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Back extensor training increases muscle

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Article in Advances in Physiotherapy · August 2011

DOI: 10.3109/14038196.2011.581696

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 Advances in Physiotherapy, 2011; 13: 110–117

ORIGINAL ARTICLE

Back extensor training increases muscle strength in postmenopausal

women with osteoporosis, kyphosis and vertebral fractures

INGRID BERGSTRÖM1, KARIN BERGSTRÖM2, ANN-CHARLOTTE GRAHN KRONHED3,4,

SUSANNE KARLSSON5∗ & JONAS BRINCK1∗
1Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden, 2Stockholm
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11

School of Economics, Stockholm, Sweden, 3Rehab Väst,Vadstena Primary Health Care Centre, Local Health Care Services in
the West of Östergötland, Sweden, 4Social Medicine and Public Health Science, Division of Community Medicine, Department of
Medical and Health Sciences, Linköping University, Sweden, 5Department of Physical Therapy, Karolinska University Hospital,
Stockholm, Sweden

Abstract
We determined the efficacy of a back muscle extensor strengthening program on the back muscle extensor strength,
kyphosis, height and thoracic expansion in women with at least one vertebral fracture, kyphosis and osteoporosis. Thirty-six
For personal use only.

patients were included and randomized to a control or a training group. The training focused on back muscle extensor
strengthening program for 1 h, twice a week for 4 months and was performed by a physiotherapist. The main outcome
measure was the back muscle extensor strength. In an intention-to-treat analysis no significant effects on back muscle
strength in the training group vs. controls could be seen (p ⫽ 0.74). In a per-protocol analysis (n ⫽ 28), the training group
increased back muscle strength from 290 ⫾ 87 to 331 ⫾ 89 N while the control group showed no improvement. After
adjusting for the strength at baseline, a significant effect of training could be demonstrated (p ⫽ 0.029). When comparing
the heights between the groups a significant group ⫻ time interaction was observed (p ⫽ 0.012) where the training women
increased their mean height with 0.3 cm (p ⫽ 0.101) and controls decreased 0.44 cm (p ⫽ 0.045). The training group
improved their thoracic expansion compared with baseline (p ⫽ 0.03). No effect of training on kyphosis was seen. In con-
clusion, a 4-months back extensor training program can improve back strength and seems to maintain height and thoracic
expansion.

Key words: Back extensor muscle training, kyphosis, postmenopausal osteoporosis, vertebral fracture

Introduction
Approximately one in four postmenopausal women
are affected by one or more osteoporotic related
vertebral fractures (1). The vertebral fracture per se
may cause acute pain and loss of function but
may also pass without serious symptoms (2,3). The
occurrence of one vertebral fracture signifies a 20%
risk for an additional vertebral fracture within 1 year
(4) and thus a risk for changing the body posture
to kyphosis.
The presence of a kyphosis in the elderly is most
likely multifactorial (5) and among other things
influenced by changes in the intervertebral discs and
in the spinal soft tissues (6). Vertebral fractures, the
most common clinical manifestation of spinal osteo-
porosis, are one of the main reasons for kyphosis
and have a significant and prolonged impact on
health-related quality of life (2,7).
Increased thoracic kyphosis may be associated
with local pain that might be caused by weak
ligaments, tendons and muscles and not by the
vertebral fractures per se (5). Increased thoracic
kyphosis predisposes the individual to chronic pain
and fatigue. With more vertebral fractures, a more
severe kyphosis develops and the height loss may
lead to iliocostal contact, resulting in costal–iliac

∗Shared last authors.

Correspondence: Ingrid Bergström, Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden, E-mail:
ingrid.b.bergstrom@karolinska.se

(Received 29 October 2010 ; accepted 12 April 2011)

ISSN 1403-8196 print/ISSN 1651-1948 online © 2011 Informa Healthcare
DOI: 10.3109/14038196.2011.581696
 Postmenopausal women with osteoporosis, kyphosis and vertebral fractures
impingement syndrome with pain in the lower back,
which may radiate into the legs (3,8).
Furthermore, kyphosis limits the rib mobility.
Thus, the respiratory function is affected with
decreased vital capacity (9). The pulmonary function
is found to be significantly reduced in patients
with osteoporosis and vertebral fractures compared
with patients without osteoporosis but with chronic
low back pain (10). In patients with osteoporosis,
the back extensor strength is significantly weaker
than in healthy women (11). Weaker back extensors
are associated with thoracic kyphosis (5,6). Back
extensor strength decreases with age (5) and is neg-
atively correlated to the number of vertebral fractures
(12). Back strengthening exercises have been shown
to improve back extensor strength, decrease kypho-
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11
sis, decrease pain and improve the health-related
quality of life in patients with osteoporosis (13).
Current medical practice of the kyphotic patient
is generally limited to pharmacological therapy
addressing osteoporosis (8) and omits taking muscle
training into consideration. There are only a few
randomized prospective studies on the effects of
physical training on osteoporotic women with pre-
existing vertebral fractures (14–16). Gold et al. (16)
For personal use only.
could demonstrate improved trunk extension strength
and psychological symptoms in a group of elderly
women after 6 months of physical intervention. There
seems to be a long-term protective effect of back
resistance training on the spine after its cessation in
estrogen-deficient women. A 10-year follow-up study
by Sinaki et al. (17) found that the relative risk of
vertebral fracture was 2.7 times greater in a control
group than in a back exercise group.
Studies with physical training intervention are
rare and with small cohorts. To compensate for this,
it is of importance to add new studies although the
endpoint is similar. In the present study, we aimed
to determine the effect of a back muscle extensor
strengthening program on the back muscle extensor
strength, kyphosis, height and thoracic expansion
in elderly women with established osteoporosis, i.e.
with at least one vertebral fracture, kyphosis and
osteoporosis.
Materials and methods
Subjects
Postmenopausal women with kyphosis attending the
osteoporosis outpatient clinic at Karolinska Univer-
sity Hospital, Huddinge were invited to join a pro-
spective randomized study evaluating the effect of a
back muscle strengthening program on kyphosis,
height and thoracic circumference (Figure 1). The
inclusion criteria were: (i) at least one vertebral
111
fracture (older than half a year) related to osteopo-
rosis diagnosed with dual X-ray absorptiometry;
(ii) bisphosphonate medication for at least 4 months
before the study; and (iii) the ability and willingness
to participate in the training. Vertebral fractures
were diagnosed with X-ray. The exclusion criteria
were: medication or known diseases that could inter-
fere negatively with bone metabolism or secondary
osteoporosis. Excluded were also patients with car-
diovascular disease and musculoskeletal disorders
that could prevent them from participating in the
training intervention or test measurements, and
patients already performing training at the level or
above that of the intervention program. All women
received oral and written information by the investi-
gator, and signed consent was obtained.
We recruited and included 36 patients during
4 years, which was more than the required 32 sub-
jects according to the power calculation, with the
notion that training subjects have a tendency for
dropping out (18). The subjects were randomized
according to a standardized procedure where the
women picked lottery tickets (C or T) out of a basket
to a control (n ⫽ 16) and a training (n ⫽ 20) group.
A study nurse prepared the lottery tickets and ran-
domized the patients. The groups did not differ in
any baseline characteristics (Table I). No one was on
hormone replacement therapy.
Intervention
The group training program took place in an exer-
cise hall in the Physiotherapy Clinic at Karolinska
University Hospital, Huddinge and was supervised
by a physiotherapist. The women performed a 60-min
group training program twice a week for 4 months.
The training program was performed to background
music and consisted of a warm-up phase that lasted
10 min and included walking steps in a standing
position, scapular retraction, overhead arm raising,
and raising shoulders towards ears and rolling
backwards.
The strengthening training focused on back
muscle exercise training using elastic bands (thera-
bands) or the woman’s body weight as resistance.
The resistance level was individualized for each indi-
vidual and was progressively increased according to
her capacity to improve back muscular strength. The
following exercises were performed in standing posi-
tion with elastic band: (i) facing the wall bars the
scapular retraction was done by double arm exten-
sions pulling the arms backwards in a straightened
position; (ii) scapular retraction was also trained
with the elastic band attached in front of the body;
(iii) lateral pull down overhead was done with the
back against wall bars; (iv) with the side against the
 112 I. Bergström et al.

Postmenopausal women with osteoporosis

and vertebral fractures passing the clinic
examination and consented to the study
(2003-2006) (n=36)

Randomized (n=36)

Allocated to control (n=16) Allocated to physical intervention (n=20)

Received allocated intervention (n=15) Received allocated intervention
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11

Lost to follow-up (n=1) Lost to follow-up (n=2)

♦ Discontinued because of diagnosis of ♦ Discontinued because of personal reasons

sarcoidosis and withdrew consent
For personal use only.

Analysed (n=13)
Analysed (n=15)
♦ Excluded from analysis due to protocol
♦ Excluded from analysis due to protocol
violation with extensive back muscle
violation with insufficient back muscle
training (n=2)
training (n=2)

♦ Excluded from analysis due to accurate

measurement problems (n=1)

Figure 1. Flow-chart.

wall bars a single shoulder horizontal abduction
was performed with the elastic band attached at
shoulder level at the opposite side. Without the elas-
tic band: (v) standing facing a wall straightening of
the back by raising the arms supported by the wall;
(vi) back muscular strength was trained standing
with the back as straight as possible against the
wall while pressing the thoracic spine backwards;
(vii) push-ups at wall bars were also performed;
(viii) positioned on hands and knees the women
raised one leg and the opposite arm in a diagonal
plane. The training program also included exercise
with squats and heel rises. The women trained in a
sitting position: (i) extension of the spine by lifting a
pole over their head; (ii) thoracic spine extension was
also trained by straightening the trunk over the back
of a chair; (iii) isometric press of the shoulder blades,
one at a time, against the back of a chair. Finally
there was a cool-down phase with head and shoulder
movements.
The physiotherapist carefully instructed the
participants to perform all exercises with a proper
posture. Bent positions or trunk flexion exercises
were strictly avoided. The number of repetitions, 30,
was constant and was performed while the physio-
therapist supervised and counted the repetitions. As
the woman’s strength increased, her elastic bands
were exchanged with bands with greater resistance.
Measurements
Height was measured with the Harpenden Stadio-
meter (Holtain Ltd, Crosswell, UK). The patient was
positioned with her heels, buttocks and scapulae in
contact with the stadiometer. If the spinal deforma-
tion prevented this, the most posterior part of the
 Postmenopausal women with osteoporosis, kyphosis and vertebral fractures 113
Table I. Baseline data.

Control, n ⫽ 16 Training, n ⫽ 20 Comparison, (p-value)a

Age, years 74.1 (6.0) 73.2 (8.9) N.S.

Menopause ⬎10 years ago 16 20 –
Height, cm 159.6 (6.0) 158.9 (7.8) N.S.
BMI, kg/m2 25.0 (2.9) 25.5 (4.1) N.S.
Vertebral fractures, n
1 5 5 –
2 5 6 –
3 4 4 –
ⱖ4 2 5 –
Other fractures, n
Hip 2 4 –
Proximal arm 2 1 –
Fore arm 5 10 –
Pelvis 1 0 –
Calcium and D-vit. usage, n 16 20 –
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11

Cumulative bisphosphonate usage, months 21 (8–51) 31 (10–55) N.S.

BMD, T-score
L1–L4 ⫺2.8 (1.0) ⫺2.2 (0.9) N.S.
Hip total ⫺2.2 (0.6) ⫺2.1 (0.8) N.S.
Back strength, N 236 (108) 296 (84) N.S.
Kyphosis, cm
Kyphometer 45.7 (8.8) 38.1 (11.9) N.S.
C7–wall distance 6.5 (5.8–7.5) 5.5 (4.4–8.1) N.S.
Thoracic expansion, cm 3.0 (2.5–4.0) 3.0 (2.0–4.5) N.S.

n, mean or median (SD or 25–75th percentiles). aT-test or Mann–Whitney U-test. BMD, bone mineral density; N.S., not significant.
For personal use only.

back touched the stadiometer. The patient was asked
to stand up as straight as possible and to hold her
head up so that the junction of the ear and scalp, the
posterior angle of her eye lined up horizontally
parallel to the floor. The head-block was slowly
moved down so that it rested on the patient’s scalp.
The patient was instructed to take a deep breath and
stand up straight. At this point, the observer applied
pressure to the mastoid process to hold the position
that the subject lifted to by breathing deeply. The
height was recorded to the nearest completed milli-
meter. The patient was asked to step away from
the stadiometer and the measurement was repeated
twice. If any of the three height measurements dif-
fered by four or more millimeters from the other two,
the height measurement was repeated twice (total of
five). The best result was used. Quality control of the
Harpenden Stadiometer was performed every day a
patient was seen but not less than once a week. The
coefficient of variation for the Stadiometer according
to Coles et al. (19) ranged from 0.9 to 1.7 mm.
Back extensor strength was measured when the
patient was in a standing position with an isometric
dynamometer according to Viitasalo et al. (20). The
dynamometer “Good Strength” (Metitur Oy, Finland)
was used. The vertical and sagittal locations of the
transducer as well as the pelvic support components
were set according to anatomical landmarks for
each patient. The locations of these adjustable
components were recorded and thus the same
positioning after 4 months could be easily redone.
After positioning, the patient was asked to make a
smooth maximal extension of the trunk against the
transducer at a uniform level, sudden explosive force
production was not allowed. The signal from the
transducer was amplified by the help of a DC ampli-
fier and the peak force produced during each trial
was shown in a numerical display. The woman was
given verbal encouragement during the effort with
the same phrase, word by word, for all women. She
was allowed two to three practice trials before testing
where the best result of three to five maximal efforts
was recorded. The number of repetitions was indi-
vidualized dependent on how well the woman techni-
cally performed the measurement. She was told to
rest between the measurements.
The kyphosis was measured by a kyphometer:
the patients were asked to stand straight up and “be
as long as possible”. The kyphometer was placed
between the spinous processes of Th2–Th3 and
between the spinous processes of Th11–Th12. In
those cases when the chest was deformed and the
measuring points thus uncertain, the measuring
points were instead indicated in the protocol as cen-
timeters in relation to C7. The patients were then
asked to make a maximum bending backward – an
extension. The extension was repeated three times and
in three extended positions the measurements were
 114 I. Bergström et al.
performed. This procedure was repeated once after a
short rest and the best result was recorded (21).
Thoracic expansion is defined as the difference
in chest circumference between maximal inhalation
and exhalation. Measurements were done by placing
a tape measure around the chest at the level of the
xiphoideus process. The process was repeated three
times and the best result was recorded (22).
All measurements were performed at baseline
and after 4 months and were blinded as to the
participant. The study nurse examined and evaluated
all women.
Statistical analysis
A power calculation was performed during the
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11
design of the study for the change in back extensor
strength between control and intervention after
4 months of training based on estimates from other
studies. A two group t-test with a 0.05 two-sided
significance level will have 80% power to detect the
difference between a control group mean, of 0.0
and a training group mean, of 10.0 kg, assuming
that the common standard deviation is 13.0, when
the sample sizes in the two groups are 16 each (9).
For personal use only.
Wilcoxon matched-pairs tests and Mann–
Whitney U-tests were used for simple significance
testing for normal and non-normal (thoracic expan-
sion) distributed variables respectively. In compari-
sons between control and training patients, an
analysis of variance (ANOVA) for repeated measures
was performed. Simple main effects tests were used
to evaluate heterogeneous effects in presence of a
significant interaction. For variables where the homo-
geneity of baseline values was doubtful, an analysis
of covariance (ANCOVA) was used with baseline
values as the covariate. Means and adjusted means
and 95% confidence intervals (CI) were estimated
from the ANOVA and ANCOVA models. Correla-
tion between the outcome variables, with respect to
changes from baseline, was calculated with Pearson’s
product moment correlation coefficient; p ⬍ 0.05
was considered statistically significant. The Ethics
Committee of Karolinska Institutet approved the
study.
Results
Intention-to-treat analysis
Out of the 36 included and randomized women,
two women (training) ceased training and withdrew
from the study, and one woman (control) was diag-
nosed with sarcoidosis and was started on corticos-
teroid medication; these three women were lost to
follow-up. Since only baseline data was available for
these three women, we used the principle “last obser-
vation carried forward” (i.e. baseline measurements
at 4 months) in the intention-to-treat analysis on the
main outcome variable, back extensor strength.
Mean (⫾SD) back extensor strength at baseline was
236 ⫾ 108 N for controls and 296 ⫾ 84 N for the
training group. After 4 months, it had increased
to 254 ⫾ 85 N and 302 ⫾ 108 N, respectively.
No significant group ⫻ time interaction was observed
when comparing the changes in back strength,
F ⫽ 0.12, p ⫽ 0.74.
Per-protocol analysis
The effect of the back extensor training program
was evaluated by statistical analysis of the 28 women
who complied with the study protocol of at least
90% attendance in the training group. Two women
(training) were excluded because of inadequate
training (less than 50% attendance) because of a
myeloma diagnosis and a severe back pain period not
connected to the intervention. The controls were
interviewed after study cessation concerning their
physical activity. Two women were excluded because
of extensive back extensor exercising. Another woman
had severe flank pain making adequate measuring
impossible. Mean (⫾SD) back extensor strength at
baseline was 260 ⫾ 101 N for controls and 290 ⫾ 87
N for the training group. After 4 months, it had
increased to 263 ⫾ 79 N and 331 ⫾ 89 N, respec-
tively. No significant group ⫻ time interaction was
observed when comparing the changes back strength,
F ⫽ 2.73, p ⫽ 0.11 (Figure 2a). However, after
adjusting for the strength at baseline, a significant
effect of training could be demonstrated, F ⫽ 5.37,
p ⫽ 0.029. The estimated difference between the
groups was 44 N (95% CI 5–83) (Figure 2b).
When comparing heights between the groups a
significant group ⫻ time interaction was observed
suggesting different divergent changes, F ⫽ 7.28,
p ⫽ 0.012 (Figure 3). Training women increased
their height on average 0.30 cm (95% CI ⫺ 0.06 to
0.66), which was not, however, significant (p ⫽ 0.101),
whereas women in the control group lost on average
0.44 cm (95% CI ⫺ 0.87 to ⫺ 0.01) (p ⫽ 0.045).
Thoracic expansion was measured at baseline
and after 4 months (Figure 4). The medians (25–75th
percentiles) for the control group were 3.5 cm
(2.0–4.0 cm) and 4.5 cm (3.0–5.0 cm) and for the
training group 3.2 cm (2.0–4.7 cm) and 3.7 cm
(3.0–5.0 cm), respectively. No difference was observed
between the groups after intervention (p ⫽ 0.90).
However, the training group significantly improved
their thoracic expansion after 4 months compared
with baseline, p ⫽ 0.03, whereas the control group did
not (p ⫽ 0.06). No significant changes were found in
 Postmenopausal women with osteoporosis, kyphosis and vertebral fractures 115

(a)
400 165

164
360
163
320
Strength (N)

162

280 161

Height (cm)
240 160

159
200
158

157
0
baseline 4 months
156
(b)
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11

340 0
baseline 4 months
320
Figure 3. Height for controls (filled circles) and training group
Strength (N)

300 (open circles) before and after physical intervention. Means and
95% confidence intervals.
280

260 exercise when the proportion of non-adherents to

study protocol is usually larger than normal (23).
240
For personal use only.

In this clinical setting, the per-protocol analysis guar-

0
Control Training
Groups
Figure 2. Mean changes and 95% confidence intervals for back
extensor strength (a) before intervention, controls (filled circles)
and training group (open circles), and (b) after 4 months of
intervention adjusted for the mean of the covariate (baseline).
the measurements of kyphosis measured with a
kyphometer or C7-to-wall distance (data not shown).
antees a proper evaluation of the intervention effec-
tiveness, whereas an intention-to-treat analysis may
provide an excessively conservative estimate of the
treatment effect.
The subjects in the training group maintained
body height, in contrast to the control group, maybe
because of stronger back muscles achieved by the
training program. Strong back muscles can counteract
the gravitational pull and help kyphotic women to keep
a more adequate posture for ordinary activities. An

11
Discussion
10
Our study suggests that a short-term back muscu-
9
Thoracic expansion (cm)

lar extension training program can be effective in

8
increasing the back muscle strength in a group of
elderly women with at least one vertebral fracture, 7
kyphosis and osteoporosis. The result is comparable 6
with the result from Gold et al. (16) with regard to 5
increase of strength. Gold et al. (16) present, in their 4
study of 185 postmenopausal women with at least 3
one vertebral fracture randomized to training three
2
times a week during 6 months, that training improves
1
the trunk strength and leads to better physical mobil-
ity. The statistically significant results in our study Control Training
were obtained in a per-protocol analysis but were Groups
not seen when analyzing data according to the inten-
Figure 4. Thoracic expansion of controls and the training group
tion-to-treat method. Although the latter is consid- before and after physical intervention. Measurements at baseline
ered as the gold standard, a per-protocol analysis (open boxes) and after 4 months (gridded boxes). Box-whisker
can be relevant in intervention studies with physical plot indicates median, 25–75th percentiles and min–max values.
 116 I. Bergström et al.
increased height is a precondition for a better posture
(24). Martin and co-workers (25) found that women
with height loss had difficulties in activities of daily life.
Height loss in elderly women has also been found to
affect the quality of life negatively (26). Thus, it appears
that an increase in height is desirable for women with
kyphosis. The measured difference in height between
our two study groups is very small but is above the
measurement error of the stadiometer. According
to these results, strengthening the back extensor
muscles seem to preserve height. This is in agreement
with a training study for middle-aged healthy women,
where spinal extension exercises for 1 year prevented
the natural progression of kyphosis (27).
The usage of thoracic expansion as a marker
for respiratory function is debated. Schlaich et al. (10)
Adv Physiother Downloaded from informahealthcare.com by 81.231.187.141 on 08/30/11
did not find in his study any correlation between
maximal thoracic expansion and lung function in
patients with spinal osteoporotic fractures. In contrast,
a thoracic expansion of ⬍3.8 cm in patients with idio-
pathic scoliosis is strongly correlated with diminished
vital capacity (28). In our study, the training group
increased its thoracic expansion. Speculatively, this
could have a positive effect on respiratory function.
Contrary to our expectation, no effect of the
For personal use only.
exercise on the kyphosis could be observed. This
might be related to the small number of participants
studied, drop-outs and to the short period of train-
ing that was limited to 4 months. Another limitation
of our study is that controls randomized to sedentary
life had to be excluded because of extensive exercis-
ing. Unfortunately, this phenomenon is a well known
problem in training studies.
Strom et al. (29) described that the long term
costs and loss in quality of life related to vertebral
fractures are higher than previously believed. Up
until now, the treatment for this patient group has
mainly been pharmacological. This study and the
results of others suggest that physiotherapy focusing
on back muscle training should be taken into con-
sideration in the care of women with vertebral frac-
tures and kyphosis. This approach may also hold
important economical values in the future.
Acknowledgements
The authors wish to thank Catharina Sjöberg,
Department of endocrinology, metabolism and
diabetes, Karolinska University Hospital, Stockholm,
for excellent help with measurements of patients and
Sanofi-aventis for the purchase of the dynamometer
“Good Strength”.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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