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Paper text:
chronic obstructive pulmonary disease ( copd ) is characterized by airflow limitation , and 
 its symptoms include dyspnea , cough , and sputum1 , 
 2 .
its diagnosis requires a spirometry , 
 copd may be diagnosed when the ratio of forced expiratory volume in one second over forced 
 vital capacity ( fev1/fvc )  70%1 . due to physiological deterioration ,
elderly people experience 
 weakened respiratory function , stiffness in the joints and connective tissues of the rib 
 cage , and increased thoracic kyphosis3,4,5 . 

copd leads to decreased force strength and endurance of the respiratory muscles , as well as 
 deteriorated gait ability6 ; thoracic 
 kyphosis causes severity of flexed posture , geriatric depression , muscular impairment , and 
 gait impairment in elderly people7 . 

accordingly , when an elderly person has thoracic kyphosis with copd , the consequent damages , 
 combined with signs of aging , can negatively affect the entire body .
alignment of the skeletal system in the chest , aling with chest wall compliance , are 
 related to respiratory function8 , 9 , while thoracic kyphosis and consequent 
 changes in the rib cage lead to decreased lung capacity10 .
specialized pulmonary physical therapy should be explored to 
 address the combined problems of thoracic kyphosis with copd .
earlier studies have shown 
 that joint mobilization and stretching of the thoracic spine can be very effective for 
 reducing pain and improving mobility , range of motion , posture , and respiratory 
 function11,12,13,14 . however , there are few studies that have examined the effect of 
 joint mobilization and stretching via orthopedic manual therapy on respiratory function , 
 spinal curve , and spinal movement of elderly people with thoracic kyphosis and very severe 
 copd .
this research conducted a case study of an elderly copd patient with thoracic kyphosis to 
 examine the effect of joint mobilization and stretching of the thoracic cage on respiratory 
 function , spinal curve , and spinal movement .
she is 1.56  m in height , 42  kg in 
 weight ( underweight ) with bmi of 17.25  kg / m .
she was diagnosed with unspecified 
 copd in 2001 at a division of pulmonology based on the results of her computer tomography 
 ( ct ) scan and spirometry .
her 
 thoracic curve was measured with spinal mouse(idag , swiss ) , and the results 
 confirmed thoracic kyphosis ( 50.5  0.7 ) . a spirometer ( fitmate med , italy ) was used to 
 measure her respiratory function , and the result indicated very severe copd with 
 fev1/fvc < 70% and fev1 predicted 30%1 .
she scored a 28 on the korean version of the mini - mental state 
 exam , indicating normal cognitive function15 .
she could walk alone , and had no history of surgical operations in 
 the vertebral region .
the local ethics committee of the namseoul university of cheonan , 
 south korea approved the protocol for this study ( nsu-140929 - 2 ) .
the patient went through a total of 24 sessions of 30 minute intervention three times per 
 week for eight weeks between september and november 2014 .
the intervention method included 
 joint mobilization using kaltenborn - evjenth orthopedic manual therapy ( keomt ) and evjenth 
 and hamberg stretching ( eh stretching)12,13,14 . 

all treatment was applied by a therapist who had completed a keomt spine advance course . for joint mobilization ,
thoracic segmental mobilization ( traction with extension ) and 
 specific rib mobilization ( ventral ) were applied14 .
joint mobilization was applied at the intensity of sliding grade 
 iii16without discomfort to the 
 patient  within anatomic range of the joint for 710 seconds14 .
stretching was applied to the rectus abdominalis muscle , 
 sternocleidomastoid muscles , and pectoralis major muscles .
the stretching technique began 
 with 5 seconds of isometric contraction of the muscle , followed by 23 seconds of 
 relaxation ; then , the therapist slowly moved the patient into the posture of passive 
 stretching12 , 13 , which was held for 18 seconds .
then , 5 seconds of isometric 
 contraction of the antagonist muscle was applied , followed by 10 seconds of relaxation . to examine the effect of the intervention , the patient s respiratory function , spinal 
 curve , and spinal movement were measured . to assess respiratory function ,
this device has a high level of credibility in terms of correlation coefficients and 
 intra - class coefficients for flexion and extension18 .
all measurements were done three times : before intervention , at 4 week , and at 8 week .
the patient s respiratory function did not change noticeably when measured before the 
 intervention and after 8 weeks of intervention , even though her fvc , fev1 , and 
 fev1/fvc increased slightly . as for spinal curve and movement ,
her thoracic 
 kyphosis curve decreased , whereas her lumbar lordosis curve and spinal movement gradually 
 increased as the intervention progressed . the changes between before the intervention and 

after 8 weeks of intervention were as follows : thoracic kyphosis curve 5.01.4 , lumbar 
 lordosis curve 4.52.1 , thoracic flexion 4.53.5 , thoracic extension 3.01.4 , lumbar 
 flexion 3.52.1 , and lumbar extension 2.50.7. these indicate positive changes in the 
 patient s spinal curve and movement ( table 
 1table 1.changes of respiratory function , spinal curve and spinal movementvariablepre4 weeks8 weeks8 weeks  prerespiratory functionfvc ( % predicted)57.5  3.550.5  13.458.0  1.40.5  4.9fev1 ( % predicted)24.5  2.123.5  3.525.5  0.71.0  1.4fev1/fvc ( % ) 47.5  0.752.0  5.648.0  1.40.5  0.7spinal curvethoracic ( )50.5  0.746.0  1.445.5  0.75.0  1.4lumbar ( )3.5  0.76.5  0.78.0  1.44.5  2.1spinal movementthoracic ( )flexion7.5  3.510.5  3.512.0  0.04.5  3.5extension5.0  1.46.0  1.48.0  0.03.0  1.4lumbar ( )flexion14.0  1.415.5  0.717.5  0.73.5  2.1extension6.0  0.08.5  0.78.5  0.72.5
fev1 : forced expiratory volume in 1 second , fvc : 
 forced vital capacity ) .
in this study , a case study was conducted to examine the effect of thoracic cage of joint 
 mobilization and eh stretching of the thoracic cage on respiratory function , spinal curve , 
 and spinal movement for a single copd patient with thoracic kyphosis .
the patient s 
 respiratory function ( fvc , fev1 , fev1/fvc ) did not change noticeably . 

putt et al.19 reported that application 
 of a hold - relax technique to the pectoralis major muscle of copd patients resulted in 
 increased lung capacity , which was not consistent with our research outcomes .
we view that 
 the patient s respiratory function did not change noticeably because of her advanced age , 
 thoracic kyphosis , the long duration of her disease ( over 10  years ) , and her underweight 
 condition in terms of bmi .
celedon et al.20 reported that being underweight was associated with asthma and 
 symptomatic airway hyperresponsiveness in females ; thus , her underweight status could have 
 significantly affected the outcomes of our research .
respiratory muscle strength exercise or 
 electrical stimulation is recommended , since respiratory function is related to weakenss of 
 the respiratory muscles in patients with copd21 , 
 22 .
however , our research outcomes 
 provided important information : the patient s age , bmi , duration of the disease , copd level , 
 and posture should be considered in the clinical decision making onto perform pulmonary 
 physical therapy on for copd patients .
meanwhile , positive changes were observed in the patient s spinal curve and movement as the 
 intervention progressed . between before the intervention and after 8 weeks of intervention , 
 the patient s thoracic and lumbar curves both improved in a standing posture .
also , we found 
 that joint mobilization and stretching of the thoracic cage had a positive effect on lumbar 
 curve and movement .
bautmans et al.23 found that after three 
 months of joint mobilization , the angle of the thoracic curve of an elderly female with 
 osteoporosis and thoracic kyphosis decreased from 52.52.2 to 49.12.0 , and her posture 
 improved markedly , which is consistent with the findings of our research .
as thoracic 
 kyphosis grows more severe , spine extensor muscles weaken7 ; thus , stretching and extensor muscles exercise is necessary24 . eh stretching was used in this study , 
 which involves hold - relax of the agonist muscle followed by contraction of the antagonist 
 muscle .
this stretches the flexor muscles of the front part of the trunk that had been 
 shortened due to a distorted posture ; it also strengthens extensor muscles on the back part 
 of trunk , which resulted in decreased thoracic kyphosis and increased spinal movement . 

similarly , etnyre and abraham25 compared 
 the effects of static stretching , contract - relax stretching , and 
 contract - relax - antagonist - contract stretching ; they argued that the last method was the most 
 effective for improving the range of motion of the joint .
the limitation of our research is that the case study only involved one elderly copd 
 patient with thoracic kyphosis , which makes it difficult to apply the results more 
 broadly .
although the study results showed that joint mobilization and stretching of the thoracic 
 cage had little effect on improving respiratory function of very severe copd patients with 
 thoracic kyphosis , the same intervention could be effective in improving patients spinal 
 curve and movement thus , the patient s age , bmi , duration of the disease , copd level , and 
 posture should be considered in clinical decision making on pulmonary physical therapy for 
 very severe copd patients with thoracic kyphosis .
lastly , future research could examine 
 physical therapies that improve both respiratory function and spinal curve and movement for 
 copd patients with thoracic kyphosis .
[ purpose ] the purpose of this study was to analyze the effect of joint mobilization and 
 stretching of the thoracic cage for very severe chronic obstructive pulmonary disease 
 ( copd ) on a patient with thoracic kyphosis . 
 [ subject and methods ] the subject is a 
 73-year - old female copd patient with thoracic kyphosis . 
 the intervention methods were 
 comprised of joint mobilization and stretching . the program consisted of 30 minute 
 sessions three days per week for eight weeks . 
 respiratory function , spinal curve , and 
 spinal movement ( thoracic and lumbar spine ) were measured . 
 [ results ] joint mobilization 
 and stretching did not result in noticeable changes in the respiratory function of the 
 patient ; however , positive changes were observed , including decreased thoracic kyphosis 
 curve , increased lumbar lordosis curve , and increased spinal movement . 
 [ conclusion ] the 
 results of the analysis show that the patient s age , body mass index , duration of the 
 disease , copd level , and posture should be considered in the clinical decision to perform 
 pulmonary physical therapy for patients with complicated diseases such as copd with 
 thoracic kyphosis .