Move Forward Guide
Physical Therapist's Guide to
Hyperkyphosis is a spinal deformity causing a forward-curved posture of the upper back (thoracic spine). Posture is the characteristic way you position your body; posture changes many times throughout the day due to a variety of factors, including what you are doing and how long you have been doing it. Sometimes, however, a person's posture can cause the thoracic curvature to become excessive and stiff, making it difficult to change. Such is the case with hyperkyphosis (sometimes called “humpback,” “round back,” or “dowager’s hump”). This condition can affect people of all ages, but the thoracic curvature most often begins to increase in people over 40 and continues 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 occurs when the natural forward-curving shape of the upper back becomes excessive. It results in the appearance of rounded shoulders with the head and neck positioned forward of the trunk. People with this condition often have difficulty standing up straight. The worsening of the curvature is associated with a higher risk of health problems, including back and neck pain, breathing difficulties, and falls.
Hyperkyphosis can result from conditions such as osteoporosis or thinning bones, and fractures of the vertebrae that result from osteoporosis or Scheuermann's disease. However, research has found that two-thirds of people with hyperkyphosis do not have spinal fractures. Suspected causes for development of this spinal deformity when vertebral (spinal) fractures are not present are:
- Poor habitual posture
- Muscle weakness
- Degenerative disc disease
- Ligament degeneration
- Hereditary factors
Signs and Symptoms
The most prominent symptom of hyperkyphosis you might notice is the appearance of a rounded back.
- You may not immediately recognize a change in your back posture because in most cases, the change is gradual over time. Friends and family may notice it before you do.
- Other subtle signs can include changes in the way your shirts fit, feeling like it takes a lot of effort to stand or sit up straight, and feeling more fatigued with walking and other activities.
CAUTION: If you notice a sudden increase in the curvature of your back, call your doctor. A sudden change in the curve of the spine can be associated with other health problems.
Untreated hyperkyphosis can cause:
- Difficulty in the performance of normal tasks such as bathing, getting out of a chair, bending, or walking
- Decreased flexibility and strength of the trunk muscles
- Associated changes in alignment that result in a change of the body’s center of gravity and increase the energy expenditure necessary to complete common tasks
- Balance changes due to the shift in the center of gravity that can increase the risk of falls and related injury
- Upper back pain
- Spinal fractures as the condition advances
If you have advanced hyperkyphosis, you may experience:
- Difficulty breathing even though you do not have a history of lung or heart disease
- A 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
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°, hyperkyphosis is diagnosed.
Sometimes spinal changes occur because of fractures due to thinning bones or a condition called osteoporosis. Spinal changes also can result from degenerative disc 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.
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. Your physical therapist will begin by observing, measuring, and recording your postural alignment, trunk strength, range of motion, and flexibility in movement. If you are experiencing difficulty walking or keeping your balance, your physical 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 will design a treatment program to address your specific needs and goals. Your treatment may include:
- Postural alignment training, stretching, and strengthening exercises to help reduce the spinal curvature, decrease pain, and prevent the condition from advancing. Adherence to the prescribed program in the clinic as well as at home is essential for success. Most often, altering the way you sit, stand, and complete your daily activities has the greatest impact on lessening or slowing the progression of the curve.
- Balance exercises and walking (gait) training to increase your tolerance of activity and improve your safety by reducing your risk of falls.
- Education to improve your activities of daily living and ease your physical functioning. Your 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.
- Breathing exercises to help improve your tolerance for physical activity by increasing your lung capacity.
- Myofascial/soft tissue manual therapy (hands-on massage techniques), and in some cases joint mobilization (gentle movements guided by your physical therapist) to help improve spinal flexibility.
- Specialized braces or therapeutic taping to help reduce the angle of the curve.
- Pain management using modalities such as heat, ice, and/or electrical stimulation such as transcutaneous electrical nerve stimulation (TENS). Your physical therapist will choose what modality will be most beneficial to you—and help reduce the need for pain medication, such as opioids.
Remember, all cases of hyperkyphosis are different. Your physical therapist will choose the best treatment options for you based on your specific condition.
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 reduce 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 physical therapist about specific recommendations for your needs.
- Maintain bone health to prevent thinning bones. It is well known that weight-bearing exercises and getting enough calcium and vitamin D are important for strong bones. Some people may be prescribed other medications for bone health. Talk with your doctor and physical therapist to find solutions for your particular needs.
Real Life Experiences
Julie is a 68-year-old retired executive who notices that her shirts are not fitting her well anymore. Her friend tells her that she seems to be slumping over while sitting, has more difficulty getting out of chairs, and that her 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 no fractures. He tells her she has osteopenia—low bone density—but not osteoporosis (thin bones at risk of fracture). He 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. She also observes Julie’s 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.
Julie’s physical therapist prescribes treatment to improve flexibility and strength to better support her postural alignment. Over several visits, Julie receives treatments that include exercises and manual (hands-on) 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 and balance exercises.
Julie practices these exercises every day at home. Her physical therapist progresses her exercises as she gets stronger and more flexible. Regular measurements of her posture, strength, range of motion, activity tolerance, and pain are recorded as she progresses toward the goals she and her physical therapist established during her evaluation.
On her last visit, Julie's physical therapist measures a marked improvement in her alignment, and a lessening of the hyperkyphosis. Julie reports she can stand and walk for longer periods of time without pain. She no longer experiences fatigue, and her backache has actually resolved.
These days, Julie feels stronger and more certain about her walking and balance than she has in years. She calls her physical therapist to report that she looks forward to doing her prescribed exercises daily, because they make her feel so much better as she completes her usual tasks. She has also joined a walking group with local seniors—something she would never have considered doing before her physical therapy!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
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 in orthopedic or geriatric physical therapy.
- A physical therapist who has completed a fellowship in spine therapy.
These types of physical therapists have advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who 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.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
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.
National Osteoporosis Foundation. Proper body alignment. Accessed June 28, 2018.
Suwannarat P, Amatachaya P, Sooknuan T, et al. Hyperkyphotic measures using distance from the wall: validity, reliability, and distance from the wall to indicate the risk for thoracic hyperkyphosis and vertebral fracture. Arch Osteoporos. 2018;13(1):25. Article Summary in PubMed.
Aboutorabi A, Arazpour M, Ahmadi Bani M, Keshtkar AA. Effect of spinal orthoses and postural taping on balance, gait and quality of life in older people with thoracic hyperkyphosis: protocol for a systematic review and meta-analysis. BMJ Open. 2018;8(1):e015813. Free Article.
Roghani T, Khalkhali Zavieh M, Rahimi A, et al. The reliability and validity of a designed setup for the assessment of static back extensor force and endurance in older women with and without hyperkyphosis. Physiother Theory Pract. 2018 January 25 [E-pub ahead of print]. Article Summary in PubMed.
Bettany-Saltikov J, Turnbull D, Ng SY, Webb R. Management of spinal deformities and evidence of treatment effectiveness. Open Orthop J. 2017;11:1521–1547. Free Article.
Roghani T, Khalkhali Zavieh M, Rahimi A, et al. The reliability of standing sagittal measurements of spinal curvature and range of motion in older women with and without hyperkyphosis using a skin-surface device. J Manipulative Physiol Ther. 2017;40(9):685–691. Article Summary in PubMed.
Katzman WB, Parimi N, Gladin A, et al. Sex differences in response to targeted kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial. BMC Musculoskelet Disord. 2017;18(1):509. Free Article.
Senthil P, Sudhakar S, Radhakrishnan R, Jeyakumar S. Efficacy of corrective exercise strategy in subjects with hyperkyphosis. J Back Musculoskelet Rehabil. 2017;30(6):1285–1289. Free Article.
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.
* 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.
Revised by Michael Miller, PT. Authored by Mary Kay Zane, PT, MEd, board-certified orthopaedic clinical specialist. Reviewed by the editorial board.