI: -16 to 24) points, and Patient-Reported Outcomes Measurement Information System (PROMIS) mental health T-score measure of HRQoL increased 1.1 (95% CI: -1.0 to 3.1) points, but these improvements were not significantly more than change pre-/postintervention, P > .050. Other measures of physical function (modified Physical Performance Test [PPT], Timed Up and Go, and 6-minute walk) and HRQoL (Scoliosis Research Society [SRS-30] self-image and PROMIS physical function and physical health) declined at follow-up, significantly more than change pre/postintervention, P ≤ .050. Comparing change in outcomes pre-/postintervention and postintervention to follow-up, stratified by sex, both males and females increased lordosis, and decreased modified PPT and 6-minute walk measures of physical function, P < .050. Males and females differed in long-term change postintervention to follow-up. Time loaded standing and PASE improved in females compared with males, P = .008 and P = .092, respectively, and PROMIS mental health, physical health, and physical function declined in females compared with males, P = .073, P = .025, and P = .005, respectively.

CONCLUSIONS

In our follow-up study, a mean of 3.0 (0.07) years after a 3-month kyphosis exercise and posture training intervention, kyphosis maintained and did not progress as expected with age. There was long-term improvement in lordosis. Compared with treatment effects from the short-term intervention, gait speed maintained equally well in males and females, while trunk endurance improved in females. Further investigation of long-term benefits of a short-term kyphosis exercise and posture training intervention is warranted.

Exploring thoracic kyphosis and incident fracture from vertebral morphology with high-intensity exercise in middle-aged and older men with osteopenia and osteoporosis: a secondary analysis of the LIFTMOR-M trial

Our aim was to explore change in kyphosis and vertebral fracture incidence following 8 months of high-intensity resistance and impact training (HiRIT) or machine-based isometric axial compression (IAC) training in men with osteopenia and osteoporosis. HiRIT and IAC improved posture. HiRIT participants did not experience progression or incident vertebral fracture. IAC participants did experience progression and incident vertebral fracture.

INTRODUCTION

The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial examined efficacy and safety of an eight-month, supervised, high-intensity progressive resistance and impact training (HiRIT) program compared with machine-based isometric axial compression (IAC) training in middle-aged and older men with low areal bone mineral density (aBMD). The primary purpose of the current work was to explore change in thoracic kyphosis and incident fracture from vertebral morphology following eight-months of HiRIT or IAC training. The secondary purpose was to explore change in clinical kyphosis measures for HiRIT, IAC and a non-randomized, matched control group.

METHODS

Men (≥ 45 yrs), with low aBMD, were recruited and randomized to HiRIT or IAC, or designated control. Clinical measures of thoracic kyphosis with inclinometry were determined. Cobb angle of kyphosis and vertebral fracture assessment using the Genant semi-quantitative method were determined from lateral thoracolumbar DXA (Medix DR, Medilink, France). Per-protocol (n = 40) and intention-to-treat (n = 93) analyses were conducted.

RESULTS

Forty participants (HiRIT n = 20, IAC n = 20; 66.1 ± 7.8 yrs.; lumbar spine T-score - 0.1 ± 0.8; femoral neck T-score - 1.5 ± 0.5) underwent clinical kyphosis measures and thoracolumbar DXA at baseline and follow-up. No between-group differences were detected in kyphosis change, however, within-group improvements in neutral (HiRIT - 2.3 ± 0.8°; IAC - 2.5 ± 0.8°) and 'standing tall' (HiRIT - 2.4 ± 0.8°; IAC - 2.0 ± 0.8°) postures were observed (p < 0.05). HiRIT improved Cobb angle (- 3.5 ± 1.5°, p = 0.027) from baseline. Over the 8 months, no incident vertebral fractures nor progression of prevalent vertebral fractures occurred for HiRIT participants. Five incident fractures of thoracic vertebrae occurred for IAC and one wedge fracture progressed. Ninety-three participants underwent clinical kyphosis measures at both time-points (HiRIT n = 34, IAC n = 33, control n = 26). HiRIT exhibited a reduction in 'standing tall' kyphosis compared to control (- 2.3 ± 0.6° versus 1.4 ± 0.7°, p < 0.05), but no other between-group differences were detected.

CONCLUSIONS

Although there was no difference in change between intervention groups, thoracic kyphosis appeared to improve in both HiRIT and IAC with exercise exposure. HiRIT improved 'standing tall' posture in comparison to usual activities. HiRIT was not associated with vertebral fracture progression or incident vertebral fracture, but for some IAC participants there was evidence of progression of vertebral fracture severity and incident vertebral fractures, in our small sample. Larger trials are required to confirm the observations of the current work, which was exploratory in nature.

Kyphosis and 3-year fall risk in community-dwelling older men

Hyperkyhosis is thought to be a fall risk factor in older adults. This large study of older men found that fall risk increased with greater kyphosis measured with the blocks method, but did not find an association between kyphosis and falls when measured by the commonly used the Cobb angle method.

INTRODUCTION

Research suggests an association between hyperkyphosis and falls in community-dwelling older adults, though this has not been investigated within large, population-based studies. This study sought to determine whether two measures of kyphosis prospectively predict fall risk over 3 years among older men.

METHODS

Within the Osteoporotic Fractures in Men Study (MrOS), we conducted two 3-year prospective studies of 2346 and 2928 men. The first group had kyphosis measured by the Cobb angle at visit 1, while the second group had kyphosis assessed with the blocks method at visit 3; both groups then self-reported falls tri-annually for 3 years. Poisson regression with GEE was used to obtain relative risks (RR) of falls.

RESULTS

The fall rates over 3 years were 651/1000 person-years among the visit 1 sample (mean age 74 ± 6 years) and 839/1000 person-years among the visit 3 sample (mean age 79 ± 5 years). In adjusted models of the visit 3 sample, the risk of falls was increased by 12% for each standard deviation increase (1.4 blocks) in the number of blocks required to achieve a neutral head and neck position (RR = 1.12, 95% CI = 1.06, 1.18). The Cobb angle was not associated with falls in the visit 1 sample.

CONCLUSIONS

Although the Cobb angle did not predict falls in community-dwelling older men over 3 years, the blocks method of measuring kyphosis was predictive of falls in this population. This difference could be due to the Cobb angle's focus on thoracic kyphosis, whereas the blocks method may additionally capture abnormal cervical spine curvature.

Evaluation of the Normal Range of Thoracic Kyphosis and Lumbar Lordosis Angles Using EOS Imaging

Background: The use of EOS technology provides information about scoliosis and sagittal balance as well as pelvic parameters. Given that there are few studies about the normal range of kyphosis and lordosis angles in individuals through EOS imaging in Iran, the current study aims to evaluate the normal range of thoracic kyphosis and lumbar lordosis angles using EOS imaging. Material and methods: This cross-sectional descriptive-analytical study was conducted on adult males and females with low back pain who were referred to the Radiology Department of Shahid Sadoughi Hospital, Iran, for spinal imaging during 2016-2018. Kyphosis and lordosis angles were measured by EOS imaging. Information including sex and age were extracted from medical records. Results: In the current study, a total of 403 patients, of which 214 (53.1%) women and 189 (46.9%) men, were classified into four age groups (18-30, 31-40, 41-50 and 51-60 years old). The mean angle of lordosis and kyphosis was 32.42±6.29 and 43.55±6.44, respectively. The mean angle of lordosis in women was greater than men in all age groups. Comparison of kyphosis angle in men and women aged over 40 showed that men had greater values than women. Moreover, there was a significant relation between kyphosis and lordosis in men (r=0.286, p.0.001) and women (r=0.519, p.0.001), respectively. In men, no significant correlation was seen between age and lordosis (p=0.842) and kyphosis (p=0.459). In women, age was not notably associated with either lordosis (r=0.087, p=203) or kyphosis (r=0.010, p=0.123). Conclusion: Assessment of the angle of kyphosis and lordosis can be used to detect early spinal and pelvic anomalies. It is also used for standardization of the spinal column after fracture of the vertebrae or congenital and pathologic defects. Moreover, individuals' age did not affect the angle of kyphosis and lordosis. In addition, the mean angle of lordosis was sex-dependent.

The Clinical Relevance of Hyperkyphosis: A Narrative Review

The kyphosis angle of the thoracic spine tends to increase with aging. Hyperkyphosis is a kyphosis angle, exceeding the normal range. This narrative literature review aims to provide an overview of the current literature concerning kyphosis measurement methods, the etiology and adverse health effects of hyperkyphosis. As of yet, a well-defined threshold for hyperkyphosis is lacking. To attain more generalizability and to be able to compare study results in older adults, we propose to define age-related hyperkyphosis as a Cobb angle of 50° or more in standing position. Hyperkyphosis may be a potentially modifiable risk factor for adverse health outcomes, like fall risk and fractures. Additionally, hyperkyphosis may indicate the presence of osteoporosis, which is treatable. Prospective and intervention studies, using a Cobb angle of 50° as a clear and uniform definition of hyperkyphosis, are warranted to investigate the clinical relevance of hyperkyphosis.

A Longitudinal Study of Trunk Muscle Properties and Severity of Thoracic Kyphosis in Women and Men: The Framingham Study

BACKGROUND

Cross-sectional studies suggest that trunk muscle morphology in the lumbar spine is an important determinant of kyphosis severity in older adults. The contribution of age-related changes in muscle morphology in the thoracic and lumbar spine to progression of kyphosis is not known. Our objective was to determine cross-sectional and longitudinal associations of thoracic and lumbar muscle size and density with kyphosis.

METHODS

Participants were 1,087 women and men (mean age: 61 years) of the Framingham Heart Study who underwent baseline and follow-up quantitative computed tomography (QCT) scanning 6 years apart. We used QCT scans to measure trunk muscle cross-sectional area (CSA, cm2) and density (HU) at the thoracic and lumbar spine and Cobb angle (degrees) from T4 to T12. Linear regression models estimated the association between muscle morphology and kyphosis.

RESULTS

At baseline, smaller muscle CSA and lower density of thoracic (but not lumbar) spine muscles were associated with a larger (worse) Cobb angle in women and men. For example, each standard deviation decrease in baseline thoracic paraspinal muscle CSA was associated with a larger baseline Cobb angle in women (3.7 degrees, 95% CI: 2.9, 4.5) and men (2.5 degrees, 95% CI: 1.6, 3.3). Longitudinal analyses showed that loss of muscle CSA and density at the thoracic and lumbar spine was not associated with progression of kyphosis.

CONCLUSIONS

Our findings suggest that kyphosis severity is related to smaller and lower density trunk muscles at the thoracic spine. Future studies are needed to determine how strengthening mid-back musculature alters muscle properties and contributes to preventing kyphosis progression.

Thoracic vertebral fractures and hyperkyphosis in elderly patients with end-stage kidney disease; do these patients have different clinical outcomes?

BACKGROUND AND OBJECTIVES

Elderly patients with end-stage kidney disease (ESKD) are at high risk for fractures. However, the prevalence of vertebral fractures and hyperkyphosis is not studied well. This is relevant, because in the general population, both vertebral fractures and hyperkyphosis are associated with poor outcome. Therefore, the primary aim of our study was to assess the prevalence of vertebral fractures and hyperkyphosis in the ESKD population. The secondary aim was to assess if patients with vertebral fractures and/or hyperkyphosis more often have poor outcome after starting dialysis, such as accidental falling, functional decline and mortality compared to the patients without vertebral fractures and/or hyperkyphosis.

DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS

This study included patients ≥65 years with ESKD who were enrolled in the Geriatric assessment in Older patients starting Dialysis (GOLD) study of whom a lateral chest radiograph was available. Chest radiographs were scored independently by two observers for vertebral fractures (Genant ≥1) and hyperkyphosis (≥50 degrees). The relation between vertebral fractures and hyperkyphosis with clinical outcomes (falls, decline in ADL and IADL, mortality) was studied using the Chi-square test.

RESULTS

Of the 196 enrolled patients, chest radiographs were available for 160 patients. Mean age was 75.3 (SD ±6.9), and 35% were female. The prevalence of vertebral fractures was 43% and of hyperkyphosis 22%. Patients with hyperkyphosis had a higher one-year mortality compared to patients without hyperkyphosis (20% vs. 8%, p = 0.04). No differences were observed between patients with and without hyperkyphosis, vertebral fractures and the remaining outcomes after six months of follow-up.

CONCLUSIONS

In patients ≥65 years old with ESKD starting dialysis, vertebral fractures are highly prevalent. In contrast to the general population, patients with vertebral fractures did experience poor outcome as often as patients without vertebral fractures. Remarkably, patients with hyperkyphosis did have a higher one-year mortality. However, these patients did not experience more functional decline or accidental falls.

Comparison of grip and pinch strength in young women with and without hyperkyphosis: A cross-sectional study

BACKGROUND

Hyperkyphosis is a common postural defect with high prevalence in the 20 to 50 year old population. It appears to compromise proximal scapular stability. Grip and pinch strength are used to evaluate general upper extremity function.

OBJECTIVE

The aim of this study was to compare pinch and grip strength between young women with and without hyperkyphosis.

METHODS

Thirty young women (18-40 years old) with hyperkyphosis and 30 healthy women matched for age and body mass index participated in the study. Hyperkyphosis was confirmed by measuring the kyphosis angle with a flexible ruler. Grip strength was measured with the Waisa method and a dynamometer. Pinch strength was assessed with a pinch meter.

RESULTS

Grip (P= 0.03) and pinch strength (P= 0.04) were significantly lower in women with hyperkyphosis compared to the control group. Kyphosis angle correlated weakly with grip (r= 0.26) and pinch strength (r= 0.23).

CONCLUSIONS

Hyperkyphotic posture has led to decreased grip and pinch strength compared to people without hyperkyphosis.

Associations Between Lean Mass, Muscle Strength and Power, and Skeletal Size, Density and Strength in Older Men

Studies examining the relationship between muscle parameters and bone strength have not included multiple muscle measurements and/or both central and peripheral skeletal parameters. The purpose of this study was to explore the relationship between lean mass, muscle strength and power, and skeletal size, bone density, and bone strength. We studied the association between appendicular lean mass (ALM), grip strength, and leg power, and central quantitative computed tomography (QCT) parameters in 2857 men aged 65 years or older; peripheral QCT was available on a subset (n = 786). ALM, grip strength, and leg power were measured by dual-energy X-ray absorptiometry (DXA), Jamar dynamometer, and the Nottingham Power Rig, respectively. Multivariable models adjusting for potential confounders including age, race, study site, BMI, and muscle measurements were developed and least squares means were generated from linear regression models. For the multivariable model, percent differences of bone parameters between lowest (Q1) and highest quartiles (Q4) of ALM, grip strength, and leg power were reported. ALM was significantly associated with central and peripheral QCT parameters: percent higher values (Q4 versus Q1) ranging from 3.3% (cortical volumetric bone mineral density [vBMD] of the femoral neck) to 31% (vertebral strength index of the spine). Grip strength was only significantly associated with radial parameters: percent higher values (Q4 versus Q1) ranging from 2.5% (periosteal circumference) to 7.5% (33% axial strength index [SSIx]). Leg power was associated with vertebral strength and lower cross-sectional area with percent lower values (Q4 versus Q1) of -11.9% and -2.7%, respectively. In older men, stronger associations were observed for ALM compared to muscle strength and power. Longitudinal studies are needed to examine the relationship between independent changes in muscle measurements and skeletal size, density and strength. © 2018 American Society for Bone and Mineral Research.

The shape and mobility of the thoracic spine in asymptomatic adults - A systematic review of in vivo studies

A comprehensive knowledge of the thoracic shape and kinematics is essential for effective risk prevention, diagnose and proper management of thoracic disorders and assessment of treatment or rehabilitation strategies as well as for in silico and in vitro models for realistic applications of boundary conditions. After an extensive search of the existing literature, this study summarizes 45 studies on in vivo thoracic kyphosis and kinematics and creates a systematic and detailed database. The thoracic kyphosis over T1-12 determined using non-radiological devices (34°) was relatively less than measured using radiological devices (40°) during standing. The majority of kinematical measurements are based on non-radiological devices. The thoracic range of motion (RoM) was greatest during axial rotation (40°), followed by lateral bending (26°), and flexion (21°) when determined using non-radiological devices during standing. The smallest RoM was identified during extension (13°). The lower thoracic level (T8-12) contributed more to the RoM than the upper (T1-4) and middle (T4-8) levels during flexion and lateral bending. During axial rotation and extension, the middle level (T4-8) contributed the most. Coupled motion was evident, mostly during lateral bending and axial rotation. With aging, the thoracic kyphosis increased by about 3° per decade, whereas the RoM decreased by about 5° per decade for all load directions. These changes with aging mainly occurred in the lower region (T6-12). The influence of sex on thoracic kyphosis and the RoM has been described as partly contradictory. Obesity was found to decrease the thoracic RoM. Studies comparing standing, sitting and lying reported the effect of posture as significant.

Effect of spinal orthoses and postural taping on balance, gait and quality of life in older people with thoracic hyperkyphosis: protocol for a systematic review and meta-analysis

INTRODUCTION

Thoracic hyperkyphosis is one of the most common spinal disorders in older people, creating impairment, postural instability, gait disorders and a reduced quality of life. The use of spinal orthoses and/or postural taping may be feasible conservative interventions, but their efficacy is uncertain. The aim of this review is therefore to investigate the effectiveness of spinal orthoses and taping on the balance and gait of older people with hyperkyphosis.

METHODS AND ANALYSIS

We will include randomised controlled trials and clinical trial studies which assess the efficacy of spinal orthoses and taping using the WHO International Classification of Functioning, Disability and Health (ICF) outcome measures in older people with hyperkyphosis of the thoracic spine. A search will be performed in PubMed, SCOPUS, ISI Web of Knowledge, CENTRAL, EMBASE, CINAHL, AMED, PEDro, REHAB DATA and RECAL databases with no restriction of language. Two independent reviewers will perform the study selection and data extraction. Quality assessment will be implemented using modified Down and Black checklists. Publication bias and data synthesis will be assessed by funnel plots, Begg's and Egger's tests, and plots using STATA software V.12.1 version.

ETHICS AND DISSEMINATION

No ethical issues are predicted. These findings will be published in a peer reviewed journal and presented at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42016045880.

Sex differences in response to targeted kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial

BACKGROUND

Hyperkyphosis, an excessive anterior curvature in the thoracic spine, is associated with reduced health status in older adults. Hyperkyphosis is highly prevalent, more common in older women than men. There is no standard intervention to reduce age-related hyperkyphosis. Sex differences in response to a kyphosis-specific exercise intervention are not known.

METHODS

We conducted a randomized controlled trial of a targeted kyphosis-specific exercise and postural training program on the primary outcome Cobb angle of kyphosis, and investigated whether the magnitude of change differed between men and women. One hundred twelve participants aged ≥60 years with kyphosis ≥40° were enrolled and randomized to exercise or waitlist control, and 101 participants had analyzable baseline and follow-up radiographs for Cobb angle measurements. A group intervention including 10 participants per group was delivered by a physical therapist, 1-h, twice a week for 3-months. Controls were placed on a waitlist for 3 months before receiving a delayed intervention. Primary outcome was change from baseline to 3-months in Cobb angle measured from standing lateral spine radiographs. Secondary outcomes included change over 3-months in kyphometer-measured kyphosis, physical function and quality of life. Groups were combined for analysis after both received the intervention, and sex differences in response to the intervention were tested with ANOVA.

RESULTS

Participants (60 women, 41 men) were 70.0 (SD = 5.7) years old with mean Cobb angle 55.9 (SD = 12.2) degrees at baseline. The active group had higher baseline modified Physical Performance Test scores than control, p = 0.03. Men had greater baseline kyphometer-measured kyphosis, p = 0.09, and higher bone mineral density (BMD), spine strength, more vertebral fractures and diffuse idiopathic skeletal hyperostosis (DISH) than women, p ≤ 0.01. There was no statistically significant difference between groups in change in Cobb at 3-months, p = 0.09, however change in kyphometer-measured kyphosis differed by 4.8 (95% CI:-6.8,-2.7) degrees, p < 0.001, favoring the active group. There were no differences between men and women in change in either kyphosis measurement after intervention, p > 0.1.

CONCLUSIONS

A 3-month targeted spine strengthening exercise and posture training program reduced kyphometer-measured, but not radiographic-measured kyphosis. Despite sex differences in baseline kyphosis, BMD, spine strength, fractures and DISH, sex did not affect treatment response.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01766674.

Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial

A 6-month randomized controlled trial of spine-strengthening exercise and posture training reduced both radiographic and clinical measures of kyphosis. Participants receiving the intervention improved self-image and satisfaction with their appearance. Results suggest that spine-strengthening exercise and postural training may be an effective treatment option for older adults with hyperkyphosis.

INTRODUCTION

The purpose of the present study is to determine in a randomized controlled trial whether spine-strengthening exercises improve Cobb angle of kyphosis in community-dwelling older adults.

METHODS

We recruited adults ≥60 years with kyphosis ≥40° and enrolled 99 participants (71 women, 28 men), mean age 70.6 ± 0.6 years, range 60-88, with baseline Cobb angle 57.4 ± 12.5°. The intervention included group spine-strengthening exercise and postural training, delivered by a physical therapist, 1-h, three times weekly for 6 months. Controls received four group health education meetings. The primary outcome was change in the gold standard Cobb angle of kyphosis measured from standing lateral spine radiographs. Secondary outcomes included change in kyphometer-measured kyphosis, physical function (modified Physical Performance Test, gait speed, Timed Up and Go, Timed Loaded Standing, 6-Min Walk), and health-related quality of life (HRQoL) (PROMIS global health and physical function indexes, SRS-30 self-image domain). ANCOVA was used to assess treatment effects on change from baseline to 6 months in all outcomes.

RESULTS

There was a -3.0° (95% CI -5.2, -0.8) between-group difference in change in Cobb angle, p = 0.009, favoring the intervention and approximating the magnitude of change from an incident vertebral fracture. Kyphometer-measured kyphosis (p = 0.03) and SRS-30 self-esteem (p < 0.001) showed favorable between-group differences in change, with no group differences in physical function or additional HRQoL outcomes, p > 0.05.

CONCLUSIONS

Spine-strengthening exercise and posture training over 6 months reduced kyphosis compared to control. Our randomized controlled trial results suggest that a targeted kyphosis-specific exercise program may be an effective treatment option for older adults with hyperkyphosis.

TRIAL REGISTRATION NUMBER AND NAME OF TRIAL REGISTER

ClinicalTrials.gov; identifier NCT01751685.

Thoracic Kyphosis and Physical Function: The Framingham Study

OBJECTIVE

To evaluate the association between thoracic kyphosis and physical function.

DESIGN

Prospective cohort.

SETTING

Framingham, Massachusetts.

PARTICIPANTS

Framingham Heart Study Offspring and Third Generation cohort members who had computed tomography (CT) performed between 2002 and 2005 and physical function assessed a mean 3.4 years later (N = 1,100; mean age 61 ± 8, range 50-85).

MEASUREMENTS

Thoracic kyphosis (Cobb angle, T4-T12) was measured in degrees using supine CT scout images. Participants were categorized according to Cobb angle to compare those in the highest quartile (Q4, most-severe kyphosis) with those in the lowest quartiles (Q1-Q3). Quick walking speed (m/s), chair-stand time (seconds), grip strength (kg), and self-reported impairments were assessed using standardized procedures. Analyses were adjusted for age, height, weight, smoking, follow-up time, vertebral fractures, and prevalent spinal degeneration.

RESULTS

Thoracic kyphosis was not associated with physical function in women or men, and these results were consistent in those younger than 65 and those aged 65 and older. For example, walking speed was similar in adults younger than 65 with and without severe kyphosis (women, Q4: 1.38 m/s, Q1-Q3: 1.40 m/s, P = .69; men, Q4: 1.65 m/s, Q1-Q3: 1.60 m/s; P = .39).

CONCLUSION

In healthy relatively high-functioning women and men, kyphosis severity was not associated with subsequent physical function. Individuals at risk of functional decline cannot be targeted based on supine CT thoracic curvature measures alone.

Severity of Kyphosis and Decline in Lung Function: The Framingham Study

Background

Hyperkyphosis reduces the amount of space in the chest, mobility of the rib cage, and expansion of the lungs. Decline in pulmonary function may be greater in persons with more severe kyphosis; however, no prospective studies have assessed this association. We conducted a longitudinal study to quantify the impact of kyphosis severity on decline in pulmonary function over 16 years in women and men.

Methods

Participants included a convenience sample of 193 women and 82 men in the Framingham Study original cohort (mean age: 63 years; range: 50-79 years), who had measurements of kyphosis angle from lateral spine radiographs obtained in 1972-1976 and forced expiratory volume in 1 second (FEV1) from spirometry taken four times over 16 (±1.87) years from 1972 through 1988.

Results

Kyphosis severity was associated with greater decline in FEV1 in women but not in men. Adjusted mean change in FEV1 over 16 years was -162, -245, and -261mL (trend, p = .02) with increasing tertile of kyphosis angle in women and -372, -297, and -257mL (trend, p = .20) in men, respectively.

Conclusions

This longitudinal study found that kyphosis severity increased subsequent decline in pulmonary function in women but not in men. Reasons for an association between kyphosis and pulmonary function in women but in not men may be due, at least in part, to the small number of men in our study. Nevertheless, our findings suggest that preventing or slowing kyphosis progression may reduce the burden of pulmonary decline in older adults.

Exercise, muscle, and the applied load-bone strength balance

A fracture occurs when the applied load is greater than the bone can withstand. Clinical practice guidelines for the management of osteoporosis include recommendations for exercise; one of the few therapies where the proposed anti-fracture mechanisms that include effects on both bone strength and applied loads, where applied loads can come in the form of a fall, externally applied loads, body weight, or muscle forces. The aim of this review is to provide an overview of the clinical evidence pertaining to the potential efficacy of exercise for preventing fractures in older adults, including its direct effects on outcomes along the causal pathway to fractures (e.g., falls, posture, bone strength) and the indirect effects on muscle or the muscle-bone relationship. The evidence is examined as it pertains to application in clinical practice. Considerations for future research are discussed, such as the need for trials in individuals with low bone mass or students that evaluate whether changes in muscle mediate changes in bone. Future trials should also consider adequacy of calorie or protein intake, the confounding effect of exercise-induced weight loss, or the most appropriate therapeutic goal (e.g., strength, weight bearing, or hypertrophy) and outcome measures (e.g., fracture, disability, cost-effectiveness).

Heritability of Thoracic Spine Curvature and Genetic Correlations With Other Spine Traits: The Framingham Study

Hyperkyphosis is a common spinal disorder in older adults, characterized by excessive forward curvature of the thoracic spine and adverse health outcomes. The etiology of hyperkyphosis has not been firmly established, but may be related to changes that occur with aging in the vertebrae, discs, joints, and muscles, which function as a unit to support the spine. Determining the contribution of genetics to thoracic spine curvature and the degree of genetic sharing among co-occurring measures of spine health may provide insight into the etiology of hyperkyphosis. The purpose of our study was to estimate heritability of thoracic spine curvature using T4 -T12 kyphosis (Cobb) angle and genetic correlations between thoracic spine curvature and vertebral fracture, intervertebral disc height narrowing, facet joint osteoarthritis (OA), lumbar spine volumetric bone mineral density (vBMD), and paraspinal muscle area and density, which were all assessed from computed tomography (CT) images. Participants included 2063 women and men in the second and third generation offspring of the original cohort of the Framingham Study. Heritability of kyphosis angle, adjusted for age, sex, and weight, was 54% (95% confidence interval [CI], 43% to 64%). We found moderate genetic correlations between kyphosis angle and paraspinal muscle area (ρˆG , -0.46; 95% CI, -0.67 to -0.26), vertebral fracture (ρˆG , 0.39; 95% CI, 0.18 to 0.61), vBMD (ρˆG , -0.23; 95% CI, -0.41 to -0.04), and paraspinal muscle density (ρˆG , -0.22; 95% CI, -0.48 to 0.03). Genetic correlations between kyphosis angle and disc height narrowing (ρˆG , 0.17; 95% CI, -0.05 to 0.38) and facet joint OA (ρˆG , 0.05; 95% CI, -0.15 to 0.24) were low. Thoracic spine curvature may be heritable and share genetic factors with other age-related spine traits including trunk muscle size, vertebral fracture, and bone mineral density. © 2016 American Society for Bone and Mineral Research.

Cross-Sectional and Longitudinal Associations of Diffuse Idiopathic Skeletal Hyperostosis and Thoracic Kyphosis in Older Men and Women

OBJECTIVE

To investigate cross-sectional and longitudinal associations of diffuse idiopathic skeletal hyperostosis (DISH) and thoracic kyphosis in older persons.

METHODS

DISH and kyphosis were assessed in 1,500 men from the Osteoporotic Fractures in Men (MrOS) study and in 1,267 women from the Study of Osteoporotic Fractures (SOF). DISH was assessed using baseline lateral spine radiographs, and Cobb angle of kyphosis was measured from baseline and followup radiographs, a mean 4.6 years later in men, and 3.7 and 15 years later in women. Linear regression was used to analyze associations of DISH with baseline Cobb angle and with percent annualized change in Cobb angle. We tested for heterogeneity among studies.

RESULTS

DISH was identified in 222 participants in MrOS (15%) and in 156 participants in SOF (12%). Participants with DISH in both cohorts had higher baseline Cobb angles (P < 0.05), after adjustment for covariates. After approximately 4 years of followup, there was no significant difference in annualized percent change in Cobb angle in those with DISH compared to those without DISH (P > 0.05) for men or women. Women with DISH had less kyphosis progression over 15 years (0.25% less annualized change in Cobb) than those without DISH.

CONCLUSION

Prevalent DISH is associated with greater kyphosis in older men and women, and is not significantly associated with a change in kyphosis over 4-5 years. However, in women followed over 15 years, DISH was associated with less progression of kyphosis. These results suggest that DISH influences kyphosis and may slow progression over the long term. Additional studies of DISH/kyphosis associations are warranted to understand the functional implications of this finding.

Reliability and Validity of Nonradiologic Measures of Forward Flexed Posture in Parkinson Disease

OBJECTIVE

To examine the intertester reliability and validity of 5 nonradiologic measures of forward flexed posture in individuals with Parkinson disease (PD).

DESIGN

Cross-sectional observational study.

SETTING

University outpatient facility and community centers.

PARTICIPANTS

Individuals (N=28) with PD with Hoehn and Yahr scores of 1 through 4.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occiput to wall status, tragus to wall distance, C7 to wall distance, photographically derived trunk flexion angle, and inclinometric kyphosis measure.

RESULTS

Participants were older adults (mean, 69.7±10.6y) with a 14-month to 15-year (mean, 5.9±3.5y) history of PD. Intertester reliability was excellent for all measures (κ=.89 [cued condition] and 1.0 [relaxed condition] for occiput to wall status; intraclass correlation coefficients, .779-.897 for tragus to wall distance, C7 to wall distance, flexion angle, and inclinometric kyphosis measure). Convergent validity was supported for all measures by significant correlations between the same measures obtained during relaxed and cued conditions (eg, occiput to wall relaxed and cued) and for most measures by significant correlations between measures obtained under the same condition (eg, occiput to wall cued and tragus to wall cued). Significant correlations between tragus to wall distance, C7 to wall distance, flexion angle, and inclinometric kyphosis measure and the Unified Parkinson Disease Rating Scale item 28 (posture) also supported convergent validity. Significant differences between tragus to wall distance, C7 to wall distance, and inclinometric kyphosis measure values under relaxed and cued conditions supported known condition validity. Known group validity was demonstrated by significant differences in tragus to wall distance, C7 to wall distance, and inclinometric kyphosis measure obtained from individuals able and individuals unable to touch their occiput to wall when cued to stand tall.

CONCLUSIONS

Tragus to wall distance, C7 to wall distance, and inclinometric kyphosis measure are reliable and valid nonradiologic measures of forward flexed posture in PD.

Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With Hyperkyphosis

BACKGROUND

Hyperkyphosis negatively affects health status, physical mobility, and quality of life, but there is no standard protocol for treating people with hyperkyphosis. Treatment options include targeted exercise.

OBJECTIVES

This single-site randomized controlled trial (RCT) will determine the efficacy of a targeted multimodal spine-strengthening exercise program, compared with no exercise intervention, among community-dwelling men and women aged ≥60 years.

DESIGN

The RCT is a parallel-group design, with 1:1 randomization to exercise and attentional control groups.

SETTING

The study will be conducted at one primary site (one academic medical center partnered with one local community medical center).

PARTICIPANTS

One hundred men and women, aged ≥60 years, with thoracic kyphosis ≥40 degrees will be randomized.

INTERVENTION

The targeted multimodal spine-strengthening exercise intervention includes exercise and postural training delivered by a physical therapist in a group of 10 participants, 3 times a week for 6 months. Controls receive monthly health education meetings in a group of 10 participants and monthly calls from the study coordinator to monitor physical activity and any adverse events.

MEASUREMENTS

The primary outcome is change in Cobb angle of kyphosis measured from lateral spine radiographs at baseline and 6 months. Secondary outcomes include change in physical function (assessed with the modified Physical Performance Test, Timed "Up & Go" Test, timed loaded standing, 4-m walk, and Six-Minute Walk Test) and health-related quality of life (assessed with the modified Scoliosis Research Society instrument [SRS-30] self-image domain and Patient Reported Outcomes Measurement Information System [PROMIS] global health and physical function indexes). Additional secondary outcomes include pain, physical activity level, spinal flexion and extension muscle strength, paraspinal extensor muscle density, and adverse events.

LIMITATIONS

Blinding of the participants and instructors providing the intervention is not possible.

CONCLUSIONS

The efficacy of a high-quality, adequately powered exercise intervention in men and women with kyphosis ≥40 degrees will be evaluated to determine whether targeted multimodal spine-strengthening exercise reduces hyperkyphosis in older adults and improves important secondary outcomes of physical function and health-related quality of life.

Correlations among four measures of thoracic kyphosis in older adults

SUMMARY

There are many ways to measure thoracic kyphosis ranging from simple clinical to more complex assessments. We evaluated the correlation among four commonly used kyphosis measures: Cobb angle, Debrunner kyphometer, kyphotic index, and the blocks method. Each measure was correlated with the others, confirming high clinical and research applicability.

INTRODUCTION

The purpose of this study was to assess the associations among four commonly used measures of thoracic kyphosis in older adults.

METHODS

Seventy two men and women aged 65-96 were recruited from the San Diego community. Four kyphosis measures were assessed in the same person during a baseline clinic visit. Two measures were done in the lying (L) and two in the standing (ST) position: (1) Cobb angle calculated from dual X-Ray absorptiometry (DXA) images (L), (2) Debrunner kyphometer (DK) angle measured by a protractor (ST), (3) kyphotic index (KI) calculated using an architect's flexicurve ruler (ST), and (4) the blocks method involving counting the number of 1.7 cm-thick blocks required to achieve a neutral head position while lying flat on the DXA table (L). Spearman rank correlation coefficients were used to determine the strength of the association between each kyphosis measure.

RESULTS

Using the Cobb angle as the gold standard, the blocks method demonstrated the lowest correlation (r(s) = 0.63, p < 0.0001), the Debrunner method had a moderate correlation (r(s) = 0.65, p < 0.0001), and the kyphotic index had the highest correlation (r(s) = 0.68, p < 0.0001). The correlation was strongest between the kyphotic index and the Debrunner kyphometer (r(s) = 0.76, p < 0.0001).

CONCLUSION

In older men and women, all four measures of thoracic kyphosis were significantly correlated with each other, whether assessed in the lying or standing position. Thus, any of these measures demonstrate both potential clinical and research utility.

Kyphosis and Sleep Characteristics in Older Persons: The Rancho Bernardo Study

BACKGROUND

Kyphosis is a forward curvature of the thoracic spine that is associated with multiple adverse health outcomes. This cross-sectional study examined the association between kyphosis and sleep characteristics.

METHODS

Participants were 468 white, community-dwelling individuals (women = 255; men = 213) from the Rancho Bernardo cohort who had kyphosis assessed using a flexicurve ruler at a 2007-09 follow-up research clinic visit and sleep quality assessed by mailed survey in 2010 with the Pittsburgh Sleep Quality Index (PSQI), scored 0-18, with >5 indicative of poor sleep quality.

RESULTS

Women had a mean age of 73.3 ± 8.8 years; men 74.2 ± 8.1 years. Mean flexicurve measures were 12.6 ± 3.2 for women and 12.1 ± 2.6 for men. No significant associations were found between kyphosis and any self-reported sleep measure in men, but women with worse kyphosis had poorer sleep quality, based on total PSQI score and two PSQI subcomponents. In women, with each unit increase in kyphosis, after adjusting for age, marital status, height, general health, calcium supplement use, estrogen use, exercise, arthritis, and depression, there was an associated increase in total PSQI score, indicating worse sleep quality (standard β-estimate = 1.37, 95% CI: 1.03, 1.82). Women with worse kyphosis were also more likely to sleep ≤ 7 hours (Odds Ratio (OR) = 1.11, 95% CI: 1.02, 1.22) and report use of sleep medications (OR = 1.14, 95% CI: 1.03, 1.25).

CONCLUSIONS

In women only, those with worse flexicurve kyphosis had worse scores on the PSQI, slept fewer hours (≤ 7 hours) and were more likely to report sleep medication use than those with less kyphosis. The association between kyphosis and objective sleep measures in older persons deserves further investigation.