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Tuesday, June 6, 2023

Hyperkyphosis as a Predictor of Mortality in the Elderly

Brent Brookbush

Brent Brookbush


Research Review: Hyperkyphosis as a Predictor of Mortality in the Elderly

By Stefanie DiCarrado DPT, PT, NASM CPT & CES

Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Kado, D.M., Huang, M., Karlamangla, A.S., Barrett-Connor, E., Greendale, G.A. (2004). Hyperkyphotic posture predicts mortality in older community-dwelling men and women: A prospective study. JAGS S2: 1662-1667 - ABSTRACT

Normal vs Hyperkyphotic Spine

Why is this relevant?: Increased sedentary desk jobs along with overuse of computers, cellphones, and tablets can lead to a hyperkyphotic posture resulting in neck and shoulder pain (1 ). This study was the first to examine the link between hyperkyphosis in the elderly and a higher mortality rate. This may indicate the need for postural re-education to prevent hyperkyphosis; as means of enhancing function, the quality of life, and decreasing the rate of mortality.

Study Summary

Study Design  Prospective cohort study
Level of Evidence  III: Evidence from a non-experimental descriptive study
Subject Demographics
  • Age: 45 y.o. - 98 y.o. (mean: 73 y.o.)
  • Gender: 575 male, 778 female (267 participants died)
  • Characteristics: Participants in the Rancho Bernardo Heart & Chronic Disease Study having visits pertaining to osteoporosis between 1988-1991
  • Inclusion Criteria: NA
  • Exclusion Criteria: NA
Outcome Measures
  • Kyphosis (measured supine by placing 1.7cm blocks under the head until the neck was considered in neutral posture.)
  • Mortality rate
  • Cause of death
  •  Hyperkyphosis is more common in males than females (44% vs 22%)
  • For the 267 that passed away
    • Age & sex adjusted analysis: average 1.44 greater rate of mortality in those with hyperkyphosis:
      • 1 block: 1.25 increased rate of mortality
      • 2 blocks: 1.56 increased rate of mortality
      • 3+ blocks: 1.5 increased rate of mortality

    • Order of survival rates (lowest to highest)
      • Males with hyperkyphosis
      • Males without hyperkyphosis
      • Women with hyperkyphosis
      • Women without hyperkyphosis
  • Relative mortality risk equal among both genders with hyperkyphosis
  • Cause-specific mortality analysis: specific association between hyperkyphosis and increased mortality rate due to atherosclerosis
  • Hyperkyphosis found as a "significant predictor of increased all-cause mortality" (pg 1665)
Conclusions The relationship between posture, hyperkyphosis, activity, and the resultant decrease in cardiopulmonary function may be the reason individuals with hyperkyphosis have higher mortality rates.
Conclusions of the Researchers Higher mortality rates exist among elderly individuals with excessive kyphosis.

Review & Commentary:

This article examines an interesting correlation between hyperkyphosis and an increased rate of mortality. Poor posture and related musculoskeletal injuries are often the focus of research and clinical practice, but this article sought out the long-term effects of a hyperkyphotic posture. Based on the results of this study, perhaps it is not the neck, shoulder , and scapular/thoracic pain that should motivate one to perform postural exercise/training, but the stress from compression on the heart, lungs, and circulatory system that should be of great concern. The effect posture has on breathing and pulmonary health has been noted by those in pulmonary rehab for decades; consider how years of compression could lead to pulmonary and cardiac complications, a reduction in circulation, and atherosclerosis noted in this study.

The researchers analyzed data collected from a separate study and correlated values of hyperkyphosis with age and cause of death. The aforementioned Rancho Bernardo Heart & Chronic Disease Study measured kyphosis by assessing the distance between the occiput and the DEXA scan table (dual-energy x-ray absorptiometry) while the subject lie supine for a bone scan. Researchers placed 1.7 cm blocks underneath the subject's head until his/her neck was in neutral alignment. The need for any blocks indicated hyperkyphosis. The authors stated this method was similar to the more standard methods of measurement in which a person stands against a wall, and therefore was assumed to be a valid and reliable measure (2).

Researchers obtained the cause of death for over 96% of individuals who passed away during this study and classified them into atherosclerosis, cancer, pulmonary, and other. They found a hyperkyphotic posture was more related to death by atherosclerosis rather than pulmonary causes as is typically documented.

The authors listed three limitations within the study: the method of measuring hyperkyphosis, the non-homogenous sample, and possibly unreliable cause of death. The block method used does not isolate the thoracic spine and so individuals with forward head posture may have erroneously been labeled hyperkyphotic. However, very rarely, if ever, does forward head posture exist without some hyperkyphosis. Subjects were the same race and same socioeconomic status; the authors feel the study could be stronger with a more diverse sample size. The cause of death was obtained from death certificate which may have variable reliability within an aging population.

Why is this study important?

This study is important because it demonstrates a correlation between the postural dysfunction of hyperkyphosis and rate of mortality. Hyperkyphosis is a commonly acquired posture typically associated with osteoporosis (although this study did not find the same correlation). However, with the increase in sedentary desk jobs and use of cellphones, younger individuals are developing kyphotic postures. Previous studies by Leech et al. (1990), Chow & Harrison (1987), and Ryan & Fried (1997) indicated a correlation between hyperkyphosis and decreased lung function. The current study found a higher correlation between hyperkyphosis and atherosclerosis. All studies indicate stress placed on the cardiopulmonary system can lead to a higher risk of mortality as one ages.

How does it affect practice?

Clinicians must address postural dysfunction in individuals of all ages to preserve health and optimal functional status. When treating persons with structural deformity due to small vertebral fractures, clinicians will have to focus on maintaining and preventing a worsening of postural dysfunction.

How does it relate to Brookbush Institute Content?

The Brookbush Institute lists hyperkyphosis as a common compensation noted in those with Upper Body Dysfunction (UBD) . As mentioned previously, hyperkyphosis is notoriously associated with older women who have osteoporosis, and perhaps not considered often enough in a younger, less active, desk-bound population. Many movement professionals understand the link between dysfunction in the upper extremity, cervical spine, and thoracic spine but are unsure of the mechanisms. During the overhead squat assessment , arms falling forward and elevation of the scapula are both indications of UBD . To remove the latissimus dorsi (LD) , which may be over-active due to lumbopelvic hip complex dysfunction (LPHCD), we ask the individual to place their hands on their hips and repeat the squat. Individuals with UBD will often flex the spine once the hands are on the hips - exhibiting a hyperkyphosis in the thoracic spine or a posterior pelvic tilt. (For more on assessing compensation patterns using the overhead squat assessment ) Compensations of this nature indicate an overactive Anterior Oblique Subsystem (AOS) with an under-active Intrinsic Stabilization Subsystem (ISS) and Posterior Oblique Subsystem (POS) . Perhaps the individuals in this study exhibited this compensation, left unchecked along with poor postural habits, leading to the structural changes noted in the hyperkyphotic aging spine. This study may indicate one more important reason to address posture throughout one's lifetime - hyperkyphosis, leading to compression of the lungs and heart, leading to decreased respiratory efficiency, poor oxygen circulation, and eventually an increase in health-related problems.

The videos below demonstrate corrective exercise and self-mobilization to address a hyperkyphotic thoracic spine and restore proper muscle balance and movement.

Upper Body Dysfunction Self Mobilization Playlist (Pay special attention to the "Thoracic Mobility" exercises, particularly with the goal of prevention in a younger population)

Pectoralis Major and Minor SA Active Stretch

Crucifixion Stretch

Lower Trapezius Activation Taping

Prone Cobra on Foam Roll

Static Lunge to Row POS Integration


1. Otoshi, K., Takegami, M., Sekiguchi, M., Onishi, Y., Yamazaki, S., Otani, K., Shishido, H., Shinichi, K., Shinichi, K. (2014). Association between kyphosis and subacromial impingement syndrome: LOHAS study. Journal of Shoulder and Elbow Surgery. 23. e300-e307

2. Leidig-Bruckner, F. Minne, H.W., Schlaich, C., et al (1997). clinical grading of spinal osteoporosis: Quality of life components and spnal deformity in women with chronic low back pain and women with vertebral osteoporosis. J Bone Miner Res. 12:663-675

3. Leech, J.A., Dulberg, C., Kellie, S. et al. (1990). Relationship of lung function to severity of osteoporosis in women. am Rev Respir Dis 141: 68-71

4. Chow, R.K., Harrison, J.E. (1987). Relationship of kyphosis to physical fitness and bone mass on post-menopausal women. Am J Phys Med 66:219-227

5. Ryan, S.D., Fried, L.P. (1997) The impact of kyphosis on daily functioning. J Am Geriatric Soc 45: 1479-1486

© 2015 Brent Brookbush

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