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Effect of Seated Thoracic Manipulation on

Changes in Scapular Kinematics and
Scapulohumeral Rhythm in Young
Asymptomatic...

Article in Journal of manipulative and physiological therapeutics September 2013

DOI: 10.1016/j.jmpt.2013.07.006 Source: PubMed

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EFFECT OF SEATED THORACIC MANIPULATION ON
CHANGES IN SCAPULAR KINEMATICS AND SCAPULOHUMERAL
RHYTHM IN YOUNG ASYMPTOMATIC PARTICIPANTS:
A RANDOMIZED STUDY
Dayana P. Rosa, PT, a Francisco Alburquerque-Sendn, PhD, b Tania F. Salvini, PhD, c and
Paula R. Camargo, PT, PhD c

ABSTRACT

Objective: The purpose of this study was to evaluate the immediate effects of seated thoracic manipulation on
scapulothoracic kinematics and scapulohumeral rhythm during arm flexion in young asymptomatic participants.
Methods: A convenience sample of 42 young asymptomatic participants was randomly divided in 2 groups:
manipulation and sham group. Measurements were taken before and after the intervention. All participants completed
the Disabilities of the Arm, Shoulder, and Hand questionnaire to assess pain and physical function. The manipulation
group received the manipulation (high velocity, low amplitude), which was performed by a physical therapist with the
patient in the seated position and with the arms crossed over the chest and hands passed over the shoulders. For the
sham group, the same procedure was performed, with the exception that the high-velocity thrust was not applied.
Three-dimensional (3D) kinematic data were collected with the participants in a relaxed standing position using a 3D
electromagnetic tracking system. All participants performed 3 repetitions of arm flexion before and after manipulation.
Results: There were no differences (P = .79) in Disabilities of the Arm, Shoulder, and Hand scores when the
manipulation (3.37 3.72) was compared with the sham group (3.68 4.27). The 3-way analysis of variance showed
no significant interaction among group, angle, and time differences for the outcomes (scapulothoracic internal/external
rotation [F = 0.43; P = .82], upward/downward rotation [F = 0.08; P = .99], tilt [F = 0.23; P = .94], and
scapulohumeral rhythm [F = 4; P = .86]). The intragroup effect was small for the outcomes measured in both groups.
Conclusions: Thoracic manipulation in the seated position did not affect scapulohumeral rhythm and 3D scapular
kinematics during arm flexion in young asymptomatic participants. (J Manipulative Physiol Ther 2013;xx:1-9)
Key Indexing Terms: Rehabilitation; Shoulder; Spine; Scapula; Manipulation; Musculoskeletal Manipulations

T
horacic manipulation is defined as a high-velocity/
low-amplitude movement or thrust directed at any
segment of the thoracic spine 1 and has been widely
used to treat different musculoskeletal conditions such as
neck, shoulder, and back pain. 1-3 Recent studies have eval-
a
Physical Therapist, Physical Therapy Graduate Program,
Methodist University of Piracicaba, Piracicaba, SP, Brazil.
b
Professor, Department of Physical Therapy, University of
Salamanca, Salamanca, Spain.
c
Professor, Department of Physical Therapy, Federal Univer-
sity of So Carlos, So Carlos, SP, Brazil.
Submit requests for reprints to: Paula R. Camargo, PT, PhD,
Professor, Department of Physical Therapy, Federal University of
So Carlos, Rodovia Washington Luis, km 235, 13565-905 So
Carlos, SP, Brazil (e-mail: paularezendecamargo@gmail.com).
Paper submitted September 5, 2012; in revised form July 23,
2013; accepted July 25, 2013.
0161-4754/$36.00
Copyright 2013 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2013.07.006
uated the immediate effects of spinal manipulation in asymp-
tomatic participants showing no consensus on the results. 4-9
These studies bring different aspects about possible effects of
spinal manipulation: reduction of the -motoneuronal activity
(muscle tone) with no alteration of the pressure pain
thresholds 9 and increase of phasic perineal contraction and
basal perineal tonus 5 after manipulation at the sacroiliac joint,
changes in the nocioceptive afferent system 7 and in pressure
pain threshold 4 after thoracic manipulation, and no changes
in spine stiffness 6 and in lumbar range of motion 8 after
thoracic and lumbar manipulation, respectively. The absence
of consensus in the literature may be caused by the hetero-
geneity of the intervention and assessment procedures. It is
suggested that more studies on the motor component should
be done. 10,11
Theodoridis and Ruston 12 have considered that the bio-
mechanical relationship between the arm and the thoracic
spine is important to clinical practice because of the
contribution of the thoracic spine to shoulder movements.
This relationship leads us to the term regional
2 Rosa et al Journal of Manipulative
Thoracic Manipulation and Scapular Kinematics Month 2013

interdependence, which refers to the concept that seemingly METHODS

unrelated impairments in a remote anatomical region may
This was a controlled laboratory study of immediate
contribute to, or be associated with, the patient's primary
effects (before/after intervention) that took place at Uni-
complaint. 13 The clinical rationale for using thoracic
versidade Federal de So Carlos. Volunteers were recruited
manipulation to treat the shoulder in this example is based
from December 2009 to January 2011 at the University and
on this theory. Nevertheless, the dimension of this
relationship in specific samples of participants with and community. A convenience sample of 42 asymptomatic
patients participated in this study. They were randomly
without shoulder pain is not known.
divided into 2 groups: manipulation group and sham group.
Investigations have shown that thoracic manipulation
The last author was responsible for the randomization, which
may be effective in reducing pain and increasing range
was performed by using www.randomization.com. Alloca-
of motion of the shoulder. 14-17 In addition, thoracic
tion of each participant was only known by the time of
manipulation in asymptomatic participants was demon-
evaluation. Figure 1 shows the flow diagram of progress of
strated to increase the strength of the lower trapezius, 18
both groups in the study. Table 1 shows the descriptive data
which is strongly associated with the scapular motion. 19
Because appropriate motion of the scapula during for both groups. All participants were recruited by direct
contact and screened by the first author.
elevation of the arm is one of the most important
The participants were included if they had no history of
aspects to be considered in shoulder dysfunctions, it
shoulder or cervical pathology and if they had range of
would be interesting to know if thoracic manipulation
motion for shoulder elevation next to 150 as evaluated by
has any effect on scapular kinematics and scapulohum-
visual observation. Exclusion criteria included the follow-
eral rhythm. There is only one study in the literature
ing: pregnancy, ligamentous laxity based on positive
that evaluated the effects of thoracic manipulation on
Sulcus 22 and Apprehension 23 tests; positive impingement
scapular kinematics and muscle activation in participants
with shoulder pain. 17 The authors suggested that tests based on Hawkins and Kennedy, 24 Neer, 25 and Jobe
and Moynes, 26 or pain during external rotation with the
the decreased pain and improved function of the
arm in 90 of elevation in the coronal plane; history of
shoulder after the thoracic manipulation are not likely
clavicle, scapula, or humerus fracture; systemic illnesses;
associated with changes in scapular kinematics or
apprehension of being manipulated; tape allergy; and body
changes in muscle activation. This finding shows that
mass index greater than 28 kg/m 2 (the amount of subcu-
different pathways for sensory and motor changes may
taneous tissue can compromise the quality of the motion
exist in the shoulder after the application of thoracic
data because surface sensors are used to track the bones).
manipulation. However, the absence of a control group
and blinding were limitations from the previous study. This project was approved by the Ethical Committee
in Human Research of Universidade Federal de So
Mechanisms to explain how thoracic manipulation can
Carlos (protocol number 331/2010). The participants gave
be associated with improved shoulder pain and motion are
their written and informed consent agreement to partic-
not well defined. The consequences of applying a thoracic
ipate in this study, which was conducted according to the
manipulation to elicit changes in shoulder motion have not
Helsinki Statement.
been adequately proven yet, neither in patients nor in
healthy participants. As such, there is a need of research that
evaluates the motor component and helps to better under- Disabilities of the Arm, Shoulder, and Hand Questionnaire
stand the mechanisms by which thoracic manipulation The Disabilities of the Arm, Shoulder, and Hand
might induce the changes usually described. Specifically, (DASH) self-assessment questionnaire contains 30 ques-
there is a lack of studies on thoracic manipulation and tions to measure physical function and symptoms of the
3-dimensional (3D) shoulder kinematics. upper limbs of the participants. Each question has 5 pos-
It is important to evaluate asymptomatic participants in sible responses, ranging from no difficulty to unable to
an attempt to eliminate factors (pain, for example) that can perform activity, and is scored on a 1- to 5-point rating
have influence on the results avoiding the confusion of scale. The questionnaire score is calculated by applying an
cause and effect and also adverse effects that might advise established formula in which the maximum score is 100,
against the application of the thoracic manipulation. Based which indicates the worst possible condition. 27 This
on the neurophysiologic effects of the spine manipulation questionnaire has been shown to be a reliable, valid, and
already demonstrated by some studies, 20,21 it was hypoth- responsive measure. 28,29
esized that the thoracic manipulation would increase sca-
pular upward rotation and posterior tilt. Therefore, the
purpose of this study was to evaluate the immediate effects Three-Dimensional Scapular Kinematics
of thoracic manipulation on 3D scapulothoracic kinematics For 3D scapular kinematics, data capture and analysis
and scapulohumeral rhythm during arm flexion in young were completed using Flock of Birds (miniBird; Ascension
asymptomatic participants. Technology Corporation, Burlington, VT) hardware
Journal of Manipulative and Physiological Therapeutics
Volume xx, Number x
Assessed for eligibility (n = 49)
Randomized (n = 45)
Allocated to manipulation group (n = 24)
Received allocated intervention (n = 24)
Analysed (n=21)
Excluded from analysis (no cavitation) (n = 3)
Fig 1. Flow diagram of the progress of participants in the study.
Table 1. Descriptive data of both groups
Manipulation group (n = 21)
Sex 11 women; 10 men
Age (y), mean SD 23.81 3.75
Body mass (kg), mean SD 68.31 14.6
Height (cm), mean SD 173 1.0
Evaluated side 13 dominants;
8 nondominants
integrated with MotionMonitor (Ascension Technology
Corporation) software. The Flock of Birds is a direct current
electromagnetic tracking device able to locate multiple
sensors relative to a source transmitter. The 3D position and
orientation of each sensor can be tracked simultaneously at
sampling rates of 30 to 144 Hz. The sensors are small and
lightweight (1.8 0.8 0.8 cm). In a metal-free
environment up to a 76-cm distance from the transmitter,
the root mean square accuracy of the system is 0.5 for
orientation and 0.18 cm for position, as reported by the
manufacturer. One of the sensors is attached to a stylus with
known offsets to digitize anatomical landmarks for building
the joint coordinate systems.
The electromagnetic sensors were attached with double-
sided adhesive tape to the sternum, to the acromion of the
scapula, and to a thermoplastic cuff secured to the distal
humerus to track humeral motion. These surface sensor
placements have been previously used. 30-33 The participant
stood with the arms relaxed at the side in a neutral position
with the transmitter directly behind the shoulder tested
while bony landmarks on the thorax, scapula, and humerus
were palpated and digitized to allow transformation of the
sensor data to local anatomically based coordinate systems.
Thorax landmarks included the sternal notch, C7 spinous
Rosa et al 3
Scapular Kinematics and Scapulohumeral Rhythm
Excluded (n = 4)
Not meeting inclusion criteria (n = 4)
Allocated to sham group (n = 21)
Received allocated intervention (n = 21)
Analysed (n = 21)
Excluded from analysis (n = 0)
Sham group (n = 21) P
11 women; 10 men 1.00
23.95 3.2 .89
68.38 11.23 .49
171 0.9 .63
10 dominants; 11 nondominants .35
process, T8 spinous process, and xyphoid process. Scapular
landmarks included the root of the spine, posterolateral
acromion, and the inferior angle of the scapula. Humerus
landmarks included the lateral and the medial epicondyles.
The center of the humeral head was estimated by moving
the arm passively through short arcs (b 45) to define the
pivot point. 34
Data Reduction
Local coordinate systems were established for the trunk,
clavicle, scapula, and humerus using the digitized landmarks
following the International Society of Biomechanics
recommended protocol. 35 The z-axis pointed laterally; the
x-axis, anteriorly; and the y-axis, superiorly. The YXZ
sequence was used to describe scapular motions relative
to the trunk. For the scapula, the rotations were described in
the order of internal/external rotation, upward/downward
rotation, and anterior/posterior tilt. The humeral position
with reference to the trunk was determined using the YXY
sequence. The first rotation defines the plane of elevation,
the second defines the humeral elevation angle, and the third
defines internal/external rotation. The humeral position with
reference to the scapula was determined using the XZY
sequence. The first rotation defines glenohumeral elevation,
4 Rosa et al Journal of Manipulative
Thoracic Manipulation and Scapular Kinematics Month 2013

the second defines the plane of glenohumeral elevation, and

the third defines internal/external rotation.

Scapulohumeral Rhythm
The ratio of glenohumeral elevation relative to scapular
upward rotation was determined by calculating the slope of
the linear regression line using scapular upward rotation as
the X value and glenohumeral elevation as the Y value, as
proposed by Braman et al. 36 The ratio was calculated from
30 to 120 of humerothoracic elevation and at 30
increments (30-60, 60-90, 90-120).

Interventions
The thoracic manipulation used in this study has been
previously described in other studies 37-39 and was per-
formed by a physical therapist with more than 10 years of
experience. The participant was seated with the arms
crossed over the chest and hands passed over the shoulders.
The therapist placed his upper chest at the level of the
participant's middle thoracic spine and grasped the
participant's elbows (Fig 2). The participant was instructed Fig 2. Therapist and participant position for the manipulation
to take a deep breath in and let it out while a gentle flexion procedure. (Color version of figure is available online.)
of the thoracic spine was introduced until slight tension
was felt in the tissues at the contact point between the Procedures
therapist's chest and participant's back. Then, a distraction
Kinematic data collection was done with the participants
thrust manipulation in a superior/posterior direction was
in a relaxed standing position. Kinematic motion analysis
applied. 40 Cavitation was expected to occur during the
involved selecting scapular data at humerothoracic eleva-
manipulation procedure. If no popping was heard on the
tion angles of initial, 30, 60, 90, 120, and maximum
first attempt, the therapist repositioned the participant and
elevation. Participants were asked to maintain light fin-
performed a second manipulation. A maximum of 2 gertip contact with a flat planar surface to keep positioning
attempts were performed on each participant, as previously
of the arm in the sagittal plane (Fig 3). They were also
described. 38 Three participants were excluded from the
instructed to keep their hand with their thumb pointing
study because no cavitation occurred after the second
toward the ceiling when tested at each humeral elevation.
attempt. The sham group received the same procedure, and
Three repetitions were performed before and immediately
the participant was positioned the same as the manipulation
after the intervention (manipulation or sham). Participants
group, with the exception that the high-velocity thrust
were asked to elevate their arm from the rest position
was not performed in these participants. No participants
through their full range of motion at a speed such that it
from both groups had any adverse events with the mani- took around 3 seconds to elevate their arm and 3 seconds
pulation technique.
to lower it. All measurements were taken by the primary
Participants were given incomplete information about
investigator. The tested side, dominant or nondominant,
the purpose of the study to control any effects that their
was randomly chosen. The sensors were not removed or
expectations about the results would cause. Same instruc-
replaced between repetitions, or for the intervention
tions were given to participants in the manipulation and
(manipulation or sham). This method has been previously
sham groups before the testing session. Examiner and
established to have good repeatability within the same
therapist were not the same person. The examiner was
testing session. 41
responsible for managing the computer to register the
kinematic data, and the therapist applied the assigned inter-
vention. Because the tool used to track the kinematics was Statistical Analysis
an electromagnetic system, the data were not collected The results were analyzed using the SPSS statistical
directly by the examiner but had to undergo computer package (16.0 version; SPSS, Chicago, IL). The 2 and the
processing, decreasing the examiner's ability to influence Student t test were conducted to determine if the 2 groups
the outcomes. differed on the demographic characteristics. Normality test
Journal of Manipulative and Physiological Therapeutics
Volume xx, Number x
Fig 3. Participant during kinematics evaluation. They were asked
to maintain light fingertip contact with a flat planar surface to
keep positioning of the arm in the sagittal plane. (Color version of
figure is available online.)
(Kolmogorov-Smirnov) was conducted for the dependent
variables, which presented normal behavior (P N .05). An
independent t test was used to analyze the DASH scores
between both groups. For each dependent variable (scapular
internal rotation, upward rotation, posterior tilt), a 3-way
repeated-measures analysis of variance was used to test for
main effects of group (manipulation and sham), time
(preintervention and postintervention), and angle of arm
elevation (initial, 30, 60, 90, 120, and maximum), or for
interactions of time and group or of time, group and angle,
separately. For scapulohumeral rhythm, a 3-way repeated-
measures analysis of variance was also used to test main
effects of group, time and interval (30-120, 30-60, 60-
90, 90-120), or for interactions. Tukey post hoc analyses
were performed to investigate significant interactions. A
P value of less than .05 was considered significant.
Intragroup effect sizes for each scapular rotation across
humerothoracic elevation angles and for scapulohumeral
rhythm at each interval were calculated using Cohen d
coefficient 42 for both manipulation and sham groups. An
effect size greater than 0.8 was considered large; around
0.5, moderate; and less than 0.2, small.
RESULTS
The DASH Questionnaire
There were no differences (P = .79) in DASH scores
when the manipulation group (3.37 3.72) was compared
Rosa et al 5
Scapular Kinematics and Scapulohumeral Rhythm
Fig 4. Mean and SE values for scapular internal rotation across
humerothoracic elevation angles for both manipulation and sham
groups before and after the intervention. (Color version of figure
is available online.)
with the sham group (3.68 4.27). Also, no adverse events
were reported from the study participants.
Three-Dimensional Scapular Kinematics
For scapular internal rotation, there was no significant
interaction among group, angle, and time (P = .91, df = 5,
F = 0.29) for elevation of the arm (Fig 4). There was also no
interaction between group and time during elevation (P =
.06, df = 1, F = 3.59) of the arm. The average differences
between preintervention and postintervention for both
manipulation and sham groups were 1.14 and 2.27,
respectively, during elevation of the arm.
For scapular upward rotation, there was no significant
interaction among group, angle, and time (P = .97, df = 5,
F = 0.17) for elevation of the arm (Fig 5) and also between
group and time (P = .98, df = 1, F = 0.001). The average
differences between preintervention and postintervention
for both manipulation and sham groups were 1.2 and 1.1,
respectively, during elevation of the arm.
For scapular posterior tilt, there was no significant
interaction among group, angle, and time (P = .97, df = 5,
F = 0.16) for elevation of the arm (Fig 6). There was also no
interaction between group and time (P = .06, df = 1, F =
3.55) during elevation of the arm. The average differences
between preintervention and postintervention for both
manipulation and sham groups were 0.09 and 0.66,
respectively, during elevation of the arm.
The intragroup effect size for all scapular rotations
across humerothoracic elevation angles for both groups was
small (Table 2).
6 Rosa et al
Thoracic Manipulation and Scapular Kinematics
Fig 5. Mean and SE values for scapular upward rotation across
humerothoracic elevation angles for both manipulation and sham
groups before and after the intervention. (Color version of figure
is available online.)
Scapulohumeral Rhythm
There was no significant interaction among group,
interval, and time (P = .86, df = 0.31, F = 4) and between
group and time (P = .25, df = 1, F = 1.32) for scapu-
lohumeral rhythm during elevation of the arm. Table 3
shows the glenohumeral/scapulothoracic ratios for arm
elevation for both manipulation and sham groups. The
intragroup effect size was small for all intervals evaluated
(Table 4).
DISCUSSION
This study brings new information about the effects of
thoracic manipulation on scapular kinematics and scapulo-
humeral rhythm. The results suggest that the seated thoracic
manipulation technique used in this study does not have
immediate effect on scapular kinematics during elevation
of the arm in young asymptomatic participants. The lack
of effect was demonstrated by both inferential analysis and
effect size.
A recent investigation demonstrated a small but sig-
nificant increase in middle trapezius muscle and a decrease
in scapular upward rotation after the thoracic manipulation
in participants with shoulder pain. 17 However, this fact did
not explain the improvement in pain and function presented
by them because the change in kinematics and muscle
activation was not clinically important. This finding sup-
ports a dichotomy between sensory and motor effects of
the thoracic manipulation. Cleland et al 18 have suggested
that thoracic manipulation can increase lower trapezius
Journal of Manipulative
Month 2013
Fig 6. Mean and SE values for scapular posterior tilt across
humerothoracic elevation angles for both manipulation and sham
groups before and after the intervention. (Color version of figure
is available online.)
muscle strength in asymptomatic participants owing to the
activation of the mechanoreceptors around the manipulated
joint. Considering the controversial results from the pre-
vious studies and that the lower trapezius is an important
scapular upward rotator, 19 we would expect that scapular
kinematics could change after the manipulation. However,
changes in scapular kinematics and scapulohumeral rhythm
were not found in this study.
Although other studies have demonstrated the effects of
spinal manipulation in asymptomatic participants, 4-9 the
scapular kinematics was not measured in these past studies.
As such, some aspects are important to be discussed to
explain the lack of effects demonstrated in this investiga-
tion. Despite the absence of symptoms in our participants,
we considered the concept of regional interdependence. A
recent study 43 has shown that manipulation with thrust
can increase muscle activity in muscles adjacent to the
manipulated segment. However, Campbell and Snodgrass 6
suggested that the mechanical effects that might occur
during manipulation is specific to the level manipulated and
not to other levels. This fact can indicate that the intra-
articular dynamic where manipulation is applied is more
likely to benefit and that adjacent regions may not be
affected. Although it is known that there is a functional
relationship between the shoulder and the spine during arm
elevation, the thoracic manipulation may not influence the
adjacent regions enough to change the scapular muscle
activation and kinematics, at least in asymptomatic parti-
cipants, as observed in the present study.
Pickar 21 has suggested that the application of manipu-
lation to a specific restricted segment may facilitate the
Journal of Manipulative and Physiological Therapeutics Rosa et al 7
Volume xx, Number x Scapular Kinematics and Scapulohumeral Rhythm

Table 2. Intragroup effect size (Cohen d coefficient) for scapular internal rotation, upward rotation, and posterior tilt across
humerothoracic elevation angles for both manipulation and sham groups
Manipulation group (n = 21) Sham group (n = 21)
Scapular internal Scapular upward Scapular posterior Scapular internal Scapular upward Scapular posterior
rotation rotation tilt rotation rotation tilt
Initial 0.14 0.11 0.02 0.33 0.15 0.16
position
30 0.15 0.10 0.001 0.35 0.16 0.14
60 0.13 0.11 0.01 0.39 0.05 0.16
90 0.08 0.12 0.01 0.35 0.19 0.07
120 0.06 0.17 0.02 0.31 0.18 0.03
Maximum 0.27 0.15 0.05 0.24 0.16 0.01
Cohen d coefficient was calculated as follows: drepeated measures = (mean 1 mean 2)/(pooled SD/SE of the difference).

Table 3. Glenohumeral/scapulothoracic ratios at 30 increments during elevation of the arm throughout the arc of motion for both
manipulation and sham groups before and after the intervention
Manipulation group (n = 21) Sham group (n = 21)
Before After Before After
30-120 2.24 0.19 (1.84-2.63) 2.41 0.25 (1.88-2.95) 2.99 0.49 (1.96-4.03) 3.61 0.91 (1.70-5.52)
30-60 2.34 0.19 (1.93-2.76) 2.13 0.16 (1.79-2.49) 2.40 0.20 (1.97-2.82) 2.14 0.17 (1.77-2.51)
60-90 1.88 0.17 (1.51-2.25) 1.96 0.24 (1.46-2.46) 2.11 0.15 (1.78-2.44) 2.14 0.18 (1.77-2.51)
90-120 1.56 0.21 (1.11-2.00) 1.44 0.18 (1.06-1.81) 1.78 0.30 (1.15-2.41) 2.02 0.32 (1.34-2.69)
Results are mean SE (95% confidence interval).

mechanoreceptors activity resulting in decreased neural in-
hibition and increased muscle activation. The evaluation of
specific segmental restrictions was not done in the present
study, and this may have contributed for not finding
differences in the scapular kinematics between premanipu-
lation and postmanipulation because possible differences
could be related to alteration in scapular muscle activity. It is
important to consider that the thoracic spines of young
participants are relatively mobile, resulting in smaller
changes after manipulation in this population (any possible
biomechanical effect would not be enough to change
scapular kinematics).
It is well known that full range of motion during elevation
of the arm necessitates motion of scapula. Studies have
shown that excessive thoracic flexion can decrease shoulder
range of motion, change scapular kinematics, and decrease
scapular muscle strength. 44-46 Because postural evaluation
was not performed in the current study, it is possible that
some of our participants had thoracic rectification contrib-
uting for lack of differences in the scapular kinematics when
comparing premanipulation and postmanipulation.
The findings of this investigation contribute to the
literature about manipulative therapy. Despite the fact that
no effects on scapular kinematics and scapulohumeral
rhythm were shown, the manipulation was not harmful in
young asymptomatic participants. Also, no adverse effects
were reported, suggesting that the manual therapy used in
this study was relatively safe. Conversely, the findings of
this study suggest that seated thoracic manipulation does
not cause pathologic motion of the scapula. Researchers
should continue investigating the effects of the manipula-
Table 4. Intragroup effect size (Cohen d coefficient) for
scapulohumeral rhythm for both manipulation and sham groups
Manipulation group Sham group
(n = 21) (n = 21)
30-120 0.02 0.1
30-60 0.03 0.03
60-90 0.01 0.005
90-120 0.02 0.03
Cohen d coefficient was calculated as follows: drepeated measures = (mean 1
mean 2)/(pooled SD/SE of the difference).
tive therapy in people with shoulder dysfunction because its
mechanisms are not well understood, despite of the high use
in the clinical practice. These investigations are necessary to
better understand and describe the concept of regional
interdependence when treating shoulder pain disorders with
thoracic manipulation.
Study Limitations
The present study has some limitations. Because only the
immediate effects of a specific type of manipulation were
evaluated, the results cannot be generalized to long-term
effects and to other manipulation techniques. The manip-
ulation technique used in this research was only one type
and performed by only one person. As such, we cannot
assert if another practitioner or another type of thoracic
manipulation technique would have the same effect, as, for
example, manipulation with the patient supine or prone,
which are usually more used because it can be more specific
8 Rosa et al
Thoracic Manipulation and Scapular Kinematics
to a certain segment. 6-47 The absence of a random sampling
could have introduced selection bias in the studied sample.
This study used young asymptomatic participants without
history of shoulder or cervical pathology and who had good
range of shoulder motion. Therefore, our study cannot be
extrapolated to participants with shoulder pain or dysfunction
and to the general population. Because the participants had no
shoulder dysfunction, the expected result of an effective
therapy would likely be small. As such, future research
analyzing long-term effects and using participants with
shoulder pain and dysfunction would be important. The
inclusion of a no-treatment group would also be interesting as
well as the performance of other types of manipulation
techniques to determine which technique is the most effective
and if the thoracic manipulation can influence scapular
kinematics. It should also be addressed that the assessor was
not completely blinded to the allocation group of the
participants. Also, it is possible that the sham manipulation
may have had some therapeutic effect because the patient was
positioned, and thus, some movement was applied. Future
studies should take these limitations in to consideration.
CONCLUSION
The results of the present study suggest that middle
thoracic manipulation in the seated position does not
influence scapulohumeral rhythm and scapular kinematics
during arm flexion in young asymptomatic participants.
Furthermore, the thoracic manipulation does not provoke
harmful consequences in asymptomatic participants.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
Financial assistance of this study was provided by
Fundao de Amparo Pesquisa do Estado de So Paulo
(2010/18124-0, 2010/18439-0). No conflicts of interest
were reported for this study.
Practical Applications
Immediate effects on 3D scapular kinematics
were not observed after seated thoracic manip-
ulation in young asymptomatic participants.
Studies with participants with shoulder pain or
kyphosis may be necessary to conclude on
possible effects of thoracic manipulation on
scapular kinematics during arm elevation.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
DPR, FA, TFS, PRC.
Journal of Manipulative
Month 2013
Design (planned the methods to generate the results):
DPR, FA, TFS, PRC.
Supervision (provided oversight, responsible for orga-
nization and implementation, writing of the manuscript):
DPR, FA, TFS, PRC.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
DPR, FA, TFS, PRC.
Analysis/interpretation (responsible for statistical analy-
sis, evaluation, and presentation of the results): DPR,
FA, TFS, PRC.
Literature search (performed the literature search): DPR,
FA, TFS, PRC.
Writing (responsible for writing a substantive part of the
manuscript): DPR, FA, TFS, PRC.
Critical review (revised the manuscript for intellectual
content; this does not relate to spelling and grammar
checking): DPR, FA, TFS, PRC.
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