The Better Bones Blog

by Dr. Susan Brown, PhD.

A “dowager’s hump” does not always mean spinal fracture

Much of the fear generated around osteoporosis stems from pictures of stooped, hump-backed, downward-looking elderly women. This vertebral deformity, often called a “dowager’s hump” and technically known as “kyphosis,” has come to be a dreaded tell-tale sign of the crippling potential of osteoporosis. New research, however, indicates that contrary to popular opinion, this feared spinal deformity does not necessarily indicate that one has a vertebral fracture. Nor does having a dowager’s hump seem to predict the probability of a future spinal fracture.

Actually, this new Australian research is of great interest to me. In my office I have seen more than one very stooped, elderly woman whom I might well think was crippled by osteoporosis, yet her bone tests showed no such problem. While the dowager’s hump and severe kyphosis can be caused by multiple spinal fractures, it often is not. In fact, the relationship between kyphosis and spinal fracture was so weak that these Australian researchers concluded that the existence of even severe kyphosis is only of limited value in determining a person’s risk of having a vertebral deformity and is no value in determining that individual’s risk of future vertebral fracture. Spinal deformities and vertebral fractures can only be reliably diagnosed using x-ray technology or by means of vertebral fracture assessment, also known as vertebral morphometry deformity assessment. Thus, if I see someone very worried about spinal fractures, I suggest that they ask their physician for a spinal x-ray or a vertebral fracture assessment.

So, if having a dowager’s hump or kyphosis does not necessarily mean you have osteoporosis, what else might it mean? Well, the most common reason for such a hump is postural slouching associated with a loss of musculoskeletal integrity and strength. For many, standing tall and holding good posture is an exercise in itself. Other non-fracture reasons include certain diseases, developmental or congenital causes, and nutritional issues such as rickets from vitamin D deficiency.



Prince, RL, et al. 2007. The clinical utility of measured kyphosis as a predictor of the presence of vertebral deformities. Osteoporosis International, 18:621-627.


Back strengthening exercises to prevent spinal fractures

You have probably heard that back strengthening exercises help prevent spinal osteoporotic fractures — but are all types of exercises equally beneficial? No, they are not, as clearly documented by an early Mayo Clinic study (Sinaki and Mikkelsen 1984). This study showed clearly that extension-type back-strengthening exercises effectively prevented further spinal deformation in osteoporotic women. Flexion-type exercises, on the contrary, actually increased the risk of further spinal compression and wedging.

This landmark 1984 Mayo Clinic study took 59 postmenopausal women (49–60 yrs old) with spinal osteoporosis and/or existing spinal fractures and back pain. The women were grouped into four different treatment programs (1) extension exercise (bending backwards, spine lengthening exercises); (2) flexion exercise (bending forward exercises) (3) both extension and flexion exercises, and (4) no therapeutic exercise. Spinal x-rays were analyzed before and after the mean 1.5-year study period. Although small in number, the study was large in significance. Only 16% of women doing the extension exercise experienced further spinal wedging or compression. On the other hand, a whopping 89% of those doing the flexion exercises had worsened spinal deformities, as did 53% of those doing the combined extension and flexion exercises and 67% of the non-exercisers.

Exercise is a key component of the Better Bones, Better Body approach, and in this regard, a favorite ally is a good physical therapist who can help individuals with back pain and/or existing spinal deformities develop a safe and effective back strengthening program to help prevent new spinal fractures.



Sinaki, M and Mikkelsen, BA. 1984. Postmenopausal spinal osteoporosis: Flexion versus extension exercises. Arch Phys Med Rehabil, 65:593–596.


High calcium intake does not prevent fractures

Years ago, in the first edition of my book, Better Bones, Better Body, I noted that high calcium intakes did not seem to prevent fractures. Cross-cultural data, in fact, suggested that countries with the highest calcium intake actually had the highest rates of osteoporotic hip fractures. Recently, sophisticated meta-analysis of the major published studies on the topic confirm my early breakthrough observation—and go beyond it to suggest possible risks of high, imbalanced calcium intakes. High calcium intakes do not prevent fractures, and may actually increase risk of hip fracture among some.

In my blog post, “Vitamin D is more important than calcium” I report on the US NHANES 111 survey finding that only for women with very low vitamin D levels is a higher calcium intake associated with better bone density. The large national survey (Bischoff-Ferrari et al. 2009) found that if women were not deficient in vitamin D (that is they had a vitamin D level above 20 ng/mL), a calcium intake higher than 566 mg per day was not associated with any greater bone density than with an intake of 566 mg calcium per day.

I doubt this lack of association between bone density and higher calcium intake among all but the vitamin D deficient came as a surprise to Bischoff-Ferrari and colleagues.

And why do I say these researchers were likely not surprised?

Because these scientists had already carefully analyzed all the studies on calcium intake and fracture risk.

• In 2005, Bischoff-Ferrari et al. conducted an overview analysis of studies on vitamin D and fracture prevention and concluded, ‘Thus, additional calcium supplementation may not be critical for non-vertebral fracture prevention once 700-800 IU of vitamin D are provided.” (Bischoff-Ferrari et al. 2005)

• Then again in 2007, the same group conducted a monumental meta-analysis of all major studies looking at calcium intake and risk of hip fracture. As they reported, “Pooled results from prospective cohort studies suggest that calcium intake is not significantly associated with hip fracture risk in women or men. Pooled results from randomized controlled trials show no reduction in hip fracture risk with calcium supplementation and an increased risk is possible. For any nonvertebral fractures, there was a neutral effect in the randomized trials.” (Bischoff-Ferrari et al. 2007)

And what about the possible increased risk of fracture they suggest?

In their meta-analysis they found four clinical trials which reported separate results for hip fracture. These clinical trials involving 6,504 subjects found a 64% greater risk of hip fractures with calcium supplementation. While this question of if, and how, high calcium intake could actually increase hip fracture risk is both complicated and speculative, a logical explanation the researchers mention is that “calcium alone may not prevent hip fractures in women” and that other nutrients are essential for bone strength. The other nutrients they mention include vitamin D, protein, and phosphorus — at least one of which (phosphorus) can be detrimentally impacted by high calcium intakes health.

All this new research supports our long-standing Better Bones position that at least 20 nutrients are key to bone health and that all these nutrients should help keep one nutrient in balance with the others.



Bischoff-Ferrari, HA, et al. 2005. Fracture prevention with vitamin D supplementation: A meta-analysis of randomized controlled trials. JAMA, 293(18): 2257-2264.

Bischoff-Ferrari, HA, et al. 2007. Calcium intake and hip fracture risk in men and women: A meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr, 86:17980-90.

Bischoff-Ferrari, HA, et al. 2009. Dietary calcium and serum 25-hydroxyvitamin D status in relation to BMD among U.S. adults. J of Bone Miner Res, 24(5):935-942.


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