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Introduction

Postural changes are a very common phenomenon with advanced age.1,2 Changes in the thoracic spine with advanced age contribute to hyperkyphosis, the exaggeration of the anterior curvature of the thoracic spine is known as hyperkyphosis. The prevalence of hyperkyphosis is 20 to 40 percent in the elderly population.3,4 Increasing thoracic kyphosis leads to limit spinal mobility, reduces pulmonary functions, affects balance, decreases physical performance, and affects the quality of life.3,5 Hyperkyphosis is associated with morbidity and mortality in older elders.3,6,7 Quantitative measurement is essential for the evaluation of hyperkyphosis. So early detection can limit the advancement of hyperkyphosis posture in older adults.

Although in past years different postural assessment tools were developed for kyphosis assessment like radiographic method, flexicurve, debrunner kyphometer, gravity-dependent inclinometer, tragus to wall distance, block method, occiput-to- wall (OTW), photographic method, and spinal mouse, yet there was no clear agreement on assessment method, suited best for determining hyperkyphotic posture.3 The radiological method is considered the gold standard for determining the cobb’s angle, but its radiation effects, discourage the use of the radiographic method.8 There were no clear defining criteria for hyperkyphosis.5,9 The objective of this review is to provide a comprehensive overview of methods and equipment used to determine hyperkyphosis in the elderly population.

Methods

The PubMed, Cochrane Library, Google Scholar, Research Gate, Scopus, and Education Resources Information Center (ERIC), databases were searched with the combination of the following keywords was used: kyphosis OR hyperkyphosis OR spine, OR posture, OR flexed posture, AND assessment, OR measurement, AND elders, OR older adults, OR elderly. Inclusion criteria were as follows: (1) The studies must have older adults aged ≥ 60 years; (2) studies must be published in the English language; (3) studies must include hyperkyphotic subjects. Exclusion criteria were as follows: (1) studies were not included if no measurement tool was used for the measurement of hyperkyphosis; (2) studies were excluded if hyperkyphosis is congenital or not age- related hyperkyphosis; (3) the systematic review, case reports, and narrative reviews were also excluded. This literature review examines the methods used in the last two decades for kyphotic posture assessment in older adults aged ≥ 60 years.

After removing duplicate studies, two independent reviewers performed a screening of titles and abstracts. Full-text studies were reviewed based on the inclusion criteria. Relevant studies were selected for this review. The disagreements were resolved by discussion. The identification and selection of studies are summarized in Figure 1.

Figure 1: Flow chart for studies selection

Results and Discussion
The electronic database search produced 4166 studies. One hundred fifty relevant studies were identified through reading titles and abstracts. Twenty-six studies were selected after complying with inclusion criteria and exclusion criteria. The characteristics of selected studies are summarized in Table 1.
Of all 26 studies included in this review, The age of the participants varied from 60 years to 88 years.

The angle of thoracic kyphosis ranged from 40° to 50° as a cut-off angle for defining hyperkyphosis. Lateral radiographic, Flexicurve ruler, Debrunner kyphometer, Gravity-dependent inclinometer, Tragus to wall distance (TWD), Occiput-wall distance (OWD), Block Method, and Spinal Mouse device are the methods used in the selected studies for the measurement of posture. The reliability and validity of methods used for kyphosis assessment are described in Table 2.

Table 1: Summary of selected studies

Lateral spine radiographic

The Lateral spine radiographic method is considered a gold standard tool for the measurement of kyphosis.8 For taking an X-ray for kyphosis, one must stand straight barefoot, both knees straight, and take full inspiration during the lateral scan. Two lines are drawn, first from the superior endplate of the 4th thoracic vertebrae and the second one from the inferior endplate of the 12th thoracic vertebrae, and the angle formed in between the two perpendiculars on these lines is considered as cobb’s angle.19 The greater the angle of kyphosis, the more the severity of kyphosis. This method has high interrater and intrarater reliability reported so far, although the limitation of the radiographic method is radiation exposure.5

Flexicurve ruler

Flexicurve is one of the simplest non-invasive method used for the assessment of posture in elders.36 A flexicurve ruler is 50 cm in length and 2 cm wide and it is used to determine the kyphosis index. For the measurement, two anatomical landmarks are marked on the dorsal spine, and then a semi-flexible ruler takes the shape of the 

curvature of the spine after the curve is recreated on paper to determine the angle of the thoracic kyphosis. For measurement one stands still in a comfortable position, legs should be apart, and then flexicurve placed on the exposed anatomical landmarks of the spine. The 7th cervical vertebra (C7) to the 12th thoracic vertebra (T12) are used as anatomical landmarks. Greendale et al. reported that the flexicurve is more accurate and more precise than the Debrunner instrument.34

Debrunner kyphometer

Debrunner kyphometer is a non-invasive, protractor-like mechanical device that is used to measure kyphosis.39,40 It is mounted at both ends and the angle of kyphosis is determined through the angle made by the protractor. This device has a one-degree precision.34 Debrunner kyphometer placed between the interspace of 2nd and 3rd thoracic spinous process and another anatomical landmark used as interspace between 11th and 12th thoracic spinous process.19 For the measurement, one needs to stand straight, in a relaxed posture. The angle recorded from the protractor is named as kyphosis angle with debrunner kyphometer.

Gravity-dependent inclinometer

Gravity-dependent inclinometers are used to measure kyphosis. Dual inclinometer consists of 2 inclinometers with 2 feet on the bottom face, used to measure of Angle of Thoracic Kyphosis (ATK).25 The measurement from the inclinometer can be taken in a relaxed standing posture or standing tall.15 One needs to stand straight as tall as possible for measurements. Inclinometer placed over the spinal processes of T1 and T2, and the T12 and L1 vertebrae. The thoracic kyphosis angle can be measured and recorded by checking the angles displayed on the inclinometers.

Tragus to wall distance (TWD)

Tragus to wall distance is used to measure Forward Head Posture (FHP), a conventional, quick, and cost- effective measurement tool. This method required a ruler of 30 cm in length and a wooden block of a width of 5 cm, the participant need to stand still and a wooden block has to place between the participant’s heel and wall to avoid trunk movement. The distance between the wall and tragus is noted with help of the ruler. Three trials are allowed and the average of three is considered for final scoring.14

Occiput-wall distance (OWD)

The occiput to wall distance method is a cheap, easy, and quick alternative method for the assessment of kyphosis. This method of assessment required only two rulers must be placed perpendicular, one vertically touching the occiput and another one placed horizontally from wall to occiput. The horizontal scale provides a reading of the distance from the wall to the occiput. For measurement one should stand stood with heels together, pelvis touching the wall and head positioned in Frankfort horizontal plane. If the score is more than 5 cm, then it reflects the risk of hyperkyphosis. The advantage of this method is very easy to perform as compared to other methods of kyphosis measurement. Can be used for screening purposes to determine the severity of kyphosis in older adults.13

Block Method

This is another method used for the assessment of kyphosis, in this method a block of 1.5 cm height is used. The subject has to lie on their back on a table and the examiner put the blocks in between the table and the occiput.26 The number of blocks used will determine the severity of kyphosis. The more the blocks are used more the severe kyphosis. If 0-2 blocks are used then it is classified as mild kyphosis and if 3 blocks are used then it is classified as severe kyphosis.16 The block method is an effective and practical tool for screening and assessing hyperkyphosis in the elderly.41

Spinal Mouse device

It is an electronic device comprising a hand-held inclinometer that is connected to a computer wirelessly. Participants sit upright and then maximally flexed position on an armless chair. Examiner rolls the spinal mouse paravertebrally along the spine from the 7th cervical vertebra to the 3rd sacral vertebra. Each measurement was repeated thrice and the mean score from the measurement was considered the final score. This device does not require any induvial to calculate the angle of thoracic, measurement can be done with the help of the software. This device can be used for screening for hyperkyphotic posture. Another advantage of this device is that it can be used for mobility assessment of the spine.21

This study is the first of its kind of study that gives a detailed description of the various method used for the assessment of kyphosis in the elderly population. The most frequent method used to screen kyphotic posture is the block method, since it requires minimal skills to perform, is inexpensive in nature, and is also convenient for the participants. The radiography method is used more commonly for defining hyperkyphosis via cobbs angle. The radiography method showed excellent interrater and intrarater reliability and validity. The major disadvantage of this method is its cost and harmful radiation effects. It’s practically not possible to screen a large sample with the radiography method. Flexicurve is one the cheapest non-invasive method for assessing kyphosis, the major advantage of using flexicurve is its excellent reliability and validity when compared to the radiography method. The disadvantage of this method is participant’s body type affects the measurement values.

Debrunner  kyphometer and inclinometer  are used for determining the angle of thoracic kyphosis, both instruments showed high reliability.4 The kyphometer sometimes wobbles on the thoracic spine at T7th or T12th, this instability needs to be corrected for precise measurement. The variability of placement of instruments on the dorsal spine was noted in this review. Occiput-wall distance (OWD) and 7th cervical vertebra wall distance (C7WD) are also used for the assessment of kyphotic posture, these methods are cheap and quick for screening the kyphotic posture. No study was found in this review that used photographic methods for determining hyperkyphotic posture in the elderly population. Spinal mouse and photographic methods are the advanced methods for the analysis of hyperkyphotic posture few studies used the spinal mouse to quantify kyphosis. Spinal mouse showed high reliability and validity. The spinal mouse was found to be not a widely used measurement method, future studies need to be conducted to find the correlation between the spinal mouse and other measures of kyphosis.

Conclusion

This review showed the variability in defining criteria for hyperkyphosis in the elderly population. Lack of uniformity found in choosing anatomical landmarks for the measurement of hyperkyphotic posture. The block method and flexicurve are widely used methods for assessing hyperkyphotic posture in older adults. This review suggested that more measurement tools should be developed for the measurement of hyperkyphosis, that are more consistence, cost-effective, quick, easy to use, and with excellent reliability and validity.

Acknowledgment

We are thankful to the UGC (University Grant Commission, India) for providing fellowship and Department of Physiotherapy, Jamia Hamdard for their cooperation and motivation for research.

References
1. Benedetti MG, Berti L, Presti C, Frizziero A, Giannini S. Effects of an adapted physical activity program in a group of elderly subjects with flexed posture: clinical and instrumental assessment. J Neuroeng Rehabil. 2008;5:32. Published 2008 Nov 25. doi:10.1186/1743-0003-5-32

2. Ailon T, Shaffrey CI, Lenke LG, et al., Progressive spinal kyphosis in the aging population. Neurosurgery. 2015;77 Suppl 4:S164-S172. doi:10.1227/NEU.0000000000000944
3. Bansal S, Katzman WB, Giangregorio LM. Exercise for improving age-related hyperkyphotic posture: a systematic review. Arch Phys Med Rehabil. 2014;95(1):129-140. doi:10.1016/j.apmr.2013.06.022
4. Roghani T, Zavieh MK, Manshadi FD, et al., Age-related hyperkyphosis: update of its potential causes and clinical impacts— narrative review. Aging clinical and experimental research.2017 Aug;29(4):567-77. https://doi.org/10.1007/s40520-016- 0617-3
5. Koelé MC, Lems WF, Willems HC. The Clinical Relevance of Hyperkyphosis: A Narrative Review. Front Endocrinol (Lausanne). 2020;11:5. Published 2020
Jan 24. doi:10.3389/fendo.2020.00005
6. Kado DM, Miller-Martinez D, Lui LY, et al. 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;29(10):2210-2216. doi:10.1002/jbmr.2251
7. Wang MY, Greendale GA, Kazadi L, Salem GJ. Yoga improves upper-extremity function and scapular posturing in persons with hyperkyphosis. Journal of yoga & physical therapy. 2012 Jun 6;2(3):117. doi:10.4172/2157-7595.1000117
8. Katzman WB, Wanek L, Shepherd JA, et al., Age-related hyperkyphosis: its causes, consequences, and management. J Orthop Sports Phys Ther. 2010;40(6):352-360. doi:10.2519/jospt.2010.3099
9. Roghani T, Zavieh MK, Talebian S, Baghban AA, Katzman W. Back muscle function in older women with age-related hyperkyphosis: A comparative study. Journal of Manipulative and Physiological Therapeutics. 2019 May 1;42(4):284-94. doi:10.1016/j.jmpt.2018.11.012

10. Karimian MR, Yeowell G, Saberi S, et al. A comparison of the effectiveness of three types of trunk orthoses on the balance performance of older people with osteoporotic hyperkyphosis: A cross-over study. Musculoskelet Sci Pract. 2021;55:102430. doi:10.1016/j.msksp.2021.102430
11. Kaufmann CN, Shen J, Woods GN, et al. Hyperkyphosis and self-reported and objectively measured sleep quality in older men. PLoS One. 2020;15(2):e0228638. Published 2020 Feb 11. doi:10.1371/journal.pone.0228638
12. Roghani T, Khalkhali Zavieh M, Rahimi A, et al. The Reliability of Standing Sagittal Measurements of Spinal Curvature and Range of Motion in Older Women With and Without Hyperkyphosis Using a Skin- Surface Device. J Manipulative Physiol Ther. 2017;40(9):685-691. doi:10.1016/j.jmpt.2017.07.008
13. Katzman WB, Gladin A, Lane NE, et al. Feasibility and Acceptability of Technology-Based Exercise and Posture Training in Older Adults With Age Related Hyperkyphosis: Pre-Post Study. JMIR Aging. 2019;2(1):e12199. doi:10.2196/12199
14. Jang HJ, Hughes LC, Oh DW, Kim SY. Effects of Corrective Exercise for Thoracic Hyperkyphosis on Posture, Balance, and Well-Being in Older Women: A Double- Blind, Group-Matched Design. J Geriatr Phys Ther. 2019;42(3):E17-E27. doi:10.1519/JPT.0000000000000146
15. Watson SL, Weeks BK, Weis LJ, et al. High- intensity exercise did not cause vertebral fractures and improves thoracic kyphosis in postmenopausal women with low to very low bone mass: the LIFTMOR trial. Osteoporos Int. 2019;30(5):957-964. doi:10.1007/s00198-018-04829-z
16. Sugai K, Michikawa T, Takebayashi T, et al. Association between muscle strength, mobility, and the progression of hyperkyphosis in the elderly: The Kurabuchi Cohort Study. J Gerontol A Biol Sci Med Sci. 2019;74(12):1987-1992. doi:10.1093/gerona/glz136
17. Naderi A, Rezvani MH, Shaabani F, et al. Effect of kyphosis exercises on physical function, postural control and quality of life in elderly men with hyperkyphosis. Iranian Journal of Ageing. 2019 Jan 10;13(4):464-79.
18. McDaniels-Davidson C, Davis A, Wing D, et al. Kyphosis and incident falls among community-dwelling older adults. Osteoporos Int. 2018;29(1):163-169. doi:10.1007/s00198-017-4253-3
19. Katzman WB, Parimi N, Gladin A, et al. Sex differences in response to targeted kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial. BMC Musculoskelet Disord. 2017;18(1):509. Published 2017 Dec 4. doi:10.1186/s12891-017-1862-0
20. Katzman WB, Vittinghoff E, Lin F, et al. Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial. Osteoporos Int. 2017;28(10):2831- 2841. doi:10.1007/s00198-017-4109-x
21. Roghani T, Khalkhali Zavieh M, Talebian S, et al. Back muscle function in older women with age-related hyperkyphosis: A Comparative Study. J Manipulative Physiol Ther. 2019;42(4):284-294. doi:10.1016/j.jmpt.2018.11.012
22. Yokoyama Y, Nishiwaki Y, Michikawa T, et al. The association of kyphosis assessed in supine and standing positions with future activities of daily living dependence: the Kurabuchi Study. Arch Osteoporos. 2017;12(1):105. Published 2017 Nov 22. doi:10.1007/s11657-017-0401-9
23. Yamamoto J, Bergstrom J, Davis A, et al. Trunk lean mass and its association with 4 different measures of thoracic kyphosis in older community dwelling persons. PLoS One. 2017;12(4):e0174710. Published 2017 Apr 3. doi:10.1371/journal.pone.0174710
24. Tran TH, Wing D, Davis A, et al. Correlations among four measures of thoracic kyphosis in older adults. Osteoporos Int. 2016;27(3):1255-1259. doi:10.1007/s00198-015-3368-7
25. Jang HJ, Kim MJ, Kim SY. Effect of thorax correction exercises on flexed posture and chest function in older women with age- related hyperkyphosis. J Phys Ther Sci. 2015;27(4):1161-1164. doi:10.1589/jpts.27.1161
26. Katzman WB, Harrison SL, Fink HA, et al. Physical function in older men with hyperkyphosis. J Gerontol A Biol Sci Med Sci. 2015;70(5):635-640. doi:10.1093/gerona/glu213
27. van der Jagt-Willems, Hanna C et al. Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC geriatrics vol. 15 34. 28 Mar. 2015, doi:10.1186/s12877-015-0018-z
28. Hojjati Zidashti, Zahra & Sheikhpour, Leila. (2013). Seated exercise therapy improves posture and balance in hyperkyphotic elderly females, a Randomized Control Trail. World Applied Sciences Journal. 24. 331-335, doi:
10.5829/idosi.wasj.2013.24.03.794
29. Quek J, Pua YH, Clark RA, et al. Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults. Man Ther. 2013;18(1):65-71. doi:10.1016/j.math.2012.07.005
30. Azadinia F, Kamyab M, Behtash H, et al. The effects of two spinal orthoses on balance in elderly people with thoracic kyphosis.    Prosthet    Orthot    Int. 2013;37(5):404-410. doi:10.1177/0309364612474487
31. Katzman W, Cawthon P, Hicks GE, et al. Association of spinal muscle composition and prevalence of hyperkyphosis in healthy community-dwelling older men and women. J Gerontol A Biol Sci Med Sci. 2012;67(2):191-195. doi:10.1093/gerona/glr160
32. Bautmans I, Van Arken J, Van Mackelenberg M, et al. Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal  patients with osteoporosis. J Rehabil Med. 2010;42(2):129-135. doi:10.2340/16501977-0486
33. Regolin F, Carvalho GA. Relationship between thoracic kyphosis, bone mineral density, and postural control in elderly women. Brazilian Journal of Physical Therapy. 2010;14:464-9.
34. Greendale GA, Huang MH, Karlamangla AS, et al. Yoga decreases kyphosis in senior women and men with adult-onset hyperkyphosis: results of a randomized controlled trial. J Am Geriatr Soc. 2009;57(9):1569-1579. doi:10.1111/j.1532-5415.2009.02391.x
35. Hinman MR. Comparison of thoracic kyphosis and postural stiffness in younger and older women. Spine J. 2004;4(4):413- 417. doi:10.1016/j.spinee.2004.01.002
36. Kado DM, Lui LY, Ensrud KE, et al. Hyperkyphosis predicts mortality independent of vertebral osteoporosis in older women. Ann Intern Med. 2009;150(10):681-687. doi:10.7326/0003-4819-150-10- 200905190-00005
37. Ebrahim Mousavi M, Ahmadi Bani M, Aboutorabi A, et al. The effect of a semi- rigid thoracolumbosacral orthosis (TLSO) on foot pressure in elderly subjects presenting with spinal hyperkyphosis. Disabil Rehabil Assist Technol. 2020;15(2):205-210. doi:10.1080/17483107.2018.1555289
38. Mohebi S, Torkaman G, Bahrami F, et al. Postural instability and position of the center of pressure into the base of support in postmenopausal osteoporotic and nonosteoporotic women with and without hyperkyphosis. Arch Osteoporos. 2019;14(1):58. Published 2019 Jun 3. doi:10.1007/s11657-019-0581-6
39. Kado DM, Prenovost K, Crandall C. Narrative review: hyperkyphosis in older persons. Ann Intern Med. 2007;147(5):330-338. doi:10.7326/0003-4819-147-5- 200709040-00008
40. González-Gálvez N, Gea-García GM, Marcos-Pardo PJ. Effects of exercise programs on kyphosis and lordosis angle: A systematic review and meta-analysis. PLoS One. 2019;14(4):e0216180. Published 2019 Apr 29. doi:10.1371/journal.pone.0216180
41. Chokphukiao, Pakwipa et al. “Validity and reliability of the block method for measuring thoracic hyperkyphosis. Physiotherapy theory and practice, 1-8. 7 Sep. 2021, doi:10.1080/09593985.2021.1975335