title: Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review.
abstract: BACKGROUND
  Excessive thoracic kyphosis is considered a predisposing factor for shoulder pain, though there is uncertainty about the nature of the relationship between shoulder pain and thoracic spine posture. The aim of this systematic review was to investigate the relationship between thoracic kyphosis and shoulder pain, shoulder range of motion (ROM) and function.
  
  
  METHODS
  Two reviewers independently searched eight electronic databases and identified relevant studies by applying eligibility criteria. Sources of bias were assessed independently by two reviewers using a previously validated tool (Ijaz et al., 2013). Data were synthesised using a level of evidence approach (van Tulder et al., 2003).
  
  
  RESULTS
  Ten studies were included. Four studies were rated as low risk of bias, three at moderate risk of bias and three at high risk of bias. There is a moderate level of evidence of no significant difference in thoracic kyphosis between groups with and without shoulder pain. One study at high risk of bias demonstrated significantly greater thoracic kyphosis in people with shoulder pain (p < 0.05). There is a strong level of evidence that maximum shoulder ROM is greater in erect postures compared to slouched postures (p < 0.001), in people with and without shoulder pain.
  
  
  CONCLUSIONS
  Thoracic kyphosis may not be an important contributor to the development of shoulder pain. While there is evidence that reducing thoracic kyphosis facilitates greater shoulder ROM, this is based on single-session studies whose long-term clinical relevance is unclear. Higher quality research is warranted to fully explore the role of thoracic posture in shoulder pain.
authors.affiliation: Department of Clinical Therapies, University of Limerick, Ireland. Electronic address: evabarrett@live.ie.
authors.forename: Eva
authors.initials: E
authors.lastname: Barrett
authors.affiliation: Department of Clinical Therapies, University of Limerick, Ireland. Electronic address: mary.okeeffe@ul.ie.
authors.forename: Mary
authors.initials: M
authors.lastname: O'Keeffe
authors.affiliation: Department of Clinical Therapies, University of Limerick, Ireland. Electronic address: Kieran.OSullivan@ul.ie.
authors.forename: Kieran
authors.initials: K
authors.lastname: O'Sullivan
authors.affiliation: Department of Allied Health Professions and Midwifery, University of Hertfordshire, UK; Musculoskeletal Services, Central London Community Healthcare NHS Trust, London, UK; Department of Clinical Therapies, University of Limerick, Ireland. Electronic address: jeremy.lewis@LondonShoulderClinic.com.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Lewis
authors.affiliation: Department of Clinical Therapies, University of Limerick, Ireland. Electronic address: Karen.McCreesh@ul.ie.
authors.forename: Karen
authors.initials: K
authors.lastname: McCreesh
mesh_terms: D001696:Biomechanical Phenomena; D006801:Humans; D007738:Kyphosis / Q000150:complications*; D011187:Posture; D016059:Range of Motion, Articular / Q000502:physiology*; D020069:Shoulder Pain / Q000209:etiology* / Q000503:physiopathology*; D013904:Thoracic Vertebrae / Q000503:physiopathology*
keywords: Posture; Review; Shoulder; Thoracic kyphosis