Journal of Bodywork & Movement Therapies (2014) 18, 608e615

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FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY

Fascial Manipulation
method applied to

pubescent postural hyperkyphosis: A pilot
study
FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY

 c
Vilma Cosi , PT a, Julie Ann Day, PT b,*, Pietro Iogna, PT c,
Antonio Stecco, MD d

a
Private Clinic, Center Postura, Split, Croatia
b
Ulss 16, Padova, Italy
c
Private Clinic, Udine, Italy
d
Department of Internal Medicine, University of Padua, Italy

Received 30 September 2013; received in revised form 8 December 2013; accepted 14 December 2013

KEYWORDS Summary Background: Treatment of pubescent postural hyperkyphosis commonly includes

Postural postural exercises and auto-elongation. Myofascial imbalances can be involved in functional,
hyperkyphosis; sagittal plane deviations of spinal curves. This pilot-study assesses the effects of one manual
Manual therapy; therapy approach that addresses fascial dysfunctions (Fascial Manipulation
) in pubescent sub-
Fascia; jects with postural hyperkyphosis.
Fascial Manipulation Methods: 17 subjects (mean age 11.8 DS 0.8; 9 males, 8 females) were evaluated for familiar-
ity; psychological aspects; sport; pain; anteposition of shoulders, head, and pelvis; distance C7
and L3 from plumb-line; distance fingers to floor on forward bend.
Each subject received 2e4 weekly sessions of Fascial Manipulation
. Parameters were eval-
uated before and after manual treatment, with a follow-up at 7 months.
Results: A statistically significant difference (p < 0.05) was present in all the parameters ana-
lysed before and after treatment and at a 7 month follow-up.
Conclusions: Results suggest that Fascial Manipulation
could represent an approach to inte-
grate into treatment of postural hyperkyphosis in pubescent subjects.
ª 2013 Elsevier Ltd. All rights reserved.

* Corresponding author. Centro Socio Sanitario dei Colli, Physiotherapy, Ulss 16, Via dei Colli 4, Padova, Italy. Tel.: þ39 (0) 498216032; fax:
þ39 (0) 498216045.
E-mail address: lavitava@gmail.com (J.A. Day).

1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.12.011
Fascial Manipulation
treatment of pubescent postural hyperkyphosis
Introduction
Sagittal spinal deformity can be defined as pathological
deviations of the posterior (kyphosis) or anterior (lordosis)
physiological curve of the spine on the sagittal plane due to
structural alterations of discs, ligaments, and bony struc-
tures as well as myofascial tensional imbalances. Deviations
can present as either excessive (thoracic hyperkyphosis or
curved back, lumbar hyperlordosis), reduced (flat back,
concave back, hypolordosis, lumbar kyphosis) or altered in
their normal distribution (lumbar kyphosis, cervico-dorsal
kyphosis) and may have various aetiologies (Shelton, 2007).
It is necessary to distinguish between structured curves and
correctable functional curves in pubescent subjects, even
though correctable curves (curved back, postural hyper-
kyphosis, postural lumbar hyperlordosis) can potentially
evolve in terms of stiffness and structural changes. In
adults, hyperkyphosis is mostly structural and cannot be
completely reversed.
In reference to the Cobb angle measured on X-rays taken
in standing, normal kyphosis in the developing age and in
adolescence can be between 20 and 45 . The condition
described as ‘flat-back’ is applied for angles less than 20
whereas ‘thoracic hyperkyphosis’ (THK) is applied for an-
gles more than 45 . Only 2% of subjects with this type of
deformity require orthopaedic and/or physiotherapy
treatment (Dimeglio et al., 1995).
The postural curved back consists of THK generally
accompanied by pronounced lumbar lordosis, however
inversion of the lumbar lordosis can also occur.
Some authors affirm that THK can be painful (Bernstein
and Cozen, 2007) and that it is more frequent in adoles-
cence and in males (Poussa et al., 2005).
Aetiology of thoracic hyperkyphosis
The aetiology of THK can be attributed to a variety of
causes including perceptive, postural, sports, trauma,
psychological aspects, post-surgical and genetic factors.
Scheuermann’s disease is one of the more common
causes of hyperkyphosis, with a reported incidence of 18%
in the general population (Lowe, 1990). This disease is
characterised by reduced growth of the anterior portion of
the vertebral body due to alterations in the cartilaginous
end plates (a form of osteochondritis) that inhibit bone
growth via mechanical factors and cause anterior vertebral
body wedging (Aufdermaur and Spycher, 1986; Digiovanni
et al., 1989). In subjects with Scheuermann’s kyphosis,
three or more vertebrae, generally located in the middle of
the thoracic segment, present anterior wedging with an
anterior cuneiform deformation greater than 5 (Sorensen,
1964).
Nevertheless, structural deformation of the vertebrae or
the intervertebral joints is not the cause for the increase in
the dorsal curve in the majority of cases of postural THK.
Altered dynamics in the thorax that involve the intercostal,
intrinsic thoracic, thoracolumbar, abdominal and long dor-
sal muscles can produce changes in the relationship be-
tween tension along the length of the curve favouring the
anterior muscle groups, which are already stronger and
shorter (Wojtys et al., 2000). These tensional changes may
609
interfere with the activation of the longer and weaker
posterior muscles. Consequently, this vicious circle not only
maintains the spinal deviation, it also involves segments
adjacent to the thorax (cervical, lumbar) by altering the
neutral position and the functional dynamics, resulting in
forward head, rounded shoulders and an increase in the
lumbar lordosis. While various aetiological factors exist,
one study of the hip and pelvic regions in 629 children with
idiopathic scoliosis (including THK) highlighted contractures
or shortening, particularly in the region of right hip, of the
iliotibial tract, fascia lata, joint capsule, fasciae of gluteus
medius and minimus, sartorius, and rectus femoris muscles
(Karski, 2002) as important biomechanical components.
The spine and pelvis are functionally interdependent and,
in normal subjects, their relationships result in a stable and
compensated posture, presumably to minimize energy
expenditure (Mac-Thiong et al., 2007) and as adaptation in
FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY
the presence of pathology (Roussouly and Pinheiro-Franco,
2011). Therefore, any shortening or rigidity of the myo-
fascial components in the neck, trunk and pelvis needs to
be addressed in postural THK. Rib articulations, vertebral
positions and myofascial elements are all interconnected
with the elastic expansion of the thorax on the three spatial
planes, which is essential for normal breathing (Chaitow
et al., 2002), should also be considered.
Traditional treatment
The more common reasons to treat THK include the
aesthetic appearance of the dorsal curve, back pain,
quality of life, progression into adulthood and psychological
well-being (de Mauroy et al., 2010), as well as prevention of
shoulder (Gumina et al., 2008), neck and back pain in later
years.
According to Negrini et al. (2005), treatment of THK
should aim to:
- correct or limit progression of the curve and the
vertebral changes
- improve biomechanical efficiency of vertebral column
support mechanisms
- improve neuromotor control
- improve the aesthetic aspect
- limit psychological stress
- and, where necessary, reduce pain.
Treatment is generally based on the degree of Cobb
angle, whether the curve is correctable and the presence of
pain, and ranges from therapeutic exercises for totally
correctable curves, bracing for partially correctable curves
to surgery if results from conservative treatment are un-
satisfactory (Negrini et al., 2008).
One review of rehabilitation and conservative ortho-
paedic approaches (Zaina et al., 2009) suggests that exer-
cise programmes should always include:
B patient awareness of spinal alignment
B patient awareness of neutral and correct position of
the vertebral column
B mobilisation of the thoracic cage
B muscular reinforcement and neuromotor integration
 610
B awareness of an ergonomic position for work and study.
Despite these recommendations, another recent sys-
tematic review of the efficacy of specific exercises for
adolescent idiopathic scoliosis (Romano et al., 2013) in-
dicates that there is actually a lack of strong evidence for
specific exercises and that higher quality research in this
field is required.
Manual therapy treatment
The use of manual therapies in the treatment of adolescent
idiopathic spinal curvature is relatively common. One sys-
tematic review of evidence regarding the efficacy of
manual therapy as a conservative treatment for such cases
(Romano and Negrini, 2008) found 145 articles, including
several case reports, concerning manipulative and passive
FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY
techniques performed by an external operator. However,
the authors state that the lack of any serious scientific data
precludes conclusions about efficacy.
Recent studies have demonstrated involvement of con-
nective tissue structures in the aetiology of low back pain
(Langevin et al., 2009), yet there is little research regarding
the possible role of muscular fascia in idiopathic scoliosis or
postural hyperkyphosis. One case-study (LeBauer et al.,
2008) has examined the effects of a manual therapy tech-
nique (myofascial release) on an adult with idiopathic
scoliosis but similar studies on pubescent or adolescent
subjects are lacking. It has been suggested that pectoral
fascia dysfunctions could potentially cause tensional
changes in the upper limbs (Stecco et al., 2009a,b) and that
changes in the thoracolumbar fascia, gluteus maximus
fascia and fascia lata can affect the lower limbs (Stecco
et al., 2013b).
The efficacy of manual therapies in pubescent postural
hyperkyphosis is yet to be demonstrated.
This pilot study explores the feasibility of applying one
manual therapy approach, known as Fascial Manipulation
,
as a potential adjunct to therapeutic exercises in pubes-
cent non-structural THK. This manual method proposes to
reduce movement limitations by applying manual friction to
deep muscular fascia restrictions in specific areas to
improve range of movement, muscle recruitment and
reduce pain. It was hypothesised that by improving move-
ment and muscle recruitment these subjects would be able
to adopt and maintain correct postural positions more
easily.
Materials and methods
Non-structural postural thoracic hyperkyphosis in pubes-
cent children constituted inclusion criterion.
Subjects with non-structural postural thoracic hyper-
kyphosis were recruited during a Croatian primary school
medical screening programme involving 6th and 7th year
classes. Written permission to include their children in this
pilot study was obtained from parents of 17 subjects (9
males and 8 females, mean age 11.8; DS 0.8) and partici-
pation was on a purely voluntary basis. Parents and subjects
were informed about every single treatment modality and
the modes of evaluation.
 
V. Cosi c et al.
Subjects with spinal deviations on planes other than the
sagittal plane, vertebral lesions and/or neurological signs
and subjects who had previously undergone any spinal
correction surgery constituted exclusion criteria.
All subjects were evaluated according to the Italian So-
ciety of Physical Medicine and Rehabilitation (S.I.M.F.E.R)
guidelines (Negrini et al., 2005). History taking recorded
familiarity, any sport practised by subjects, pain, psycho-
logical introversion and time evolved since diagnosis. Static
postural analysis included evaluation of rounded shoulders,
forward head, and anteversion of the pelvis or anterior
pelvic tilt (Table 1).
All subjects were then evaluated in the standing position
and were instructed to maintain straight legs and a habitual
posture. Measurements included:
 distance of C7 spinous process from plumb-line placed
on the axis of the column (extremity located at the
apex of the sacral cleft (S2) with the hand holding the
plumb-line close to the occiput, and the line at a
tangent to the apex of the kyphosis in T7)
 distance of L3 spinous process from plumb-line
 distance from fingertips to ground on maximum anterior
flexion of the trunk.
Each subject then received 2e4 sessions of Fascial
Manipulation
once a week.
At the end of the treatment cycle, the same parameters
were re-evaluated in all subjects and a follow-up was car-
ried out at 7 months. Subjects were not involved in any
specific exercise programmes for the duration of treatment
and in the period between the end of treatment and the
follow-up.
One physiotherapist (P. I.) performed assessments pre
and post treatment and at follow-up, while another phys-
iotherapist (V.C.) performed the treatment.
Data was analysed using SPSS 15.0, a software package
for statistical analysis.
Manual treatment method
In this study, the manual method known as Fascial Manip-
ulation
(Stecco, 2004) was applied to each subject by the
same therapist (V.C) once a week for 2e4 sessions (mean
number of sessions 2.94).
In-depth analysis of this method has been presented in a
previous paper (Day et al., 2012). In brief, following an
Table 1 History and general parameters.
Number of subjects (total 17)
Familiarity 1
Psychological introversion 5
Sport 11
Pain 11 Cervical; 1 Lumbar;
1 Dorsal
Time elapsed from diagnosis 16 <1 year; 1 >1 year
Rounded shoulders 15
Forward head 16
Anterior pelvic tilt 10
Fascial Manipulation
treatment of pubescent postural hyperkyphosis
initial evaluation, including location of pain and limitation
of movement within body segments on the three spatial
planes, the aim is to identify the exact body segments and
planes of movement involved in any given dysfunction. In
this study, movements of the neck, thorax, lumbar and
pelvic regions were examined in all subjects. In some sub-
jects with concomitant lower limb dysfunctions, lower limb
movements were also examined.
Having recorded movement limitations, the therapist
selected the most implicated segments and, according to
Fascial Manipulation
protocol (Stecco and Stecco, 2009),
proceeded with a comparative palpatory assessment of
specific areas of the deep fascia called Centres of Coordi-
nation (CC). During palpatory assessment, the therapist
noted relative values of pain, lack of sliding in the tissues
and the presence of any referred pain. A combination of
altered CCs was then chosen in each individual case and the
treatment involved a deep manual friction of these CCs.
According to the anatomical location of the targeted
muscular fascia, the therapist used knuckles and/or elbows
to apply deep compression and friction to these areas.
Treatment of CCs has previously been seen to have an
average duration of 3.24 min (Ercole et al., 2010). Within
this average period, a 50% reduction of initial pain or
discomfort caused by manual pressure over altered tissue
has been noted to coincide with a palpable change in tissue
quality. The aim of the manipulation in the area of each
altered CC is to restore sliding between the multi-strata
collagen fibre layers of the deep muscular fascia (see
Discussion).
In each subject, treatment principally involved manip-
ulation of the deep muscular fascia on the circumference of
the trunk, without working directly on the spinal column or
the intervertebral discs (Fig. 1).
The subjects in this study were manipulated in a com-
bination of CCs located in the neck, thorax, and lumbar
regions as well as the pelvic and scapular girdles and, in
some subjects, in the lower limbs.
Results
Familiarity was reported only in one case; 58.8% of subjects
practised some form of sport (volleyball, soccer or swim-
ming); 29.4% reported some degree of psychological intro-
version and 94.1% had been diagnosed one year before,
whereas only one subject had been diagnosed more than a
year before.
Static postural analysis of the 17 subjects evidenced that
88.2% of subjects presented rounded shoulders and 94.1% a
forward head position. 58.9% of subjects presented anterior
pelvic tilt. Pain was reported in the cervical (64.7%), lum-
bar (0.06%) and thoracic regions (0.06%), while 23.5% of
subjects reported they did not have any pain.
The mean values of the plumb-line measurements prior
to treatment were:
 distance of C7 spinous process from plumb-line
5.11 cm þ/ 0.67
 distance of L3 spinous process from plumb-line
4.92 cm þ/ 1.03
 distance from fingertips to ground (maximum anterior
trunk flexion) 4.11 cm þ/ 5.87
611
The plumb-line measurements (see Fig. 2) and the dis-
tance of fingertips to ground were the only measurements
analysed statistically at the end of the treatment sessions
and at the follow-up. Pre and post treatment static postural
photographs were also taken (see Fig. 3).
The mean values of the plumb-line measurements
immediately after treatment were:
 distance of C7 spinous process from plumb-line
3.98 cm þ/ 0.51
 distance of L3 spinous process from plumb-line
4.05 cm þ/ 0.35
 distance from fingertips to ground (anterior trunk
flexion) 2.91 cm þ/ 3.16
Pre and post-treatment differences were analysed sta-
tistically using the paired t-test (SPSS Statistics 15.0) with
FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY
the following results:
- difference pre-post C7 1.12 cm, p < 0.0001
- difference pre-post L3 0.87 cm, p Z 0.0003
- difference pre post fingertips to ground 1.70 cm,
p Z 0.027
The differences between the pre-treatment measure-
ments and measurements at a 7-month follow-up were
analysed statistically using paired t-test (SPSS Statistics
15.0) with the following results:
- Difference pre-treatment e 7 month C7 1.20 cm,
p < 0.0001 (see Graph 1)
- Difference pre-treatment e 7 month L3 1.07 cm,
p Z 0.0047 (see Graph 2)
- Difference pre-treatment e 7 month fingertips to
ground 2.52 cm, p Z 0.0058 (see Graph 3)
Discussion
All parameters showed statistically significant improve-
ments (p < 0.05) in both the immediate post-treatment
evaluation and the 7 month follow-up.
However, several limitations of this pilot study do need to
be addressed in future studies. These include a more accurate
method of measurement of pre and post treatment variations.
The use of a pocket compass needle goniometer (Gravina
et al., 2012) could be advisable. The inclusion of a control
group is another essential element in order to validate these
preliminary results. For example, in a future study, similar
parameters could be measured in a group of children with
postural hyperkyphosis that did not receive any treatment
during the period of the treatment phase (1 month). Alterna-
tively, a number of Fascial Manipulation
treatments could be
added as treatment to one part of a homogeneous group of
children undergoing a therapeutic exercise programme.
Mean values at the 7-month follow-up showed a further
improvement as compared with post-treatment evaluation.
In only 5 out of 17 cases there was a small regression in the
distance from C7 to the plumb-line at the 7-month follow
up with respect to post treatment evaluation.
These results could be attributed to the following
particular characteristics of deep muscular fascia:
 612  
V. Cosi c et al.
FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY

Figure 1 Schematic illustration of location of altered CCs identified and treated in two sessions in one 11-year-old male subject
with postural THK. Black dots (over deep fascia of the sternocleidomastoid, erector spinae and psoas muscles) represent CCs
treated in first session. White dots (over deep fascia of pectoralis major and iliacus muscles and the origin of quadratus lumborum
from the iliolumbar ligament) represent CCs treated after one week.

 Anatomical continuity of deep fascia: anterior conti-
nuity of deep fascia on a sagittal plane can be traced
from the tibialis anterior fascia to the quadriceps,
which continues with the fascia lata to the ileopsoas
fascia that continues upwards over the fascia of the
iliacus and psoas minor muscles. Together with the
inferior rectus abdominis, which is surrounded by the
lateral raphe, the iliacus and its fascia is involved in
antiversion of the pelvis. Posteriorly, the abdominal
muscles join with the middle and posterior layers of the
thoracolumbar fascia. Proximally, the thoracolumbar
fascia connects with the latissimus dorsi and the erec-
tor spinae muscles while distally the sacrotuberous
ligament provides continuity between the thor-
acolumbar fascia and the deep fascia of the hamstring
muscles. Anteriorly, the abdominal fascia continues
with the fascia of the pectoralis muscles, and proxi-
mally with the fascia of the sternocleidomastoid
muscles.

Functional muscular control requires healthy fascia that

is capable of sliding and tensing appropriately in response
to muscular contraction to allow for a continuous interplay
between myofascial components for dynamic postural
control and flexibility of joints. Any stiffness within the
deep fascia due to incorrect postural habits, muscular im-
balances or trauma could interfere with normal mechanical
function and proprioception (Stecco et al., 2011).

 Innervation: different studies have demonstrated that

Figure 2 Plumb-line measurements. deep muscular fascia is well-innervated (Stecco et al.,
Fascial Manipulation
treatment of pubescent postural hyperkyphosis 613

FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY

Figure 3 Static postural photographs.

2007; Benetazzo et al., 2011) and has a partial elas-

ticity due to its undulating collagen fibre bundles and
elastic fibres (Stecco et al., 2006), characteristics
which allow for its involvement in the perception and
Graph 2 Difference pre-treatment e 7 month L3 1.07 cm,
p Z 0.0047.

coordination of movement. The nerves that pass

 Viscoelasticity: lack of sliding or stiffness of deep fascia
Graph 1 Difference pre-treatment e 7 month C7 1.20 cm,
p < 0.0001.
through the deep fascia are surrounded by loose con-
nective tissue and are therefore subject to traction
when the fascia is stretched but, at the same time,
they are protected. Whenever nerves terminate in re-
ceptors (for example, free nerve endings) there is a
direct insertion onto the surrounding collagenic fibres.
The arrangement of numerous free nerve endings and
encapsulated receptors within fascial tissue could
ensure the activation of specific patterns of receptors
and potentially provide spatial and directional infor-
mation. Any lack of physiological sliding between
collagen fibre layers could alter receptor activity,
contributing to changes in movement patterns and
proprioception.
is apparently due to changes in the ground substance of
the loose connective tissue layer lying between the
collagen fibre layers of the deep fascia (Stecco et al.,
2013a). Recent studies (Stecco et al., 2013c) have
shown that increased thickness of fascial tissues can be
considered as an indicator of involvement of these tis-
sues in myofascial pain syndromes and that, in partic-
ular, the loose connective tissue layers within deep
muscular fasciae may have a significant role in the
pathogenesis. Variations of thickness of the deep
muscular fascia were correlated with the increase in
 614
Graph 3 Difference pre-treatment e 7 month fingertips to ground 2.52 cm, p Z 0.0058.
FASCIA SCIENCE AND CLINICAL APPLICATIONS: PILOT STUDY
quantity of the loose connective tissue between
collagen fibre layers and not of the collagen fibre layers
themselves. The hyaluronic acid (HA) component of the
loose connective tissue layers appears to play a key role
in lack of sliding within fascial tissues (Chaudhry et al.,
2013). Fluid pressure of HA increases dramatically as
fascia is deformed during manual therapies potentially
improving sliding between intra-fascial collagen layers,
which could allow muscles to work more efficiently.
Therefore, lack of sliding in fascial tissues is not an
irremediable or permanent condition and manipulation
of specific areas can restore physiological characteris-
tics to these tissues.
The subjects in this study all had specific areas of
palpable fascial stiffness, often located at a distance from
the kyphotic thoracic curve. The authors hypothesise that
by restoring fascial gliding in these specific areas subjects’
post-treatment ability to adopt and maintain correct
postural positions was facilitated.
In terms of clinical implications for postural hyper-
kyphosis, therapeutic exercises could be introduced once
any fascial dysfunctions have been addressed, allowing for
more effective postural correction, auto-elongation and
muscular reinforcement.
Conclusion
This pilot study aims at assessing the feasibility of one manual
therapy method (Fascial Manipulation
) in pubescent postural
hyperkyphosis as a possible adjunct to traditional rehabilita-
tion for this condition. Given the results obtained from a
relatively brief period of treatment (one month) and their
overall maintenance at a 7-month follow-up, the association
of this type of manual therapy together with therapeutic ex-
ercises and clinical monitoring may represent a cost-effective
approach for this condition. This pilot study could lay the
groundwork for a more complete research study in the future.
Ethical standards
This pilot study was performed in accordance with ethical
standards on human experimentation and with the Helsinki
 
V. Cosi c et al.
Declaration of 1975, as revised in 1983. The investigation
and use of patient data for research purposes were in
accordance with the Declaration of the World Medical As-
sociation. Written informed consent was obtained as
required. The studies follow Good Clinical Practice. An
ethics statement was not needed because non-invasive
conventional treatments were used. Patients were
informed about every single treatment modality and the
modes of evaluation.
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