Dowager’s hump is estimated to affect two of every five men and women above the age of 55. You might develop dowager’s hump due to various causes. Those could be degenerative disease or muscle weakness. Regardless of the cause, it negatively affects your quality of life. Early intervention and treatment of this condition can alter its course and provide many health benefits. At Injurymap, we take this “age-related condition” seriously. We provide evidence-based options to treat Dowager’s hump and help you prevent it from getting worse.
- What Is Dowager’s Hump?
- Measurement Of Hyperkyphosis
- Common Causes Of Dowager’s Hump
- Symptoms Of Dowager’s Hump
- Treating Dowager’s Hump
- Preventing Dowager’s Hump
- Do’s and Don’t in Dowager’s Hump
- Dowager’s Hump Can Be Fixed
What Is Dowager’s Hump?
Dowager’s hump or hyperkyphosis is an excessive curvature of the spine. Usually, this occurs in the thoracic or chest curve of the spinal column. Often it is also simply called kyphosis, which is a forward curvature of the spine and can range from being completely normal to grossly abnormal.
Normally, the spine does have an anterior curvature. If you look at a 3-D model of the spine, you’ll notice that it has a convex curve or spherical curve shape in the chest area. This is due to the natural shape of the spinal bones and the discs in between them. An angle of over 40 degrees towards from the spine is called hyperkyphosis. At 40 degrees of curvature, the spine is still considered normal as it falls in the 95th percentile of spine measurements in young adults.
Curvatures of over 40 degrees are deemed problematic. In fact, right from childhood until the third decade, the angle of the spine changes due to the stresses on the spine, from 20 degrees to 29 degrees. After you turn forty, the kyphosis angle rapidly increases. This usually occurs as the degenerative processes due to aging begin. This progression is more marked in women than it is in men. This is due to osteoporosis being more common in women. And with osteoporosis, weaker spinal bones, this leads to a higher disposition towards Dowager’s hump.
Among men, the average mean of the curvature angle is around 44 degrees. In women, it can range from 3 degrees in women at age 55 to 52 degrees at age 80. That’s a very sharp increase. This is why you’ll notice that people become shorter as they age. The average person loses about half an inch of height with every decade that they age due to the compressive stresses on the spine.
Measurement Of Hyperkyphosis
So how you do you measure the extent of the hyperkyphosis you have? The gold standard is a standard lateral spine X-ray. These radiographs are the best tool for orthopedic assessment of the thoracic or chest kyphosis angle. If the person can’t stand for some reason, they can do a supine radiograph but the lateral or sideways X-ray is the best.
The kyphosis angle or Cobb’s angle is measured by drawing perpendicular lines on the radiograph. The line extends through the upper endplate of the vertebral body where the thoracic curve starts at T4 vertebrae and the lower endplate of the vertebral body at the end of the thoracic curve at T12 vertebrae.
There are other methods to accurately measure the kyphosis angle. These include the Debrunner kyphometer and the flexicurve ruler. They are both conducted while standing and difficult to perform if you have limited mobility. The kyphometer is a protractor like device placed along the thoracic curve. You may remember using the semicircular device in your geometry class in school!
The flexicurve ruler as its name suggests is a moldable device made of plastic. It measures the kyphosis index. The index is calculated by dividing the width by the length of the thoracic spine multiplied by 100. A kyphosis index over 13 is considered hyperkyphotic.
While all these methods are reliable, they’re not when the angle is over 50 degrees, as is the case in elderly women. (Because in women the angle of kyphosis could be greater than 50 degrees.) The most accurate measurement comes from the lateral thoracic spine radiographs. Why is the measurement important? The angle determines the treatment and prevention of the Dowager’s hump. It also determines the extent of the deformity of your vertebral bodies.
Common Causes Of Dowager’s Hump
Dowager’s hump has not received the kind of scientific attention, osteoporosis, stroke and cancer receive. Because it’s considered part of the normal “aging” process, it hasn’t been studied in great detail. As a result, the causes of Dowager’s hump haven’t been fully described. Yet, a few common causes for its occurrence have been identified by doctors.
Degenerative Disc Disease
In many people with Dowager’s hump, radiographic findings have revealed degenerative disc disease. In a study of women from age 39 to 91 years, it was found that as the anterior disc height increased, the kyphotic angle increased. The majority of older adults who do have Dowager’s hump tend to have degenerative disc disease, without evidence of vertebral fractures or osteoporosis.
There exists a strong correlation between the height of the spinal vertebral body and the degree of kyphosis. Combined with degenerative disc disease, it accounts for a significant portion of the Dowager’s hump causes.
As the number of vertebral fractures increases, the kyphosis becomes more pronounced. This applies more so for thoracic/ higher vertebral fractures than lower/ lumbar fractures. Women who have multiple anterior thoracic wedge fractures have very prominent kyphosis. Vertebral wedging is the compression of the front part of the spinal bone. So if you’re someone who has had vertebral fractures in the past, you are at risk of developing Dowager’s hump.
If you also have an osteoporotic spine, even the added stresses of daily life load the spine and cause it to develop compression fractures and vertebral wedging. Osteoporosis is a condition, where the bones soften and become weak, due to a lack of dietary calcium and vitamin D. With time, as the wedging increases, the density of the bone mineral decreases. This leads to more compression fractures. The vicious circle continues and cascades into an increased predilection for hyperkyphosis.
Weak spinal extensor muscles are associated with Dowager’s Hump, according to studies. We have large back muscles holding up the spine. In postmenopausal women in good health, the weaker the spinal muscles, the higher the kyphosis angle. Exercise can strengthen the spinal muscles and thus hold the spine erect. This will help maintain the natural curvature of the spine. If you think only the spinal muscles can affect the spine, think again. In reality, posture is affected by many muscles of the body.
Unsurprisingly, the worse the grip and ankle strength in a person, the higher the likelihood of Dowager’s hump. This suggests your skeletal muscle strength affects posture. So the overall strength of muscles is of utmost importance when it comes to preventing Dowager’s hump.
Age affects many of the contributing, ligaments, joints, muscles and connective tissues; all of which affect posture. How they may contribute to kyphosis is not yet identified. However, with decreased spinal mobility, the ability to maintain a good posture and stand erect are reduced.
It remains unclear if the shorter muscles of the chest and hip are pulling down the spine or the bent spine is causing these muscles to contract and shorten. What has been proven though is that the shortening of the chest or pectoral muscles and hip flexor muscles causes severe hyperkyphosis.
Sensory Neuro Deficits
Deficits in your vision, hearing and sensory system affect your ability to maintain balance and posture. When vibratory input from your joints and sensory input is affected, your perception of erect spinal alignment is impaired. Most elderly individuals have no idea they’re not standing erect. Elderly people pitch their head far more compared to younger people when they’re moving.
Similarly, with a loss of hearing, they tend to rely more on their vision as far as movement and posture are concerned. If you thought, holding your spine is all about the back, think again. A whole series of body systems work together to keep your spine aligned. If you want to fix Dowager’s hump, you’ll have to work on improving each of them.
Birth defects can cause kyphosis. If you were born with spinal defects, it can cause you to have a kyphotic spine later in life. One of these is Scheuermann's disease or Scheuermann's kyphosis. Commonly seen in boys, it can cause kyphosis. Here, the curvature increase occurs before the pubertal growth spurt occurs and can severely affect the spine.
Symptoms Of Dowager’s Hump
Physical and Functional Symptoms
Excessive hyperkyphosis can severely affect your physical and functional limitations. Women who have a severe Dowager’s hump have difficulty simply raising themselves from a chair. You will also have a poor balance, slower gait, require a wider stance to support yourself and cannot climb stairs quickly. As a result, you might be more prone to falls. Osteoporotic women tend to have a higher postural sway which also adds to their risk for falls.
If you have Dowager’s hump, then your overall level of functioning is affected. You have difficulty doing basic activities around the house and their scores when it comes to activities of daily living are much lower compared to their normal peers. If you’re developing Dowager’s hump, you might also notice the following symptoms:
- Muscles fatigue easily
- Gradual postural changes
- Chronic pain in the back, neck, and shoulders
- Loss in height
- Multiple vertebral compression fractures
- Protruding abdomen
- Repeated falls
- Back stiffness
- Pain in the hips
- No sensation in the chest area
If you have Dowager’s hump you might experience difficulty breathing. The added kyphosis puts pressure on your lungs affecting their expansion and thus breathing. Breathing exercises and focusing on strengthening spinal muscles can help you to breathe fuller.
Severe progression of the Dowager’s hump can compress your digestive tract. As a result, you may have trouble with swallowing, acid reflux and slow clearance of your food. Also, if your spinal column is severely affected, you may experience a loss of bladder and bowel function.
If you’re experiencing digestive tract symptoms, increase your fiber and eat softer food. Fiber tends to hasten the passage of food through your gut. Softer food requires less time for digestion, allowing the gut to absorb nutrients faster in your system.
Dowager’s hump is disfiguring. Since most people don’t understand how it occurs and that it’s a part of natural aging, you may have to suffer labels such as “hunch-back” etc. All of this can psychologically affect you. In younger adults, it can lead to shame, aggression and anxiety. Older individuals might feel isolated socially and you may even feel depressed. There’s no need to be. Get a life coach or meet with a counselor to help you deal with any crippling emotions and anxiety.
Quality of Life
With limited mobility and a physical deformity, some women report physical difficulties with everyday living. If you’re a woman with Dowager’s hump you may also require more adaptation and have higher fears about your ability to function. Overall, men and women who live with this condition, are less satisfied with their health, functioning, relationships and economic conditions. As a result, you might limit your outdoor activities and public life and this furthers impairs your quality of life and level of functioning. Don’t let Dowager’s hump from living your best life. Have yourself diagnosed and then treated.
Diagnosing Dowager’s Hump
Apart from Xray’s,your doctor might suggest doing a CT scan, and an MRI may be recommended. He will do this is to evaluate your bones, the disc, the disc space and to rule out any tumors or secondary causes of your symptoms. The doctor may also conduct a thorough physical examination which will involve Adam’s bend test. Pulmonary function tests may be requested to evaluate how much your lungs have been affected by the condition.
Treating Dowager’s Hump
There are many treatment options for Dowager’s hump. They range from physiotherapy to surgery. The sooner you treat it, the more effective you will be in halting its progression. Studies have shown that with the right exercises and treatment, Dowager’s hump can be halted from getting worse if identified and treated early. Here’s a look at some of them.
Physiotherapy And Example Exercises
Physiotherapy is the mainstay of the treatment of Dowager’s hump. Because even if you do brace, tape, take medications and get surgery, the muscles, joints and bones that assist and make up your spine need to be strengthened. Your treatment choice will vary depending on the severity but it will have to be supplemented with physiotherapy if it isn’t the main treatment choice for you.
To start with you should improve the strength of the spinal muscles, which in turn will improve the flexibility of your spine. The following exercise is great for this purpose.
Next, the hip extensors can be trained, followed by the ankle. The lying glute stretch exercise is great for the hip extensors, and sitting foot stretches are good for the ankle.
You can also do the thoracic side-lying glute-curve stretch to extend the range of motion of the hip extensors and rotator muscles which will increase the expansion of your chest.
Additional exercises that strengthen the muscles groups will include lunges, presses, and bridge exercises. The following video shows you how to perform the lunge exercise.
You can also work on postural correction. This can be done while sitting or standing, with arms by the side or raised behind the head, where you retract the scapula. Stand in front of a mirror and visualize the lengthening through the crown of your head as you lift your chest. Try to keep a neutral spine throughout the day. This will require conscious practice.
The exercises and postural correction will improve any back pain associated with this condition. Avoid curl up flexion exercises that strain the spine. The goal is to extend the spine and each of the exercises should open up your spine more, with every set or rep you perform.
In children, teenagers and young adults, a brace can be worn for about two hours per day. This usually halts the progression of the kyphosis as the bones are still growing and can be molded to reduce spine curvature. A weighted spinal kyphosis orthosis can be worn by older adults especially when they’re moving. This brace also facilitates upright postural alignment thus reducing the number of falls.
In a trial of 62 older women with kyphosis of over 60 degrees, wearing a spinomed brace improved outcomes. The women wore the spinal orthosis 2 hours a day for 6 months. It resulted in a reduction of the kyphosis angle by 11%, improved standing height, more spinal extensor strength, and decreased postural sway.
During any of your physiotherapy exercises, you can also use tape. You can apply the therapeutic tape from the highest point of your shoulder joint diagonally across the trapezius muscle to the T6 vertebrae on both sides. This provides passive support to the spine.
Taping during three individual static standing tasks that lasted 40 seconds demonstrated good results. It revealed they had reduced kyphotic angle almost immediately after the task - compared with people who had sham taping or no taping at all.
There’s no medication to fix the bent spine. Painkillers and narcotics are prescribed to keep your pain at bay. As you exercise, you’ll realize that with the stress relieved form the spine, the pain will ease and your requirement on pain medications will wane.
Spinal fusion Surgery
For individuals with hyperkyphosis, more than 50 degrees surgery might be warranted. If you’re also experiencing nervous systems deficits like pinching of the nerve roots as they emerge from the spinal column or damage to the spinal column itself, doctors may recommend surgery.
One of the most common surgical procedures done is spinal fusion surgery. It is basically like a “welding” procedure where two vertebrae are fused together so they heal and move like a single solid bone. Fusion will take away some spinal flexibility. However, since few bones are involved, it doesn’t affect mobility and motion.
Alternately, doctors may recommend cutting the bone in a procedure called osteotomy. The Smith-Peterson osteotomy is a procedure where the bone in the back of the spine which connects the facet joints is cut. The removal of this bone and the involving joints can help the spine to move backwards. This extends it and allows it a more upright position.You must remember that even after a procedure like this, physiotherapy will still be recommended to keep the spine flexible and make the muscles strong and stable.
Preventing Dowager’s Hump
Now that you’ve read the causes of Dowager’s hump, you know that it can certainly be prevented.
Smoking has been identified as a risk factor for osteoporosis and bone fracture. The nicotine in tobacco slows down your production of bone cells. It also affects the absorption of calcium. It stimulates the production of cortisol which accelerates the breakdown of bones. Studies have shown that one year after quitting smoking, the bone density of these participating women improved considerably compared with women who continued to smoke.
Eat A Healthy Diet
A diet rich in calcium and vitamins will produce strong bones. Also, lay off the soda. We’re specifically talking about colas. They contain an ingredient called phosphoric acid that affects bone mineral density. Phosphoric acid tends to leach calcium from the bones. Additionally, caffeine has also been linked to lower bone mineral density. So go easy on the lattes and chai.
Cut Down Alcohol
Alcohol can also affect bones. It interferes with the absorption of vitamin D from the gut which in turn affects calcium absorption. Also, alcohol lowers the production of estrogen and testosterone. Both these hormones contribute to the ability to build bones and bone cells.
Stave off Osteoporosis
You can do with a regular intake of calcium. The recommended daily intake of calcium is 1,000 milligrams (mg) a day for women ages 50 and younger and men. In women over 50, 1,200 mg for women per day is the requirement. As we age, the bone density drops. It drops further without the bone building effect of estrogen. Along with calcium, make sure you get 800 IU of Vitamin D which helps in the absorption of calcium. Also ensure, you’re not taking medications that affect the bones like steroids and cancer medications.
You can read above, why mobility and flexibility of the spine affect the balance and posture. Weight bearing exercises and stretches are key to staying flexible. They also help maintain, stronger joints, taut ligaments and better connective tissue. Weight bearing exercises will also strengthen the bones.
In a randomized trial studying 60 post-menopausal women, the benefits of exercises were reinforced. The angle of kyphosis and strength of the back extensor muscles improved among women even with the most severe kyphosis, including those with significant weakness of the spinal extensor muscles, as scientists’ findings showed. What did the women do? 10 repetitions of face-down trunk extension exercises five times a week for a year while wearing a weighted backpack. After a ten-year follow-up among these same women, the rate of vertebral fractures was much lower, even though the women had stopped the exercises in the intervening ten-year period. Wow! Just imagine the effect of a lifetime of exercise. The evidence speaks for itself. Dowager’s hump can be improved with modified by spinal extensor muscle strengthening exercises.
You can also do the same exercise at home: Lie prone over a pillow and wear a backpack secured to your upper back. Squeeze your shoulder blades together, tighten your gluteal or butt muscles and lift your chest off the mat, keeping neck and lower spine in neutral. Start with 1 set of 10 repetitions.
You can progress to adding small weights in the backpack. Instead a weighted backpack, you can use a handheld dumbbells and do the same exercise by bending your elbows bent and keeping your hands by your ears. Do 3 sets.
Correct Posture Early
While this may seem like silly advice, few of us think of it consciously. Square your shoulders and sit straight. Stand erect. Be mindful of your posture. Whether you’re carrying a backpack, having dinner or eating out, watch how you slouch when it’s convenient. Maintaining an erect posture requires the active involvement of multiple muscle groups from your back all the way down to your hips.
Prevent hearing Loss and Check your Vision
Since hearing and vision contribute to our posture, check them at every physical exam to ensure you have good vision and hearing. Treat any secondary disease that affects them like diabetes, hypertension, and infections.
Do’s and Don’t in Dowager’s Hump
Here are a few do’s and don’ts while you fix Dowager’s hump.
Maintain a good posture while you exercise. Keep your spine neutral. Don’t slouch over.
Strengthen core stabilizing muscles like your obliques and transversus abdominis muscles. These muscles provide the counter balance to your spine. They run diagonally and horizontally but keep your spine stable.
While coughing or sneezing, keep your back in a neutral position. Try and maintain the natural curves of your neck and back. Here’s how to do this: stretch your neck, imagine you’re making the crown of your head longer.
When you bend and lift heavy objects bend at the hips and knees, keeping the object close to your body.
While you get off the bed, roll off your side, before sitting up.
Avoid using exercise machines that curl up the spine. This includes seated rowing machines.
Avoid crunches and traditional sit-ups. The goal is to extend the spine. Crunches and sit-ups tend to compress the spine, which is the last thing you want to do if you already have Dowager’s hump.
It’s easy to forget during routines of daily life. Often, we do things automatically without thinking. Repeated motions of spine curling activity gradually affect our spine and their curvature.
Avoid leaning over and doing a pelvic tilt while standing.
Avoid forceful trunk flexion as happens during a cough.
Don’t twist the spine while lifting objects.
Don’t sit up directly from a horizontal position.
Don’t bend over to reach anything.
Dowager’s Hump Can Be Fixed
Dowager’s Hump is NOT inevitable. You won’t get it simply because you age. You get it when you become inactive, inflexible and immobile. At Injurymap, we have a series of core stabilizing and back muscles strengthening exercises to gradually build the integrity of your spinal column.
The NHS in the UK recommends physical therapy for children as young as 5 who demonstrate signs of an increased spinal curvature. The American Academy of Orthopedic surgeons lists physical therapy as one of the first steps in treating kyphosis, irrespective of age or cause.
The existing evidence clearly supports the use of exercise, Spinomed bracing and taping interventions. Used together, they can certainly reduce hyperkyphosis. In turn leading to an improved quality of life and reduced risk of future fractures in both men and women.
About the author
Pamela Q. Fernandes is a doctor, author and medical writer. Having practiced preventive and family medicine for the last ten years, she's a keen advocate of health education and preventive medicine in her medical practice.
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