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pain. It is important to note that rigidity of the thoracic spine also impacts the cervical spine by similarly requiring it to increase its range of motion to compensate for the rigid hypomobile thoracic spine. This places increased stress on the musculature and joints of the cervical spine, resulting in further pain and dysfunction there as well. ASSESSMENT OF ROUNDED BACK Assessment of a rounded-back posture is straightforward. Simply observe the client from the side and assess the degree of the thoracic kyphotic curve. This should be followed by palpation of the pectoral musculature, as well as palpation of the extensor musculature of the thoracic spine and retractor musculature of the shoulder girdle. Because chronic rounded-back posture results in rigidity of the spine being stuck in fl exion, gentle but fi rm palpation of the thoracic spinal joints should be done by challenging these joints to move into extension. This is accomplished by pressing (gently but fi rmly) directly midline on the thoracic spine of the prone client with the palm of the hand; placing the spinous processes in the intereminential groove (the groove between the thenar and hypothenar eminences); and feeling for the end-feel motion of the joints (Image 7). A healthy joint has a fi rm but slightly elastic springy bounce at end-feel. If, instead, the end-feel is rigid (like hitting a concrete wall), then the joints being assessed are locked/hypomobile, likely due to intrinsic muscular spasming and fascial adhesions. Because thoracic rigidity can cause dysfunctional compensations elsewhere, if thoracic hypomobility is identifi ed, it is important to then assess for all of the possible related conditions. TREATMENT OF ROUNDED BACK All effective clinical orthopedic manual therapy treatment should be directed at the fundamental underlying biomechanical and neurologic mechanisms causing the rounded-back condition. With thoracic rounded back, the underlying mechanism is a chronic hyperfl exed posture of the thoracic spine that then creates locked-short pectoral musculature anteriorly, locked- long thoracic musculature posteriorly, and hypomobile thoracic joints. Treating the Myofascial Tissue Treatment of myofascial tissue should be directed toward loosening the anterior musculature, and loosening and strengthening the posterior musculature. Therefore, the target muscles to which treatment must be directed are the pectoral muscles anteriorly (pectoralis major, pectoralis minor, and the subclavius), and the posterior muscles of thoracic spinal extension (erector spinae and transversospinalis), shoulder girdle retraction (rhomboids and trapezius, especially middle trapezius), and humeral medial rotation (subscapularis, teres major, latissimus dorsi, anterior deltoid, and pectoralis major). There is no one magical soft-tissue technique for loosening musculature, but a general approach is to use moist heat, followed by deep- tissue massage and then stretching. If it is within your scope of practice, it is important to recommend to the client to strengthen the musculature of thoracic extension, shoulder girdle retraction, and humeral lateral rotation. Treating the Thoracic Joints All of this wonderful myofascial work will be ineffective if the client's thoracic spinal joints are rigid and stuck in fl exion. For these clients, it is imperative that Grade IV joint mobilization is performed, especially directed toward extension.* Grade IV joint mobilization involves repeated gentle but fi rm oscillations directed toward moving the joint into the ranges of motion that are decreased. These oscillations are usually repeated for approximately 15–30 seconds. For extension joint mobilization, the therapist simply directs the force from posterior to anterior midline on the spine of the prone client. In other words, it is performed in an identical manner to the motion palpation assessment technique (Image 7). If this treatment technique is not within your scope of practice, then the client should be referred to a soft-tissue-oriented chiropractor or osteopath for adjunctive care. Note: be aware that joint mobilization is contraindicated if the client has any hypermobility/instability of tissue locally where the treatment is being rendered (for example, osteoporosis/osteopenia). Self-Care Recommendations Following in-offi ce treatment, home care consists of a hot shower (or other form of moist heat) followed by foam rolling or 80 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 6 Motion palpation assessment of the thoracic spine into extension. Reproduced with permission from Joseph E. Muscolino. * Grade IV joint mobilization is legal and ethical for most massage therapists in the United States and Canada. To be sure that this technique is within your scope of practice, please check with your state licensing body. It should be emphasized that Grade IV joint mobilization does not involve a fast thrust.