714591

research-article2017
CRE0010.1177/0269215517714591Clinical RehabilitationFeng et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effect of a corrective functional 2018, Vol. 32(1) 48­–56

© The Author(s) 2017
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DOI: 10.1177/0269215517714591
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thoracic kyphosis in teenagers: journals.sagepub.com/home/cre

a randomized controlled trial

Qiang Feng1, Mei Wang1, Yanfeng Zhang1 and Yu Zhou2

Abstract
Objective: To investigate the effects of a corrective functional exercise program on postural thoracic
kyphosis in teenagers in China.
Design: A single-blind randomized controlled trial including students with a thoracic kyphosis angle
(TKA) >40° measured using the SpinalMouse.
Setting: China Institute of Sport Science and three middle schools in Beijing, China.
Subjects: A total of 181 subjects were included in this trial; of these, 164 subjects were included in the
analyses (intervention group, n = 81; control group, n = 83).
Intervention: The intervention group received a functional exercise program designed to correct
postural thoracic kyphosis, and the control group received an exercise program designed in accordance
with the state-regulated curriculum.
Main measures: The primary outcome variable was TKA. Secondary outcome variables were lumbar lordosis
angle (LLA), sacral angle (SA), and incline angle (INA) measured in the upright position; thoracic, lumbar, and
sacral spine range of motion (ROM) and INA ROM (change in center of gravity) measured in the forward
bending and extended positions; and changes in TKA, LLA, SA, and INA measured during the Matthiass test.
Results: There were significant differences in pretest and posttest TKA in both groups (intervention group:
pretest 47.09 ± 5.45, posttest 38.31 ± 9.18, P < 0.0001; control group: pretest 47.47 ± 6.06, posttest 43.59 ± 7.49,
P < 0.0001). After adjustment for gender and pretest values, there were significant differences in posttest TKA,
change in SA, and thoracic ROM in the intervention group compared to the control group (P < 0.05).
Conclusion: The corrective functional exercise program designed for this study improved exaggerated
thoracic kyphosis in teenagers.

Keywords
Functional exercise program, teenager, abnormality of the sagittal posterior process of thoracic
vertebrae

Received: 6 December 2016; accepted: 19 May 2017

1China Institute of Sport Science, Beijing, China Corresponding author:

2National Institute of Education Sciences, Beijing, China Qiang Feng, China Institute of Sport Science, No. 11, Tiyuguan
Road, Dongcheng District, Beijing 100061, China.
Email: [email protected]
Feng et al. 49

Introduction to compare the effects of a corrective functional

exercise program and an exercise program designed
Postural hyperkyphosis is a common spinal curva- according to the state-regulated curriculum on pos-
ture disorder1,2 caused when high external loads are tural thoracic kyphosis in teenagers with sagittal
applied to the spine of individuals in the upright misalignment. We hypothesized that the corrective
stance who have poor overall muscle strength.3 functional exercise program would achieve a
Hyperkyphosis is associated with rapid degenera- greater decrease in our primary outcome measure
tion of the spinal column as well as disorders of the of TKA compared to the exercise program designed
thoracic and cervical vertebrae,4 including cervical according to the state-regulated curriculum.
lordosis, which can result in upper crossed syn-
drome.5 In rapidly growing teenagers, abnormal
flexion of the spine impedes development of the Methods
viscera, and exaggerated thoracic kyphosis is asso-
ciated with altered respiratory function.6 In addi-
Study design
tion, hyperkyphosis can affect a teenager’s posture This study is a single-blind randomized controlled
and appearance and may therefore impact their trial (Registration # ChiCTR-INR-16008860).
physical and psychological health. Instructors were blinded to the clinical characteris-
The normal range of thoracic kyphosis in teen- tics of the study participants. The study was con-
agers is 20°–40°, and a hyperkyphosis diagnosis is ducted according to China Institute of Sport
considered beyond 45°.7,8 Accumulating evidence Science guidelines and was approved by the ethics
suggests that individuals with exaggerated kypho- committee of our institution (No. 16-32). Written
sis often present with deformities in the sagittal informed consent was obtained from each study
plane.9–11 In teenagers, sagittal misalignment can subject and their parents.
result from sitting for extended periods of time as
well as poor posture while sitting and standing.12
Corrective exercise programs for hyperkyphosis
Participants
in adults are designed according to Kendall’s the- Students from three middle schools in Beijing City,
ory, which involves stretching and strengthening of China (Beijing No. 156 Middle School, West City
muscles in the affected area.13 However, a lack Experimental Middle School, and Beijing No. 35
of controlled studies testing the effectiveness of School), were chosen for this study. Study subjects
Kendall’s theory has led researchers to question the were recruited during a period of one month (1
utility of corrective exercise programs for postural September 2015 to 30 September 2015). The inclu-
hyperkyphosis.14 Furthermore, most currently sion criterion was TKA >40°measured using the
available corrective exercise programs for hyper- SpinalMouse system (Idiag, Fehraltorf, Switzerland).
kyphosis are limited, as evidence indicating that The SpinalMouse is a non-invasive test of spinal
they achieve a clinically important improvement in morphology and spinal function. It uses a surface-
the thoracic kyphosis angle (TKA) is scarce. This based procedure to measure the range of motion
may be because the programs are short and rely on (ROM) and intersegmental angles of the sagittal
self-training, and qualitative methods are used to spine. The SpinalMouse has high accuracy when
measure the TKA. In particular, these corrective testing spinal morphology and function in the sagittal
exercise programs are targeted to the thoracic ver- plane.18–20 It is sufficiently reliable and valid com-
tebrae, which is in contrast to the holistic approach pared to X-ray.21 Intraclass coefficients (ICCs) for
that is increasingly favored for the treatment of curvature measurement with the SpinalMouse are
exaggerated thoracic kyphosis.15–17 0.92–0.95,18 and intra- and inter-rater ICCs range
Studies on corrective exercise programs for from 0.82 to 0.83 and 0.81 to 0.86,22 respectively.
exaggerated thoracic kyphosis due to deformities Exclusion criteria were as follows: structural
in the sagittal plane in teenagers are scarce. The thoracic kyphosis, defined as thoracic kyphosis that
objective of this randomized controlled study was did not partially or completely disappear during
50 Clinical Rehabilitation 32(1)

prone extension, as assessed by a physical therapist; their arms to 90°.23 Spinal curvature and pelvic
medical history of spinal fracture, spinal surgery, tilt were measured. The subject was instructed
shoulder joint injury, pelvic injury, or other spinal to retain this posture for 30 seconds, at which
diseases; presence of scoliosis on Adam’s forward time a second spinal curvature and pelvic tilt
bend test; spinal kyphosis due to visible thoracic measurement was made.
deformity; students undergoing professional sports
training; and students with medical conditions that Functional exercise program
restricted activity.
Students who met the inclusion criterion and All study subjects received two 15–20 minute exer-
none of the exclusion criteria were randomly cise sessions each week for eight weeks during their
assigned to an intervention group or a control physical education classes at high school. Total dura-
group by simple random sampling using random tion of the physical education classes was 20 min-
number generation. Study subjects were followed- utes. The time spent on the exercise sessions during
up from 1 October 2015 to 15 December 2015. the physical education classes was determined by
discussions with the physical education teachers and
the administration leaders of the schools.
Spinal shape and motility measurements The intervention group took part in a functional
exercise program designed to correct postural tho-
Students’ spinal shape and motility was evaluated
racic kyphosis, which incorporated specific exercises
before the intervention (pretest) and during week 9,
for the cervical, thoracic, and lumbar spine as well as
after the intervention (posttest). Pretest and post-
the pelvis (Appendix A, supplementary data). The
test, spinal shape, and motility were evaluated with
exercises, repetitions, and hold time were selected
the SpinalMouse system. During the procedure,
based on the authors’ clinical experience. Physical
subjects stood on the floor without coats or shoes.
education teachers at the participating schools were
The spinal process at vertebra C7 and the top of the
provided training to ensure consistent application of
anal crease at S3 were marked with a pen. Spinal
the functional exercise program. The functional exer-
curvature and pelvic tilt were measured for each
cise program aimed to recover ROM in the cervical,
subject in several positions:
thoracic, and lumbar spine and to improve subjects’
muscle strength and proprioception.
Upright position. Study subjects were instructed
The control group received an exercise program
to stand upright in a casual position, feet shoul-
designed according to the state-regulated curricu-
der-width apart bearing equal weight, arms by
lum, which included abdominal curls, pushups
their sides, and looking straight ahead.
with the toes or knees, a 50 m run, and squats
Forward bending position. Study subjects were (Appendix B, supplementary data).
instructed to stand with their feet shoulder-
width apart and to flex the torso forward while
Statistical analysis
keeping the legs straight and allowing the arms
to fall naturally. Statistical analyses were conducted using SPSS
v19.0 software (SPSS, Inc., Chicago, IL). Study
Extended position. Study subjects were
sample size was based on the assumption that a 5°
instructed to stand with their feet shoulder-
change in TKA is a clinically important difference.
width apart bearing equal weight, arms by their
Assuming an SD of 2°, and using the two-tailed
sides or supported by the hips, looking straight
hypothesis, α = 0.05, and 80% power, a sample size
ahead. Subjects were asked to stretch the torso
of ≥51 per group was required for this study.
backward as far as possible.
The primary outcome variable was TKA.
Matthiass test. Study subjects were instructed to Secondary outcome variables were lumbar lordo-
stand with their feet shoulder-width apart, look- sis angle (LLA), sacral angle, and incline angle
ing straight ahead. When asked, subjects flexed (INA) measured in the upright position; thoracic,
Feng et al. 51

lumbar, and sacral spine ROM and INA ROM control groups. There were significant differences in
(change in center of gravity) measured in the for- pretest and posttest thoracic ROM (intervention
ward bending and extended positions; and group: pretest 14.56 ± 17.92, posttest 22.53 ± 19.19,
changes in TKA, LLA, sacral angle, and INA P = 0.003) and change in sacral angle (intervention
measured during the Matthiass test. group: pretest 0.10 ± 4.81, posttest −1.89 ± 3.55,
Results are presented as mean  ± 
SD. The P = 0.004) in the intervention group.
Kolmogorov–Smirnov test was used to deter- Tables 4 and 5 show between-group differences.
mine if variables were normally distributed. After adjustment for gender and pretest values,
Differences in pretest and posttest values in the there were significant decreases in posttest TKA
intervention and control groups were compared and change in sacral angle (P < 0.004) in the inter-
with the Student’s t-test for normally distributed vention group compared to control (Table 4).
data and Wilcoxon test (Mann–Whitney U test) Furthermore, after adjustment for pretest values,
for variables that were not normally distributed. there was a significant difference in the change in
Where significant differences in pretest and thoracic ROM in the intervention group compared
posttest values were found, covariance analysis to control (P < 0.05; Table 5).
was used to adjust for gender and pretest value.
Independent t-test was applied to evaluate
Discussion
between-group differences when pretest value
was identified as an extraneous variable. This study investigated the effects of a corrective
functional exercise program on postural thoracic
kyphosis in teenagers with sagittal misalignment.
Results The corrective functional exercise program
A total of 212 subjects were eligible for this study. achieved a clinically significant decrease in TKA
In all, 181 subjects met all the inclusion criteria and (approximately 9°), as well as changes in the sacral
none of the exclusion criteria. Of these, 90 subjects angle and thoracic ROM. Furthermore, the posttest
were randomized to the intervention group and 91 TKA and change in sacral angle was significantly
were randomized to the control group; 81 subjects different following the corrective functional exer-
in the intervention group and 83 subjects in the cise program compared to control. The corrective
control group were finally included in the analyses exercise program used a holistic approach that con-
(Figure 1). Baseline characteristics of the study sidered muscle flexibility and strength and proprio-
subjects are shown in Table 1; there were no sig- ception along the length of the spine. Interestingly,
nificant between-group differences. there was also a decrease in TKA in study subjects
Tables 2 and 3 show the primary and secondary participating in the control exercise program.
outcome variables in the intervention and control Although the decrease was not as great as in study
groups before and after the exercise programs. There subjects participating in the corrective functional
was a significant difference in pretest and posttest exercise program, this finding emphasizes the
TKA in both the intervention and control groups importance of general exercise for spine health in
(intervention group: pretest 47.09 ± 5.45, posttest teenagers.
38.31 ± 9.18, P  < 
0.0001; control group: pretest The findings from this study are in accordance
47.47 ± 6.06, posttest 43.59 ± 7.49, P < 0.0001). with previous reports in adults. An in-home exer-
There were also significant differences in pretest cise program targeting Erector Spine strength, cer-
and posttest INA (intervention group: pretest vical retraction, interscapular muscle strengthening,
3.15 ± 5.04, posttest −0.16 ± 4.40, P < 0.0001; control and pectoral stretching achieved a statistically but
group: pretest 2.41 ± 4.64, posttest 0.31 ± 6.53, not clinically significant 3° decrease in TKA after
P = 0.01) and change in INA (intervention group: 13 weeks.24 In adult males, an intervention that
pretest−0.69 ± 3.10, posttest −2.20 ± 3.09, P = 0.002; involves stretching and flexion of the thoracic ver-
control group: pretest −2.65  ± 3.13, posttest tebrae plus muscle strength training alleviated pain
−1.89 ± 3.42, P = 0.04) in both the intervention and and decreased thoracic kyphosis by 7°.25 In females
52 Clinical Rehabilitation 32(1)

Figure 1.  CONSORT 2010 Flow Diagram.

aged 50–59 years, a long-term intervention that and dynamic loads. This study is among the first to
included stretching the upper and lower back, design and implement a corrective functional exer-
shoulders, and neck reduced the progression of cise program for postural thoracic kyphosis in teen-
thoracic kyphosis; however, compliance with the agers with sagittal misalignment.
program was low.26 The corrective functional exercise program had a
An effectively designed corrective exercise pro- significant effect on sacral angle compared to the
gram should consider muscle flexibility as well as control exercise program, as shown by the Matthiass
strength and proprioception along the length of the test, which assesses an individual’s capacity to
spine. Adherence to this type of corrective program maintain their posture against an external load.27 A
will restore the spine to its normal position and large sacral angle indicates that the pelvis is tilting
movement and allow the body to automatically forward and is a risk factor for spinal disorders.28,29
maintain the orientation of the spine during static In this study, the sacral angle among subjects in the
Feng et al. 53

Table 1.  Baseline demographics of study subjects.

N Gender Age Height Weight BMI

Intervention (n = 90) 51 Male (56.7%) 14.2 ± 1.43 171.9 ± 7.80 64.4 ± 16.03 21.6 ± 4.35
  39 Female (43.3%) 14.0 ± 1.52 163.4 ± 5.71 56.6 ± 14.25 21.1 ± 4.54
Control (n = 91) 53 Male (58.2%) 13.5 ± 1.47 171.0 ± 8.44 64.7 ± 15.01 21.9 ± 4.04
  38 Female (41.8%) 13.6 ± 1.54 162.5 ± 7.01 53.4 ± 9.40 20.2 ± 3.00

BMI: body mass index.

Table 2.  Primary and secondary outcomes (paired-sample t-test).

N Pretest Posttest Within-group T value 95% CI P

difference
Primary outcome
Thoracic kyphosis angle
 Intervention 81 47.09 ± 5.45 38.31 ± 9.18 3.81 ± 3.67 88.74 66.78 to 10.78 <0.0001
  Control group 83 47.47 ± 5.80 43.59 ± 7.49 4.08 ± 4.28 −4.9 −2.30 to 5.46 <0.0001
Secondary outcomes
Sacral angle
 Intervention 81 10.32 ± 7.75 10.75 ± 6.89 2.73 ± 2.58 −0.45 −2.35 to 1.48 0.66
 Control 83 12.93 ± 6.43 11.57 ± 7.38 2.30 ± 2.72 1.67 −0.26 to 2.98 0.099
Lumbar lordosis angle
 Intervention 81 22.07 ± 8.97 23.69 ± 8.47 3.30 ± 3.32 1.74 −0.23 to 3.47 0.09
 Control 83 26.23 ± 6.38 25.63 ± 8.31 2.78 ± 2.55 −0.71 2.28 to 1.08 0.48
Incline angle
 Intervention 81 3.15 ± 5.04 −0.16 ± 4.40 2.40 ± 2.07 5.15 2.03 to 4.59 <0.0001
 Control 83 2.41 ± 4.64 0.31 ± 6.53 2.20 ± 2.39 2.56 0.47 to 3.72 0.01
Sacral ROM
 Intervention 81 68.46 ± 23.36 65.44 ± 25.86 17.43 ± 14.73 1.19 −2.01 to 8.03 0.24
 Control 83 72.13 ± 23.51 71.39 ± 22.63 17.52 ± 16.66 0.28 4.55 to 6.04 0.78
Thoracic ROM
 Intervention 81 14.56 ± 17.92 22.53 ± 19.19 19.53 ± 15.09 −3.06 −13.16 to 2.80 0.003
 Control 83 16.77 ± 16.60 17.95 ± 20.90 14.77 ± 12.92 −0.55 −5.47 to 3.11 0.59
Lumbar ROM
 Intervention 81 66.88 ± 21.69 69.38 ± 17.27 15.28 ± 13.16 −1.13 −6.94 to 1.93 0.27
 Control 83 75.88 ± 16.79 72.13 ± 17.60 12.92 ± 11.07 1.87 −0.22 to 7.71 0.06
Incline angle ROM
 Intervention 81 129.52 ± 19.47 130.16 ± 19.65 15.46 ± 13.88 −0.28 −5.25 to 3.97 0.78
 Control 83 141.08 ± 18.34 138.98 ± 17.07 13.22 ± 13.45 1.022 −2.00 to 6.21 0.31
Change in sacral angle
 Intervention 81 0.10 ± 4.81 −1.89 ± 3.55 2.73 ± 2.58 2.93 0.64 to 3.34 0.004
 Control 83 −0.88 ± 4.33 −0.27 ± 3.70 2.30 ± 2.72 −1.084 −1.74 to 0.51 0.28
Change in lumbar lordosis angle
 Intervention 81 −1.09 ± 5.69 −0.68 ± 3.68 3.30 ± 3.32 −0.60 −1.76 to 1.00 0.55
 Control 83 −1.70 ± 4.92 −2.05 ± 4.78 2.78 ± 2.55 0.53 −0.98 to 1.67 0.6

CI: confidence interval; ROM: range of motion.

Bold values indicate p<0.05.
54 Clinical Rehabilitation 32(1)

Table 3.  Secondary outcomes (Wilcoxon test).

N Pretest Posttest Within-group difference T value P

Secondary outcomes
Change in thoracic kyphosis angle
 Intervention 81 −0.51 ± 5.45 −0.07 ± 5.04 –0.31 ± 5.30 −0.28 0.78
 Control 83 −1.83 ± 5.37 −1.36 ± 7.03 1.02 ± 5.85 −0.35 0.72
Change in incline angle  
 Intervention 81 −0.69 ± 3.10 −2.20 ± 3.09 0.62 ± 3.12 −3.04 0.002
 Control 83 −2.65 ± 3.13 −1.89 ± 3.42 −0.16 ± 3.26 −2.09 0.04

Table 4.  Between-group differences (covariance Table 5.  Between-group differences in thoracic
analysis). kyphosis angle (independent-sample t-test).

Variable Mean square F P N Difference T 95% CI P

Thoracic kyphosis angle 1049.73 17.19 <0.001 Intervention 81 7.98 ± 23.44 2.013 0.13–13.46 0.046
Incline angle 15.55 0.511 0.476 Control 83 1.18 ± 19.66 – – –
Change in sacral angle 114.625 8.661 0.004 CI: confidence interval.
Change in incline angle 14.452 1.456 0.229 Bold values indicate p<0.05.

Bold values indicate p<0.05.

rotation ROM. Improvements in thoracic ROM facil-
intervention group decreased, which indicates that itate recovery of the normal curvature of the thoracic
the corrective functional exercise program enabled spine. However, it is currently unclear whether the
study subjects to maintain their sacral angle and pos- improvement in TKA after the corrective functional
ture under a load. This may be the result of the sta- exercise program implemented in this study was
bility-based training component of the corrective directly related to the changes in thoracic ROM.
functional exercise program, which is targeted at the The Matthiass test showed improvements in the
muscles of the lower back and hips. INA in both the intervention and control groups. The
After the corrective functional exercise pro- INA represents the angle between a line connecting
gram, study subjects were able to accommodate an T1 and S1 and the vertical. Pretest, study subjects
external load and maintain the shape of their had a tendency to lean forward; this was corrected
sacrum and pelvis through the strength of the mus- by the functional exercise program and the control
cles in the core. However, these results should be exercise program. A forward posture loads weight
interpreted with caution. Study subjects were onto the extensor muscle of the spine and can have a
instructed to keep their knees straight during the negative effect on spinal health. Further research is
Matthiass test; therefore, due to the anatomical required to elucidate the association between a for-
relationship between the sacrum and pelvis, values ward posture and thoracic kyphosis.
of the sacral angle measured with the SpinalMouse Recovery of proprioception is important for cor-
system could reflect the position and ROM of the recting posture problems and maintaining good pos-
pelvis rather than the sacral angle. ture. Therefore, corrective exercise programs should
In addition to the improvements in TKA and sacral include components targeted at restoring propriocep-
angle, the corrective functional exercise program had tion. Evidence suggests that dynamic movements
a significant effect on thoracic ROM compared to the improve proprioception more than static move-
control exercise program. The corrective functional ments.30 Therefore, in this study, most of the move-
exercise program included two exercises that were ments included in the corrective functional exercise
expected to improve thoracic ROM, including the program were designed to be dynamic. Study sub-
thoracic spine extension ROM and the thoracic spine jects were taught how to stand correctly, and the
Feng et al. 55

importance of maintaining correct posture was exaggerated thoracic kyphosis in teenagers. The
emphasized throughout the program thereby reinforc- exercise program also improved thoracic ROM,
ing proprioception. We propose this is a key element function of the muscles around the pelvis, and
of our corrective functional exercise program. capability to accommodate weight loaded onto the
This study had several strengths. First, it was a upper and the lower body. This program could be
single-blind randomized controlled trial. Second, incorporated into high school physical education
the intervention and control exercise programs were curricula in China to promote spine health in
implemented by physical education teachers in teenagers.
schools, and all participating schools included stu-
dents in the intervention and control groups. Third, Clinical Messages
covariance analysis was used to correct outcome •• A corrective functional exercise program
measures for pretest values. This minimized bias that focuses on the entire spine has a pos-
and ensured the validity and reliability of the data. itive effect on thoracic kyphosis in
However, the study also has some limitations. teenagers.
First, the SpinalMouse system was used to measure •• This corrective functional exercise pro-
spinal curvature. Although a recent systematic review gram is feasible to incorporate in high
confirmed the reliability of the SpinalMouse as a non- school physical educational classes and
invasive measure for thoracic kyphosis, X-ray pro- could promote the spine health in
vides the most accurate measure of spinal curvature, teenagers.
and values obtained from the SpinalMouse may be
smaller than those measured by X-ray,18,19,21 particu- Acknowledgements
larly in the sagittal spine.31 Second, we propose that
The authors thank the students and teachers who helped
the corrective functional exercise program improved
make this study possible.
muscle strength and enhanced proprioception in the
study population; however, quantitative measurement Declaration of Conflicting Interests
and analysis of proprioception are challenging.32
The author(s) declared no potential conflicts of interest
Future studies should focus on developing a reliable
with respect to the research, authorship, and/or publica-
test for the evaluation of proprioception, which may tion of this article.
contribute to understanding the mechanisms of
change. Third, the corrective functional exercise pro- Funding
gram was designed to improve cervical, thoracic,
The author(s) disclosed receipt of the following financial
and lumbar ROM and associated muscle strength.
support for the research, authorship, and/or publication
However, there was no obvious change in lumbar lor- of this article: This study was supported by the
dosis and lumbar ROM in the intervention group. The Fundamental Research Fund from China Institute of
duration of the corrective functional exercise program Sport Science (No. 16-32).
may have been too short to affect lumbar lordosis as
evidence suggests the lumbar spine becomes func- Registration information (ISRCTN)
tionally and mechanically deconditioned very quickly Registry name: The effect of a corrective functional
during sedentary behavior,33,34 and these changes are exercise program on postural thoracic kyphosis in teen-
long-lasting and may be challenging to reverse. In agers: a randomized controlled trial. Registration num-
addition, the cat stretch exercise, which was devel- ber: ChiCTR-INR-16008860.
oped to address lumbar ROM, was difficult to per-
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