Here’s What Causes Hunchback and How to Prevent It
Posture awareness, targeted exercises and healthy bones can help stave off excessive back rounding in older adults.
This article is based on reporting that features expert sources.
The mild outward curve of your upper spine, called kyphosis, is normal. However, for some people, that spinal curvature increases noticeably with age, creating a stooped-over, head-forward posture. That condition, called hyperkyphosis, is sometimes known as a roundback, dowager’s hump or hunchback.
Hyperkyphosis can disrupt your quality of life and function, in addition to affecting a person’s self-image. It may lead to physical symptoms, such as reduced mobility and lung capacity, and escalate your risks of falls.
If you have age-related hyperkyphosis, the good news is that it may improve with treatments such as physical therapy, targeted exercises and postural awareness. If your spine is healthy, you can take steps now to protect your bones, maintain a flexible, upright posture and avoid having a hump in your back.
Kyphosis Definition
Your spine naturally has mild curves in the lower back (lumbar) spine, the middle (thoracic) spine and the upper (cervical) spine, which includes the neck. These curves work together to hold up your head, and align your body’s center over your pelvis and hips.
Although these curves are normal, they can increase by a significant degree, causing disruptions to the body’s balance, symmetry and function. Some forms of hyperkyphosis are congenital, some appear in childhood or early adulthood, while others develop later in life among older adults who previously had normal posture.
A normal kyphosis measurement ranges from 20 degrees to 45 degrees, according to the American Academy of Orthopedic Surgeons. Hyperkyphosis is a thoracic curve of more than 50 degrees, though precise ranges can vary by definition, with normal maximums of 40 or 45 degrees.
Doctors can have the degree of curvature measured with a full spinal X-ray as patients stand. In some cases, CT scans can provide a more detailed image. Patients are frequently referred to spinal specialists or spinal clinics for initial evaluation and care.
Kyphosis vs. Lordosis
The inward, C-shaped curve of your lumbar spine is called lordosis. This is also a natural curve but can become too extreme. When that occurs, the deep curve of the lower spine causes the abdomen to protrude and the pelvis to curve backward and upward, out of alignment.
The cervical spine also has a natural, inward C-shape. With cervical kyphosis, the cervical spine becomes straight (known as military neck) or curves in the wrong direction, pushing the head forward and compromising flexibility and stability.
The Impact of a Hunched Back
If you notice your spine is rounding, it’s important to seek treatment to prevent further curvature as much as possible and minimize the impact on your health, which can be significant.
Among people with excessive kyphosis, “In the future, they’re more likely to have falls, impaired physical function, fractures and mortality,” says Dr. Deborah Kado, a pioneer in research on age-related hyperkyphosis. Reduced balance and a weakened spine make it harder to bend or lift, and contribute to both the risk of falls and resulting trauma.
The greater the degree of spinal curvature, the worse the risk to the individual, according to Kado, who is a specialist in geriatric medicine, a professor of medicine at Stanford University and co-director of the Stanford Longevity Center.
In one study, Kado looked at the connection between curvature rate and mortality, using data from X-rays on 9,575 women over 65, including about 600 who also had measurements of thoracic kyphosis. “Women who were more hunched over were more likely to die over the next eight years,” she says. Although some study participants had vertebral fractures, that alone didn’t account for the additional risk, she notes, as only one-third of those who died had such fractures.
Among women in the study with kyphosis who died, in many cases it was due to lung conditions such as chronic obstructive pulmonary disease (COPD), which decreases airflow from the lungs, or pneumonia, Kado says, which could be due to reduced lung capacity from being hunched over.
Age, Posture and Kyphosis
“Getting stooped posture is not an inevitable part of aging,” says Wendy Katzman, an orthopedic clinical specialist and professor emeritus in the physical therapy and rehabilitation science department at the University of California-San Francisco.
“With commitment, you can improve it if it’s already developed,” says Katzman, who has conducted extensive research on the impact of exercise on preventing and minimizing the effects of kyphosis.
As people age, “there’s a loss of proprioception in the spine, so a loss of ability to sense where you are in space,” Katzman says. For instance, the vestibular system of the inner ear is involved with your sense of balance.
“After the age of 50, we tend to lose visual, vestibular and proprioceptive sensory input,” she explains. Losing those important sources of sensory information to the brain can impair your ability to know how upright alignment feels.
Exercise to strengthen supporting muscles and maintain flexibility can help prevent excessive spinal curvature or improve existing hyperkyphosis. Postural awareness – actively standing straighter and avoiding slumped sitting throughout the day – also makes a real difference.
Kyphosis Variations
“There are really a lot of different types of kyphosis,” says Dr. Jason Lowenstein, chief of scoliosis and spinal deformity surgery at Morristown Medical Center and medical director of scoliosis and spinal deformity surgery at the Atlantic Health System in Morristown, New Jersey. “Some are kyphosis that develops in childhood and then progresses in later adulthood.”
Geriatric kyphosis can occur as people get older and their discs wear out and they start developing worsening posture, Lowenstein explains. “That can eventually turn into structural hyperkyphosis,” he says. Your back gets rounded at this point.
Cervical kyphosis involves the uppermost spine supporting the neck. When that’s affected, a person can lose their ability to keep their head upright. They may develop ‘chin on chest’ syndrome, in which their head drops forward and their chin typically rests on their neck.
“Unfortunately, it’s like a self-evolving cycle where if you already have curvature of your back, as you get older and develop more osteoporosis – if your bones are softer and you’re at risk of falling and you fall and you fracture, it can cause worsening kyphosis,” Lowenstein says. That, in turn, can cause worsening deformity and worsening pain, becoming increasingly challenging to treat and manage, he says.
Kyphosis Risk Factors
Bone and muscle strength are essential for spinal support. Two common conditions involving bone and muscle weakness– osteoporosis and sarcopenia – are top causes of age-related kyphosis. Those and other risk factors for excessive kyphosis include:
- Osteoporosis. In osteoporosis, which means ‘porous bone,’ the quality and density of bone decline. Bones become fragile and brittle, making people more vulnerable to fractures. Women are more likely to develop osteoporosis because of hormonal changes during menopause.
- Age-related bone loss. Men can develop kyphosis, too, as bone mass naturally declines after reaching peak bone mass in the early 30s and 40s.
- Sarcopenia. Age-related loss of skeletal muscle mass and strength, called sarcopenia, can begin as early as your 30s and continue to increase with age.
- Being sedentary. A sedentary lifestyle that involves continual sitting and a lack of physical activity is a risk factor for bone-related conditions. Weight-bearing exercise helps maintain healthy bones, while walking promotes balance and good posture. A physical therapist can help you gradually increase your activity level.
- Family history. There appears to be a genetic link to kyphosis, Kado says: “If you have a family member who’s been affected by hyperkyphosis, if you notice it in your own family, you might think a little bit about your own posture.”
- Unneeded weight loss in older adults. For people over 65, losing weight may affect overall bone health and contribute to kyphosis progression. Kado points out.
How Common Is Hyperkyphosis?
The exact prevalence of excessive kyphosis in older adults is uncertain, as definitions aren’t always consistent and many cases may go undiagnosed, but these figures offer perspective:
- It’s estimated that among adults ages 60 and older who live in the community (rather than in a facility like a nursing home, for instance), about 20% to 40% have hyperkyphosis.
- Women experience the sharpest increase in the angle of kyphosis during their 50s, according to a study of healthy women between 30 and 79 years old, published in the journal Osteoporosis International.
- Kyphosis increased by about 9 degrees per decade in a small study of older adults in Italy, published in November 2019 in the Spine Journal.
Strategies to Combat Kyphosis
Certain core training, muscle-strengthening and flexibility exercises have been shown to help prevent or reduce hyperkyphosis. You can incorporate these exercises and habits into your fitness routine:
In a six-month, randomized controlled trial of adults ages 60 or older with hyperkyphosis – who did not have major medical conditions and did not use any assistive devices – those who attended an hour-long yoga class three days per week experienced more improvement in their degree of spinal curvature than the non-yoga comparison group. The yoga involved was limited to four specific poses that targeted spinal extension, so all yoga, in general, may not be beneficial.
A different study of healthy adults ages 18 to 68 measured the degree of thoracic spinal curvature among yoga practitioners compared to participants who did not practice yoga. Yoga adherents had less-pronounced thoracic kyphosis (as well as less lumbar lordosis) than those in the control group.
“The results suggest that yoga exercises can affect the shape of the anterior-posterior curves of the spine and may be an efficient training method for shaping proper posture in adults,” concluded the authors of the study published in September 2021.
Safer Yoga Poses
The National Osteoporosis Foundation, which Katzman suggests as a resource, recommends these yoga exercises for your bones:
- Balance. Tree and half-moon poses.
- Dynamic alignment. Triangle pose.
- Leg strength. Chair, high lunge and warrior two and three poses.
- Spinal extension. Upward dog, cobra and locust poses.
Yoga Poses to Avoid
You should not do these intense poses if you have very low bone density or osteoporosis:
- Forward bends like standing forward fold (uttanasana) or seated forward bend (paschimottanasana).
- Plow pose (halasana).
- Deep twists like seated twist (matsyendrasana) and revolved triangle (parivrtta trikonasana).
- Deep hip stretches like pigeon pose (eka pada rajakapotasana).
Focus on your posture at frequent intervals to avoid increasing kyphosis. “Keying into your postural alignment and straightening up your spine can be really beneficial and necessary to prevent it from becoming a fixed curvature,” Katzman says. “So, reversing that flexed curvature multiple times a day can be helpful to prevent it from becoming permanent.”
Set up text or calendar reminders. In a small, six-week pilot study, older adults with hyperkyphosis received text messages to practice a few simple exercises and pay attention to their posture at least three times a day.
Participants showed improvement in kyphosis and physical function, demonstrating that a low-tech, easy-to-apply approach can change your posture and ability to function, says Katzman of the study published in JMIR Aging.
Consider working with a physical therapist. A physical therapist can help guide you with posture-improving techniques. In a six-month study led by Katzman, participants who attended a physical therapist-led group exercise program in three weekly, hour-long sessions, had increased improvement in their posture angle, particularly for those older than 75, compared to participants who only received health education.
Simple Exercises for Bone Health
American Bone Health, another online resource recommended by Katzman, illustrates and suggests incorporating exercises like these into your daily routine to improve posture, balance and strength:
- Sit to stand/stand to sit.
- Standing hip abduction, flexion and extension.
- Toe and heel raises.
- Cervical and thoracic extension.
- Standing ‘Y,’ standing ‘W’ and standing’ T.’
- Squat variations.
- Pelvic tilt and bridges.
Hyperkyphosis: Symptoms and Risks
A stooped appearance is the outward sign of excessive kyphosis. But it can also cause a variety of functional changes and associated risks. As spinal curvature increases, people may notice the following:
- Losing height. “They’re not as tall as they used to be,” Lowenstein says. “Because as their curvature increases, their head is getting close to the ground.”
- Being off-balance. Forward-leaning can develop, possibly with side-leaning, as well. “Kyphosis can oftentimes happen along with scoliosis,” Lowenstein explains. “So you can start falling off to one side of the other as well as going forward.”
- Problems going from seated to standing. Difficulty getting up from a chair or sitting down is a common example of impaired function, Kado says.
- Rounding appearance. A glimpse at a full-length mirror can be the first indication of spinal rounding, or someone else may remark on the recent change.
- Discomfort. Kyphosis can make daily routines uncomfortable and more difficult. “Sometimes it can be painful sitting at a computer,” Katzman says. A head-forward position can cause headaches and backaches, she notes.
- Pain with comorbidities. Although kyphosis is not necessarily painful in itself, Katzman says, pain can be present, particularly when associated with underlying when it’s associated with underlying fractures or degenerative disc disease.
- Muscle fatigue. Some people have a structural imbalance that causes them to stand forward instead of straight, Lowenstein notes. “They have to expend a tremendous amount of energy to be in that position,” he says. “They often have to use an assistive device like a cane or walker to help them maintain their positioning.” All this “can result in a fair amount of muscle fatigue and also pain.”
- Neurologic pain. In some cases, kyphosis can contribute to compression of the spinal cord or nerve roots, causing dysfunction and pain, Lowenstein says. Kyphosis pain from strained muscles and pinched nerves can radiate, or extend, into the neck, head, back and arms causing tingling or weakness.
- Breathing difficulty. Shortness of breath and decreased lung function can be associated with spinal curvature.
Prioritizing Your Bone Health
It’s never too soon to start promoting and protecting a strong, healthy spine. Here’s what you can do:
- Determine your bone density. Ask your doctor if tests to measure bone density are appropriate for you. Noninvasive tests include a DEXA scan (dual-energy X-ray absorptiometry) and a quantitative CT scan. If results show significantly low bone density, further medical evaluation and treatment may be indicated. Treatment for low bone density can include medications, dietary changes and weight-bearing exercise.
- Do weight-bearing exercises. If your bones are healthy, resistance training exercises such as deadlifts, barbell squats and overhead dumbbell presses can increase bone strength when performed regularly.
- Incorporate core work. Your core muscles help stabilize the spine. Rowing exercises, resistance-band work and cable machine exercises can target both your back and core.
- Consult with an expert. If you have low bone density or a diagnosed condition like osteoporosis, a physical therapist can suggest gentler exercises that exert less stress on the spine. If you have hyperkyphosis, physical therapists can also recommend effective posture-improvement techniques.
- Avoid undue spinal flexion. Similarly, if you already have hyperkyphosis or related bone conditions, stay away from bending, crunching or twisting exercises. Also, be careful not to slouch throughout the day, which can intensify spinal curvature.
- Eat a balanced diet. A well-rounded eating plan that provides adequate amounts of important nutrients such as calcium, vitamin D and protein is vital to your bone health.
- Get some sun. Being in the sun exposes you to vitamin D absorption. 15 minutes of sun daily helps activate vitamin D to its active form. Supplementation with oral vitamin D can also be effective if you’re unable to get outdoors.
- Talk to a women’s health specialist. A study conducted by Kado, published in the July 2018 issue of the journal Menopause, suggests that older women who’ve undergone hormone replacement therapy may have reduced kyphosis risk. Although HRT is not appropriate for everyone, some women may benefit.
Treatment Options
With age-related kyphosis, the emphasis is usually on noninvasive treatment. Exercise, physical therapy and pain management are mainstays. Some people wear posture braces for back support, or use assistive devices like walkers.
Pain and discomfort can be addressed in several ways. “Some people start developing pain associated with kyphosis as they get older,” he says. “Typically, we’ll try physical therapy. We try to strengthen the muscles through exercise, and sometimes it can improve their deformity. Usually, it doesn’t necessarily change the kyphosis but it can improve their pain and possibly slow the worsening deformity.”
For older adults in a tremendous amount of kyphosis-related pain, pain management consultations can help patients by exploring medical options to alleviate it, he says. “Sometimes that strategy of working with a pain management consultant, in conjunction with physical therapy, can be beneficial.”
A pain management consultant may recommend stronger prescription medications or minimally invasive treatment such as epidural steroid injections around the spinal cord.
In severe cases in which patients don’t respond to other treatments, surgery may be discussed.
“If patients develop spinal deformities that are refractory to conservative care, and they really start developing progressive worsening deformity or really significant pain, sometimes we’ll consider surgical treatment options,” Lowenstein says.
However, he adds, such major surgery typically involves a long recovery period. Surgery has the potential for complications, Lowenstein notes, particularly for patients with bone conditions like osteoporosis, so surgeons are extremely selective and careful when evaluating potential surgical candidates.
