Original Editors - Louise Burrion
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).
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:
- 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 increasing risk of development vertebral compression fractures
- Increase risk of falling and fractures due to poor gait
- Have an impact on the basic functioning and daily living, which affects the quality of life.
Clinically Relevant Anatomy
- Cervical Spine: it contains 7 vertebrae (C1-C7) and has a lordotic curve. This region has the greatest mobility.
- 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 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.
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.
There are ligaments between the ribs and vertebrae and these ligaments limits the rotation of the thorax but only in the transverse plane.
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.
Thoracic kyphosis varies in life between 20-29 degrees. Incidence and prevalence of hyperkyphosis vary between 20% to 40% among both men and women.  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 such as depression, insecurity, despondency and anxiety. 
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. 
Hyperkyphosis may develop further with muscle weakness (often because of a weakening spinal extensor muscle)  , 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. 
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. 
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. 
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.
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.
In severe cases of Hyperkyphosis, people can have trouble breathing, because of the loss of vital capacity of the lungs.
- Vertebrale fracture
- Muscle imbalance caused by neuromuscular disease
- ankylosing spondylitis
There are different validated diagnostic procedures for measuring hyperkyfosis:
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).
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.
Standing clinical measurement
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.
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.
There is a reasonable correlation (ICC = 0.68) between a radiologic and standing clinical measurement of kyphosis.
- 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. 
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)
- 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.
Pharmacological treatment focus on anti-resportive or bone-building medication because many patients with age-related hyperkyphosis have low bone density or spine fractures.
There are two surgical options: vertebroplasty and kyphoplasty. These options mainly help relieve pain and decrease physical disability, but in some cases, surgery can reduce the kyphosis angle.
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.  
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.   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.
The risk of this surgery is that the cement can leak, and potentially damage the spinal cord.
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. 
This surgery has the same risk as a kyphoplasty, namely leaking fluid and potentially damaging the spinal cord.
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. (Level of Evidence = 1A) 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.
The main goals of physical therapy management should be:
• Increased back extensor strength
• Increased spinal extension mobility
• Improved postural awareness
• Prevention of vertebral compression fractures
PT Management strategies include:
- Postural correction training through stretching, and strengthening exercises to help reduce the hyperkyphotic curvature and prevent the condition from advancing.
- Breathing exercises to help improve tolerance for physical activity by increasing lung capacity.
- 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:
(All modalities below has been studied using RCTs: level of evidence= 1B)
- Hatha Yoga modified for individuals with hyperkyphosis:Postures should focus on breathing techniques, stretching tight muscle groups and strengthening weak/inhibited muscle groups (e.g. rhomboids)
- Manual mobilisations : Mobilisations should be done according to Maitland Joint Mobilization Grading Scale
- Active mobilisations/stretches of pectoral region, shoulders and Latissimus Dorsi muscle
- Muscle strengthening   :Thoracic extension (paravertebral muscles),Abdominal muscles
Scapular adductors,Shoulder flexion, adduction, abduction  and Standing elbow flexion/extension
- Postural awareness training (standing, sitting), with:visual (images, mirror)auditive (therapist giving cues)
and/or tactile feedback (therapist, taping).  
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 & 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 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.
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