THORACIC HYPERKYPHOSIS

What is Thoracic Hyperkyphosis?

As we all have learnt about the evolution of man, how we all use to walk on all 4s (Quadruped stance) and over the period of years of evolution in human race we started walking on our two legs (Bipedal stance). As the evolution took place and our species evolved, our spine slowly started to develop to allow for a straighter, more upright posture. Our spine curvature today is in proper alignment and maintains ‘S’ shape curvature. Normal thoracic kyphosis maintains this ‘S’ shape whereas in thoracic hyperkyphosis this ‘S’ shape spine gets disturbs and becomes a ‘C’ shape.

Thoracic Hyperkyphosis is also known as hunch back.

The normal thoracic kyphosis angle in the younger population is in between 20 degrees to 40 degrees. Thoracic curvature greater than 40 degrees considered to be a hunch back or thoracic hyperkyphosis {1} .

Whereas in older population the normal thoracic kyphosis Cobb’s angle is 48 degrees to 58 degrees in females and in males it usually 44 degrees {2} .

Whenever there is an excessive load on your spine like prolonged standing unsupported sitting etc., the thoracic region take the maximum load. Due to these bending forces on the spine there is excessive load on the soft tissues like ligaments and muscles {3} .

What causes thoracic kyphosis?

Age related changes- the thoracic angle increases with age; it is 50% in men and 65% in females above 65 years of age. Increase in thoracic kyphosis may typically due to osteoporosis and degeneration in the spine due to age but studies suggests that up to 70% of patients with age-related hyperkyphosis do not suffer from decreased bone mineral density {4} .

Poor Posture-

Weakness in upper back and shoulder blade muscles resulting in poor posture may also result in hyperkyphosis at the thoracic level. People who have sedentary jobs which demands prolonged sitting in front of laptop or desktop are more prone to kyphosis.

A study done to analyze posture of Fibromyalgia syndrome (FMS) in women compared with healthy subjects to establish if posture assessment could be useful to characterize the syndrome. The study concluded that FMS female population present an altered trunk posture and an inability to maintain trunk position. Since this does not appear to be influenced by a more or less active lifestyle, specific treatment programs are needed to manage this clinical

condition {5} .

Daily activities with poor posture e.g. protruding head positions and loss of shoulder range induced by: slouched sitting; ill-fitting school desks; overloaded backs, and backpacks {5} .

Congenital (At birth defect) causes- There can be a bone defect present in the thoracic spine at birth resulting in increasing in the Cobb’s angle {6} . As the age increase so as the hunch back.

The common type of kyphosis present at birth which worsens by age is Scheuermann’s kyphosis (SK).The true cause of SK remains unclear; however, various theories include growth irregularities, mechanical factors, genetic factors, and/or poor bone quality as the causes {7} .

Kyphosis can be a result of Scoliosis. A study was done to determine the different risk factors for development of proximal junctional kyphosis (PJK) in patients with adult scoliosis, this study concluded that increased age, as well as increased body mass index, is a risk factor for the development of PJK. The proximal extent of the construct is also shown to be a risk factor for PJK, but fusion to the sacrum is a risk factor only if fusion extends to the proximal (Thoracic spine)TS. Moderate PJK was observed with under correction of the

sagittal balance and severe PJKs with overcorrection of the sagittal balance {8} .

What are the symptoms?

The common symptom in kyphosis is the hunch back or round back. Back pain, muscle fatigue and weakness in the upper back and scapular muscles may be present. In rare cases, kyphosis can lead to compression of the spinal cord with neurologic symptoms including loss of sensation in the upper limbs, or loss of bowel and bladder control.

Severe cases of thoracic kyphosis can also limit the amount of space in the chest due to the tightness in the anterior chest muscles and cause cardiac and pulmonary problems leading to chest pain or shortness of breath with eventual pulmonary and/or heart failure.

How to manage thoracic kyphosis?

Medical management- Antiresorptive or bone building medications can be prescribed to the patients with kyphosis. Antiresorptive type of medications helps in slowing or blocking reabsorption of bone.

Surgical interventions like Osteotomy, vertebroplasty or kyphoplasty can be depending upon the severity of the condition.

Physiotherapy management- the first approach while managing the kyphosis should be physiotherapy which may include Thoracic manual therapy, upper back scapular muscle strengthening exercises, tapping, bracing, breathing exercises and self stretching techniques.

Thoracic mobilization techniques using Original Kaltenborn concept wedge used to mobilize the thoracic spine in the patients with thoracic hyperkyphosis {9} .

Upper back and scapular muscle strengthening exercise to manage the muscular weakness.

Kyphosis is becoming more common due to our modern lifestyle and our longer life expectancy. Taking precaution at a younger age can help prevent formation of Kyphosis. Once the hyperkyphosis develop there are ways to reverse the changes at the spinal level thus improving the posture and thus slowing down the long term effects of the condition. .

References-

1] Fon GT, Pitt MJ, Thies Jr AC. Thoracic kyphosis: range in normal subjects. American Journal of Roentgenology. 1980 May 1;134(5):979-83.

2] Kado DM, Prenovost K, Crandall C. Narrative review: hyperkyphosis in older persons. Annals of internal medicine. 2007 Sep 4;147(5):330-8.

3] Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Manual therapy. 1997 Aug 1;2(3):132-43.

4] Perriman DM, Scarvell JM, Hughes AR, Lueck CJ, Dear KB, Smith PN. Thoracic hyperkyphosis: a survey of Australian physiotherapists. Physiotherapy Research International. 2012 Sep;17(3):167-78

5] Sempere-Rubio N, Aguilar-Rodríguez M, Espí-López GV, Cortés-Amador S, Pascual E, Serra-Añó P. Impaired Trunk Posture in Women With Fibromyalgia. Spine (Phila Pa 1976). 2018;43(22):1536-1542. doi:10.1097/BRS.0000000000002681.

6] de Mauroy JC. Kyphosis physiotherapy from childhood to old age. InPhysical Therapy Perspectives in the 21st Century-Challenges and Possibilities 2012 Apr 5. IntechOpen.

7] Sardar ZM, Ames RJ, Lenke L. Scheuermann's Kyphosis: Diagnosis, Management, and Selecting Fusion Levels. J Am Acad Orthop Surg. 2019;27(10):e462-e472. doi:10.5435/JAAOS-D-17-00748.

8] Sebaaly A, Sylvestre C, El Quehtani Y, et al. Incidence and Risk Factors for Proximal Junctional Kyphosis: Results of a Multicentric Study of Adult Scoliosis [published correction appears in Clin Spine Surg. 2018 May;31(4):184]. Clin Spine Surg. 2018;31(3):E178-E183.

doi:10.1097/BSD.0000000000000630.

9] Hwangbo PN, Hwangbo G, Park J, Lee S. The Effect of Thoracic Joint Mobilization and Self-stretching Exercise on Pulmonary Functions of Patients with Chronic Neck Pain. J Phys Ther Sci. 2014;26(11):1783-1786. doi:10.1589/jpts.26.1783