The Association Between Physical Function and Hyperkyphosis in Older Females: A Systematic Review and Meta-analysis.

BACKGROUND AND PURPOSE: Thoracic hyperkyphosis may adversely influence physical function in older adults, but the literature is mixed and confounded by possible sex differences. This systematic review and meta-analysis aimed to examine the association between hyperkyphosis and physical function in older females. METHODS: Scopus, ISI Web of Science, Cochrane Library, PubMed, CINAHL, and PEDro databases were searched through 2021 for studies that included measures of thoracic hyperkyphosis and physical function with extractable data for women older than 60 years. Studies were excluded if they were qualitative, case reports, case series, ecological studies, reviews, or were not published in English. The study quality and risk of bias were assessed using checklists from the National Heart, Lung, and Blood Institute. Data were synthesized using Cohen's d effect size and 95% confidence interval (CI), and random-effects models were used for the meta-analyses. RESULTS AND DISCUSSION: Three cohort and 22 cross-sectional studies of fair to good quality met the inclusion criteria. Eight studies reporting single-group data showed a moderate association between greater kyphosis angles and lower physical function ( d = -0.57; 95% CI -0.73, -0.40). Fourteen studies reporting 2-group data showed a large negative effect on physical function for groups with greater kyphosis angles ( d = -1.16; 95% CI -1.53, -0.78). Three studies that reported multivariate data also tended to show negative associations between physical function and hyperkyphosis. Limitations include a relative lack of causal evidence; confirming causation requires additional longitudinal studies. Studies have assessed various physical function categories, including strength, gait, and balance. Future studies could determine the categories of function most affected so that preventive interventions could target hyperkyphosis appropriately. CONCLUSIONS: Hyperkyphosis was associated with lower physical function in older women. Three cohort studies suggest that greater kyphosis angles may predict greater loss of physical function over time. These results imply that therapies that help to minimize hyperkyphosis may help preserve function in older women.

Factors associated with the 6-minute walk test performance in older adults with hyperkyphosis.

Age-related hyperkyphosis is associated with adverse health outcomes, such as falls, fractures, and mortality. However, few studies investigated the relationship between the severity of hyperkyphosis and physical endurance in older adults. This study examined whether a degree of hyperkyphosis curvature was independently associated with the 6-minute walk test (6MWT) distance. We analyzed the baseline data of 112 older adults aged 60-92 enrolled in the Specialized Center of Research (SCOR) Kyphosis trial. The majority of the sample had at least a college degree and were white. On average, participants walked 503.9 (SD 82.3) meters in 6 minutes. Multivariate regression results showed that the degree of hyperkyphosis curvature was not independently associated with the 6MWT distance, but taller height, lighter weight, and less prescription medication were significant predictors of better performance on the 6MWT distance. Validation of the study findings in a large, diverse older adult population is warranted.

Slower upper extremity function in older adults with hyperkyphosis negatively impacts the 6-min walk test.

BACKGROUND: Approximately 30% to 40% of older adults have hyperkyphosis, defined as excessive curvature of the thoracic spine. Hyperkyphosis is associated with increased morbidity and mortality. This study aimed to determine whether hyperkyphosis (Cobb's angle) and upper extremity tasks were independently associated with the 6-min walk test (6MWT) in community-dwelling older adults with hyperkyphosis. METHODS: In this cross-sectional study, we studied 71 women and 28 men aged 60-87 from the study of hyperkyphosis, exercise, and function trial (SHEAF) who had kyphosis, 3 timed upper extremity tasks and the 6MWT assessed at their baseline visit. We used standing lateral spine radiographs and a standardized protocol for thoracic kyphosis (T4-T12) to measure Cobb angle of kyphosis. In addition, 3 activity of daily living (ADL) extremity tests (putting on and removing a laboratory coat, picking up a penny from the floor, and lifting a 7-lb. book to a shelf) were used. RESULTS: The mean ± SD age was 70.1 ± 6.1 years. The mean ± SD Cobb angle of kyphosis was 57.4 ± 12.5 degrees. On average ± SD, the participants walked 504.8 ± 84.2 m in 6 min and took 2.4 ± 2.2 prescription medications. The mean ± SD height was 164.7 ± 8.5 cm, weight was 68.7 ± 13.1 kg, and BMI was 25.2 ± 4.0 kg/m2. Multivariate regression revealed that age, height, upper extremity book lift task, and the number of prescribed medications were significant predictors of performance on the 6MWT (p < 0.05). CONCLUSIONS: While kyphosis was not associated with the 6MWT, timed tests of upper extremity function indicated that upper body dynamics can affect walking performance. In addition, sociodemographic factors and the number of prescribed medications were significant contributing factors to the 6MWT in older adults with mild to moderate hyperkyphosis. These results illustrate multifactorial influences on physical performance and the need for an integrated and targeted approach in helping older hyperkyphotic adults maintain healthy physical functioning as they age.

Lumbar motor control training as a complementary treatment for chronic neck pain: A randomized controlled trial.

OBJECTIVE: We investigated whether adding lumbar motor control training with a pressure biofeedback unit improves outcomes of a conservative deep cervical flexor motor control program on neck pain, neck disability, deep cervical flexor endurance, and health status in middle-aged patients with chronic neck pain and forward head posture after eight weeks of interventions. DESIGN: Randomized controlled trial. SETTING: Outpatient setting. SUBJECTS AND INTERVENTIONS: A total of 113 males and females (mean age 39 ± 5 years) with chronic neck pain were randomized to three treatment groups, group 1 (n = 38) combined deep cervical flexor motor-control training and lumbar motor control exercise, group 2 (n = 37) deep cervical flexor motor control training alone, and group 3 (n = 38) passive treatment and education. MAIN OUTCOME MEASURES: Pain, neck disability, deep cervical flexor muscular endurance, and health status. RESULTS: There were significant improvements in the combination group compared with the deep cervical flexor motor-control group alone (d = 2.03, 95% confidence interval (CI): -2.8 to -1.27, P = 0.021) for pain (d = -0.99, 95% CI = -1.75 to -0.23, P = 0.023), disability (d = 1.92, 95% CI = 0.86 to 2.98, P = 0.001), deep cervical flexor endurance, and (d = -2.75, 95% CI = -8.81 to -1.68, P = 0.037) for health status favoring the combination group. There were significant between-group differences favoring both active groups versus the passive control in all out comes. CONCLUSION: The addition of Lumbar motor control training as a complementary treatment may enhance effectiveness of deep cervical flexor motor control training on neck pain, neck disability, and deep cervical flexor endurance in patients with chronic moderate neck pain and forward head posture.

Secondary analysis of change in physical function after exercise intervention in older adults with hyperkyphosis and low physical function.

BACKGROUND: Hyperkyphosis is common in older adults and associated with low physical function and reduced health related quality of life (HrQol). Improved kyphosis has been previously established in kyphosis-targeted interventions in randomized controlled trials in older adults with hyperkyphosis; however, evidence for improved physical function is conflicting. Few studies have investigated change in physical function after a targeted kyphosis intervention in older adults with low physical function. The primary aim in this descriptive study was to explore change in physical function after a progressive high-intensity 3-month targeted kyphosis exercise and posture training intervention in older adults with low physical function and hyperkyphosis. Secondary aims were to explore change in HrQol, spinal strength and spinal curvature, and adherence and safety of the intervention. METHODS: In this secondary analysis of the Specialized Center of Research (SCOR) Kyphosis randomized trial, 101 community dwelling older men and women with hyperkyphosis who completed the intervention were divided into a low function group (LFG) and high function group (HFG). Baseline characteristics were compared between LFG and HFG. Physical function, HrQol, spinal strength and spinal curvature (kyphosis and lordosis) pre/post intervention change scores were explored within and between groups. Adherence and adverse events were examined in the LFG and HFG. RESULTS: Twenty-six (26%) older adults were LFG, mean Short Phyiscal Performance Battery (SPPB) 9.62 (SD = 1.17) points. At baseline, the LFG was older than HFG (p = 0.005), experienced more pain, (p = 0.060), had worse physical function and HrQol (p ≤ 0.001), and comparable kyphosis (p = 0.640). SPPB changed 0.62 (95% CI: - 0.20 to 1.44) points in the LFG and - 0.04 (95%CI: - 0.28 to 0.19) points in the HFG, p = 0.020. Gait speed changed 0.04 (95% CI: - 0.02 to 0.10) m/s in the LFG. Kyphosis improved equally in both groups. Adherence to the intervention was 83% in the LFG and 79% in the HFG. There were no adverse events in either group. CONCLUSIONS: Older adults with low physical function and hyperkyphosis may improve physical function after a kyphosis targeted intervention. Older adults with low physical function may safely participate in targeted high-intensity kyphosis exercise and posture training. This observation needs to be confirmed in larger adequately powered studies. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01766674 .

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.

Feasibility and Acceptability of Technology-Based Exercise and Posture Training in Older Adults With Age-Related Hyperkyphosis: Pre-Post Study.

Background: Hyperkyphosis is common among older adults, and is associated with multiple adverse health outcomes. A kyphosis-specific exercise and posture training program improves hyperkyphosis, but in-person programs are expensive to implement and maintain over longer-periods of time. It is unknown if a technology-based posture training program disseminated through a smartphone is a feasible or acceptable alternative to in-person training among older adults with hyperkyphosis. Objective: The primary purpose of this study was to assess the feasibility of subject recruitment, short-term retention and adherence, and the acceptability of a technology-based exercise and postural training program disseminated as video clip links and text messaging prompts via a smartphone. The secondary purpose was to explore the potential efficacy of this program on kyphosis, physical function and health-related quality of life in older adults with hyperkyphosis. Methods: This was a 6-week pre-post design pilot trial. We recruited community-dwelling adults ≥65 years with hyperkyphosis ≥40 (±5) degrees and access to a smartphone. The intervention had two parts: 1) exercise and posture training via video clips sent to participants daily via text messaging which included 6 weekly video clip links to be viewed on the participant's smartphone and 2) text messaging prompts to practice good posture. We determined subject recruitment, adherence, retention and acceptability of the intervention. Outcomes included change in kyphometer-measured kyphosis, occiput to wall (OTW), Short Physical Performance Battery (SPPB), Scoliosis Research Society SRS-30, Center for Epidemiological Studies Depression (CESD) and Physical Activity Scale for the Elderly (PASE). Results: 64 potential participants were recruited, 17 participants were enrolled and 12 completed post-intervention testing at 6-weeks. Average age was 71.6 (SD=4.9) years and 50% were female. Median adherence to daily video viewing was 100%, (range 14 to 100) and to practicing good posture 3 times or more per day was 71%, (range 0 to 100). Qualitative evaluation of acceptability of the intervention revealed the smartphone screen was too small for participants to view the videos well and daily prompts to practice posture were too frequent. Kyphosis, OTW and physical activity significantly improved after the 6-week intervention. Kyphosis decreased by 8 (95% CI: 12, 5) degrees (p<0.001), OTW decreased 1.9 (95% CI: 3.3, 0.7) cm (p=0.007), and physical activity measured by PASE increased 29 (95% CI: 3, 54) points (p=0.03). The health-related quality of life SRS-30 score increased 0.11 (SD=0.19) points, but it was not statistically significant, p=0.09. Conclusions: Technology-based exercise and posture training using video clip viewing and text messaging reminders is feasible and acceptable in a small cohort of older adults with hyperkyphosis. Technology-based exercise and posture training warrants further study as a potential self-management program for age-related hyperkyphosis that may be more easily disseminated than in-person training.

Reliability of sagittal vertical axis measurement and association with measures of age-related hyperkyphosis.

[Purpose] Persons with age-related hyperkyphosis often have concomitant sagittal plane imbalance of the spine. This study investigated the reliability of sagittal vertical axis (SVA) measurement of sagittal balance, association between thoracic Cobb angle of kyphosis and SVA measure of sagittal balance, and compared the degree of SVA in males and females with age-related hyperkyphosis. [Participants and Methods] Measurements of SVA and Cobb angle of kyphosis were obtained from baseline radiographs of 112 community-dwelling males and females, mean age 70.0 (SD=5.7) years with kyphosis ≥40 degrees, recruited for a randomized controlled trial. Spearman correlation coefficients were used to determine associations between SVA and kyphosis, and Wilcoxon nonparametric tests to compare SVA between genders. [Results] SVA was acquired with excellent intra-rater [0.95 (95% CI: 0.88, 0.98)] and inter-rater reliability [0.93 (95% CI: 0.83,0.97)]. There was no significant correlation between Cobb angle of thoracic kyphosis and SVA, (r=-0.05). More males than females had sagittal imbalance (SVA≥5 cm). [Conclusion] In older adults with hyperkyphosis, SVA was a reliable measure of sagittal balance, and more extreme in males. SVA was not associated with Cobb angle of thoracic kyphosis, and could be considered an independent phenotype of age-related hyperkyphosis to be targeted in future intervention trials.

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.

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.