My wife and I were traveling in Bulgaria when she asked me “why does that woman have a bulge in her upper back?” This bulge is technically called thoracic hyperkyphosis and suddenly, we were noticing it everywhere: a young woman holding a baby, and older woman walking with a cane, the taxi driver, the bank teller, on and on. Now, this dowager’s hump is not considered a mark of youth and beauty by most and Quasimodo didn’t woo Esmerelda with his smashing good looks but is this flexing forward of the upper back just as medically harmless as the large wart over Quasimodo’s eye or does it have more severe health implications? Is this curling forward of the upper back just a natural part of aging? Is it genetic destiny? And if having a stooped spine, dowager’s hump, hunchback, gibbous deformity, thoracic hyperkyphosis, hyperkyphotic posture whatever-you-want-to-call-it is a medical problem, is there anything you can do about it?
To answer the above questions I found a systematic review published in 2014 by Symron Bansal Msc, Wendy Katzman DPTsc and Lora Giangregorio PhD titled “Exercise for Improving Age-Related Hyperkyphotic Posture: A Systematic Review.” The authors searched the literature for studies on the effect of exercise on thoracic hyperkyphotic posture in adults age 45 and over. They found thirteen studies that met their criteria, seven of which were randomized controlled trials.
How is Thoracic Hyperkyphotic Posture Measured?
Thoracic hyperkyphotic posture can be measured via the Cobb angle on an x-ray or Debrunner kyphometer (pictured at the top of the page) or with the kyhosis index using a flexible ruler (pictured below). The later is the most accessible way to measure. A kyphosis index of >13 is considered hyperkyphosis . This is not a measurement you can do on yourself, but a physical therapist (or a friend and a trip to the local fabric store to get a ruler) should do the trick.
Source: Reprinted from Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related
hyperkyphosis: its causes, consequences, and management. J Orthop
Sports Phys Ther 2010;40:352-60 with permission of the Academy of Geriatric Physical Therapy . The Geriatric Section of the American Physical Therapy Association sells a DVD on flexible ruler measurement for those who are interested.
How Common is Thoracic Hyperkyphotic Posture?
I don’t have any reason to believe that the bulge we saw in Bulgaria was any more prevalent there than in California and Japan where the average prevalence’s are estimated at 20-40% in older adults [3,4]. The prevalence of hyperkyphotic posture increases rapidly after age 40, especially in women. 
Does it Matter?
The overwhelming answer is yes, thoracic hyperkyphotic posture is an important indicator of health as it has been found to correlated with the following conditions, none of which are positive:
-poor lung function
-reduced quality of life 
-impaired performance in activities of daily living [4,6]
-slower gait, impaired balance and increased sway which can increase fall risk [7,8]
-increased spinal fracture risk [9,10]
-fracture risk in general 
-decreased life expectancy 
What causes thoracic hyperkyphotic posture?
Thoracic hyperkyphosis is the result of a network of interconnected factors which can be placed in one of two main categories: 1) posture and 2) physical impairments. The posture one adopts can worsen the impairments and the impairments make it harder to change one’s posture.
Thoracic hyperkyphosis is essentially a posture of thoracic flexion that becomes more and more difficult to reverse over time. There are many potential reasons a person could adopt a flexed posture and speculation regarding why people adopt this posture include: computer use, holding children and clinical depression. In Bulgaria, we noticed a lot of women holding children on the front of their hips and it seemed like they were using the flexion of their thoracic spines to counter the weight of the child. While there is nothing harmful about adopting this posture for short periods of time, a lifetime of habitual thoracic flexion can lead to the following physical impairments which then make it harder to reverse that posture.
2) Physical Impairments
These are the physical impairments that have been correlated with increased thoracic kyphosis
-weak spinal extensor muscles [13,14,15]
-shortened pectoral and hip flexor muscles 
-thoracic compression fractures and vertebral wedging 
Can it be reversed?
The good news is that exercise can help! Wendy Katzman PT, PTDSc at UCSF developed an exercise program to address the physical measures correlated with thoracic kyphosis and then tested it with an uncontrolled clinical trial. The results showed a significant improvements in usual (−6°±3°) and best kyphosis (−5°±3°) (P3 degrees [18,19].
What You Can Do About It
If you live in the San Francisco Bay Area you can:
-Enroll as a participant in ongoing research on exercise and hyperkyphotic posture at UCSF
–Take the class in San Francisco at the Bakar Center at Mission Bay
-Contact me if you are interested in taking the class in Oakland: email@example.com
If you cannot make it to the class:
-Consult with your physician and physical therapist for objective assessment of your risk of fracture. The following is a quote from a recent consensus statement on exercise in individuals at high risk of fracture:
“Individuals at high risk of fracture should consider consulting a physical therapist with expertise in osteoporosis prior to initiating a new exercise program, and all individuals with osteoporosis should learn how to move safely or take precautions when performing twisting or bending during transitions between movements, when workingwith loads, when performing movements that challenge balance, or when performing activities outdoors in slippery weather.” 
-If your fracture risk is low: Order the Stand Tall DVD and do the exercises. An example of the class is available on vimeo.
– Having a physical therapist measure your kyphosis before starting and again at 3 and 6 months will give you an objective assessment of your progress.
-Be sure to commit a sufficient time period to get results: In the research studies the hour long program was done 2-3x a week for 3-6months.
1. Bansal S, Katzman W, Giangregorio L. Exercise for Improving Age-Related Hyperkyphotic Posture: A Systematic Review. Archives of Physical Medicine and Rehabilitation. January 2014, Vol.95(1):129–140, doi:10.1016/j.apmr.2013.06.022
2. Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related
hyperkyphosis: its causes, consequences, and management. J Orthop
Sports Phys Ther 2010;40:352-60.
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