ATP Series

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 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 Jun/Jul 2020 issue of Mobility Management.