Age related hyperkyphosis, chiropractor Taylorsville UT, and conservative therapy
This post is important for everyone however, it is especially important for our elderly patients. If you remember from the spinal anatomy blog post, the thoracic spine has a curvature which is concave to the front, called a kyphosis. It is important to understand that this curvature is natural due to the shape of the vertebral bodies as well as the intervertebral discs in the thoracic spine. The vertebral bodies as wells as the discs are taller in the back than the front creating a stacking shape that develops a curve. A complication that is common as we age is the exaggeration of this curvature which can develop into a condition called hyperkyphosis, chiropractor Taylorsville UT, sometimes also referred to as a dowager’s hump, or gibbous deformity. In childhood and through the third decade of life the angle of kyphosis averages from 20° to 29°. After 40 years of age the kyphosis angle begins to increase, and more rapidly in women than men. There is reported to be a mean of 43° in women aged 55 to 60 years to a mean of 52° in women 76 to 80 years of age. The same reports of prevalence and incidence of this condition in older adults varies from approximately 20% to 40% among both men and women.
It has been demonstrated that as this kyphosis angle increases, physical performance and quality of life decline, making early intervention a priority. Lets discuss in more detail what the literature says about the negative consequences that have been associated with hyperkyphosis on physical performance.
Women with hyperkyphosis have demonstrated
- difficulty rising from a chair repeatedly without using their arms
- having significantly poorer balance and slower gait velocity
- having a wider base of support with stance and gait
- difficulty reaching and performing heavy housework
- decreased stair climbing speed.
These impairments have been demonstrated to impair mobility to the point where they increase the incidence and risk for falls and fractures in the elderly population. Also, it has been documented that an increase in mortality is the result of these patients having a reduced vital capacity, which is predictive of increased incidence of pulmonary death. It has been suggested that hyperkyphosis development is predominately from muscle weakness and subsequent degenerative disc disease which leads to vertebral fractures and worsening of the condition. This however is not as conclusive as it might sound, for there is no real proof to identify which of these factors happen first and it is most likely that the muscle weakness and disc disease happen simultaneously. It has also been documented that individuals can generate this condition of the same magnitude from different processes.
Regardless of the cause, it has been suggested repeatedly in the literature that the significant negative consequences of hyperkyphosis indicate early conservative intervention. The gold standard orthopaedic technique for assessing the kyphosis angle is a standing lateral xray of the thoracic spine. The measurement of choice is called the cobb angle, which is the same measure used to detect scoliosis. There is also a more conservative measure called the debrunner kyphometer measurement which has been shown to be relatively accurate as well.
Some of the consequences to your musculoskeletal system from this accentuated curve are pain and risk of dysfunction in the shoulder, pelvic girdle, and spine. The forward head posture, scapula protraction, reduced lumbar lordosis, and decreased standing height which is common in postural decompensation syndromes has a negative domino effect on your body. This type of deformity increases the flexion bias of the hips and shoulders which both promote further exacerbation of the problem.
Older women with hyperkyphosis have a 70% increased risk of future fracture, independent of age or prior fracture, and the risk for fracture increases as hyperkyphosis progresses.
Risk factors that have been associated with hyperkyphosis are vertebral fractures (wedging of the anterior vertebral body), muscle weakness, degenerative disc disease, sensory deficits, and decreased mobility.
Lets discuss each of these in a bit more detail. It is important to note however that compression fractures, although a risk factor, are not as common as it would appear without the data.
studies of older adults report only approximately 40% of men and women with the most severe hyperkyphosis have vertebral compression or wedge fractures.
A common radiographic finding associated with hyperkyphosis among older adults is degenerative disc disease. As the anterior disc height is decreased the angle of kyphosis is increased. The majority of older adults 50 to 96 years of age with hyperkyphosis had degenerative disc disease and no evidence of vertebral fractures or osteoporosis, suggesting that hyperkyphosis does not predict fractures or osteoporosis.
Several studies do confirm that hyperkyphosis, chiropractor Taylorsville UT, is associated with spinal extensor muscle weakness. There is also an inverse relationship between grip and ankle strength and kyphosis, suggesting that age related hyperkyphosis may be part of a larger geriatric syndrome associated with adverse health outcomes. Decreased spinal extension mobility occurs with aging, interfering with the ability to stand erect and maintain normal postural alignment. Furthermore, shorter pectoral and hip flexor muscles are linked to severe hyperkyphosis, Age-related deficits in the sensory, visual, and balance systems likely contribute to the loss of upright postural control.
With a loss of proprioceptive and vibratory input from the joints in the lower extremities in elderly adults compared with young adults, the perception of erect vertical alignment becomes impaired. This problem is further increased among older adults wearing bifocals during stair descent.
There is a lack of efficacious medical interventions for hyperkyphosis and exercise rehabilitation should be a first-line approach, particularly because many of the causes of hyperkyphosis are of musculoskeletal origin.
Lets discuss the current treatments for hyperkyphosis. While osteoporosis treatments help to prevent incidence of spinal fractures, no medications have been shown to improve hyperkyphosis, Chiropractor Taylorsville UT. Vertebroplasty and kyphoplasty are surgical procedures primarily used to treat refractory pain following vertebral fractures and they have been shown to reduce kyphosis angle in select patient populations only. The current evidence suggests that physical disability and pain relief may be improved after vertebroplasty and kyphoplasty compared to medical management but only within the first 3 months after the intervention.
Research suggests that forces applied to the spine during exercise can alter the occurrence of subsequent vertebral compression fractures in women with prior fractures. In one study, 68% of the women who performed flexion (bending the trunk forward) exercises developed a subsequent fracture within the following 6 months, compared with only 16% of those who performed extension exercises, suggesting that flexion exercises increase fracture risk. It is important to train individuals with age-related hyperkyphosis to avoid flexion stresses on the spine during exercise and activities of daily living, regardless of whether they have had a prior fracture. Trunk stabilization should avoid curl-up exercises to reduce flexion bias on the spine.
Now lets discuss the importance of thoracic spinal extension. A large randomized trial of prone trunk extension exercises in 60 healthy postmenopausal women, the angle of kyphosis and back extension strength improved among women with the most severe kyphosis and significant weakness of the spinal extensor muscles at base- line, suggesting that hyperkyphosis may be modified by spinal extensor muscle strengthening exercises.
Patients treated with 10 repetitions of prone trunk extension exercises 5 times a week for 1 year while wearing a weighted backpack, at 10- year follow-up showed a significant decrease in the number of compression fractures in the intervention group compared with controls, regardless of kyphosis or strength.
Kyphosis as well as forward head posture were significantly reduced among the compliant exercise groups compared with the noncompliant group in another study that employed respiratory muscle exercises combined with back extensor muscle strengthening and aerobic exercises in a study of 14 women with osteoporosis. They found that respiratory pressures improved 12% to 23%, exercise tolerance increased 13%, and thoracic curvature was reduced 5%
Additional therapies such as myofascial, spinal, and scapular mobilization techniques improve postural alignment in patients with hyperkyphosis. Some active therapeutic movement techniques such as self-mobilization lying on your back on a foam roller has been used successfully in a multidimensional exercise program that reduced kyphosis among hyperkyphotic women.
What does the research say about stretching the kyphosis away? A randomized controlled trial among 118 men and women 60 years and older with kyphosis greater or equal to 40°, participation in modified classical yoga 3 days a week for 24 weeks resulted in a 5% improvement in kyphosis index and a 4.4% improvement in kyphosis angle measured from the flexicurve device. This intervention did not result in statistically significant improvement in kyphometer angle, measured physical performance, or self-assessed health- related quality of life.
Other common treatments are the use of spinal orthosis. The research done on orthosis consisted of a wearing of 2 hours a day for 6 months which did result in an 11% decrease in kyphosis angle, improved standing height, increased spinal extensor strength, and decreased postural sway. Although the orthosis appeared to be beneficial, passive bracing does not provide the beneficial effects of exercise on bone. While not yet studied, bracing used in combination with therapeutic exercises may provide additional beneficial effects. Therapeutic taping may also reduce kyphosis angle according to preliminary research in 15 women with osteoporotic vertebral fractures; those with the greatest initial kyphosis had the greatest reduction in kyphosis with taping evidence supports the use of exercise, bracing, and taping interventions to reduce hyperkyphosis, improves quality of life, and reduce risk for future fractures for men and women. Relatively simple, available, and inexpensive conservative interventions may have a beneficial effect.
Here is a helpful list of Do’s and Don’t’s of postural alignment during exercise and activities of daily living.
Lets start with the Do’s.
- Maintain good postural alignment during exercise.
- Strengthen core stabilizer muscles, such as transversus abdominis, obliques, and multifidus
- When bending or lifting objects, keep the lumbar spine (low back) neutral and bend with your hips and knees while keeping the load close to your body.
- When getting out of bed, roll onto the side before sitting up (log roll)
- When coughing or sneezing, stabilize the trun in neutral by hugging a pillow, or placing both hnds on your knees while hip hinging, or place hand in small of back to help keep neutral.
- Maintain natural curves in your neck and back while sitting and standing. Imagine that you are lengthening the crown of your head.
- If you use a walker, adjust the height to stand up straight and stay within the confines as you walk.
- Avoid seated rowing machines or upper body ergometers
- Avoid crunches, curl-ups, or flexed position (traditional sit-ups)
- Don’t twist or bend your spine when lifting objects
- Don’ sit straight up from a horizontal position
- Avoid forceful trunk flexion while coughing or sneezing
- Avoid leaning over towards your work, or standing in pelvic tilt, bending to reach or push walker
At Camp4, we specialize in functional movement assessment and treatment with manual therapy as well as exercise rehabilitation. If you are a patient who are concerned about this particular condition call the clinic for your appointment.
Wendy B. Man, PT, DPT. Linda Wanek PT, PhD. John A. Shepherd PhD. Deborah E. Sellmeyer MD. Age-Related Hyperkyphosis: Its Causes, Consequences, and Management . Journal of orthopaedic & sports physical therapy. June 2010 vol 40(6)