## 5 Discussion  
The results of the present study suggested that rib cage joint mobilization and inspiratory muscle training aimed at improving chest wall movements resulted in increased pulmonary function, increased chest expansion, and improved inspiratory muscle activity. Furthermore, it was observed that additional joint mobilization augments respiratory function when compared with inspiratory muscle training alone. These results indicate the importance of rib cage joint mobilization in pulmonary rehabilitation of stroke patients. These results are consistent with the results of other studies, which showed that addition of joint mobilization to conventional rehabilitation induces treatment effects on pulmonary function at which the respiratory intervention is specifically aimed [16; 17; 18; 28]. When compared with studies regarding the effects of joint mobilization and manual therapy applied to the spine on respiratory function [18; 19; 28], the present study showed a wider range of therapeutic effects of rib cage joint mobilization such as improved chest expansion, inspiratory muscle activity, and pulmonary function. A previous study evaluated respiratory function through the effect of only the pulmonary function after the application of cervical or thoracic mobilization. The wide range of therapeutic benefits observed in the present study may be explained by restricted chest wall movements and decreased pulmonary function in chronic stroke patients. Therefore, chest expansion and inspiratory muscle activity were additionally confirmed, and ribcage mobilization was applied. The variety of effects on inspiratory function may be explained by inspiratory muscle training and rib cage joint mobilization instead of spine mobilization [16] provided in the present study [24]. Thoracic kyphosis decreases respiratory function, while thoracic joint mobilization improves it with subsequent improvement in respiratory function. However, the movements required during inspiration are bucket handle movement and pump handle movement [20]. Rib cage joint mobilization was applied to increase the movement of the costovertebral joint and the costotransverse joint [15; 16]. The movements of the ribs \begin{table}
\begin{tabular}{c c c c c} \hline \hline
**Measure/Group** & **Baseline Test 1 ** & **Within-Subjects Change 3 ** & **Between Group Change 4 ** \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Changes of in primary outcome and secondary outcome on two intervention groups. from the thoracic spine can increase chest expansion by improving pump handle and bucket handle movements through rib cage joint mobilization [29; 30]. Joint mobilization applied to T6 and T12 vertebrae was reported to increase the lower trapezius strength due to articular reflexogenic effects [31]. Joint mobilization increased maximal inspiratory pressure and maximal expiratory pressure in patients with chronic obstructive pulmonary disease [17]. Hence, the results of the present study may be attributed to increased rib cage flexibility and respiratory muscle length. Thus, inspiratory muscle activity may be improved through articular reflexogenic effects of rib cage joint mobilization, increased rib cage flexibility, and increased respiratory muscle length. Stroke patients exhibit a significant decrease in pulmonary function and chest expansion when compared with healthy individuals [13]. Inspiratory muscle training has an indirect positive effect on FVC, FEV1, and PEF, which denote the expiratory pulmonary function [23]. In healthy people, FVC and FEV1 are positively correlated with upper and lower chest expansion [32]. However, stroke patients showed no significant correlation between pulmonary function and chest expansion [13]. Rib cage joint mobilization is designed to improve inspiration. The pulmonary function did not differ significantly between the experimental group and the control group. This finding may be attributed to the fact that FVC, FEV1, and PEF represent expiratory pulmonary function.