**5.2. Case 2**

**5. Case studies**

158 Innovations in Spinal Deformities and Postural Disorders

*History*: MD is a very active, extremely flexible, 9-year-old girl. She is passionate about ballet. She reports right hip pain and limited motion with some dance moves. Her shoulders occasionally "pop out of joint." Her mother reports numerous falls. MD was diagnosed with left thoracolumbar scoliosis at age 8, with a Cobb angle of 13°. Her doctor recommended to "wait and see." One year later, at age 9, the Cobb angle had increased to 27°. Again, her doctor recommended to "wait and see." MD's mother decided to seek conserva-

*Initial evaluation findings*: Observation—general laxity, swayback, forward head posture, restless, constantly moving into different end-range extension positioning. Standing posture—stands on left leg, left knee hyperextension, left hip shifted to left, left pelvis positioned in swing phase (AFER), right knee bent, minimal right weight bearing. Unilateral stance—left leg 20 s, right leg 6 s. Bilateral stance (equal weight bearing)—10 s, then reverts to left stance. Forward bend—¼ range of motion, no lumbar reversal, states "my back will break." Seated hip rotation—internal: right 59°, left 45°, external: right 45°, left 45°. Spirometry (FEV)—average of three trials 1173 cc (age norm 1550 cc), weak exhale. Gait extreme lumbar lordosis, bilateral Trendelenburg. Unable to maintain test position for ADT

MD being hypermobile demonstrated the common finding of decreased proprioception. In her physiological attempts to feel stable, she resorted to end-range positioning via hyperextension. In the sagittal plane, this lordotic posturing caused anterior pelvic rotation and anterior ribcage elevation. Chronic anterior ribcage elevation decreased diaphragmatic efficiency and resulted in the diaphragm acting as a postural extensor muscle. Due to chronic pelvic anterior rotation and overuse of her right leg, especially in dance class, right hip impingement developed. MD shifted off the right leg to avoid impingement pain. This became a strong pattern, and she could no longer maintain bilateral stance. To balance her left-sided shift, her

Treatment began with a practice of bilateral and right stance. This was pain-free, but very challenging. *Sagittal plane*: repositioning was introduced at the second visit via the *All Four's Belly Lift Walk* (see **Figure 16**). This activity inhibited the tight paraspinals while shortening and strengthening lateral abdominals. Over the next few visits 90/90 *Hip Lift* activities were added to inhibit the paraspinal muscles in a supported position while isolating the hamstring muscles to establish pelvic neutrality. A balloon blow was added to 90/90 *Hip Lift* to increase recruitment of lateral abdominals while in a pelvic neutral position (see **Figure 15**). A sitting exercise with back supported, balloon blow, and left arm reach was added to challenge her in a more upright position. MD also practiced sitting in a chair blowing out through a straw to

**5.1. Case 1**

tive treatment.

due to restlessness.

*5.1.1. Clinical reasoning and treatment progression*

spine migrated right. She remained in hyperextension.

help her learn how to breathe diaphragmatically.

*History*: RM is a 12-year-old female who was diagnosed with scoliosis at age 11. Her X-rays showed a right thoracic, left lumbar PRI nonpatho curve pattern, measuring 28° from T6–T12, and 21° curve from T12–L4. Her sagittal view film showed 52.4° of lumbar lordosis and 42° of thoracic kyphosis. She was told by her physician to "wait and see" and return 6 months later. New X-rays revealed progression to 38° from T6–T12 and 26° from T12–L4. She was still a Risser 0 and had not yet started menses. She was fitted for a Boston Brace, which she wore for 16–20 hours a day, for about 2½ years weaning to nights only at the beginning of her freshman year of high school and continuing. RM is an athlete playing basketball, tennis, and ultimate frisbee and more recently, doing yoga. She spends the summers at a 6-week sleep-away camp and travels internationally with her family.

*Initial evaluation findings*: Her starting height was 5′3″. It is speculated that she had a growth spurt from time of diagnosis over the 6-month period in which her curve progressed by roughly 10°. Standing posture—anterior pelvis, knee hyperextension left greater than right, the right medial border of scapula more prominent with the right scapula being rounded forward, protracted, and slightly elevated, her right hip is higher and shifted slightly to the right. In the sagittal view, her weight is shifted anteriorly toward her toes. Gait—arm swing was greater on the left than right, right shoulder is higher, and she lacks knee flexion at the loading response bilaterally. Her upper body stays stiff and her pelvis moves in the frontal plane more than in the transverse plane. Forward bend—visible left lumbar curve with slightly elevated right rib cage. Spirometry (FEV)—2200 cc, (age norm – 2150 cc.) Scoliometer—5° rotation to the right in mid-thoracic spine, 4° rotation to the left in midlumbar spine.

*Clinical testing*: PRI testing—*ADT* indicated left anterior hemipelvis rotation, right hemipelvis neutral position (see **Figure 12**). *HGIR* indicated bilateral ribcage elevation and external rotation, left greater than right (see **Figure 13**). *TRT*—knees go farther to the left, indicating suspected iliolumbar ligament laxity (see **Figure 14**). Both *Right Apical Chest Wall Expansion* and *Left Posterior Mediastinum (left thoracic concavity) Expansion* were limited. *Single limb stance for 60 s*—more stable in right stance, and trunk is more symmetrical in right stance than left stance. In left stance, her hip and pelvis are shifted anteriorly. Her favorite position is to stand on her right leg with her left leg crossed in front, her right hip out to the side with her right hand propping on her right hip. She was *pain-free*.
