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C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 81 working with therapeutic balls to address the myofascial tissue. Stretching after moist heat application is also extremely valuable. One easy and excellent way to stretch the thoracic spine into extension is to use a gym ball (Image 8). Strengthening exercises for spinal extension, shoulder girdle retraction, and glenohumeral lateral rotation should also be done on a regular basis. Addressing Posture Finally, given that the root cause of thoracic spinal hyperkyphosis is chronically assuming a rounded-forward posture into flexion, it is imperative that the client begins to make lifestyle changes that eliminate these postures. For this reason, it is important to counsel the client about a wide range of postures, especially when using a desktop, laptop, tablet, or smartphone; postures when writing or reading a book; postures when driving; and any other posture that might involve working down in front of the body. Treating the Sequelae Given that a rounded thoracic postural distortion pattern can spin off and create other secondary problems, it is important to not only assess for these secondary conditions, but to also treat them as needed. Often, when the initial primary cause of a secondary condition is removed, the secondary condition resolves on its own without needed treatment. However, when the secondary condition is allowed to be present for a long period of time (months, years, or even decades), it becomes entrenched in the body. In these cases, it is usually not enough to simply remove the initial cause; rather, the secondary conditions must be individually targeted and treated. MOTIVATIONS FOR TREATMENT The two most common signs and symptoms that direct a client toward seeking manual therapy treatment are pain and stiffness. Pain usually indicates that tissue damage is occurring and is probably the primary reason clients seek manual therapy. Stiffness (loss of range of motion), which usually indicates taut soft tissues, is far less powerful toward compelling a client to seek care. Decreased range of motion is often ignored or not even noticed, especially when it occurs in small increments over long periods of time. This, unfortunately, is the circumstance with rounded-back posture. Because the progressively greater thoracic kyphosis occurs so insidiously—often over months, years, or even decades—the client pays little or no attention to it. Even becoming self-aware of the distortional posture is not that noticeable to the client, because looking in the mirror affords the client an anterior view, which does not show the condition well; a lateral view is usually needed to appreciate the extent of the rounded posture that is occurring. THE THORACIC SPINE AS SILENT SABOTEUR The major reason rounded-back posture does not motivate the client to seek care is that the ensuing rigidity of the thoracic spine rarely causes pain. As a result, by the time the client notices a problem, it has usually been chronic for years and decades, and is now much more firmly entrenched. By this point in time, it has set in motion the other postural distortional sequelae of the cervical spine, head, shoulder girdles, arms, and lumbar spine. It is often the pain in these other regions that initially motivates the client to seek manual therapy. While direct manual therapy at this point is needed for these other regions of the body for immediate alleviation of their symptoms, manual therapy to the asymptomatic thoracic region is crucially important for long-term relief. For example, when clients come in with neck pain, I often like to tell them that if they want their neck to feel better today, I will work the neck today; but if they want their neck to feel better six months from now, I need to work their thoracic spine. It is simply not possible for a neck to be functional and healthy if the thoracic spine is hyperkyphotic! The same concept often holds true for the shoulders or low back. For all these regions, the thoracic spine is truly a silent saboteur that must be considered and addressed when performing clinical orthopedic manual therapy care with our clients. Joseph E. Muscolino, DC, has been a massage therapy educator for more than 25 years and is the author of numerous textbooks on manual therapy, including The Muscle and Bone Palpation Manual (Elsevier, 2016), Kinesiology (Elsevier, 2011), The Muscular System Manual (Elsevier, 2017), Manual Therapy for the Low Back and Pelvis (Lippincott Williams & Wilkins, 2015), and Advanced Treatment Techniques for the Manual Therapist: Neck (Lippincott Williams & Wilkins, 2013). He teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT). Visit www.learnmuscles.com for more information. Using a gym ball to stretch and open the thoracic spine into extension. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti.