###### Abstract  
After stroke, limited ribcage movement may lead to impaired respiratory function. Combining threshold inspiratory muscle training with rib cage joint mobilization has been shown to enhance the recovery of respiratory function in patients with stroke. The present study investigated whether the combination of rib cage joint mobilization and inspiratory muscle training would improve chest expansion, inspiratory muscle activity, and pulmonary function after stroke. Thirty stroke patients were recruited and randomly assigned to one of the two groups, namely 6-week rib cage joint mobilization with inspiratory muscle training (experimental group) or inspiratory muscle training alone (control group). Outcome measures included upper and lower chest expansion, activity of accessory inspiratory muscles (latissimus dorsi (LD) and upper trapezius (UT)), and pulmonary function (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and peak expiratory flow (PEF)). All evaluations were conducted at baseline and after 6 weeks of inspiratory muscle training. Significant increases were observed in upper and lower chest expansion, LD and UT muscle activity, FVC, FEV1, and PEF in both the groups. Upper and lower chest expansion and muscle activity of UT and LD were significantly higher in the experimental group than in the control group. No significant differences were observed in FVC, FEV1, and PEF between the groups. Inspiratory muscle training is effective in improving chest expansion, inspiratory muscle activity, and pulmonary function after stroke. The addition of rib cage joint mobilization further increases chest expansion and inspiratory muscle activity.  
joint mobilization; inspiratory muscle training; chest expansion; pulmonary function; muscle activity +
Footnote †: journal:  
patients should be designed to increase the total volume of the ribcage [10] and to strengthen the inspiratory muscles [11].  
In patients with chronic stroke, anteroposterior excursion of the affected hemithorax is decreased in deep breathing when compared with that of the nonaffected hemithorax [12]. Stroke patients showed a significant decrease in chest excursions compared to healthy subjects [13]. Total lung capacity is decreased when rib cage expansion is restricted. However, lung function returns to normal when the restriction is removed [14].  
Joint mobilization is a manual therapy that applies passive movements to the joint capsules and the soft tissue to restore the arthrokinematics rather than the osteoarthritis of the joint [15]. The sustained stretch mobilization performed in the present study is used to increase the range of motion by changing the viscoelastic structures [15]. Joint mobilization and inspiratory muscle training are used clinically to increase the inspiratory capacity in order to restore the chest wall movements. Thoracic spine joint mobilization can improve chest expansion [16], inspiratory muscle strength [17], pulmonary function [18], inspiratory function, and dynamic balance [19].  
Although these interventions are commonly used in the clinical setting, evidence regarding the effectiveness of rib cage joint mobilization and inspiratory muscle training for chest expansion, inspiratory muscle activity, and pulmonary function in stroke patients is still lacking. In addition, not only the spine movements, but also the movements of the ribs are required for better expansion of the chest wall for respiration [20].  
Therefore, the specific aim of the present study was to investigate the effect of the combination of ribcage joint mobilization and inspiratory muscle training on chest expansion, inspiratory muscle activity, and pulmonary function in stroke patients and to compare this effect with that of intervention with inspiratory muscle training alone.