Thoracic Hyperkyphosis

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Original Editors - Bo Hellinckx, Matthias Steenwerckx, Fien Selderslaghs, Mirabella Smolders, Wout Theys

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Search Strategy

Databases used: Pubmed, Web of knowledge, American college of rheumatology.
Keywords used: Thoracic hyperkyphosis, spine, definition, epidemiology, etiology, examination, treatment (or a combination of these words).


Thoracic hyperkyphosis, commonly known as hunchback, is described as an excessive antero-posterior curvature of the thoracic spine of greater than 40°.[1] Normal kyphosis angles can vary between 20° and 40° in the younger public, however, in older population, the mean kyphosis angle is 48° to 50° in women and about 44° in men. [6]

Hyperkyphosis appears thus commonly more rapidly in women than in men. Kado D.M. et al. states that “the angle increases with age, but there hasn’t been uniform accepted thresholds for defining either hyperkyphosis or “normal” thoracic spine changes associated with aging.”

It can be classified in five categories:

1. Scheuermann’s Disease [4]: The juvenile form of hyperkyphosis. Defined as a defect of the vertebral body growth plate at the cortical level, results in weakening the vertebral body and causing wedging. It stops at the end of growth, when the growth cartilage is no longer active.

2. Postural Kyphosis [4]: Most frequent form of kyphosis. It is a result of poor posture and weakened muscles and ligaments of the spine with no vertebrae deformities visible.
3. Congenital Kyphosis [4]: Bone defect detected at birth. Kyphosis angle will increase if not treated in time.

4. Age-related Hyperkyphosis [2], [5]: Kyphosis angle increases with age, resulting in age-related hyperkyphosis. Despite the fact that increased kyphosis is one of the typical results of osteoporosis, up to 70% of patients with age-related hyperkyphosis do not suffer from decreased bone mineral density. [2] The exact prevalence of patients for non-osteoporotic hyperkyphosis is unknown, yet it is estimated that 10% to 45% of the people aged over 50 years are properly diagnosed. Genderwise, thoracic hyperkyphosis increases to 50% in men and 65% in women over the age of 65 years. [3]

5. Neurological Hyperkyphosis [4]: Can be a result of the paralysis of abdominal muscles.

Clinically Relevant Anatomy

The thoracic part of the spine has a forward rounding, well known as ‘kyphosis’. This thoracic curvature is the result of a slight wedging of the vertebrae. In some limited studies, the normal degree of thoracic convexity in the sagittal plane is measured. This should be present in the range of 20°-40°.[1], [8] Thoracic hyperkyphosis is a defect that is easy to see from the side, in a lateral point of view. This is detected when the flexion curve of the thoracic part is over 40°. [7]

                                      Thor 1.png             Thor 2.png

It is also important to know that the stability of the thoracic spine is connected with the rib cage and his articulations. For this reason, thoracic hyperkyphosis could have detrimental effects on other functions such as breathing. [9], [10]

In standing postures, the gravity line passes ventral to the vertebral bodies. The load of the gravity will increase the thoracic kyphosis. These bending forces bring anatomical changes. The anatomical changes include a passive constraint of the posterior ligaments, contraction of the deep one-joint muscles and the thoracic parts of the long extensors. [9]

There is suggested that muscle activation (measured with EMG) has a little effect on the thoracic kyphosis. But thoracic kyphosis is usually the result of osseous asymmetry of the vertebral bodies. [9], [11] These effects increase the possibility of voluntary (or involuntary) postural changes. This is associated with a poked forward head. This is an alignment defect in which the neck is extended on a rounded upper back. And the head is partially tilted forward and upward.

Epidemiology /Etiology

The normal range of kyphosis is related to both age and gender of the patient. It has been proven that the level of kyphosis increases with age. [1] The precise prevalence in the population remains still uncertain, but considering the study of Nishiwaki et al. [12] this disease appears after the age of 40. There is also a difference in gender, namely hyperkyphosis appears commonly more rapidly in women than in men. [1], [12]

Besides age and gender, there are also other risk factors which are responsible for the evolution of thoracic hyperkyphosis, namely musculoskeletal-, neuromuscular- and sensory impairments can lead to a higher degree of kyphosis. However, there are patients without developing some of these factors (idiopathic cause). [5], [14], [15]
The effect of psychosocial factors is also indicated. A hyperkyphosis can have a correlation with factors such as [1], [13]:
- Depression,
- Anxiety,
- Insecurity,
- Despondency.

Biomechanically, thoracic hyperkyphosis can be explained with higher spinal loads and trunk muscle force in upright stance. This may accelerate degenerative process and contribute to dysfunction and pain. [13]

In our daily activities, protruding head positions and loss of shoulder range induced by slouched sitting, ill-fitting school desks, overloaded backs and backpacks, contributes to an increased thoracic kyphosis. We should avoid these risk factors in the future as prevention for the development of thoracic hyperkyphosis. [16]

Characteristics/Clinical Presentation

Alignment impairments such as hyperkyphosis of the thoracic spine, can be postural or structural. Patients may also present with a combination of both alignment impairments.
range of motion,
Most of the time, postural impairments are flexible and respond to positional changes or cues to change alignment. [8]
The most prominent symptom you might notice is the appearance of a rounded back. You can see an exaggerated anterior curvature of the thoracic spine. [5]

• The change in back posture is mostly gradual over time.[18][19]

                                                           Thor 3.png

Structural alignment impairments are fixed alignments of the boney structures that persist, regardless of the position of the individual. Recognition of these impairments and accommodation of the fixed impairments must be made to reduce mechanical stress and pain. [8] Scheuermann’s disease is a typical structural impairment of the thoracic spine.

When there is a combination of structural and postural alignment impairments, postural correction may only be partial successful.

The uncorrected habit of thoracic flexion can develop over time into permanent alignment changes.[8] In this case, kyphosis that started as a postural fault becomes a structural impairment. This phenomenon commonly is not painful until a severe thoracic kyphosis has developed. [8]

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. [17]

Other health outcomes and problems that can occur due to and simultaneously with hyperkyphosis include physical functional limitations, thoracic back pain, respiratory compromise, restricted spinal range of motion and osteoporotic fractures. [17]

Multiple studies have demonstrated a negative effect of hyperkyphosis on physical function, however none have been able to say with absolute certainty whether the impaired function might be explained by another associated predictor underlying spinal osteoporosis. These studies had small (13 patiënts) sample sizes so more research has to be done. [5]

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) [18]

Differential Diagnosis

The diagnosis of thoracic hyperkyphosis can be established by clinical examination, and can be confirmed by radiologic imaging. Some individuals may develop the same magnitude of hyperkyphosis from different processes [5], which leads to a common misinterpretation. Some differential diagnosis can be: [5], [20]
1. Scheuermann’s disease:
2. Osteoporosis
3. Trauma-related spinal changes
4. Tumor
5. Infection
6. Vertebral fractures
7. Degenerative disc disease Diagnostic Procedures/ Examination

Diagnostic Procedures

Conventional, plain radiography continues to be the starting point of any diagnostic investigation of the thoracic spine. Before any complex imaging procedure, it is recommended to consult plain radiography. Also the interpretation of these complex studies should be undertaken with the plain radiographs at hand. Anteroposterior and lateral radiographs are always required. [21], [22]

Plain radiographs, reformatted CT scans and MR images display the overall curvature of the spine and can give us a clear image whether or not there is a kyphosis or not. [22]

Anteroposterior and lateral views of the thoracic spine are helpful in assessing alignment. Anteropostenior radiographs are easy to obtain, diagnostic lateral radiographs to the contrary may be more difficult to obtain especially in patients with multisystem trauma because a lateral radiograph is performed with the patient in the supine position. [21]

Anteroposterior radiographs come in very handy for the evaluation of the vertebral bodies, while the lateral radiographs are more helpful in assessing vertebral body height, disk height, endplate irregularity, erosions, and alignment. [21]

Outcome Measures

Some tests which can be used to determine the progress of a patient during the treatment, are mentioned below:

1. Scoliosis Research Society – 22 Patient Questionnaire [23], [24]
Is a reliable and validated questionnaire for score distribution in a spinal deformity population between 7 and 78 years. [24] This measurement instrument consists of 7 domains:
• Pain
• General Self-image
• General Function
• Overall Level of Activity
• Post-operative self-image
• Post-operative function
• Satisfaction

2. Visual Analogue Scale [26]
Is a measurement instrument that measures the intensity of various symptoms (e.g. the amount of pain). The score of this 100 mm horizontal line is determined by measuring the distance:
• 0 – 4 mm: no pain
• 5 – 44 mm: mild pain
• 45 – 74 mm: moderate pain
• 75 – 100 mm: severe pain

3. Quebec Back Pain Disability Scale [27]
Is a self-administered measurement to evaluate the level of functional disability in individuals with back pain. It includes 20 questions about actitivities of daily living and consists of 6 domains:
• Bed - Rest
• Sit - Stand,
• Run,
• Movement,
• Stoop,
• Move heavy objects

4. McGill Quality of Life Questionnaire [28]
This questionnaire measures the quality of life in people with life-threatening illness, which includes positive as well as negative factors. It consists of 4 domains: physical, psychological, existential and support.


Typical signs of age-related hyperkyphosis are: [2]
- Pain and dysfunction of both spine and shoulder [13];
- Loss of range of movement and increased stiffness;
- Reduced physical function [29];
- Respiratory compromise;
- Increased risk of osteoporotic fracture [30];
- Increased mortality rates in the elderly.

The physiotherapist begins with observing the patient during the acquaintance. According to Zaina et al. (2009), abnormalities during gait, speech and undressing can be noticed very quickly. [19] Next, the patient is examined in sagittal plane in standing and relaxed position “in order to assess the most affected somatic areas and posture alterations.” (Zaina et al., 2009)
De Mauroy (1983) describes it as follows: “The standing position of the clinical examination needs to be reproducible. Ankles and toes are placed in a neutral anatomical posture. The lower limbs are stretched straight limiting an excessive recurvatum. The trunk and upper limbs are relaxed, palms of the hands on the lateral thighs, the eye is looking horizontally”. [4]

A plumbline can also be used to evaluate the thoracic kyphosis. The distance between the plumbline and C7 will be measured, if it is between 1-1,5 cm it can be considered as normal. If more than 1,5 cm, a thoracal hyperkyphosis can be diagnosed. This test can also be done on T12 and L3. [19]

Thoracic kyphosis angle is the most important component in order to diagnose thoracic hyperkyphosis. However, it can’t be measured precisely during global examination. There are a few methods to calculate the angle, the first one being X-rays that will be discussed later on. Another example is the “Kyphosis Cobb Angle”. [2], [17] To measure it, a perpendicular is taken that is extended from a line through superior landmark marking from T4 and an inferior marking of T9. [13] When the angle is between 40-45° we consider it as a thoracal hyperkyphosis.

There is also alternative equipment to measure the thoracic kyphosis angles.
These are:
- Modified Cobb Angle: Line extended through mid-points of superior and inferior end-plates of T4 and similar for T9
- The pantograph
- The Debrunner kyphometer: Arms of the kyphometer is place on C7 and T12, we read the angle from the protractor
- The flexicurve index: Place a marker on C7 and the lumbar-sacral joint space. Then use a flexicurve carefully and place it between C7 and the L-S joint space. When you take the flexicurve away from the back it will conserve the form of the whole back. Then put the flexicurve on a 10x10 paper and draw a vertical line and then the TW and LW lines you need to measure

We can also do some functional examination such as eventual rib cage abnormalities such as pectus excavatum or carnatum, from the back we can evaluate the symmetry of the shoulders, scapulae, thorax, waist and the head.



Generally, an increased kyphosis is a result of musculoskeletal dysfunction in the affected area, hence physical management should be considered as a first-line approach. According to Katzman W. (2010) there is a shortage of effective medical interventions for patients with thoracic hyperky¬phosis, while other sources claim surgery is needed when patients are experiencing uncontrolled pain (due to compression of neurologic structures), cardiac or pulmonary complaints. [5] (Level of Evidence: 5)

There are multiple surgical procedures that can be applied, depending on:

  • Flexibility: X-rays will be taken to determine how flexible the spine is. If it’s flexible, a posterior approach may be adequate. If the patient is less flexible, an anterior or combined approach will be needed. These techniques are based on bone fusion with screws and rods. [31] (Level of Evidence: 2B)
  • The surgeon can also choose for an osteotomy (a surgical operation in which a bone is cut to shorten, lengthen, or change its alignment.). An osteotomy often gives some good results on patients.
  • Osteoporosis: An osteoporotic thoracic hyperkyphosis can be caused by a collapsed vertebra. This can be treated with a kyphoplasty, whereby a balloon is inserted into the affected vertebra and filled with liquid that hardens to restore the vertebral height.

Surgical interventions regarding painful vertebral fractures, vertebroplasty and kyphoplasty are procedures that are minimally invasive and that are gaining their wider acceptance as effective treatments for unmanageable pain and possible kyphosis. [5] (Level of Evidence: 5) They even have resulted in a decreased kyphosis angle. Several published case series of both procedures and reviews of cases reported reduced pain, improved physical function, vertebral height restoration of up to 90%, and kyphosis angle correction ranging from 8.5° to 14°. However, this only is in select patient populations and just within the first 3 months after the intervention.[6] (Level of Evidence: 1A), [31] (Level of Evidence: 2B)

To the contrary, there are no published randomized, controlled trials that have evaluated or compared benefits and disadvantages of the procedures. There is a need for randomized tri¬als from a higher quality and with a long-term follow-up to investigate benefits of these proce¬dures on subsequent vertebral fractures. Also there are no studies that investigated the effects on kyphosis of combined treatment with medications, surgical interventions, and physical therapy interventions. [6] (Level of Evidence: 1A) More invasive surgical interventions for hyperkyphosis are associated with high rates of intra- and perioperative complications (33%). These interventions are normally reserved for patients with documented curve progression, intractable pain, or neurologic compromise. [5] (Level of Evidence: 5)

Posterior spine fusion using Harrington compression instrumentation is an other technique tested by T.C. Taylor et al (1979). Patients with postural roundback deformity were reviewed with a mean follow-up of 27.6 months. At the beginning of the study, before the operation, the mean curve was 72 degrees and at review the curve amounted to 46.1 degrees. The mean loss of correction in the fusion from initial examination to final follow-up was 5.7 degrees. It is shown in this study that this procedure can achieve a satisfactory correction of deformity as well as pain relief. It is also believed that Harrington compression instrumentation and spine fusion are indicated in selected cases of roundback deformity. Further studies need to be done to come to a final conclusion. [32] (Level of Evidence: 2B )

In terms of medications, antiresorptive or bone-building medications are taken by patients with thoracic hyperkyphosis due to their low bone density or spine fractures. According to Katzman W. (2010) “osteo¬porosis treatment helps to prevent in¬cident spine fractures, however no medications have been shown to improve hyperky¬phosis.” [5] (Level of Evidence: 5)


Physical therapy for thoracic hyperkyphosis, including manual therapy, taping and bracing, will be implemented in an early stage and is regularly a first-line treatment. [33] (Level of Evidence: 1A) The main goal of any therapy for patients with thoracic hyperkyphosis is to reduce the excessive antero-posterior curvature as well as improve the physical function and decrease the pain. Recognition and treatment of hyperkyphosis could contribute to reduced risk of falls, fractures, and functional limitations.[5] (Level of Evidence: 5)

A. Manual Therapy
Thoracic joint mobilizations are required in patients diagnosed with hyperkyphosis because of the reduced thoracic motion. Regarding Katzman W.B. et al., [5] (Level of Evidence: 5) scapular, myofascial and spinal mobilization techniques increase postural alignment in these patients. Besides those passive mobilizations, self-mobilization techniques are also effective when treating hyperkyphosis, e.g. diaphragmatic breathing on foam roller for expanding the rib cage. Additionally, these exercises can be performed at home when properly instructed. [5] (Level of Evidence: 5)

Considering the tight muscles, also stretching will be implemented during the physical therapy. Below are a few stretching exercises with the intention of decreasing the tonus of the muscles mentioned: [5] (Level of Evidence: 5), [34] (Level of Evidence: 2B)

  • Chest stretching on foam roller: lengthening pectoralis muscles
  • Prone hip extension/ knee flexion: lengthening iliopsoas and rectus femoris
  • Supine knee extension with hip at 90° flexion: lengthening hamstrings

Jang H.J. et al.,[35] (Level of Evidence: 2B) suggests that thoracic correction exercises (e.g. scapular posturing [36] (Level of Evidence: 1B)) are effective for patients with thoracic hyperkyphosis. The main goal of this type of exercises is to correct the thoracic position as well as improve the structural alignment and stiffness of the thorax. Despite the positive results which obtained an improvement of the mobility of the rib cage, show these correction exercises no significant effect on flow volume of the lungs. [35] (Level of Evidence: 2B)

Furthermore, other treatment for patients with thoracic hyperkyphosis such as heat therapy, muscle strengthening, Pilates and muscle relaxation (e.g. yoga) can be helpful. [35] (Level of Evidence: 2B), [37] (Level of Evidence: 1B), [38] (Level of Evidence: 2B) Below a few exercises for muscle strengthening: [5] (Level of Evidence: 5)

  • Prone trunk lift to neutral: strengthening spinal extensors, middle- and lower trapezius
  • Prone trunk lift to neutral with weighted backpack: strengthening spinal extensors
  • Quadruped alternate arm/leg lift: strengthening spinal extensors, scapula and trunk stabilization, reducing anterior tightness

B. Bracing
Bracing is only recommended when the hyperkyphosis is no longer reversible through exercises because it is too stiff or because exercises have already proved insufficient. It’s preferable as a physiotherapist to choose for exercise therapy, because it’s less invasive and is thus a better first line option. [19] (Level of Evidence: 1A)

Bracing is a very important element in the physical treatment of thoracic hyperkyphosis, but it gives only beneficial outcomes in conjunction with physical therapy. The combination of both, reduces the spinal stiffness. Passive bracing without the addition of physical therapy, doesn’t have any effect on the thoracic spine. [33] (Level of Evidence: 1A), [5] (Level of Evidence: 5), [19] (Level of Evidence: 1A)

A few types of bracing for thoracic hyperkyphosis are mentioned below:

  • A Milwaukee Brace is the most common brace used by patients with a thoracic hyperkyphosis. This brace has posterior pads pushing anteriorly on the kyphosis. The neck and the pelvis are controlled by the other segments of the brace. The patients should wear this brace 23 hour a day for 1-2 years. [19] (Level of Evidence: 1A)
  • The results of the Lyon Antikyphosis Brace were very satisfactory in most patients with thoracic hyperkyphosis.[33] (Level of Evidence: 1A)
  • Also a new bracing design called the Kyphologic Brace has been shown to have a good in-brace correction at average. [39] (Level of Evidence: 2B)
  • Another kind of brace using the two 3-point pressure system, is the ‘Gschwend type’ brace. This brace is mostly used in Germany. [34] (Level of Evidence: 2B)

                                 Thor 4.png Thor 5.png

C. Taping
There is also a small evidence found on the effect of taping on the reduction of thoracic hyperkyphosis. Therapeutic taping may also reduce kyphosis. The therapist should tape from the anterior aspect of acromioclavicular joint, over the muscle bulk of the upper trapezius, and diagonally over the spinous process of T6. Further investigation is necessary.[5] (Level of Evidence: 5)

D. Spinal orthosis
A SpinoMed is a spinal orthosis which can be used for a thoracic hyperkyphosis. There is some evidence found about the use of this device. The patient should wear this for 2 hours a day during 6 months. This will result in a decrease in kyphosis angle, an improvement of standing height, an increase in spinal extensor strength and a decreased postural sway. [5] (Level of Evidence: 5)

Conclusion, according to international studies the conservative treatment for patients with thoracic hyperkyphosis is regarded as being effective. [34] (Level of Evidence: 2B)

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)


1. Fon G.T. et al., Thoracic Kyphosis: Range in Normal Subjects, American Journal of Roentgenology, 1980, 134 (5): 979–983. (Level of Evidence: 1B)
2. Perriman D.M. et al., Thoracic Hyperkyphosis: A Survey of Australian Physiotherapists, Physiotherapy Research International, 2012, 17: 167-178. (Level of Evidence: 1A)
3. Bartynski W.S. et al., Severe Thoracic Kyphosis in the Older Patient in the Absence of Vertebral Fracture: Association of Extreme Curve with Age, American Journal of Roentgenology, 2005, 26 (8): 2077–2085. (Level of Evidence: 2B)
4. De Mauroy J.C. et al., Kyphosis Physiotherapy from Childhood to Old Age, Physical Therapy Perspectives in the 21st Century - Challenges and Possibilities, InTech, 2012, 382 pagina’s. (Level of Evidence: 5)
5. Katzman W.B. et al., Age-Related Hyperkyphosis: Its Causes, Consequences, and Management, Journal of Orthopaedic & Sports Physical Therapy, 2010, 40 (6): 352–360. (Level of Evidence: 5)
6. Kado D.M. et al., Narrative Review: Hyperkyphosis in Older Persons; Annals of Internal Medicine, 2007, 147: 330-338. (Level of Evidence: 1A)
7. Ackland T.R et al., Applied Anatomy and Biomechanics in Sport, Blackwell Publishing. 2009, 376 pages. (Level of Evidence: 5)
8. Sahrmann S., Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine, 2011, 568 pages. (Level of Evidence: 5)
9. Edmonston S.J. et al., Thoracic Spine: Anatomical and Biomechanical Considerations for Manual Therapy, School of Physiotherapy, 1997, 2(3): 132)143. (Level of Evidence: 2A)
10. Culham E.G. et al., Thoracic Kyphosis, Rib Mobility, and Lung Volumes in Normal Women and Women With Osteoporosis, Spine, 1994, 19(11): 1250-1255. (Level of Evidence: 3B)
11. Sinaki M. et al., Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength, Osteoporos Int, 2005, 16(8): 1004-1010. (Level of Evidence: 1B)
12. Nishiwaki Y. et al., Association of thoracic kyphosis with subjective poor health functional activity and blood pressure in the community-dwelling elderly, Environ Health Prev Med, 2007, 12(6): 246-250. (Level of Evidence: 2B)
13. Lewis J.S. et al., Clinical Measurement of the Thoracic Kyphosis. A Study of the Intra-rater Reliability in Subjects with and without Shoulder Pain, BMC Musculoskeletal Disorders, 2010, 11 (39): 1-7. (Level of Evidence: 1B)
14. Negrini S. et al., SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth, Scoliosis, 2012, 7:3. (Level of Evidence: 5)
15. Ashton-Miller J.A. et al., Thoracic hyperkyphosis in the young athlete: A review of the biomechanical issues, Curr Sports Medecine Rep, 2004, 3(1): 47-52. (Level of Evidence: 2C)
16. Britnell S.J. et al., Postural health in women: the role of physiotherapy, J Obstet Gynaecol Can. 2005, 27(5): 493-510. (Level of Evidence : 1B)
17. Greendale G.A. et al., The Reliability and Validity of Three Non-Radiological Measures of Thoracic Kyphosis and their Relations to the Standing Radiological Cobb Angle, Osteoporosis International, 2011, 22 (6): 1897-1905. (Level of Evidence: 1B)
18. Zane M.K. et al. Physical Therapist's Guide to Hyperkyphosis (Humpback) in Adults. American Physical Therapy Association. 2014 (Level of evidence: 5)
19. Zaina F. et al., Review of Rehabilitation and Orthopedic Conservative Approach to Sagittal Plane Diseases During Growth: Hyperkyphosis, Junctional Kyphosis, and Scheuermann Disease, European Journal of Physical and Rehabilitation Medicine, 2009, 45 (4): 595-603. (Level of Evidence: 1A)
20. D’Antoni A.V. et al., Frederico di Montefeltro’s hyperkyphosis: a visual-historical case report, Journal of Medical Case Reports, 2008, 2: 11. (Level of Evidence: 3B)
21. EI-Khoury G.Y. et al., Trauma to the Upper Thoracic Spine: Anatomy, Biomechanics, and Unique Imaging Features, AJR Am J Roentgenol, 1993, 160(1): 95-102. (Level of Evidence: 5)
22. Naidich T.P. et al., Imaging of the spine, Jaypee Brothers Medical Publishers, 2001. (Level of Evidence: 5)
23. Monticone M. et al., Reliability of Scoliosis Research Society-22 Patient Questionnaire in mild adolescent vertebral deformities, Italian Scientific Spine Insitute, 2004, 40(3): 191 – 197. (Level of Evidence: 2C)
24. Maty B.S. et al., The Relationship Between Thoracic Hyperkyphosis and the Scoliosis Research Society Outcomes Instrument, Health Services Research, 2007, 32(20): 2226 – 2231. (Level of Evidence: 2B)
25. Glattes R.C. et al., The Reliability and Current Validity of the Scoliosis Research Society-22r patient Questionnaire Compared with the Child Health Questionnaire-CF87 patient Questionnaire for Adolescent Spinal Deformity, Spine Phila Pa, 2007, 32(16): 1778 – 1784. (Level of Evidence: 4)
26. Jensen M.P. et al., Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain, J Pain, 2003, 4(7): 407 – 414. (Level of Evidence: 1A)
27. Jacek A. et al., The Quebec Back Pain Disability Scale: Measurement Properties, Lippincott-Raven Publishers, 1995. (Level of Evidence: 2C)
28. Cohen S.R, Existential well-being is an important determinant of quality of life: Evidence from the McGill quality of life questionnaire, American Cancer society, 1998, 77(3): 576 – 586. (Level of Evidence: 5)
29. Kado D.M. et al., Hyperkyphotic posture and poor physical functional ability in older community-dwelling men and women: the Rancho Bernardo study, The Journals of Gerontology Series A, Biological Sciences and Medical Sciences, 2005, 60: 633–637. (Level of Evidence: 2B)
30. Huang M.H. et al., Hyperkyphotic posture and risk of future osteoporotic fractures: the Rancho Bernardo study, Journal of Bone and Mineral Research, 2006, 21: 419–423. (Level of Evidence: 2B)
31. Lundine K. et al., Thoracic Hyperkyphosis: Assessment of the Distal Fusion Level, Global Spine, 2012, 2: 65-70. (Level of Evidence: 2B)
32. Taylor T.C. et al; Surgical Management of Thoracic Kyphosis in Adolescents, Journal of Bone and Joint Surgery, 1979; 61 (4): 496 -503. (Level of Evidence: 2B)
33. De Mauroy J.C. et al., Historical Lyonaise Brace Treatment for Adolescent Hyperkyphosis. Results of 272 cases reviewed 2 years minimum after removal of the brace, Scoliosis, 2010, 5 (1): 069. (Level of Evidence: 1A)
34. Weiss H.R. et al., Kyphosis (Physical and technical rehabilitation of patients with Scheuermann’s disease and kyphosis), International Encyclopedia of Rehabiliation, 2010. (Level of Evidence: 2B)
35. Jang H.J. et al., Effect of thorax correction exercises on flexed posture and chest function in older women with age-related hyperkyphosis, J. Phys. Ther. Sci. 2015, 27(4): 1161–1164 (Level of Evidence: 2B)
36. Wang M.Y. et al., Yoga Improves Upper-Extremity Function and Scapular Posturing in Persons with Hyperkyphosis, J Yoga Phys Ther, 2012, 2(3): 117. (Level of Evidence: 1B)
37. Greendale G.A. et al., Yoga Decreases Kyphosis in Senior Women and Men with Adult-Onset Hyperkyphosis: Results of a Randomized Controlled Trial, J Am Geriatr Soc., 2009, 57(9): 1569–1579. (Level of Evidence: 1B)
38. Kuo Y.L. et al., Sagittal spinal posture after Pilates-based exercise in healthy older adults, PubMed, 2009, 34(10): 1046 – 1051. (Level of Evidence: 2B)
39. Weiss H.R. et al., In-brace corrections in patients with kyphosis using the kyphologic brace. Scoliosis, 2009, 4(2): 061. (Level of evidence: 2B)


see adding references tutorial.