Author Names
Hughes, L., Galloway, R., Fisher, S.
Reviewer Name
Becca Seeger, SPT
Reviewer Affiliation(s)
Duke University, Division of Physical Therapy
Paper Abstract
Background and Purpose: Thoracic hyperkyphosis is a common condition that progresses with aging and has been associated with impaired functional performance, increased risk of falls, and even mortality. Previous studies to improve posture primarily used exercise for durations of 3 months or longer. The purpose of this pilot study was to examine the feasibility of a manual therapy intervention in community-dwelling older adults over a 4-week time frame that is comparable to the typical clinical setting, to test the appropriateness and procedures for the measurement of posture and function in the older population with hyperkyphosis, and to collect preliminary data to describe change in posture and function measures. Methods: Twenty-four participants with hyperkyphosis or forward head posture were recruited, and 22 participants completed this pilot study. Feasibility was measured based on attendance, tolerance, safety, and retention. Issues with measurement procedures were recorded. The intervention included manual therapy and exercise 3 times a week for 4 weeks to target spinal and peripheral joint stiffness, muscle lengthening, and muscle activation. Outcomes included height, kyphotic index (KI), Block Test, Acromion to Table (ATT), Timed Up and Go (TUG), 5 times sit-to-stand (5XSTS), Functional Reach (FR), 2-minute walk test (2MWT), and Patient-Specific Functional Scale (PSFS). Data collected at visits 1, 6, and 12 were analyzed using 1-way repeated-measures multivariate analysis of variance. Results and Discussion: Measurement and intervention protocols were found to be feasible. A significant effect for the aggregate dependent variables change over time was found. Univariate analysis of each dependent variable showed significance except for FR. All postural measures (height, KI, Block Test, and ATT) significantly improved statistically. The KI and ATT exceed the minimal detectable change for clinical significance. Function showed statistical improvements in the TUG, 5XSTS, 2MWT, and PSFS. Clinical significance was reached with the PSFS. Seven of 9 measures showed a statistically significant change in just 2 weeks. Conclusions: This pilot study suggests that manual therapy and exercise applied to older adults shows promise for improvement in measures of posture and functional performance in a clinically feasible 4-week time frame.
NIH Risk of Bias Tool
Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group
- Was the study question or objective clearly stated?
- Yes
- Were eligibility/selection criteria for the study population prespecified and clearly described?
- Yes
- Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?
- No
- Were all eligible participants that met the prespecified entry criteria enrolled?
- Yes
- Was the sample size sufficiently large to provide confidence in the findings?
- Yes
- Was the test/service/intervention clearly described and delivered consistently across the study population?
- Yes
- Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?
- Yes
- Were the people assessing the outcomes blinded to the participants’ exposures/interventions?
- No
- Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?
- Yes
- Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?
- Yes
- Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?
- No
- If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Manual therapy and exercise delivered three times per week for four weeks increased the height of participants and reduced the forward head, rounded shoulders posture associated with excessive thoracic kyphosis.
Key Finding #2
Manual therapy and exercise delivered three times per week for four weeks improved functional measures in older adults such as the Timed Up and Go test, the 5 times sit-to-stand test, the 2-minute walk test, and the Patient-Specific Functional Scale.
Key Finding #3
Over the twelve visits, feasibility benchmarks of adherence to the schedule, tolerance to the intervention, safety of the intervention, and retention of participants were met.
Please provide your summary of the paper
This article examined the effects of manual therapy interventions in addition to exercise on posture and functional performance in community-dwelling older adults with hyper kyphosis. Additionally, the study aimed to see if it was feasible for change to occur over a 4-week time frame that is comparable to a standard clinical setting. The study utilized manual therapy that included myofascial release techniques as well as joint mobilizations from grade II to grade V. Manual therapy for each participant was tailored to their individual needs and was most commonly performed in the thoracic spine and ribs but was also performed in the extremities for some. After the manual therapy was performed, weak musculature was targeted for activation and neuromotor re-education. The goal was not to increase strength due to the 4-week time period of the study but rather to increase muscular activation through new ranges of motion that were provided as a result of the manual therapy techniques. The intervention occurred over 4 weeks with 3 visits per week resulting in 12 total visits. At the end of the 12 visits, it was found that there was a significant change in the primary postural measures of height, thoracic curvature, rounded shoulders, and forward head that exceeded measurement error. Additionally, it was found that there was significant improvement in measures including the Timed Up and Go test, the 5 times sit-to-stand test, the 2-minute walk test, and the Patient-Specific Functional Scale. In terms of feasibility, 22 of 24 participants completed all 12 visits, no adverse events were reported, and only 2 participants withdrew from the study meaning all benchmarks were met.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Although the response to the intervention is promising, there are several limitations to this study. The group of participants for this study were a sample of convenience meaning they were already motivated to participate and were all relatively high functioning. Additionally, this group lacked many of the comorbidities seen in the older adult population today. So while these results are encouraging, it is unlikely that they can be generalized to the whole older adult population. Additionally, there was no control group and no post intervention follow up. This study provides great results to back up the use of this intervention to improve posture and function in older adults but progressing to a RCT and including a wider variety of older adults including those with additional comorbidities would be necessary to actually prove the effectiveness of this intervention for this specific population. Even though further research appears to be needed on this intervention, in this time frame, for the older adult population, the results allow clinicians to consider manual therapy as a potential intervention to improve posture in aging adults. Additionally, it is important to consider that by changing the posture of older adults, clinicians can impact their functional movement and work towards preventing falls and other injuries. The results of this study also suggest that a 4-week clinical period is a feasible time frame to make meaningful change through the use of manual therapy and exercise.
