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Effect of upper thoracic mobilization on cervical alignment in stroke patients with forward head posture: A case study

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J Int Acad Phys Ther Res 2018; 9(2): 1513~1516 ISSN 2092-8475

www.iaptr.org https://doi.org/10.20540/JIAPTR.2018.9.2.1513

Stroke patients usually have muscle weakness and muscle imbalance and decreased postural control and body asymmetry 1). Especially, the asymmetrical pos- ture in median plane following a stroke causes unstable posture 2). Upper trunk flexion, which is common in the stroke patients often causes hyperex- tension of the cervical vertebrae, resulting in forward head posture (FHP) 3,4,5). FHP induces mechanical dysfunction of the cervical spine and increases cranial vertical angle (CVA) and cranial rotation angle in long-term work situations 6). It also referred to as cervical kyphosis and straight neck 7). Stroke with FHP can have relationship with neck function and upper extremity function, so postural control inter- vention necessary about FHP 5).

FHP patients generally have reduced cervical mobil- ity 8). This can lead to cervical pain and neuropathic

pain as well as neurological problems. In neck dys- function patients, the negative influence of thoracic kyphosis is exerted through an increase in FHP 9). Movement of the cervical and thoracic spine is bio- mechanically related, and thus thoracic mobilization can increase the range of motion of the cervical spine and reduce cervical pain 10). Recently, manual therapy has been developed and applied to the thoracic spine as a treatment for mechanical neck pain 11,12). Especially, upper thoracic spine mobilization has been shown to be more effective than upper cervical spine mobilization as measured by range of motion and neck disability index in FHP patients 13).

However, there are few data available concerning the effect of upper thoracic mobilization in stroke patients with FHP. Therefore, the purpose of this study was to examine the effect of upper thoracic mobilization on cervical alignment in stroke patients with FHP.

Effect of upper thoracic mobilization on cervical alignment in stroke patients with forward head posture: A case study

INTRODUCTION

The purpose of this study was to identify the effect of upper thoracic mobiliza- tion on cervical alignment in stroke patients with forward head posture. The subject's of this study were two stroke patients with forward head posture and a cervical curve angle (four-line Cobb's method; FLCM) less than 40°. The intervention, central posterior-anterior (PA) mobilization, was applied to the T1-T4 vertebrae (upper thoracic spine) following the Maitland concept. This mobilization was applied three times per week for four weeks. In the results, the cervical curve angle (FLCM) increased for both subject 1 and 2. However, Jochumsen method score was decreased in subject 1, while it was increased in subject 2. These results demonstrate that upper thoracic mobilization had the positive effect on the cervical curve angle but not on Jochumsen method score. These findings suggest that PA mobilization on the upper thoracic spine could correct cervical curve angle measured by FLMC in stroke patients with FHP.

Key words: Forward head posture; Upper thoracic mobilization; Cervical alignment

Sin Jun Parka, Si Eun Parkb

aGangdong College, Yeoju; bPohang University, Pohang, Republic of Korea

Received : 22 April 2018 Revised : 17 May 2018 Accepted : 28 May 2018

Address for correspondence Si Eun Park, PT, Ph.D

Department of Physical Therapy, Pohang College: 60 Sindeok-ro, Heunghae-eup, Buk-gu, Pohang-si, Republic of Korea Tel: 82-10-3930-2361

E-mail: si-yaa@hanmail.net

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Effect of Upper Thoracic Mobilization on Cervical Alignment in Stroke Patients with Forward Head Posture: A Case Study

The subject’s of this study were two stroke patients with FHP. The subjects were selected from patients at the Paramil Hospital (Anseong, South Korea). The following inclusion criteria were applied: subject should have a cervical curve angle (four-line Cobb’s method; FLCM) less than 40°, and primary complaint of neck pain (posterior part of cervical spine). In this study, pain score assessed using a visual analogue scale (VAS).

The subject agreed to participate in the study after receiving explanations, and the study protocol was approved by the local ethics committee of Yongin University.

Subject 1 was a 62-year-old female who had been diagnosed with a stroke in August 2016. The patient’s cervical curve angle was 33.4°. She was 175 cm in height and weighted 90 kg. The subject was experi- encing neck pain and stiffness. The VAS score of the subject was 7.5.

Subject 2 was a 58-year-old female who had been diagnosed with a stroke in February 2017. The patient’s cervical curve angle was 36.8°. She was 158 cm in height and weighted 72 kg. The subject was experiencing thoracic pain. The VAS score of the subject was 6.

The intervention applied to the subjects was central posterior-anterior (PA) mobilization of T1-T4 verte- brae (upper thoracic spine) following the Maitland concept 14). The treatment was performed with the subjects in the prone position. The mobilization applied to improve the upper thoracic extension. The palm of therapist was placed on the vertebral spinous process of target segment (T1-T4). The upper tho- racic mobilization was applied three times per week for four weeks.

We evaluated cervical alignment by measuring the cervical curve angle (FLCM) and via the Jochumsen method (JM) 15). The angle measurement used the lateral view of a cervical spine X-ray. The cervical curve angle (FLCM) was measured by drawing two lines on the film, the first line connecting the anterior and posterior tubercles of the atlas, and the second line drawn under the 7th cervical vertebra.

Perpendicular lines were then drawn from each of these two lines, and the angle where the perpendicu- lar lines intersected was measured as the cervical

curve angle. The JM used lines drawn from the front of the anterior arch of C1 to the vertebral body of C7.

The distances between this line and the front of the vertebral body of C5 were then measured 15). Measurements were taken prior to the beginning of treatment and after completion of the intervention (4 weeks).

Measurements of cervical curve angle (FLCM) and the Jochumsen method (JM) were measured to quan- tify the cervical alignment. In the case of subject 1, the FLCM angle increased from 33.4° to 39.1°. The subject’s JM score decreased from 1 mm to 0 mm (Fig. 1). In the case of subject 2, both the FLCM angle and the JM score were increased. The FLCM angle increased from 36.8° to 39.6°, and the JM score increased from -1 mm to 0 mm (Fig. 2).

SUBJECTS AND METHODS

Subjects

Intervention Methods

RESULTS

Fig. 1. Lateral view of the cervical spine in subject 1

(left: pre, right: post)

JM: Jochumsen method; FLCM: four-line Cobb’s method

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S.J. Park, S.E. Park

FHP in stroke patients is often related to neck and upper extremity function, and thus postural control intervention of FHP should be considered in rehabili- tation programs 5). FHP is often described as an excessive anterior position of the head in relation to a vertical line and rounded shoulders with thoracic kyphosis 16). This study investigated the effect of cen- tral PA mobilization of the upper thoracic vertebrae in stroke patients with FHP. The cervical curve angle (FLCM) increased in both subjects after intervention.

In subject 1, the angle increased by 5.7° (from 33.4° to 39.1°), and in subject 2 the angle increased by 2.8°

(36.8° to 39.6°). The normal mean value of the cervi- cal curve angle is 40° 15). In this study, the cervical curve angles of the subjects were close to 40° after intervention. This suggests that the upper thoracic mobilization had a positive effect on the cervical

curve angle. The combination of upper thoracic mobilization and mobility exercise produced better overall outcomes in CVA treatment compared with upper cervical mobilization and stabilization exercise in FHP patients 13). This was consistent with the results of the present study in that upper thoracic mobilization had a positive effect on the cervical alignment of FHP patients. Subjects 1 and 2 differed in their JM scores; in subject 1 the score decreased by 1 mm (from 1 mm to 0 mm), while in subject 2 the score increased by 1 mm (from -1 mm to 0 mm). The normal mean value of the JM score ranges from 3–8 mm; 1–2 mm indicates hypolordosis, and 1–3 mm indicates cervical straightening 15). Both subjects in the present study would be classified as experiencing cervical straightening. After intervention, the JM scores were relatively unchanged, with both scores in the range indicating cervical straightening. This sug- gests that further intervention should be applied to improve the cervical alignment in stroke patients with FHP.

The main limitation of this study is the small sample size; thus, it is difficult to generalize our results.

Previous studies have demonstrated that FHP in stroke patients is related to upper extremity function of the unaffected side 5). Therefore, future studies should be conducted using more subjects, and effort should be made to identify the effects on upper extremity function in stroke patients with FHP.

However, few studies have been done using stroke patients with FHP. Therefore, our results are mean- ingful in that we considered cervical alignment of stroke patients with FHP.

This study investigated the effect of central PA mobilization of the upper thoracic vertebrae in stroke patients with FHP. The subjects were two stroke patients and a cervical curve angle less than 40°. The results revealed that cervical curve angle increased for both subject 1 and 2. Cervical curve angle increased for both subject 1 and 2. In Jochumsen method score, subject 1 has decreased, but subject 2 has increase. These results demonstrate that upper thoracic mobilization had positive effect on the cervi- cal curve angle but not on Jochumsen method score.

Thus, this study suggests to applying various inter- ventions with upper thoracic mobilization in stroke patients with FHP.

Fig. 2. Lateral view of the cervical spine in subject 2

(left: pre, right: post)

JM: Jochumsen method; FLCM: four-line Cobb’s method

DISCUSSION

CONCLUSION

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Effect of Upper Thoracic Mobilization on Cervical Alignment in Stroke Patients with Forward Head Posture: A Case Study

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Ryerson S, Levit K. Functional movement reedu- cation: a contemporary model for stroke rehabili- tation, New York: Churchill Livingstone, 1997.

Page P, Frank CC, Lardner R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Illinois. Human Kinetics, 2010: 53-56.

Lim HC, Kong SW, Jung YW, et al. The effect of forward head posture on upper extremity func- tion, pain, depression in patients with stroke. The Korean Entertainment Industry Association 2016:

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