Hyperkyphosis in older persons

INTRODUCTION — 

Hyperkyphosis is excessive curvature of the thoracic spine (sometimes referred to as the "dowager's hump"). Although it is also referred to simply as kyphosis, the term kyphosis is meant to describe the normal sagittal convexity, or forward curvature, of the thoracic spine.

The evaluation and treatment of hyperkyphosis are challenging due to the lack of standardized diagnostic criteria and evidence-based treatment options. Exercise programs, spinal orthotics, and other interventions have been studied that may help delay the progression of age-related kyphosis.

This topic will focus on the etiology, evaluation, and management of hyperkyphosis in older adults. Hyperkyphosis in children and adolescents is discussed separately. (See "Back pain in children and adolescents: Causes".)

DEFINITION — 

Hyperkyphosis is an excessive forward curvature of the thoracic spine, often quantified using the Cobb angle measurement. Cobb angle measurements above 40 degrees are usually considered excessive and consistent with hyperkyphosis. Women tend to have greater kyphotic angles than men [1-4] (figure 1). (See 'Measuring kyphosis' below.)

PREVALENCE — 

There is no widely accepted definition of hyperkyphosis, and therefore the prevalence of hyperkyphosis is not precisely known. Estimates range between 20 and 40 percent among community-dwelling individuals aged ≥60 years [5-7]. Estimates are higher in certain countries such as Nepal and China, where up to 75 percent of adults aged ≥60 years may be affected [8,9].

The prevalence of hyperkyphosis increases with age in all adults, with the greatest increase occurring among women aged 50 to 59 years [10]. In a study of 154 adults aged 60 and older living in Italy, kyphosis increased by approximately 8 to 9 degrees per decade [11].

ETIOLOGY AND PATHOGENESIS — 

The vertebral bodies and intervertebral discs are the major anatomical structures that contribute to spinal contour (figure 1). Thus, any process that affects either of these supporting structures can lead to hyperkyphosis. Deformities that result in anterior wedge-shaped vertebra will accentuate the angle of kyphosis. As with other age-related conditions, hyperkyphosis occurs as a result of multiple contributing factors.

Common causes

●Vertebral fractures – Vertebral bodies account for the majority of height in the spinal column, and it is commonly believed that age-associated hyperkyphosis mainly results from vertebral fractures and that such fractures worsen its severity [12-16]. However, only 36 to 38 percent of older persons with the worst degrees of kyphosis have underlying vertebral fractures [12,17]. Nonetheless, large observational studies report that with each vertebral fracture, kyphosis increases by approximately 3.7 to 3.8 degrees [18-20]. Wedge-shaped vertebral fractures are thought to increase biomechanical stress and compressive load on adjacent vertebrae [21,22].

Unlike limb fractures, vertebral fractures represent a continuum of deformity, and achieving an acceptable level of radiologic agreement in defining a vertebral fracture is challenging. Vertebral compression fractures are discussed in detail separately. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment".)

●Low bone density – Multiple studies have demonstrated that low bone density, even in the absence of underlying vertebral fractures, contributes to worse kyphosis in older adults [19,23-25]. Greater rates of bone density loss have been associated with worse kyphosis progression in older women. A lower trabecular bone score, reflecting cancellous bone quality of the lumbar spine, has been associated with hyperkyphosis in males [19,25]. It is hypothesized that low bone density may exacerbate the slight wedge shape present in normal thoracic vertebral bodies, in which the height of the anterior side of the vertebra tends to be shorter than the posterior side.

●Degenerative disc disease – The intervertebral discs in the thoracic spine range from 1 to 2 cm in thickness. With age, the discs can desiccate and lose height, and anterior wedging may occur. There is a significant association between degenerative disc disease and the degree of kyphosis [12,19,26].

●Postural changes – The postural configuration of the cervical, lumbar, and sacral spine may influence thoracic curvature [27]. Subjects with thoracic hyperkyphosis are more likely to have cervical or lumbar lordosis [28,29].

Postural flexibility, which decreases with age, likely contributes to hyperkyphosis. Compared with younger women, women aged 66 years and older had greater flexicurve kyphosis, measured by an architect's ruler, and were less able to actively correct their usual relaxed posture to an erect position [30]. Spinal proprioceptive sense also has been reported to be impaired in older persons with hyperkyphosis defined as >50 degrees compared with those with kyphosis angles ≤50 degrees [31].

●Muscle weakness – It is unclear whether hyperkyphosis precedes or results from muscle weakness. Most [32-41], but not all [42-44], studies report an inverse correlation between muscle strength and hyperkyphosis. A study of 1172 older adults aged 70 to 79 years assessed spinal extensor muscle cross-sectional area and density using computed tomography (CT) and found that lower spinal muscle density was associated with hyperkyphosis (defined as >40 degrees) [45]. Data from 1087 participants of the Framingham Heart Study confirm that smaller thoracic trunk muscle area was associated with worse kyphosis, especially in women, although loss of muscle density was not associated with kyphosis progression over an average of six years of follow-up [41]. However, using magnetic resonance imaging (MRI), another study of lumbar paravertebral muscle fatty infiltration in a small sample of 28 adults ranging in age from 55 to 84 reported that erector spinae fatty infiltration was significantly correlated with thoracic kyphosis [46].

Less common causes

●Short vertebral height – Causes of vertebral deformity other than fractures or osteoporosis are collectively called "nonfracture" deformities. These deformities may be the result of developmental abnormalities with or without degenerative changes. The most common developmental hyperkyphosis is Scheuermann disease, an inherited kyphotic deformity of the spine that usually occurs in early adolescence [47-49]. Scheuermann disease is defined by a thoracic Cobb angle of >45 degrees with anterior vertebral wedging of three or more consecutive vertebrae, end-plate irregularity with Schmorl nodes and disc space narrowing, and has an estimated population prevalence of 8.3 percent [50]. (See "Back pain in children and adolescents: Causes", section on 'Scheuermann (juvenile) kyphosis'.)

●Intervertebral ligaments – With aging, intervertebral ligaments that provide stability to the spine are susceptible to loss of elastic tissue, calcification, and ossification [51,52]. Diffuse idiopathic skeletal hyperostosis (DISH) is diagnosed by the presence of ossification of the ligaments in the anterolateral thoracolumbar spine involving at least four contiguous segments, without evidence of intervertebral disc degeneration. Studies have found that older persons with DISH tend to have greater degrees of thoracic kyphosis [53,54].

●Genetic conditions – Early-onset hyperkyphosis is often observed in inherited genetic conditions including osteogenesis imperfecta, Ehlers-Danlos syndrome, Marfan syndrome, cystic fibrosis, mucopolysaccharidoses, spondylo-epiphyseal dysplasia, and Scheuermann disease.

Age-associated hyperkyphosis is most likely a complex inherited trait. In a population-based cohort, investigators found that those who reported a family history of dowager's hump were more likely to have greater kyphosis [19]. A twin study comparing monozygotic and dizygotic older twin women reported a significant genetic influence on the degree of thoracic kyphosis, with a heritability estimate of 61 percent (95% CI 46-72) [27]. Analysis of data from the Framingham Study, based on CT images in over 2000 adults, estimated the hereditable component at 54 percent (95% CI 43-64 percent) [55].

●Other causes – Other causes in older adults can include spondylolisthesis, ankylosing spondylitis, spinal tuberculosis, postlaminectomy syndrome, and other complications from spinal surgical procedures [56].

HEALTH CONSEQUENCES — 

The health conditions associated with hyperkyphosis are varied.

Impaired pulmonary function — Several studies have shown that increasing kyphosis is associated with decreased forced vital capacity as well as other measures of pulmonary function [57-59]. This is discussed in detail separately.(See "Chest wall diseases and restrictive physiology", section on 'Kyphosis and scoliosis'.)

Diminished physical function — Multiple observational studies and meta-analyses suggest that hyperkyphosis is associated with poor physical function including decreased back extensor strength and grip strength [6,32,34,35,60-66]. Hyperkyphosis is also associated with worse physical performance functional measurements, including walking speed, the timed get up and go test, and the standing from a chair test, as well as daily functioning such as dressing oneself, cooking, and bathing [6,60-65,67,68]. Some studies report declining function over time, although one of the largest, which included 1100 adults, reported no differences in measured walking speed, chair-stand time, and grip strength after an average of 3.4 years of follow-up [69-72]. Notably, those 1100 adults were on average younger than those in other studies (mean age 61 years old) and they had less severe kyphosis than reported in other studies.

Falls — It has been hypothesized that hyperkyphosis fundamentally alters balance, thus increasing fall risk [35,73,74], although studies have not consistently demonstrated an association between various measures of balance and hyperkyphosis [36,75-77]. Differences in study results may stem from the wide age range of people studied (from just over 50 to 85 years old) to differences in the kyphosis measures, balance assessments, and fall ascertainment methods used. Alternatively, it may be that with age-related increases in kyphosis, there are compensations in pelvic alignment that serve to stabilize the skeleton such that fall risk is not increased [78]. The association between thoracic kyphosis and falls, if present, appears to be minimal but may be most significant for older patients [79-82].

Increased fractures — Hyperkyphosis is associated with thoracic vertebral fractures, and it is presumed that the fracture leads to hyperkyphosis [13,14]. However, with forward-bent posture, changes in gravitational loads may also increase the risk of sustaining a spinal or other osteoporotic fracture [22].

In prospective cohort and case-control studies in older women, hyperkyphosis has been found to be associated with increased risk of fracture [83-86]. However, it is possible that such increased risk is due to underlying baseline spine fractures (an established future fracture risk factor) [20,87,88].

Pain — Pain symptoms, particularly back pain, are associated with hyperkyphosis [13,67,89]. In addition, there are many case reports of associations between hyperkyphosis and insufficiency fractures of the sternum where patients tend to present with chest pain that is at first confused with that of acute myocardial infarction or pulmonary embolism [90,91].

Other health-related consequences — Age-related hyperkyphosis may be associated with other adverse health effects such as:

●Gastrointestinal problems including dysphagia, reflux esophagitis, hiatal hernia, Barrett esophagus, and intrathoracic stomach [92-96].

●Greater risk of pelvic prolapse and stress incontinence [97-99].

●Poor sleep health. (See "Evaluation of sleep-disordered breathing in adult patients with neuromuscular and chest wall disorders", section on 'Kyphoscoliosis'.)

Increased mortality — Hyperkyphosis and vertebral fractures are associated with increased mortality in older adults [5,17,100,101]. Until recently, most have assumed that the degree of hyperkyphosis simply represents the severity of underlying vertebral fractures. However, in a prospective cohort of 610 women, each standard deviation increase in kyphosis was associated with an increased risk of all-cause mortality (relative risk [RR] 1.15, 95% CI 1.01-1.30) [100]. This association was adjusted for age, bone mineral density, and prior vertebral fracture, suggesting that low bone density and underlying vertebral fractures were not the only causes for the increased mortality risk. This study, and a smaller study in patients with end-stage kidney disease, also demonstrated that the combination of hyperkyphosis and vertebral fracture is an added risk factor for mortality [100,102].

EVALUATION

Measuring kyphosis — Patients with hyperkyphosis have an inability to lay their heads flat on an examination table or to place their heads flat against the wall when standing without hyperextending their neck. Although hyperkyphosis can be easily noted from the patient's appearance (picture 1), objective measurement is useful to determine severity. The degree of kyphosis can be measured clinically or radiographically.

●Clinical measurement – In the sagittal plane, the normal spine contains three curves: the cervical region that is convex anteriorly, or lordotic; the thoracic region that is concave anteriorly, or kyphotic; and the lumbar region that is convex anteriorly, also lordotic (figure 1). Clinical methods use devices such as the flexicurve ruler [2], goniometer [32], inclinometer [103], or Debrunner kyphometer (in which a protractor is applied to the upper back) (picture 2) [104]. Among these devices, the flexicurve ruler is the least expensive and relatively easy to use. Less precise but more practical clinical measures of kyphosis include the occiput-to-wall distance [105], the number of 1.7 cm blocks between the head and examination table while lying flat with the neck in a neutral position (figure 2) [5], and qualitative visual measures.

●Radiographic measurement (Cobb angle) – The radiologic methods generally use lateral spine radiographs with either manual or computer-assisted calculation of an angle of curvature, termed the Cobb angle. The Cobb angle is measured by drawing perpendicular lines from two lines: a line from the upper border of the vertebral body marking the beginning of the thoracic curve (commonly T4) and a line from the inferior border of the vertebral body representing the interface between the thoracic-lumbar curves (commonly T12). The Cobb angle is then calculated as the angle of intersection of these perpendicular lines (figure 3). Although the Cobb angle was first developed to assess scoliosis angles on spinal radiographs, it was later modified to measure kyphosis and is considered by some to be the gold standard of kyphosis measurement [106]. Unless specifically requested, radiologists do not routinely calculate the Cobb angle of kyphosis from lateral spine radiographs. With artificial intelligence tools beginning to impact health care, work is underway by several groups to develop and validate computer-aided diagnoses of sagittal spinal curves, including thoracic kyphosis [107-110].

Determining symptom severity — In addition to objective measurement of hyperkyphosis, symptom assessment is an important part of the evaluation. We classify symptoms as mild, moderate, or severe:

●Mild/moderate symptoms and signs – Examples of mild to moderate symptoms include difficulty lifting one's head up, difficulty seeing forward while walking, and impaired balance. Although some patients may be asymptomatic due to lack of pain or overt functional impairment, signs such as the inability to lie flat (including on an examining table) identify patients who may benefit from treatments aimed at preventing disease progression.

●Severe symptoms – We define severe symptoms as impaired breathing (restrictive lung disease), significant pain, or severe functional impairment. Such patients should have pulmonary function testing.

Determining need for referral — We refer patients with severe symptoms to a clinician with experience in evaluating and treating hyperkyphosis (eg, physiatrist, orthopedic surgeon). If the patient has impaired breathing (restrictive lung disease), neurologic compromise and/or severe functional impairment due to hyperkyphosis, we consider referral to a spine specialist for potential surgical treatment, if the patient otherwise has good functional status and is interested in pursuing surgical options for symptomatic relief. For other patients, we refer to physical therapy those who cannot lay flat on an examination table or cannot put their head flat against the wall when standing without hyperextending the neck.

Assessing for osteoporosis and fractures — Hyperkyphosis may indicate the presence of other associated conditions, which we evaluate for.

●Osteoporosis – All patients with hyperkyphosis require an evaluation for osteoporosis. This topic is reviewed in detail separately. (See "Screening for osteoporosis in postmenopausal women and men" and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women" and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men".)

●Vertebral fractures – If clinical parameters are used to measure kyphosis, a plain spine radiograph should be performed to rule out underlying osteoporotic vertebral fractures. Ideally, a musculoskeletal radiologist should read the film since interrater reliability in reading vertebral fractures is rather poor, even among skilled radiologists [111]. The radiologist should also assess for previously undiagnosed Scheuermann disease, anterior wedge compression of the intervertebral discs, or other spinal pathologies. Patients with an acute fracture should delay exercise therapy until they have been evaluated by a physical therapist. Symptoms generally improve after three to six months but can take up to a year to fully improve. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment", section on 'Imaging abnormalities'.)

MANAGEMENT

General approach — We suggest exercise-based interventions focused on the rehabilitation of postural abnormalities as first-line treatment for hyperkyphosis. There are no standardized management guidelines. Other treatments include spinal orthoses, postural taping, manual therapy, breathing exercises, pharmacologic therapy, and surgery. Our approach is presented in the algorithm (algorithm 1).

Patients with mild/moderate symptoms — Patients without severe symptoms should be offered exercise-based treatments.

Exercise — We suggest exercise as an initial treatment for all patients, under the guidance of a physical therapist if possible. Exercise should focus on postural alignment, as well as flexibility and core strengthening, including the back extensor muscles. Once learned, exercises should be continued over the patient's lifetime, with short daily practices. In general, a frequency of two to three sessions per week of exercise during an 8- to 12-week period has been shown to improve at least one measure of posture [112-115].

If a physical therapist is not available to instruct the patient, the following exercises can be demonstrated in the clinician's office for daily home practice:

●Have the patient stand up with their back and feet against the wall to obtain as upright a posture as possible, with their eye gaze straight forward. Once positioned correctly, teach them to engage the diaphragm for deep breathing to make them aware of their core abdominal muscles. Next, instruct them to take five deep breaths, paying attention to their posture so they can continue to practice good posture throughout the day.

Secondly, instruct the patient to raise their arms above their head and then into a cactus position, extending their chest upwards and forwards, and repeat the breathing exercises.

●Have the patient transition to an "all fours" posture on the floor and instruct them to practice the cat-cow positions (alternating spinal rounding and extension). With the cow, take a deep breath, and with the cat, exhale. Repeat approximately five times (figure 4).

Back exercises are also available in a patient education topic. (See 'Information for patients' below.)

Digital technologies involving mobile phones and apps can deliver short instructional video clips (45 to 60 seconds long) on best posture and spinal strengthening. In a trial of 40 persons aged 60 years and older with thoracic kyphosis >40 degrees, corrective postural and respiratory exercises three times weekly for six weeks delivered via telerehabilitation resulted in decreased kyphosis and improved chest expansion compared with general stretching exercises [116].

In the primary care setting, clinical response to exercise can be measured by having the patient return to the office to demonstrate the movements. The clinician can then record their own subjective impression of the ease of performance and flexibility as well as elicit patient feedback. We recheck the patient's posture and ability to lay flat on an examination table or put their head flat against the wall. The interval at which reassessing posture can be done anywhere from three to six months, as benefits have been documented trials of this duration. As with any physical exercise intervention, the practice of spinal strengthening will require continuation to appreciate continued benefits.

Meta-analyses of trials among older adults with kyphosis demonstrate that exercise interventions improve kyphosis measurements and symptoms [112,114]. For example, in a trial among adults 60 years and older with kyphosis of at least 40 degrees, exercise interventions performed three times weekly for six months under supervision of a physical therapist improved kyphosis by 3 degrees, when compared with those receiving health education [117]. Such exercise appears to be safe among older adults with osteoporosis; in a trial of high-intensity resistance and impact training (HiRIT) in postmenopausal women with low bone mass, HiRIT decreased kyphosis without increasing vertebral fractures [118].

Breathing therapy — Whether symptomatic or not from a respiratory standpoint, teaching patients with hyperkyphosis about diaphragmatic breathing introduces them to being able to safely exercise their core musculature which is important in maintaining good posture. While some patients may innately use their diaphragm to maximize breathing strategies, many have trouble engaging their core correctly, and teaching them how to maximize their breath is helpful for postural control, and associated pain. Trials evaluating respiratory exercises to improve lung capacity and excursion, delivered using telerehabilitation and in-person interventions, have shown promising results [116,119].

Additional treatments — The available data on the efficacy of spinal orthoses, postural taping, and manual therapy are limited and mixed. Some studies suggest that these therapies may modestly improve extensor strength and/or the degree of kyphosis, while other studies showed little to no benefit. Nevertheless, these modalities are a reasonable option for patients who have inadequate improvement despite exercise-based therapy. In our experience, some patients do appear to benefit from these therapies and there is little risk in trialing them.

Spinal orthosis — There are a wide variety of flexible spinal orthoses (back braces) designed to improve posture [120-122]. In addition, spinal orthoses may facilitate stimulation of proprioception to improve unconscious muscle strengthening [123]. One study compared three types of trunk orthoses ranging from rigid to semirigid to soft thoracolumbosacral orthoses (TLSO) on the degree of kyphosis in older persons with osteoporotic hyperkyphosis. Because trunk orthoses may adversely affect balance and function, functional measures including a forward reach test, timed up and go test, and posture stability were also assessed. While all three orthoses served to reduce the kyphosis angle, only the rigid orthosis adversely affected functional reach [124].

Two randomized trials have tested whether the use of spinal orthoses in older women with osteoporosis has a favorable effect on either hyperkyphosis or back extensor muscle strength [125,126]. In one trial, the year-long use of a brace for 12 hours a day (not used in resting or sleeping positions) resulted in a decrease in kyphosis of 7 degrees. In the other trial, in which participants wore a brace for at least two hours a day, there was a 27 percent improvement in back extensor strength at six months, but no change in kyphosis. In a third randomized trial of a semirigid thoracolumbar orthosis involving 48 adults aged >60 years with kyphosis >50 degrees, compared with the control group, those assigned to wear the orthotic for two to four hours daily for three months demonstrated improvement in kyphosis of 14.8 degrees with associated improvements in back muscle performance [127].

In a semiblinded 16-week trial among 80 women aged 65 and older with a history of vertebral fracture, back pain, and kyphosis ≥50 degrees, those who received the "Spinomed active" orthosis (a tightly fitting body suit with traction and pressure elements, including a supportive aluminum back splint customized to the individual) had greater improvements in pain, kyphosis, and trunk strength compared with those in the control group, although 14 participants (17.5 percent) dropped out [128]. In a second trial, the Spinomed orthosis was found to be equivalent to the Spinomed orthosis with biofeedback posture trainer in improving balance [129].

Other orthoses — Based upon prior studies that demonstrate improvements in gait speed and low back pain, investigators postulated that a heel lift could increase the lumbar angle as well as improve spinal kyphosis and walking ability. In a small study of 33 older persons of mean age 78 years old with hyperkyphosis defined as >53 degrees, using a 10 mm heel lift significantly decreased the thoracic angle by approximately 7 degrees, improved the walking speed by 0.1 meter/second, and increased step length by an average of 3 cm. Though a small study, consideration of using a 10 mm heel orthotic to improve posture is a feasible and affordable intervention [130].

Postural taping — Therapeutic spinal postural taping involves tape applied from the anterior aspect of the acromioclavicular joint, over the muscle bulk of the upper trapezius, and then diagonally towards and just past the spinous process of T6. The tape is applied bilaterally, intersecting at T6 (figure 5). In a study of therapeutic postural taping, control taping, or no taping in 15 women over the age of 50 with vertebral fractures, therapeutic tape significantly decreased kyphosis compared with control taping [131], with similar results confirmed in a small trial of 10 healthy older adult men and women with minimal hyperkyphosis [132]. It is unclear whether the immediate effects of therapeutic taping led to longer-term beneficial effects. Taping is usually performed by a physical therapist on a short-term basis.

Manual therapy — Manual techniques including massage, mobilization, muscle energy, and myofascial release may potentially improve kyphosis through both biomechanic and neurophysiologic mechanisms, although data from older adults is limited [133-135].

Pharmacologic therapies — Few data are available showing benefit of pharmacologic therapies in treating hyperkyphosis and may be due to improvement in associated osteoporosis. In the Fracture Intervention Trial of 4432 postmenopausal women with low bone density, those randomly assigned to alendronate had reduced height loss compared with those randomly assigned to placebo (7.0 versus 8.5 mm) [136]. However, in a secondary analysis of the Fracture Intervention Trial, there was no benefit of alendronate in delaying kyphosis progression over an average of 4.2 years [137].

A study that combined results from two randomized trials reported that treatment with strontium ranelate decreased progression in kyphosis index over three years compared with placebo (3.7 versus 4.7 percent, respectively) [87]. Kyphosis index was defined as the percentage ratio between the maximum depth of thoracic curvature and the height measured from the T4 to the T12 vertebrae. As the difference in kyphosis index progression was only 1 percent, the beneficial effect of strontium on delaying kyphosis progression, if present, is likely of minimal consequence.

Surgical interventions for patients with severe symptoms — For most older persons with hyperkyphosis, surgery does not play a role in the management since surgery carries a high risk of complications in this population with only modest benefits [138,139]. The corrective surgeries for those affected with severe kyphotic deformities (>65 degrees) involve lengthy procedures that may use either anterior or posterior approaches, usually with spinal fusions and screws, metal plates, and/or rod placement. Surgeries to correct severe kyphotic deformities are highly individualized and depend on the patient's age, comorbidities, degree of functional impairment, and their values and preferences. Patients who are interested in pursuing surgery should be referred to a spine surgeon as well as a bone health specialist for further evaluation.

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Kyphosis in adults (The Basics)")

●Basics topics (see "Patient education: Back exercises (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition and prevalence – Hyperkyphosis is excessive curvature of the thoracic spine that tends to worsen with age. Since there is no widely accepted definition of hyperkyphosis, the prevalence of hyperkyphosis in older persons is not precisely known. However, estimates range between 20 to 40 percent among community-dwelling older adults. (See 'Prevalence' above.)

●Adverse health consequences – Hyperkyphosis is associated with several adverse health conditions including thoracic pain, decreased pulmonary function, limited physical functioning, increased fractures, and increased mortality. (See 'Health consequences' above.)

●Evaluation – The degree of kyphosis can be measured clinically with devices such as a kyphometer or radiographically with plain film (figure 1 and picture 2). While there are no widely accepted thresholds for assessing hyperkyphosis, many clinicians consider ≥40 degrees the defining cutoff for hyperkyphosis. (See 'Evaluation' above.)

●Management approach – Our approach to management is summarized in the algorithm (algorithm 1). (See 'General approach' above.)

•First-line intervention (exercise-based therapy) – For most patients with hyperkyphosis, we suggest an exercise-based treatment program rather than other interventions such as spinal orthosis, postural taping, or pharmacologic therapies (Grade 2C). Exercise-based treatment programs focus on postural alignment, as well as flexibility and strengthening of back extensor muscles. (See 'Exercise' above.)

•Patients with inadequate improvement despite exercise-based therapy – Spinal orthoses, postural taping, and manual therapy may modestly improve extensor strength and/or the degree of kyphosis, and are a reasonable option for patients who have inadequate improvement despite exercise-based therapy. (See 'Additional treatments' above.)

•Role of surgery – Spine surgery may play a role for selected patients with restrictive lung disease, neurologic compromise, severe pain, or severe functional impairment resulting from kyphosis. However, surgeries to correct severe kyphotic deformities are highly individualized and depend on the patient's age, comorbidities, degree of functional impairment, and their values and preferences. (See 'Surgical interventions for patients with severe symptoms' above.)