Effect of Mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength

Abstract

Loss of hip extension is often compensated for by extension of the lumbar spine. This compensation can result in hypermobility and ultimately be a source of low back dysfunction and pain. Joint mobilizations have been known to return physiologic and accessory motion to hypomobile structures. Mobilization has also been demonstrated to improve muscular strength when secondary to joint hypomobility. The purpose of this study was to determine the usefulness of posteroanterior (P-A) hip-joint mobilization in improving strength of the gluteus maximus muscle. Forty subjects were randomly assigned to a control group (Grade I P-A mobilization) and an experimental group (Grade IV P-A mobilization). The subjects performed a pretest/posttest set of five isometric repetitions on the Cybex Norm? isokinetic machine. The peak torque was determined for both pretest and posttest measurements. The data collected were analyzed using an independent t-test with a significance level of p < .05. The results demonstrated a statistically significant difference between the experimental and control groups (t=1.68, p=0.002). This study demonstrated a significant increase in gluteus maximus strength in response to Grade IV P-A mobilizations performed on the anterior hip capsule. Clinicians can utilize these findings in everyday practice to improve muscle strength by integrating manual therapy with therapeutic exercise.     

Short-Term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength

Abstract

Lower trapezius muscle-strength deficits are a common clinical finding in patients presenting with poor postural habits. It has been speculated that zygapophyseal extension restrictions in the middle to lower thoracic spine are associated with these muscle-strength deficits. This may be a direct result of muscle inhibition related to reflexogenic influences from dysfunctional joints. The purpose of this study was to investigate the effects of manipulation applied to the lower thoracic spine (T6-T12) of asymptomatic individuals on lower trapezius muscle strength. A convenience sample of 40 subjects was randomly split into control and experimental groups of equal size. Pre-test and post-test measurements of isometric lower trapezius muscle strength were collected using a Nicholas Manual Muscle Tester. Both groups received identical assessment procedures. The experimental group received thoracic manipulations while the control group received a placebo technique. An independent group t-test was used to compare the mean change in lower trapezius muscle strength between the groups. Results revealed a significantly greater (p < 0.025) percentage increase in lower trapezius strength in the manipulation group (14%) as compared to the controls (3%). The results suggest that lower thoracic manipulation techniques may be beneficial in reducing the lower trapezius muscle inhibition commonly associated with many postural syndromes.     

The effect of thoracic spine mobilization and stabilization exercise on the muscular strength and flexibility of the trunk of chronic low back pain patients

[Purpose] To investigate whether thoracic spine mobilization added to stabilization exercises increases the muscular strength and range of motion of the thoracic vertebrae of chronic low-back pain patients. [Subjects] This study enrolled 20 patients with chronic low back pain, who were divided into two groups. Ten subjects were randomly selected for the stabilization exercise group and the remaining 10 subjects received thoracic spine mobilization in addition to performing the stabilization exercises. [Methods] The patients performed stabilization exercises and received thoracic spine mobilization for 12 weeks. The range of motion and isometric muscular strength of the vertebrae of all subjects were measured before and after the intervention. [Results] In the comparison of muscular strength before and after the intervention, the change in muscular strength of the trunk flexors in the stabilization exercise group was 16.0±7.4 Nm, and that of the thoracic spine mobilization group was 34.2±7.6 Nm, a significant difference in each group. In the post-intervention intergroup comparison, the muscular strength of trunk flexors in the stabilization exercise group was 111.1±16.9 Nm, while that of the thoracic spine mobilization group was 125.9±11.3 Nm, a significant difference. Also, the muscular strength of the trunk extensors in the stabilization exercise group was 148.9±31.8 Nm, while that of the thoracic spine mobilization group was 182.9±37.2 Nm, a significant difference. The thoracic spine flexion in the stabilization exercise group was 29.8±9 degrees, while that of the thoracic spine mobilization group was 38.7±6.9 degrees, a significant difference. However, there was no significant difference in lumbar flexion values between the two groups. [Conclusion] Thoracic spine mobilization added to a stabilization exercise increased the muscular strength of patients with chronic low back pain.Key words: Isometric muscle strength, Lumbar stabilization exercise, Thoracic spine mobilization exercise     

Immediate and Carryover Changes of C5-6 Joint Mobilization on Shoulder External Rotator Muscle Strength

ObjectiveClinical evidence has shown that extremity dysfunction, such as muscle weakness or inhibition, is associated with spinal disorders. Spinal manual therapy is a common therapeutic approach used to address extremity muscle weakness. The purpose of the study was to assess changes in the maximal muscle strength of the shoulder external rotators immediately and at 10, 20, and 30 minutes after cervical joint mobilization at the C5-6 segment.MethodsEighteen participants with existing or a history of neck pain were screened by 2 investigators independently for muscle weakness of shoulder external rotators. Fifteen qualified participants underwent shoulder external rotator strength testing with a handheld dynamometer. Each participant was tested 6 times, twice before, immediately after, and at 10, 20, and 30 minutes after a C5-6 joint mobilization on the involved side. The 2 strength data collected before the mobilization were used to determine intratester reliability.ResultsThe intratester reliability of the shoulder external rotator strength was excellent (intraclass correlation coefficient_3,2 = 0.985). One-way analysis of variance with repeated measures showed a statistical significance in strength data (P = .002). Post hoc tests revealed a significant increase between prejoint mobilization and immediately postjoint mobilization (P = .003) and between pre joint mobilization and 10-minute post joint mobilization (P < .001).ConclusionsThe results of the study suggest that C5-6 joint mobilization increases muscle strength of the shoulder external rotators immediately and its effect carries over for 10 minutes but not after 20 minutes.     

Development of a clinical prediction rule for identifying women with tension-type headache who are likely to achieve short-term success with joint mobilization and muscle trigger point therapy

(Headache 2011;51:246‐261) Objective.— To identify prognostic factors from the history and physical examination in women with tension‐type headache (TTH) who are likely to experience self‐perceived clinical improvement following a multimodal physical therapy session including joint mobilization and muscle trigger point (TrP) therapies. Background.— No definitive therapeutic intervention is available for TTH. It would be useful for clinicians to have a clinical prediction rule for selecting which TTH patients may experience improved outcomes following a multimodal physical therapy program. Methods.— Women diagnosed with pure TTH by 3 experienced neurologists according to the International Headache Society criteria from different neurology departments were included. They underwent a standardized examination (neck mobility, pressure pain thresholds, total tenderness score, presence of muscle TrPs, Medical Outcomes Study 36‐Item Short Form, the Neck Disability Index [NDI], the Beck Depression Inventory, and the Headache Disability Inventory) and then a multimodal physical therapy session including joint mobilization and TrP therapies. The treatment session included a 30‐second grade III or IV central posterior‐anterior nonthrust mobilization applied from T4 to T1 thoracic vertebrae, at C7‐T1 cervico‐thoracic junction and C1‐C2 vertebrae for an overall intervention time of 5 minutes Different TrP techniques, particularly soft tissue stroke, pressure release, or muscle energy were applied to head and neck–shoulder muscles (temporalis, suboccipital, upper trapezius, splenius capitis, semispinalis capitis, sternocleidomastoid) to inactivate active muscle TrPs. Participants were classified as having achieved a successful outcome 1 week after the session based on their self‐perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of success. Results.— Data for 76 subjects were included in the analysis, of which 36 experienced a successful outcome (48%). Eight prognostic variables were retained in the regression model: mean age <44.5 years, presence of left sternocleidomastoid TrP, presence of suboccipital TrP, presence of left superior oblique muscle TrP, cervical rotation to the left > 69°, total tenderness score <20.5, NDI <18.5, referred pain area of right upper trapezius muscle TrP >42.23. Conclusions.— The current clinical prediction rule may allow clinicians to make an a priori identification of women with TTH who are likely to experience short‐term self‐report improvement with a multimodal session including joint mobilizations and TrP therapies. Future studies are necessary to validate these findings.     

The Effect of Joint Manipulation Techniques on Active Range of Motion in the Mid-Thoracic Spine of Asymptomatic Subjects

Abstract

This study assesses the effect of the manipulation of restricted thoracic spine segments on thoracic active range of motion (AROM). Range of motion (ROM) is measured routinely to assess joint mobility, tissue extensibility, and function of the spine and the extremities. Manipulation has been used to restore normal joint mechanics and increase ROM. However, no research specifically shows that ROM in the thoracic spine increases after spinal manipulation. Seventy-eight healthy subjects (29 male, 49 female), ages 18-44, were divided into three categories. Group 1 was the control, group 2 received mobility testing only, and group 3 received mobility testing and joint manipulation to a restricted segment. All subjects were pre-tested for AROM of T3-T8; then either rested, received mobility tests, or were manipulated, after which post-test measurements were performed. Forward bending and side bending right and left were measured. In a comparison of pre-treatment versus post-treatment AROM, a significant difference was seen in side bending to the left only. This demonstrates that one session of manipulation techniques can influence AROM in the mid-thoracic spine.     

Differential diagnosis and treatment in a patient with posterior upper thoracic pain

BACKGROUND AND PURPOSE: Determining the source of a patient's pain in the upper thoracic region can be difficult. Costovertebral (CV) and costotransverse (CT) joint hypomobility and active trigger points (TrPs) are possible sources of upper thoracic pain. This case report describes the clinical decision-making process for a patient with posterior upper thoracic pain. CASE DESCRIPTION: The patient had a 4-month history of pain; limited cervical, trunk, and shoulder active range of motion; limited and painful mobility of the right CV/CT joints of ribs 3 through 6; and periscapular TrPs. Interventions included CV/CT joint mobilizations, TrP release, and flexibility and postural exercises. OUTCOMES: The patient reported intermittent mild discomfort after 7 physical therapy sessions. Examination findings were normal, and he was able to resume all preinjury activities. DISCUSSION: This case suggests that CV/CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient.     

Trapezius muscle activation levels and ratios during scapular retraction exercises: A comparative study between patients with subacromial impingement syndrome and healthy controls

BackgroundLittle is known about trapezius muscle activities during scapular retraction exercises in patients with subacromial impingement syndrome. The aim of this study was to compare upper trapezius, middle trapezius and lower trapezius muscle activity and upper/middle and upper/lower trapezius ratios between patients with subacromial impingement syndrome and healthy individuals during six scapular retraction exercises.MethodsTwenty-two patients with subacromial impingement syndrome and 22 healthy individuals participated. Upper, middle, and lower trapezius activities were measured by surface electromyography, while the participants performed six scapular retraction exercises at different shoulder abduction angles in a standing position. Upper/middle and upper/lower trapezius ratios were also calculated. Repeated-measures analyses of variance were performed to determine whether muscle activation levels and ratios differed between groups during exercises.FindingsThere was no significant exercise × group interactions for upper, middle, and lower trapezius activation levels and upper/middle and upper/lower trapezius ratios (P > .05). A main effect for the exercise was observed for the upper/middle and upper/lower trapezius ratios (P < .05).InterpretationCompared to healthy individuals, patients with subacromial impingement syndrome did not exhibit different upper, middle, and lower trapezius activity and had similar upper/middle and upper/lower trapezius ratios during the various scapular retraction exercises. Therefore, scapular retraction exercises with various shoulder abduction could be safely offered for the patients with subacromial impingement syndrome since it does not lead to abnormal compensatory trapezius muscle activity. If the goal is to minimize upper/middle and upper/lower trapezius ratios, the scapular retraction exercises at 0° shoulder abduction may be used in early stage of shoulder rehabilitation.     

Comparison of scapular kinematics and muscle strength between those with a positive and a negative Scapular Assistance Test

BackgroundThe Scapular Assistance Test was suggested to directly assess the influence of scapular motion on pain and indirectly measure the function of the scapular rotators. However, it is still not clear if individuals with a positive Scapular Assistance Test actually present changes in scapular motion and muscle strength. This study compared scapular kinematics and muscle strength between those with a positive Scapular Assistance Test and those with a negative Scapular Assistance Test.MethodsFifty individuals with shoulder pain were randomly allocated to: positive (n = 25) or negative Scapular Assistance Test (n = 25) group. Scapular kinematics was measured during elevation and lowering of the arm. Strength of the serratus anterior and lower trapezius was also measured. Two-way analysis of variance was used to compare kinematics between groups. Unpaired Student's t-test and Mann-Whitney test were used to compare strength of serratus anterior and lower trapezius, respectively.FindingsThere were no differences (P > 0.05) in scapular internal rotation and upward rotation between both groups. For scapular tilt, there was group main effect (P < 0.05) during elevation and lowering of the arm, whereas the positive Scapular Assistance Test group presented greater scapular anterior tilt. There was no difference (P > 0.05) in strength between groups.InterpretationIndividuals with a positive Scapular Assistance Test are more likely to present decreased scapular posterior tilt in those with shoulder pain. Strength of the scapular muscles seems to be same in those with a positive and a negative Scapular Assistance Test.     

THORACIC REGION SELF-MOBILIZATION: A CLINICAL SUGGESTION

Limitations in thoracic spine motion may be due to restrictions in contractile or non-contractile tissues. Joint mobilizations are indicated when hypomobility of a joint (non-contractile tissue) is identified. The ability for a patient to perform self-mobilizations of the thoracic spine and ribs may help maximize intervention outcomes. The purpose of this article is to describe a low cost, portable device which can be used for thoracic spine self-mobilization techniques.     

Autonomic Effects of Spinal Manipulative Therapy: Systematic Review of Randomized Controlled Trials

ObjectiveThe purpose of this study was to systematically review the effects of spinal manipulative therapy (SMT) on autonomic nervous system (ANS)-mediated outcomes, in both symptomatic and healthy populations, and to assess the quality of evidence for the most prevalent outcomes with the Grading of Recommendations, Assessment, Development and Evaluation approach.MethodsPubMed, Cochrane Library, PEDro, Web of Science, and EMBASE were searched from their inception to March 2014. Randomized controlled trials involving SMT, such as mobilization and manipulation, that reported at least 1 outcome related to the ANS, with placebo, control groups, or other SMT techniques as comparators, with either healthy or symptomatic samples were included. The Physiotherapy Evidence Database scale and the Grading of Recommendations, Assessment, Development and Evaluation approach were used to assess risk of bias and the quality of evidence, respectively.ResultsEighteen trials were included in this systematic review. Passive accessory intervertebral mobilization produced sympathoexcitation independently of the treated region (cervical, thoracic, or lumbar spine); although sustained natural apophyseal glides did not influence the ANS, conflicting results were observed regarding manipulation techniques. The overall quality of evidence for all analyzed outcomes ranged from low to very low quality.ConclusionThere is evidence pointing toward the existence of sympathoexcitatory short-term effects following passive accessory intervertebral mobilization mobilizations, but not for sustained natural apophyseal glide mobilizations. There is conflicting evidence regarding the ability of manipulation to elicit sympathoexcitation. However, the low quality of the evidence precludes a definitive conclusion of such effects. Based on the current evidence, there is uncertainty regarding the true effect estimates of SMT on ANS-mediated outcomes.     

Scapular muscle imbalance: implications for shoulder pain and pathology

Abstract

Background: The scapula is important for normal shoulder function. The correct length, strength, and sequence of recruitment of the scapulothoracic muscles are important in controlling the movement of the scapula which must maintain an optimal position in relation to the elevating humerus. Changes in the action of scapulothoracic muscles may potentially affect alignment and forces and may contribute to glenohumeral joint pathology.

Objective: The purpose of this paper is to review the literature that associates abnormal scapulothoracic muscle function with shoulder joint pain and pathology.

Major findings: Shoulder impingement syndrome, superior labrum anterior to posterior (SLAP) lesions and multidirectional instability have all been associated with dysfunctional movement patterns of the scapula. It is not clear if the observed changes in scapular movements and muscular control are the result of or are the cause of these various pathologies at the shoulder joint. Alterations in the force production of the scapulothoracic musculature including all parts of the trapezius and serratus anterior muscles have been reported. Tightness in the pectoralis minor and/or in the posterior glenohumeral joint capsule may also affect movement due to a general anterior tilting of the scapula which impairs its ability to attain a normally upwardly rotated position.

Conclusions: The results of the investigations reviewed imply that appropriate assessment of the length, strength, and activation of all parts of the upper trapezius, serratus anterior, and pectoralis minor are important in the rehabilitation of patients with glenohumeral joint pathology.     

Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report

Donovan JS, Kerber CW, Donovan WH, Marshall LF. Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH₂O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.     

Kinesiologic considerations for targeting activation of scapulothoracic muscles – part 2: trapezius

BackgroundThe trapezius is an extensive muscle subdivided into upper, middle, and lower parts. This muscle is a dominant stabilizer of the scapula, normally operating synergistically with other scapular muscles, most notably the serratus anterior. Altered activation, poor control, or reduced strength of the different parts of the trapezius have been linked with abnormal scapular movements, often associated with pain. Several exercises have been designed and studied that specifically target the different parts of the trapezius, with the goal of developing exercises that optimize scapular position and scapulohumeral rhythm that reduce pain and increase function.MethodsThis paper describes the anatomy, kinesiology, and pathokinesiology of the trapezius as well as exercises that selectively target the activation of the different parts of this complex muscle.ConclusionsThis review provides the anatomy and kinesiology of the trapezius muscle with the underlying intention of understanding how this muscle contributes to the normal mechanics of the scapula as well as the entire shoulder region. This paper can guide the clinician with planning exercises that specifically target the different parts of the trapezius. It is recommended that this paper be read as a companion to another paper: Kinesiologic considerations for targeting activation of scapulothoracic muscles – part 1: serratus anterior.     

A COMPARISON OF CHANGE IN 3D SCAPULAR KINEMATICS WITH MAXIMAL CONTRACTIONS AND FORCE PRODUCTION WITH SCAPULAR MUSCLE TESTS BETWEEN ASYMPTOMATIC OVERHEAD ATHLETES WITH AND WITHOUT SCAPULAR DYSKINESIS

Background

The significance of scapular dyskinesis is being challenged due to a lack of the association with pain and ability to predict injury in athletic populations. However, it is unknown whether asymptomatic overhead athletes with dyskinesis cope by normalizing scapular position with higher demand activities.

Hypothesis/Purpose

The purpose of this study was to compare change in scapular kinematics from an active unweighted contraction to a maximal isometric contraction in asymptomatic overhead athletes with and without scapular dyskinesis. Secondarily, force generated with manual muscle tests were explored for differences and relationships with kinematics.

Study Design

Cross‐sectional laboratory study

Methods

Twenty‐five matched asymptomatic overhead athletes with (n=14) and without (n=11) scapular dyskinesis, defined with a reliable and validated clinical method, participated in this study. Three‐dimensional scapular kinematics were evaluated in an active unweighted condition, and during maximal isometric contractions at 90 ° of shoulder flexion. Isometric force produced with lower trapezius and serratus anterior manual muscle tests were assessed with a dynamometer. Changes in scapular kinematics were compared between groups. Differences in force generated with manual muscle tests between groups and relationships with kinematics were explored.

Results

Athletes with dyskinesis demonstrated greater deficits in scapular upward rotation with maximal contraction (p=<0.001), less external rotation (p=0.036) and weaker lower trapezius manual muscle test strength (p=0.031). Lower trapezius (p=0.003;r=0.57) and serratus anterior (p=0.042;r=0.41) manual muscle test strength deficits were fair to moderately associated with a lack of scapular upward rotation during maximal contraction.

Conclusion

Small to moderate changes in scapular kinematics are normal responses to a maximal contraction, but with scapular dyskinesis this response is accentuated. Athletes with dyskinesis generate less force with lower trapezius manual muscle testing compared to athletes without dyskinesis. Decreased strength with lower trapezius and serratus anterior manual muscle testing was also related to a lack of upward rotation in all athletes.

Level of Evidence

3     

The Effect of Thoracic Joint Mobilization and Self-stretching Exercise on Pulmonary Functions of Patients with Chronic Neck Pain

[Purpose] The objective of this study was to determine the effect of thoracic joint mobilization and self-stretching exercise on the pulmonary functions of patients with chronic neck pain. [Subjects] The present study was performed with 34 patients with chronic neck pain featuring thoracic kyphosis; we divided them into a thoracic joint mobilization group (TJMG, n = 11), self-stretching exercise group (SSEG, n = 11), and thoracic joint mobilization and self-stretching exercise group (TJMSSEG, n = 12). [Methods] Treatments and exercise were conducted three times a week for six weeks in TJMG, SSEG, and TJMSSEG; the subjects’ pulmonary functions in terms of forced vital capacity (FVC), forced expiratory volume at one second (FEV1), and peak expiratory flow (PEF) were measured using CardioTouch equipment. [Results] Comparisons of the individuals within each of the TJMG, SSEG, and TJMSSEG showed that all of FVC, FEV1, and PEF increased significantly; Comparisons within each of the showed that FVC, FEV1, and PEF increased significantly. Among the study groups, FVC was significantly higher in TJMSSEG than in TJMG after six weeks; FEV1 was significantly higher in TJMSSEG than in TJMG and SSEG after four and six weeks; and PEF was significantly higher in TJMSSEG than in TJMG and SSEG after six weeks. [Conclusion] The study results indicate that thoracic joint mobilization and self-stretching exercise are effective interventions for increasing FVC, FEV1, and PEF among pulmonary functions.Key words: Thoracic joint mobilization, Self-stretching exercise, Pulmonary function     

Psychometric Properties of Pressure Pain Thresholds Measured in 2 Positions for Adults With and Without Neck-Shoulder Pain and Tenderness

ObjectiveThe purpose of this study was to determine the psychometric properties of pressure pain threshold (PPT) testing in adults with and without neck-shoulder pain and tenderness and to compare the differences in PPT measurements between the seated and prone positions.MethodsThirty asymptomatic adults and 30 symptomatic patients with intermittent neck-shoulder pain and tenderness completed the study. A pressure algometer was used to assess PPTs at specific points on the middle deltoid, levator scapulae, and upper trapezius muscles of the dominant side of the asymptomatic individuals and the painful side of the patients. Four trials were performed on each muscle in both the seated and prone positions. To determine between-day reliability, a subset of the participants returned to repeat the testing.ResultsThe intraclass correlation coefficients showed good to excellent within-session reliability and fair to excellent between-day reliability of PPT measurements in both the seated and prone positions for both groups. There were significant differences between groups for all muscles in both positions (P < .05) except for the upper trapezius muscle in the prone position. In addition, significant differences were found between the 2 testing positions for the middle deltoid and upper trapezius muscles in the symptomatic group and for the middle deltoid muscle in the asymptomatic group.ConclusionThe results of the study suggest that PPT testing could be useful for distinguishing individuals with and without neck-shoulder pain and tenderness. Further, the patient’s position should be considered when testing PPT, specifically at the middle deltoid or upper trapezius muscles.     

Posteroanterior spinal mobilization: state of the art review and discussion

Posteroanterior spinal mobilization is a commonly used technique among physical therapists to diagnose and treat lower back pain patients. Human subjects and instruments have been used to test for the reliability of physical therapists' ability to detect intervertebral motion, but studies confirm unreliable testing. Despite documented efficacy of manual treatment the mechanical response to posteroanterior spinal mobilization is not well understood, and this has been emphasized in recent studies. Various modes of instrumental methodology have been used for objective measurements of force application and joint displacement. Some instruments serve to mobilize the spine others serve as measurement tools for mobilization. The literature does not provide a gold standard for the ideal magnitude of force applied or joint displacement. The terminology used in the field of manual therapy is often confusing, and terms need to be defined. A review and discussion is presented here to highlight the issues and gaps.     

Comparison of manual therapy and exercise therapy for postural hyperkyphosis: A randomized clinical trial

Objective: To compare the efficacy of a manual therapy and an exercise therapy program in improving postural hyperkyphosis among young adults. Methods: Forty-six women between the ages of 18 to 30 years with thoracic kyphosis diagnosed by flexicurve ruler were randomly assigned to either an exercise therapy or a manual therapy group. The exercise therapy program focused on stretching and strengthening exercises in 15 sessions over 5 weeks. The manual therapy group received 15 sessions of manual techniques including massage, mobilization, muscle energy and myofascial release. Kyphosis angle and back extensor muscle strength were measured with a motion analysis system and a dynamometer at the baseline and after treatment. The data were analyzed with paired and independent t-tests. Results: After treatment, the angle of thoracic kyphosis was smaller and back extensor muscle strength was significantly greater in both the exercise and manual therapy groups (p < 0.001). We found no significant differences between groups in the changes in kyphosis angle or muscle strength after treatment (p > 0.05). Conclusion: Manual therapy was as effective as exercise therapy in reducing kyphosis angle and increasing back extensor muscle strength in young women with postural hyperkyphosis.