Thoracic kyphosis is the rounding of the middle and upper spine. While it is normal for the thoracic spine to have a slight kyphotic (outward) curve compared to the lordotic (inward) curve of the lumbar spine, this rounding can sometimes become exaggerated. When thoracic kyphosis is particularly extreme, the spine (seen from the side) resembles the letter “C.” An abnormal curvature of this degree is commonly called a “dowager’s hump” or “hunchback.”
“If the spine is ideally aligned, you could drop a weighted string from the ear through the shoulder, and on down through the hips and the heels,” says Bill Reif, a physical therapist in Atlanta and author of The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It. “But for many of those with excessive thoracic kyphosis, that plumb line falls somewhere in front of the chest.”
If the spine is ideally aligned, you could drop a weighted string from the ear through the shoulder, and on down through the hips and the heels.
Excessive thoracic kyphosis (from here on, simply “kyphosis”) is a common postural misalignment in many yoga students, though particularly in more mature students. It is worth understanding, as it has implications for not only the poses we practice, but also for the way we practice them.
Causes, Consequences, and Cautions
According to Reif, while diseases like osteoarthritis, osteoporosis, and (in younger adults) Scheuermann’s Disease can cause kyphosis, the way we move, sit, and stand is often a major factor in the degeneration of the spine. “Imperfect body mechanics while we lift and carry can cause the wear and tear on the spine, leading to ‘degenerative kyphosis.’ Poor prolonged sitting posture results in muscular imbalances known as “upper and lower crossed syndrome,” says Reif. He adds, “If these imbalances are not addressed, the result can be ‘postural kyphosis’ for students of any age.”
The consequences of kyphosis, according to Reif, are a loss of spinal height and flexibility, as well as reduced range of motion (particularly in the neck and shoulders). “Many people with kyphosis are unable to turn the head fully, due to the loss of length in the cervical spine,” Reif says. “Since the shoulder blades protract [move away from each other] and the shoulders internally rotate as the upper back rounds, those with kyphosis may be unable to reach overhead and/or behind the back. This shoulder position can also cause an impingement or ‘pinching’ of the glenohumeral joint, which, if unchecked, can lead to several common diagnoses including biceps tendinitis, rotator cuff tears and strains, and bursitis.”
Reif’s primary goal when working with patients with kyphosis is to create length in the spine, or to keep the length that still exists. The extent to which the “C” may be straightened depends upon the degree to which the spinal changes have advanced. Reif explains that “shortened muscles, tendons, and ligaments surrounding the spine cause a flexible abnormal curve, whereas vertebral changes due to degeneration of the bone surface may cause permanent curvature of the spine. If caught early enough, when the changes have not yet solidified, the kyphosis can often be reversed. But for the older student, who may have undergone irreversible bony changes, the primary goal would be to prevent any further increase of the curvature.”
Practice Guidelines for Kyphosis Reif recommends yoga to his patients with kyphosis. At the same time, because of the vulnerability of their spines and shoulders, he advises that they be cautious with certain movements (and skip some entirely). For example, he does not recommend that yoga students with kyphosis do poses that flex (round) the spine, which would reinforce their undesirable postural habits and may even lead to more fractures for those whose kyphosis is caused by osteoporosis and osteoarthritis. “For those with a fragile, kyphotic spine stemming from one of these diseases, even the spinal flexion that comes from hugging the knees to the chest while lying down could cause vertebral collapse,” he explains.
Additionally, poses in which the hands and arms are asked to bear weight—like plank, chaturanga, and arm balances—are poses yoga students with kyphosis should steer clear of initially (and perhaps forever). “Because thoracic kyphosis is associated with shoulders that are protracted and internally rotated, students are at a mechanical disadvantage and especially vulnerable to shoulder injuries,” says Reif. “It’s important to mobilize and strengthen the shoulders before asking them to bear weight.” First, the shoulders must be brought back and the shoulder blades pulled toward each other (as shown in the image below). Once the shoulders can hold this healthy position while bearing no weight at all (in a pose like mountain), and then keep this position while supporting a modest amount of weight (in poses like tabletop and sphinx), students can gradually increase the load on the shoulders (with plank and chaturanga). Reif cautions, “Some students with an extreme hunch may never get to a place where their arms can support the full weight of their upper body without injury.”
Reaching the arms overhead, as in upward reaching mountain or downward facing dog, can be risky as well. Reif says, “Moving too far or too fast into an overhead reach can aggravate both shoulder pinch and upper back pain.” Instead of reaching up quickly, aiming to bring their arms in line with their ears, students with kyphosis should lift the arms up slowly, with control, bringing them only as high as they comfortably can, focusing on keeping the shoulders back, and the shoulder blades pulled toward each other.
Inversions like headstand, handstand, and shoulderstand are inadvisable for those with kyphosis, not only because of the demands they place on imperfectly positioned shoulders, but also because the thoracic spine is not properly aligned to channel weight. In headstand and shoulderstand, Reif says, “Going vertical increases pressure on the cervical spine, and injury may occur. A student whose cervical disc space has narrowed from decades of wear and tear due to rounded posture will never be able to tolerate the stress of going into headstand or shoulderstand.”
Reif recommends that students with kyphosis focus on spinal lengthening and shoulder placement in neutral-spine poses and in gentle backbends, sidebends, and twists. Eleven of the poses and movements Reif finds most helpful in treating kyphosis are below. For some of those, he recommends, you will need a wall, doorway, and support (such as a block, book, folded blanket, or towel) to place underneath your head. These poses could be practiced in this sequence, interspersed throughout a yoga practice, or used at different times during the day.
Reif recommends that students with kyphosis focus on spinal lengthening and shoulder placement in neutral-spine poses and in gentle backbends, sidebends, and twists.
Reif encourages his patients to check their posture throughout the day while standing, walking, and even while driving, since the greater one’s postural awareness throughout daily life, the greater the opportunity for improvement. Reif encourages, “Notice if your head moved away from the headrest. If it has, look out: You’re moving back into that ‘C.’”
Therapeutic Poses For Kyphosis
1. Mountain Pose Stand up straight with your back against a wall. In this mountain pose, and whenever you’re standing in your daily life, imagine a plumb line dropping from your ears down through your shoulders, hips, and heels. Check your alignment with the help of the wall: With your buttocks against the wall, can you bring the back of your head to the wall as well? Don’t force your head to the wall by tipping your chin up and shortening the back of the neck; instead, bring the back of the head as close as you can to the wall while keeping the back of the neck long.
After years of slumping, our spines may have "forgotten" what to do. Reif helps his patients reclaim an upright standing posture by encouraging them to envision a marionette string pulling them up by the crown of the head. Because thoracic kyphosis often brings the gaze (and the head) forward and down, Reif likes the instruction, “Look straight ahead as you imagine being pulled up by this marionette string.”
Throughout practice, students with thoracic kyphosis can benefit from finding as much length as possible in neutral-spine poses such as high lunges; in warrior poses (lifting the arms only as high as they comfortably can, or keeping them down at their sides); and in seated poses like staff (in which they can lean back and press their hands into the floor to help them lift and broaden the chest).
2. Shoulder Rolls and Scapular Retraction While standing in mountain pose or seated up straight, roll your shoulders forward, up, and back several times. Then practice “pinching” your shoulder blades together on your back. Aim to keep your shoulders in this position through as many of your yoga poses, and as much of your life, as possible.
“Those with kyphosis exhibit a rounding between the shoulder blades, and the knobby spinous processes of the thoracic spine visibly protrude,” says Reif. “When the shoulders are in the ‘right place,’ there is a crease between the shoulder blades, and the thoracic spine is flat rather than protruding.”
When students with kyphosis begin bearing weight on their hands in poses like tabletop and sphinx, they should lower the chest close enough to the floor that they create this crease between the shoulder blades. (It is easy to drop the head while finding this shoulder alignment. In both of these poses, students should attempt to line up the ears with the shoulders while keeping the back of the neck long.) It is important that a student with kyphosis be able to create and maintain this healthy shoulder alignment in tabletop and sphinx before adding to the shoulder load with poses like plank, chaturanga, and arm balances.
3. Chest and Shoulder Stretch, with Doorway Standing on one side of a doorway, bring your palms to the wall on either side of the door frame at shoulder height or slightly higher, elbows bent. Then step one foot forward through the doorway, pressing both hands into the wall, and leaning forward slightly (as if beginning to fall); hold here for several deep breaths. Step back, and then repeat, this time taking your hands up the wall just above your head (elbows bent at shoulder-height). Again, hold for several breaths. Step back, and repeat one more time. This time, climb your hands up the wall as high as you comfortably can, and then lean forward again. Hold for several breaths. (Alternate which foot steps forward when you practice this stretch to ensure that you're working both sides of the body evenly.)
Reif values this pose for anyone whose shoulders have rounded forward. “It is a stretch for the deltoids, pectorals (major and minor). and biceps (long and short heads),” Reif says. “As you take your hands up higher, the latissimus dorsi will also lengthen.”
4. Chin Tucks While standing or seated upright, look straight ahead, chin level with the earth. As you exhale, tuck the chin slightly toward the chest as if you are nodding slowly. On the inhale, lift the chin again. Repeat several times.
“This movement encourages the neck to lengthen by stretching the scalenes, omohyoid, and sternocleidomastoid, muscles that are often tight for those with thoracic kyphosis,” says Reif.
5. Hands-and-Knees Flow Start on hands and knees in tabletop pose, aiming to create a neutral spine, with the head and hips in one line. Inhale here. Then create a slight arch as you exhale, moving toward cow pose. On your next inhale, move back to your neutral tabletop position. On your next exhale, rock back toward child’s pose as far as you comfortably can while keeping your arms outstretched and palms rooted in front of you on the mat. With your next inhale, move back to all fours, re-creating a neutral spine. Repeat the cycle several times.
‘This movement encourages full use and flexibility of the spine,” says Reif. “As your mobility increases, gradually move from neutral toward both extremes—bringing the hips closer toward the heels when you go back from tabletop, and lifting into an upward facing dog as you come forward from tabletop.”
6. Cobra and Sphinx Lying on your belly, come up onto your hands (cobra) or forearms (sphinx), lifting your chest while moving the shoulders up and back, and bringing your shoulder blades toward each other on your back. Reach up through the crown of your head, allowing the back of your neck to lengthen.
Reif explains: “Backbends strengthen the erector spinae, multifidus, latissimus, longissimus, and iliocostalis muscles. Especially when they’re done on the belly, small backbends are particularly valuable to help reverse the "C" (due to the help you get from gravity). Your belly and trunk can ease toward the floor as you maintain the support of your hands and forearms.”
All of us, but especially those with osteoporosis, should avoid any pain when moving into gentle backbends like these.
7. Bird Dog From all fours, create a neutral spine, lengthening as much as possible from the crown of the head to the tailbone, and lowering the chest until you can pull the shoulder blades together on the back. With as little swaying as possible, on an exhale, slowly reach the right arm forward and the left leg back—bringing both as close to parallel with the earth as you comfortably can. Hold for several breaths, and then lower with control. Repeat on the other side. Alternate sides several times.
Reif recommends this pose for students with kyphosis to "increase multifidi and paraspinal strength and create spinal stability.”
8. Supported Fish Pose Recline, placing a rolled-up towel, blanket, or foam roller (for a bigger stretch) across the back, just underneath the bottom tips of the shoulder blades. Take your arms out to the sides, elbows comfortably bent, palms up. (Support the backs of your hands with blankets or towels if they do not touch the floor.) Be sure to keep your shoulders and arms above the towel or blanket roll in order to encourage your shoulders to drop. In this pose, and whenever you lie on your back, place a support (such as a block, book, folded towel, or blanket) underneath the head (not the neck), at the lowest height that allows the back of your neck to lengthen comfortably. You can straighten your legs out in front of you, or bend your knees up toward the ceiling (with feet on the floor). Hold here for a few minutes, taking deep, easy breaths.
Reif recommends this pose to gently encourage spinal extension.
9. Snow Angels Lie on your back, with a block, folded blanket, or towel under your head (not your neck), at the lowest height comfortable for your neck. Start with your hands alongside your hips, palms up. As you exhale, slowly glide your straight arms up overhead, grazing the floor with the backs of your hands. As you inhale, bring your arms back down alongside you. Repeat this movement several times.
Reif recommends “making snow angels” for posture restoration. “This movement slowly and gently stretches the pectorals and biceps, which can become tightened during daily activities,” says Reif. “As you improve, you can make snow angels while standing up, with your back against a wall.”
10. Head Press Lie down with support, such as a block, underneath the head (not the neck), at the lowest height at which you feel no strain in your neck. As you inhale deeply, gently press your head into the block and hold this pressure for several seconds. As you exhale thoroughly, slowly stop applying this pressure and focus on length, reaching the crown of the head back and the tailbone forward. Repeat this action several times.
“This will lengthen your neck in much the way traction does,” says Reif. “Over time, you’ll be able to lower the support, using a smaller book or blanket under your head.” Your goal is to eventually be able to comfortably rest your head on the floor with no strain in the neck.
11. Lie down on your back, again with the minimal support under the head necessary for neck comfort. Take deep, easy breaths, imagining that each breath is increasing the space between the vertebrae, allowing the bottom tip of the tailbone and the crown of the head to drift away from each other.