Kyphosis: Correct or Accommodate?
Kyphosis Is a Common Postural Problem for Wheelchair Users, But Seating Approaches Vary from Client to Client
- By Laurie Watanabe
- Jun 01, 2020
KYPHOTIC SPINE LATERAL VIEW: DEPOSITPHOTOS.COM/CLIPAREA
Kyphotic postures are common among clients who use
Complex Rehab Technology (CRT) wheelchairs. But
that commonality doesn’t simplify how kyphosis should
be addressed, because it can be caused by a number of
different factors… and because, of course, every CRT client
has a unique history and a unique set of personal goals.
Which can make addressing kyphosis — and
addressing whether to accommodate it or try to correct
it — challenging.
How Kyphosis Presents
“Kyphosis is an exaggerated, forward rounding of the
back,” said Linda Bollinger, PT, DPT, ATP, Clinical
Education Manager for Sunrise Medical. “It can occur
at any age, but over time will result in the vertebrae
becoming more wedge shaped. A person sitting in
a kyphotic posture will present with a +sagittal
pelvic angle (posterior pelvic tilt), rounding of
the trunk and neck, and a forward head. Some
progress to sitting on the sacrum, which can
lead to pressure injuries.”
Tricia Garven, MPT, ATP, Regional
Clinical Education Manager at Permobil, said a seated kyphotic posture “usually looks like someone with
a rounded shoulders and upper back. Often, someone with a
kyphosis will have a forward head position that is looking down
towards their lap — or maybe a hyperextended cervical spine,
so they can still see in front of them. Kyphosis can definitely be
progressive in nature due to the natural changes with advanced
age (weight gain, decreased strength/endurance, bone mineral
density changes in the spine, etc.) in addition to the posture or
position someone in a wheelchair may assume to be functional.”
While kyphosis looks similar from wheelchair user to wheelchair
user, its basis can vary drastically.
“Kyphosis is a risk with many diagnoses, especially folks
with decreased trunk control and balance,” Garven said. “Even
upper-extremity weakness may lead to increased trunk kyphosis
to maximize the movement and strength in one or both arms.
Kyphosis may also be the result of someone sitting in a posterior
pelvic tilt, either by choice (because it increases their balance and
independence for function) or forced into a posterior pelvic tilt by
ill-fitting equipment (such as a seat depth that is too long).”
Many different diagnoses can cause kyphotic postures,
Bollinger explained: “Kyphosis can be congenital (present at
birth), or due to acquired conditions that may include neuromuscular
conditions, osteogenesis imperfecta (“brittle bone disease”),
spina bifida, Scheuermann’s disease and postural kyphosis.
Other potential causes for kyphosis include structural spinal
deformity, and diminished head control and compensation for
visual impairment. If a person has low muscle tone or trunk
weakness, they may be unable to straighten their spine against
gravity. Individuals with diagnoses such as cerebral palsy or
multiple sclerosis may demonstrate this.
“Postural kyphosis is the most common type of kyphosis, and
it generally becomes noticeable in adolescence with slouching
versus a spinal abnormality. We may also see a postural kyphosis
develop in someone who spends much of their time reaching
forward for activities, such as operating a power scooter tiller.
This posture combined with trunk weakness and/or low muscle
tone can lead to a severe kyphosis. Elderly individuals may
develop kyphosis after years of sitting with poor posture, but
may compensate by sliding their pelvis, or choosing soft cushions.
When they begin sitting in a wheelchair, the forward head
posture often becomes more pronounced.”
Building an Optimal Seating System
Bollinger said choosing whether to accommodate or correct a
kyphotic posture depends on several factors.
“When deciding the best seating approach for someone who
presents with kyphosis, the first thing to determine is whether
the kyphosis is reducible or non-reducible,” she noted. “If it is a
reducible orthopaedic asymmetry, then one can look for solutions
to correct the kyphosis. Solutions might include using gravity
to facilitate an upright posture by either opening up the seat-to-back angle, tilting the wheelchair posteriorly, or setting the
wheelchair with a fixed posterior angle.
“Another thing to consider is preventing the pelvis from going
into a posterior pelvic tilt by maintaining it in neutral. However,
if the individual still cannot maintain an upright posture, a
secondary support might need to be considered.”
A non-reducible kyphosis, Bollinger added, “will need to be
accommodated. Once the position is determined, then the most
functional orientation in space should be provided. If the head
and shoulder are so rounded that visual orientation is off, then
the use of a tilt to realign the eyes to the horizontal may be indicated.
Again, it may be necessary to utilize secondary supports to
prevent the rounding posture from worsening.”
Garven said that regardless of what caused the kyphosis,
it’s important to address it “for function, and managing pain/comfort as well. It can be difficult to do because the tendency is
to move forward or further from the seating surfaces. Orientation
in space (slight to significant amounts of tilt) can definitely be
helpful, as well as backrests that have increased contours and
possibly customization of the contours, such as the boa straps
in the [Permobil] Acta-Relief backrest. Or the customization of
ROHO air cells in a ROHO AGILITY back to create top-to-bottom
contours in addition to the typical lateral contours we think of
with back supports.”
“If the goal is to accommodate the spine,” Bollinger said,
“then a cushion that allows the pelvis to be posterior tilted with
shear-reducing capabilities would be indicated. Sunrise Medical’s
JAY Care cushion has an extended well which accommodates the
‘sacral sitting’ position common with fixed posterior pelvic tilt
postures. Its integrated JAY Flow fluid pad conforms to each individual’s
shape and ensures proper fluid placement beneath bony
prominences to help protect the skin from breakdown.
“The back support should allow for the accommodation of the
spine without causing pressure on the spinous process, which
may be more pronounced in a kyphotic spine.” An example of an
intervention, Bollinger said, is the JAY Care back, which “allows
the seat-to-back angle to be opened to accommodate the pelvic
position. If the adjustable-angle hardware is not sufficient, then
additional degrees can be obtained using angle adjustments from
the backcanes of the wheelchair.”
This article originally appeared in the June/July 2020 issue of Mobility Management.
Laurie Watanabe is the editor of Mobility Management. She can be reached at firstname.lastname@example.org.