One of the most important concepts in working with people with low bone density (osteopenia or osteoporosis) is reducing the hyper-kyphosis of the spine. Notice I’m saying HYPER-kyphosis, not just kyphosis which should be present in the thoracic spine. Because the anterior portion of the vertebral bodies is where most spinal fractures occur, an increase in the Cobb angle beyond 40-50 degrees places increased pressure on that area. This can result in increased risk of fractures or may be an indication that a fracture has previously occurred.

There are several ways to measure an individual’s thoracic hyper-kyphosis with x-rays being the gold standard. However, we as clinicians can use the Flexicurve, a protocol advanced by physical therapist, Carleen Lindsey. (1)

The Flexicurve ruler is a tool used to measure thoracic kyphosis and can help identify hyper-kyphosis. It is available on Amazon or found in some fabric stores. To use the Flexicurve, the ruler is molded to the patient's thoracic and lumbar curves in standing and then the curves are traced on graph paper. Measurements of the curves are then taken by measuring the width of the T curve, divided by the length of the T curve X 100. A kyphosis index is calculated to quantify the curvature. An index greater than 13 is often considered hyper-kyphotic, according to a study from the NIH. (2)

One of the advantages that I love is that after the measurement is traced on graph paper and dated, the patient has a visual of their spine which helps with exercise compliance. It also helps to explain why we are targeting specific muscles and areas of the spine, not just general strengthening. Following our exercise program, the patient can be re-measured, and the new drawing placed adjacent to the initial one. Patients can see the improvement which further motivates them to keep exercising Typically, with the reduction in thoracic hyper-kyphosis come a subsequent increase in height!

So how do we reduce the curve? By strengthening the upper back extensors. First you must make sure the individual is trained in neutral lumbar spine and core control. Many people with hyper-kyphosis compensate by increased lumbar lordosis which often results in lumbar hypermobility and resultant pain. And doesn’t strengthen the upper back.

Once they understand and can maintain neutral lumbar spine, we proceed with the Decompression and Re-alignment Routine developed by Sara Meeks, PT. This is practiced in the supine position and progressed to prone. Using visuals is a great way to “get your ideas of movement” into your patient’s body. I like to use the “person being shot out of a cannon” as my visual. The abdominal stabilization, spinal elongation, and activation of scapulo-thoracic musculature are all embodied in the image.

Educating patients and giving them visuals to see the improvement goes a long way toward helping them remain compliant with their exercise program.

My colleague and partner, Dr. Frank Ciuba and I would welcome you to our upcoming remote course, Osteoporosis Management: An Introductory Course for Healthcare Professionals where you will learn additional assessments and exercises for people with low bone density. Our next courses are scheduled for September 6 or November 8.

References:

1. https://www.researchgate.net/figure/Flexicurve-ruler-measurement-of-kyphosis-A-Mark-the-C7-spinous-process-and-the-L5-S1_fig3_44639136
2. J Lam, T Mukhdomi. Kyphosis, Stat Pearls, NIH. (Aug 2023

AUTHOR BIO
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT (she/her) has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete, where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.