Effects of modified long stick exercise on hyperkyphosis,muscle imbalance and balance control in elderly community-dwelling women with hyperkyphosis

Abstract

BACKGROUND:

Hyperkyphosis is a condition often seen in older women. This condition causes muscle imbalance in the upper back of the body and impacts balance control. Long stick exercise (LSE) is an exercise programme for the elderly that improves muscle strength and balance control.

OBJECTIVE:

This research was designed to investigate the effects of a modified LSE on hyperkyphosis, muscle imbalance and balance control in elderly community-dwelling women with hyperkyphosis.

METHODS:

Twenty-eight elderly women with hyperkyphosis were divided into experimental and control groups. The experimental group was assigned to practice the modified LSE programme 30–40 minutes/day, 3 days/week, for 12 weeks. Hyperkyphosis, pectoralis minor length, muscle strength, functional reach test (FRT) and timed up and go test (TUG) were obtained at baseline, after 6 weeks and after 12 weeks of exercise.

RESULTS:

The experimental group demonstrated improved hyperkyphosis, pectoralis minor length, muscle strength, FRT, and TUG after 12 weeks of training. Moreover, the experimental group exhibited significantly greater improvements in all outcomes than the control group ( $p<$ 0.05).

CONCLUSION:

The modified LSE programme is an alternative exercise that is easy and low-impact for improving hyperkyphosis, muscle imbalance, and balance control in elderly community-dwelling women with hyperkyphosis.

Keywords

Kyphosis exercise training gerontology

1. Introduction

Ageing is likely to be accompanied by a decline in the body system functioning and changes in the musculoskeletal system that lead to osteoporosis, such as degeneration of the vertebral disc, loss of bone mineral density and weakening of the muscles [1, 2]. These changes result in a loss of spinal stability and lead to hyperkyphosis [3, 4, 5, 6]. Hyperkyphosis is a progressive condition that is characterised by an excessive backward deviation of the thoracic spine exceeding 40 degrees [7]. The condition is particularly evidenced in the elderly up to 40% and the proportion of hyperkyphosis increased in elderly women up to 65% more than men [6, 8]. This condition often affects posture and various health conditions.

In addition to changes in the thoracic spine, hyperkyphosis also results in a change in the alignment of the scapula plane, causing the scapula to be more protracted [9, 10, 11]. This condition impacts the length and tension of the muscles that attach to the scapula, causing those muscles to become imbalanced in the form of shortened anterior shoulder muscles and lengthened posterior shoulder muscles, which promotes the progression of hyperkyphosis [12, 13]. Moreover, hyperkyphosis progression can induce various adverse health consequences. The condition shifts the upper body anteriorly, which moves the body’s centre of mass forward. This promotes the displacement of the centre of gravity (COG) at levels close to the limits of stability. Individuals with hyperkyphosis, therefore, experience impaired balance control [14, 15, 16]. These consequences can further decrease quality of life and lead to mortality in elderly with hyperkyphosis [13, 16, 17, 18]. Early prevention and treatment that can help slow the progression of hyperkyphosis may help to reduce the consequences for elderly individuals with hyperkyphosis.

Currently, many interventions are available for treating hyperkyphosis, including manual mobilization, taping, yoga and stretching and strengthening exercises. The study results show that these interventions can attenuate the angle of the hyperkyphosis in elderly [19, 20, 21, 22, 23]. However, the findings of some studies indicate that the angle of the participants’ hyperkyphosis did not improve as a result of such interventions or due to the limitations of the research. These contradictory findings may have resulted from the use of short exercise periods, a small sample size and the requirement for physical therapists to progress the intensity of the exercise [24, 25]. Meanwhile, one study found no changes in the hyperkyphosis angle after exercise, possibly due to the subject’s baseline characteristics contributing to the ceiling effect of exercise [26]. Therefore, there are limitations to previous studies in their implementation in large populations or community areas.

Long stick exercise (LSE), or Krabong, is an exercise performed in parks and open spaces using long sticks of bamboo or polyvinyl chloride (PVC) that is usually practiced by adults and older individuals [27]. The exercise is characterised by stretching, body awareness and continuous movement of all body parts, especially in the upper back of the body [28]. This is an uncomplicated, low to moderate intensity exercise that is easy to perform and suitable for practice in a community area [29]. Prior research that has examined use of the LSE by healthy elderly individuals has demonstrated that the LSE can improve strength, flexibility, balance, depression, physical fitness and quality of life [27, 28, 30, 31]. Therefore, applying the LSE for elderly participants with hyperkyphosis is of interest because the exercise programme involves the use of upper back movement, which is consistent with the problem in participants with hyperkyphosis. However, the LSE programme followed during a previous study was frequently performed in a flexion posture that increased the risk of vertebral fracture in participants with hyperkyphosis and, therefore, may not be appropriate for participants with hyperkyphosis. As a result, the researcher modified and developed the LSE programme by focusing on stretching muscles prone to tightening and strengthening muscles prone to weakening in the upper back of the body as an alternative exercise that can be practised individually or as a group exercise in a community area, assuming that the modified LSE can improve hyperkyphosis, muscle imbalance and balance control in participants with hyperkyphosis. This study was designed to test this hypothesis by determining the effect of the modified LSE on hyperkyphosis, muscle imbalance and balance control in elderly community-dwelling women with hyperkyphosis.

2. Materials and methods

2.1 Participants

This randomized controlled trial (registered under no. TCTR20200926001) was conducted from August 2020 to June 2022. The participants were elderly community-dwelling women aged 60 years and older with a normal body mass index (18.5–29.9 kg/m ${}^{2}$ ) who had been diagnosed with thoracic hyperkyphosis determined using the 7 ${}^{\text{th}}$ cervical vertebra wall distance (C7WD) between 7.5–9.5 centimetres. Participants were excluded from the study if they had any conditions that may have limited the ability to locate their C7 bony prominence or impacted the training intervention or outcome measurements, such as an abnormal fat mass in the upper thoracic area, a buffalo hump, a wing scapula, pain or inflammation in the muscles or joints, spinal or limb deformities (i.e. scoliosis, amputation or leg-length discrepancy), high blood pressure, previous participation in another exercise programme within the six months prior to the study, a history of movement dysfunction (stroke, Parkinson’s disease) or the inability to understand and follow a simple command [32].

The sample size calculation for a comparative study [33] with a set power of test of 80%, an alpha of 0.05 using effect sizes from 10 pilot cases and a 20% dropout indicated that at least 14 participants were needed per group for the study. All experimental procedures were in accordance with the standards of the Ethics Committee in Human Research, Khon Kaen University and approved under no. HE632188. Written informed consent was obtained from all participants before they engaged in the study.

2.2 Research protocols

On the first day, the eligible participants were interviewed using a questionnaire to collect their demographic information. Their physical activity was assessed using the Thai version of the Short Format International Physical Activity Questionnaire (IPAQ-SF) [34, 35]. Next, they were assessed for their functional outcomes, and then they were randomly stratified into a control group and an experimental group using age range (60–70 and $>$ 70 years) and physical activity level (low and moderate) [35] as the criteria for the group arrangement (Fig. 1).

On the following day, participants in the experimental group began the modified LSE programme, which they practised for 30–40 minutes/day, 3 days/week, for 12 weeks. The functional outcomes were reassessed at 6 weeks and 12 weeks of training. The training programmes and outcome measures are explained next.

2.3 Experimental protocols

2.3.1 Control group

Participants in the control group were provided with information about hyperkyphosis and general self-care for hyperkyphosis in the elderly.

2.3.2 Experimental group: Modified LSE

Participants in the experimental group received the same information about hyperkyphosis and general self-care for hyperkyphosis in the elderly that the control group received; plus, they participated in the modified LSE programme for 30–40 minutes/day, 3 times/week, for 12 weeks (36 sessions total) with supervision by a physical therapist. The modified LSE was focused on stretching muscles prone to tightening, strengthening muscles prone to weakening and spinal extension movements to correct the kyphosis angle. Each exercise session consisted of a 10-minute warm-up, 10–20 minutes of exercise and a 10-minute cool-down period.

Warm-up and cool-down periods involved static stretching of the levator scapulae, upper trapezius, middle deltoid and triceps muscles. Participants stretched the muscle, holding for 30 seconds, with 2 repetitions for each side and rested between postures for 30 seconds.

During the exercise period, participants practiced the following 8 postures, as shown in the table below.

Exercise	Dosage	Weeks
1. Stretch pectoralis minor muscle: Participant lifted a stick 45 degrees obliquely to the top and held it	30 sec hold, 2 reps for each side	1–12
2. Stretch latissimus dorsi muscle: Participant lifted and held the stick while leaning to the side	30 sec hold, 2 reps for each side	1–12
3. Scapula movement: Participant held stick in two hands and rotated in a circle from left to	8 reps	1–3
right	8 reps (hold 5 secs)	4–6
	8 reps x 2	7–9
	8 reps x 2 (hold 5 secs)	10–12
4. Strengthen rhomboid and middle trapezius muscles: Participant lifted stick to chest level and	8 reps	1–3
pushed elbows back	8 reps (hold 5 secs)	4–6
	8 reps x 2	7–9
	8 reps x 2 (hold 5 secs)	10–12
5. Retract scapula: Participant held stick in two hands, lifted stick to chest level and then pushed	8 reps	1–3
elbows back	8 reps (hold 5 secs)	4–6
	8 reps x 2	7–9
	8 reps x 2 (hold 5 secs)	10–12
6. Spinal extension movement: Participant held stick in two hands and lifted stick above the	8 reps	1–3
head but not above shoulder level	8 reps (hold 5 secs)	4–6
	8 reps x 2	7–9
	8 reps x 2 (hold 5 secs)	10–12
7. Retract scapula and strengthen lower trapezius and serratus anterior muscles: Participant	8 reps	1–3
lifted stick above the head and pressed elbows down	8 reps (hold 5 secs)	4–6
	8 reps x 2	7–9
	8 reps x 2 (hold 5 secs)	10–12
8. Strengthen lower trapezius and serratus anterior muscles: Participant held stick in two hands	8 reps	1–3
and moved stick in frontal plane (shoulder abduction) to the end of the movement	8 reps (hold 5 secs)	4–6
	8 reps x 2	7–9
	8 reps x 2 (hold 5 secs)	10–12

In the first three weeks of the programme, participants performed 1 set of 8 repetitions for each side in each exercise posture. In the fourth through the sixth weeks, participants performed 1 set of 8 repetitions of holding at the end of a movement for 5 seconds in each exercise posture. In the seventh through the ninth weeks, participants performed 2 sets of 8 repetitions for each side in each exercise posture. Finally, in the last three weeks of the programme (weeks 10–12), participants performed 2 sets of 8 repetitions of holding at the end of a movement for 5 seconds in each exercise posture. Every first week of exercise transitions received a supervision from a physical therapist. In addition, each participant had to complete at least 80% of all exercise sessions (or 29 sessions).

2.4 Outcome measures

The participants were assessed for outcome measurements in the following order: C7WD, pectoralis minor length test, muscle strength test, functional reach test (FRT) and timed up and go test (TUG). These assessments are explained in the following subsections.

The 7 ${}^{\text{th}}$ cervical vertebra wall distance (C7WD)

The C7WD is a simple screening and monitoring tool used to determine the presence of thoracic hyperkyphosis [32, 36]. This method has excellent concurrent validity with the Cobb method (ICC $=$ 0.85–0.99) [32]. For this assessment, the participants stood upright as tall as possible on bare feet with the back of their heels against the wall, their sacrum and back touching the wall and their head in a neutral position. The assessor used two rulers to quantify the outcomes. The first ruler was placed on the C7 bony prominence, and the second was used to quantify the perpendicular distance from the wall to the landmark [32]. Three trials of the measurements were documented, and the average of those three results was used for data analysis.

Pectoralis minor length test

The pectoralis minor length test is a measure of the linear distance from a table to the posterior aspect of the acromion. For this measurement, participants were asked to lie supine on a table with their arms by their sides [37]. The distance between each participant’s posterolateral acromion and the table was measured in centimetres with a ruler scale that was positioned vertically [38, 39]. The participants were assessed on their dominant side three times. The average of those outcomes was used for data analysis.

Muscle strength test

A Baseline ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ 500 lb digital hydraulic push-pull dynamometer (HHD) was used to measure the strength of the maximum isometric contraction in the middle trapezius, lower trapezius, rhomboid and serratus anterior muscles. HHD was measured by make test protocol. For each action, participants exerted a maximum force against the stationary HHD and made no movement. Then their dominant side was assessed, and the assessment was repeated in 3 trials for each muscle and held 3 to 5 seconds. The rest period in between trials was 1 minute to prevent fatigue [40]. The average outcomes for each muscle in pounds were used for data analysis. The position of each muscle testing is described next [41].

Middle trapezius muscle: The participant was in a prone position with the arm at 90 ${}^{\circ}$ of abduction and the elbow at 90 ${}^{\circ}$ of flexion. The dynamometer was placed on the posterolateral corner of the acromion.

Lower trapezius muscle: The participant was in a prone position with the arm at 150 ${}^{\circ}$ with the thumb up. The dynamometer was placed on the posterolateral corner of the acromion.

Rhomboid muscle: The participant was in a prone position with the hand on the small of the back. The dynamometer was placed on the humerus halfway between the acromion and the lateral epicondyle.

Serratus anterior muscle: The participant was in a seated position with the arm at 130 ${}^{\circ}$ of flexion. The dynamometer was placed on the humerus distally to the deltoid attachment, and the curved end piece was used.

Functional reach test (FRT)

The FRT is usually applied to assess the stability limit and dynamic balance. This test measures the length of an outstretched arm in a maximal forward reach from a standing position while maintaining a fixed base of support [42, 43, 44]. The assessor instructed the participants to reach forward as far as possible without stepping or falling. The assessor then marked and recorded the location at the end of the middle finger, which was used to determine the length of the individual’s reach [43, 45]. The measurements were repeated for three trials, and the average outcomes were used for data analysis.

Timed up and go test (TUG)

The TUG is reliable and comprises many mobility subtasks involved in daily activities. The outcomes are commonly used to indicate dynamic balance ability and fall risk in the elderly [46]. Participants were instructed to stand up from a chair, walk around a traffic cone that was located 3 metres away from the chair and then return to the chair and sit down. The time spent on the task was recorded in seconds using a stopwatch that started timing at the command ‘Go’ and continued until the subject’s back was against the backrest of the chair [47, 48]. The measurements were repeated for three trials, and the average outcomes were used for data analysis.

2.5 Intra-rater reliability

Prior to data collection for this study, the reliability of the raters was examined. The intra-rater reliability (ICC ${}_{3,3}$ ) of the C7WD, pectoralis minor length test, muscle strength test, FRT and TUG was evaluated using 10 participants with hyperkyphosis. The outcome measurements were calculated from a mean score based on three trials for each test on one day and a repeated assessment with a time interval on the seventh day after the first assessment. Moreover, the standard error of measurement (SEM) was calculated for each test using the formula SEM $=$ SD $\surd$ (1 $-$ ICC). The results showed that all outcome measurements were associated with excellent intra-rater reliability, as the following data illustrate: C7WD (ICC $=$ 0.95; SEM $=$ 0.27), pectoralis minor length test (ICC $=$ 0.91; SEM $=$ 0.30), muscle strength test (ICC $=$ 0.93–0.95; SEM $=$ 0.60–0.79), FRT (ICC $=$ 0.96; SEM $=$ 0.44) and TUG (ICC $=$ 0.95; SEM $=$ 0.22).

2.6 Statistical analyses

A data analysis was executed using SPSS for Windows. The normal distribution of dependent variables was determined by the Shapiro-Wilk test [49]. Descriptive statistics were used to explain the participants’ demographic data and the findings of the study. The repeated measures ANOVA using post hoc tests (the Bonferroni correction) was used to detect within-group time effects at different time points (pre-training, at 6 weeks of training and at 12 weeks of training). The analysis of covariance (ANCOVA) was applied to compare the differences in the outcomes between the groups at 6 weeks of training and at 12 weeks with an adjusted mean difference and 95% confidence interval for each outcome. This analysis used the pre-training outcomes (baseline data) as a covariate.

The magnitude and precision of the effect of the modified LSE were calculated by effect size. The partial eta squared ( $n_{p}^{2}$ ) was used to determine between-group effects. Effect sizes were interpreted as follows: $\geqslant$ 0.80 indicated large, 0.50–0.79 indicated moderate, 0.20–0.49 was small and $<$ 0.20 was trivial [50, 51]. The level of statistical significance was set to a $p$ -value of less than 0.05.

3. Results

3.1 The participants’ demographic and baseline outcome measurements

For this study, 28 elderly women with hyperkyphosis were assigned to either the experimental group ( $n=$ 14) and the control group ( $n=$ 14), as shown in Fig. 1. The average age of the participants was 74 years, and each had a normal body mass index. Most participants reported moderate levels of physical activity. Moreover, the baseline outcome measurements demonstrated that no differences existed between the experimental and control group for all outcomes (Table 1).

Table 1
Demographic characteristics of the participants and baseline outcome measurements

Characteristic and outcomes	Overall ( $n=$ 28)		Control group ( $n=$ 14)		Experimental group ( $n=$ 14)		$P$ value
Age (years)	73.82	$\pm$ 5.98	74.14	$\pm$ 6.50	73.50	$\pm$ 5.63	0.78
Weight (kg)	54.16	$\pm$ 8.29	54.50	$\pm$ 9.25	53.83	$\pm$ 7.55	0.84
Height (cm)	155.11	$\pm$ 5.96	155.21	$\pm$ 6.23	155.00	$\pm$ 5.91	0.93
Body mass index (kg/m ${}^{2}$ )	22.53	$\pm$ 3.38	22.66	$\pm$ 3.90	22.40	$\pm$ 2.90	0.84
Physical activity;
Low: $n$ (%)	14 (35.71)		7 (35.71)		7 (35.71)		1.00
Moderate: $n$ (%)	14 (64.29)		7 (64.29)		7 (64.29)		1.00
C7WD (cm)	8.23	$\pm$ 0.65	8.32	$\pm$ 0.76	8.14	$\pm$ 0.52	0.48
Functional reach test (in)	7.51	$\pm$ 2.07	7.67	$\pm$ 2.15	7.36	$\pm$ 2.04	0.71
Timed up and go test (sec)	12.10	$\pm$ 2.72	12.99	$\pm$ 2.94	11.20	$\pm$ 2.22	0.08
Pectoralis minor length test (cm)	8.66	$\pm$ 1.85	8.95	$\pm$ 1.99	8.37	$\pm$ 1.71	0.42
Muscle strength test (lb)
Lower trapezius	8.23	$\pm$ 2.19	7.86	$\pm$ 1.83	8.59	$\pm$ 2.52	0.38
Middle trapezius	8.04	$\pm$ 2.33	7.67	$\pm$ 1.74	8.41	$\pm$ 2.83	0.42
Rhomboid	6.76	$\pm$ 2.27	6.33	$\pm$ 1.82	7.19	$\pm$ 2.64	0.33
Serratus anterior	7.92	$\pm$ 2.44	7.55	$\pm$ 2.09	8.29	$\pm$ 2.77	0.43

Abbreviation: kg: kilogram, cm: centimeter, kg/m ${}^{2}$ : kilogram per square meter, in: inch, sec: second, lb: pound, C7WD: the 7 ${}^{\text{th}}$ cervical vertebra wall distance. Note: Data are presented as Mean $\pm$ Standard deviation or n (percentage), as appropriate. $p$ -values were calculated from independent sample $t$ -test.

3.2 Outcome measurements

Within-group differences, a repeated measures ANOVA showed a significant within-group differences for all outcomes. Post hoc test comparisons revealed a significant improvement in middle trapezius, rhomboid and serratus anterior muscle strength at 6 weeks of training when compared with the pre-training data. At 12 weeks of training, the C7WD, pectoralis minor length, muscle strength, FRT and TUG showed significant improvement when compared with pre-training measurements, while the control group showed no statistically significant differences in any outcomes (Table 2).

Table 2
Outcomes measurement of the participants within groups at pre-test, at 6-week, and at 12-week of training

	Experimental group ( $n=$ 14)		Control group ( $n=$ 14)
Variable	Mean $\pm$ SD (95% CI)	Mean change scores (95% CI) ${}^{\text{a}}$	Mean $\pm$ SD (95% CI)	Mean change scores (95% CI) ${}^{\text{a}}$
C7WD (cm)
Pre-test	8.14 $\pm$ 0.52 (7.84 to 8.44)		8.32 $\pm$ 0.76 (7.88 to 8.76)
After 6-week training	8.05 $\pm$ 0.57 (7.72 to 8.38)	$-$ 0.09 ( $-$ 0.21 to 0.03)	8.36 $\pm$ 0.80 (7.90 to 8.83)	0.04 ( $-$ 0.03 to 0.11)
After 12-week training	7.61 $\pm$ 0.53 (7.30 to 7.91)	$-$ 0.54 ( $-$ 0.74 to $-$ 0.33) ${}^{\ast\ast}$	8.55 $\pm$ 0.88 (8.04 to 9.06)	0.23 (0.03 to 0.43)
Pectoralis minor length (cm)
Pre-test	8.37 $\pm$ 1.71 (7.38 to 9.36)		8.95 $\pm$ 1.99 (7.80 to 10.10)
After 6-week training	8.10 $\pm$ 1.79 (7.08 to 9.13)	$-$ 0.27 ( $-$ 0.67 to 0.14)	9.25 $\pm$ 1.87 (8.17 to 10.33)	0.30 ( $-$ 0.08 to 0.67)
After 12-week training	7.37 $\pm$ 1.49 (6.51 to 8.23)	$-$ 1.01 ( $-$ 1.47 to $-$ 0.54) ${}^{\ast\ast}$	9.43 $\pm$ 1.99 (8.28 to 10.58)	0.48 (0.14 to 0.82)
Lower trapezius muscle (lb)
Pre-test	8.59 $\pm$ 2.52 (7.14 to 10.05)		7.86 $\pm$ 1.83 (6.80 to 8.91)
After 6-week training	8.86 $\pm$ 2.53 (7.40 to 10.32)	0.26 ( $-$ 0.25 to 0.77)	7.62 $\pm$ 1.70 (6.64 to 8.60)	$-$ 0.24 ( $-$ 0.48 to 0.01)
After 12-week training	9.90 $\pm$ 2.66 (8.37 to 11.44)	1.31 (0.21 to 2.41) ${}^{\ast}$	7.52 $\pm$ 1.77 (6.50 to 8.55)	$-$ 0.33 ( $-$ 0.53 to $-$ 0.14)
Middle trapezius muscle (lb)
Pre-test	8.41 $\pm$ 2.83 (6.77 to 10.04)		7.67 $\pm$ 1.74 (6.66 to 8.67)
After 6-week training	9.38 $\pm$ 2.85 (7.74 to 11.03)	0.98 (0.30 to 1.66) ${}^{\ast\ast}$	7.31 $\pm$ 1.55 (6.42 to 8.20)	$-$ 0.36 ( $-$ 0.92 to 0.21)
After 12-week training	10.60 $\pm$ 3.09 (8.81 to 12.38)	2.19 (1.13 to 3.25) ${}^{\ast\ast}$	7.19 $\pm$ 1.59 (6.27 to 8.11)	$-$ 0.48 ( $-$ 0.96 to 0.01)
Rhomboid muscle (lb)
Pre-test	7.19 $\pm$ 2.64 (5.67 to 8.72)		6.33 $\pm$ 1.82 (5.29 to 7.38)
After 6-week training	7.98 $\pm$ 2.62 (6.47 to 9.49)	0.79 (0.18 to 1.39) ${}^{\ast}$	6.31 $\pm$ 1.71 (5.32 to 7.30)	$-$ 0.02 ( $-$ 0.67 to 0.62)
After 12-week training	9.33 $\pm$ 3.02 (7.59 to 11.08)	2.14 (1.09 to 3.19) ${}^{\ast\ast}$	6.12 $\pm$ 1.75 (5.11 to 7.13)	$-$ 0.22 ( $-$ 1.04 to 0.61)
Serratus anterior muscle (lb)
Pre-test	8.29 $\pm$ 2.77 (6.69 to 9.88)		7.55 $\pm$ 2.09 (6.34 to 8.75)
After 6-week training	9.10 $\pm$ 2.92 (7.41 to 10.78)	0.81 (0.07 to 1.55) ${}^{\ast}$	7.57 $\pm$ 1.76 (6.56 to 8.59)	0.02 ( $-$ 0.65 to 0.70)
After 12-week training	9.90 $\pm$ 2.96 (8.20 to 11.61)	1.62 (0.51 to 2.73) ${}^{\ast\ast}$	7.12 $\pm$ 1.59 (6.20 to 8.04)	$-$ 0.43 ( $-$ 1.48 to 0.63)

Abbreviation: SD: standard deviation, CI: confidence interval, cm: centimeter, lb: pound, C7WD: the 7 ${}^{\text{th}}$ cervical vertebra wall distance. Note: The data are presented using mean $\pm$ standard deviation (95% confidence intervals). ${}^{\text{a}}$ The data were compared with baseline (pre-test), and the data were analyzed using the repeated measure ANOVA and post-hoc (Bonferroni) test. Superscripts indicated significant differences with the $p$ -value ${}^{\ast}<$ 0.05, ${}^{**}p<$ 0.01.

When evaluating between-group differences at 6 weeks of training, the C7WD, pectoralis minor length, muscle strength and FRT assessments demonstrated significant differences with small effect sizes; only the TUG did not demonstrate such differences. At 12 weeks, the C7WD, pectoralis minor length, muscle strength, FRT and TUG showed significant differences with small to moderate effects. Moreover, the improvement in the experimental group was significantly greater than that of the control group ( $p<$ 0.05, Table 2).

Table 2

Outcomes measurement of the participants within groups at pre-test, at 6-week, and at 12-week of training (cont.)

Variable	Mean $\pm$ SD (95% CI) l	Mean change scores (95% CI) ${}^{\text{a}}$	Mean $\pm$ SD (95% CI)	Mean change scores (95% CI) ${}^{\text{a}}$
	Experimental group ( $n=$ 14)		Control group ( $n=$ 14)
Functional reach test (in)
Pre-test	7.36 $\pm$ 2.04 (6.18 to 8.54)		7.67 $\pm$ 2.15 (6.42 to 8.91)
After 6-week training	7.93 $\pm$ 2.12 (6.71 to 9.15)	0.57 ( $-$ 0.33 to 1.46)	7.37 $\pm$ 1.96 (6.24 to 8.50)	$-$ 0.30 ( $-$ 0.76 to 0.16)
After 12-week training	8.36 $\pm$ 2.30 (7.03 to 9.69)	1.00 (0.38 to 1.61) ${}^{\ast\ast}$	6.96 $\pm$ 2.12 (5.75 to 8.19)	$-$ 0.70 ( $-$ 1.45 to 0.05)
Timed up and go test (sec)
Pre-test	11.20 $\pm$ 2.22 (9.92 to 12.48)		12.99 $\pm$ 2.94 (11.29 to 14.69)
After 6-week training	10.95 $\pm$ 2.16 (9.70 to 12.20)	$-$ 0.25 ( $-$ 0.54 to 0.04)	13.75 $\pm$ 4.11 (11.38 to 16.12)	0.76 ( $-$ 0.33 to 1.85)
After 12-week training	10.73 $\pm$ 2.04 (9.55 to 11.92)	$-$ 0.47 ( $-$ 0.93 to $-$ 0.01) ${}^{\ast}$	13.84 $\pm$ 3.94 (11.57 to 16.12)	0.85 ( $-$ 0.20 to 1.91)

Abbreviation: SD: standard deviation, CI: confidence interval, in: inch, sec: second. Note: The data are presented using mean $\pm$ standard deviation (95% confidence intervals). ${}^{\text{a}}$ The data were compared with baseline (pre-test), and the data were analyzed using the repeated measure ANOVA and post-hoc (Bonferroni) test. Superscripts indicated significant differences with the $p$ -value ${}^{\ast}<$ 0.05, ${}^{**}p<$ 0.01.

Figure 1.

Flowchart of participants.

Table 3

Comparison of clinical outcomes measure between the groups

Variable	Experimental group ( $n=$ 14)	Control group ( $n=$ 14)	Adj mean difference between groups (95% CI)		$P$ -value ${}^{\text{a}}$	Effect size ${}^{\text{b}}$
	Adj mean	Adj mean
C7WD (cm)
After 6-week training	8.14	8.27	$-$ 0.13	( $-$ 0.23 to $-$ 0.02) ${}^{\ast}$	0.02	0.20
After 12-week training	7.70	8.46	$-$ 0.76	( $-$ 0.98 to $-$ 0.54) ${}^{\ast\ast}$	$<$ 0.01	0.67
Pectoralis minor length (cm)
After 6-week training	8.38	8.98	$-$ 0.60	( $-$ 1.02 to $-$ 0.18) ${}^{\ast\ast}$	$<$ 0.01	0.26
After 12-week training	7.63	9.17	$-$ 1.54	( $-$ 1.96 to $-$ 1.1) ${}^{\ast\ast}$	$<$ 0.01	0.69
Lower trapezius muscle (lb)
After 6-week training	8.51	7.97	0.54	(0.11 to 0.97) ${}^{\ast}$	0.02	0.21
After 12-week training	9.57	7.86	1.71	(0.86 to 2.56) ${}^{\ast\ast}$	$<$ 0.01	0.41
Middle trapezius muscle (lb)
After 6-week training	9.05	7.65	1.40	(0.73 to 2.06) ${}^{\ast\ast}$	$<$ 0.01	0.43
After 12-week training	10.25	7.54	2.72	(1.82 to 3.61) ${}^{\ast\ast}$	$<$ 0.01	0.61
Rhomboid muscle (lb)
After 6-week training	7.59	6.70	0.89	(0.23 to 1.56) ${}^{\ast}$	0.01	0.23
After 12-week training	8.93	6.52	2.42	(1.38 to 3.45) ${}^{\ast\ast}$	$<$ 0.01	0.48
Serratus anterior muscle (lb)
After 6-week training	8.76	7.91	0.85	(0.10 to 1.61) ${}^{\ast}$	0.03	0.18
After 12-week training	9.61	7.41	2.20	(1.10 to 3.31) ${}^{\ast\ast}$	$<$ 0.01	0.40
Functional reach test (in)
After 6-week training	8.06	7.24	0.82	(0.08 to 1.56) ${}^{\ast}$	0.03	0.17
After 12-week training	8.50	6.82	1.68	(0.94 to 2.42) ${}^{\ast\ast}$	$<$ 0.01	0.47
Timed up and go test (sec)
After 6-week training	12.03	12.67	$-$ 0.64	( $-$ 1.44 to 0.15)	0.11	0.10
After 12-week training	11.75	12.83	$-$ 1.08	( $-$ 1.97 to $-$ 0.20) ${}^{\ast}$	0.02	0.20

Abbreviation: CI: confidence interval, cm: centimeter, lb: pound, in: inch, sec: second, C7WD: the 7 ${}^{\text{th}}$ cervical vertebra wall distance. Note: Adj Mean $=$ Mean adjusted for baseline values; ${}^{\text{a}}$ Analysis of covariance (ANCOVA); ${}^{\text{b}}$ Partial eta squared ( $n_{p}^{2}$ ) effect size. Superscripts indicated significant differences with the $p$ -value ${}^{\ast}<$ 0.05, ${}^{**}p<$ 0.01.

4. Discussion

This study investigated the effect of the modified LSE on hyperkyphosis, muscle imbalance and balance control in elderly community-dwelling women with hyperkyphosis. The participants in the experimental group showed significant improvement related to hyperkyphosis, as measured using the C7WD, pectoralis minor length, muscle strength, FRT and TUG after 6 and 12 weeks of the participants’ engagement in the modified LSE training ( $p<$ 0.05, Table 2). Moreover, the experimental group exhibited significantly greater improvement than the control group (Table 2).

Previous studies have reported on the use of exercise and modalities to treat hyperkyphosis in the elderly [19, 20, 21, 22, 23]. However, these studies had limitations to their application in the community. LSE is becoming very popular among elderly people living in the community because it is easy to learn and does not require any certain skills [28]. The LSE uses sticks as a component of the exercise, which helps with movement in the upper back of the body [52, 53]. Furthermore, the LSE has a low impact and low velocity, which minimises the risk of orthopaedic complications, such as pain or fracture, resulting from engaging in the activity [27]. Therefore, LSEs should be appropriate for use in the elderly. In our study, the researchers applied the advantages of using a stick during exercise to develop an exercise programme for the elderly with hyperkyphosis. The exercise pattern was focused on stretching muscles prone to tightening and strengthening muscles prone to weakening in the upper back of the body, which involved a combination of isometric exercise and range of motion (ROM) exercise. After 12 weeks of participating in the modified LSE programme, no adverse effects or complications for the elderly participants were reported.

This study showed that hyperkyphosis, as measured by the C7WD, improved at 12 weeks in the experimental group, which demonstrated a greater degree of improvement than the control group at 6 weeks and 12 weeks, with a moderate effect size at 12 weeks. We hypothesized that the decrease in hyperkyphosis resulted from stretching and strengthening the muscles attached to the scapula. The exercise posture in this study is thoracic extension and retraction of scapula, which reverses to kyphosis. Stretching muscles lengthen the shape of receptors (muscle spindle, Golgi tendon organ) and lead to muscle relaxation. Considering the length-tension relationship, muscle tension will also be decreased due to sarcomere extension. According to the stages of motor control, the mobility improvement of tightened muscles can consequently enhance the optimal contraction of weak muscles. Henceforth, this current exercise should be proven to correct muscle imbalance in the long-term study [54]. The pectoralis minor length and lower trapezius muscle strength showed significant improvements in the experimental group at 12 weeks, while the same group demonstrated improved strength of the middle trapezius, rhomboid and serratus anterior muscles at 6 weeks and 12 weeks. When compared with the control group, the experimental group showed a greater degree of improvement in muscle imbalance outcomes at 6 weeks and 12 weeks with a low to moderate effect size. Consistent with previous studies, the results indicate that exercise intervention that promotes scapular alignment improves hyperkyphosis angle and abnormal posture [55, 56]. The activities in the modified LSE programme in the study were isometric and ROM exercises. When performing isometric exercises, muscle tension is continuously improved, which causes the size of the active muscle fibres to increase. The amount of muscle protein and muscle size increases because of larger muscular fibres, which also results in larger muscles and more power [57]. During ROM exercises, joints or muscles are moved to the maximum. Joint movement facilitation gradually reduces stiffness and encourages a change in muscle fibres. The muscle that is used more frequently might become stronger and delay the degradation of the muscles [57, 58]. Thus, the modified LSE program had the benefit of improving hyperkyphosis and muscle imbalance in the upper back of the body in elderly women with hyperkyphosis.

A change in the body’s centre of mass (COM) or centre of gravity (COG) occurs in elderly people who have hyperkyphosis, and this becomes one of the factors that affects balance control. Leaning forward with the body impacts the body’s COM, which, in turn, affects body sway, making the ability to stay balanced while standing and walking challenging [59, 60, 61]. The results of this study revealed that the FRT and TUG improved at 12 weeks in the experimental group, who showed greater improvement than the control group at 6 weeks and 12 weeks, with a small effect size. The LSE programme in this study involved posture exercises that focused on retraction of the scapular and correcting the posture, which decreased hyperkyphosis by measuring the distance from the C7 to the wall and promoting posture adjustment, resulting in improved balance control during standing. Moreover, previous studies have reported that hyperkyphosis was correlated with balance control during walking [62, 63]. The researchers hypothesised that improved balance control during walking was likely due to improvements in hyperkyphosis after exercise. Some of the exercise postures employed for previous research were similar to those used in this study, which focused on scapula retraction, but the results did not indicate changes in balance control. This may be due to the small sample size and the short duration of the exercise [25]. Thus, the modified LSE programme improved balance control in elderly women with hyperkyphosis.

This is the first study to examine the effect of modified LSEs in elderly community-dwelling women with hyperkyphosis. All participants were randomised using a stratified block randomisation and matched by age and level of physical activity. The modified LSE programme can be uncomplicated and suitable for use in a community area. Moreover, the exercise programme has been shown not to have an adverse effect on elderly subjects during exercise. However, this study does have some limitations. First, the study only included elderly women, which may restrict the applicability of its conclusions to the entire elderly population. Therefore, future studies should recruit elderly men to participate so the findings can be generalised. Second, the study did not incorporate a plan to monitor the long-term effect of the modified LSE. As such, long-term follow up should be considered in future studies.

5. Conclusion

This study demonstrated that the modified LSE decreased hyperkyphosis and muscle imbalance, which is related to the progression of hyperkyphosis. In addition, this exercise programme improved balance control during standing and walking. Therefore, the modified LSE is a good exercise programme for improving hyperkyphosis, muscle imbalance and balance control. It may be applied as an alternative exercise regimen for improving the health status of elderly community-dwelling women with hyperkyphosis, especially since the exercise is easy to practice and suitable to be used in a community area.

Ethical approval

The study was approved by the Ethics Committee in Human Research of Khon Kaen University (HE632188).

Funding

No funding was received for this study.

Informed consent

Not applicable.

Author contributions

All authors contributed to the concept/idea and research design. NC and LM wrote the manuscript. NC contributed to the data collection and data analysis. All authors read and approved the final manuscript.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors have no conflicts of interest to declare.

References

Amarya

Singh

Sabharwal

. Ageing Process and Physiological Changes. Available at: https://www.intechopen.com/books/gerontology/ageing-processand-physiological-changes.

Rodrigues

ACC

Romeiro

CAP

Patrizzi

. Evaluation of thoracic kyphosis in older adult women with osteoporosis by means of computerized biophotogrammetry. Rev Bras Fisioter. 2009; 13(3): 205-9.

Culham

Jimenez

King

. Thoracic kyphosis, rib mobility, and lung volumes in normal women and women with osteoporosis. Spine. 1994; 19(11): 1250-5.

Lorbergs

O’Connor

Zhou

Travison

Kiel

Cupples

, et al. Severity of kyphosis and decline in lung function: The Framingham study. J Gerontol A Biol Sci Med Sci. 2017; 72(5): 689-94.

Lombardi

Oliveira

Mayer

Jardim

Natour

. Evaluation of pulmonary function and quality of life in women with osteoporosis. Osteoporos Int. 2005; 16(10): 1247-53.

Katzman

Wanek

Shepherd

Sellmeyer

. Age-related hyperkyphosis: Its causes, consequences, and management. J Orthop Sports Phys Ther. 2010; 40(6): 352-60.

Kado

Huang

Nguyen

Barrett-Connor

Greendale

. Hyperkyphotic posture and risk of injurious falls in older persons: The Rancho Bernardo Study. J Gerontol A Biol Sci Med Sci. 2007; 62(6): 652-7.

Bartynski

Heller

Grahovac

Rothfus

Kurs-Lasky

. Severe thoracic kyphosis in the older patient in the absence of vertebral fracture: Association of extreme curve with age. AJNR Am J Neuroradiol. 2005; 26(8): 2077-85.

Culham

Peat

. Spinal and shoulder complex posture. II: Thoracic alignment and shoulder complex position in normal and osteoporotic women. Clin Rehabil. 1994; 8(1): 27-35.

10.

Imagama

Hasegawa

Wakao

Hirano

Muramoto

Ishiguro

. Impact of spinal alignment and back muscle strength on shoulder range of motion in middle-aged and elderly people in a prospective cohort study. European Spine Journal. 2014; 23(7): 1414-19.

11.

Kanlayanaphotporn

. Changes in sitting posture affect shoulder range of motion. Journal of Bodywork and Movement Therapies. 2014; 18(2): 239-43.

12.

Singla

Veqar

. Association between forward head, rounded shoulders, and increased thoracic kyphosis: A review of the literature. J Chiropr Med. 2017; 16(3): 220-9.

13.

Sangtarash

Manshadi

Sadeghi

. The relationship of thoracic kyphosis to gait performance and quality of life in women with osteoporosis. Osteoporos Int. 2015; 26(8): 2203-8.

14.

Siminoski

Warshawski

Jen

Lee

. The accuracy of clinical kyphosis examination for detection of thoracic vertebral fractures: Comparison of direct and indirect kyphosis measures. J Musculoskelet Neuronal Interact. 2011; 11(3): 249-56.

15.

Sinaki

Brey

Hughes

Larson

Kaufman

. Balance disorder and increased risk of falls in osteoporosis and kyphosis: Significance of kyphotic posture and muscle strength. Osteoporos Int. 2005; 16(8): 1004-10.

16.

Arnold

Busch

Schachter

Harrison

Olszynski

. The relationship of intrinsic fall risk factors to a recent history of falling in older women with osteoporosis. J Orthop Sports Phys Ther. 2005; 35(7): 452-60.

17.

Kado

Huang

Karlamangla

Barrett-Connor

Greendale

. Hyperkyphotic posture predicts mortality in older community-dwelling men and women: A prospective study. J Am Geriatr Soc. 2004; 52(10): 1662-7.

18.

Kado

. The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med. 2009; 45(4): 583-93.

19.

Bautmans

Van Arken

Van Mackelenberg

Mets

. Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal patients with osteoporosis. J Rehabil Med. 2010; 42(2): 129-35.

20.

Greig

Bennell

Briggs

Hodges

. Postural taping decreases thoracic kyphosis but does not influence trunk muscle electromyographic activity or balance in women with osteoporosis. Man Ther. 2008; 13(3): 249-57.

21.

Katzman

Sellmeyer

Stewart

Wanek

Hamel

. Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil. 2007; 88(2): 192-9.

22.

Benedetti

Berti

Presti

Frizziero

Giannini

. Effects of an adapted physical activity program in a group of elderly subjects with flexed posture: Clinical and instrumental assessment. J Neuroeng Rehabil. 2008; 5(1): 1-11.

23.

Greendale

Huang

Karlamangla

Seeger

Crawford

. Yoga decreases kyphosis in senior women and men with adult-onset hyperkyphosis: Results of a randomized controlled trial. J Am Geriatr Soc. 2009; 57(9): 1569-79.

24.

Renno

Granito

Driusso

Costa

Oishi

. Effects of an exercise program on respiratory function, posture and on quality of life in osteoporotic women: A pilot study. Physiotherapy. 2005; 91(2): 113-8.

25.

Bennell

Matthews

Greig

Briggs

Kelly

Sherburn

Wark,

. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: A randomised, single-blind controlled pilot trial. BMC Musculoskeletal Disorders. 2010; 11(1): 1-11.

26.

Bergström

Kronhed

ACG

Karlsson

Brinck

. Back extensor training increases muscle strength in postmenopausal women with osteoporosis, kyphosis and vertebral fractures. Advances in Physiotherapy. 2011; 13(3): 110-7.

27.

Permsirivanich

Lim

Promrat

. Long stick exercise to improve muscular strength and flexibility in sedentary individuals. Southeast Asian J Trop Med Public Health. 2006; 37(3): 595-600.

28.

Janmookda

Dajpratham

. The effect of the modified Boonmee long stick exercise on balance, flexibility and strength in elderly. J Thai Rehabil Med. 2008; 18(2): 59-64.

29.

Seephim

Nualnetr

. The effects of wand exercise training on physical function, grip strength and pain in persons with rheumatoid arthritis. J Med Tech Phy Ther. 2016; 28(2): 144-53.

30.

Jarupunt

Paokanha

Subgranon

Piputvanicha

. Effectiveness of an applied boonmee long-stick danced exercise program with self-efficacy theory on depression and physical fitness for older adults in nursing home. The Journal of Faculty of Nursing Burapha University. 2011; 19(1): 42-56.

31.

Thanakwang

Rattanawitoon

. Effects of ram mi-plong mong soeng muang nan on physical fitness and health-ralated quality of life in sedentary older women. Nursing Journal. 2013; 40(2): 148-61.

32.

Suwannarat

Amatachaya

Sooknuan

Tochaeng

Kramkrathok

Thaweewannakij

, et al. Hyperkyphotic measures using distance from the wall: Validity, reliability, and distance from the wall to indicate the risk for thoracic hyperkyphosis and vertebral fracture. Arch Osteoporos. 2018; 13(1): 25.

33.

Jirawatkul

. Statistics for health science research, Bangkok, 2009, 160.

34.

Kim

Park

Kang

. Convergent validity of the international physical activity questionnaire (IPAQ): Meta-analysis. Public Health Nutr. 2013; 16(3): 440-52.

35.

Rattanawiwatpong

Khunphasee

Pongurgsorn

Intarakamhang

. Validity and reliability of the Thai version of Short Format International Physical Activity Questionnaire (IPAQ). J Thai Rehabil. 2006; 16(3): 147-160.

36.

Wongsa

Amatachaya

Saengsuwan

Amatachaya

. Concurrent validity of occiput-wall distance to measure kyphosis in communities. J Clin Trials. 2012; 2(10.4172): 2167-0870.

37.

Weber

Enzler

Wieser

Swanenburg

. Validation of the pectoralis minor length test: A novel approach. Man Ther. 2016; 22: 50-5.

38.

Lewis

Valentine

. The pectoralis minor length test: A study of the intra-rater reliability and diagnostic accuracy in subjects with and without shoulder symptoms. BMC musculoskeletal Disord. 2007; 8(1): 64.

39.

Srijessadarak

Sae-Lee

Paungmali

Bumrerraj

Boonprakob

. Investigations of upper crossed syndrome’s characteristics in dental students. Journal of Associated Medical Sciences. 2017; 50(3): 404-404.

40.

Sisto

Dyson-Hudson

. Dynamometry testing in spinal cord injury. J Rehabil Res Dev. 2007; 44(1): 123.

41.

Turner

Ferguson

Mobley

Riemann

Davies

. Establishing normative data on scapulothoracic musculature using handheld dynamometry. J Sport Rehabil. 2009; 18(4): 502-20.

42.

Duncan

Weiner

Chandler

Studenski

. Functional reach: A new clinical measure of balance. J Gerontol. 1990; 45(6): 192-7.

43.

Bennie

Bruner

Dizon

Fritz

Goodman

Peterson

. Measurements of balance: Comparison of the Timed “Up and Go” test and Functional Reach test with the Berg Balance Scale. Journal of Physical Therapy Science. 2003; 15(2): 93-7.

44.

Persad

Cook

Giordani

. Assessing falls in the elderly: Should we use simple screening tests or a comprehensive fall risk evaluation? European Journal of Physical and Rehabilitation Medicine. 2010; 46(2): 249-59.

45.

Jonsson

Henriksson

Hirschfeld

. Does the functional reach test reflect stability limits in elderly people? Journal of Rehabilitation Medicine. 2003; 35(1): 26-30.

46.

Podsiadlo

Richardson

. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991; 39(2): 142-8.

47.

Steffen

Hacker

Mollinger

. Age-and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther. 2002; 82(2): 128-37.

48.

Jalayondeja

. Falls screening by Timed Up and Go (TUG). J Med Tech Phy Ther. 2014; 26(1): 5-16.

49.

Das

Imon

AHMR

. A brief review of tests for normality. Am J Theor Appl Stat. 2016; 5(1): 5-12.

50.

Richardson

. Eta squared and partial eta squared as measures of effect size in educational research. Educ Res Rev. 2011; 6(2): 135-147.

51.

Middel

Van Sonderen

. Statistical significant change versus relevant or important change in (quasi) experimental design: some conceptual and methodological problems in estimating magnitude of intervention-related change in health services research. Int J Integr Care. 2002; 2.

52.

Puengsuwan

Promdee

Sruttabul

Na Nagara

Leelayuwat

. Effectiveness of Thai Wand Exercise training on health-related quality of life in sedentary older adults. Chula Med J. 2008; 52(2): 107-21.

53.

Pantong

. The effect of Boonmee Long-stick exercise on reduction of blood sugar in type 2 diabetic patients. Prince of University 2005.

54.

Guissard

Duchateau

. Neural aspects of muscle stretching. Exerc Sport Sci Rev. 2006; 34(4): 154-8.

55.

Yoo

. Effects of thoracic posture correction exercises on scapular position. J Phys Ther Sci. 2018; 30(3): 411-2.

56.

Lynch

Thigpen

Mihalik

Prentice

Padua

. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Br J Sports Med. 2010; 44(5): 376-81.

57.

Safa’ah

Srimurayani

. Effectiveness of isometric and range of motion (ROM) exercise toward elderly muscle strenght in Pasuruan integrated service unit, elderly social services in Lamongan. Biomed Eng. 2017; 3(1): 7-15.

58.

Jenkins

. Maximizing Range of Motion In Older Adult. The Journal on Active Aging, January February, Vol 4; third ed, 2005; 50-55.

59.

Lynn

Sinaki

Westerlind

. Balance characteristics of persons with osteoporosis. Arch Phys Med Rehabil. 1997; 78(3): 273-7.

60.

Wijaya

Munawwarah

Amir

. Correlation between Hyperkyphosis and Balance of Elderly Who Join Osteoporosis Gymnastics at Royal Taruma Hospital, West Jakarta 2020.

61.

Balzini

Vannucchi

Benvenuti

Benucci

Monni

Cappozzo

Stanhope

. Clinical characteristics of flexed posture in elderly women. J Am Geriatr Soc. 2003; 51(10): 1419-26.

62.

O’Brien

Culham

Pickles

. Balance and skeletal alignment in a group of elderly female fallers and nonfallers. J Gerontol A Biol Sci Med Sci. 1997; 52(4): B221-6.

63.

Abe

Aoyagi

Tsurumoto

Chen

Kanagae

Mizukami

Kusano

. Association of spinal inclination with physical performance measures among community-dwelling J apanese women aged 40 years and older. Geriatr Gerontol Int. 2013; 13(4): 881-6.

Effects of modified long stick exercise on hyperkyphosis,muscle imbalance and balance control in elderly community-dwelling women with hyperkyphosis

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Participants

2.2 Research protocols

2.3 Experimental protocols

2.3.1 Control group

2.3.2 Experimental group: Modified LSE

2.4 Outcome measures

The 7 th cervical vertebra wall distance (C7WD)

Pectoralis minor length test

Muscle strength test

Functional reach test (FRT)

Timed up and go test (TUG)

2.5 Intra-rater reliability

2.6 Statistical analyses

3. Results

3.1 The participants’ demographic and baseline outcome measurements

Table 1 Demographic characteristics of the participants and baseline outcome measurements

Table 2 Outcomes measurement of the participants within groups at pre-test, at 6-week, and at 12-week of training

5. Conclusion

Ethical approval

Funding

Informed consent

Author contributions

Footnotes

Acknowledgments

Conflict of interest

References

The 7 ${}^{\text{th}}$ cervical vertebra wall distance (C7WD)

Table 1
Demographic characteristics of the participants and baseline outcome measurements

Table 2
Outcomes measurement of the participants within groups at pre-test, at 6-week, and at 12-week of training