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.
Father holding child in thoracic hyperkphotic posture. Source: Getty Embeded Images.
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: firstname.lastname@example.org
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.
3. Kado DM, Huang MH, Karlamangla AS, Barrett-Connor E,
Greendale GA. Hyperkyphotic posture predicts mortality in older
community-dwelling men and women: a prospective study. J Am
Geriatr Soc 2004;52:1662-7.
4. Takahashi T, Ishida K, Hirose D, et al. Trunk deformity is associated
with a reduction in outdoor activities of daily living and life satisfaction
in community-dwelling older people. Osteoporosis Int 2005;16:273-9.
5. Teramoto S, Suzuki M, Matsuse T, et al. [Inﬂuence of kyphosis on
the age-related decline in pulmonary function] [Japanese]. Nihon
Ronen Igakkai Zasshi 1998;35:23-7.
6. Ryan SD, Fried LP. The impact of kyphosis on daily functioning. J
Am Geriatr Soc 1997;45:1479-86.
7. Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and risk of injurious falls in
older persons: the Rancho Bernardo Study. J Gerontol A Biol Sci
Med Sci 2007;62:652-7.
8. Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR. Balance
disorder and increased risk of falls in osteoporosis and kyphosis:
significance of kyphotic posture and muscle strength. Osteoporosis
9. Bartynski WS, Heller MT, Grahovac SZ, Rothfus WE, Kurs-
Lasky M. Severe thoracic kyphosis in the older patient in the absence
of vertebral fracture: association of extreme curve with age. Am J
10. Huang MH, Barrett-Connor E, Greendale GA, Kado DM. Hyper-
kyphotic posture and risk of future osteoporotic fractures: the Rancho
Bernardo Study. J Bone Miner Res 2006;21:419-23.
11. Kado D, Miller-Martinez D, Li-Yung L, Cawthon P, Katzman W, Hillier T, Fink H, Ensrud K. Hyperkyphosis, Kyphosis Progression, and Risk of Non-Spine Fractures in Older Community Dwelling Women: The Study of Osteoporotic Fractures (SOF). J Bone Miner Res 2014; This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: [10.1002/jbmr.2251]
12. Ensrud KE, Black DM, Harris F, Ettinger B, Cummings SR. Correlates of kyphosis in older women. The Fracture Intervention Trial Research Group. J Am Geriatr Soc. 1997;45:682–687.
13. Itoi E, Sinaki M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc. 1994; 69: 1054– 1059.
14. Sinaki M, Itoi E, Rogers JW, Bergstralh EJ, Wahner HW. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil. 1996; 75: 370– 374.
15. Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10-year follow-up of post-menopausal women. Bone. 2002; 30: 836– 841.
16. Balzini L, Vannucchi L, Benvenuti F, et al. Clinical characteristics of flexed posture in elderly women. J Am Geriatr Soc. 2003; 51: 1419– 1426.
17. Katzman WB, Sellmeyer DE, Stewart AL, Wanek L, Hamel KA. Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil. 2007; 88: 192– 199.http://dx.doi.org/10.1016/j.apmr.2006.10.033
18. Bennell KL, Matthews B, Greig A, et al. Effects of an exercise and
manual therapy program on physical impairments, function and
quality-of-life in people with osteoporotic vertebral fracture: a rand-
omised, single-blind controlled pilot trial. BMC Musculoskelet
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tation using manual mobilization for thoracic kyphosis in elderly
postmenopausal patients with osteoporosis. J Rehabil Med 2010;42:
20. Canales JZ1, Cordás TA, Fiquer JT, Cavalcante AF, Moreno RA. Posture and body image in individuals with major depressive disorder: a controlled study. Rev Bras Psiquiatr. 2010 Dec;32(4):375-80.
21. Giangregorio L, Papaioannou A, MacIntryre J, Ashe M, Heinonen A, Shipp K, Wark J, McGill S, Keller H, Jain R, Laprade J, Cheung A. Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporos Int (2014) 25:821–835
Excellent review with helpful tips! I also wonder about the relationship between increased thoracic kyphosis and shoulder injuries–rotator cuff tears and impingement, specifically. These actions seem to require thoracic extension in order for the kinematics of the shoulder joint to be efficient. Thoughts?
There is almost certainly some relationship. The question is whether it os strong enough to show up statistically.
The population I would look study for this relationship would be baseball pitchers woth scheumann’s disease. Both rotator cuff tears and kyphosis increase woth age so I think you would find a correlation there but they both may be symptoms of again and you couldn’t be sure of causation.
Great posture review. People need to take their posture more seriously – its a very big issue. That being said – exercise is the best way – seriously the only way to reverse the hunch and achieve strong posture for life. I use the perfectore posture transformer to work long hours in front of the computer. Its like a wearable exercise system that also will give you great support. I think everyone should have one – its a life saver.
Do you have any evidence to support the efficacy of your wearable device?
This is a bit in a different direction, but some people (like me!) have the opposite postural pattern, and I’ve always mildly envied others’ ability *to* hunch.
I have very straight upper spinal posture (“are you a dancer?” Uh.. No, I’m just stuck like this), with great difficulty in upper back flexion.
Ultimately, we want freedom in range of motion, so although I don’t see any obvious health problems with “straight back”, it does inhibit movement. Plane and bus seats always make me feel like I’m being forced into an uncomfortable hunch.
I wonder, too, about the possible psychological causes and effects of being hunchy vs being too straight.
Followup article, for the straight backs, please! 🙂
I have seen a fair number of straight upper backs in the clinic, they run into problems in sports like rowing and cycling where thoracic flexion can be used to spare lumbar flexion (disc herniation is rare in the former but painfully common in the latter). It seems treatable though I haven’t come across any research on it directly.