Kyphosis and Flat Back

If the curve corrects when the patient extends the spine or lies flat, it is postural and exercise changes it. If it does not, the vertebrae themselves are wedged and no amount of strengthening will realign them.

The assessment establishes which it is before any programme starts. Promising posture correction to a patient with a structural curve is a common and avoidable dishonesty.

An increasing kyphosis with height loss in an older adult can mean osteoporotic vertebral fractures, often silent ones, so they are looked for rather than assumed 1. The curve alone does not prove them: in a community study of 1,407 adults aged 50 to 96, only 36.2% of men and 36.9% of women with the most pronounced curves had a thoracic vertebral fracture 1. Where fractures are found or suspected, the priority changes entirely: bone density assessment and osteoporosis treatment come first, and the exercise programme is adapted to avoid loaded forward bending.

Spinal traction and end-range manipulation are not used where osteoporosis is established or suspected.

Thoracic extension mobility, strengthening of the spinal extensors and scapular muscles, hip flexor and pectoral flexibility, and retraining how the patient sits and works. Results are measured against a postural assessment rather than against how the patient feels they look.

In adolescents with Scheuermann disease, bracing during growth is a specialist decision and exercise is an addition to it, not a replacement.

Increasing thoracic curvature in later life is often blamed on osteoporotic fractures, yet many of the older adults most affected have no vertebral fracture 2. In a large community study, degenerative disc disease was the finding most often associated with the curve 1.

The assessment therefore covers bone density, fracture risk and back extensor strength, and loaded forward bending is removed from the exercise programme wherever bone is fragile.

Not necessarily. In a population study of 610 women aged 65 to 91, the 10% with the most pronounced curves had lower bone density and had lost more height, but they reported no more back pain or back-related disability than the others 4.

In a study of people with Scheuermann disease followed for an average of 32 years, back pain was more intense than in matched controls, yet they had no more days off work, interference with daily activities or use of pain medication 5. In later life, a larger curve is linked with lower physical function in older women, although most of the studies behind this are cross-sectional and cannot show cause 6.

It can reduce a flexible curve, but the change is often modest. A 2021 meta-analysis of randomised trials found low- to moderate-quality evidence that structured exercise programmes of three months or less reduce thoracic hyperkyphosis, with a much larger effect in younger than in older adults, while in older adults longer programmes were not shown to reduce it 7.

However, a six-month trial in 99 adults aged 60 and over with a curve of at least 40 degrees found that spine strengthening and posture training reduced the Cobb angle by 3.0 degrees more than health education sessions and improved how participants felt about their appearance, but physical function did not differ between the groups 8.