Assessing & Answering Clients’ Varied Needs
- By Laurie Watanabe
- Apr 01, 2011
Kyphosis is, according to the U.S. National Library of Medicine, “a curving of the spine that causes a bowing or rounding of the back, which leads to a hunchback or slouching posture.” Sounds basic enough. But the challenges that kyphosis can present to seating & mobility professionals are numerous and varied in nature.
Add to that the fact that clients with kyphosis can be of any age and have a range of diagnoses, and the challenges for the rehab team keep mounting.
Understanding the Causes of Kyphosis
Lois Brown, MPT, ATP, rehab clinical education specialist for Invacare Corp., says kyphosis “is usually described as a pathological forward or anterior curvature of the spine with a noted convex posterior curvature.” She adds that kyphotic postures can be the result “of a degenerative disease such as arthritis, developmental diagnoses, osteoporosis with compression fractures, musculoskeletal weakness, and associated postural asymmetries, such as a posterior pelvic tilt of the pelvis. This is typically seen in clients who, due to poor postural control, have decreased ability to maintain an upright sitting posture due to weakness, abnormal tone, or orthopedic changes.”
Ryan Hagy, OTR/L, ATP, sales director of the western United States for Quantum Rehab, says, “The primary issue with kyphosis is it’s really related to a root cause, typically, of decreased strength or muscle tone in the trunk.” Among pediatric clients, expect to potentially see kyphosis “with your muscular dystrophy populations, your Duchenne kiddos, your multiple sclerosis kids, even with cerebral palsy and spina bifida.”
Among adults, Hagy says, “You’ll typically see it in the elderly population, because that’s where (you’ll see) longer effects from gravity, just weighing down on you. The spine will just start to bend in that direction.”
Brown adds, “With aging and a loss of musculoskeletal integrity, and the effects of gravity, an older adult may develop a hyperkyphosis or ‘dowager’s hump,’ and associated vertebral fractures are usually present. One of most common postures observed in long-term care facilities, it is the loss of a normal lumbar curve, rounded shoulders, thoracic kyphosis, and lower cervical fl exion with upper-cervical extension. Oftentimes it’s the seating systems and ‘our’ interventions that can cause or aggravate the posture.”
It’s important, Hagy says, to determine the root cause of the kyphosis, which can impact the rehab team’s technology recommendations.
“What is truly causing the kyphosis in the person?” he asks. “If it’s a bone issue, you have to figure on potential fractures in the future, if they have a history of them, and how to protect the bones — versus if it’s a low-tone, no-trunk-strength issue. It’s a different strategy.”
The Impact of Kyphosis
The impact of kyphosis goes far beyond seating.
For instance, Hagy says of children with Duchenne muscular dystrophy, “As they get farther and farther along, they’re really, really kyphotic. Sometimes their chests are almost on their knees. They usually end up passing away from respiratory (issues) because they don’t have the capacity they used to, and pneumonia can find its way into the areas of the lungs they’re not using anymore.”
Therefore, an important seating question, he says, is “How straight can we get them up, and how straight can they be and still maximize their respiratory capacity?”
Hagy says neck problems are also common: “I see a lot of neck issues in the elderly population. And with Duchenne’s kiddos, once they get that fixed kyphotic posture, you see them driving around in 25 to 30 degrees of tilt because when they’re hunched over that far, they have to tilt back just to be able to see straight ahead. They’re compensating in other ways for letting the kyphosis run its course.”
“Due to the impact kyphosis has on head position, respiration, and swallowing, minimizing the effects of a kyphosis becomes paramount,” Brown says. “Beyond that, there are many significant reasons to align the head and eyes to a horizontal position, where the individual can interact with others, navigate the environment, and operate a wheelchair or speech device or computer.”
Of course, kyphosis also causes a range of seating difficulties.
“Some common associated movements or positions are increased flexion at hips in sitting, flexion in the thoracic area, flexion of the shoulder (rounded), increased or floppy tone, abdominal weakness, poor trunk control, and/or weak back extensors,” Brown says. “In addition, increased tone can cause the pelvis to be pulled back (i.e., hamstrings) into a posterior tilt.
“Further, the individual may have developed a functional postural tendency to sit in a posterior tilt to gain overall postural stability. Related to the wheelchair fit, this postural asymmetry may be attributed to a lack of sacral support, use of sling back upholstery, or armrests that are positioned too low or too high, whereby the patient rolls forward in the trunk to place forearms on the armpad for support. Another cause can be the backrest being too high and pushing the individual forward in the seating system.”
While clients with kyphotic postures may not be at increased risk of pressure ulcers compared to other clients, their kyphosis does cause pressure points in different locations.
“Typically, it’s a little harder to do a push off the armrest to relieve some weight off the ITs,” Hagy says. “But leaning farther forward, that’s actually a great pressure relief off your ITs and your sacrum. So inadvertently, they’re doing a little bit of that.
“We need to look at some different sites, like the apex of the curvature — you might look for some pressure ulcer development around there. We need to make sure the backrest is a proper fit for them, whether it be a mold or one adjusted properly for them off the shelf, or built by a seating system manufacturer, making sure that it fits them properly so we’re spreading the surface area out over their entire back and really relieving that spot.”
Assistive Technology Responses
Kyphosis is typically progressive, Hagy says.
“You always try to put them in the most supportive system to slow down the process of the kyphosis,” he explains. “But you’re really trying to limit the impact, limit the progression, because it truly is gravity pulling them down and pulling down on that spine. Gravity is not going away, so it depends on how well they can typically manage throughout the day, whether it be in that seating system or getting into different positioning — beds or side-lying or whatever it may be to take (weight) off that spine as much as possible. It really is how much they can slow that progression down.
“I don’t think you’re ever really going to stop it. Doctors will do rodplacement surgeries; they’ll physically correct it. Then again (the clients are) just weighing on those rods now. They still have the underlying issue: no tone in the trunk, or the fractures in the spine. That’s not going away, and they didn’t correct themselves. They’re still there.”
Fortunately, seating & mobility technology can help.
“The overall goals when addressing kyphosis,” Brown says, “are to prevent further spinal deformity, prevent respiration and swallowing/digestion difficulties, neutral alignment of the trunk over the pelvis, have increased head control without having to work hard to hold the head up, pressure distribution over the posterior trunk, and improve the client’s visual field.”
As an example, she says, “When measuring and trialing backs for upper-thoracic support, try to have the back height fall below the inferior angle of the scapula. This allows upper-thoracic extension and promotes excursion of the scapula through shoulder movement. Support ending at shoulder height for clients who may use tilt in space — support with caution to (avoid) an increased shoulder protraction, which can increase kyphosis.”
Brown says it is “Cliché but true: Improving postural control and addressing a kyphosis begins with pelvic stabilization. The two common terms used when talking about management of kyphosis is to ‘correct’ a ‘fl exible’ curvature, which may apply to musculoskeletal weakness in the young population, but in relative terms means to minimize the progression — versus ‘accommodate’ a fixed posture.”
To correct flexible postures, Brown suggests, “There are several factors that need to be addressed. Determine the location and amount of support to achieve a balanced head/shoulder posture. Be the least restrictive. In other words, try to create postural stability and accommodation through the seating system before moving toward more restrictive external positioning components.
“The worst things I ever saw in the clinic would be the kids that would come in, and they’d be almost dumped out sideways underneath a lateral on their chair,” Hagy says, adding that he’d wonder, “How did you get there? Why is that (lateral) even there? Where did we go wrong?”
“The key is to get to the root of problem,” Brown acknowledges. “It is imperative that you observe and try to understand why the person is sitting the way they are.
“Let’s say they have tight hip flexion with resultant posterior pelvic tilt and associated mild/moderate thoracic kyphosis. They come into the clinic ‘slumped’ in a standard manual chair with a fixed seat-toback angle and a hard-shell linear back. How do you know if it’s their body that does not fit the existing chair, or if the chair is contributing to
The answer, Brown says, is “The client must be evaluated out of the wheelchair in order to determine limitations in range of motion at the hips and knees and spinal alignment, specifically their true passive range of motion and fl exibility of their pelvis and spine. Look for the apex of curve, noting that the center of gravity of the upper torso is T9. This is a common area to see the apex, but is not exclusive.
“The primary concern is to disperse pressure away from the apex, considering depth of contour and surface materials used to allow immersion and envelopment. A clinical decision will need to be made whether an ‘off-the-shelf’ or ‘custom’ molded back will be necessary to address the severity of the kyphosis.”
Brown also says clinicians and providers can work to establish “three-point control” of the kyphosis, “much like for a scoliosis, by creating three contact points. This is accomplished by a firm backrest, anterior shoulder or chest support (last resort), and stabilizing the pelvis anteriorly and posteriorly.
“For instance, ensure the back is contacting the individual at the lumbopelvic junction, and utilize an appropriate positioning belt, such as a two-point or four-point belt. It is extremely important to consider the degree of pull at the hips to decrease the tendency to slide. Often times a 60° pull is effective to prevent sliding, but it is very individual. Also consider the use of a cushion that has a posterior shelf to provide more sacral control to prevent the associated posterior pelvic tilt.”
More aggressive support options, Brown says, include a soft or hard thoracic lumbar spinal orthosis (TLSO), which the seating system would be designed to accommodate.
“If the patient is transitioned out of the TLSO, the seating system would need to be modified to provide further external support,” Brown adds. “Other times, an abdominal binder or corset is used to assist with weak or absent abdominal musculature which can often, along with seating components, improve physiology as well as posture.”
Brown recommends trying to use the seating system to bring about resolutions: “Before considering external supports such as anterior trunk support, shoulder straps, shoulder retractors (in severe cases whereby respiration and swallowing would be affected), butterfly vest or upper-extremity support surface, go back to the pelvis and seating system as a first attempt to accomplish alignment. It is less restrictive, and oftentimes external components are not utilized consistently by caregivers, resulting in poor postures.”
For “fixed” postures, Brown says, “Consider the position of head over shoulders in functional midline position, and determine where the pelvis must sit to accommodate this posture. For instance, if the thoracic kyphosis is severe with associated posterior pelvic tilt, and you tried to place the hips at 90 degrees, you would cause the person to fall forward in the seating system and accentuate the forward lean of the trunk and head into a non-functional position. The goal is to establish a posture where the individual can achieve a consistent posture, comfort, and enhance functional ability, such as improving upperextremity functional reach. Utilizing a contoured/curved back with different depth contours, depending on the shape of the kyphosis, and tilt/recline angles will be the first line of defense. Use an adjustable drop base, modular back with angle-adjustable hardware. Providing tilt in the seat/frame and opening the back angle changes orientation of the visual field, which provides sacral support, adjusts thoracic extension, shoulder retraction and head positioning. A tilt and/or recline system provides ‘gravity-assisted’ positioning and is adjusted until the head is able to maintain upright position without significant effort.”
Respecting Comfort & Function
Regardless of which strategies are chosen by the rehab team to address kyphotic postures, Hagy says, “The clinician or provider is truly looking at how (the client is) going to function — what is their best functional position? — and also function as it relates to comfort. If we can kind of straighten them out, it may not be the most comfortable position for them — so they’re just going to migrate out of that position anyway, or they’ll wedge more pillows behind them or do something different. So we have to try to walk that balancing act between the best functional position we can possibly find and also the most comfortable position.”
Brown concurs that “correcting” a kyphosis needs to work on several levels.
“When ‘correcting’ the client into the desired position, determine if the position is tolerable and provides more function,” she says. “Then determine how much force is required to hold this position — minimal, moderate, maximum. If you are applying a degree of force that is difficult to maintain, it will be a challenge to support with external components.
“There is also a greater risk of pressure with additional contact points on the body. Generally, moving approximately 5° from the end range can ease pressure and increase compliance and tolerance. Ask yourself if the final position is one where they can swallow, communicate, breathe and function. And finally, is this position repeatable by more than one caregiver for consistency of positioning? Will it work with slings and lifts?”
Hagy also emphasizes that this is a client population that will need to be re-assessed frequently: “These are definitely clients that (need) following up with, not just every five years when they need a new seating system, but on a more regular basis because their posture is changing.”
And as those postures change, providers and clinicians will need to continue to strike a balance between form and function/comfort. “Even if we can correct them perfectly, if they’re not comfortable or functional in that position, that’s not going to be the best place to put them,” Hagy says. “We always try to put them in the most optimal postural alignment, but also while optimizing function. We can make them look pretty, but if they can’t do anything, it doesn’t matter.”
This article originally appeared in the April 2011 issue of Mobility Management.