Hypercifosis: Symptoms, Diagnosis, Clinical Consequences, Causes and Treatment

It is the term given to an accentuated thoracic spinal curvature.

Age-related postural hyperkyphosis is an exaggerated anterior curvature of the thoracic spine, sometimes referred to as a hump or Dowager gibbous deformity .

This condition affects mobility and increases the risk of falls and fractures. The natural history of hyperkyphosis is not firmly established.

Hyperkyphosis can develop from muscle weakness and degenerative disc disease, which leads to vertebral fractures and worsening of hyperkyphosis, or from initial vertebral fractures that precipitate its development.

It is also possible that different individuals develop the same magnitude of hypercyphosis of different processes, some of vertebral fractures and others of muscular weakness, degenerative disc disease or other genetically determined processes.

However, there are significant negative consequences of hyperkyphosis, and early intervention and treatment of hyperkyphosis can have important clinical and public health benefits.

While a small amount of anterior curvature of the thoracic spine is normal and present due to the shape of the vertebral bodies and intervertebral discs, an angle of kyphosis greater than 40 °, which is the 95th percentile of the normal for young adults , is defined as hyperkyphosis.

Hyperkyphosis in children is usually due to the disease known as “Scheuermann’s kyphosis” or may be postural (wedging of 3 or more vertebral bodies and discs). In children, a thoracic curve greater than 50 ° is called “hyperkyphosis”.

In childhood and during the third decade of life, the kyphosis angle averages from 20 ° to 29 °. After 40 years, the angle of kyphosis begins to increase, more rapidly in women than in men, from an average of 43 ° in women aged 55 to 60 years to an average of 52 ° in women aged 76 to 80 years.

Reports of prevalence and incidence of hyperkyphosis in older adults vary from approximately 20% to 40% between men and women. As the kyphosis angle increases, physical performance and quality of life often decrease, which makes early intervention for hyperkyphosis a priority.

Hyperkyphosis in adults can have many contributing factors, the most notable being vertebral fractures and / or osteoporosis, as well as posture. In adults, a thoracic curve above 60 ° is generally classified as “hyperkyphosis”.

Signs and symptoms of hyperkyphosis

The most prominent symptom you can notice is the appearance of a rounded back. You may not recognize a change in back position at the beginning because the change is gradual over time in most cases. Your friends and family can notice it before you.

You may notice a sudden increase in a rounded back. In this case, consult your doctor, since a sudden change in the curve of the spine may be associated with other health problems.

If the hyperkyphosis is not treated, people may have difficulty performing normal tasks, such as bathing, getting out of a chair, bending or walking. They can also experience balance changes that can lead to falls and injuries.

In some cases, back pain may also be associated with curvature; Some people may experience spinal fractures as the condition progresses. When there is hyperkyphosis, you may notice that you are:

  • Having difficulty getting out of a chair, getting out of bed or getting out of the bathtub.
  • Walk more slowly
  • Feeling “unbalanced” and / or losing balance or almost falling.
  • Feeling more tired than normal (fatigue).
  • Having difficulty breathing (in more severe cases).

How is it diagnosed?

Hyperkyphosis will be evaluated first with a visual inspection of your back. Your spinal curve can be measured with a flexible ruler or x-ray. If an x-ray is taken, a radiologist will measure the spinal angles on the x-ray. If a curve measures more than 40 degrees, hypercryosis is diagnosed.

Sometimes, spinal changes occur due to fractures due to a thinning of the bones or a condition called osteoporosis. Spinal changes can also be the result of a degenerative disc disease or arthritis. These problems are commonly associated with aging.

Other problems not associated with aging can also cause a sudden change in posture; however, problems such as tumor, infection or neurological changes are rare.

Your doctor may prescribe imaging tests such as x-rays or magnetic resonance imaging of the thoracic spine to determine if you have any of these less common conditions that affect your posture.

If you have advanced hyperkyphosis, you may experience difficulty breathing even if you have no history of lung or heart disease. You may also notice that there is a decrease in the distance between the lower ribs and the bones of the pelvis.

In this case, pulmonary function tests may be prescribed to measure whether your hyperkyphosis is restricting your breathing.

Clinical consequences

Functional limitations

Excessive kyphosis has detrimental effects on physical performance, the ability to perform activities of daily living and the quality of life in general.

Women with a hypercrotic posture demonstrate difficulty getting up from a chair repeatedly without using their arms, significantly poorer balance and slower walking speed, more support base with posture and gait, and decreased climbing speed that have been associated with an increased risk of falls.

In addition, osteoporotic women with hyperkyphosis have a greater mastery of posture compared to those with a normal posture.

Hyperkyphosis is also associated with self-reported decline in physical functioning. Women with hyperkyphosis report greater difficulty in reaching and performing heavy household tasks and score lower in the basic activities of the daily life scale compared to their peers.

Musculoskeletal disorders

As kyphosis increases, there are concomitant alterations in the alignment of the normal sagittal plane that can cause pain and risk of dysfunction in the shoulder and pelvic girdle, and in the cervical, thoracic and lumbar spine.

Forward head posture, scapular protraction, reduced lumbar lordosis, and decreased foot height are often associated with hyperkyphosis.

These postural changes increase the bending bias around the hip and shoulder joints that can interfere with the mechanics of the normal joint and movement patterns.

Hyperkyphosis is a significant risk factor for future vertebral and extremity fractures.

Older women with hyperkyphosis have a 70% higher risk of future fracture, regardless of age or a previous fracture, and the risk of fracture increases as hyperkyposis progresses.

Quality of life

Women with hyperkyphosis report more physical difficulties, more adaptations in their lives and more generalized fears than women without hyperkyphosis.

In addition, men and women living in the community who are 65 years old or older with hyperkyphosis report worse satisfaction with subjective health, family relationships, economic conditions and their lives in general.

Mortality

The hyperchromic posture has been associated with higher mortality, with higher mortality rates associated with the severity of kyphosis.

The reduction of vital capacity is associated with hyperkyphosis, and severe hyperkyphosis is predictive of lung death among women living in the community.

Women in the highest quartile of kyphosis were more likely to die of lung death compared to those in the lower quartiles of kyphosis.

Two recent cohort studies confirm these adverse health effects of hyperkyphosis even after adjusting for vertebral fractures and bone mineral density.

Causes

The causes of hyperkyphosis have not yet been fully elucidated. However, musculoskeletal, neuromuscular and multiple sensory impairments are significant predictors of age-related hyperkyphosis.

Vertebral fractures

Kyphosis increases with the number of vertebral fractures and is more related to thoracic fractures than to lumbar fractures. Hyperkyphosis is more prominent in women with multiple thoracic anterior wedge fractures.

Women without vertebral fractures, who have a higher degree of kyphosis, are more likely to suffer a posterior vertebral fracture.

Biomechanical models of stress loading in the spine suggest that forces applied to the osteoporotic spine during daily life can cause vertebral wedges and compression fractures.

The severity of wedging increases as bone mineral density decreases, resulting in a greater number of vertebral compression fractures and an additional cascade of increasing hyperkyphosis.

Degenerative disc disease

Many people believe that vertebral fractures are the underlying cause of age-related hyperkyphosis, although studies in older adults report that only about 40% of men and women with more severe hyperkyphosis have vertebral compression or wedge fractures.

A common radiographic finding associated with hyperkyphosis among older adults is degenerative disc disease.

In a study of healthy women aged 39 to 91 years, there was a significant correlation between the height of the anterior disc and the angle of kyphosis (r = -0.34, P <.001); as the height of the previous disc decreased, the kyphosis angle increased.

Others have reported that the majority of adults aged 50 to 96 years with hyperkyphosis had degenerative disc disease and had no evidence of vertebral fractures or osteoporosis, suggesting that hyperkyposis does not predict fractures or osteoporosis.

However, a strong association between the relationship of anterior to posterior height of the vertebral body and the angle of kyphosis suggests that it is the combined influence of degenerative disc disease and anterior vertebral deformities that explains the significant variation in kyphosis.

Muscular weakness

Several studies confirm that hyperkyphosis is associated with weakness of the spinal extensor muscle. In healthy postmenopausal women, the strength of the spinal extensor muscles is inversely related to kyphosis (r = -0.30, P = .019).

There is also an inverse relationship between grip and strength of the ankle and kyphosis, 2 suggesting that age-related hyperkyphosis may be part of a major geriatric syndrome associated with adverse health outcomes that adversely affect physical function.

Decreased mobility

The decreased mobility of the spinal extension occurs with aging, which interferes with the ability to stop and maintain a normal postural alignment.

The studies of corpses suggest that calcification and ossification of the anterior longitudinal ligament in the thoracic region could contribute to the increase of the angle of kyphosis of Cobb .

In addition, the flexor muscles of the pectoral and hip muscles are related to severe hyperkyphosis, although it is not known if short muscles pull the shoulders and hips previously, or if the kyphotic posture results in a shorter anterior musculature. .

It is likely that there are other muscular, ligamentous, connective tissue and joint alterations that have not been identified.

Sensory deficits

Age-related deficits in the somatosensory, visual and vestibular systems probably contribute to the loss of vertical postural control.

With a loss of proprioceptive and vibratory input from the joints in the lower extremities in older adults compared to young adults, the perception of upright vertical alignment deteriorates.

Similar decreases occur in the visual system with aging, and the primary diseases related to age in the eyes, including cataracts and macular degeneration, aggravate the decrease in visual acuity.

The position of head nodding was found to be greater during locomotion for normal elderly compared to young adults, and increased even more among older adults who wore bifocals during descent of the ladder.

In addition, age-related sensory loss in the vestibular system increases reliance on already diminished visual and somatosensory cues, and may further affect vertical postural alignment.

Treatment of hyperkyphosis

There is a lack of effective medical interventions for hyperkyphosis. Physiotherapy should be a first-line approach, particularly because many of the causes of hyperkyphosis are of musculoskeletal origin.

The recognition and treatment of hyperkyphosis could help reduce the risk of falls, fractures and functional limitations. Several physical therapy interventions aimed at reducing hyperkyphosis are currently available.

Medications and surgery

Many men and women with prevalent hyperkyphosis are treated with antiresorptive osteoporosis or bone formation drugs because they have low bone density or fractures of the spine.

While treatment of osteoporosis helps prevent incident spinal fractures, no medication has been shown to improve hyperkyphosis.

Vertebroplasty and kyphoplasty are surgical procedures that are used primarily to treat refractory pain after a vertebral fracture, and have been shown to reduce the angle of kyphosis only in populations of selected patients.

However, evidence suggests that physical disability and pain relief may improve after vertebroplasty and kyphoplasty compared to medical treatment, but only within the first 3 months after the intervention.

In addition, recent evidence from 2 randomized controlled trials suggests that clinical improvement in physical disability and pain is similar among patients undergoing vertebroplasty, compared with the sham procedure for painful vertebral fractures, at 1-month follow-up and 6 months.

High-quality randomized trials with long-term follow-up are needed to investigate the benefits of these procedures in posterior vertebral fractures.

No study has investigated the effects on kyphosis of combination treatment with medications, surgical interventions and physical therapy interventions.

Exercise: indications and contraindications

Sinaki et al’s seminal research suggests that forces applied to the spine during exercise can alter the appearance of posterior vertebral compression fractures in women with a previous fracture.

In this study, 68% of the women who performed flexion exercises developed a posterior fracture in the following 6 months, compared to only 16% of those who did extension exercises, suggesting that the flexion exercises increase the risk of fracture.

In addition, conceptual models of spinal load suggest that flexion stress in the spine increases the risk of fractures when underlying bone strength deteriorates and may partially explain why older women with hyperkyphosis have an increased risk of future fractures regardless of the age or previous fracture.

Therefore, it is important to train people with age-related hyperkyphosis to avoid flexion stresses in the spine during exercise and activities of daily living, regardless of whether they have had a previous fracture.

In addition, training that uses trunk stabilization should avoid curling exercises to reduce flexion bias in the spine.

Therapy / manual mobilization

Three case reports suggest that myofascial, spinal and scapular mobilization techniques improve postural alignment in patients with hyperkyphosis.

Physiotherapists reported decreased kyphosis after myofascial mobilization, neurodevelopment, spinal cord and scapular soft tissue and active therapeutic movement techniques. These techniques have not been subjected to a rigorous evaluation in clinical trials.

Therapeutic exercise, such as self-mobilization in supine position on a foam roller, has been successfully used in a multidimensional exercise program that reduced kyphosis in hypercritical women. This type of self-mobilization technique can be applied appropriately in this population.

A physiotherapist can help rehabilitate the postural changes and functional limitations associated with hyperkyphosis.

Your physiotherapist will start by reviewing your past and present medical history with you, as well as what medications you normally take. If you report a sudden change in your posture, severe pain, or a significant change in your physical function, you will be referred to your primary care physician.

A sudden increase in rounding of the back may indicate a more serious health problem. When a more serious problem is ruled out, your physiotherapist will perform special tests to evaluate your unique condition.

The therapist will begin by observing, measuring and recording their postural alignment, trunk strength, range of motion and flexibility in movement. He or she can also measure your spinal curve with a special rule.

If you have difficulty walking or maintaining balance, your therapist will watch your movement and perform tests to determine the level of difficulty and if you have a higher risk of falling.

Your physiotherapist can help you with a variety of treatment options, including specific exercises to help reduce kyphotic posture and decrease pain.

Training of postural alignment, stretching and strengthening exercises to help reduce the curvature and prevent the condition from progressing. The exercises will emphasize the strength of the upper back, as well as the strength of the shoulder and hips.

Breathing exercises to help improve your tolerance to physical activity by increasing your lung capacity.

Pain management using modalities such as heat, ice and / or electrical stimulation such as transcutaneous electrical nerve stimulation. Your physiotherapist will help you choose the modality that is most useful to you.

Manual myofascial / soft tissue therapy (using practical techniques) and mobilization of the shoulder to help improve spinal flexibility.

Education to improve their activities of daily life and facilitate their physical functioning. The physiotherapist can teach you how to get in and out of bed safely, in and out of the bathtub, or a chair, and how to lean and walk more easily.

Balance exercises and walking training to increase your activity tolerance and improve your safety by reducing the risk of falls.

Remember, all cases of hyperkyphosis are different. Your physiotherapist will choose the best treatment options for you based on your evaluation of your specific problem.

Orthopedic devices

Although orthoses appear to be beneficial, passive braces do not provide the beneficial effects of exercise on bones. Although not yet studied, the use of bracings in combination with therapeutic exercises can provide an additional beneficial effect.

The spinal-weighted kyphosis orthosis is another bracing alternative for hyperkyphosis. According to reports, this lightweight vest device improves balance and reduces pain among women with osteoporotic hyperplasia.

Neuromuscular bandage

The therapeutic bandage can also reduce the angle of kyphosis according to preliminary research in 15 women with osteoporotic vertebral fractures; those with the largest initial kyphosis had the greatest reduction in kyphosis with the therapeutic bandage.

Bandaging during static 40-second individual tasks reduced the kyphosis angle immediately after the tasks, compared to the simulated or unbanded dressing.