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REP 10: REVERSING THE BEND…SO WE DO NOT BREAK

Judi Laprade

 

Postural hyperkyphosis could be simply slouchy posture or wedging fractures, either of which may result in pain, stiff joints, and soft tissue imbalance. It might seem that treatment approaches for both should be similar – stretch what is tight, strengthen what is weak, mobilize what is stiff. However, introduce the presence of sub-optimal bone density and the risk of fracture and this changes the game entirely…but should it?

The big idea

I believe that I have ‘anatomy x-ray vision’, that I can actually look through skin and ‘see’ the dysfunction and how to fix it. When I was working part-time as a manual therapist while going through grad school in the Department of Anatomy, I had the best of both worlds constantly blending anatomy review into clinical practice. As someone with a PhD, it almost seems sacrilegious that I now say publicly that at times my anatomy and biomechanics knowledge informed my clinical decision making far more than a current research paper, but it is true. And I believe we should do it more.

My take on things…

If you had asked me before 2009 to define osteoporosis (OP), I would have recited that it was a disease causing low bone density which can lead to fractures… a frail, little old lady condition to be exact. I had no idea that the vertebral fracture was one of the top three low-trauma fractures, or the serious sequelae associated with their presence and progression.

I had a fledgling thought questioning whether we do enough clinically to halt the progression of kyphosis, let alone prevent it .

Then along came an opportunity to manage a research project on osteoporosis for Dr Susan Jaglal. Within a few months, I became immersed in all things OP and was traveling the province providing education forums about the the facts and stats of fractures and the existing care gap in fracture identification and follow-up. The next six months were spent phoning over 900 persons aged 40 and up with a low-trauma. This provided a rare insight into patients concerns and how fractures impacted their lives. It opened my eyes to thesneakiness of this disease, particularly in the case of the non-symptomatic vertebral fractures, and it was then that I had a fledgling thought questioning whether we do enough clinically to halt the progression of kyphosis, let alone prevent it .

The next five years I worked with Osteoporosis Canada, teaching Bone Fit to hundreds of PTs and other health and exercise practitioners. A big focus in our workshop is on providing thebest evidence available on how we can manage, limit, or prevent hyperkyphosis through postural exercise. Each year, workshop revisions are made based on new research, or practical applications of anatomy coming from the challenges facing the practitioners, or simply questions raised.

It is these questions from clinicians that always drives me to seek out more answers, typically using my anatomy and biomechanics foundation, with a sprinkle of research on top. Questions in particular about the safety of extensions in the thoracic region were frequent. “Is it safe to do foam roller stretching?” “Are prone extension exercises harmful to the spinous processes?” “ If a fracture is present, is the risk increased?” “Can patients self mobilize in a chair or can we mobilize them without fear of further damage?”

The big answer…almost

At this point, the anatomy visionist in me is taking over. When applying extension forces, whether through passive stretches, muscle forces, or manual mobilizations to the vertebrae, typically the force would be through the spinous,  transverse or articular processes: essentially the posterior bony arch. This is not at all where OP vertebral fractures typically occur – it is the anterior body which succumbs to wedge-fractures. Anatomically speaking, the thoracic posterior bony arch is built for rib, muscle and ligamentous attachment and, therefore, withstanding multiple forces and movements. So, is there risk in creating a fracture through the posterior column through extension forces?

In my mind, the highest theoretical risk to the posterior column is through manual mobilizations, with all other activities requiring less force. Therefore, I needed to know two things:

  1. How much force results from a PA mobilization? and
  2. How much force does it take to fracture a spinous process?

Some of the answers are provided by fellow physiotherapist, Dr Meena Sran. Through several biomechanical studies she ultimately concludes that there is a reasonable margin of safety in PAs, but that the upper end of therapist-produced forces measured in patients (106-233 N) do cross into that failure range for the spinous processes measured in cadavers (from 200-728 N).

There have been a few studies (Bautmans et al.Roberts & WolfeBennell et al.) in addition to Dr Sran’s group looking at the clinical intervention of mobilizing OP clients, or those with fractures, and there is promising results that manual therapy used within guidelines might indeed be safe for individuals with back pain and prior vertebral fractures.

So now, you might assume that I’m advocating active extensions and mobs for everyone! Not so fast…at present my anatomical and clinical personas are at a stand-off. Anatomy-me is feeling pretty encouraged that there are some data to feel confident about PA mobilizations. Physio-me is cautiously willing to apply this data, but with a judicious amount of careful assessment and clinical judgement.

Word cloud of recent posture research by keyword.

Likely higher intensity extension exercises, mobilizations, and manipulations are out for someone with multiple thoracic levels fractured, severe kyphosis, and limited tolerance to supine lying. For someone with healed discrete fractures, notable postural changes, and moderate movement limitations, I would include progressive postural exercises, and perhaps manual therapy.

This is my constant pursuit, blending clinical research and my ‘evidence-informed practice’ (that being, anatomy and biomechanics) to come up with the rational individualization for the case at hand.

And sometimes, I just squint really hard and use my ‘anatomy x-ray vision’.

Dig Deeper

For those who  are interested in exploring things in more detail, I’ve included links to a few (non-open source) articles from Dr Sran’s group below:

  1. Sran MM, Khan KM, Zhu Q, McKay HA, et al. (2004). Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization. Spine 29(21):2382-8.
  2. Sran MM, Khan KM. (2006). Is spinal mobilization safe in severe secondary osteoporosis?-a case report. Manual Therapy 11(4):344-351.
  3. Katzman WB, Sellmeyer DE, Stewart AL, et al. (2007).  Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women.  Arch Phys Med Rehabil 88(2); 192-9.

Discuss

What would drive your decision for using or limiting extension exercises or thoracic mobilizations on a client with osteoporosis? Should we take the risk to give the benefit of functional improvement, reduced pain and perhaps less falls?

Can we make better clinical decisions by using our anatomical/biomechanical foundational ‘truths’ along with clinical trials than simply being driven by research alone?

Let’s chat in the comments box below, or via the CPA Facebook page or on Twitter (hashtag  #30Reps).

About Judi Laprade

Judi is a physiotherapist, a senior lecturer in the Division of Anatomy at University of Toronto, and head consultant and lead trainer for the Bone Fit workshops through Osteoporosis Canada. Her teaching responsibilities include course spanning gross anatomy, histology and neuroanatomy for students in Medicine, Dentistry and Kinesiology and of course many weekends are spent teaching Bone Fit across Canada. Most important she never stops trying to figure out how to teach anatomy so that everyone has a little x-ray vision.

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