1st Case Presentation

Wednesday, December 30th, 2020

REHABILITATION OF PATIENT
WITH KHYPOTIC THORACAL DEFORMITY DUE TO
SPONDYLITIS TUBERCULOSA

Presented By:
Indra Putera Hasri, MD

Supervised by:
Dr. Marina A. Moeliono, dr. SpKFR (K)
Dr. Vitriana, dr. Sp.KFR (K)

PHYSICAL MEDICINE AND REHABILITATION DEPARTMENT

FACULTY OF MEDICINE PADJADJARAN UNIVERSITY
BANDUNG
2020
 CASE REPORT

I. Identity

Name : Mr. AM

Sex : Male

Date of birth (age) : August 21th, 1999 (21 years old)

Religion : Islam

Marital status : Single

Job : College student

Referral diagnose : Khypotic deformity at Thoracal region due to suspect

sequele spondylitis TB

II. History Taking (auto anamnesis from the patient, December 14th, 2020)

a. Chief complaint

Appearance of roundback

b. History of present illness

Patient have changes of his back appearance since 2017. The roundback

become stiffness in the beginning 2019 since that, the patient cannot straight his

back. Stiffness progressively to his neck, shoulder, hip and knee. The patient now

walking with the legs wide apart and easily feel fatigue after walking more than

300 meter since 2017. Patient felt pain since 2017 at upper back if sitting or

standing more than 2 hours (NRS 3), while change position from sit to stand

(NRS 4), pain reduce when walking (NRS 2), no radiculating pain, tingling

sensation, nor numbness.

1
 The patient has lost his weight in the last 3 years from 56 kg to 40 kg.

Complain of cough, fever, dyspneu or night sweats are denied.

c. History of past illness

June 2019 patient consult to Orthopaedic at Hasan Sadikin Hospital and

diagnosed with khypotic deformity at thoracal region Dd/ Ankylosing spondylitis,

then patient reffered to DOTS policlinic and diagnosed with bone tuberculosis and

start medication for tuberculosis since July 2019 until now with OAT FDC three

tablets one time a day, no history of dropping out of drug. November 2020 the

patient reffered to Rheumato policlinic and the result was no sign of rheumatic

disease.

d. Hystory of family illnes

The patient grandfather had Tuberculosis of lung since 2016 and have the

medication until finish.

e. History of functional ability

He can do his activities of daily living (ADL) independently. Defecate in

sitting position with sitting closet.

f. History of habit

Since the pandemic condition, he always at home attend the lectures via

online and drive a motorcycle when he need go to campus.

2
g. History of nutrition

He rare having a breakfast, at lunch and dinner time he ate one rice spoon

with chicken/fish, tofu/tempe. He seldom ate vegetable and fruit. He drinks 8-10

glass of water a day. Since OAT medication he often loss his appetite.

h. History of vocational and avocational

Before illnes he usually playing futsal once a week until 2017. He had

work at cotton factory for 6 month in 2018, he bring the cart fullfilled with cotton

about 200 kg with his work partner, no complain about health condition nor pain.

He stop work because he went go to college.

i. History of psychosocial economy status

He is single. He was active college student 5 th semester at State Islamic

University. He live with parents and 2 other siblings. Daily living expences from

his parents. His parents income about 2 million rupiah a month an work as cadger

since pandemic condition. His big brother work as freelancer and his little brother

still study in junior high school.

j. House and environment assessment

He lives in his parents house, 42 meter square with two level house. The

house had terrace on front, clothes line area at second level house, have 3

bedrooms, 2 bathrooms, 1 kitchen, and 1 living room. The house has poor

ventilation and ligthning from the sunlight.

3
 His bedroom is very small about 3 x 1,5 meter with poor ventilation. He

spent a lot of time in his room playing or get lecture from his smartphone. The

toilet is squatting toilet. The main road to the patient house about 100 meter with

narrow alley ±1.5 meter.

III. Physical Examination

The patient comes to the PMR clinic walking independently (with wide steps)

without assited walking device.

General Physical Examination

Consciousness : Compos Mentis

Nutritional status :

Body weight : 40 kg

Body height : 165 cm

BMI : 14.7 kg/m2 (underweight)

Vital sign :

Blood pressure :120/80mmHg Temperature : afebrile

Pulse rate : 98x/minute SpO2 : 98%

Respiratory rate : 18x/minute

Internal Status
Head : Deformity (-), conjungtiva: anemic (-) /(-)
Neck : JVP is not elevated, lymph node is not palpable
Thorax : Symmetrical shape and movement
Lung : Sonor, Vesicular Breath Sound right = left
rhonchi (-) /(-), wheezing (-) /(-)

4
Cor : Normal heart sound (S1-S2), murmur (-), gallop (-)
Chest expansion : 1,5 cm/2cm/2,5 cm
Abdomen : Flat, hepar and lien are not palpable, normal bowel sound

Musculoskeletal Status

Head and neck region

Look : Forward head

Feel : Spasm at posterior neck muscles

Move : Range of motion:

 Neck flexion : 0-30° / 0-30° (hard end feel)

 Neck lateral bending : 0-5° / 0-5° (hard end feel)

 Neck axial rotation : 0-15° / 0-15° (hard end feel)

Manual muscle testing :5

Occiput to wall distance : 15 cm

Trunk region

Look : Deformity at thoracal region

Gibbus (-), Hump (-) / (-)

Shoulder height right < left

Scapular prominence (-) / (-)

Pelvic obliquity right = left

Feel : Inflammation sign (-)

Muscle spasm + at upperback muscle, jump sign (-)/(-)

Move : ROM: Modified-modified schober test flexion: 1,5 cm

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 Modified-modified schober test extension: 0,5 cm
Manual muscle testing: Trunk flexion = 3
Trunk extension = cbe
Straight leg test : (-) / (-)
Braggard test : (-) / (-)
Pelvic rock :+/+
Gaenslen tes :+/+
Upper extremities region

Look : Deformity (-), inflammation (-)

Feel : Tenderness (-)

Move : Range of motion and Manual Muscle Testing

ROM MMT
Shoulder Right Left End feel Right Left
Flexion 0 - 120° 0 - 110° Empty/Empty 5 5
Extension Full Full 5 5
Abduction 0 - 110° 0 - 115° Empty/Empty 5 5
Adduction Full Full 5 5
Internal full full 5 5
rotation
External full full 5 5
rotation
Scapula
Abduction and 4 5
upward
rotation
Elevation 5 5
Adduction 3* pain 3* pain
Depression 3* pain 3* pain
and adduction
Adduction and 5 5
downward
rotation
Depresion 5 5
Elbow Right Left End feel Right Left
Flexion Full Full 5 5
Extension Full Full 5 5
Supination Full Full 5 5
Pronation Full Full 5 5

6
 Wrist
Flexion Full Full 5 5
Extension Full Full 5 5
Ulnar Full Full 5 5
deviation
Radial Full Full 5 5
deviation
Thumbs
Flexion MCP Full Full 5 5
Flexion IP Full Full 5 5
Extension Full Full 5 5
MCP
Extension IP Full Full 5 5
Abduction Full Full 5 5
Adduction Full Full 5 5
Digiti II
Flexion MCP Full Full 5 5
Flexion PIP Full Full 5 5
Flexion DIP Full Full 5 5
Extension Full Full 5 5
MCP
Extension PIP Full Full 5 5
Digiti III
Flexion MCP Full Full 5 5
Flexion PIP Full Full 5 5
Flexion DIP Full Full 5 5
Extension Full Full 5 5
MCP
Extension PIP Full Full 5 5
Digiti IV
Flexion MCP Full Full 5 5
Flexion PIP Full Full 5 5
Flexion DIP Full Full 5 5
Extension Full Full 5 5
MCP
Extension PIP Full Full 5 5
Digiti V
Flexion MCP Full Full 5 5
Flexion PIP Full Full 5 5
Flexion DIP Full Full 5 5
Extension Full Full 5 5
MCP
Extension PIP Full Full 5 5
Special Test

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 Hawkin’s-Kennedy test : (-)/(-)

Yergason test : (-)/(-)

Speed test : +/+

Drop Arm test : (-)/(-)

Neer test : (-)/(-)

Patte’s test : (-)/(-)

Lift-off test : (-)/(-)

Hand Prehension :

Powergrip : Palmar/fist : good/good

Cylindrical : good/good Tip to tip : good/good

Spherical : good/good Three jaw chuck: good/good

Hook : good/good Lateral pinch : good/good

Lower extremities region

At Regio Hip and Thigh

Look : Deformity at hip joint bilateral

Feel : Spasm at quadriceps & hamstring bilateral

Move : Range of Motion and Manual muscle testing

ROM MMT
Hip Right Left End feel Right Left
Flexion 10°-80° 10°-100° Firm end feel / 5 5
Firm end feel
Extension (-80°)-(-10°) (-100°)-(-10°) Firm end feel / 5 5
Firm end feel

8
 Abduction 0°-40° 0°-40° Firm end feel / 4 4
Firm end feel
Adduction 0°-10° 0°-10° Firm end feel / 4 4
Firm end feel
Internal Full Full 5 5
rotation
External Full Full 5 5
rotation

Popliteal angle: 55°/52°

Tight circumference : 31 cm/ 31 cm

Special Test:

Ely test :+/+

Ober test : (-) / (-)

At Regio Knee

Look : Deformity at knee joint bilateral

Feel : Tenderness (-)

Warmth : (-)/(-) Patella lateral maltracking: (-)/(-)

Patellar mobility : 50% / 50%

Crepitation :+/+

Grinding Femoral Test: (-)/(-)

Ballottement test : (-)/(-)

Apley’s test : (-)/(-)

Valgus stress test : (-)/(-)

Varus stress test : (-)/(-)

Anterior drawer sign : (-)/(-)

Posterior drawer sign: (-)/(-)

9
Move : Range of motion and Manual muscle testing

ROM MMT
Knee Right Left End feel Right Left
Flexion 10°-135° 5°-135° Firm end feel / 5 5
Firm end feel
Extension (-135°)-(-10°) (-135°)-(-5°) Firm end feel / 5 5
Firm end feel

At Regio Ankle and Foot

Look : Deformity (-)

Feel : Inflammation sign (-)/(-)

Move : Range of motion and Manual muscle testing

ROM MMT
Ankle and foot Right Left End feel Right Left
Dorsi flexion Full Full 5 5
5 5
Plantar flexion Full Full
Inversion Full Full
Eversion Full Full

Calf circumference (5 inch below MTP) : 31/31 cm (Δ 0 cm)

Capillary Refill Time : < 2 second / < 2 second

Leg length discrepancy

True : 88 cm / 87 cm

Apparent : 94 cm / 93 cm

Neurological Status

Physiological reflex : Biceps tendon reflex ++/++

Triceps tendon reflex ++/++

Knee jerk reflex ++/++

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 Achilles jerk reflex ++/++

Pathological reflex : Hoffman trommer (-)/(-)

Babinski (-) / (-)

Sensibility : Light touch : normal/normal

Pin prick : normal/normal

Proprioception : good/good

Coordination : normal/normal

Postural Assessment

Anterior view

Head : Neutral

Shoulder : Right < Left

Thoracal : Symmetry

Pelvic : Symmetry

Knee : Varum

Posterior view

Head : Neutral

Scapula : Protracted

Thoracal : Neutral

Lumbal : Neutral

Pelvic : Symmetry

Lateral view

11
Head : Forward head posture

Neck : Hyperlordotic

Shoulder : Rounded shoulders

Thoracal : Kifotic

Lumbal : Flat

Abdomen : Flat

Hip : Flexion

Knee : Flexion

Gait analysis

Stance Phase

 Trunk : Anterior bending, kifosis

 Shoulder/Arm Swing: Normal

 Heel strike :

• Excessive hip flexion

• Excessive knee flexion

• Ankle plantigrade

 Loading response :

• Ankle : Netral

 Mid stance:

• Knee flexion

 Terminal stance :

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 • Excessive Hip flexion

• Excessive Knee flexion

• Ankle plantarflexion 5°

Swing Phase

 Trunk : Anterior bending, kifosis

 Pre-Swing :

• Hip flexion

• Excessive ankle plantarflexion

 Initial Swing :

• Ankle plantarflexion (normal)

 Mid swing :

• Knee flexion normal

• Excessive ankle plantarflexion 10°

 Terminal Swing :

• Excessive hip flexion

• Ankle plantarflexion

Waking speed : 1,4 m/second

Cadence : 120 step/minute

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IV. Functional Assessment

1. Functional ability and self-care test assessment

Barthel index : 20 (independent ADL)

Lawton IADL : 8 (independent)

2. Balance assessment

Static Sitting Balance : good, Dynamic Sitting Balance : good

Berg Balance Scale : 46 (use of cane needed indoors as well as

outdoors)

3. Cardiorespiratory Fitness Function

6 minute walking test:

Distance 337.5 m VO2 max = 14.105 Mets = 4.03

4. Psychological Function

Hamilton Depression Rating Scale (HDRS): 6 (normal)

5. Nutritional Function

Screening MNA Score: 22 (At risk of malnutrition)

6. Oswestry Low Back Pain Disability Questionnaire

6/45 = 13% (minimal disability)

7. Neck Disability Index

3/45 = 6,67% (minimal disability)

14
V. Supporting Examination

27/08/2020 24/09/2020 30/11/2020 Nilai Normal

LED 52 62 74 < 15
CRP
4.66 5.28 5,07 < 0.3
Kuantitatif
27/06/2019 Kesan:

• Cor dan pulmo dalam

batas normal

27/06/2019 Kesan:
• Alignment dalam
batas normal
• Discus dan foramen
intervertebralis
tidak menyempit
• Pedikel dalam batas
normal
• Tidak tampak garis
fraktur dan osteofit
• Kifosis vertebra
thorakolumbal

15
27/06/2019 Kesan :
• foto pelvis dalam
batas normal

29/02/2020 Kesan
• Tidak tampak
traumatic wet lung
atau contusio paru
• Tidak tampak
fraktur os
clavicula, costae
dan scapula
• Tidak tampak
cardiomegali

29/02/2020 Kesan

• Foto Schedel saat ini

tidak jelas tanda-
tanda fraktur

16
29/02/2020 Kesan
• Curve lurus saat ini
tidak jelas tanda-
tanda fraktur

22/10/2020 Kesan:
• Kifosis thorakalis
• Kyphotic angle 80°

17
22/10/2020 Kesan:
• Rontgenologis cor
dan pulmo dalam
batas normal

30/11/2020 Kesan :
• Foto lumbosakral
dalam batas
normal

18
VI. Assessment

Medical Diagnose

 Clinical diagnose:

Sequelle Spondylitis TB

Underweight

 Etiology diagnose: Infection

 Location diagnose: Musculoskeletal system

Rehabilitation Diagnose:

Body Function:
b 4552 Fatiguability
b 7101 Mobility of several joints
b 28013 Pain in back
b 770 Gait pattern function
b 1302 Appetite
Body Structure:
s 760 Structure of trunk
Activities & Participation:
d 4158 Maintaining a body position
d 4100 Lying down
d 4101 Squatting
d 450 Walking
d 9201 Sports
Environmental Factors:
e 355 Health professionals
e 155 Design, construction and building products and technology of

buildings for private use

e 2600 Indoor air quality

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VII. International Classification of Functioning, Disability, and Health (ICF)

Health Condition:
Kyphotic Deformities et Thoracal Region
Due To Sequelle Spondylitis TB,
Underwewight

Body Function and Structure Activities and Participation

b 4552 Fatiguability d 4158 Maintaining a body
b 7101 Mobility of several joints position
b 28013 Pain in back d 4100 Lying down
b 770 Gait pattern function d 4101 Squatting
b 1302 Appetite d 450 Walking
s 760 Structure of trunk

Environmental factors Personal Factors:

e 355 Health professionals Men, 21 years old
e 155 Design, construction and Single
building products and
technology of buildings
for private use
e 2600 Indoor air quality

20
VIII. Problem List

Medical Problems Rehabilitation Problems

1. Kyphotic Deformity due to 1. Postural disturbance (R29.3)
Spondylitis TB 2. Bilateral hip and knee joint
2. Underweight stifness (M25.6)
3. Balance disturbance (R27.9)
4. Bicipital tendinitis (M75.21)
5. Low cardiorespiratory endurance
(Z50.0)
6. Gait disturbance (R26.9)

IX. Rehabilitation Review and Management

Problem : Underweight
Cause : Tuberculosis infection
Chronic Inflammation
Obstacle : Low economic familiy condition
Low appetite
Potential : Good family support
Prognosi : Ad bonam
s
Target : Increase weight
Program : Refer to nutrisionist

Problem : Postural disturbance

Cause : Kyphotic Deformities due to Sequelle Spondylitis TB
Obstacle : Contracture of spine, hip and knee
Pain at uppper and lower back (NRS 3 occasionally)
Potential : Well educated
Prognosi : Dubia ad malam
s
Target : Acceptance
Decrease pain
Prevent complication
Program : 1. IRR a.r. neck, upper and lower back
2. ROM exercise for neck, trunk flexion and extension
3. Controlled breathing exercise (diaphragmatic breathing)
4. Shoulder mobility exercises

21
 5. Pelvic mobility exercise
6. Stretching exercise muscle of shoulder flexion, abduction
bilateral
7. Stretching exercise muscle of hip extensor and knee extensor
bilateral
8. Consult to Orthopaedics for intervention after TB infection
heal

Problem : Bicipital tendinitis

Cause : Postural disturbance
Obstacle : Contracture of spine
Potential : Good compliance
Prognosi : Dubia ad bonam
s
Target : Reduce pain
Program : 1. Laser at bilateral tendon biceps (long)
2. Education direction of hand movements

Problem : Sacroilliac joint pain

Cause : Postural disturbance
Gait disturbance
Obstacle : Contracture of spine
Potential : Well educated, good compliance
Prognosi : Ad bonam
s
Target : No pain
Program : Education of body positioning : not stay in the same position
(changing periodically)

Problem : Low cardiorespiratory endurance

Cause : Low physical activity
Obstacle : Low nutrition intake
Potential : Good compliance
Prognosi : Dubia ad bonam
s
Target : Increase cardiorespiratory endurance METs 6
Program : Ground walking exercise
Frequency: 3-5 times/week, Intensity: 50-70% (840 meter),
Type: aerobic, Time: 30 minutes, Progression : increase distance
100 meter every 2 weeks

22
23
 Case Analysis Spondylitis TB
Mr. A, 21 years old

◊
Paradiscal inflammation Weight loss
Thoracal vertebrae
◊
End plates weak Underweight
◊
Narrowing
intervertebral disc space

Hyperkyphotic Thoracal

Narrowing Postural disturbance Low chest expansion

subacromial space
ᴥ

Back pain Cervical and Lumbal Low cardiopulmonal

stiffness endurance
Pain upper Limited
extremity ROM Upper ᴥ
(bicipital Extremity Bilateral hip and
tendinitis) knee stiffnes

Gait disturbance
◊ : Inflammation process
ᴥ : Biomechanic process Low physical activity
↑Energy Fatigue
expenditure

24
X. Discussion

A 21 years old male who have kyphotic thoracal deformity due to

spondilitys tuberculosa. The patient also suffered with stiffness at his neck,

shoulder, hip and knee also pain at his low back and underweight. All of these

cause postural disturbance, joint stiffness, some muscle weakness and low

cardiopulmonale endurance.

There are four pattern lession of tubercular spinal infection which is

paradiscal, central, anterior and posterior. The most common is paradiscal type

that destruction of adjacent end plates and diminution of disc space. 1 The

paradiscal regions of vertebrae are affected in 98% of TB spine lesion. The

tuberculous lesion starts as a paradiscal inflammation. Gradually as disease

progresses the vertebral end plates become structurally weak and intervertebral

disc starts ballooning/herniating into the diseased vertebral body. It is seen on

plain X-rays as reduced disc height while truly on MRI the disc maintains its

height and hydration for quite some time and gradually herniates into the diseased

vertebral bodies. Since the line of weight transmission in thoracic spine is in the

anterior half of vertebral bodies, the vertebral body loses more anterior height

than posterior. Thoracic kyphosis increases and gradually an angular kyphosis

appears. The severity of kyphosis depends on the number of vertebral bodies

affected, severity of loss of anterior vertebral body height and segment of the

spine affected. A case of dorsal spine or dorsolumbar spinal tuberculosis with

three or more vertebral body affection is more likely to develop moderate to

severe kyphotic deformity. In cervical and lumbar spine, the line of weight

25
transmission is in posterior half of vertebral bodies hence it causes first

obliteration of natural cervical and/or lumbar lordosis and later on kyphosis starts

appearing. By the time a kyphosis appears in the spine the disease is already in

about three to four months of pathogenesis of the tuberculosis of spine. 2 This

deformity can manifest as a knuckle deformity (collapse of a single vertebra),

gibbus deformity (collapse of two or three vertebrae), or global rounded kyphosis

(involvement of multiple adjacent vertebrae).3 This patient have global rounded

kyphosis.

Tuberculosis of the spine is a chronic disease with an insidious onset.

About 90% to 100% of patients with spinal tuberculosis have had back pain. The

rate of neurological involvement has ranged from 32% to 76% and such

involvement can occur both in the active phases of the disease and in the healed

stages. In patients with active lesions, neurological deficit is the result of direct

cord compression by an abscess, granulation tissue, sequestrum, or canal

compromise due to instability. In the late stages, it is due to stretching of the cord

over an osseous ridge at the apex of the deformity. A paravertebral cold abscess is

a diagnostic feature of spinal tuberculosis and is observed in at least 50% of such

cases.4

His back pain result from kyphotic thoracal part cause the center of gravity

at further distance from her lumbal part as vulcrum. As he tried to get up, the load

at lumbal vertebra was so big when lumbal extensor muscles contract to create

force more than the body weight at center of gravity point. Muscle spasm of

thoracal paravertebra can be found at physical examination as compensation

26
mechanically changes of spine structure. Superficial heating modality such IRR

was given to his neck and back to lower the pain by reduce muscle spasm

additional with range of motion exercise and chest expansion exercise.

Orthopedics surgeon did not plan any specific procedure for the spinal

tuberculosis because the patient din’t have a neurologic, spinal deformity was

stable, good response to medical therapy and no progression of kyphosis or

instability.5

Mr. A’ posture had changed to hyperkyphosis after got the spinal

tuberculosis. His wall-occiput distance was 15 cm. The more kyphotic, the more

closer the distance of the lowest arcus costarum to crista iliaca and reduces the

abdominal space.6 Abdominal content will be pushed downward and forward to

lower resistance. Diaphragma flattening movement becomes more limited because

the abdominal content tension. Her thoracic wall compliance decrease too at this

condition. It could be seen from her low chest expansion, only 1.5 cm/ 2 cm/ 2,5

cm. Both conditions cause the decrease of lung expansion for optimal function. 7

So, breathing problem risk will decrease pulmonary function and cause

cardiopulmonal deterioration. Now, he had 4.03 METs for 6 MWT. Minimally, 6

METs was needed to walkin upstair. Activity daily living needs about 2-2.5

METs.8 It looked that his METs was enough for his activity now. Attention must

be given to his cardiopulmonary endurance because deterioration of it will make

him become more inactive. His abnormal posture can cause swallowing and

gastrointestinal problem too. The impact is nutrition problem. His Mini

Nutritional Assesment has been in risk of malnutrition already. It can be worsened

27
by those problems. He needs adequate and effective nutrition intake to maintain

her for good health status, especially for his infection by tuberculosis. Flexibility

exercise program for him is shoulder girdle mobility exercise and diaphragmatic

breathing exercise must be do regularly to maintain and prevent the worsening of

his chest expansion ability. Spirometry is needed to evaluate his pulmonary

function as an objective value.

Increased thoracic kyphosis would induce the scapula to become more

protracted and downwardly rotated. Excessive scapular protraction alters the role

of the scapula in shoulder function, and it leads to a potential compression under

the acromion and subacromial tissues including the subacromial bursa and rotator

cuff.9 In line with this patient who have hyperkyphosis thoracal with bicipital

tendinitis and limited motion of shoulder bilateral.

Other problem of thoracic hyperkhyposis in this patient is stiffness extends

to cervical and lumbar part as biomechanics process. Furthermore with the same

mechanism the stiffness at whole spine will affect to lower body, cause hip and

knee stiffness. All of those problem effect is lead to gait disturbance that can be

seen from in this patient. This walking type in this patient requiring prolong active

contraction of flexor muscle group of hip and knee, resulting in muscle fatigue.

Therefore the patient needs to be given flexibility exercise at his neck, trunk,

mobility shoulder girdle, hip mobility exercise and stretching both knee.

28
 DAFTAR PUSTAKA

1. Rajasekaran S, Kanna RM, Shetty AP. Pathophysiology and Treatment of

Spinal Tuberculosis. JBJS Reviews. 2014;2(9).
2. Jain AK, Dhammi IK, Jain S, Mishra P. Kyphosis in spinal tuberculosis -
Prevention and correction. Indian J Orthop. 2010;44(2):127-36.
3. Rajasekaran S. The Problem of Deformity in Spinal Tuberculosis. Clinical
Orthopaedics and Related Research®. 2002;398.
4. Kumar K. Spinal tuberculosis, natural history of disease, classifications
and principles of management with historical perspective. Eur J Orthop
Surg Traumatol. 2016;26(6):551-8.
5. Jain AK. Tuberculosis of the spine. Clinical orthopaedics and related
research. 2007;460:2-3.
6. Lorbergs AL, O’Connor GT, Zhou Y, Travison TG, Kiel DP, Cupples LA,
et al. Severity of Kyphosis and Decline in Lung Function: The
Framingham Study. The Journals of Gerontology: Series A.
2016;72(5):689-94.
7. Neumann DA. Kinesiology of the musculoskeletal system-e-book:
foundations for rehabilitation: Elsevier Health Sciences; 2013.
8. Medicine ACoS. ACSM's guidelines for exercise testing and prescription:
Lippincott Williams & Wilkins; 2013.
9. Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, et
al. Association between kyphosis and subacromial impingement
syndrome: LOHAS study. Journal of shoulder and elbow surgery /
American Shoulder and Elbow Surgeons [et al]. 2014;23.
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