Arch Orthop Trauma Surg
DOI 10.1007/s00402-017-2669-z
ORTHOPAEDIC SURGERY
Biomechanics oftheosteoporotic spine, pain, andprinciples
oftraining
GuidoSchrder1 AndreasKnauerhase2 HolgerS.Willenberg2 GuentherKundt3
DetlefWendig1 HansChristofSchober1
Received: 8 December 2016
Springer-Verlag Berlin Heidelberg 2017
Abstract
Introduction A fracture is a clinical manifestation of
osteoporosis and is one of the main causes of functional
limitations and chronic pain in patients with osteoporosis.
Muscle and coordination training are recommended to the
patients as general measures. We inquired whether sling
training is better than traditional physiotherapy in relieving
pain and improving abilities of daily living.
Methods Fifty patients with osteoporosis were divided
into two groups. Group A performed conventional physi-
otherapy, while Group B performed sling training exer-
cises. Data were collected before and after the intervention
and after 3 months. The registered parameters were stam-
ina, posture, and pain. Posture, torques, and the associated
* Guido Schrder
guido.schroeder1@gmx.net
Andreas Knauerhase
andreas.knauerhase@unirostock.de
Holger S. Willenberg
holger.willenberg@unirostock.de
Guenther Kundt
guenther.kundt@unirostock.de
Detlef Wendig
info@dwendig.de
HansChristof Schober
hanschristof.schober@kliniksuedrostock.de
1
Department ofInternal Medicine, Klinikum Sdstadt
Rostock, Sdring 81, 18059Rostock, Germany
2
Division ofEndocrinology andMetabolism, Department
ofInternal Medicine, Rostock University Medical Center,
E.HeydemannStr. 6, 18057Rostock, Germany
3 ing kyphosis of the thoracic spine and trunk inclination.
Institute forBiostatistics andInformatics inMedicine
andAging Research, University ofRostock,
E.HeydemannStr. 8, 18057Rostock, Germany
strength of spinal muscles were studied in a biomechanical
model in order to estimate the forces acting on the spine.
Furthermore, the factors that exerted a positive impact on
the success of therapy were registered.
Results Forty-four patients (88%) completed the study.
Positive effects of the training were noted in both groups,
but significantly better effects were observed in the group
that performed sling training. A reduction of pain inde-
pendent of the number of fractures, significantly reduced
torques, and reduced muscle strength were registered.
ConclusionsSpecific training programs helped to
increase muscle strength and straightening the back
thereby reducing the force needed on a permanent basis
and decreasing torque in the spine. Sling training was more
effective in that than traditional physiotherapy.
Keywords Osteoporosis Fracture Biomechanics Sling
exercises
Introduction
Osteoporosis is frequently accompanied by fractures of the
spine. These, in turn, lead to a change in body posture [1].
After the initial vertebral body fracture, a patient frequently
develops multiple end plate fractures [2]. The occurrence
of further fractures is associated with a higher risk of sub-
sequent fractures and a change in the statics of the spine,
followed by greater loads on adjacent vertebral bodies [3].
Loads on muscles and ligaments, and adaptive changes fol-
low [4]. Especially the erector spinae muscles are loaded to
an unphysiological extent in order to counteract the advanc-
This results in muscle exhaustion and sinking of the trunk,
and may trigger chronic pain and further fractures [5, 6].
13
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Changes in the spine as a result of vertebral body fractures
have been frequently investigated in ex vivo models, but
have not been studied so far in a biomechanical model of
the spine invivo. The purpose of our study was to develop
a patient-based biomechanical model including registra-
tion of torques in the spine. We also tested, in the clinical
setting, whether back pain caused by osteoporosis can be
explained by torques and muscle strength, and whether a
specific training program can achieve improvement.
Methods
Participants andrandomization
The present study was conducted as a prospective rand-
omized single center investigation of two treatment groups
(Table 1). Randomization was performed in a permuted
block design; the size of the block was selected randomly
[7]. Patients were recruited from the outpatient osteoporosis
departments of the Sdstadt Clinic and the Medical Univer-
sity of Rostock. Patients with proven osteoporosis requiring
treatment, with pathological DXA values (T-score2.5),
were selected. The patients were asked to perform osteopo-
rosis exercises twice a week, with the purpose of reducing
pain especially in the spine by strengthening the trunk mus-
cles and initiating muscular balance.
Exclusion criteria included all types of secondary osteo-
porosis, severe heart failure, uncontrolled hypertension,
relevant neurological deficits, vestibulopathy, and the need
for constant care. Furthermore, patients who were absent
twice or had to discontinue the exercises during the period
of investigation because of muscular or skeletal symptoms
were excluded from the study.
Intervention
Patients with osteoporosis completed a 3-month exercise
program. The exercises were performed twice a week and
Table1Patients medical history: male (m)/female (f), age in years,
body mass index in kg/m2; bone density expressed as the T-score;
physiotherapy (PT); sling training (ST)
PT (n=21) ST (n=23) p value
Gender m/w 2/19 2/21 1.000a
Age 69.73.7 71.06.1 0.409b
Body mass index 23.92.9 25.63.5 0.084b
Bone density 2.80.83 2.80.77 0.809b
Data expressed as meansSD
a
Chi-square test
b
t test for independent variables between the groups
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Arch Orthop Trauma Surg
supervised by a physiotherapist. The physiotherapy group
(PT) performed established traditional exercises [8], while
the sling training group (ST) performed similar exercises
with slings [9].
Numerical rating scale
A validated numerical scale (NRS) with 11 ratings was
used for the study [10]; 0 meant no pain and 10 meant the
worst pain imaginable. The patient selected the rating that
best suited his/her sensation of pain. The NRS was used
before the training, after the training, and during follow-up.
Videorasterstereography
The efficacy of the therapy measures used and the altera-
tion of body posture were documented with the spine scan-
ner Formetric III 3D/4D of Diers International GmbH. Vid-
eorasterstereography (VRS) is regarded as a reliable aid to
describe the sagittal profile of the spine and spine deformi-
ties [11, 12]. The scanner employs the method of raster ste-
reography for surface measurement of the spine with stere-
ophotogrammetry. The VRS enables the clinician to make
statements about the size of the kyphosis and lordosis angle
or trunk inclination in patients with osteoporosis. The x and
y coordinates of the sagittal profile served, among other
aspects, as a basis for the biomechanical model of the spine
described in the following (Fig.1c).
Biomechanical model ofthespine
Bergmarks model [13] served as the basis of the present
investigation (Fig.2). The symbols, units, and indices used
here are shown in the supporting table. Furthermore, the
following values are significant.
Trunk length
It is the perpendicular connection between the seventh
cervical vertebra (C7) and the middle of the lumbar grove
(LG), is associated with the y coordinate, and was meas-
ured with the aid of VRS.
Vertebral body height
This was taken from the investigation of Berry etal. [14].
The existing X-rays of the patients were used to evaluate
the theoretical model by performing our own measure-
ments and calculations.
Arch Orthop Trauma Surg

Fig.1Schematic diagram of video raster stereography (according to the kyphosis angle (KA), lordosis angle (LA), trunk inclination (TI),
Drerup), video camera (C), stripe projector (P), human spine surface cervicothoracic inflectional point (ICT), thoracolumbar inflectional
(H), basic distance (B) between the camera and the projector, distance point (ITL), lumbosacral inflectional point, dimple middle (DM), cor-
(D) to the patient a; Grid parallel lines on the spinal surface; vertebra responding to the kyphosis angle, lordosis angle, trunk inclination,
prominens (VP), dimple left (DL) und dimple right (DR) correspond- turning points, and the middle of the lumbar groove c
ing to the left and the right lumbar groove b; Sagittal profile with

Body mass of L5 is 22.2 mm. This is equivalent to a compression

factor of 17.8 percent.
The percentages of body mass from C7 to the first sacral
vertebra (S1) are based on Duval-Beauperes study [15].
The suggested percentage distributions are reflected in Xcoordinate
the calculation of actual body mass.
The x-coordinate (Fig. 1c) is derived graphically from
lateral VRS images.
Intervertebral disks

A quasilinear adjustment of intervertebral disk height Weight force

was performed for the model. In order to consider differ-
ences in the patients trunk length, a percentage compres- The weight force acting on each section of a segment is
sion factor was introduced. When no compression factor calculated as the product of the mass of this section and
was available, we refer to the original values stated by gravity (9.81m/s2).
Berry et al. [14] and our assumed values. Compression
was calculated according to the following formula:
Gravitational line
Reference height = Original height (1 Compression factor).
With the aid of the compression factor, one can adjust On average, it runs about 1 cm before the mid-point of
the trunk length of the model to the actual trunk length the ventral-most lumbar vertebra. According to Asmus-
(VRS). For instance, according to Berry et al. [14], the sen [16], it is the fourth lumbar vertebra.
vertebral body height of L5 is 27 mm, and for a patient
with a trunk length of 508mm, the vertebral body height

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Fig.2The geometrical parameters used to describe posture and
position of the gravity line A: insertion of the global erector spinae
muscle, B: T12-L1 disk-midpoint C: the combined center of gravity
of upper body weight and the weight that constitutes the outer load
(Q), D: origin of the global erector spinae muscle, E: L5-S1 disk-mid-
point, a: distance from the most anterior disk-midpoint to the gravity
line. The coordinates of the global muscle insertions on the thoracic
cage are given by c and h. c=59+21mm and h=100mm. The coor- describe the individual severities of the qualitative charac-
dinates of the origin D are given by d=60 mm. trunk inclination
(according to Bergmark)
Muscle strength
A global epicenter of the trunk is assumed for the calcula-
tion of muscle strength (erector spinae muscles). The fol-
lowing equations are important for the calculations:
MG = FG an
The resulting moment must be equivalent to the moment
arising from muscle strength and the lever arm c (Fig.2).
The corresponding muscle strength can be calculated there
from.
MG = MMK
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Arch Orthop Trauma Surg
FMK = MG c
Lever arm
It is the horizontal projection of the distance between the
epicenter of the observed section and the midpoint of the
vertebral body in this section. The lever arm consists of
several components. The first is distance a (Fig. 2). The
second is the sagittal shift of the midpoint of the vertebral
body in the most ventral location. The third results from
the x-shift due to trunk inclination (change in the angle).
This is selected so that the measured point (C7) coincides
with the model point. The fourth component is the respec-
tive averaged x-value of the corresponding section. The
lever arm is calculated by the following formula:
an = a + x(max.LWK) + x() xn
Ethics committee
After being informed in detail about the purpose of the
investigation, which was to improve the treatment of pain
by using various exercises regimens, each participant con-
sented in writing to the utilization of his/her anonymized
data. The clinical investigation was submitted to the ethics
committee of the regional medical association of Rostock
and approved by the same (registration number A 2009 50).
Data analysis
The collected data were analyzed with the statistics soft-
ware package SPSS, Version 19.0 (SPSS Inc., Chicago,
USA). Quantitative characteristics were described by
means, standard deviations, minimum and maximum val-
ues, and the number of available observations. These were
expressed with the interval meanstandard deviation. To
teristics, absolute and percentage frequencies were used.
For quantitative variables, comparisons between the two
groups were made using the t test for independent sam-
ples or the parameter-free Mann-Whitney U test. The Chi-
square test was used to determine whether the observed
frequencies differed significantly from the anticipated ones.
All p values are the result of two-sided statistical tests;
the level of statistical significance was set to p0.05.
Results
Initially, 50 patients with osteoporosis25 each in the PT
and ST intervention groupsparticipated in the clinical
trial. Forty-four patients (88%) were aged 62 to 84 years
(mean age 70.4years) and conducted the training program
until the end of the study period. Four patients terminated
Arch Orthop Trauma Surg

the study prematurely in the PT group, and 2 in the ST was altered in the PT and ST groups; this could be viewed
group. The reasons were diverse: some patients had joint as a statistical trend [65.542.0N (PT) vs. 38.955.0N
pain, while others could not attend the exercise sessions (ST), p=0.081] (Table2).
regularly because of multimorbid conditions or for famil-
ial reasons. Finally, 44 sagittal profiles could be included in Local torque
the biomechanical calculations.
The results of the intervention for all measured parame- Local torque is the total torque acting on each vertebral
ters before the exercise program, after the 3-month exercise body. In contrast to the overall torque, individual cent-
program, and after a follow-up time period of 3 months ers of mass arising from the shift of the x-coordinate were
without training are shown. assumed here.
Local torque was nearly identical in both groups at
Overall torque the start of the investigation (p>0.05). Even after the
training program, we found no significant difference
Overall torque was nearly identical in both groups at the [12.48.1 N m (PT) vs. 9.99.9 N m (ST), p=0.382].
start of the investigation (p>0.05). Even after the training The follow-up investigation also revealed no significant
program, there was no significant difference. Viewing over- effects between the two groups (p>0.05) (Table2).
all torque during follow-up, a difference was noted between
the two groups, which may be regarded as a statistical trend
[5.23.4 N m (PT) vs. 3.14.4 N m (ST), p=0.082] Success oftreatment
(Table2).
We rated the success of treatment (TE) on a NRS from 0 to
Global muscle strength 10. An improvement of at least one point on the NRS was
interpreted as successful treatment. We also determined
The results of the calculation of muscle strength in the erec- the factors influencing the success of treatment. Thirty-
tor spinae muscles show that, before the exercise program, three patients concluded the therapy successfully, while 11
patients of both groups had to expend the same strength patients did not.
in order to stabilize the overall system (p>0.05). After Overall torque did not differ significantly between groups
the intervention had been concluded, again no statistically at the start of the investigation (p>0.05). A significant dif-
significant difference was observed between the groups. ference was noted after the exercise program [3.73.3Nm
In contrast, during follow-up, the required muscle strength (successful therapy) vs. 6.63.6 N m (unsuccessful ther-
apy), p=0.017]. The follow-up investigation revealed a sta-
tistical trend between the groups (p=0.093).
Table2Results of group comparison: physiotherapy (PT) vs. sling Viewing the strength of the erector spinae muscles
training (ST), torque in newton meters, muscle strength in newtons, directly after the intervention, a significant statistical dif-
significance between the groups ference was noted between the groups [46.241.9N (suc-
PT (n=21) ST (n=23) p Wert cessful therapy) vs. 83.044.6 N (unsuccessful therapy),
p=0.017]. This could be observed as a statistical trend
Overall torque during follow-up (p=0.093). In contrast, the factors of
Before training 5.02.8 4.04.4 0.360a local torque, vertebral body fracture, age, and BMI showed
After trainingb 5.33.6 3.63.8 0.123a no significant differences at the individual time points of
Follow-upc 5.23.4 3.14.4 0.082a measurement (p>0.05) (Table 3). The factor of exercise
Global muscle strength therapy revealed a highly significant difference between
Before training 63.035.0 50.054.6 0.359a the successful therapy and unsuccessful therapy group
After training 66.540.7 45.347.3 0.119a (p=0.001). Table3 provides an overview of the factors that
Follow-up 65.542.0 38.955.0 0.081a influenced the success of therapy.
Local torque
Before training 12.38.9 14.111.0 0.562a
After training 12.48.1 9.99.9 0.382a
Follow-up 12.99.0 11.19.4 0.504a
Discussion

Data expressed as meansSD The biomechanics of the spine have been a subject of
a
t test for independent variables between the groups research for several years. A few models have been devel-
b
3months oped, and these provide valuable information about effec-
c
6months tive forces and stabilization [13, 1719].

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 Arch Orthop Trauma Surg

Table3 Success of therapy showed that muscle tone and muscular stiffness can be
Success- Unsuccessful p value significantly decreased by sling training [23]. Roh et al.
ful therapya therapy (n=11) compared sling training to conventional physiotherapy in
(n=33) patients with chronic back pain [24]. They found that sling
training was especially useful in the reconstitution of the
Overall torque
lumbosacral alignment and for control of back pain. Similar
Before training 4.03.4 5.94.3 0.158b
results were observed by Lee and Cho in a separate study
After trainingd 3.73.3 6.63.6 0.017b
cohort of females with chronic low back pain [25]. Inter-
Follow-upe 3.54.1 5.93.3 0.093b
estingly, they concluded that sling training had a positive
Global muscle strength
impact on intervertebral disk height and volume.
Before training 50.542.7 73.454.0 0.158b
We also found that the effect of pain relief seemed to
After training 46.241.9 83.044.6 0.017b
be independent of the number of vertebral body fractures
Follow-up 44.251.7 73.740.7 0.093b
experienced by the individual while Karunanayake et al.
Local torque
inferred from their data that only vertebral fractures and
Before training 12.59.1 15.612.5 0.382b
intervertebral disk space narrowing had a significant asso-
After training 9.88.4 14.910.1 0.104b
ciation with chronic low back pain [26]. Thus, according
Follow-up 11.59.2 13.39.4 0.585b
to our data, the re-erection of the spine by a suitable train-
Vertebral body fracture
ing program that addresses the small segmental muscles as
Yes/no 14/19 4/7 0.723c
well as the global trunk muscles seems to be an adequate
Age 70.55.4 69.94.2 0.724b
method of achieving sustained pain relief. At the segmental
BMI 25.23.3 23.43.0 0.113b
level, Kapandji [27] offers a biomechanical approach to the
Training therapy
mode of action of the autochthonous spinal muscles. Each
Physio/sling 11/22 10/1 0.001b
vertebral body may be compared to a lever whose fulcrum
a
The success of therapy was rated on the NRS 010 is the facet joint. This lever system enables the individual
b
Independent t test to absorb and pass on axial compressive forces. Direct and
c
Chi-square test passive absorption is achieved by the intervertebral disks,
d
After 3months and indirect active absorption by the deep autochthonous
e
After 6months spinal muscles. The latter start their action at the lever arm
or the vertebral arch (arcus vertebrae). Thus, exercising
the muscles close to the joint is able to reduce loads on the
The biomechanical model we developed utilizes the spine and improve overall statics.
fact that the actual height of the intervertebral disks is sub- In general, in a state of pain, the local stabilizers seem to
ject to a circadian rhythm. It is assumed that the human be atrophied or not controllable [2830]; this causes insta-
being is 1020mm taller in the morning than he/she is in bility in the segments of the spine. Muscular factors appear
the evening. The reason is the differing influence of grav- to be important for the emergence of pain, independent of
ity on the spine. Roberts et al. [20] report a height differ- vertebral body fractures.
ence of 826 mm in women. Assuming that the height of Prospective studies will be needed to answer the inter-
the intervertebral disks also increases from the cranial to esting question as to whether such training with altered
the sacral aspect, a height difference of 1116mm may be torques in the individual sections of the vertebral bodies
presumed. Thus, a connection was established between the will also reduce the increasing numbers of spinal fractures.
actually measured height difference and the model. Further- Fracture rates and posture are frequently discussed in the
more, the model describes the displacement of the spine published literature. Ross et al. [31] conducted a study to
from the ideal line. According to our data, the displacement quantify relationships between vertebral fractures, pain,
from the ideal line also appears to be responsible for pain. and physical limitations on the basis of statistical proce-
The two training programs we conducted yielded different dures (such as correlation analysis). The number of ver-
results. While traditional physiotherapy resulted in a short- tebral body deformities and their grade of severity were
term straightening of thoracic kyphosis, we observed a sus- assessed on X-rays. The results show that severe vertebral
tained effect in the group that performed sling training [21]. deformities are frequently correlated with pain and physi-
Such straightening caused the individual to expend less cal limitations. In a cross-sectional study in postmenopau-
muscle strength and thus reduced torque in the concerned sal women aged 4784 years, Sinaki et al. [32] show that
section of the spine. the strength of the back extensor muscles, the kyphosis
Likely, sling training reduces muscle stiffness which angle, and vertebral body fractures are closely linked to
is associated with back pain [22]. A recent work by Kim each other. The authors believe that the muscle strength of

13
Arch Orthop Trauma Surg
the back extensors rather than bone density should be used
as an indicator of vertebral body fractures. They conclude
that strong back muscles reduce the risk of vertebral body
fractures. These results of cross-sectional investigations are
supported by our prospective study based on various train-
ing principles.
Activating the deep stabilizers appears to relieve pain.
Whether fusion fractures can be prevented by this measure
will have to be determined in the future.
One factor that possibly distorts the results of the study
is the age-related multimorbidity of the patient population.
Therefore, the pain attributed to osteoporosis must be ques-
tioned critically.
One aspect which has not been addressed yet but is
related to body posture and posture instruction is sample
size. To perform the exercises properly and provide indi-
vidual care, a maximum sample size of 5 patients seems
to be appropriate. In the present study, the physiothera-
pists immediate feedback ensured that, on the one hand,
the probands were motivated to perform the exercises
properly (i.e. without alteration) and, on the other hand,
they experienced greater strain when performing the exer-
cises. However, since the overall size of the present sample
was too small to perform multivariate analysis, a valida-
tion study will be needed to determine relevant statistical
effects.
In conclusion, sling training helped to increase muscle
strength and straightening the back, thereby reducing the
force needed on a permanent basis and decreasing torque
in the spine. Sling training was more effective in that than
traditional physiotherapy.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict
of interest.
Ethics approval All procedures were performed in accordance with
the ethical standards of the authorized ethics committee for human
experimentation (institutional and national) and the Helsinki Declara-
tion of 1975, as revised in 2000.
Informed consent Informed consent was obtained from all patients
for being included in the study.
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