Yoga Decreases Kyphosis in Senior Women

7/25/2019 Yoga Decreases Kyphosis in Senior Women

1/19

13May 17th2014

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC37000!/

" #m $eriatr %oc. #&thor man&script' available in PMC "&l 3( 2013.

P&blishe) in *inal e)ite) *orm as:

" #m $eriatr %oc. %ep 200+' ,7-+: 1,!+1,7+.

P&blishe) online "&l 21( 200+. )oi: 10.1111/.1,32,41,.200+.023+1.

oga )ecreases yphosis in senior women an) men with a)&lt

onset hyperyphosis: res&lts o* a ran)omi5e) controlle) trial

PMC6: PMC37000!

869M%6: 869M%47+,42

$ail #. $reen)ale( M(Mei9&a 9&ang( rP9(#r&n %. ;arlamangla( Ph( M(

#&thor in*ormation ?Copyright an)


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may e grossly approximated ased on the prevalence of verteral deformities" which occur

in %!*$+ in those aged etween $!*#! years.,*-f only half of those with verteral

deformity had hyperkyphosis" its prevalence would range etween $ to &!+ in parallel with

advancing age. /hese estimates are conservative" ecause up to 0!+ of persons with

hyperkyphosis do not have verteral fractures.0*%!

Adverse health outcomes associated with hyperkyphosis include physical functional

limitations%%*%" thoracic ack pain#" respiratory compromise0" restricted spinal range of

motion%$and osteoporotic fractures.%-"%0

1ur iological model posits that there are ony" muscular" ligamentous" and postural

contriutors to hyperkyphosis and that some of these component causes of hyperkyphosis

are remediale.%2"%#Although it is commonly assumed that verteral fractures are responsile

for hyperkyphosis" only &+ of the variance in hyperkyphosis is accounted for y verteral

deformity&! the ma3ority of persons with hyperkyphosis are verteral fracture free.0"#"%!1ther

postulated" and potentially mutale" reasons for hyperkyphosis include4 loss of anterior

inter5verteral disc height %!"&%*&& weakness of the erector spinae" adominal muscles" and

shoulder girdle%%"&, postural anormalities which lead to further weakness and shortening of

under5used muscles" tendons and ligaments& or low one density which may lead to

owing of the spine without overt fracture.%%6uring normal stance" the center of gravity falls

anterior to the thoracic spine" promoting greater verteral ody and inter5verteral disc

deformity anteriorly" compared to posteriorly excess kyphosis places a relatively larger load

on the anterior structures.&$

/he 7oga for 8yphosis /rial was a -5month" single masked" randomi9ed" controlled trial(:;/) of 7oga designed to improve thoracic kyphosis angle" posture" physical function and


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nstitutional :eview oard approved the protocol and participants gave written" informed

consent.

/he 7oga intervention group attended , 7oga classes per week for - months while the

control intervention group received attention activities consisting of monthly luncheon5

seminars and mailings. /he randomi9ed controlled trial (:;/) phase is the su3ect of this

report. /he study also included a -5month post5:;/ intervention" which will e reported

suseave % received the :;/ intervention etween April and 1ctoer &!!$. >ave &

received the :;/ intervention etween Beruary and Culy &!!-.

Participants

'articipants were recruited from mailing lists referrals from physicians" physical therapists

and study participants flyers and senior education programs. nitial eligiility (e.g." age"

willingness to accept randomi9ation) was evaluated y phone. At an in5person screening"

inclusion and exclusion criteria were assessed. >omen and men aged -! years or greater

with adult5onset hyperkyphosis (noticed after age $!) were eligile if their measured

6erunner kyphometer angle was D! degrees (see elow). /he following were exclusions4

active angina uncontrolled hypertension high resting pulse or respiratory rate unstale

asthma or chronic ostructive pulmonary disease cervical spine instaility unstale knee

or shoulder 3oints hemiparesis or paraparasis use of assistive walking device unale to

hear or see ade


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aseline visit. :esearchers who conducted follow5up visits were unaware of assignments

and participants were instructed not to reveal them.

Inter!entions

/he active treatment group received 7oga" , days per week" one hour per session" for &weeks. /he control group received monthly lunchEseminars" two hours per session" for the

same duration.

"oga inter!ention

/he study used Hatha 7oga" which teaches asanas(poses) andpranas(reathing).&-y

emphasi9ing mental and physical focus during the practice of asanas" 7oga attempts to

uild concentration and ody awareness. t is a non5allistic form of physical activity that

uses slow" controlled movements (enhancing safety). ecause 7oga postures are highly

modifiale" they can e targeted at the mutale causes of hyperkyphosis while respecting

the physical limitations of this population. >e used a progressive series of poses that

addressed flexiility" strength and proprioceptive awareness of all ma3or appendicular and

trunkal muscle groups. /he first poses were done recument on the floor" a safe way to

introduce controlled reathing and simple isometric and isotonic contractions of the arms"

legs" and adomen. Advancement was made to poses in a chair" on hands and knees" in the

prone position and standing. 'oses were modified versions of standard asanas" tailored to

the physical capailities of the population. An overview of the 7oga program is contained

in>e Appendix %.

Contro# inter!ention

/he control intervention was designed to provide a social environment similar to 7oga. A

doctoral level health educator facilitated - lunch5seminars" aimed at providing an

emotionally positive and intellectually stimulating experience with sociali9ation. Fach

session included lunch" an informational component (e.g." >hat is stress and what can you

do aout itG) and an interactive component (e.g." alue ingo" an exercise in articulating

personal priorities). ;ontrol participants also received a newsletter and a senior health

maga9ine monthly.

Measurements

aseline and follow5up visits included4 %) self5report survey of demographics" health

conditions" health ehaviors" and


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Fach anthropometric and physical performance outcome was measured , times (with

repositioning) y the same staff memer at each visit. /he average of the , measures was

used as the study outcome. /he first and second of the , measures were used to assess intra5

rater reliaility. A second masked research associate" performed same5day measurements

with repositioning in most instances (#& to %!& participants). nter5rater reliaility" assessedusing intra5class correlation" ranged etween !.2# and !.#- for the 6erunner and

flexicurve kyphosis measures and etween !.0, and !.#, for the other anthropometric and

physical performance tests. ntra5rater reliaility ranged etween !.#, and !.#2 for the

6erunner and flexicurve kyphosis measures and !.2- and !.# for other anthropometric

and physical performance tests.

Primary outcomes

/he primary outcomes were change (aseline to - months) in 6erunner kyphometer5

assessed kyphosis angle" standing height" timed chair stands" functional reach and walking

speed. 'rimary outcomes were selected ecause they changed in response to the 7oga

intervention in our single5armed pilot study.%#

/he 6erunner kyphometer consists of a protractor with a one5degree precision" mounted

at the end of & doule" parallel arms (>e Appendix &). /he upper arm of the kyphometer is

placed on ;50 and the lower arm is placed on /5%&. /he circumscried kyphosis angle is read

from the protractor.#"&0'articipants had & sets of 6erunner measures made to assess spinal

flexiility4 one standing in their usual" relaxed posture and one standing as tall as possile.&2

Jtanding height was measured using a wall5mounted stadiometer.Hyperkyphosis

precluded some from touching their heels to the wall if so" we measured the distanceetween their heels and the wall and replicated this distance at follow5up. /he timed chair

stands test recorded the numer of seconds re


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values indicate greater kyphosis. ?sing geometric formulae" theflexicurve inscried

kyphosis angle was also calculated from the flexicurve tracing. y definition" an inscried

angle is systematically less than a circumscried angle. /he :ancho ernardo locks (:J5

locks) measure is an estimate of forward posture" ut is not specific for thoracic

kyphosis.,,"%,"%0

>ith the participant lying supine on a flat surface" locks are placed under theocciput to achieve a neutral head position (>e Appendix &). /he numer of locks

re


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/o allow e


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more strongly predictive of missing data in the suse


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/ale %

aseline 6emographic" ehavioral and Iedical ;haracteristics of Jtudy Jample" y

/reatment Assignment and y @oss to Bollow up

aseline characteristics did not differ etween participants who did or who did not complete

the -5month follow5up" with the exception of prevalent thoracic verteral fracture (more

common among attriters) and raceEethnicity. Mon5white sample si9es were small" however.

/he characteristics listed in /ale %did not differ etween >ave % and >ave & (data not

shown).

(ase#ine !a#ues o% primary and secondary outcomes

Jummari9ed in /ale &" on average" participants were moderately kyphotic" with a median

6erunner kyphosis angle of $2 degrees" a kyphosis index of !.%- and a flexicurve kyphosis

angle of ,- degrees. (/he flexicurve kyphosis angle is inscried" y definition systematically

lower than the circumscried 6erunner angle). Jpinal flexiility" the difference etween

kyphosis angles measured during usual posture versusest posture" was N$.-# degrees

(standard deviation" .%!) using the 6erunner instrument. y flexicurve" spinal flexiility

was N,.,$ degrees (standard deviation" &.$%). Jpinal flexiility did not differ y treatment

assignment (data not shown).

/ale &aseline Ieasures of Anthropometric" 'hysical 'erformance" and Health5:elated Luality of

@ife (H:L1@) outcomes

At aseline" Jpearman correlations etween each of the kyphosis measurements were

statistically significantly different from 9ero and were4 6erunner angle with kyphosis

index" !.0# 6erunner angle with flexicurve kyphosis angle" !.2! kyphosis index with
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T2/


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flexicurve kyphosis angle" !.##. ;orrelations etween :J locks and 6erunner angle"

kyphosis index and flexicurve kyphosis angle were !.," !.," and !.,$" respectively"

sustantially lower than correlations etween other kyphosis measures.

'articipants reported almost no limitations in role function related to physical or emotional

health or in social function4 median scores were %!!. >ith the exception of the

energyEfatigue domain" all other H:L1@ scales were rated uniformly highly. Although

health5related role limitations were generally asent" odily pain was common. /hree

ave %

and 2.-+ in >ave &. Among those randomi9ed to the control condition" 0%.0+ attended at

least of - lunch5seminars (median numer was $) >ave % and >ave & lunch5seminar

adherence rates were 0-.!+ and -2.-+" respectively.

)yp$osis* posture and $eig$t

;ompared to the control intervention" 7oga resulted in statistically significant reductions in

hyperkyphosis according to & of the , kyphosis measurement methods (/ale ,). /hemedian flexicurve kyphosis index decreased y !.!!- in those randomi9ed to 7oga and

increased y !.!!, among control participants (pO!.!!)" a $+ difference. /he median

flexicurve inscried kyphosis angle lessened y !.#, degrees in the 7oga intervention group

while that of the control participants increased y !.2& degrees (pO!.!!$)" a .+

difference. Iedian 6erunner kyphosis angle diminished y , degrees in the 7oga group"

ut it also decreased y %.,, degrees in the control group" a difference of ,+ (pO!.,0). /he

:J locks did not change in either group. A small (!.&+ etween5groups difference)

treatment enefit was evident for standing height (pO!.!$).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/table/T3/


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/ale ,

?nad3usted /reatment Arm 6ifferences in Iean >ithin5Ju3ect ;hange in

Anthropometrics and Ieasured 'hysical 'erformance * ntent5to5/reat Analyses (MO%!$) P

P$ysica# per%ormance

/he 7oga group cut %. seconds from its chair stand time (a %!+ improvement) and the

control groups chair stand time went down y aout half as much" a etween5groups

difference of approximately $+" which did not reach the level of statistical significance

(/ale ,). Bunctional reach and $!5foot walk time improved slightly in oth groups.

HR+O&

Jmall changes in each of the H:L1@ scales were apparent for oth the 7oga and the control

groups" ranging from approximately N& to 2 points" ut there were no statistically

significant effects of treatment (data not shown pD!.!- for all comparisons).

Side e%%ects

/ale summari9es the percent of participants endorsing each of 2 plausile side5effect

symptoms and each of 2 distractor symptoms at the first and final month of the :;/" as well

as the mean numer of months that each symptom was reported. ?pper ack pain was

reported half as often in the 7oga group (average !.# months) compared to the control

group (average %.2 months) (pO!.!%). n contrast to our expectation that the distractor

symptoms would e reported with e


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testing for an interaction etween treatment and prevalent verteral fracture ) testing for

an interaction etween treatment and aseline 6erunner kyphosis angle (aove or elow

the sample median) and $) testing for an interaction etween treatment arm and dose (the

numer of 7oga classes or lunch5seminars attended) in the full sample and separately for

each treatment arm. :esults of pre5specified secondary analyses were not different from theintention5to5treat analyses (data not shown).

>e conducted & non5pre5specified secondary analyses. /he first was a test for interaction

etween treatment and high spinal flexiility (defined as the median value" N$.,, degrees)"

hypothesi9ing that persons with more pliale spines would enefit more. 'articipants

randomi9ed to the 7oga intervention with high spinal flexiility achieved a N,.$ (-+) degree

median improvement in 6erunner kyphosis angle among those with low spinal flexiility

7oga produced a N&.! (,+) degree median improvement. ;ontrol group participants with

high spinal flexiility reali9ed a N,.! degree (.-+) median improvement in 6erunner

kyphosis angle while control participants with low spinal flexiility had a !.,, degreemedian change (!.$$+) (pO!., for interaction).

Binally" &2 participants kyphosis measures were flagged during the study visits as difficult"

either ecause the 6erunner kyphometer was not stale on the verteral spines (i.e."

woled) or ecause the thoracic and lumar regions were oth kyphotic (; shaped

spine). Among those who were free from measurement difficulties" 7oga5assigned

participants experienced a N$.!+ decrease in 6erunner kyphosis angle and control group

participants posted a N!.0&+ change (pO!.% for interaction).

$o to:

Discussion

/his -5month 7oga intervention resulted in statistically significant improvements in &

hyperkyphosis outcomes4 compared to control participants" those randomi9ed to 7oga

experienced a .+ greater improvement in flexicurve kyphosis angle and a $+ greater

improvement in kyphosis index. /he intervention did not result in any statistically

significant gains in measured physical performance or in self5assessed H:L1@. Mo negative

side effects of 7oga occurred rather" compared to those randomi9ed to luncheon5seminars"

7oga participants reported less upper ack pain" early morning awakening and insomnia.

/he interventions main goal was to reduce hyperkyphosis" which it accomplished ased on

the flexicurve assessments" ut not ased on the 6erunner kyphometer. /he most likely

explanation for these divergent results is that for long5term repeated measures" the

flexicurve is more accurate and more precise than is the 6erunner instrument. /he

flexicurve traces the curvature of the entire spine" determining the thoracic kyphosis ased

on the inflection point etween the thoracic kyphosis and lumar lordosis. n contrast" the
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/


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6erunner kyphosis angle is defined y the position of the instrument on external

landmarks that attempt to locate the ;50 and /5%& verterae#. 6espite careful protocols the

inferior landmark can e difficult to discern" especially when the lumar lordosis has

reversed and the entire thoraco5lumar region is kyphotic ( ; shaped).&!"&n addition"

accuracy and precision can e diminished ecause the kyphometer sometimes woles onthe /50 or /5%& spinous processes. (Mote that this instaility may e lessened y using the

protocol of 1hlen and colleagues" which places the kyphometer across two superior and two

inferior spinous processes.,Although the same5day reliailities of the 6erunner

kyphometer were similar to those of the flexicurve" the technical challenges of the

6erunner measure may have made its -5month precision lower than that of the flexicurve.

/he secondary analysis of technically difficult measurements supported this hypothesis.

/o our knowledge" there are no pulished randomi9ed" controlled" physical activity5ased

interventions to correct hyperkyphosis that are directly comparale to this :;/. However a

few non5randomi9ed or non5controlled studies of physical activity interventions suggestedthat kyphosis improvements are possile. toi and colleagues randomi9ed -!

postmenopausal women to a &5year progressive ack strengthening exercise vs. no

intervention" ut hyperkyphosis was not an entry criterion. /he intention5to5treat analysis

found no etween5groups change in radiologically measured kyphosis angles" ut apost-hoc"

non5randomi9ed analysis" which divided the study sample according to whether participants

had achieved greater than or less than the median increase in ack strength" reported a &.2

degree improvement in radiological kyphosis angle among those in the high strength gain

category"similar to the 7oga groups decrease of , degrees y kyphometer. 8at9man et.al."

reported statistically significant pre5post improvements in kyphosis in a single arm" non5linded" exercise intervention in &% women aged -$Q years who had 6erunner5measured

hyperkyphosis of at least $! degrees and high spinal flexiility (at least N$ degrees).$/he

investigators recorded a - degree reduction in usual5stance kyphosis" twice the si9e of our

7oga arms within5group reduction. /his larger effect si9e may e due in part to selection

ased on spinal flexiility. 1ur secondary analysis demonstrated a kyphometer

improvement of degrees in the high spinal flexiility sugroup.

1ther proposed interventions for hyperkyphosis include spinal orthoses" verteroplasty and

kyphoplasty. 1ne :;/ randomi9ed women aged -!Q years with at least % verteral fracture

and hyperkyphosis of D-! degrees to wear a spinal orthosis for - months or to a wait list(MO,%" each arm).-Although the authors did not report whether assessors were masked" the

orthosis arm posted a 0.# degree improvement in kyphosis angle compared to a %.#5degree

improvement in the control arm. A review of -# clinical studies of verteroplasty and

kyphoplasty (none of which were :;/s) calculated a mean kyphotic angle restoration of -.-

degrees for each of these techni


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fractured vertebrae only" which is should not e confused with the kyphosis angle of the

entire thoracic spine.

;hanges in chair stand time" functional reach and walking speed did not differ y study arm"

ut there was a trend towards etterment of chair stand time4 %!+ in the 7oga arm and $+

in the control arm (pO!.%,). >e expected that chair stand time in the control condition

would decline or remain stale during the -5month study.2mproved physical performance

in the control participants could have resulted from augmented physical activity over time"

ut self5reported home and leisure physical activity did not rise (data not shown). Iore

likely" the measurement was influenced y a practice effect" which has een reported for the

chair stand and walk tests.#

'articipants egan with almost no role or emotional limitations due to health" thus these

domains could not improve. Justantial general ody pain was reported ut pain was also

unmoved y the intervention. n


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AC)NO.&ED/EMENTS

Source of Funding:Bunding for conduct of the 7oga for 8yphosis /rial and investigator

support for 6rs. Rreendale" Huang" Jeeger and ;rawford was provided y MHEM;HH6 ($

:!% H6!$2,). 6r. 8arlamangla was supported y funding from the ?;@A5;laude 6.

'epper 1lder Americans ndependence ;enter (%',! AR!&202).

$o to:

0ootnotesCon%#ict o% interest1@he a&thors have no con*licts o* interest.

Aut$or contributions1$ail #. $reen)ale le) the )esign an) con)&ct o* the st&)y( collaborate) in thecon)&ct an) interpretation o* )ata analyses( obtaine) *&n)ing( an) )ra*te) the man&script. Mei9&a9&ang( #r&n %. ;arlamangla an) " Belsenerg 6" arlow C" et al. /he prevalence of verteral deformity in

european men and women4 /he Furopean erteral 1steoporosis Jtudy. C one Iiner

:es. %##-%%4%!%!*%!%2. S'uIedT

. 6avies 8I" Jtegman I:" Heaney :'" et al. 'revalence and severity of verteral fracture4

/he Jaunders ;ounty one Luality Jtudy. 1steoporos nt. %##--4%!-*%-$. S'uIedT

$. Ielton @C" " @ane A>" ;ooper ;" et al. 'revalence and incidence of verteral

deformities.1steoporos nt. %##,,4%%,*%%#. S'uIedT

-. Jpector /6" Ic;loskey F" 6oyle 6" et al. 'revalence of verteral fracture in women

and the relationship with one density and symptoms4 /he ;hingford Jtudy. C one Iiner

:es. %##,242%0*2&&.S'uIedT

0. @eech CA" 6ulerg ;" 8ellie J" et al. :elationship of lung function to severity of

osteoporosis in women. Am :ev :espir 6is. %##!%%4-2*0%. S'uIedT
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/http://www.ncbi.nlm.nih.gov/pubmed/6768276http://www.ncbi.nlm.nih.gov/pubmed/3757369http://www.ncbi.nlm.nih.gov/pubmed/8797123http://www.ncbi.nlm.nih.gov/pubmed/8704356http://www.ncbi.nlm.nih.gov/pubmed/8481586http://www.ncbi.nlm.nih.gov/pubmed/8352064http://www.ncbi.nlm.nih.gov/pubmed/2297189http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700806/http://www.ncbi.nlm.nih.gov/pubmed/6768276http://www.ncbi.nlm.nih.gov/pubmed/3757369http://www.ncbi.nlm.nih.gov/pubmed/8797123http://www.ncbi.nlm.nih.gov/pubmed/8704356http://www.ncbi.nlm.nih.gov/pubmed/8481586http://www.ncbi.nlm.nih.gov/pubmed/8352064http://www.ncbi.nlm.nih.gov/pubmed/2297189


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