RESEARCH ARTICLE

Thoracic Hyperkyphosis: A Survey of Australian

Physiotherapists
Diana M. Perriman1*, Jennifer M. Scarvell1, Andrew R. Hughes2, Christian J. Lueck2, Keith B. G. Dear3
& Paul N. Smith1
1
Trauma and Orthopaedic Research Unit, Canberra Hospital, The Australian National University, Canberra, Australia
2
Department of Neurology, Canberra Hospital, The Australian National University, Canberra, Australia
3
National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia

Abstract
Background. Age-related thoracic hyperkyphosis can lead to poor health outcomes including pain and dysfunction.
Physiotherapists are fundamentally involved in the assessment and treatment of this problem but there is no
published data that details assessment and treatment strategies or the attitudes of practitioners with respect to
hyperkyphosis. Purpose. The purpose of the study is to ascertain current physiotherapy practice for, and attitudes
to, the assessment and treatment of thoracic hyperkyphosis in Australia. Method. A stratied random sample
(N = 468) of Australian physiotherapists in all states and territories working in hospitals, outpatient clinics and
community clinics were sent an anonymous cross-sectional postal survey. The survey had six sections identifying
clinical prole, prevalence, measurement strategy, treatment frequency, treatment strategy and evidence source.
Results. A response rate of 47% with anonymity preserved was achieved. The majority of respondents had a
musculoskeletal practice prole (75%). Seventy-eight per cent encountered hyperkyphosis at least weekly, and three
treatment sessions were most commonly given (35%). Visual inspection was almost universally used to assess the
degree of hyperkyphosis (98%), and for 64% it was their only measurement tool. Postural re-education was the
most common treatment strategy (90%) but the range of treatments reported was diverse. The primary source
of evidence used by the majority of respondents was their undergraduate education, and there was concern
expressed that physiotherapists lack good evidence upon which to make therapeutic decisions about hyperkyphosis.
Conclusions. Thoracic hyperkyphosis is commonly encountered by physiotherapists. Measurement of treatment
efcacy is highly subjective, and the treatment modalities employed are diverse. Many physiotherapists based their
management of hyperkyphosis on their undergraduate education alone. Copyright 2011 John Wiley & Sons, Ltd.

Received 15 June 2011; Revised 4 October 2011; Accepted 16 October 2011

Keywords
physiotherapy; survey; back care

*Correspondence
Diana Perriman, Trauma and Orthopaedic Research Unit, Level 1, Building 6, Canberra Hospital, PO Box 11, Woden, ACT, Australia 2606.
Email: diana.perriman@anu.edu.au

Published online 30 December 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.529

Introduction feature of osteoporosis, up to 70% of people with age-

Thoracic hyperkyphosis is dened as an antero-posterior related hyperkyphosis do not have decreased bone
curvature of the thoracic spine of greater than 40 (Fon mineral density (Schneider et al., 2004). The precise
et al., 1980). Although increased kyphosis is a common population prevalence rates for non-osteoporotic

Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd. 167
Hyperkyphosis Survey
hyperkyphosis are unknown but estimates range from
10% to 45% of people aged over 50 years (Melton
et al., 1993; ONeill et al., 1994), increasing to 50% in
men and 65% in women over the age of 65 years
(Bartynski et al., 2005). This age-related increase in cur-
vature is accompanied by a loss of range of movement
and increased stiffness (Hinman, 2004) and is of par-
ticular importance to the physiotherapist because it is
thought to be associated with pain and dysfunction of
both spine and shoulder (Crawford and Jull, 1993;
Balzini et al., 2003), reduced physical function (Ryan
and Fried, 1997; Cook, 2002; Kado et al., 2005), respi-
ratory compromise (Di Bari et al., 2004), increased risk
of osteoporotic fracture (Huang et al., 2006) and in-
creased mortality rates in the elderly (Anderson and
Cowan, 1976; Tager et al., 2003). Thoracic hyper-
kyphosis therefore represents a major health issue. It
is very common and is a cause of signicant morbidity,
and there is a pressing need for effective treatment
strategies.
Various treatments for reducing the degree of
hyperkyphosis have been proposed. The efcacy of
some has been assessed but the results are unclear.
For example, a Pilates-based programme signicantly
reduced hyperkyphosis but the effects were short lived
(Kuo et al., 2009). Similarly, taping was shown to re-
duce hyperkyphosis while the tape was in place but
whether this effect persisted after removal of the tape
was unclear (Greig et al., 2008). Yoga reduced hyperky-
phosis if it was measured by a exicurve, but not when
it was measured by a kyphometer (Greendale et al.,
2009). Prone extension exercises were ineffective (Itoi
and Sinaki, 1994). To date, only two studies have
reported a sustained decrease in kyphotic curvature:
one involved multiple extension exercises (Ball et al.,
2009), and the other involved a combination of
postural re-education, motivational interviewing, a
stretching programme and progressive resistive
strengthening (Katzman et al., 2007). Unfortunately,
neither trial was randomized nor controlled.
Well-designed randomized controlled trials are
therefore needed to determine the effectiveness of the
various interventions aimed at reducing hyperkyphosis.
In order to inform the design of such trials, it is impor-
tant to ascertain which treatments are currently being
used by physiotherapists. To our knowledge, this has
not been surveyed previously.
Accordingly, the aim of this survey was to determine
the current practice of Australian physiotherapists
168
D. M Perriman et al.
regarding the assessment and treatment of thoracic
hyperkyphosis in terms of reducing the angle of curva-
ture. We also aimed to determine how frequently it was
encountered in routine practice, how many treatment
sessions were typically assigned by physiotherapists to
address the problem, and what educational experience
underpinned their practice.
Methods
Study design
The study was an observational, cross-sectional postal
survey, stratied by practice type and jurisdiction. Ethics
approval was granted by the ACT Health Human
Research Ethics Committee and by The Australian
National University Human Research Ethics Committee.
The questionnaire
Development
The questionnaire consisted of six questions so as
to maximize the response rate (McLennan, 1999)
(Appendix 1).The questions were formulated in order
to inform a larger trial of treatment for kyphosis being
undertaken by the authors. A pilot survey was sent to
eight experienced, but non-practicing, physiotherapists
with a request to complete and comment. The
comments and mode of completion led us to modify
the questionnaire by making Question 5 free text
(Appendix 1). The free text option was chosen in order
to avoid bias resulting from the pursuit of prestige
(Alreck and Settle, 1995), whereby respondents select
options they believe they should be using rather than
those they actually do use. The free text responses were
classied by two experienced physiotherapists into
seven categories (Appendix 2). The treatments included
in the rst six of these categories were those that aimed
to reduce the angle of kyphosis, whereas strategies such
as acupuncture, electrotherapy, breathing exercises and
general exercise were allocated to the other group be-
cause they addressed secondary effects. The level of
agreement between the assessors with respect to their
allocation of the responses to the same category was
assessed on a random sample of ve responses.
Sampling design
The questionnaire survey was distributed to phy-
siotherapists working in Australian clinics and
Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
D. M Perriman et al.
hospitals. The sample was stratied by jurisdiction (the
eight states and territories of Australia) and by place of
work (clinical group), that is hospital, community
health centre (CHC), or private practice (PP), generat-
ing a total of 24 strata. Stratication enabled us to sur-
vey similar numbers of physiotherapists in each state. It
also allowed us to include similar numbers of hospital,
CHC and PP physiotherapists who might otherwise
have been under-represented. Physiotherapy clinics
and hospitals were identied by searching State Health
Department websites. Private practitioners names were
identied by searching the telephone directory. This
strategy was employed to avoid biasing the sample by
the use of selective lists requiring membership (e.g.
the Australian Physiotherapy Association) and the
potential for a high percentage of incorrect contact
details in registration board lists (Grimmer-Sommers
et al., 2007). Twenty-one physiotherapists in each stra-
tum were randomly selected to receive questionnaires
using a random number generator to determine which
names to select from the compiled lists. In the Austra-
lian Capital Territory, the Northern Territory and
Tasmania, there were too few eligible physiotherapists
in some clinical groups to send the full quota of 21
questionnaires. In these cases, the maximum number
possible was dispatched.
Each questionnaire was labelled with the target
state and practice type but not the name of the thera-
pist or the clinical site. This strategy ensured ano-
nymity while permitting accurate identication of
the stratum when returned.
Data analysis
The responses were examined as a function of jurisdic-
tion, clinical group and also patient prole as per Ques-
tion 1 (Appendix 1). A Fishers exact test or w2 test was
used to test for differences between groups for all of the
data, and two sample t-tests were used to compare
discrete groups when the data were continuous (e.g.
treatment frequency for physiotherapists with a mus-
culoskeletal patient prole compared with those with
either a mixed, neurology, respiratory or other pro-
le). Content analysis was used to categorize the
responses to Question 5 (treatment) and to theme
the comments received from the respondents. The
treatment categories emerged from the free text
responses to Question 5 but were deliberately conned
to a restricted number in order to permit meaningful
Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
Hyperkyphosis Survey
description and analysis. The respondent comments
were themed until no further ideas emerged. A
Pearsons correlation coefcient was used to examine
the agreement between two assessors in the allocation
of the treatment modality responses to one of seven
categories (Appendix 2). The results indicated an excel-
lent agreement (r = 0.88; p < 0.0001).
Results
A total of 468 questionnaires were sent out. Of these,
228 were returned but eight were void (returned with
no responses), leaving 220 (47%) for analysis. A few
of the respondents offered comments for which the
themed responses are presented in Appendix 3.
Question 1 patient prole
Of the 220 respondents, three quarters reported that they
saw mainly musculoskeletal patients. Of the remainder,
most had a mixed patient prole: a few saw primarily
neurological or respiratory conditions and 6% fell into
the other group which included womens health, hand
therapy or unspecied.
Question 2 prevalence of thoracic
hyperkyphosis in the clinic population
Two hundred and sixteen physiotherapists responded
to this question. Regardless of clinical group, 78% of
respondents reported seeing patients with hyperkypho-
sis at least once a week. Of these, 40% saw such patients
daily (Table 1). There was no signicant difference
between the three clinical groups.
Question 3 identication and
measurement of hyperkyphosis
Five respondents did not answer this question. The vast
majority of respondents to this question (98%)
reported using visual inspection to measure the degree
of hyperkyphosis and, of these, 66% used it exclusively.
The next most common tool was a lateral X-ray (21%).
The other measurement modalities used are shown in
Table 2 including occiput-to-wall distance, temporo-
mandibular-to-wall distance and passive physiological
intervertebral movement, which were responses
detailed in other for Question 3. A signicantly larger
proportion of CHC physiotherapists (33%) used X-ray
169
Hyperkyphosis Survey D. M Perriman et al.

Table 1. Frequency with which kyphosis was encountered in

clinical practice as a function of the different clinical groups

CHC (%) PP (%) Hosp (%) Total

Daily 23 (45%) 35 (42) 28 (34) 86 (40)

Weekly 17 (33) 34 (41) 31 (37) 82 (38)
Monthly 6 (12) 11 (13) 18 (22) 35 (16)
Yearly 3 (6) 0 (0) 5 (6) 8 (4)
Never 2 (4) 3 (4) 0 (0) 5 (2)
Total 51 (100) 83 (100) 83 (100) 216 (100)
No response 1 2 1 4

CHC = Community Health Centre; PP = Private Practice;

Hosp = Hospital.

Figure 1 Number of treatment sessions that respondents indi-

Table 2. Number of respondents (n = 220) who selected the cated that they would use to treat a patient with thoracic kyphosis.
various measurement tools The median was three treatments and the range was 012

Hyperkyphosis measurement tools A B C

number of treatments devoted to ameliorating the
Visual inspection 210 141 210
X-ray 45 2 43
angular changes alone difcult.
Tragus-to-wall distance 24 1 23
Photography 15 1 14
Inclinometry 3 0 3
Question 5 treatment strategies
Occiput-to-wall distance 2 0 2 Thirteen respondents did not answer this question. In
Passive physiological intervertebral movements 1 0 1
Temporomandibular jointto-wall distance 1 1 0
total, the respondents listed 32 separate strategies,
Flexicurve 1 0 1 with each listing an average of four. As aforementioned,
Plurimeter 0 0 0 the responses were collapsed into eight categories
Electrogoniometry 0 0 0 (Appendix 2). The majority of those who responded
No response 5 - -
selected postural re-education (90%) followed by
Column A indicates all of the respondents who selected that tool; column stretching (71%), strengthening (64%) and joint mobi-
B, those where the tool was the only one selected; and column C, those lization (53%) (Table 3).
who selected the tool in conjunction with visual inspection. All of the
respondents who used more than one tool used visual inspection.
Table 3. Number of respondents (n = 220) who selected the
various treatment categories
to evaluate hyperkyphosis than either PP (19%) or
hospital (14%) (Fishers exact test, p = 0.03). Treatment category A B C

Postural re-education 191 3 191

Question 4 treatment frequency Stretching 133 1 120
Strengthening 131 1 118
Fifty respondents (23%) did not answer this question. Of Joint mobilization 110 0 101
those that did, the estimated number of sessions ranged Soft tissue mobilization 30 0 29
Bracing 11 0 11
between 0 and 9 with 35% opting for three sessions and
Other 26 0 25
22% for four (Figure 1). Compared with other patient no response 13 - -
prole groups, musculoskeletal physiotherapists reported
Whether the respondent chose a modality within the category once or
that they would allocate signicantly more treatment ses-
multiple times they were allocated just 1. Column A shows the total
sions to thoracic hyperkyphosis (3.6  1.4 vs 2.0  1.8,
number of respondents who chose the category indicated; column B
two-sample t-test of musculoskeletal patient prole the number who selected modalities within the single category only;
group versus not musculoskeletal, p < 0.0001). Forty- and column C shows the number of respondents who chose the
six per cent of the respondents who commented modality in conjunction with Postural re-education. The vast majority
(Appendix 3) indicated that hyperkyphosis was never of respondents selected multiple treatment categories and postural
the only presenting problem-making estimation of the re-education was selected most often.

170 Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
D. M Perriman et al.
There were no signicant differences between any
of the strata (jurisdiction and clinical group) regard-
ing use of postural re-education, stretching or
strengthening, nor was there an effect by patient pro-
le (Question 1). Joint mobilization and soft tissue
mobilization were only used by musculoskeletal or
mixed clinical prole respondents, and signicantly
more musculoskeletal physiotherapists used joint
mobilization compared with mixed prole physiothera-
pists (p < 0.001). There was a signicant difference
between practice groups in their use of braces
(p = 0.007). Hospital physiotherapists did not use them
at all, whereas 9% of PP physiotherapists and 6% of
CHC physiotherapists did. With respect to the number
of strategies used to treat thoracic hyperkyphosis, there
were no signicant differences between practice groups
but musculoskeletal physiotherapists used signicantly
more treatment modalities than those in other patient
prole groups (mean 4.2  1.8 vs 3.3  2.3; two-sample
t-test, p = 0.002).
Question 6 evidence supporting
treatment decisions
Eleven respondents did not answer this question. Of
the remainder, 69% reported using knowledge
gained from their undergraduate education, 42% cited
recent professional development opportunities (RPD),
34% had read relevant material, 20% reported using
clinical experience, 4% of the respondents had
performed research in the area, and 4% utilized knowl-
edge from post-graduate education (response entered in
other). There were no signicant differences between
strata.
Discussion
The aim of this study was to investigate how phys-
iotherapists in Australia assess and manage thoracic
hyperkyphosis. There were four major ndings. First,
thoracic hyperkyphosis is encountered by most phys-
iotherapists on a daily or weekly basis but it is often
not the main complaint. Second, most physiotherapists
assess hyperkyphosis using visual inspection alone.
Third, the most widely used treatment modality is pos-
tural re-education and the majority of physiotherapists
allocate an average of three treatment sessions to
ameliorate the problem. Finally, the most commonly
selected evidence on which physiotherapists base their
Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
Hyperkyphosis Survey
treatment decisions in this area is their undergraduate
education. A number of respondents commented that
they felt under-informed about the effective manage-
ment of hyperkyphosis. To our knowledge, this is the
rst time this subject has been investigated.
Prevalence
The prevalence of hyperkyphosis in the population of
patients presenting to Australian physiotherapists is
high. Over 70% of all respondents encountered hyper-
kyphosis at least once a week, and over 40% of those
working in hospitals or private practice encountered
it daily. These ndings are consistent with previously
published studies (Bartynski et al., 2005). Given that
the prevalence of hyperkyphosis is so high and that
there is evidence that it is profoundly detrimental to
function in older people (Kado et al., 2005), we believe
that this condition should be given a higher priority
than it has received in the past.
Assessment
The majority of physiotherapists used visual inspec-
tion alone to assess both magnitude and change in
hyperkyphosis. Even under the most controlled con-
ditions and with the assistance of photography, visual
inspection has been shown to demonstrate substantial
intra-observer variability (Arnold et al., 2000; Dunk
et al., 2004; Dunk et al., 2005), which makes it a very
inaccurate assessment tool.
The clinical standard method of measuring hyper-
kyphosis is the Cobb angle, which is derived from lat-
eral X-ray (McAlister and Shackelford, 1975), and this
was used by 21% of physiotherapists. Unfortunately,
the level of radiation exposure means that this is not
a practical tool for repeated assessments.
Many of the other tools cited by respondents are also
sub-optimal for the measurement of hyperkyphosis.
These include tragus-to-wall and occiput-to-wall mea-
surements (Raine and Twomey, 1997; Arnold et al.,
2000). Photography is only reliable in highly controlled
conditions when combined with skin markers (Leroux
et al., 2000; van Niekerk et al., 2008).
Paradoxically, very few objective measurement tools
that have been validated for the thoracic spine were in
day-to-day clinical use. Inclinometry has been reported
to have excellent day-to-day reliability (Mellin, 1986),
although it may lack accuracy (Loebl, 1967).
171
Hyperkyphosis Survey
The exicurve provides an accessible, objective mea-
sure that is suitable for use in physiotherapy practice. It
is an inexpensive and relatively reliable tool (Caine
et al., 1996; Lundon et al., 1998; Arnold et al., 2000;
Yanagawa et al., 2000) but it is rarely used. Our survey
showed that less than 1% of respondents used the exi-
curve, suggesting that clinicians are either unaware of
the instrument or nd the method too time consuming.
The exible electrogoniometer has been validated for use
in the thoracic spine (Perriman et al., 2010), but it is
expensive and relatively novel so that it is not very
surprising that none of the respondents indicated that
they used it. Other reliable instruments such as the
kyphometer (Ohlen et al., 1989) and the spinal mouse
(Mannion et al., 2004) were not included in the list of
options on the questionnaire and were not identied
by any of the respondents. Although these instruments
are expensive and therefore currently used for research
rather than clinical practice, their use by clinicians would
provide greater objectivity in the assessment of hyperky-
phosis and responses to different treatment approaches.
In summary, use of validated and accurate measure-
ment tools is still relatively rare.
Treatment strategies
The physiotherapists who participated in this study
reported a total of 32 different treatment strategies. In
reality, there is no strong evidence to support any of
them. The most frequently utilized category was postural
re-education followed by stretching and strengthening.
Although specic postural training with recruitment of
deep postural muscles has been shown to be effective
in the neck and lumbar regions (Hides et al., 2001; Jull
et al., 2002; Falla et al., 2007), the effectiveness in the
thoracic region has not been convincingly demonstrated.
Only two studies have demonstrated a signicant im-
provement in kyphotic angle after a therapeutic exercise
programme. The rst was a multimodal intervention
study that generated a sustained 6 change (Katzman
et al., 2007; Pawlowsky et al., 2009), and the second used
multiple extension exercises (Ball et al., 2009). Unfortu-
nately, neither trial was randomized nor controlled.
Joint mobilization for thoracic hyperkyphosis has
never been critically assessed. Nevertheless, it was used
by 50% of respondents, particularly those with muscu-
loskeletal or mixed patient proles. Joint mobilization
can ameliorate pain (Sterling et al., 2001), but there is
no evidence to support its use as a technique for
172
D. M Perriman et al.
reducing hyperkyphosis per se. Similarly, although
14% of the respondents reported using soft tissue mas-
sage, there is no published evidence to support its ef-
cacy. Similar to joint mobilization, only respondents
with either musculoskeletal or mixed patient proles
reported using it suggesting that the selection of these
two modalities may be based more on familiarity than
knowledge of their effectiveness.
A few respondents used braces. There is some evidence
that braces may be effective for reducing hyperkyphosis
after vertebral fracture (Pizzutillo, 2004) and, somewhat
counter-intuitively, one study reported increased back
strength after wearing a particular brace (Pfeifer et al.,
2004). However, the use of bracing in the non-traumatic
situation has not been studied. Of note, hospital phys-
iotherapists used braces less frequently than the other
groups, perhaps because of resource limitations.
Treatment frequency
The number of treatments needed to effect a sustained
change in posture is unknown. About a quarter of
respondents in our study nominated three sessions
but a similar number chose not to answer the question
at all. On the basis of accompanying comments, the
high non-response rate appeared to be due to the fact
that many of the respondents felt unable to separate
the treatment for hyperkyphosis from other treatment
modalities, which were specically aimed at the pre-
senting problem. In reality, three treatment sessions is
a very small number to treat a problem that develops
over a lifetime. Interestingly, musculoskeletal phy-
siotherapists, who conceivably might have more skill
and experience in the area, allocated signicantly more
sessions than the other patient prole groups.
In summary, our study has demonstrated a need for
future studies to determine the optimum method and du-
ration of treatment for reducing thoracic hyperkyphosis.
Evidence supporting clinical decisions
As aforementioned, evidence regarding the best
method of reducing thoracic hyperkyphosis is very lim-
ited (Kado et al., 2007). In our study, the majority of
respondents indicated that they relied on their under-
graduate education to inform their practice. This
accords with previous research, which found that over
90% of physiotherapists surveyed said that their choice
of treatment techniques reected what they were taught
Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
D. M Perriman et al.
during their initial training (Turner and Whiteld,
1997). Since this survey was conducted, evidence-based
medicine has become more widely taught in physio-
therapy programmes and emphasized in post-graduate
education. However, the comments that accompanied
some of the responses clearly reect a need for more
information and evidence in this area.
Limitations
The main limitation of this study is that the response
rate was relatively low, although it was comparable with
other surveys of the target group (Meakin et al., 2008;
Chipchase et al., 2009). Our low response rate (47%)
was probably primarily due to the fact that we made
the questionnaire anonymous, which has been reported
to reduce rates by up to 16% (Asch et al., 1997). In ad-
dition, we did not do follow-up mailings out of respect
for the respondents who had completed and returned
the forms (anonymity meant we were unable to target
non-responders) and also for future researchers who
would potentially be negatively impacted by respon-
dent fatigue. What constitutes an acceptable response
rate has been hotly debated (Asch et al., 1997; Dey,
1997; Barclay et al., 2002). Response rates can be low
as long as the respondents are representative of the
group as a whole and there is no suspicion of bias
(Asch et al., 1997; Dey, 1997). In our survey, the strat-
ied design protected us against potential bias by en-
suring that smaller geographical and practice areas
were well represented. Further evidence that our re-
sponse group was not biased lies in the fact that 75%
of our sample had a musculoskeletal prole similar to
the proportions reported in larger surveys of clinical
physiotherapists (McMahon et al., 2006).
Conclusion
In conclusion, this study has shown that the problem of
hyperkyphosis is highly prevalent with most Australian
physiotherapists encountering it at least weekly.
Although it has been shown to be inaccurate, most
respondents still used visual inspection as their only
measurement tool. The respondents in this study iden-
tied 32 separate treatment modalities for hyperkypho-
sis, the most common being postural re-education
followed by stretching and strengthening. Joint and soft
tissue mobilizations were only used by musculoskeletal
physiotherapists. Finally, the majority of respondents
Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
Hyperkyphosis Survey
relied on their undergraduate education to inform
their practice with respect to thoracic hyperkyphosis,
a number of respondents commenting that they felt
under-informed in the area.
Implications
There are two implications of this study. First it con-
rms the high prevalence of thoracic hyperkyphosis
and provides evidence that among treating phy-
siotherapists there is a general lack of knowledge with
respect to managing hyperkyphosis. Second, it provides
baseline data about the actual patterns of clinical prac-
tice and these will, in turn, help to inform the design of
future randomized controlled trials which seek to exam-
ine the efcacy of specic treatments for this condition.
Acknowledgements
This work was supported by the Canberra Hospital
Private Practice Fund. Diana Perriman acknowledges
NHMRC for her PhD scholarship grant.
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Hyperkyphosis Survey D. M Perriman et al.

Appendix 1 The questionnaire

Thoracic Kyphosis Questionnaire

Question (Circle most appropriate response and add notes as desired).

1. Which of the following would best describe your patient prole?

a. mostly musculoskeletal

b. mostly neurological

c. mostly respiratory

d. equally mixed patient prole.

e. Other. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

2. How often do you encounter increased thoracic kyphosis in your patient population over 40 years of age?

a. every day

b. once a week

c. once a month

d. once a year

e. never* (Please specify whether you do not see kyphosis OR people over 40)
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

*If you never see thoracic kyphosis or patients over 40 you need continue no further. Thank you for taking the time to complete this
questionnaire. Please return the questionnaire in the enclosed stamped self addressed envelope.

3. How do you identify and/or measure thoracic kyphosis? Please use the adjacent line if you wish to comment on the technique used for
example which position is used.

a. Visual inspection. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

b. X-ray (Cobb angle). . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

c. Inclinometer. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

d. Plurimeter. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

e. Photography. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

f. Flexicurve. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

g. Electrogoniometry. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ..

h. Tragus to wall measurement. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

i. Other. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ...

4. On average, how many times would you treat someone for thoracic kyphosis?
a. once only

(Continues)

176 Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
D. M Perriman et al. Hyperkyphosis Survey

b. twice only

c. three times

d. four times

e. ve times

More than this (please specify). . .. . .. . .. . .. . .. . .. . .. . ... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ... . .

5. What strategies do you use to treat patients who have poor thoracic posture whether it is related or unrelated to their presenting problem?
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .
. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

6. On what basis do you make your decisions about how to assess and treat people with increased thoracic kyphosis?

a. Undergraduate training

b. Recent professional development

c. Own reading of the literature

d. Personally conducted clinical research in this area

e. Other . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .

Additional Comments.

Thank you very much for taking the time to respond to this questionnaire, I very much appreciate your efforts. Please place in the envelope
provided and post back ASAP.

Appendix 2 Respondents view of the increased computer use in the commu-

comments nity, particularly in the young. (12/48)
The posture of the thoracic spine is a key to the suc-
Forty-eight of the respondents generously offered addi- cessful management of all spinal problems and is
tional comments. The majority fell into seven main areas. often overlooked. (5/48)
Thoracic kyphosis encountered in older patients (or
Thoracic kyphosis is not actually the reason that pa- over 40s) is related to osteoporosis (crush fractures)
tients present to a physiotherapist. Patients present and the postural changes are difcult to inuence
with cervical, shoulder or lumbar pain, headache with physiotherapy modalities. The focus is more
and/or thoracic pain. The treatment of kyphosis is on preventing falls. (5/48)
therefore used to reduce pain in the presenting area Balance and exercise classes such as Tai Chi are the
rather than because it needs treating in its own most effective modality for postural problems in the
right. (22/48) elderly. (4/48).
The management of thoracic kyphosis is an area Thoracic kyphosis is primarily the result of increased
that physiotherapists feel unsure about. There is a cervical lordosis. (3/48).
feeling that more research would be very helpful. Mobilisations are useful for pain relief in the thoracic
Addressing thoracic kyphosis now is very timely in region. (3/48).

Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd. 177
Hyperkyphosis Survey D. M Perriman et al.

Appendix 3 The treatment categories

Category Individual treatment modality Number of respondents

Postural Postural re-education 164

re-education Thoracic extension general 60
Taping 41
Ergonomics 28
Neck retraction 20
Alexander technique 1
Scapular retraction/repositioning 1
Stretching General postural stretches/ROM 70
Thoracic extension - local/towel or roll device 42
Pectoral stretch 23
Thoracic rotation 17
Hip/lower limb stretches 3
Muscle energy technique 2
Neural tension release 1
Strengthening General postural strengthening 73
Scapular stabilization 36
Core stability 27
Resisted scapula retraction 17
Resisted thoracic extension 16
Hydrotherapy 12
Shoulder exercises 11
Yoga 2
Resisted neck retraction 1
Joint mobilization Joint mobilization/manipulation 108
Soft tissue mobilization Soft tissue mobilizations 29
Bracing Back brace 11
Specialist bra 1
Other Breathing exercises 7
Electrotherapy 10
Acupuncture 1
Regular exercise advice 10
Balance/coordination exercises 1
No response No response 13

The individual treatment modalities selected by the respondents were placed in the eight categories. The numbers indicate the number of
respondents who reported using the modality.

178 Physiother. Res. Int. 17 (2012) 167178 2011 John Wiley & Sons, Ltd.
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