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Onset significantly earlier during descent compared with

3.3. The effect of thoracic kyphosis on shoulder pain
Six studies (Lewis et al., 2005a; McClure et al., 2006; Otoshi et al., 2014; Theisen et al., 2010 ; Greenfield et al., 1995; Lewis and Valentine, 2010) compared resting thoracic kyphosis in groups with and without shoulder pain. Values for these are shown in Table 5. In comparing a group with SIS to those without shoulder pain, Lewis and colleagues reported that there were no significant differences in resting standing thoracic kyphosis (Lewis et al., 2005a). While this Torin 1 study did not meet adequate statistical power and was rated at a moderate risk of bias, a later study by the same research group was at low risk of bias and reported no significant differences in resting standing thoracic kyphosis between groups with and without shoulder pain (Lewis and Valentine, 2010). Similarly, two further studies which compared a group with SIS to an age- and gender-matched control group reported no significant difference in resting thoracic posture (McClure et al., 2006 ; Theisen et al., 2010). However, these were considered to be at a moderate (McClure et al., 2006) and high (Theisen et al., 2010) risk of bias. A study with a high risk of bias which compared thoracic kyphosis in a group of people with mixed shoulder diagnoses to a pain-free control group demonstrated no significant difference between groups (Greenfield et al., 1995).
  Comparison of thoracic kyphosis and shoulder ROM in groups with and without impingement.
  StudyMean (SD) thoracic kyphosis (Pain group)Mean (SD) thoracic kyphosis (control group)p valueShoulder ROM (impingement group)Shoulder ROM (control group)p value
  ROM = range of motion, SD = standard deviation, SIS = subacromial impingement syndrome, WOT = wall-occiput test, RSE = restricted shoulder elevation, IR = internal rotation, ER = external rotation.
  Table options
3.4. The effect of changing thoracic kyphosis on shoulder function
No studies were found that investigated the effect of changing thoracic kyphosis on the outcome of shoulder function.
3.5. The effect of changing thoracic kyphosis on shoulder ROM
Two studies, of low (Kanlayanaphotporn, 2014) and moderate (Kebaetse et al., 1999) risk of bias, reported that erect postures increased shoulder ROM when compared to a slouched posture in pain-free participants. One of these compared three different sitting postures (erect, comfortable slouched and maximum slouched) and found that reduced thoracic kyphosis significantly improved shoulder flexion, abduction and external rotation (Kanlayanaphotporn, 2014). Conversely, mean shoulder internal rotation ROM increased by approximately 20% from the erect to maximum slouched posture. Kebaetse and colleagues also reported significantly more maximum active shoulder abduction ROM in an erect posture compared to a slouched posture (Kebaetse et al., 1999). A further study of low risk of bias reported similar findings people with SAPS, demonstrating a statistically significant improvement in mean angle of shoulder flexion in an erect posture in comparison to a slouched posture in people with SAPS (Bullock et al., 2005). Additionally, Amber codon study recorded pain intensity during shoulder flexion in both postures. The mean pain intensity on a 100 mm visual analogue scale (VAS) was reported as 38.89 when sitting slouched and 34.39 when sitting erect (mean difference = 4.50 ± 17.93 mm), indicating no statistically significant difference in pain intensity between image postures (Bullock et al., 2005). One study of low risk of bias reported that, in people with SIS, significantly greater shoulder ROM to the point of onset or worsening of shoulder pain was achieved following scapular and thoracic taping aimed at thoracic extension compared to normal resting posture (p < 0.001) (Lewis et al., 2005b). However, no significant differences were found on VAS pain rating for shoulder flexion (p = 0.14) or scapular plane abduction (p = 0.11) between postures. In the group who did not have shoulder pain, thoracic extension using taping significantly increased maximum shoulder ROM compared t
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