Kyphosis Correction: Physical Therapy Rehabilitation Protocol

Pathophysiology

Kyphosis refers to an excessive curvature of the thoracic spine, resulting in a rounded upper back appearance. It can be postural (flexible), structural (fixed), or due to Scheuermann's disease (vertebral wedging). Postural kyphosis is often caused by poor posture, prolonged sitting, and weak back muscles. Structural kyphosis, which includes Scheuermann's disease, involves abnormalities in the vertebral bodies themselves. This protocol focuses primarily on the management of postural kyphosis and adjunctively, the management of structural kyphosis following physician clearance.

Common impairments associated with kyphosis include:

• Increased thoracic flexion
• Weakness of thoracic extensors (erector spinae, rhomboids, trapezius)
• Tightness of anterior chest muscles (pectoralis major and minor)
• Protracted scapulae
• Forward head posture
• Limited shoulder range of motion, particularly external rotation and horizontal abduction
• Reduced respiratory function in severe cases
• Pain and stiffness in the thoracic spine, neck, and shoulders

Common Special Tests

• Adam's Forward Bend Test: Assesses for structural kyphosis. The patient bends forward at the waist, and the therapist observes the back for a rib hump or asymmetry. A rib hump suggests structural scoliosis, often associated with structural kyphosis.
• Wall Test: Patient attempts to stand with their heels, buttocks, and shoulders touching a wall. Inability to do so suggests postural impairments contributing to kyphosis.
• Shoulder ROM Assessment: Assess flexion, extension, abduction, adduction, internal rotation, external rotation, horizontal abduction, and horizontal adduction bilaterally. Limitations, particularly in external rotation and horizontal abduction, are common.
• Muscle Length Testing: Assess the length of the pectoralis major and minor muscles. Tightness is a common finding.
• Respiratory Assessment: Observe breathing patterns and assess chest expansion. Significant kyphosis can restrict lung capacity.

Phase I: Protection (Acute Phase)

Goals: Reduce pain, improve awareness of posture, and initiate gentle range of motion.

• Duration: 1-4 weeks
• Pain Management:
  • Modalities as needed (e.g., heat, ice, TENS)
  • Education on pain management strategies and activity modification
• Posture Education:
  • Instruction on proper sitting, standing, and sleeping posture
  • Use of lumbar support when sitting
  • Mirror exercises for postural awareness
• Gentle Range of Motion Exercises:
  • Chin tucks (cervical retraction) – 10-15 repetitions, 2-3 times daily
  • Scapular retractions (squeezing shoulder blades together) – 10-15 repetitions, 2-3 times daily
  • Gentle chest stretches (e.g., doorway stretch) – hold for 30 seconds, 2-3 times daily
  • Thoracic extensions over a foam roller (placed at mid-thoracic spine) – 10-15 repetitions, 1-2 times daily, only if pain-free
• Breathing Exercises:
  • Diaphragmatic breathing exercises to improve lung capacity and reduce stress
• Avoidance:
  • Activities that exacerbate pain
  • Prolonged slouched postures

Phase II: Loading (Subacute Phase)

Goals: Improve thoracic mobility, strengthen postural muscles, and progress functional activities.

• Duration: 4-8 weeks
• Continue Phase I Exercises: Progress as tolerated
• Thoracic Mobility Exercises:
  • Thoracic extension mobilization (manual therapy techniques by a physical therapist)
  • Cat-cow stretches
  • Thread the needle stretch
• Strengthening Exercises:
  • Rows (with resistance band or light weights) – 10-15 repetitions, 2-3 sets, 2-3 times per week
  • Reverse flyes (with resistance band or light weights) – 10-15 repetitions, 2-3 sets, 2-3 times per week
  • Prone trunk extension exercises (supermans) – 10-15 repetitions, 2-3 sets, 2-3 times per week
  • Lower Trapezius strengthening: Prone T's, Y's and W's – 10-15 repetitions, 2-3 sets, 2-3 times per week
  • Wall angels – 10-15 repetitions, 2-3 sets, 2-3 times per week
• Core Stabilization Exercises:
  • Plank (progress from modified plank to full plank) – hold for 30-60 seconds, 2-3 repetitions, 2-3 times per week
  • Side plank – hold for 30-60 seconds, 2-3 repetitions per side, 2-3 times per week
• Ergonomic Modifications:
  • Assessment and modification of workstation setup to promote good posture

Phase III: Return to Function (Chronic Phase)

Goals: Maintain improved posture, optimize functional activities, and prevent recurrence.

• Duration: Ongoing
• Continue Phase II Exercises: Progress resistance and intensity as tolerated
• Functional Exercises:
  • Sport-specific or activity-specific exercises that incorporate good posture and body mechanics
  • Lifting and carrying techniques
• Cardiovascular Exercise:
  • Encourage regular cardiovascular exercise that promotes good posture (e.g., swimming, walking)
• Maintenance Program:
  • Independent home exercise program to maintain strength, flexibility, and posture
  • Regular self-assessment of posture
  • Periodic check-ups with physical therapist as needed
• Education on Injury Prevention:
  • Proper lifting techniques
  • Strategies to avoid prolonged static postures