Age-related Hyperkyphosis: Difference between revisions

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== Definition/Description ==
== Introduction ==
 
Age-related hyperkyphosis affects 20-40% of older adults and can be described as an exaggerated anterior curvature of the thoracic spine that is associated with aging<ref name="Jang et al." />
Age-related hyperkyphosis affects 20-40% of older adults and can be described as an exaggerated anterior curvature of the thoracic spine that is associated with aging (increasing incidence 6-11% for every 10 years of increasing age).<ref name="Jang et al.">Jang et al., H. (2015). Effect of thorax correction exercises on flexed posture and chest function in older women wih age-related hyperkyphosis. J. Phys. Ther. Sci. , 27, 1161-1164.</ref><br>General causes of age-related hyperkyphosis that have been reported are poor posture, dehydration of the intervertebral discs and reduced back extensor muscle strength.  
* Anterior curvature of the thoracic spine is normal and present due to the shape of the vertebral bodies and intervertebral discs,
* Kyphosis angle greater than 40° is defined as hyperkyphosis.<ref name="Jang et al.">Jang et al., H. (2015). Effect of thorax correction exercises on flexed posture and chest function in older women wih age-related hyperkyphosis. J. Phys. Ther. Sci. , 27, 1161-1164.</ref>
<br>General causes of age-related hyperkyphosis that have been reported are poor posture, dehydration of the intervertebral discs and reduced back extensor muscle strength.  
''Age-related hyperkyphosis'' may'':''
* Induce the symptoms such as back soreness, neck pain, numbness of upper extremities or buttock
* Low psychological well-being such as depression and low self-esteem<ref>Jang, H.-J., Hughes, L. C., Oh, D.-W., & Kim, S.-Y. (2019). Effects of Corrective Exercise for Thoracic Hyperkyphosis on Posture, Balance, and Well-Being in Older Women: A Double-Blind, Group-Matched Design. ''Journal of Geriatric Physical Therapy'', ''42''(3), E17–E27. <nowiki>https://doi.org/10.1519/JPT.0000000000000146</nowiki></ref>
* Lead to mobility impairments of the [[Ribs|rib]] cage (connected to [[Thoracic Anatomy|thoracic spine]]) which can result in pulmonary difficulties


''Age-related hyperkyphosis may:''
* Increase biomechanical stress on the spine which can result in an increased risk of development of [[Osteoporotic Vertebral Fractures|vertebral compression fractures]]
* Lead to mobility impairments of the rib cage (connected to thoracic spine) which can result in pulmonary difficulties.
* Increase risk of [[Falls in elderly|falling]] and fractures due to poor [[gait]]
* Increase biomechanical stress on the spine which can result in increasing risk of development vertebral compression fractures
* Impaired Physical function eg has an impact on the basic functioning and daily living, which affects the [[Quality of Life|quality of life]] <ref name="Katzman et al." /><ref name="Bansal et al.">Bansal et al., S. (2014). Exercise for Improving Age-Related Hyperkyphotic Posture: A systematic Review. Arch Phys Med Rehabil , 95 (1), 129-140. (LoE: 1a)</ref>
* Increase risk of falling and fractures due to poor gait
* Mortality - may be a risk factor for premature death. As the kyphotic angle increases, the mortality rate inflates. Some studies have attributed this increase to pulmonary death<ref name=":1">Roghani T, Zavieh MK, Manshadi FD, King N, Katzman W. A[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316378/ ge-related hyperkyphosis: update of its potential causes and clinical impacts—narrative review]. Aging clinical and experimental research. 2017 Aug;29(4):567-77.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316378/<nowiki/>(Last accessed 18.4.2020)</ref>
* Have an impact on the basic functioning and daily living, which affects the quality of life.<ref name="Katzman et al." /><ref name="Bansal et al.">Bansal et al., S. (2014). Exercise for Improving Age-Related Hyperkyphotic Posture: A systematic Review. Arch Phys Med Rehabil , 95 (1), 129-140.</ref><br>  


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==
[[File:Afbeelding 3.png|right|frameless]]
The [[Spine Segmental Assessment|spine]] consists of vertebrae, intervertebral disks and [[Spinal cord anatomy|spinal cord]] and has different regions and curves. The important parts of the [[Thoracic Anatomy|thoracic spinal region]] include:
* [[Bone|Bones]]
* Joints
* Nerves
* [[Ligament]]<nowiki/>s
* [[Intervertebral disc|IV disc]]
* [[Muscle|Muscles]]


The [[Spine Segmental Assessment|spine]] consists of vertebrae, intervertebral disks and [[Spinal cord anatomy|spinal cord]] and has different regions and curves:
Thoracic spine is relatively stiff compared to the rest of the spine, because of the rib cage, [[ligament]]<nowiki/>s and the thin, rigid [[Intervertebral disc|intervertebral discs]].<ref>http://www.spineuniverse.com/conditions/kyphosis/anatomy-kyphosis</ref><ref name="Mulligan et al.">Mulligan et al., B. (2015). The Mulligan Concept of Manual Therapy: Textbook of Techniques. Chatswood, NSW, Australia: Elsevier.</ref>
 
=== Epidemiology/Etiology ===
*[[Cervical Examination|Cervical]] Spine: it contains 7 vertebrae (C1-C7) and has a lordotic curve. This region has the greatest mobility.  
*[[Thoracic Examination|Thoracic]] spine: it contains 12 vertebrae (T1-T12) which are connected with the ribs. And the thoracic spine has a kyphotic curve.  
*Lumbar spine: it contains 5 vertebrae (L1-L5) which are the largest and strongest. The lumbar spine has a lordotic curve.  
*Sacrum/coccyx: the sacrum contains 5 fused vertebrae (S1-S5) and the coccyx 4 (sometimes 5) fused vertebrae. They have a kyphotic curve.


Hyperkyphosis is most common in the [[Thoracic Hyperkyphosis|thoracic]] spine. The thoracic spine is relatively stiff compared to the rest of the spine, because of the rib cage, ligaments and the thin, rigid intervertebral discs.<ref name="Mulligan et al.">Mulligan et al., B. (2015). The Mulligan Concept of Manual Therapy: Textbook of Techniques. Chatswood, NSW, Australia: Elsevier.</ref>
* Thoracic kyphosis varies in life between 20-29 degrees.
 
* Incidence and prevalence of hyperkyphosis vary between 20% to 40% among both men and women. <ref name="Katzman et al." />
<br>The thoracic spine has frontal orientated facet joints which allow flexion and extension but these movements are small because of the limitation of the rib cage. Lateral flexion and rotation need translation in these joints. The rotation in the thoracic spine decreases with flexion, so hyperkyphosis limits the 3D movement.
* After the age of 40 the kyphotic angle begins to increase usually more rapidly in women than men.
 
* The angle varies between 43 to 52 degrees in women aged 55-60 years to 52 degrees in women between 76-80 years of age.
<br>There are ligaments between the ribs and vertebrae and these ligaments limits the rotation of the thorax but only in the transverse plane.
* Exaggeration of the normal thoracic curvature can be associated with a variety of conditions and psychosocial factors:
 
# Underlying [[osteoporosis]] and vertebral fractures. However, only one-third of those with severe kyphosis measurements have had radiographic confirmation of vertebral fractures.<ref name=":1" />
Hyperkyphosis changes the posture, plane; more flexion (more hyperkyphosis) results in more instability. So the ranges and patterns of coupled motion of the thorax appear to be strongly influenced by the posture from which the movement is initiated.<ref name="Edmondston et al.">Edmondston et al., S. (2007). Influence of posture on the range of axial rotation and coupled lateral flexion of the thoracic spine. Manipulative Phys Ther , 30 (3), 193-9.</ref><br>[[Image:Vertebra.jpg]]<br>
# [[Depression]], insecurity, despondency and anxiety <ref name="Fon et al.">Fon et al., G. (1980). Thoracic kyphosis: range in normal subjects. AJR Am J Roentgenol , 134 (5), 979-83.</ref><ref name="Lewis et al.">Lewis et al., J. (2010). Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskeletal Disorders , 1 (11), 39.</ref>
 
# Gradual changes in structure and mechanics of connective tissue which in time results in a loss of elasticity and mobility, this causes the inability to counteract gravitation that pulls the body forward <ref name="Hinman et al.">Hinman et al., M. (2004). Comparison of thoracic kyphosis and postural stiffness in younger and older women. Spine J , 4 (4), 413-7.</ref><ref name="Katzman et al." />
== Epidemiology/Etiology  ==
# Muscle weakness (often because of a weakening spinal extensor muscle) <ref name="Hinman et al." />
 
# Deficits in the somatosensory, visual and [[Vestibular System|vestibular systems]] contribute to the loss of upright postural control
Thoracic kyphosis varies in life between 20-29 degrees. Incidence and prevalence of hyperkyphosis vary between 20% to 40% among both men and women. <ref name="Katzman et al."/> After the age of 40 the kyphotic angle begins to increase usually more rapidly in women than men. The angle varies between 43 to 52 degrees in women aged 55-60 years to 52 degrees in women between 76-80 years of age.
# Declining proprioceptive and vibratory input from the joints in the lower extremities results in an impaired perception of erect vertical alignment <ref name="Katzman et al." />
 
<br>Exaggeration of the normal thoracic curvature can be associated with a variety of conditions and psychosocial factors such as depression, insecurity, despondency and anxiety. <ref name="Fon et al.">Fon et al., G. (1980). Thoracic kyphosis: range in normal subjects. AJR Am J Roentgenol , 134 (5), 979-83.</ref><ref name="Lewis et al.">Lewis et al., J. (2010). Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskeletal Disorders , 1 (11), 39.</ref> <br>Different causes can lead to a thoracal hyperkyphosis, such as the gradual changes in structure and mechanics of connective tissue which in time results in a loss of elasticity and mobility, this causes the inability to counteract gravitation that pulls the body forward. <ref name="Hinman et al.">Hinman et al., M. (2004). Comparison of thoracic kyphosis and postural stiffness in younger and older women. Spine J , 4 (4), 413-7.</ref><ref name="Katzman et al." /> <br>Hyperkyphosis may develop further with muscle weakness (often because of a weakening spinal extensor muscle) <ref name="Hinman et al." /> , degenerative disc disease, low bone mineral density which in time can lead to vertebral fractures and an even worsening hyperkyphosis. Initial fractures due to a fall can precipitate the development of a hyperkyphosis. <ref name="Katzman et al." /> <br>Deficits in the somatosensory, visual and vestibular systems contribute to the loss of upright postural control. Due to a declining proprioceptive and vibratory input from the joints in the lower extremities, this results in a perception of erect vertical alignment that is impaired. <ref name="Katzman et al." />  
 
<br>Mortality rate of Hyperkyphosis increases with the hyperkyphotic posture. With hyperkyposis, a loss of vital capacity is associated, and severe hyperkyphosis is predictive of pulmonary death among community dwelling women. <ref name="Katzman et al." /> <br>&nbsp;


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
[[File:Kyphosis.png|right|frameless|267x267px]]
Thoracic Hyperkyphosis symptoms (main ones)
* Increased anterior curvature of the thoracic spine. This can come over time and isn’t always detected by the patient, but rather by his friends and family (if a person has a sudden increase of rounded back a doctor appraisal is warranted as can be associated with other health problems).
* Difficulty rising from a chair without their arms
* Poor [[balance]] (they have the feeling that they might fall)
* Slower gait velocity
* Wider base of support with stance and gait (to avoid falling)
* Decreased stair climbing speed<ref name="Katzman et al." />
* In severe cases of Hyperkyphosis, trouble breathing, because of the loss of vital capacity of the lungs<ref name="Katzman et al." />


Thoracic Hyperkyphosis is recognizable by different symptoms, the main one being an increase in the anterior curvature of the thoracic spine (more prominent upper back). This can come over time and isn’t always detected by the patient, but rather by his friends and family. When a person has a sudden increase of rounded back, it is necessary to go see a doctor. Sudden changes in the spine curve can be associated with other health problems.
== Differential Diagnosis ==
 
[[File:Scheuerman2.png|right|frameless|306x306px]]
Along with this physical characteristic, people with Hyperkyphosis tend to have more difficulty rising from a chair without their arms, have a poorer balance (they have the feeling that they might fall), slower gait velocity, wider base of support with stance and gait (to avoid falling) and decreased stair climbing speed.<ref name="Katzman et al."/><br>In severe cases of Hyperkyphosis, people can have trouble breathing, because of the loss of vital capacity of the lungs.<ref name="Katzman et al."/><br>
 
[[Image:Kyphotic spine.jpg]]<br>
 
== Differential diagnosis  ==
 
*[http://www.physio-pedia.com/Osteoporosis Osteoporosis]  
*[http://www.physio-pedia.com/Osteoporosis Osteoporosis]  
*Vertebrale fracture  
*Vertebrale fracture  
*Muscle imbalance caused by neuromuscular disease  
*Muscle imbalance caused by neuromuscular disease  
*[http://www.physio-pedia.com/Ankylosing_Spondylitis ankylosing spondylitis]<br>
*[http://www.physio-pedia.com/Ankylosing_Spondylitis ankylosing spondylitis]
*[[Scheuermann's Kyphosis]] (see R image)


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
[[File:Cobbs_angle.jpg|right|350x350px|The alternative method of measuring Cobb's angle]]
[[File:Cobbs_angle.jpg|right|350x350px|The alternative method of measuring Cobb's angle]]
There are different validated diagnostic procedures for measuring hyperkyfosis:
There are different validated diagnostic procedures for measuring hyper-kyphosis:
 
'''''Radiologic measurements:'''''
 
The most validated method for assessing thoracic kyphosis is standing lateral spine radiographs. Elderly subjects can also do this in the supine position for more comfort. From these radiographs the ''Cobb’s angle'' of kyphosis can be calculated from perpendicular lines drawn on a standard thoracic spine radiograph. One line extends through the superior endplate of the vertebral body, marking the beginning of the thoracic curve (usually at T3/T4), and the other line extends through the inferior endplate of the vertebral body, marking the end of the thoracic curve (usually at T12).<ref name="Mulligan et al." /> 


When the angle is between 20-40° we consider it as a normal kyphosis, higher angles are considered as hyperkyphosis. However, there can be an overestimation of the kyphosis in the presence of vertebral body end-plate deformation or fracture. In this case there is an alternative method for measuring the Cobb’s angle. In this alternative method the Cobb's angle is measured by extending lines from the mid-points of the superior and inferior end-plates of T4 and T9.<ref name="Goh et al.">Goh et al. (2000). A comparison of three methods for measuring thoracic kyphosis: implications for clinical studies. Rheumatology , 310-315.</ref><br>
The most validated method for assessing thoracic kyphosis is standing lateral spine radiographs. Used to obtain a [[Cobb's angle|Cobbs angle]] measurement (from lateral spine radiograph) and is the current gold standard for quantifying thoracic kyphosis.<ref name=":1" />(Figure at right)


'''''Standing clinical measurement''' ''
Several non-invasive, skin-surface methods have been used for clinical measurement including the Debrunner’s kyphometer, Flexicurve  and Spinal Mouse
 
* The ''kyphometer'' measures the angle of kyphosis. The arms of the device are placed at the top and bottom of the thoracic curve (spinous processes of T2/T3 superiorly, and T1/T12 inferiorly). Using a mathematical formula we can strongly correlate with the radiologic measured thoracic Cobb’s angle.<ref name="Korovessis et al.">Korovessis et al. (2001). Prediction of thoracic kyphosis using the Debrunner kyphometer. J Spinal Disord , 67-72.</ref>
The ''kyphometer'' measures the angle of kyphosis. The arms of the device are placed at the top and bottom of the thoracic curve (spinous processes of T2/T3 superiorly, and T1/T12 inferiorly). Using a mathematical formula we can strongly correlate with the radiologic measured thoracic Cobb’s angle.<ref name="Korovessis et al.">Korovessis et al. (2001). Prediction of thoracic kyphosis using the Debrunner kyphometer. J Spinal Disord , 67-72.</ref>
* The ''flexicurve ruler'' is a flexible ruler that is aligned over the C7 spinous process to the L5–S1; the ruler is molded to the curvature of the spine. The kyphosis index is calculated as the width divided by the length of the thoracic curve, multiplied by 100. A kyphosis index value greater than 13 is defined as hyperkyphotic.<ref name="Teixeira et al.">Teixeira et al. (2007). Reliability and validity of thoracic kyphosis measurements using the flexicurve method. Brazilian Journal of Physical Therapy , 199-204.</ref>
 
* Spinal Mouse ® is a device that, combined with a computer program (PC), assesses the curvatures of the vertebral column without applying harmful radiation.<ref>Bowtech [https://spinalmouse.ro/en Spinal Mouse] Available from:https://spinalmouse.ro/en (last accessed 18.4.2020)</ref><br>NB: There is a reasonable correlation (ICC = 0.68) between a radiologic and standing clinical measurement of kyphosis.<ref name="Kado et al. 2006">Kado et al. (2006). Comparing a supine radiologic versus standing clinical measurement of kyphosis in older women: the Fracture Intervention Trial. Spine , 463-467.</ref>
The ''flexicurve ruler'' is a flexible ruler that is aligned over the C7 spinous process to the L5–S1; the ruler is molded to the curvature of the spine. The kyphosis index is calculated as the width divided by the length of the thoracic curve, multiplied by 100. A kyphosis index value greater than 13 is defined as hyperkyphotic.<ref name="Teixeira et al.">Teixeira et al. (2007). Reliability and validity of thoracic kyphosis measurements using the flexicurve method. Brazilian Journal of Physical Therapy , 199-204.</ref><br><br>There is a reasonable correlation (ICC = 0.68) between a radiologic and standing clinical measurement of kyphosis.<ref name="Kado et al. 2006">Kado et al. (2006). Comparing a supine radiologic versus standing clinical measurement of kyphosis in older women: the Fracture Intervention Trial. Spine , 463-467.</ref><br><br>


== Outcome Measures  ==
== Outcome Measures  ==


*[https://www.ncbi.nlm.nih.gov/pubmed/15897835 Scoliosis Research Society Outcomes Instrument] (SRS-22): The SRS -22 scores function, [[Pain Assessment|pain]], self-image, mental health, and satisfaction with management. There are findings that associate hyperkyphosis with increased pain, lower self-image, and decreased general function and overall activity. The r values for this analysis of kyphosis (0.40–0.66) were significantly greater than those reported for scoliosis magnitude versus SRS questionnaire scores (0.16–0.26). Therefore the SRS outcomes instrument may be even better suited for the evaluation of hyperkyphosis patients. <ref name="Petcharaporn et al.">Petcharaporn et al. (2007). The Relationship Between Thoracic Hyperkyphosis and the Scoliosis Research Society Outcomes Instrument. Spine , 226-231.</ref>
*[https://www.ncbi.nlm.nih.gov/pubmed/15897835 Scoliosis Research Society Outcomes Instrument] (SRS-22): The SRS -22 scores function, [[Pain Assessment|pain]], self-image, mental health, and satisfaction with management. There are findings that associate hyperkyphosis with increased pain, lower self-image, and decreased general function and overall activity. The r values for this analysis of kyphosis (0.40–0.66) were significantly greater than those reported for scoliosis magnitude versus SRS questionnaire scores (0.16–0.26). Therefore the SRS outcomes instrument may be even better suited for the evaluation of hyperkyphosis patients. <ref name="Petcharaporn et al.">Petcharaporn et al. (2007). The Relationship Between Thoracic Hyperkyphosis and the Scoliosis Research Society Outcomes Instrument. Spine , 226-231.</ref>
*[[Occiput to Wall Distance OWD|Occiput to Wall Distance]]
*[[Tragus to Wall Test|Tragus to wall]]
*[http://www.physio-pedia.com/Neck_Pain_and_Disability_Scale Neck Pain and Disability Scale]
*Timed Up and Go [[Timed Up and Go Test (TUG)|TUG]]


*[http://www.physio-pedia.com/Neck_Pain_and_Disability_Scale Neck Pain and Disability Scale]<br>
== Clinical Examination  ==
[[File:Thoracic kyphosis.png|right|frameless]]Hyperkyphotic posture can be examined clinically by therapist's qualitative visual assessment. This could be done by:


== Clinical Examination  ==
* Evaluating the anterior curvature of the spine, keeping in mind that changes in thoracic curvature can be caused by a modified posture in other regions (e.g. lumbar spine)
 
* [[Tragus to Wall Test|Tragus]] to wall test, [[Occiput to Wall Distance OWD|Occiput to Wall Distance]]


Hyperkyphotic posture can be examined clinically by therapist's qualitative visual assessment. This could be done by:
* Measurement of the number of 1.5-cm blocks needed to support the head.
**Evaluating the anterior curvature of the spine, keeping in mind that changes in thoracic curvature can be caused by a modified posture in other regions (e.g. lumbar spine)
**Measuring the occiput to wall distance (if greater than 0cm)
**Measurement of the number of 1.5-cm blocks needed to support the head.


There are no studies comparing these measures to the gold-standard radiograph.<ref name="Kado et al. 2009">Kado DM. (2009). The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med , 583-93</ref><br>  
There are no studies comparing these measures to the gold-standard radiograph.<ref name="Kado et al. 2009">Kado DM. (2009). The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med , 583-93</ref>  


== Medical Management  ==
== Medical Management  ==
'''Pharmacological treatment''' - focus on anti-resorptive or bone-building medication because many patients with age-related hyperkyphosis have low bone density or spine fractures.<ref name="Katzman et al." />


<br>Pharmacological treatment focus on anti-resportive or bone-building medication because many patients with age-related hyperkyphosis have low bone density or spine fractures.<ref name="Katzman et al."/><br>There are two surgical options: vertebroplasty and kyphoplasty.<ref name="Goh et al."/> These options mainly help relieve pain and decrease physical disability, but in some cases, surgery can reduce the kyphosis angle. <br><br>'''''Kyphoplasty:''' ''<br>Kyphoplasty is a surgical prodecure that is used to reduce the pain in patients that have spinal fractures. This surgery can correct spine deformation like hyperkyphosis.&nbsp;<ref name="Pradhan et al."/> <ref name="Goh et al."/><br>The produce involves injecting a balloon in the fractured vertebrae, which will be inflated so that it pushes the broken parts to back their initial place. When the balloon is removed, a cement gel is injected to harden and stabilize the bone.&nbsp;<ref name="Hulme et al."/> <ref name="Wardlaw et al.">Wardlaw et al., D. (2009). Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet , 373 (9668), 1016-24.</ref> The balloon is injected with a tube and the incision is made in the back, the tube passes from the back to the fractured spine.<ref name="Hulme et al.">Hulme et al., P. (2006). Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine , 31 (17), 1983-2001.</ref><br>The risk of this surgery is that the cement can leak, and potentially damage the spinal cord.<ref name="Pradhan et al."/><br>'''<br>''Vertebroplasty:''''' <br>This surgery can also reduce the pain in a spine fractured patient, you can also use this surgery for reducing spine deformation. Vertebroplasty is a surgery where the surgeon injects an acrylic bone cement directly into the vertebral fracture.<ref name="Pradhan et al."/> <ref name="Wardlaw et al."/><br>This surgery has the same risk as a kyphoplasty, namely leaking fluid and potentially damaging the spinal cord.<ref name="Pradhan et al.">Pradhan et al., B. (2006). Kyphoplasty reduction of osteoporotic vertebral compression fractures: correction of local kyphosis versus overall sagittal alignment. Spine , 15 (31(4)), 435-41.</ref><br>
'''Two surgical options''': vertebroplasty and kyphoplasty<ref name="Goh et al.">Goh et al. (2000). A comparison of three methods for measuring thoracic kyphosis: implications for clinical studies. Rheumatology , 310-315.</ref>(Mainly help relieve pain, decrease physical disability, reduce the kyphosis angle). <br>1. [[Kyphoplasty]] ''- ''a procedure that is used to reduce the pain in patients that have spinal fractures and to correct spine deformation.&nbsp;<ref name="Pradhan et al.">Pradhan et al., B. (2006). Kyphoplasty reduction of osteoporotic vertebral compression fractures: correction of local kyphosis versus overall sagittal alignment. Spine , 15 (31(4)), 435-41.</ref> <ref name="Goh et al." />


== Physical Therapy Management  ==
2. Vertebroplasty - surgeon injects an acrylic bone cement directly into the vertebral fracture.<ref name="Pradhan et al." /> <ref name="Wardlaw et al.">Wardlaw et al., D. (2009). Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet , 373 (9668), 1016-24.</ref>This surgery has the same risk as a kyphoplasty, namely leaking fluid and potentially damaging the spinal cord.<ref name="Pradhan et al." />


A 2014 systematic review of exercise for age-related hyperkyphotic posture concluded that there are few high-quality studies suggesting a modest benefit (1.67°-3.74° decrease of hyperkyphosis) for exercise compared to control. (Level of Evidence = 1A)<ref name="Bansal et al."/> Ideally these exercises should (initially) be supervised by a physical therapist or certified instructor in order to be effective and safe.  The exercise modalities and dosage should be adapted to capacities and needs of the individual patient.<br>''<br>The main goals of physical therapy management should be:<ref name="Katzman et al.">Katzman et al., W. B. (2010). Age-related hyperkyphosis: its causes, management, and consequences. J Orthop Sports Phys Ther , 40, 352-360.</ref>''<br>• Increased back extensor strength<br>• Increased spinal extension mobility<br>• Improved postural awareness<br>• Fewer incidences of vertebral compression fractures
==  Physical Therapy Management ==
A 2014 systematic review of exercise for age-related hyperkyphotic posture concluded that there are few high-quality studies suggesting a modest benefit (1.67°-3.74° decrease of hyperkyphosis) for exercise compared to control.<ref name="Bansal et al." />  


'''Exercise modalities include:'''
Exercises should (initially) be supervised by a physical therapist or certified instructor in order to be effective and safe. 


<br>(All modalities below has been studied using RCTs: level of evidence= 1B)<br>  
Exercise modalities and dosage should be adapted to capacities and needs of the individual patient.<br>''<br>'''''The main goals of physical therapy management should be:''' ''<ref name="Katzman et al.">Katzman et al., W. B. (2010). Age-related hyperkyphosis: its causes, management, and consequences. J Orthop Sports Phys Ther , 40, 352-360. (LoE: 5)</ref>''[[File:PostureTaping.jpg|330x330px|right|frameless]]


• ''(Hatha) Yoga modified for individuals with hyperkyphosi''s<ref name="Greendale et al.">Greendale et al., G. (2009). Yoga decreases kyphosis in senior women and men with adult-onset hyperkyphosis: results of a randomized controlled trial. J Am Geriatr Soc , 57, 1569-79.</ref>:Postures should focus on breathing techniques, stretching tight muscle groups and strengthening weak/inhibited muscle groups (e.g. rhomboids) 
* Increased [[Erector Spinae|back extensor]] strength


*''Manual mobilisations<ref name="Bautmans et al." /> <ref name="Bennell et al.">Bennell et al., K. (2010). Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord , 11-36.</ref>:'' Mobilisations should be done according to [http://www.physio-pedia.com/Maitland's_Mobilisations Maitland Joint Mobilization Grading Scale] [[File:Manual_mobilisations.jpg|right|330x330px]]
* Increased spinal extension mobility
* Improved postural awareness
* Prevention of vertebral compression fractures
* Maintain or restore the physical function and prevent further deterioration


*''Active mobilisations/stretches<ref name="Bautmans et al." /><ref name="Bennell et al." />''<br>
[[File:Active_mobilisation.jpg|right|330x330px]]
*''Muscle strengthening<ref name="Abreu et al.">Abreu et al., D. (2012). The effect of physical exercise on thoracic hyperkyphosis in elderly postmenopausal patients with osteoporosis. Osteoporosis Int. , 23, 120.</ref> <ref name="Bautmans et al." />&nbsp;<ref name="Benedetti et al.">Benedetti et al., M. (2008). Effects of an adapted physical activity program in a group of elderly subjects wtih flexed posture: clinical and strumental assessment. J Neuroeng Rehabil , 5, 32.</ref> <ref name="Itoi et al.">Itoi et al., E. (1994). Effects of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc , 69, 1054-9.</ref>:Thoracic extension (paravertebral muscles),Abdominal muscles''<br> ''Scapular adductors,Shoulder flexion, adduction, abduction'' <ref name="Abreu et al." /> and ''Standing elbow flexion/extension''<br>
[[File:Thoracic_extension.jpg|right|330x330px]]
* Postural awareness training (standing, sitting), with feedback<ref name="Abreu et al." />:visual (images, mirror)Auditive (therapist giving cues)<br> Tactile (therapist, taping&nbsp;<ref name="Bautmans et al.">Bautmans et al., I. (2010). Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal patients with osteoporosis. J Rehabil Med. , 42, 129-135.</ref> <ref name="Bennell et al." />)
'''Postural awareness training steps:'''
*Explaining the patient what the problematic posture is
*Demonstrating correct posture, explaining every motion that should be made:
**Belly button in &amp; down (soft contraction)
**Knees slightly bent
**Shoulders back (=scapular retraction): it can help to do external rotation in the shoulder to accompany this motion
**Chest up
**Chin slightly tucked in
*[[File:PostureTraining.jpg|right|300x300px]]Have the patient try this him/herself, the first time still going over every cue<br>- Once the patient has practiced the posture a sufficient amount of times to immediately be able to resume good posture on command, taping and random reminders (timer) can be used to ensure the posture is kept during the day.<br><br>


<br>
'''PT Management strategies include<ref name=":0">http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=a26d7f6b-85dd-4461-9685-be7a8e5d5725</ref>:'''[[File:Thoracic_extension.jpg|330x330px|right|frameless]]
[[File:PostureTaping.jpg|right|330x330px]]
<br>


<br>
* Postural correction training through [[stretching]] and strengthening exercises to help reduce the hyperkyphotic curvature and prevent the condition from advancing.


== Key Research  ==
* Breathing exercises help improve tolerance for physical activity by increasing lung capacity. eg. [[Diaphragmatic Breathing Exercises]]
* Pain management using modalities such as [[Thermotherapy|heat]], [[Cryotherapy|ice]], and/or electrical stimulation such as transcutaneous electrical nerve stimulation ([[Transcutaneous Electrical Nerve Stimulation (TENS)|TENS]]).
*[[Myofascial Release|Myofascia]]<nowiki/>l/soft tissue manual therapy (using hands-on techniques) and shoulder mobilization to help improve spinal flexibility.
* Specialized braces or therapeutic [[taping]] to help reduce the angle of the curve.
* Education to improve posture and activities of daily living and ease physical functioning.
*[[Balance]] exercises and gait training to increase general fitness and reduce risk of falls.
'''Exercise modalities include:'''[[File:Manual_mobilisations.jpg|330x330px|right|frameless]](All modalities below has been studied using RCTs: level of evidence= 1B)


1. Systematic review of exercise therapy for thoracic hyperkyphosis by Bansal et al. (2014)<br>[http://www.ncbi.nlm.nih.gov/pubmed/23850611 http://www.ncbi.nlm.nih.gov/pubmed/23850611] <br><br>2. RCT by Bautmans et al. using exercise and mobilizations, with a relatively detailed description of the intervention.<br>[http://www.ncbi.nlm.nih.gov/pubmed/20140408 http://www.ncbi.nlm.nih.gov/pubmed/20140408 ]<br>
* ''Hatha [[Yoga]] modified for individuals with hyperkyphosi''s<ref name="Greendale et al.">Greendale et al., G. (2009). Yoga decreases kyphosis in senior women and men with adult-onset hyperkyphosis: results of a randomized controlled trial. J Am Geriatr Soc , 57, 1569-79.(LoE: 1b)</ref>:Postures should focus on breathing techniques, stretching tight muscle groups and strengthening weak/inhibited muscle groups (e.g. rhomboids)


== Resources  ==
*''Manual mobilisations<ref name="Bautmans et al." /> <ref name="Bennell et al.">Bennell et al., K. (2010). Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord , 11-36. (LoE: 1b)</ref>:'' Mobilisations should be done according to [http://www.physio-pedia.com/Maitland's_Mobilisations Maitland Joint Mobilization Grading Scale]
*''Active mobilisations/stretches of pectoral region, shoulders and L''atissimus ''Dorsi'' ''muscle''<ref>https://www.t-nation.com/training/heal-that-hunchback</ref>''<ref name="Bautmans et al." /><ref name="Bennell et al." />''
*''Muscle strengthening<ref name="Abreu et al.">Abreu et al., D. (2012). The effect of physical exercise on thoracic hyperkyphosis in elderly postmenopausal patients with osteoporosis. Osteoporosis Int. , 23, 120. (LoE: 1b)</ref> <ref name="Bautmans et al." /><ref name="Benedetti et al.">Benedetti et al., M. (2008). Effects of an adapted physical activity program in a group of elderly subjects wtih flexed posture: clinical and strumental assessment. J Neuroeng Rehabil , 5, 32. (LoE: 2b)</ref> <ref name="Itoi et al.">Itoi et al., E. (1994). Effects of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc , 69, 1054-9. (LoE: 1b)</ref>:Thoracic extension (paravertebral muscles), abdominal muscles, scapular adductors,'' ''shoulder flexion, adduction, abduction'' <ref name="Abreu et al." /> and s''tanding elbow flexion/extension''
*Postural awareness training (In standing and sitting posture): visual (images or mirror), auditive (with therapist giving cues) and/or tactile feedback (therapist, taping).&nbsp;<ref name="Bautmans et al.">Bautmans et al., I. (2010). Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal patients with osteoporosis. J Rehabil Med. , 42, 129-135. (LoE: 1b)</ref> <ref name="Bennell et al." /><ref name="Abreu et al." />


1. [http://www.spineuniverse.com/conditions/kyphosis/anatomy-kyphosis http://www.spineuniverse.com/conditions/kyphosis/anatomy-kyphosis]<br><br>2. Zane M. Hyperkyphosis (Humpback) in Adults [Internet]. American Physical Therapy Association. 2014 [cited 8 May 2016]. Available from: [http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=a26d7f6b-85dd-4461-9685-be7a8e5d5725 http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=a26d7f6b-85dd-4461-9685-be7a8e5d5725]<br><br>3. Article that provides detailed instructions for various exercises: [https://www.t-nation.com/training/heal-that-hunchback https://www.t-nation.com/training/heal-that-hunchback]<br>


== Clinical Bottom Line  ==
'''Postural awareness training steps:'''
[[File:Active_mobilisation.jpg|330x330px|right|frameless]]
*Explain to the patient what the problematic posture is
*Demonstrating correct posture, explaining every motion that should be made:
# Belly button in &amp; down (soft contraction)
# Knees slightly bent
# Shoulders back (=scapular retraction): it can help to do external rotation in the shoulder to accompany this motion
# Chest up
# Chin slightly tucked in
*Have the patient try this him/herself, the first time still going over every cue. Once the patient has practiced the posture a sufficient number of times to immediately be able to resume good posture on command, taping and random reminders (timer) can be used to ensure the posture is kept during the day.


Age-related hyperkyphosis, an excessive anterior concavity of the thoracic spine, is a condition that affects many older adults (20-40%). Hyperkyphosis can impair pulmonary<br>function3 and activities of daily living performance, reduce quality of life, and predict<br>mortality independent of underlying spinal osteoporosis.<br>
== Concluding Remarks ==
Kyphosis is common in older individuals, increases the risk for fracture and mortality, and is associated with impaired physical performance, health, and quality of life.  


== References  ==
Screening for hyperkyphosis could be easily implemented in the clinical setting and the evidence to date suggests that relatively simple, available, and inexpensive conservative interventions have a beneficial effect to reduce hyperkyphosis, improve the quality of life and reduce risk for future fractures for men and women, including:
* Physiotherapy
* Exercise
* Bracing
* Taping interventions<ref>Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management. journal of orthopaedic & sports physical therapy. 2010 Jun;40(6):352-60. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907357/ (last accessed 18.4.2020)</ref><ref name=":1" />


== References ==
<references /><br>  
<references /><br>  


[[Category:Older_People/Geriatrics]] [[Category:Thoracic Spine]] [[Category:Anatomy]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Older_People/Geriatrics]]  
[[Category:Thoracic Spine]]  
[[Category:Anatomy]]  
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Thoracic Spine - Anatomy]]
[[Category:Older People/Geriatrics - Conditions]]
[[Category:Thoracic Spine - Conditions]]
[[Category:Conditions]]

Latest revision as of 04:41, 21 November 2022

Original Editors - Louise Burrion

Top Contributors - Louise Burrion, Kim Jackson, Lucinda hampton, Mariam Hashem, Yuan Chuang, Evan Thomas, Stijn Van de Vondel, WikiSysop, Lauren Lopez, 127.0.0.1, Admin, Borms Killian, Gayatri Jadav Upadhyay, Oyemi Sillo, Magdalena Hytros, Ajay Upadhyay and Cedric Cludts

Introduction[edit | edit source]

Age-related hyperkyphosis affects 20-40% of older adults and can be described as an exaggerated anterior curvature of the thoracic spine that is associated with aging[1]

  • Anterior curvature of the thoracic spine is normal and present due to the shape of the vertebral bodies and intervertebral discs,
  • Kyphosis angle greater than 40° is defined as hyperkyphosis.[1]


General causes of age-related hyperkyphosis that have been reported are poor posture, dehydration of the intervertebral discs and reduced back extensor muscle strength. Age-related hyperkyphosis may:

  • Induce the symptoms such as back soreness, neck pain, numbness of upper extremities or buttock
  • Low psychological well-being such as depression and low self-esteem[2]
  • Lead to mobility impairments of the rib cage (connected to thoracic spine) which can result in pulmonary difficulties
  • Increase biomechanical stress on the spine which can result in an increased risk of development of vertebral compression fractures
  • Increase risk of falling and fractures due to poor gait
  • Impaired Physical function eg has an impact on the basic functioning and daily living, which affects the quality of life [3][4]
  • Mortality - may be a risk factor for premature death. As the kyphotic angle increases, the mortality rate inflates. Some studies have attributed this increase to pulmonary death[5]

Clinically Relevant Anatomy[edit | edit source]

Afbeelding 3.png

The spine consists of vertebrae, intervertebral disks and spinal cord and has different regions and curves. The important parts of the thoracic spinal region include:

Thoracic spine is relatively stiff compared to the rest of the spine, because of the rib cage, ligaments and the thin, rigid intervertebral discs.[6][7]

Epidemiology/Etiology[edit | edit source]

  • Thoracic kyphosis varies in life between 20-29 degrees.
  • Incidence and prevalence of hyperkyphosis vary between 20% to 40% among both men and women. [3]
  • After the age of 40 the kyphotic angle begins to increase usually more rapidly in women than men.
  • The angle varies between 43 to 52 degrees in women aged 55-60 years to 52 degrees in women between 76-80 years of age.
  • Exaggeration of the normal thoracic curvature can be associated with a variety of conditions and psychosocial factors:
  1. Underlying osteoporosis and vertebral fractures. However, only one-third of those with severe kyphosis measurements have had radiographic confirmation of vertebral fractures.[5]
  2. Depression, insecurity, despondency and anxiety [8][9]
  3. Gradual changes in structure and mechanics of connective tissue which in time results in a loss of elasticity and mobility, this causes the inability to counteract gravitation that pulls the body forward [10][3]
  4. Muscle weakness (often because of a weakening spinal extensor muscle) [10]
  5. Deficits in the somatosensory, visual and vestibular systems contribute to the loss of upright postural control
  6. Declining proprioceptive and vibratory input from the joints in the lower extremities results in an impaired perception of erect vertical alignment [3]

Characteristics/Clinical Presentation[edit | edit source]

Kyphosis.png

Thoracic Hyperkyphosis symptoms (main ones)

  • Increased anterior curvature of the thoracic spine. This can come over time and isn’t always detected by the patient, but rather by his friends and family (if a person has a sudden increase of rounded back a doctor appraisal is warranted as can be associated with other health problems).
  • Difficulty rising from a chair without their arms
  • Poor balance (they have the feeling that they might fall)
  • Slower gait velocity
  • Wider base of support with stance and gait (to avoid falling)
  • Decreased stair climbing speed[3]
  • In severe cases of Hyperkyphosis, trouble breathing, because of the loss of vital capacity of the lungs[3]

Differential Diagnosis[edit | edit source]

Scheuerman2.png

Diagnostic Procedures[edit | edit source]

The alternative method of measuring Cobb's angle

There are different validated diagnostic procedures for measuring hyper-kyphosis:

The most validated method for assessing thoracic kyphosis is standing lateral spine radiographs. Used to obtain a Cobbs angle measurement (from lateral spine radiograph) and is the current gold standard for quantifying thoracic kyphosis.[5](Figure at right)

Several non-invasive, skin-surface methods have been used for clinical measurement including the Debrunner’s kyphometer, Flexicurve and Spinal Mouse

  • The kyphometer measures the angle of kyphosis. The arms of the device are placed at the top and bottom of the thoracic curve (spinous processes of T2/T3 superiorly, and T1/T12 inferiorly). Using a mathematical formula we can strongly correlate with the radiologic measured thoracic Cobb’s angle.[11]
  • The flexicurve ruler is a flexible ruler that is aligned over the C7 spinous process to the L5–S1; the ruler is molded to the curvature of the spine. The kyphosis index is calculated as the width divided by the length of the thoracic curve, multiplied by 100. A kyphosis index value greater than 13 is defined as hyperkyphotic.[12]
  • Spinal Mouse ® is a device that, combined with a computer program (PC), assesses the curvatures of the vertebral column without applying harmful radiation.[13]
    NB: There is a reasonable correlation (ICC = 0.68) between a radiologic and standing clinical measurement of kyphosis.[14]

Outcome Measures[edit | edit source]

  • Scoliosis Research Society Outcomes Instrument (SRS-22): The SRS -22 scores function, pain, self-image, mental health, and satisfaction with management. There are findings that associate hyperkyphosis with increased pain, lower self-image, and decreased general function and overall activity. The r values for this analysis of kyphosis (0.40–0.66) were significantly greater than those reported for scoliosis magnitude versus SRS questionnaire scores (0.16–0.26). Therefore the SRS outcomes instrument may be even better suited for the evaluation of hyperkyphosis patients. [15]
  • Occiput to Wall Distance
  • Tragus to wall
  • Neck Pain and Disability Scale
  • Timed Up and Go TUG

Clinical Examination[edit | edit source]

Thoracic kyphosis.png

Hyperkyphotic posture can be examined clinically by therapist's qualitative visual assessment. This could be done by:

  • Evaluating the anterior curvature of the spine, keeping in mind that changes in thoracic curvature can be caused by a modified posture in other regions (e.g. lumbar spine)
  • Measurement of the number of 1.5-cm blocks needed to support the head.

There are no studies comparing these measures to the gold-standard radiograph.[16]

Medical Management[edit | edit source]

Pharmacological treatment - focus on anti-resorptive or bone-building medication because many patients with age-related hyperkyphosis have low bone density or spine fractures.[3]

Two surgical options: vertebroplasty and kyphoplasty[17](Mainly help relieve pain, decrease physical disability, reduce the kyphosis angle).
1. Kyphoplasty - a procedure that is used to reduce the pain in patients that have spinal fractures and to correct spine deformation. [18] [17]

2. Vertebroplasty - surgeon injects an acrylic bone cement directly into the vertebral fracture.[18] [19]This surgery has the same risk as a kyphoplasty, namely leaking fluid and potentially damaging the spinal cord.[18]

Physical Therapy Management[edit | edit source]

A 2014 systematic review of exercise for age-related hyperkyphotic posture concluded that there are few high-quality studies suggesting a modest benefit (1.67°-3.74° decrease of hyperkyphosis) for exercise compared to control.[4]

Exercises should (initially) be supervised by a physical therapist or certified instructor in order to be effective and safe.

Exercise modalities and dosage should be adapted to capacities and needs of the individual patient.

The main goals of physical therapy management should be: [3]

PostureTaping.jpg
  • Increased spinal extension mobility
  • Improved postural awareness
  • Prevention of vertebral compression fractures
  • Maintain or restore the physical function and prevent further deterioration


PT Management strategies include[20]:

Thoracic extension.jpg
  • Postural correction training through stretching and strengthening exercises to help reduce the hyperkyphotic curvature and prevent the condition from advancing.
  • Breathing exercises help improve tolerance for physical activity by increasing lung capacity. eg. Diaphragmatic Breathing Exercises
  • Pain management using modalities such as heat, ice, and/or electrical stimulation such as transcutaneous electrical nerve stimulation (TENS).
  • Myofascial/soft tissue manual therapy (using hands-on techniques) and shoulder mobilization to help improve spinal flexibility.
  • Specialized braces or therapeutic taping to help reduce the angle of the curve.
  • Education to improve posture and activities of daily living and ease physical functioning.
  • Balance exercises and gait training to increase general fitness and reduce risk of falls.

Exercise modalities include:

Manual mobilisations.jpg

(All modalities below has been studied using RCTs: level of evidence= 1B)

  • Hatha Yoga modified for individuals with hyperkyphosis[21]:Postures should focus on breathing techniques, stretching tight muscle groups and strengthening weak/inhibited muscle groups (e.g. rhomboids)
  • Manual mobilisations[22] [23]: Mobilisations should be done according to Maitland Joint Mobilization Grading Scale
  • Active mobilisations/stretches of pectoral region, shoulders and Latissimus Dorsi muscle[24][22][23]
  • Muscle strengthening[25] [22][26] [27]:Thoracic extension (paravertebral muscles), abdominal muscles, scapular adductors, shoulder flexion, adduction, abduction [25] and standing elbow flexion/extension
  • Postural awareness training (In standing and sitting posture): visual (images or mirror), auditive (with therapist giving cues) and/or tactile feedback (therapist, taping). [22] [23][25]


Postural awareness training steps:

Active mobilisation.jpg
  • Explain to the patient what the problematic posture is
  • Demonstrating correct posture, explaining every motion that should be made:
  1. Belly button in & down (soft contraction)
  2. Knees slightly bent
  3. Shoulders back (=scapular retraction): it can help to do external rotation in the shoulder to accompany this motion
  4. Chest up
  5. Chin slightly tucked in
  • Have the patient try this him/herself, the first time still going over every cue. Once the patient has practiced the posture a sufficient number of times to immediately be able to resume good posture on command, taping and random reminders (timer) can be used to ensure the posture is kept during the day.

Concluding Remarks[edit | edit source]

Kyphosis is common in older individuals, increases the risk for fracture and mortality, and is associated with impaired physical performance, health, and quality of life.

Screening for hyperkyphosis could be easily implemented in the clinical setting and the evidence to date suggests that relatively simple, available, and inexpensive conservative interventions have a beneficial effect to reduce hyperkyphosis, improve the quality of life and reduce risk for future fractures for men and women, including:

  • Physiotherapy
  • Exercise
  • Bracing
  • Taping interventions[28][5]

References[edit | edit source]

  1. ↑ 1.0 1.1 Jang et al., H. (2015). Effect of thorax correction exercises on flexed posture and chest function in older women wih age-related hyperkyphosis. J. Phys. Ther. Sci. , 27, 1161-1164.
  2. ↑ Jang, H.-J., Hughes, L. C., Oh, D.-W., & Kim, S.-Y. (2019). Effects of Corrective Exercise for Thoracic Hyperkyphosis on Posture, Balance, and Well-Being in Older Women: A Double-Blind, Group-Matched Design. Journal of Geriatric Physical Therapy, 42(3), E17–E27. https://doi.org/10.1519/JPT.0000000000000146
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Katzman et al., W. B. (2010). Age-related hyperkyphosis: its causes, management, and consequences. J Orthop Sports Phys Ther , 40, 352-360. (LoE: 5)
  4. ↑ 4.0 4.1 Bansal et al., S. (2014). Exercise for Improving Age-Related Hyperkyphotic Posture: A systematic Review. Arch Phys Med Rehabil , 95 (1), 129-140. (LoE: 1a)
  5. ↑ 5.0 5.1 5.2 5.3 Roghani T, Zavieh MK, Manshadi FD, King N, Katzman W. Age-related hyperkyphosis: update of its potential causes and clinical impacts—narrative review. Aging clinical and experimental research. 2017 Aug;29(4):567-77.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316378/(Last accessed 18.4.2020)
  6. ↑ http://www.spineuniverse.com/conditions/kyphosis/anatomy-kyphosis
  7. ↑ Mulligan et al., B. (2015). The Mulligan Concept of Manual Therapy: Textbook of Techniques. Chatswood, NSW, Australia: Elsevier.
  8. ↑ Fon et al., G. (1980). Thoracic kyphosis: range in normal subjects. AJR Am J Roentgenol , 134 (5), 979-83.
  9. ↑ Lewis et al., J. (2010). Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskeletal Disorders , 1 (11), 39.
  10. ↑ 10.0 10.1 Hinman et al., M. (2004). Comparison of thoracic kyphosis and postural stiffness in younger and older women. Spine J , 4 (4), 413-7.
  11. ↑ Korovessis et al. (2001). Prediction of thoracic kyphosis using the Debrunner kyphometer. J Spinal Disord , 67-72.
  12. ↑ Teixeira et al. (2007). Reliability and validity of thoracic kyphosis measurements using the flexicurve method. Brazilian Journal of Physical Therapy , 199-204.
  13. ↑ Bowtech Spinal Mouse Available from:https://spinalmouse.ro/en (last accessed 18.4.2020)
  14. ↑ Kado et al. (2006). Comparing a supine radiologic versus standing clinical measurement of kyphosis in older women: the Fracture Intervention Trial. Spine , 463-467.
  15. ↑ Petcharaporn et al. (2007). The Relationship Between Thoracic Hyperkyphosis and the Scoliosis Research Society Outcomes Instrument. Spine , 226-231.
  16. ↑ Kado DM. (2009). The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med , 583-93
  17. ↑ 17.0 17.1 Goh et al. (2000). A comparison of three methods for measuring thoracic kyphosis: implications for clinical studies. Rheumatology , 310-315.
  18. ↑ 18.0 18.1 18.2 Pradhan et al., B. (2006). Kyphoplasty reduction of osteoporotic vertebral compression fractures: correction of local kyphosis versus overall sagittal alignment. Spine , 15 (31(4)), 435-41.
  19. ↑ Wardlaw et al., D. (2009). Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet , 373 (9668), 1016-24.
  20. ↑ http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=a26d7f6b-85dd-4461-9685-be7a8e5d5725
  21. ↑ Greendale et al., G. (2009). Yoga decreases kyphosis in senior women and men with adult-onset hyperkyphosis: results of a randomized controlled trial. J Am Geriatr Soc , 57, 1569-79.(LoE: 1b)
  22. ↑ 22.0 22.1 22.2 22.3 Bautmans et al., I. (2010). Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal patients with osteoporosis. J Rehabil Med. , 42, 129-135. (LoE: 1b)
  23. ↑ 23.0 23.1 23.2 Bennell et al., K. (2010). Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord , 11-36. (LoE: 1b)
  24. ↑ https://www.t-nation.com/training/heal-that-hunchback
  25. ↑ 25.0 25.1 25.2 Abreu et al., D. (2012). The effect of physical exercise on thoracic hyperkyphosis in elderly postmenopausal patients with osteoporosis. Osteoporosis Int. , 23, 120. (LoE: 1b)
  26. ↑ Benedetti et al., M. (2008). Effects of an adapted physical activity program in a group of elderly subjects wtih flexed posture: clinical and strumental assessment. J Neuroeng Rehabil , 5, 32. (LoE: 2b)
  27. ↑ Itoi et al., E. (1994). Effects of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc , 69, 1054-9. (LoE: 1b)
  28. ↑ Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management. journal of orthopaedic & sports physical therapy. 2010 Jun;40(6):352-60. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907357/ (last accessed 18.4.2020)


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