Hyperkyphosis is a spinal deformity causing a forward-curved posture of the upper back or thoracic spine. Your posture is the characteristic way you position your body; normal posture changes many times throughout the day. Sometimes, however, a person’s body curvature can become excessive and unchanging. Such is the case with hyperkyphosis (sometimes called “humpback or “round back”). Curvature of the upper back can begin to increase in people after 40 years of age and continue with advancing age. It is believed that 20% to 40% of older adults — both men and women — will develop hyperkyphosis.

What is Hyperkyphosis?

Hyperkyphosis is a spinal deformity that looks like a forward-curved posture of the head, upper back or thoracic spine. It can become excessive over time. The worsening of the curvature is associated with a higher risk of health problems.

Hyperkyphosis can result from conditions such as osteoporosis or thinning bones, and fractures of the vertebrae that result from thin bones. However, research has found that two thirds of people with hyperkyphosis do not have spinal fractures. There are several suspected causes for development of this spinal deformity when vertebral fractures are not present. Hyperkyphosis may result from poor habitual posture, muscle weakness, degenerative disc disease, ligament degeneration, or hereditary factors.

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Signs and Symptoms

The most prominent symptom you might notice is the appearance of a rounded back.

  • You may not recognize a change in your back posture at first because the change is gradual over time in most cases. Friends and family may notice it before you do.
  • You may notice a sudden increase of a rounded back. In this case, see your doctor, as a sudden change in the spine curve can be associated with other health problems.

If hyperkyphosis is not treated, people can have difficulty performing normal tasks such as bathing, getting out of a chair, bending, or walking. They can also experience balance changes that may result in falls and injury. In some cases, upper back pain may also be associated with the curvature; some people may experience spinal fractures as the condition advances.

When hyperkyphosis is present, you may notice you are:

  • Having difficulty getting up from a chair, out of bed, or out of the bathtub
  • Walking more slowly
  • Feeling “off-balance,” and/or losing your balance, or almost falling
  • Feeling more tired than usual (fatigue)
  • Having difficulty breathing (in more severe cases)

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How Is It Diagnosed?

Hyperkyphosis will be assessed first with a visual inspection of your back. Your spinal curve may be measured using a flexible ruler or x-ray. If an x-ray is taken, a radiologist will measure the spinal angles on the x-ray. If a curve measures greater than 40 degrees, hyperkyphosis is diagnosed.

Sometimes spinal changes occur because of fractures due to thinning bones or a condition called osteoporosis. Spinal changes can also result from degenerative disk disease or arthritis. These problems are commonly associated with aging. Other problems not associated with aging could also cause a sudden change in posture; however, problems such as a tumor, infection, or neurologic changes are uncommon. Your physician may prescribe imaging tests such as x-rays or an MRI of the thoracic spine to determine whether you have any of these less common conditions affecting your posture.

If you have advanced hyperkyphosis, you may experience difficulty breathing even though you do not have a history of lung or heart disease. You may also notice that there is lessening of the distance between your lowest ribs and your pelvic bones. In this case, pulmonary function tests may be prescribed to measure whether your hyperkyphosis is restricting your breathing.

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How Can a Physical Therapist Help?

A physical therapist can help rehabilitate the postural changes and functional limitations associated with hyperkyphosis.

Your physical therapist will begin by reviewing your past and present medical history with you, as well as what medications you normally take. If you report a sudden change in your posture, severe pain, or a significant change in your physical function, you will be referred to your primary care physician. A sudden increase in the rounding of your back may indicate a more serious health problem.

When a more serious problem is ruled out, your physical therapist will perform special tests to assess your unique condition. The therapist will begin by observing, measuring, and recording your postural alignment, trunk strength, range of motion, and flexibility in movement. He or she may also measure your spinal curve with a special ruler. If you are experiencing difficulty walking or keeping your balance, your therapist will observe your movement and perform tests to determine the level of difficulty, and whether you have an increased risk of falling.

Your physical therapist can help with a variety of treatment options, including:

  • Specific exercises to help reduce the kyphotic posture and lessen any pain.
  • Postural alignment training, stretching, and strengthening exercises to help reduce the curvature and prevent the condition from advancing. Exercises will emphasize upper back strength, as well as strength of the shoulder and hips.
  • Breathing exercises to help improve your tolerance for physical activity by increasing your lung capacity.
  • Pain management using modalities such as heat, ice, and/or electrical stimulation such as transcutaneous electrical nerve stimulation (TENS). Your physical therapist will help to choose what modality would be most helpful for you.
  • 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 your activities of daily living and ease your physical functioning. The physical therapist can teach you how to safely get in and out of bed, in and out of the bathtub, or out of a chair, and how to bend and walk with more ease.
  • Balance exercises and walking (gait) training to increase your tolerance of activity and improve your safety by reducing your risk of falls.

Remember, all cases of hyperkyphosis are different. Your physical therapist will choose the best treatment options for you based on his or her evaluation of your specific problem.

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Can this Injury or Condition be Prevented?

Research has not shown that hyperkyphosis can be prevented. However, it has shown that maintaining and improving posture and physical fitness can significantly improve hyperkyphosis and prevent it from worsening with the normal aging process.

Protecting your spine in daily activity may also be important in preventing progression or worsening of hyperkyphosis. Your physical therapist may advise you to:

  • Avoid bending too far from the waist or twisting your trunk too far.
  • Avoid carrying heavy objects.
  • Keep your posture upright when you cough or sneeze: Don’t bend forward.
  • Avoid exercises that involve a lot of bending forward such as toe-touches, sit-ups, or crunches.
  • Change how you get in and out of bed.  By rolling to your side when you get up, you can help to lessen hyperkyphosis progression.
  • Make changes to your environment to help support your posture, such as using a back cushion and a supportive chair when sitting. Talk to your therapist about specific recommendations for your needs.
  • Maintain bone health to prevent thinning bones, which can result in spinal fractures and hyperkyphosis. Getting enough calcium and vitamin D is important for strong bones. Talk with your doctor and therapist for recommendations for your particular needs.

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Real Life Experiences

Julie is a 68-year old woman who notices that her shirts are not fitting her well anymore. Her friend notices that she seems to be slumping over, and that Julie’s back looks more rounded. Julie also notices that she gets very fatigued when she is standing up for a long while, and would rather be sitting. Sometimes her upper back aches when she stands or walks a long time, but it gets better when she sits.

Julie decides to see her physician. He observes that Julie has a rounded back. The doctor orders an x-ray and a bone-density test. The results of the tests show that Julie has an increased kyphosis in her thoracic spine, but she does not have any fractures. She has osteopenia — low bone density — but not osteoporosis (thin bones at risk of fracture). The doctor makes dietary recommendations for bone strength, and refers Julie to physical therapy.

Julie’s physical therapist tests her physical strength; flexibility; the range of motion of her back, arms, and legs; and her spinal joint mobility. The therapist also observes her postural alignment and measures the curve of her thoracic spine. The tests show that Julie has lost the ability to fully straighten her back, and that the upper back muscles have become too weak to support her posture well. Also, her neck and shoulder muscles have become tight. The result is difficulty straightening up, difficulty maintaining a straight posture, and fatigue and pain when she spends time in positions without support, such as standing. Balance testing shows a mild loss of balance in walking.

Her therapist prescribes treatment to improve flexibility and strength to better support Julie’s postural alignment. Over several visits, Julie receives treatment that includes manual therapy to improve flexibility of the spinal joints. She also learns exercises to stretch the tight restrictive muscles, strengthening exercises for the upper back and trunk muscles, and walking/balance exercises. Julie practices these exercises every day at home. On her last visit, Julie’s physical therapist measures an improvement in her hyperkyphosis. Julie reports improvement in her tolerance for standing and walking. She no longer experiences fatigue, and her backache has resolved. Julie intends to continue her exercise program now that her physical therapy is completed so that she can prevent any worsening of her hyperkyphosis.

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What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat hyperkyphosis. However, you may want to consider:

  • A physical therapist who has treated people with hyperkyphosis. Some physical therapists have a practice with an orthopedic or geriatric focus.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or geriatric physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you’re looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with hyperkyphosis.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.

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Further Reading

The following articles provide some of the best scientific evidence related to physical therapy treatment of hyperkyphosis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a Pub Med* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management. J Orthop Sports Phys Ther. 2010;40:352-360. Free Article.

Kado DM. The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med. 2009;45:583-593. Free Article.

National Osteoporosis Foundation. Proper body alignment. Available here.

* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Acknowledgements: Mary Kay Zane, PT, M.Ed., OCS

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