Effectiveness of Thoracic Mobility Exercise Versus Manual Release Technique in Minimizing Mechanical Upper Back Pain Among Undergraduates in Sri Lanka
Phase: NA
Conditions: Upper Back Pain
Sponsor: University of Dhaka

i 
 
EFFECTIVENESS OF THORACIC MOBILITY EXERCISE VERSUS 
MANUAL RELEASE TECHNIQUE IN MINIMIZING MECHANICAL 
UPPER BACK PAIN AMONG UNDERGRADUATES IN SRI LANKA 
 
THESIS PROPOSAL  
 
Submitted by 
Vithursha Sivakumar  
Part – I, M.Sc. in Rehabilitation Science 
BHPI, CRP, Savar, Dhaka-1343 
Date : 09.10.2023 
Session: 2021-2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                                                  
 

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TABLE OF CONTENT 
1. Introduction 
Page No 
1.1 Introduction with Literature Review 
1 
1.2 Objectives 
4 
2. Design and Method 
5 
2.1 Study site 
5 
2.2 Study Population 
5 
2.3 Study Setting 
5 
2.4 Study Design 
5 
2.5 Hypothesis 
5 
2.6 Sample Size 
7 
2.7 Sampling Method 
7 
2.8 Data Collection 
7 
2.9 Data Collection tool 
7 
2.10 Ethical Considerarion 
10 
2.11 Outcome Measures 
10 
2.12 Data Analysis 
11 
2.13 Time Duration 
11 
3. Expected Outcome 
12 
4. References  
13 
5. Appendices 
15 
4.1 Consent Form 
15 
4.2 Data Collection Tool 
19 
      4.2.1 Pre Test Questionnaire 
19 
     4.2.2 Post Test Questionnaire 
24 
4.3 Treatment Protocoal 
27 
 
 
 
 
 
 

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LIST OF ABBREVIATION 
PSEQ – Pain Self Efficacy Questionnaire 
BMI – Body Mass Index 
VAS – Visual Analogue Scale 
MRC – Medical Research Council 
ROM – Range Of Motion 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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EFFECTIVENESS OF THORACIC MOBILITY EXERCISE VERSUS 
MANUAL RELEASE TECHNIQUE IN MINIMIZING MECHANICAL UPPER 
BACK PAIN AMONG UNDERGRADUATES IN SRI LANKA 
1. INTODUCTION 
1.1 INTRODUCTION WITH LITERATURE REVIEW  
Upper back refers to the region anywhere between cervical regions to thoracic region. 
Pain in this region referred as upper back pain. According to the available literature, 
there is no any clear definition for upper back pain. In some literature it often referred 
as thoracic back pain(Fouquet et al., 2015). Thoracic back pain has to consider as a 
serious issue than neck and low back pain because vital organs such as heart and lungs 
belong to its anatomical land mark. Thoracic spine mobility affects the mobility of rib 
cage, stiffness in the thoracic spine reduce the effectiveness of respiratory mechanism.  
Thoracic pain mainly occurs due poor posture and overuse injuries. Long term sitting 
with bad posture leads to the tightness chest muscles mainly pectoralis major, minor, 
subclavius and intercostals, lead to hunched position, while the muscles of the upper 
back and neck mainly trapezius, rhomboids, levator scapulae, splenius and erector 
spinae become weak (Lin et al., 2020). These imbalances can lead to tension and pain. 
Long term screening which includes smartphone and laptop usage exaggerating this 
condition among young population (Shete and Shah, 2019; Puntumetakul et al., 2022). 
In addition to that, mental health factors like academic and personal stressors and 
physical inactivity significantly influence this condition among high school or 
undergraduate students (Shan et al., 2013). Further, it was increased after the COVID-
19 pandemic (Amro et al., 2020; Leirós-Rodríguez et al., 2020; Akulwar-Tajane et al., 
2021; Elghomati et al., 2022). 
Generally, Prevalence of acute or subacute thoracic back pain and chronic pain is 
ranging from 3.4%- 34.8%  and 15.6%- 19.5% respectively among general population 
(Fouquet et al., 2015). Prevalence of Upper back pain among high school students is 
high, a study conducted among Finnish high school students depicts 17% reported 
disturbing symptoms in the neck, upper back and shoulder (Niemi et al., 1997). Further 
a study conducted in Saudi Arabia among undergraduates who are following dentistry 
complained about neck pain (69.2%) followed by shoulder (67.1%) and upper back 
pain (46.9%)(Felemban et al., 2021).   

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A systematic review on “The effectiveness of non-invasive interventions for 
musculoskeletal thoracic spine and chest wall pain” depicts about lack of quality studies 
regarding no physical therapy management regarding musculoskeletal thoracic pain. 
Further, this study shows that, multimodal program includes manual therapy, heat or 
advice and exercise clinically not important pain reduction like spinal manipulation 
(Southerst et al., 2015).   
Thoracic Spinal mobilization technique forwarded by Maitland suggests that  Grade I 
and II oscillatory technique mainly contributes in reduction of pain can potentially help 
reduce pain in the spine through several mechanisms including gate control theory, by 
release of endorphins, and improve blood flow to the muscle and Grade III and Grade 
IV techniques mainly contributes in improving mobility (Lee and Lee, 2017).  
Application of Maitland’s mobilization technique grades will be differ according to the 
patient’s individual factors and pain intensity. In addition, Myofascial release therapy 
is a type of gentle, constant massage that releases tightness and pain throughout your 
myofascial tissues. Few literature forwarded that pressure or tension should be applied 
for nearly 40 to 120 seconds in an angle of 30- 60 degree for the effective release of 
trigger points(Kim, Sung and Lee, 2017). Application of pressure increases the blood 
flow and removal of potential waste product from the specific muscle. It will cause the 
pain reduction. Furthermore, Thoracic mobility exercises are found to be very 
significant in mobility of the spine and improve the muscle strength of thoracic 
extensors which mainly includes Cat and Camel exercises, Horizontal chest expansion 
and cross arm chest expansion (Cho, Lee and Lee, 2017). It aims to enhance the 
flexibility, strength, and alignment of the spine, while the incorporation of controlled 
breathing can further aid in relaxation, stress reduction, and improved movement 
patterns(Csepregi et al., 2022). 
Prevalence of musculoskeletal pain among undergraduates in Sri Lanka depicts a 
significant increase after the COVID-19 due to increase screen time, sitting in long time 
lecture hours for nearly seven hours and increase of academic work load (Patterson and 
Warnakulasuriya, 2022).  It act as a vicious cycle in increase upper back pain among 
undergraduates. Proper ergonomic guidance and exercises will be possible solutions for 
this specific pain. Further, it will help to improve the academic performance among 
undergraduates and to achieve their future endeavour. In addition, availability of 
research regarding upper back pain prevalence and physiotherapy treatment is very low. 

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Proper evidence regarding treatment of upper back pain is very important due to 
increase of screening and stress day by day. In clinical settings, thoracic mobility 
exercise combination with breathing depicts a significant improvement in upper back 
pain rather than manual therapy. As a researcher, effectiveness of both therapies should 
be checked scientifically.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1.2 OBJECTIVES 
General Objective: 
To find out the effectiveness thoracic mobility exercise compared with manual 
release technique in minimizing upper back pain 
Specific Objective: 
-To evaluate correlation between the sociodemographic factors and pain 
intensity of participants in experimental and control group. 
-To evaluate the effectiveness of thoracic mobility exercise and manual release 
technique in improving upper back pain intensity 
-To evaluate the effectiveness of thoracic mobility exercise and manual release 
technique in improving upper thoracic mobility 
-To evaluate the effectiveness of thoracic mobility exercise and manual release 
technique in improving trunk upper back muscle strength 
-To evaluate the effectiveness of thoracic mobility exercise and manual release 
technique in improving disability  
 
 
 
 
 
 
 
 
 
 
 

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2. DESIGN AND METHOD 
2.1 Study Site: 
Study will be conducted University of Peradeniya. 
2.2 Study Population: 
Undergraduates who are currently having upper back pain for more than seven days 
will be selected as sample. Participants who will have sub-acute and chronic pain which 
means who will have pain more than a week or seven days will be selected as sample 
and who have subjected to any recent surgeries, recent fractures, accidents or injuries 
in upper back will be excluded from the study. 
2.3 Study Setting: 
Study will be conducted in Service unit of Department of physiotherapy at University 
of Peradeniya.  
2.4 Study Design: 
This study is a Randomized Control Trial, Double- Blinded study. Participants and 
accessors will be blinded. Participants will be allocated randomly in to two groups 
which are experimental group which will receive thoracic mobility exercises and 
control group which will receive myofascial release and joint mobilization treatment.  
2.5 Hypothesis: 
1. Hypothesis about difference in baseline characteristics of partcipants between  
control and experimental groups 
             Null Hypothesis: Ho: µ1 - µ2 = 0 
There is no difference in baseline characteristics of participants between 
experimental and control group. 
             Alternate Hypothesis: H1: µ1 - µ2 ≠ 0 
There is a difference in baseline characteristics of participants between 
experimental and control group 
2. Hypothesis about differences in pain intensity between control group and 
experimental group. 

6 
 
Null Hypothesis: Ho: µ1 - µ2 = 0 
There is no difference in pain intensity of participants between experimental and 
control group. 
     Alternate Hypothesis: H1: µ1 - µ2 ≠ 0 
There is a difference in pain intensity of participants between experimental and 
control group 
 
3. Hypothesis about differences in thoracic mobility (Range of Motion) between 
control group and experimental group. 
Null Hypothesis: Ho: µ1 - µ2 = 0 
There is no difference in thoracic mobility of participants between   
experimental and control group. 
            Alternate Hypothesis: H1: µ1 - µ2 ≠ 0 
There is a difference in thoracic mobility of participants between experimental 
and control group 
4. Hypothesis about differences in muscle strength of spinal extensors between 
control group and experimental group. 
Null Hypothesis: Ho: µ1 - µ2 = 0 
There is no difference muscle strength of spinal extensors of participants 
between experimental and control group. 
            Alternate Hypothesis: H1: µ1 - µ2 ≠ 0 
There is a difference in muscle strength of spinal extensors of participants 
between experimental and control group 
5. Hypothesis about differences in disability of participants between control group 
and experimental group. 
Null Hypothesis: Ho: µ1 - µ2 = 0 

7 
 
There is no difference in disability of participants between   experimental and 
control group. 
            Alternate Hypothesis: H1: µ1 - µ2 ≠ 0 
There is a difference in disability of participants between experimental and 
control group. 
2.6 Sample Size:  
Sample size is Calculated by using G*power 3.1.9.4 software by assigning power 80% 
effective size 0.5, type I error = 0.05 and type II error = 0.2. Therefore calculated sample 
size was 42. Drop down rate of participants is assigned as 25 %. Therefore final sample 
size which obtained is 60 (Kang, 2021).  
2.7 Sampling method: 
Simple Random Sampling will be used as sampling technique as well as 30 Participants 
will be randomly allocated to each group. Participant will be allocated to the groups by 
using lottery method. 
2.8 Data collection:  
Undergraduates who are having upper back pain more than 7 days will be selected as 
sample and those who are having any contraindications, recent surgeries, fractures, 
accidents will be excluded from the students. Informed consent will be obtained from 
the participants. Participants will be allocated to one group by blindly select the number 
by lottery method. Thirty participants will be allocated randomly to each group. 
Allocation was concealed. Accessors will not be aware of intervention or control group 
and collect the demographic data, Pain assessment, Range of Motion and muscle 
strength at the baseline and after two weeks of intervention. 
2.9 Data collection tool: 
Measurement tool contains two sections such as pre-test and post-test questionnaire. In 
Pre-test questionnaire, there are six sections which includes personal details of the 
participants, pain related questions, Measurement of range of motion at base line, 
muscle strength at base line and pain-self-efficacy Questionnaire (PSEQ) at base line. 
In Post-test questionnaire, there are 4 sections which include, pain related questions 

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mainly pain intensity after two weeks, muscle strength after two weeks, Range of 
motion after two weeks and pain-self-efficacy Questionnaire (PSEQ).  
Personal details of the participants will be collected separately for the concealed 
allocation and participants will be identified by code number. Participants’ age, gender, 
height, weight, BMI, family size, bread winner of the family, monthly income and 
financial support for the study will be collected in the demographic data section. In third 
section, questions related to occurrence of pain, pain duration and treatments which 
were undertaken for the pain will be collected from the participants.  
VAS scale will be used to measure the intensity of pain in different situations which 
include present pain intensity, in sitting, in forward bending, in standing, in walking, in 
sleeping, in transferring and during day to day activities. Visual Analogue Scale will be 
used to measure the pain intensity. Subjects will be asked to mark the number between 
0 and 10 that fits best to their pain intensity. Zero indicates ‘no pain at all’ whereas 10 
represents ‘the worst pain ever possible’ (Figure 1). Measurement will be obtained in 
the baseline and at the end of two weeks. 
  
 
 
 
 
 
Figure 1- VAS Scale 
Thoraco-Lumbar flexion and Extension of thoracic spine Range of Motion will be taken 
in the fourth section. Measurement will be taken by using measuring tape. Measurement 
will be taken at the baseline and after two weeks. In the fourth section, muscle strength 
of thoracic spine extensors will be measured using Oxford-Grading Scale. 
Measurement will be taken at the baseline and after two weeks. The Oxford Muscle 
Scale is a numerical rating scale used to quantify the power or strength produced by the 
contraction of a muscle. The scale was originally developed by a UK government 
research group called the Medical Research Council (MRC). Reliability of the scale 

9 
 
explained by Intraclass Correlation Coefficient (ICC) and Interrator Reliability. It 
shows high ICC coefficient of 0.95 (ranging from 0.92 to 0.97) (Hermans et al., 2012).  
Muscle Strength Grading Scale (Oxford Scale) 
0/5 
No Contraction 
1/5 
Visible/palpable muscle contraction but no movement 
2/5 
Movement with gravity eliminated 
3/5 
Movement against gravity only 
4/5 
Movement against gravity with some resistance 
5/5 
Movement against gravity with full resistance 
Table 1 
In the sixth section, The Pain Self-Efficacy Questionnaire (PSEQ) is a 10-item 
questionnaire developed to assess the confidence people with ongoing pain have in 
performing activities while in pain. The PSEQ has high internal consistency (0.92 
Cronbach’s alpha) and test-retest reliability is high of a 3-month period. 
 
0 
“not at all 
confident” 
 
1 
2 
3 
4 
5 
6 
"completely 
confident" 
 
1. I 
can 
enjoy 
things, despite 
the pain. 
 
 
 
 
 
 
 
2. I can do most of 
the 
household 
chores 
(e.g. 
tidying-up, 
washing dishes, 
etc.), despite the 
pain. 
 
 
 
 
 
 
 
3. I can socialise 
with my friends 
or 
family 
members 
as 
often as I used 
to do, despite 
the pain. 
 
 
 
 
 
 
 

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4. I can cope with 
my pain in most 
situations. 
 
 
 
 
 
 
 
5. I can do some 
form of work, 
despite the pain. 
('work' includes 
housework, 
paid and unpaid 
work). 
 
 
 
 
 
 
 
6. I can still do 
many 
of 
the 
things I enjoy 
doing, such as 
hobbies 
or 
leisure activity, 
despite pain. 
 
 
 
 
 
 
 
7. I can cope with 
my pain without 
medication. 
 
 
 
 
 
 
 
8. I 
can 
still 
accomplish 
most 
of 
my 
goals in life, 
despite the pain. 
 
 
 
 
 
 
 
9. I can live a 
normal lifestyle, 
despite the pain. 
 
 
 
 
 
 
 
10. I can gradually 
become 
more 
active, 
despite 
the pain. 
 
 
 
 
 
 
 
Table 2 
2.10 Ethical Considerations: 
Ethical approval will be obtained from the Institutional Review Board of Bangladesh 
Health Professional Institute. Written informed consent will be obtained from all the 
subjects who are willing to participate in the study. Participation in this research is 
entirely voluntary basis and the participants have the right to withdraw from the study 
at any time. 
2.11 Outcome measures: 
Baseline outcome measures are demographic characteristics of participants such as age, 
gender, BMI, family size, bread winner of the family, monthly income and financial 

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support for study; Pain duration; Pain intensity at present moment, sitting, forward 
bending, standing, walking, sleeping, transferring and pain when performing day to day 
activities; Range of Motion of thoraco-lumbar flexion and extension; Muscle strength 
of thoracic spine extensors and overall scale of Pain-Self- efficacy Questionnaire. After 
two weeks same outcome measures will be obtained other than demographic 
characteristics and pain duration. 
2.12 Data analysis: 
Two sample t test will be used to compare the group at baseline to determine the sample 
characteristics in the both group will be statistically equal. To find out the significant 
variation in the group after the intervention again two sample t test will be used. 
2.13 Time Duration: 
This study will be conducted from July 2022 to July 2024, for two years with three 
months data collection. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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3. EXPECTED OUTCOME 
The main outcome of this research study find the effectiveness of Thoracic mobility 
exercise in comparison with manual release technique in treating upper back pain. Over 
all expected outcome of the research is thoracic mobility exercise will be more effective 
than manual release technique which includes myofascial release and Maitland’s 
thoracic mobilization technique. Thoracic mobility exercises involve a series of 
movements and stretches aimed at improving the flexibility, range of motion, and 
strength of the thoracic spine and spinal extensors. These exercises can target specific 
muscle groups and promote better posture and spinal alignment. It is anticipated that 
thoracic mobility exercises will help patients by addressing the root causes of upper 
back pain. These exercises may improve posture, reduce muscle imbalances, and 
increase the overall mobility of the thoracic spine.  
Myofascial release involves applying sustained pressure to specific trigger points or 
knots in the muscles and fascia of the upper back. Maitland's thoracic mobilization 
technique, on the other hand, is a hands-on manual therapy approach that focuses on 
joint mobilization and spinal manipulation. It provide immediate pain relief by targeting 
specific areas of tension or dysfunction in the upper back. 
In this research, Pain intensity is measured using VAS Scale; Both intervention 
targeting pain relief; therefore it provides significant pain relief after the administration. 
In terms of Range of Motion, Strength and Disability, thoracic mobility exercise will 
provide more improvement compared to the manual therapy technique. Thoracic 
mobility exercise will provide long term benefit when compared to the manual therapy 
technique by eliminating root cause of upper back pain. 
 
 
 
 
 
 
  

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4. REFERENCES: 
Akulwar-Tajane, I. et al. (2021) ‘Effects of COVID-19 pandemic lock down on posture 
in physiotherapy students: A cross-sectional study’, Medical & Clinical Research, 6(1), 
pp. 91–102. 
Amro, A. et al. (2020) ‘Musculoskeletal disorders and association with social media 
use among university students at the quarantine time of COVID-19 outbreak’. 
Cho, J., Lee, E. and Lee, S. (2017) ‘Upper thoracic spine mobilization and mobility 
exercise versus upper cervical spine mobilization and stabilization exercise in 
individuals with forward head posture: a randomized clinical trial’, BMC 
musculoskeletal disorders, 18(1), pp. 1–10. 
Csepregi, É. et al. (2022) ‘Effects of classical breathing exercises on posture, spinal and 
chest mobility among female university students compared to currently popular training 
programs’, International Journal of Environmental Research and Public Health, 19(6), 
p. 3728. 
Elghomati, A. et al. (2022) ‘Short-term impacts of mobile touch-screen device use on 
musculoskeletal disorders during Covid-19 pandemic: risk assessment modelling and 
verification’, South African Journal of Industrial Engineering, 33(2), pp. 62–77. 
Felemban, R.A. et al. (2021) ‘Prevalence and predictors of musculoskeletal pain among 
undergraduate students at a dental school in Saudi Arabia’, Clinical, cosmetic and 
investigational dentistry, pp. 39–46. 
Fouquet, N. et al. (2015) ‘Prevalence of thoracic spine pain in a surveillance network’, 
Occupational Medicine, 65(2), pp. 122–125. 
Kim, J., Sung, D.J. and Lee, J. (2017) ‘Therapeutic effectiveness of instrument-assisted 
soft tissue mobilization for soft tissue injury: mechanisms and practical application’, 
Journal of exercise rehabilitation, 13(1), p. 12. 
Lee, K.-S. and Lee, J.-H. (2017) ‘Effect of maitland mobilization in cervical and 
thoracic spine and therapeutic exercise on functional impairment in individuals with 
chronic neck pain’, Journal of physical therapy science, 29(3), pp. 531–535. 
Leirós-Rodríguez, R. et al. (2020) ‘Musculoskeletal pain and non-classroom teaching 
in times of the COVID-19 pandemic: Analysis of the impact on students from two 

14 
 
Spanish universities’, Journal of Clinical Medicine, 9(12), p. 4053. 
Lin, I. et al. (2020) ‘What does best practice care for musculoskeletal pain look like? 
Eleven consistent recommendations from high-quality clinical practice guidelines: 
systematic review’, British journal of sports medicine, 54(2), pp. 79–86. 
Niemi, S.M. et al. (1997) ‘Neck and shoulder symptoms of high school students and 
associated psychosocial factors’, Journal of adolescent health, 20(3), pp. 238–242. 
Patterson, N.M. and Warnakulasuriya, S.S.P. (2022) ‘Screen Time and Associated 
Health Problems Among Undergraduates of University of Sri Jayewardenepura, Sri 
Lanka’, Sri Lankan Journal of Nursing, 1(1). 
Puntumetakul, R. et al. (2022) ‘Prevalence and associated factors of clinical 
myelopathy signs in smartphone-using university students with neck pain’, 
International Journal of Environmental Research and Public Health, 19(8), p. 4890. 
Shan, Z. et al. (2013) ‘Correlational analysis of neck/shoulder pain and low back pain 
with the use of digital products, physical activity and psychological status among 
adolescents in Shanghai’, Plos one, 8(10), p. e78109. 
Shete, M.G. and Shah, R. (2019) ‘Effect of posture correction exercises and ergonomic 
advices in people having postural abnormalities among chronic smartphone users’, 
International Journal of Health Sciences & Research, 9(7), pp. 121–125. 
Southerst, D. et al. (2015) ‘The effectiveness of noninvasive interventions for 
musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario 
Protocol for Traffic Injury Management (OPTIMa) collaboration’, Journal of 
Manipulative and Physiological Therapeutics, 38(7), pp. 521–531. 
 
 
 
 
 
 

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5. APPENDICES 
5.1 Annex I: Consent Form 
Informed-Consent Form 
I am a postgraduate student of Bangladesh Health Professional Institute currently 
following Masters in Rehabilitation Science program conducting a research on 
“Effectiveness of thoracic mobility exercises versus manual release technique in 
minimizing mechanical upper back pain among undergraduates - A Randomized 
Control Trail.” This study will help to identify the effect of thoracic mobility exercises 
versus manual release techniques which are used to treat upper back pain among 
undergraduates. Further, this study will help to identify which treatment method is 
superior among both treatment methods in reduce pain in upper back in different 
positions such as sitting, standing, walking, sleeping and transferring, improve muscle 
strength  and improve mobility or movement of upper back. 
This form provides you information regarding the above mentioned research and invites 
you to be a part of this research. You may discuss the research with anyone you are 
comfortable with before making a decision to participate or not. This form may contain 
certain words that you may not clearly understand. Please do not hesitate to stop us to 
inquire from us at any point if you have any questions or need clarification. If any 
questions/doubts arise at a later time, you may inquire from us at any time during this 
research.  
Information sheet 
Academic work load among undergraduates of Sri Lanka is most significantly noticed 
in renounced universities. Due to increase workload and stress most of the students 
complained upper back pain. Increased study hours, wrong position which they are 
following during their studies trigger upper back pain and neck pain among 
undergraduates. In addition, in Sri Lankan university setting most of the exams are 
following in hand written method, continuous writing, ergonomic issues in writing and 
sitting act as provoking factors for upper back pain. Students who are suffered with 
upper back pain complained poor performance in academics as well as effectiveness in 
study period also reduced. Even though numerous physiotherapy treatments are 
available for upper back pain. Students showed improvements in particular treatments. 

16 
 
This study is going to evaluate the most effective treatment method for upper back pain. 
This study will help for physiotherapists to identify the best treatment method to treat 
upper back pain. Further, prevalence of upper back pain among undergraduates also 
will be minimized as well as helps to improve the academic achievement of the 
undergraduates in Sri Lanka. 
Procedure of the Research: 
After obtaining your consent to participate in the study, we will assess you and you will 
be given physiotherapy treatment.  The treatment will include manual therapy and 
exercises which is a routinely practiced treatment approach in physiotherapy clinics to 
reduce pain, improve mobility and muscle strength in upper back. Proper instructions 
and demonstrations will be provided prior to each treatment session. This treatment will 
Measurement 
Procedure 
Pain 
You will be given a scale numbered 0-10. 
Number “0” indicates “no pain at all”, 
while number “10” indicates “the worst 
pain ever possible”. You have to mark a 
number between 0 – 10 which best 
describes the amount of pain you have in 
different positions such as sitting, 
standing, 
walking, 
sleeping 
and 
transfering.  
 
 
Range of Motion 
The available range of motion of the back 
in Forward bending and backward 
bending will be measured using a small 
plastic equipment called “inclinometer” 
and measuring tabe. You will be 
positioned 
appropriately 
by 
the 
physiotherapist, 
and 
then 
the 
measurements of the movements will be 
taken 
Muscle strength 
You will be positioned by the therapist in 
an appropriate way and strength of back 
muscle will be examined by the therapist. 
Function or Disability 
“Pain Self-Efficacy Questionnaire” will 
be given to assess the confidence to 
perform a set activities, despite of pain. It 
consist of 10 questions about the actions 
on can do in daily life which was rated by 
using Likert scale from 0 to 6. Here, “0” 
represents no confidence at all and “6” 
represents completely confidents. You 
have to mark your confidence level to 
perform each actions. 

17 
 
be delivered three times weekly for two weeks. One session will last for atleast 20 mins. 
At the end of the two weeks, you will be assessed again to check for any progressions. 
COVID19 guidelines will be followed during assessments and treatments.  
 
You will be positioned appropriately by the physiotherapist, and the proper 
instructions/demonstrations will be provided prior to the treatment session. 
Participant selection and voluntary participation: 
If you are an undergraduate of any universities in Sri Lanka who is having Upper back 
pain more or equal to 7 days, you could engage in this study. Your participation in this 
research is entirely voluntary. If you choose not to participate in this research project, 
please do not hesitate to let us know of your decision. You can change your mind at 
any time during this research and stop participating even if you agreed to participate 
now. 
Duration: 
Treatment duration will be 2 weeks. You will receive the treatments three times per 
week, and a minimum of 20 minutes of treatment per day. 
Risks/Hazards/Benefits: 
You would be able to improve your health status (reducing the pain in upper back) and 
quality of life by participating in this research, also your participation is likely to help 
us find the answers to the research question. 
You may feel mild discomfort during manual therapy. If you possess any 
contraindication for the treatments, you will be excluded. 
Reimbursement: 
We are unable to reimburse you for your participation in this research either monetarily 
or by any other form of gift(s). We are grateful for your participation. 
Confidentiality: 
The information that we collect from this research project will be kept confidential. 
Information about you that will be collected during the research will be put away and 
no-one but the researchers will be able to see it. Any information about you will have 

18 
 
a number on it instead of your name. Only the researchers will know what your number 
is and we will lock that information up with a lock and key. It will not be shared with 
anyone else. Privacy will be maintained when applying the treatments. 
Right to Refuse or Withdraw: 
You do not have to take part in this research if you do not wish to do so and your 
decision will not affect any services you may receive at this facility by us as. You may 
also stop participating in the research at any time you choose. It is your choice and all 
of your rights will still be respected. 
Whom to Contact: 
If you have any questions, you may ask us now or later, even after the study has started. 
If you wish to ask questions later, you may contact any time through the following 
contact details. 
Name with tittle: Ms Vithursha Sivakumar (researcher) 
Contact details: 0764168500 
 
 
 
 
 
 
 
 
 
 
 
 

19 
 
5.2 Annex: II: Data Collection tool 
5.2.1 Pre Test Questionnaire 
Effectiveness of Thoracic mobility exercises versus manual release technique in 
minimizing mechanical upper back pain among undergraduates in Sri Lanka 
1. 
 Personal Details 
1.1 
Name :        
 
    ……………………..……………………….. 
1.2 
Address:   
 
     .…………………………………………...... 
1.3 
Permanent Address:  ……………………………………………… 
1.4 
Phone / Mobile No:    ………………………………………………. 
Code No:……………………………….. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

20 
 
 
Effectiveness of Thoracic mobility exercises versus manual release technique in 
minimizing mechanical upper back pain among undergraduates in Sri Lanka 
Code No:…………………………… 
2. 
Demographic Data 
2.1 
Age  
 
: ……………………………………………… 
2.2 
Gender 
: ……………………………………………… 
2.3 
Height  
: ……………………………………………… 
2.4 
Weight 
: ……………………………………………… 
2.5 
BMI 
 
: ……………………………………………… 
2.6 
Family Size 
 
: ……………………………………………… 
2.7 
Bread Winner of the family:……………………………………….. 
2.8 
Monthly Income 
: ……………………………………………… 
2.9 
Financial support for study:………………………………………... 
Pre Test Questionnaire 
3. 
Pain related questions:- Baseline 
3.1 
How long have you been experiencing Upper back or thoracic pain? 
……………………………………………………………………..  
3.2 
When did your pain occur for the first time? 
……………………………………………………………………… 
3.3 
What are the treatments that you underwent so far? 
………………………………………………………………………. 
In the following scale, mark a number which best describes your pain. Number “0” 
indicates “no pain at all”, and number 10 indicates “the worst pain ever possible”.You 

21 
 
have to denote the number which best describes your pain in following instance and 
please denote the number respective to each activity in the following chart. 
 
 
 
4. 
Range of Motion (ROM) – Base Line 
Joint 
Movement 
ROM  
Thoraco- Lumbar 
 
Flexion 
 
extension 
 
 
Aspect 
VAS/ Pain scale number 
3.4 Present Pain Intensity 
 
3.5 Sitting 
 
3.6 forward Bending 
 
3.7 Standing 
 
3.8 Walking  
 
3.9 Sleeping 
 
3.10 Transferring 
 
3.11 Performing day to day activities 
 

22 
 
5. 
Muscle Strength – Base Line 
Muscle strength of Thoracic spine 
extension  
MMT Scale (Oxford- Grading Scale) 
 
 
 
6. 
Pain- Self- efficacy Questionnaire (PSEQ) – Baseline  
Please rate how confident you are that you can do the following things at present, 
despite the pain. To indicate your answer tap one of the options on the scale under each 
item, from "not at all confident" to "completely confident". 
(Fill the appropriate field only) 
 
0 
“not at all 
confident” 
 
1 
2 
3 
4 
5 
6 
"completely 
confident" 
 
. I can enjoy things, despite 
the pain. 
 
 
 
 
 
 
 
. I can do most of the 
household chores (e.g. 
tidying-up, 
washing 
dishes, etc.), despite the 
pain. 
 
 
 
 
 
 
 
. I can socialise with my 
friends 
or 
family 
members as often as I 
used to do, despite the 
pain. 
 
 
 
 
 
 
 
. I can cope with my pain in 
most situations. 
 
 
 
 
 
 
 
. I can do some form of 
work, despite the pain. 
('work' 
includes 
housework, 
paid 
and 
unpaid work). 
 
 
 
 
 
 
 
. I can still do many of the 
things I enjoy doing, such 
 
 
 
 
 
 
 

23 
 
as hobbies or leisure 
activity, despite pain. 
. I can cope with my pain 
without medication. 
 
 
 
 
 
 
 
. I can still accomplish 
most of my goals in life, 
despite the pain. 
 
 
 
 
 
 
 
. I can live a normal 
lifestyle, despite the pain. 
 
 
 
 
 
 
 
. I can gradually become 
more active, despite the 
pain. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

24 
 
5.2.2 Post Test Questionnaire 
Effectiveness of Thoracic mobility exercises versus manual release technique in 
minimizing mechanical upper back pain among undergraduates in Sri Lanka 
Post Test Questionnaire 
Code No:…………………………… 
1. 
Pain related questions:   
In the following scale, mark a number which best describes your pain. Number “0” 
indicates “no pain at all”, and number 10 indicates “the worst pain ever possible”. You 
have to denote the number which best describes your pain in following instance and 
please denote the number respective to each activity in the following chart 
 
 
 
 
 
 
 
 
Aspect 
VAS/ Pain scale number 
1.1Present Pain Intensity 
 
1.2Sitting 
 
1.3forward Bending 
 
1.4Standing 
 
1.5Walking  
 
1.6Sleeping 
 
1.7Transferring 
 
1.8Performing day to day activities 
 

25 
 
2. Range of Motion (ROM)  
Joint 
Movement 
ROM  
Thoraco- Lumbar 
 
Flexion 
 
extension 
 
 
5. 
Muscle Strength  
Muscle strength of Thoracic spine 
extension  
MMT Scale (Oxford- Grading Scale) 
 
 
 
6. 
Pain- Self- efficacy Questionnaire (PSEQ)  
Please rate how confident you are that you can do the following things at present, 
despite the pain. To indicate your answer tap one of the options on the scale under each 
item, from "not at all confident" to "completely confident". 
(Fill the appropriate field only) 
 
0 
“not at all 
confident” 
 
1 
2 
3 
4 
5 
6 
"completely 
confident" 
 
. I can enjoy things, despite 
the pain. 
 
 
 
 
 
 
 
. I can do most of the 
household chores (e.g. 
 
 
 
 
 
 
 

26 
 
tidying-up, 
washing 
dishes, etc.), despite the 
pain. 
. I can socialise with my 
friends 
or 
family 
members as often as I 
used to do, despite the 
pain. 
 
 
 
 
 
 
 
. I can cope with my pain in 
most situations. 
 
 
 
 
 
 
 
. I can do some form of 
work, despite the pain. 
('work' 
includes 
housework, 
paid 
and 
unpaid work). 
 
 
 
 
 
 
 
. I can still do many of the 
things I enjoy doing, such 
as hobbies or leisure 
activity, despite pain. 
 
 
 
 
 
 
 
. I can cope with my pain 
without medication. 
 
 
 
 
 
 
 
. I can still accomplish 
most of my goals in life, 
despite the pain. 
 
 
 
 
 
 
 
. I can live a normal 
lifestyle, despite the pain. 
 
 
 
 
 
 
 
. I can gradually become 
more active, despite the 
pain. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

27 
 
5.3 Annex III: Treatment Protocol 
Experimental Group: 
Thoracic Mobility exercises 
1. Cat and Camel exercise: 
Subject has to position himself on their hands and knees on the floor. Head 
has to be in relaxed position and allowed to drop down (figure 5.3.1). First, 
Subject has to round his back toward the ceiling until he or she feel a nice 
stretch in his or her upper and middle back. When Perform this technique 
subject has to inhale (figure 5.3.2). Hold this stretch for 10 seconds. Then 
subject has to return to the starting position with flat back. While doing this 
subject has to exhale. Subject has to let his back sway by pressing his or 
stomach toward the floor (Figure 5.3.3). Hold this Position for 10 seconds. 
Repeat for 5 times. 
 
 
 
 
 
 
 
 
 
 
                      Figure5.3.1 
 
 
 
 
 
 
                     Figure 5.3.2 

28 
 
 
 
 
 
 
 
 
 
Figure 5.3.3 
 
2. Horizontal Chest Expansion: 
Subject has to stand shoulder width apart. Bring the hands in front of the body 
to the shoulder level and palm of each hand to be touched each other (parallel 
to the floor)(figure 5.3.4). While breathing in or inhaling bring both hands 
apart from each other to the side and go beyond the side of the body (Figure 
5.3.5). After that, This Position has to hold for 10 seconds. Then, while 
exhaling hands have to return back to the normal position. Exercise has to 
repeat for 5 times. 
 
 
  
 
 
 
 
 
 
 
 
 
 
Figure 5.3.4                                                                       Figure 5.3.5 
 
3. Cross arm chest expansion: 

29 
 
Subject has to stand shoulder width apart. Subject has to gently cross 
arms, so that finger tips point to the opposite shoulder. Then, Subject has 
to keep the lower body stable and turn the upper body from side to side 
allowing with head to follow the movement. Subject has to keep the 
movement controlled and smooth (figure 5.3.6). Repeat 5 times. 
Figure 5.3.6 
 
Subjects has to perform these exercise two times a day. Exercise has to 
be performed with 5 minutes break for up to two weeks. Participants to 
be examined 3 times in a week whether they performed correctly. 
 
 
 
 
 
 
 
 
 

30 
 
Control Group: 
Myofascial release: 
Participants will be properly placed in prone lying position and adequate 
Therapist will palpate the muscle (spinal extensors) and trigger points will 
be identified. Constant pressure will be applied for 90 seconds to release 
the painful points as illustrated in Figure 5.3.7 
 
 
 
 
 
 
 
 
 
Figure 5.3.7 
 
Thoracic Spine Mobilization (Maitland technique): 
Postero-anterior central vertebral pressure: 
Starting position:  
Subject will be positioned in prone with forehead relaxed in the back of 
the hands. For mobilizing upper thoracic spine (T1-T5). Therapist 
positioned himself to the right angle to the mobilizing surface area of the 
body. The pads of the thumbs are placed on the spinous process, pointing 
transversely across the vertebral column, and the fingers of each hand are 
spread out over the posterior chest wall to give stability to the thumbs. 
The pressure should be transmitted through the thumbs so that the inter-
phalangeal joints are hyperextended with a slight degree of Flexion in the 
metacarpophalangeal joints (as illustrated in figure 5.3.8 - C). 

31 
 
To mobilize the mid-thoracic spine (T5–9), the physiotherapist should 
stand at the patient’s side at the waist level with her thumbs placed 
longitudinally along the vertebral column so that they point towards each 
other. The fingers can then spread out over the posterior chest wall, to 
each side of the vertebral column above and below the thumbs (as 
illustrated in Figure 5.3.8 -A). 
For the lower thoracic spine (T10–12), the physiotherapist’s position 
depends upon the shape of the patient’s chest. Either of the latter two 
positions described above may be used, but the essential factor is that the 
direction of the pressure must be at right angles to the body surface at the 
level (as illustrated in Figure 5.3.8 -B). 
Figure 5.3.8  

32 
 
 
Method:  
The mobilizing is carried out by an oscillating pressure on the spinous 
processes, produced by the body and transmitted through the arms to the 
thumbs. It is important that this pressure is applied by the body weight 
over the hands and not by a squeezing action with the thumbs 
themselves. 
According to the Maitland’s concept of joint mobilization technique, 
Grade I will be provided to improve pain, Grade II mobilization will be 
provided to improve pain and Range of motion and Grade III mainly 
applied for mainly to improve range of motion. Therefore, according to 
the pain intensity of the patient therapist will decide the grades 
(Hengeveld & Banks, 2014).  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

33 
 
Annex :  IRB Approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

34