Research Review By Dr. Joshua Plener©


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Date Posted:

June 2022

Study Title:

Decreasing thoracic hyperkyphosis – Which treatments are most effective? A systematic literature review and meta-analysis


Jenkins H, Downie A, Fernandez M & Hancock MJ

Author's Affiliations:

Departments of Chiropractic and Health Professions, Macquarie University, Sydney, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, Brisbane, Australia

Publication Information:

Musculoskeletal Science and Practice 2021; 56:102438

Background Information:

Average thoracic kyphosis angle ranges between 20 to 45 degrees, with increases seen in females and in older adults (1). Thoracic hyperkyphosis is defined as an increase in the thoracic curvature beyond 40 degrees, which ranges in incidence between 20-40% in the general population (2). Underlying pathologies can result in hyperkyphosis such as Scheuermann’s kyphosis and osteoporosis, but many cases of hyperkyphosis are idiopathic or due to age-related changes (3). Age related changes in thoracic kyphosis can be a result of spinal degenerative changes, lack of mobility, and/or reduced postural muscle strength (3).

Hyperkyphosis is often associated with poor posture, including forward head posture and rounded shoulders (4). There are conflicting findings relating to the clinical importance of thoracic hyperkyphosis, such as the potential associations with increased pain, lack of mobility or function, poor balance, reduced quality of life, increased risk of falls and increased risk of osteoporotic fractures (3).

Many treatments have been used to treat thoracic hyperkyphosis including exercise, manual therapy, bracing, and surgery. The aims of this systematic review and meta-analysis are to:
  1. Describe conservative interventions that have been assessed to reduce thoracic hyperkyphosis; and
  2. assess and synthesize the effectiveness of individual conservative interventions to reduce thoracic hyperkyphosis.

Pertinent Results:

6637 studies were identified, with 96 full text articles assessed for eligibility and ultimately 28 being included in the final review. Eighteen studies targeted populations over 55 years of age or with a higher risk of osteoporosis (10 studies used younger study populations). Thoracic kyphosis was assessed using external measures in the majority of studies, with four studies employing radiographic measurements.

Exercise was the most common intervention to be assessed (in 21 studies), with programs ranging from simple stretching exercises to strengthening exercises, and most included strength and flexibility exercises targeting the thoracic spine. Four studies used rigid bracing for 3 to 6 months to improve upright posture and reduce thoracic hyperkyphosis. Multimodal therapy was performed in 4 studies consisting of exercise combined with manual therapy and/or taping. There were also single studies assessing taping, electrical stimulation, or biofeedback training in isolation.

Five meta-analyses were conducted across 17 studies:
  1. There is low quality evidence that a structured strengthening and flexibility exercise program of three months or less duration in a younger population has a large effect in reducing thoracic hyperkyphosis.
  2. There is moderate quality evidence that a structured strengthening and flexibility exercise program of three months or less duration in an older population has a small effect in reducing thoracic hyperkyphosis.
  3. There is low quality evidence that a structured strengthening and flexibility exercise program of more than three months duration in an older population is not effective in reducing thoracic hyperkyphosis.
  4. There is low quality evidence that bracing of more than three months duration in an older population has a large effect in reducing thoracic hyperkyphosis.
  5. There is low quality evidence that multimodal therapy of three months or less duration in an older population is not effective in reducing thoracic hyperkyphosis.

Clinical Application & Conclusions:

This review found moderate-quality evidence that short-term (less than 3 months), structured exercise programs in older adults have a small effect in reducing thoracic hyperkyphosis and there is low-quality evidence that short term structured exercise programs in younger adults and bracing in older adults have a large effect in reducing thoracic hyperkyphosis. Structured exercise programs of over three months duration and multimodal care with manual therapy and exercise did not show evidence of effectiveness in older adults. In single studies, multimodal care was effective in younger adults and other interventions including electrical stimulation of muscles, biofeedback training, taping and home-based exercise programs were not effective.

This review provides low to moderate quality evidence that short term structured exercise programs of up to 3 months should be considered as a treatment option to reduce thoracic hyperkyphosis in both younger and older adults. Generally, the exercise programs consisted of structured, (physio)therapist supervised programs performed one to four times per week, combining thoracic strength/stabilization and mobility/flexibility exercises. Exercise should be used as the initial treatment option, with bracing utilized if exercise is unsuccessful.

As you may have noticed, there is a general paucity of literature pertaining to the specific role of manual therapy (including chiropractic care) in reducing thoracic hyperkyphosis in both older and younger patients. Exercise as a primary pillar of this treatment approach is logical, but the potential complimentary nature of manual therapy interventions for this purpose requires further study.

There is still uncertainty if improving thoracic hyperkyphosis is clinically relevant. Future studies investigating the relationship between changes in hyperkyphosis and changes in clinical symptoms are important to further inform clinical practice.

Study Methods:

MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to March 2021 using terms related to kyphosis or spinal curvature, thoracic spine, treatment, and randomized controlled trial(s).

The inclusion criteria were:
  • Full-text articles of randomized controlled trials
  • Adults aged 18 years of age with hyperkyphosis with a mean kyphosis angle at baseline greater than 40 degrees
  • Participants with osteoporosis with or without osteoporotic compression fractures
  • Any conservative interventions aimed to reduce thoracic hyperkyphosis
Studies were excluded if thoracic hyperkyphosis was secondary to acute traumatic injury or underlying serious pathology.

The Cochrane Risk of Bias tool was used to assess risk of bias. This tool assesses selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias. GRADE was used to assess the quality of the evidence.

Study Strengths / Weaknesses:

  • All conservative interventions were included in this review.
  • To address the wide variation of outcome measures, standardized mean differences were used in meta-analyses.
  • All outcome measures included in this review demonstrated validity and inter-rater reliability for the measurement of thoracic kyphosis.
  • There was a small number of studies for some intervention comparisons, limiting conclusions that can be made.
  • The strength of evidence was downgraded for a variety of reasons such as imprecision and publication bias.

Additional References:

  1. Fon GT, Pitt MJ, Thies AC. Thoracic kyphosis: range in normal subjects. Am J Roentgenol 1980; 134: 979–983.
  2. Kado DM, Prenovost K, Crandall C. Narrative review: hyperkyphosis in older persons. Ann Intern Med 2007; 147: 330–338.
  3. Roghani T, ZaviehMK, Manshadi FD, et al. Age-related hyperkyphosis: update of its potential causes and clinical impacts—narrative review. Aging Clin Exper Res 2017; 29: 567–577.
  4. Singla D, Veqar Z. Association between forward head, rounded shoulders, and increased thoracic kyphosis: a review of the literature. J Chiro Med 2017; 16: 220–229.

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