Face-to-face vs. telerehabilitation for thoracic hyperkyphosis in children- A randomized controlled pilot study

Abstract

Purpose

This pilot study aimed to compare the effects of face-to-face and telerehabilitation approaches on thoracic hyperkyphosis, back extensor muscle strength, and discomfort in children.

Methods

A randomized clinical trial was conducted in Türkiye with twenty children (aged 9–12 years) diagnosed with thoracic hyperkyphosis (thoracic kyphosis angle >40°). Participants were randomly allocated to a face-to-face rehabilitation group (n = 10) or a telerehabilitation group (n = 10) using the Fiziu Digital Exercise Platform. Both groups performed the same supervised exercise program three times per week for six weeks. Thoracic kyphosis angle (TKA), manual muscle testing (MMT) of the back extensors, and Visual Analog Scale (VAS) scores for discomfort were assessed pre- and post-intervention.

Results

In the face-to-face group, significant improvements were observed in all outcome measures. TKA decreased by 2.00° (p < .001), MMT increased by 0.50 points (p = .037), and VAS decreased by 1.90 points (p < .001). In the telerehabilitation group, TKA also showed a significant reduction of 1.55° (p = .002), and VAS decreased significantly by 1.30 points (p = .009). Although MMT increased by 0.40 points in the telerehabilitation group, this change did not reach statistical significance (p = .072). No significant between-group differences were observed for any outcome at post-intervention (TKA p = .34; MMT p = .693; VAS p = .27).

Conclusions

Both face-to-face and telerehabilitation approaches improved posture, muscle strength, and discomfort in children with thoracic hyperkyphosis. Telerehabilitation using the Fiziu platform may be a practical and accessible alternative in pediatric rehabilitation.

Keywords

adolescent kyphosis posture telerehabilitation digital health exercise therapy

Introduction

Thoracic hyperkyphosis is a frequent postural deformity in children and adolescents, defined as a forward curvature of the thoracic spine exceeding 40 degrees.^1,2 While primarily structural, this condition often leads to functional limitations such as reduced respiratory function, back pain, impaired balance, and psychosocial effects including low self-esteem and social withdrawal.^3,4 Consequently, if left untreated during childhood, it may lead to persistent musculoskeletal discomfort, reduced mobility, and a lower quality of life in adulthood.⁵ Contributing factors typically include weak spinal extensors, prolonged sedentary behavior, and poor postural habits associated with musculoskeletal imbalances.^3,6

Concurrently, the prevalence of thoracic hyperkyphosis has risen in recent years, especially among school-aged children.^7,8 This trend is largely attributed to lifestyle changes, such as excessive screen time and sedentary behaviors associated with prolonged use of smartphones, tablets, and computers.^9,10 Children aged eight to 14 are especially vulnerable due to ongoing musculoskeletal development and the formation of long-term postural habits.¹¹ These risks were further intensified during the COVID-19 pandemic, which increased daily screen exposure and limited physical activity—both recognized contributors to postural dysfunction.¹²

Conventional physiotherapy approaches for hyperkyphosis typically involve face-to-face interventions that emphasize strengthening spinal extensors, stretching shortened anterior structures, and improving neuromuscular control. While such programs have shown efficacy in improving postural alignment and enhancing body awareness, the use of digital health tools has recently expanded these interventions beyond traditional clinical settings.^13–17 Telerehabilitation, the remote delivery of physiotherapy services via digital platforms, has gained momentum, particularly in pediatric populations following the COVID-19 pandemic.^18,19 Its effectiveness has been demonstrated in various musculoskeletal and neurological conditions,^20–22 offering potential advantages in pediatric rehabilitation such as improved accessibility, family engagement, and enhanced adherence.^23,24 By enabling therapy in the child's natural home environment, telerehabilitation helps mitigate barriers like transportation, financial limitations, and caregiver burden.^25–28 Furthermore, it aligns with the principles of family-centered care by actively involving caregivers in the therapeutic process.^29–31

Although promising results have been reported in pediatric motor development and family satisfaction outcomes, there is limited research on the efficacy of telerehabilitation in correcting postural disorders such as thoracic hyperkyphosis.^28,32–34 Seidi et al. emphasized the importance of age-specific corrective strategies, noting that the effectiveness of interventions may vary according to developmental stage.³⁵ Given the rising prevalence of posture-related issues in children and the demand for accessible, home-based care solutions, further investigation is warranted. Accordingly, this pilot study was designed to compare the effects of face-to-face and telerehabilitation-based physiotherapy on thoracic kyphosis angle, back extensor strength, and self-reported discomfort in children aged nine to 12 years. It was hypothesized that both delivery modes would result in measurable improvements and that telerehabilitation could offer comparable outcomes to conventional in-person care.

Material and methods

This study was designed as a randomized, parallel-group, controlled clinical trial with a 1:1 allocation ratio to compare the effects of face-to-face and telerehabilitation programs on thoracic hyperkyphosis in Turkish children aged 9–12 years. The study was conducted in a primary school setting. No methodological changes were made after the trial commenced.

Participants

A total of 20 children diagnosed with thoracic hyperkyphosis were recruited. Inclusion criteria were (1) age between nine and 12 years, (2) thoracic kyphosis angle greater than 40°, measured using a flexicurve ruler,^35,37 and (3) no prior treatment for hyperkyphosis within the past six months. Exclusion criteria included congenital spinal deformities, scoliosis, vertebral fractures, spinal tumors, or any diagnosed mental health conditions that could interfere with participation.

A formal sample size calculation was not performed. Instead, a target of 10 participants per group (total n = 20) was determined based on feasibility and previous studies investigating postural correction in pediatric populations.¹¹ Given the short intervention period and low risk of harm, no interim analyses or stopping guidelines were required.

Randomization and allocation concealment

Participants were randomly assigned to either the face-to-face rehabilitation group or the telerehabilitation group using a computer-generated random sequence with a 1:1 allocation ratio. The allocation sequence was prepared by an independent researcher not involved in recruitment and concealed in sealed, opaque, sequentially numbered envelopes. These envelopes were opened only after baseline assessments were completed. To minimize bias, group assignments were managed by the independent researcher, while all clinical assessments were conducted by a blinded physiotherapist who was not involved in the randomization process or treatment delivery.

Consent and baseline assessment

Prior to enrollment, written informed consent was obtained from parents or legal guardians.^38,39 Baseline demographic data (age, sex, weight, height, body mass index) were collected, and clinical assessments were conducted before randomization.⁴⁰

Outcome measures

The primary outcome was the thoracic kyphosis angle (TKA), assessed using the validated flexicurve method. Secondary outcomes included back extensor muscle strength, measured with manual muscle testing (MMT), and perceived discomfort, evaluated using the Visual Analog Scale (VAS).^41,42 All assessments were performed at baseline and after the six-week intervention by the same physiotherapist, who was blinded to group allocation and not involved in the intervention delivery to minimize measurement bias. No changes were made to outcome definitions after trial commencement.

Three outcomes were selected to balance clinical relevance, feasibility, and child-friendliness. Objective tools such as dynamometry or radiographic measurements were not feasible in the school-based setting and may have posed ethical or logistical challenges. TKA via flexicurve, MMT, and VAS were therefore selected as valid, low-burden measures that are commonly used in pediatric postural rehabilitation studies.^11,43,44 Follow-up measurements were not included due to time and resource constraints in the school setting; this limitation is addressed in the discussion.

TKA

TKA was calculated using a flexicurve ruler according to the method described by Yanagawa et al.⁴⁵ Participants stood in a relaxed, natural upright posture while the flexible ruler was molded along the thoracic curvature from the spinous process of C7 to T12 (Figure 1). The traced contour was then transferred to graph paper, where two distances were measured:

Length (L): The linear distance between C7 and T12

Height (H): The perpendicular distance from the apex of the curve to the baseline (Figure 2)

Figure 1.

Measurement of thoracic kyphosis angle using the flexicurve ruler, aligned along the C7–T12 vertebrae.

Figure 2.

Flexicurve measurement scheme

The thoracic kyphosis angle was then calculated using the following formula:

θ = 4 \times \arctan (2 H / L)

This method has demonstrated high inter- and intra-rater reliability (ICC = 0.91) and is widely accepted for clinical kyphosis assessment.^43,45

MMT

Back extensor strength was evaluated using the MMT on a 0–5 point scale, with higher scores indicating greater muscle strength.⁴² Participants were positioned prone on a flat surface with their hands clasped behind the head. They were instructed to lift their upper trunk off the table against gravity, maintaining extension through the thoracic spine. The examiner stabilized the lower extremities by applying gentle pressure over the ankles and delivered manual resistance at the thoracic spine to assess muscle strength.

This testing procedure evaluates the combined action of the thoracic and lumbar extensors and is adapted from standard pediatric neuromuscular assessment protocols. MMT is widely used in clinical pediatric rehabilitation settings due to its simplicity, feasibility, and minimal equipment requirements. While MMT is inherently subjective, several studies have demonstrated moderate to high intra-rater and inter-rater reliability, particularly when standardized protocols are followed.^46,47 Prior studies have demonstrated that the validity of MMT improves when consistent examiner technique and standardized scoring criteria are used. In pediatric populations, MMT remains a practical tool for tracking functional strength over time and evaluating response to therapeutic interventions.⁴²

VAS

Perceived spinal discomfort was assessed using a 10 cm VAS, where 0 indicated “no discomfort” and 10 indicated “worst imaginable discomfort.” Participants were asked to mark their discomfort level based on their usual experience during daily activities.^41,48 The VAS was chosen due to its simplicity and accessibility for children, and previous literature supports its validity and reliability as a pain measurement tool in clinical settings. Although it remains a subjective scale, the VAS is considered a practical and widely used interval scale in pediatric populations when appropriately explained and visually supported.^44,49

Interventions

Participants in both groups performed a standardized corrective exercise program designed to address thoracic hyperkyphosis. The protocol was developed based on established postural correction principles and existing pediatric rehabilitation literature. Specific exercises targeting thoracic mobility, pectoral flexibility, back extensor strength, and scapular stabilization were selected due to their reported effectiveness in improving sagittal alignment in children with postural deformities.^1,14,50 The structure of the program was based on prior studies conducted in similar pediatric populations, with sessions scheduled three times per week over a six-week period, each lasting approximately 30 to 40 min. This design was adapted to support both home-based and school-based implementation, with the aim of enhancing feasibility and adherence.^11,51

Face-to-Face rehabilitation (group 1)

Children in the face-to-face group completed the program in a supervised school-based setting under the direct guidance of a physiotherapist. During each session, the physiotherapist provided hands-on instruction, postural correction, and individualized feedback to ensure proper technique and safe exercise performance.

Telerehabilitation (group 2)

Children in the telerehabilitation group followed the same exercise protocol using the Fiziu Digital Exercise Platform.³⁶ The platform provided exercise demonstrations and audio instructions, ensuring consistency across sessions. All participants’ caregivers were sent the exercise programs directly, allowing them to review and support proper execution of each session.

To maintain safety, engagement, and adherence, caregivers were instructed to supervise all home-based sessions directly. Sessions were scheduled in advance with flexible timing according to the family's availability. During all planned time slots, a physiotherapist was available via WhatsApp to provide real-time clarification or support through voice messages, calls, or short video exchanges as needed.

After each session, caregivers confirmed completion via a digital log form and were asked to send short videos demonstrating select exercises. These were reviewed by the physiotherapist, who provided corrective feedback when necessary. This hybrid model of asynchronous monitoring and synchronous availability ensured that participants received individualized support and maintained exercise fidelity throughout the intervention.

The exercise content, frequency, and duration were identical to the face-to-face group; the only difference was the delivery method (Figure 3).

Figure 3.

Six-Week exercise program administered to children three times per week.

Statistical analysis

Statistical analyses were conducted using Jamovi software (The Jamovi Project, Sydney, Australia). The normality of data distribution was assessed using the Shapiro–Wilk test. Continuous variables (TKA, VAS) demonstrated a normal distribution, whereas MMT scores were analyzed as ordinal non-parametric data.

Descriptive statistics were expressed as mean ± standard deviation (SD) with 95% confidence intervals for continuous variables. Baseline characteristics were compared between groups using independent samples t-tests for continuous variables, the Chi-square test for gender, and the Mann–Whitney U test for MMT.

Within-group changes from pre- to post-intervention were analyzed using paired samples t-tests for TKA and VAS, and the Wilcoxon signed-rank test for MMT. To evaluate intervention effects, a mixed-model analysis of variance (ANOVA) was conducted for continuous variables (TKA, VAS) to examine group × time interactions. For MMT, between-group differences in change scores were assessed using the Mann–Whitney U test.

Effect sizes were reported as Cohen's d for parametric tests and rank-biserial correlation (r) for non-parametric tests. Cohen's d values were interpreted as small (0.2), medium (0.5), and large (≥0.8). Statistical significance was set at p < 0.05. All 20 participants completed the intervention and follow-up assessments; thus, analyses were conducted per protocol without imputation for missing data.

Results

At baseline, there were no statistically significant differences between the face-to-face and telerehabilitation groups in any demographic or clinical variables (Table 1). Chi-square analysis showed equal gender distribution between groups (p = 1.00). Independent samples t-tests indicated no significant differences in age (p = 0.87), height (p = 1.00), or weight (p = 0.95). Similarly, baseline clinical measures including TKA, MMT, and VAS scores were comparable between groups (TKA: p = 0.08; MMT: p = 0.73; VAS: p = 0.59), with the MMT comparison performed using the Mann–Whitney U test due to its ordinal scale. These findings demonstrate the baseline equivalence of the two groups in both demographic and clinical characteristics, supporting the internal validity of the study.

Table 1.

Baseline demographic and clinical characteristics of the participants.

Variable	Face-to-Face	Telerehabilitation	p
Gender (F/M)	5/5	5/5	1.00 ¹
Age (years)	10.0 ± 1.25	10.1 ± 1.37	0.87 ²
Height (cm)	139.5 ± 3.03	139.5 ± 3.03	1.00 ²
Weight (kg)	33.8 ± 3.88	33.9 ± 3.84	0.95 ²
TKA (°)	47.10 ± 2.56	45.00 ± 2.58	0.08 ²
MMT (0–5)	2.70 ± 0.68	2.80 ± 0.63	0.73 ³
Pain (VAS, 0–10)	7.50 ± 1.08	7.20 ± 1.32	0.59 ²

Data are presented as mean ± standard deviation for continuous variables and frequency for categorical variables.

¹Chi-square test was used for gender comparison.

²Independent samples t-tests were used for normally distributed continuous variables.

³Mann–Whitney U test was used for MMT due to ordinal scale and non-normality assumptions.

Each group consisted of 10 participants (n = 10 per group).

Abbreviations: TKA = thoracic kyphosis angle; MMT = manual muscle testing; VAS = Visual Analog Scale; F = female; M = male.

After the six-week intervention, both groups demonstrated significant improvements in TKA and VAS (Table 2). In the face-to-face group, mean TKA significantly decreased from 47.10 ± 2.56° to 45.10 ± 2.42° (p < .001, d = 2.12), while the telerehabilitation group showed a similar improvement from 45.00 ± 2.58° to 43.45 ± 2.25° (p = .002, d = 1.42). MMT scores increased significantly in the face-to-face group from 2.70 ± 0.68 to 3.20 ± 0.42 (W = 0.0, p = .037, r = 1.00). In contrast, MMT scores increased from 2.80 ± 0.63 to 3.20 ± 0.63 in the telerehabilitation group, but this change did not reach statistical significance (W = 0.0, p = .072, r = 1.00). VAS scores decreased significantly in both groups from 7.50 ± 1.08 to 5.60 ± 1.27 (p < .001, d = 1.73) in the face-to-face group and from 7.20 ± 1.32 to 5.90 ± 0.74 (p = .009, d = 1.04) in the telerehabilitation group.

Table 2.

Pre- and post-intervention scores, within- and between-group, and mixed ANOVA group × time interaction effects.

Outcome	Group	Pre	Post	Δ change	Test, p (within)	d / r	t / U, p (between)	d / r	F, p (Group × time)
TKA (°)	Face-to-Face	47.10 ± 2.56	45.10 ± 2.42	−2.00 ± 0.94	t = 6.71, p < .001	d = 2.12	t = 0.99, p = .34	d = 0.44	F = 0.973, p = .337
TKA (°)	Telerehabilitation	45.00 ± 2.58	43.45 ± 2.25	−1.55 ± 1.09	t = 4.49, p = .002	d = 1.42	t = 0.99, p = .34	d = 0.44	F = 0.973, p = .337
MMT (0–5)	Face-to-Face	2.70 ± 0.68	3.20 ± 0.42	+0.50 ± 0.53	W = 0.0^†, p = .037	r = 1.00	U = 45.0, p = .693	r = 0.10	- ^‡
MMT (0–5)	Telerehabilitation	2.80 ± 0.63	3.20 ± 0.63	+0.40 ± 0.52	W = 0.0^†, p = .072	r = 1.00	U = 45.0, p = .693	r = 0.10	- ^‡
Pain (VAS, 0–10)	Face-to-Face	7.50 ± 1.08	5.60 ± 1.27	−1.90 ± 1.10	t = 5.46, p < .001	d = 1.73	t = 1.14, p = .27	d = 0.51	F = 1.30, p = .270
Pain (VAS, 0–10)	Telerehabilitation	7.20 ± 1.32	5.90 ± 0.74	−1.30 ± 1.25	t = 3.29, p = .009	d = 1.04	t = 1.14, p = .27	d = 0.51	F = 1.30, p = .270

^† Wilcoxon statistic indicates all values changed in the same direction.

^‡ Mixed-model ANOVA was not performed for MMT due to its ordinal nature; between-group differences were assessed via change scores using the Mann–Whitney U test.

Within-group comparisons were conducted using paired samples t-tests, except for MMT (Wilcoxon signed-rank test).

Between-group comparisons of pre-post change scores were analyzed using independent samples t-tests (TKA, VAS) and Mann-Whitney U test (MMT).

Group × time interaction effects were assessed using two-way mixed ANOVA for continuous variables (TKA, VAS).

Data are presented as mean ± standard deviation. Statistical significance was set at p < 0.05. Cohen's d represents effect sizes: small (0.2), medium (0.5), and large (≥0.8).

Abbreviations: TKA: thoracic kyphosis angle; MMT: manual muscle testing; VAS: Visual Analog Scale.

Between-group comparisons of pre-post change scores did not yield statistically significant differences for TKA (p = .34, d = 0.44), MMT (U = 45.0, p = .693, r = 0.10), or VAS (p = .27, d = 0.51). Mixed-model ANOVA revealed no significant group × time interaction for TKA (F = 0.973, p = .337) or VAS (F = 1.30, p = .270) (Table 2).

Discussion

The present trial demonstrated that a six-week corrective exercise program significantly improved TKA and reduced VAS in children with thoracic hyperkyphosis, regardless of whether the intervention was delivered face-to-face or via telerehabilitation. While both groups exhibited improvements in MMT, statistical significance was reached only in the face-to-face group. The comparable outcomes between the two groups highlight the potential of remotely delivered rehabilitation as a viable alternative to conventional physiotherapy, especially in pediatric populations where accessibility and adherence are possible limiting factors.

Both the face-to-face and telerehabilitation groups demonstrated statistically significant improvements in TKA after six weeks of corrective exercise. This suggests that even short-term, moderately intensive interventions can produce measurable postural improvements in school-aged children. These results align with a separate randomized controlled trial involving 164 adolescents that supports the effectiveness of relatively brief, targeted interventions in improving postural alignment during dynamic musculoskeletal development.⁴ Another nine-month randomized trial assessed the effects of a Pilates program on sagittal spinal curvatures in adolescents and found that the progression of curvature was prevented, though thoracic kyphosis did not significantly improve.⁵² Although this distinction between preventive and corrective effects is clinically meaningful, the present six-week intervention yielded notably significant reductions in TKA over a much shorter period compared to the prolonged duration of the earlier study. These findings indicate that a moderately intensive, well-designed exercise program may offer both preventive and corrective benefits for postural deformities, which is especially advantageous in clinical settings with constraints on treatment duration, cost, or adherence.

Furthermore, the comparable improvements observed in both groups reinforce the feasibility of telerehabilitation in pediatric physiotherapy. Current findings are consistent with prior reports indicating that digitally delivered interventions can yield meaningful clinical outcomes in children. For instance, a study on telerehabilitation-based pediatric physiotherapy reported both qualitative and quantitative improvements, along with high caregiver satisfaction and active family participation.²⁸ This is particularly relevant to the telerehabilitation model used in this study, which was implemented through caregiver supervision in the home environment. Involving caregivers in the exercise process may have enhanced adherence and motor learning by providing consistent guidance, especially for children aged 8–12. Delivering the intervention in a familiar home setting may have also contributed to increased ecological validity and reduced common logistical barriers such as transportation difficulties, school absence, or the stigma sometimes associated with clinic visits.^53,54 Taken together, these results support the dual clinical and logistical value of telerehabilitation, particularly in managing early-stage postural disorders that may not require intensive in-person physiotherapy.

The improvements observed in this trial also reflect the corrective potential of structured exercise programs in children with thoracic hyperkyphosis. A prior study involving a 12-week intervention in adolescents with more severe deformities (TKA ≥ 50°) reported greater reductions in thoracic kyphosis angle in a comprehensive exercise group compared to controls.⁵⁵ Although that protocol was longer in duration, the present six-week program still achieved statistically significant improvements, indicating that shorter, moderately intensive interventions may yield measurable benefits even in younger populations with less severe postural deviations. Moreover, the comparable outcomes between telerehabilitation and face-to-face modalities further support the viability of digital delivery for postural correction. Consistent with these observations, an eight-week online training program in adolescent girls was shown to significantly improve both posture and pain levels.⁵³

Finally, in the present trial, telerehabilitation produced clinical improvements comparable to those achieved through face-to-face rehabilitation. This echoes findings from adult populations; a recent systematic review reported no significant differences in pain, function, or patient satisfaction between telerehabilitation and in-person care for musculoskeletal conditions.⁵⁶ Importantly, a similar pattern has been observed in pediatric research. Baek et al. found no significant differences in head and shoulder posture outcomes between adolescents completing a six-week digital exercise program versus those receiving equivalent face-to-face sessions.¹³ Although the targeted spinal regions differed between studies, these consistent effectiveness profiles highlight that well-designed, remotely delivered exercise programs can support postural correction in youth populations just as they do in adults. From a clinical standpoint, such remotely delivered programs offer distinct advantages, helping to overcome barriers like transportation issues, limited clinical access, and scheduling conflicts. As a pilot trial, this study provides initial evidence for the feasibility of this approach in children with thoracic hyperkyphosis, supporting the potential of digital strategies to expand access to early intervention.

Limitations

This study has several limitations that should be acknowledged. First, it was designed as a pilot investigation to evaluate the feasibility and preliminary efficacy of a telerehabilitation-based corrective exercise protocol. The relatively small sample size (n = 20) limits the generalizability of the findings and prevents detailed subgroup analyses. Larger, adequately powered trials are needed to confirm these outcomes in broader pediatric populations. Additionally, while the six-week intervention period demonstrated short-term improvements, future studies with longer follow-up are needed to examine the sustainability of these effects. Pain was assessed using a subjective measure (VAS), and incorporating objective functional outcomes could strengthen future research. Lastly, the sample was limited to children aged 9–12 years, suggesting that further work is needed to evaluate age-specific responsiveness across wider developmental stages.

Despite these limitations, this study provides preliminary evidence supporting the feasibility and effectiveness of both face-to-face and telerehabilitation approaches for managing thoracic hyperkyphosis in children.

Conclusion

This study demonstrated that a structured digital exercise program delivered via the Fiziu Digital Exercise Platform produced improvements in thoracic posture, back extensor strength, and discomfort levels comparable to those achieved through traditional face-to-face rehabilitation in school-aged children with hyperkyphosis. These findings add to emerging evidence supporting the use of telerehabilitation for pediatric musculoskeletal conditions and suggest that digitally delivered postural exercise programs are a feasible alternative to conventional therapy.

Such approaches may be particularly valuable in expanding access to rehabilitation services in contexts where face-to-face care is constrained by geographic, logistical, or public health barriers. Future research with larger sample sizes and longer follow-up periods is warranted to confirm these results and to further explore the role of digital platforms in pediatric rehabilitation.

Footnotes

ORCID iDs

Seda Gözener Canbülbül

Batuhan Canbülbül

Ethical approval and informed consent

This study was approved by the Non-Interventional Clinical Research Ethics Committee of İstanbul Medipol University (Approval Number: E-10840098-202.3.02-3767). All procedures were conducted in accordance with the ethical standards of the institutional and national research committees and the principles of the Declaration of Helsinki.

Consent to participate

Written informed consent was obtained from the parents or legal guardians of all participants prior to enrollment in the study.

Author contributions

SGC, SIO and YK designed the study. SGC and BC supervised the data collection. SIO and YK performed the data collection and intervention. SGC analyzed the data and wrote the manuscript. All authors reviewed and approved the final version of the manuscript.

ClinicalTrials.gov ID

NCT06730269.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data supporting this study's findings are available from the corresponding author upon reasonable request.

References

Katzman

Wanek

Shepherd

, et al. Age-related hyperkyphosis: its causes, consequences, and management. J Orthop Sports Phys Ther 2010; 40: 352–360.

Roghani

Zavieh

Manshadi

, et al. Age-related hyperkyphosis: update of its potential causes and clinical impacts-narrative review. Aging Clin Exp Res 2017; 29: 567–577.

Lewis

Valentine

. Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskelet Disord 2010; 11: 39.

Feng

Wang

Zhang

, et al. The effect of a corrective functional exercise program on postural thoracic kyphosis in teenagers: a randomized controlled trial. Clin Rehabil 2018; 32: 48–56.

Keller

Harrison

Colloca

, et al. Prediction of osteoporotic spinal deformity. Spine (Phila Pa 1976) 2003; 28: 455–462.

Rahnama

Bambaeichi

Taghian

, et al. Effect of 8 weeks regular corrective exercise on spinal columns deformities in girl students. J Isfahan Med Sch 2010; 27: 676–686, https://jims.mui.ac.ir/article_13117_en.html (accessed 30 April 2025)..

Maciałczyk-Paprocka

Stawińska-Witoszyńska

Kotwicki

, et al. Prevalence of incorrect body posture in children and adolescents with overweight and obesity. Eur J Pediatr 2017; 176: 563–572.

Mahlknecht

. The prevalence of postural disorders in children and adolescents: a cross sectional study. Z Orthop Unfall 2007; 145: 338–342.

Yang

Yan

, et al. Prevalence of incorrect posture among children and adolescents: finding from a large population-based study in China. iScience 2020; 23: 101043.

10.

Straker

Howie

. Young children and screen time: it is time to consider healthy bodies as well as healthy minds. J Dev Behav Pediatr 2016; 37: 265.

11.

Abdel-Aziem

Abdel-Ghafar

MA-F

Ali

, et al. Effects of smartphone screen viewing duration and body position on head and neck posture in elementary school children. J Back Musculoskelet Rehabil 2022; 35: 185–193.

12.

Rossi

Behme

Breuer

. Physical activity of children and adolescents during the COVID-19 pandemic-A scoping review. Int J Environ Res Public Health 2021; 18: 11440.

13.

Baek

C-Y

Ahn

J-H

Lee

, et al. Effect of digital health corrective posture exercise program on head and shoulder posture in adolescents: a cluster randomized controlled trial. Medicine (Baltimore) 2025; 104: e41893.

14.

Jang

H-J

Hughes

D-W

, et al. Effects of corrective exercise for thoracic hyperkyphosis on posture, balance, and well-being in older women: a double-blind, group-matched design. J Geriatr Phys Ther 2019; 42: E17–E27.

15.

Hanfy

Awad

Allah

AHAA

. Effect of exercise on postural kyphosis in female after puberty. Indian Journal of Physiotherapy & Occupational Therapy-An International Journal 2012; 6: 184–188.

16.

Troyanovich

Harrison

. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998; 21: 37–50.

17.

Ball

Cagle

Johnson

, et al. Spinal extension exercises prevent natural progression of kyphosis. Osteoporos Int 2009; 20: 481–489.

18.

Arienti

Lazzarini

Andrenelli

, et al. Rehabilitation and COVID-19: systematic review by cochrane rehabilitation. Eur J Phys Rehabil Med 2023; 59: 800–818.

19.

Suso-Martí

La Touche

Herranz-Gómez

, et al. Effectiveness of telerehabilitation in physical therapist practice: an Umbrella and mapping review with meta–meta-analysis. Phys Ther 2021: pzab075.

20.

Hwang

Bruning

Morris

, et al. Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. J Physiother 2017; 63: 101–107.

21.

Brouns

van Bodegom-Vos

de Kloet

, et al. Effect of a comprehensive eRehabilitation intervention alongside conventional stroke rehabilitation on disability and health-related quality of life: a pre-post comparison. J Rehabil Med 2021; 53: jrm00161.

22.

Johnson

Williams

Gucciardi

, et al. Can an online exercise prescription tool improve adherence to home exercise programmes in children with cerebral palsy and other neurodevelopmental disabilities? A randomised controlled trial. BMJ Open 2020; 10: e040108.

23.

Beckers

LWME

Schnackers

MaP

Janssen-Potten

, et al. Feasibility and effect of home-based therapy programmes for children with cerebral palsy: a protocol for a systematic review. BMJ Open 2017; 7: e013687.

24.

Roy

Salles

Neveu

, et al. Exploring the perspectives of health care professionals on digital health technologies in pediatric care and rehabilitation. J Neuroeng Rehabil 2024; 21: 156.

25.

Fergus

. A novel mobility device to improve walking for a child with cerebral palsy. Pediatr Phys Ther 2017; 29: E1–E7.

26.

Iacono

Dissanayake

Trembath

, et al. Family and practitioner perspectives on telehealth for services to young children with autism. Stud Health Technol Inform 2016; 231: 63–73.

27.

Dunst

Trivette

Hamby

. Meta-analysis of family-centered helpgiving practices research. Ment Retard Dev Disabil Res Rev 2007; 13: 370–378.

28.

McKenzie

Titzer

Hutchinson

, et al. Analysis of a model for pediatric physical therapy and clinical education via telehealth. PRM 2024; 17: 271–288.

29.

Harniess

Gibbs

Bezemer

, et al. Parental engagement in early intervention for infants with cerebral palsy—A realist synthesis. Child Care Health Dev 2022; 48: 359–377.

30.

Dirks

Hadders-Algra

. The role of the family in intervention of infants at high risk of cerebral palsy: a systematic analysis. Develop Med Child Neuro 2011; 53: 62–67.

31.

Akhbari Ziegler

Hadders-Algra

. Coaching approaches in early intervention and paediatric rehabilitation. Develop Med Child Neuro 2020; 62: 569–574.

32.

Dirks

Hielkema

Hamer

, et al. Infant positioning in daily life may mediate associations between physiotherapy and child development—video-analysis of an early intervention RCT. Res Dev Disabil 2016; 53–54: 147–157.

33.

Camden

Pratte

Fallon

, et al. Diversity of practices in telerehabilitation for children with disabilities and effective intervention characteristics: results from a systematic review. Disabil Rehabil 2020; 42: 3424–3436.

34.

Hall

Luechtefeld

Woods

. Adoption of telehealth by pediatric physical therapists during COVID-19: a survey study. Pediatr Phys Ther 2021; 33: 237–244.

35.

Seidi

Rajabi

Ebrahimi

, et al. The efficiency of corrective exercise interventions on thoracic hyper-kyphosis angle. J Back Musculoskelet Rehabil 2014; 27: 7–16.

36.

Fiziu Digital Exercise Platform, https://www.fiziu.com.

37.

Kado

Prenovost

Crandall

. Narrative review: hyperkyphosis in older persons. Ann Intern Med 2007; 147: 330–338.

38.

Smith

Samuels

. A scoping review of parental roles in rehabilitation interventions for children with developmental delay, disability, or long-term health condition. Res Dev Disabil 2021; 111: 103887.

39.

Çavuş

Çetin

Korkmaz

, et al. The Effect Of Postural Kinesiotaping In The Treatment Of Thoracic Kyphosis, https://www.jtss.org/articles/the-effect-of-postural-kinesiotaping-in-the-treatment-of-thoracic-kyphosis/doi/27994 (accessed 30 April 2025).

40.

Lepola

Needham

Mendum

, et al. Informed consent for paediatric clinical trials in Europe. Arch Dis Child 2016; 101: 1017–1025.

41.

Alghadir

Anwer

Iqbal

, et al. Test-retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain. J Pain Res 2018; 11: 851–856.

42.

Cuthbert

Goodheart

. On the reliability and validity of manual muscle testing: a literature review. Chiropr Osteopat 2007; 15: 4.

43.

Barrett

McCreesh

Lewis

. Intrarater and interrater reliability of the flexicurve index, flexicurve angle, and manual inclinometer for the measurement of thoracic kyphosis. Rehabil Res Pract 2013; 2013: 475870.

44.

Koo

Yang

S-W

. Visual analogue scale. Encyclopedia 2025; 5: 190.

45.

Yanagawa

Maitland

Burgess

, et al. Assessment of thoracic kyphosis using the flexicurve for individuals with osteoporosis. Hong Kong Physiotherapy Journal 2000; 18: 53–57.

46.

Wadsworth

Krishnan

Sear

, et al. Intrarater reliability of manual muscle testing and hand-held dynametric muscle testing. Phys Ther 1987; 67: 1342–1347.

47.

Paternostro-Sluga

Grim-Stieger

Posch

, et al. Reliability and validity of the medical research council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. J Rehabil Med 2008; 40: 665–671.

48.

Srouji

Ratnapalan

Schneeweiss

. Pain in children: assessment and nonpharmacological management. Int J Pediatr 2010; 2010: 1–11.

49.

Bieri

Reeve

Champion

, et al. The faces pain scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain 1990; 41: 139–150.

50.

Kamali

Shirazi

Ebrahimi

, et al. Comparison of manual therapy and exercise therapy for postural hyperkyphosis: a randomized clinical trial. Physiother Theory Pract 2016; 32: 92–97.

51.

Mokhtaran

Piri

Sheikhhoseini

, et al. Comparing two corrective exercise approaches for body image and upper-quadrant posture in schoolgirls with hyperkyphosis. Sci Rep 2025; 15: 3882.

52.

González-Gálvez

Marcos-Pardo

Trejo-Alfaro

, et al. Effect of 9-month pilates program on sagittal spinal curvatures and hamstring extensibility in adolescents: randomised controlled trial. Sci Rep 2020; 10: 9977.

53.

Sarvari

Mokari Saei

Rahimzadeh

, et al. The effect of an online corrective training intervention on the upper cross syndrome and feelings of fatigue and pain in adolescents. Journal of Pediatric Perspectives, Epub ahead of print 1 April 2022. DOI: 10.22038/ijp.2022.62644.4789

54.

Dietzen

Ide

Pavone

. Telehealth in pediatric rehabilitation medicine: a survey of clinician reported utilization and experience. PRM 2020; 13: 281–288.

55.

Elpeze

Usgu

. The effect of a comprehensive corrective exercise program on kyphosis angle and balance in kyphotic adolescents. Healthcare (Basel) 2022; 10: 2478.

56.

Krzyzaniak

Cardona

Peiris

, et al. Telerehabilitation versus face-to-face rehabilitation in the management of musculoskeletal conditions: a systematic review and meta-analysis. Phys Ther Rev 2023; 28: 1–17.