INTRODUCTION: Locomotive syndrome is a degenerative condition of reduced mobility due to the impaired musculoskeletal system, which has received increasing attention as a Japan’s national health policy target. The Japanese Orthopaedic Association recommends locomotion training (basically squatting and single-leg standing) to be effective in preventing locomotive syndrome. However, the extent to which locomotion training affects the sagittal spinopelvic alignment, potentially affecting the quality of life, is unknown. Therefore, we developed a locomotion training-based rehabilitation program and designed a 2-year prospective cohort study of the spinopelvic alignment in outpatients with locomotive syndrome.
METHODS: Outpatients who fulfilled the criteria for locomotive syndrome (≥risk level 1) were enrolled and prospectively followed (n=261: age, 76.7±5.9 years; male:female, 23:238). While 63 cases completed locomotion training-based outpatient rehabilitation once per week for 24 months (20-min stretching and achievement evaluation), 70 denied the exercise participation but performed self-exercise at home and received clinical follow-up examinations. Additionally, 73 dropped out of outpatient rehabilitation but visited clinical follow-up. Total 206 outpatients took 2-year follow-up (78.9%). Standing radiographs for the global spinopelvic alignment and the presence of vertebral fracture (≥grade 2), bone mineral density (BMD), Oswestry disability index (ODI) questionnaire, and the severity of locomotive syndrome (risk levels 1–3) were evaluated at 0, 6, 12, and 24 months. The chai-squared test, Student’s t-test, or multi-way repeated measures analysis of variance with Tukey’s post-hoc test was used.
RESULTS: No significant differences in baseline demographics and radiographic characteristics including the sagittal vertical axis (SVA) were detected between the outpatient rehabilitation and self-exercise observation groups (p=0.23). The rehabilitation group presented time-course decreases in SVA [mm] from 49.5 at baseline, 40.8 at 6 months, 41.9 at 12 months, to 39.5 at 24 months (p<0.01) whereas the self-exercise group increased SVA from 38.3, 42.1, 44.6, to 51.8 (p<0.01), indicating sustained locomotion training effects. Then, the dropped-out group during 12–24, 6–12, and <6 months presented increases in SVA from 34.6 at 12 months to 46.5 at 24 months (p=0.19), 36.2 at 6 months to 44.2 at 12 months (p=0.25), and 42.7 at baseline to 54.1 at 6 months (p<0.01), respectively; thus, the trend toward the deterioration in SVA after dropping-out of rehabilitation is relatively consistent. While the increased lumbar lordosis (LL) (p<0.01) and decreased pelvic incidence minus LL (p<0.01), pelvic tilt (p=0.049), T1 pelvic angle (p=0.04), and hip flexion angle (p<0.01) were observed in the rehabilitation group, suggesting that SVA improvement potentially results from the lumbar spine−pelvis−lower extremity axis. Furthermore, ODI was improved in the rehabilitation (p<0.01) but not self-exercise (p=0.84) group. Similarly, 60.3% of the rehabilitation group but 14.3% of the self-exercise group improved locomotive syndrome risk levels (p<0.01). Multivariable logistic regression analysis identified outpatient rehabilitation as the significant predictive factor of SVA improvement (odds ratio 3.31, p=0.04), without correlations of vertebral fracture and BMD.
DISCUSSION: This study highlights the importance of sustained locomotion training-based rehabilitation at outpatient clinics to protect against locomotive syndrome-associated degeneration including positive SVA shift. Setting-up of social systems capable of continuous rehabilitation is desirable.