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.
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.
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.
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.
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
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Takahashi T, Ishida K, Hirose D, Nagano Y, Okumiya K, Nishinaga M et al (2005) Trunk deformity is associated with a reduction in outdoor activities of daily living and life satisfaction in community-dwelling older people. Osteoporos Int 16(3):273–279. doi:10.1007/s00198-004-1669-3
Kado DM, Huang MH, Karlamangla AS, Barrett-Connor E, Greendale GA (2004) Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. J Am Geriatr Soc 52(10):1662–1667
Katzman W, Cawthon P, Hicks GE, Vittinghoff E, Shepherd J, Cauley JA et al (2011) Association of spinal muscle composition and prevalence of hyperkyphosis in healthy community-dwelling older men and women. J Gerontol A Biol Sci Med Sci. doi:10.1093/gerona/glr160
Kobayashi T, Atsuta Y, Matsuno T, Takeda N (2004) A longitudinal study of congruent sagittal spinal alignment in an adult cohort. Spine (Phila Pa 1976) 29(6):671–676
McDaniels-Davidson C, Davis A, Wing D, Nichols J, Kado D (2016) editors. Kyphosis, balance dynamics, and incident falls in community dwelling older adults. J Am Geriatr Soc
van der Jagt-Willems H, de Groot M, van Campen J, Lamoth C, Lems W (2015) Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatr 15(1):34
Kado DM, Miller-Martinez D, Lui LY, Cawthon P, Katzman WB, Hillier TA et al (2014) Hyperkyphosis, kyphosis progression, and risk of non-spine fractures in older community dwelling women: the study of osteoporotic fractures (SOF). J Bone Miner Res 29(10):2210–2216. doi:10.1002/jbmr.2251
Kado DM, Huang MH, Barrett-Connor E, Greendale GA (2005) Hyperkyphotic posture and poor physical functional ability in older community-dwelling men and women: the Rancho Bernardo study. J Gerontol A Biol Sci Med Sci 60(5):633–637
Katzman WB, Harrison SL, Fink HA, Marshall LM, Orwoll E, Barrett-Connor E et al (2014) Physical function in older men with hyperkyphosis. J Gerontol A Biol Sci Med Sci. doi:10.1093/gerona/glu213
Katzman WB, Huang MH, Lane NE, Ensrud KE, Kado DM (2013) Kyphosis and decline in physical function over 15 years in older community-dwelling women: the Study of Osteoporotic Fractures. J Gerontol A Biol Sci Med Sci. doi:10.1093/gerona/glt009
Bayliss M, Miltenburger C, White M, Alvares L (2013) A conceptual and disease model framework for osteoporotic kyphosis. Osteoporos Int 24(9):2423–2432. doi:10.1007/s00198-013-2317-6
Hongo M, Miyakoshi N, Shimada Y, Sinaki M (2012) Association of spinal curve deformity and back extensor strength in elderly women with osteoporosis in Japan and the United States. Osteoporos Int 23(3):1029–1034. doi:10.1007/s00198-011-1624-z
Kado DM, Huang MH, Karlamangla AS, Cawthon P, Katzman W, Hillier TA et al (2013) Factors associated with kyphosis progression in older women: 15 years’ experience in the study of osteoporotic fractures. J Bone Miner Res 28(1):179–187. doi:10.1002/jbmr.1728
Katzman WB, Parimi N, Mansoori Z, Nardo L, Kado DM, Cawthon PM et al (2016) Cross-sectional and longitudinal associations of diffuse idiopathic skeletal hyperostosis (DISH) and thoracic kyphosis in older men and women. Arthritis Care Res. doi:10.1002/acr.23115
Katzman WB, Miller-Martinez D, Marshall LM, Lane NE, Kado DM (2014) Kyphosis and paraspinal muscle composition in older men: a cross-sectional study for the Osteoporotic Fractures in Men (MrOS) research group. BMC Musculoskelet Disord 15:19. doi:10.1186/1471-2474-15-19
Kado D, Browner W, Palmero L, Nevitt M, Genant H, Cummings S (1999) Vertebral fractures and mortality in older women. A prospective study. Arch Intern Med 159:1215–1220
Katzman WB, Sellmeyer DE, Stewart AL, Wanek L, Hamel KA (2007) Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil 88(2):192–199. doi:10.1016/j.apmr.2006.10.033
Bansal S, Katzman WB, Giangregorio LM (2014) Exercise for improving age-related hyperkyphotic posture: a systematic review. Arch Phys Med Rehabil 95(1):129–140. doi:10.1016/j.apmr.2013.06.022
Borson S, Scanlan JM, Chen P, Ganguli M (2003) The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 51(10):1451–1454
Katzman WB, Vittinghoff E, Kado DM, Schafer AL, Wong SS, Gladin A et al (2016) Study of hyperkyphosis, exercise and function (SHEAF) protocol of a randomized controlled trial of multimodal spine-strengthening exercise in older adults with hyperkyphosis. Phys Ther 96(3):371–381. doi:10.2522/ptj.20150171
Itoi E, Sinaki M (1994) Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc 69(11):1054–1059
Greig AM, Briggs AM, Bennell KL, Hodges PW (2014) Trunk muscle activity is modified in osteoporotic vertebral fracture and thoracic kyphosis with potential consequences for vertebral health. PLoS One 9(10):e109515. doi:10.1371/journal.pone.0109515
Hinman MR (2004) Comparison of thoracic kyphosis and postural stiffness in younger and older women. Spine J 4(4):413–417
Pollock ML, Wenger NK (1998) Physical activity and exercise training in the elderly: a position paper from the Society of Geriatric Cardiology. Am J Geriatr Cardiol 7(4):45–46
Van Dillen LR, Norton BJ, Sahrmann SA, Evanoff BA, Harris-Hayes M, Holtzman GW et al (2016) Efficacy of classification-specific treatment and adherence on outcomes in people with chronic low back pain. A one-year follow-up, prospective, randomized, controlled clinical trial. Man Ther 24:52–64. doi:10.1016/j.math.2016.04.003
Lundon KM, Li AM, Bibershtein S (1998) Interrater and intrarater reliability in the measurement of kyphosis in postmenopausal women with osteoporosis. Spine 23(18):1978–1985
Reuben DB, Siu AL (1990) An objective measure of physical function of elderly outpatients. The Physical Performance Test. J Am Geriatr Soc 38(10):1105–1112
Studenski S, Perera S, Wallace D, Chandler JM, Duncan PW, Rooney E et al (2003) Physical performance measures in the clinical setting. J Am Geriatr Soc 51(3):314–322
Podsiadlo D, Richardson S (1991) The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 39(2):142–148
Shipp KM, Purse JL, Gold DT, Pieper CF, Sloane R, Schenkman M et al (2000) Timed loaded standing: a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis. Osteoporos Int 11(11):914–922
Laboratories ATSCoPSfCPF (2002) ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 166(1):111–117. doi:10.1164/ajrccm.166.1.at1102
Washburn RA, Smith KW, Jette AM, Janney CA (1993) The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol 46(2):153–162
Asher MA, Min Lai S, Burton DC (2000) Further development and validation of the Scoliosis Research Society (SRS) outcomes instrument. Spine (Phila Pa 1976) 25(18):2381–2386
Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D (2010) The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. Journal of applied measurement 11(3):304–314
Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8(9):1137–1148
Resnick D, Shapiro RF, Wiesner KB, Niwayama G, Utsinger PD, Shaul SR (1978) Diffuse idiopathic skeletal hyperostosis (DISH) [ankylosing hyperostosis of Forestier and Rotes-Querol]. Semin Arthritis Rheum 7(3):153–187
Childs JD, Piva SR, Fritz JM (2005) Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976) 30(11):1331–1334
Armstrong RB (1984) Mechanisms of exercise-induced delayed onset muscular soreness: a brief review. Med Sci Sports Exerc 16(6):529–538
Greendale GA, Huang MH, Karlamangla AS, Seeger L, Crawford S (2009) Yoga decreases kyphosis in senior women and men with adult-onset hyperkyphosis: results of a randomized controlled trial. J Am Geriatr Soc. doi:10.1111/j.1532-5415.2009.02391.x
Judge TA, Erez A, Bono JE, Thoresen CJ (2002) Are measures of self-esteem, neuroticism, locus of control, and generalized self-efficacy indicators of a common core construct? J Pers Soc Psychol 83(3):693–710
Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM (1986) The role of self-efficacy in achieving health behavior change. Health Educ Q 13(1):73–92
Al-Herz A, Snip JP, Clark B, Esdaile JM (2008) Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clin Rheumatol 27(2):207–210. doi:10.1007/s10067-007-0693-z
Katzman WB, Huang MH, Lane NE, Ensrud KE, Kado DM (2013) Kyphosis and decline in physical function over 15 years in older community-dwelling women: the Study of Osteoporotic Fractures. J Gerontol A Biol Sci Med Sci 68(8):976–983. doi:10.1093/gerona/glt009
Lorbergs AL, O’Connor GT, Zhou Y, Travison TG, Kiel DP, Cupples LA et al (2016) Severity of kyphosis and decline in lung function: the Framingham study. J Gerontol A Biol Sci Med Sci. doi:10.1093/gerona/glw124
Solomonow M, Zhou BH, Baratta RV, Burger E (2003) Biomechanics and electromyography of a cumulative lumbar disorder: response to static flexion. Clin Biomech (Bristol, Avon) 18(10):890–898
Bohannon RW (2006) Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 29(2):64–68
Bohannon RW (2008) Population representative gait speed and its determinants. J Geriatr Phys Ther 31(2):49–52
This research was supported by the National Institute on Aging (NIA) RO1AG041921 and by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number UL1 TR000004. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The authors wish to acknowledge the Data Safety Monitoring Board for their study oversight, Nicole King and Scott Puracchio for their assistance in data collection, and Lorenzo Nardo for data acquisition.
The study protocol was approved by the University of California San Francisco and Kaiser Permanente Northern California Institutional Review Boards.
Conflicts of interest
This research was supported by the National Institute on Aging (NIA) RO1AG041921.
D. M. Kado and N. E. Lane are joint senior authors.
About this article
Cite this article
Katzman, W.B., Vittinghoff, E., Lin, F. et al. 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. Osteoporos Int 28, 2831–2841 (2017). https://doi.org/10.1007/s00198-017-4109-x
- Clinical trials
- Skeletal muscle