*5.2.1. Treatment progression and clinical reasoning*

Postural awareness and behavior changed during activities of daily living—she lightened her backpack and began to use a waist strap to redistribute weight to her pelvis from her spine. We encouraged her to sense her heels and improve standing posture. We incorporated spinal precautions (hip hinge instead of spinal flexion) due to relative anterior spinal overgrowth (RASO) and encouraged corrective postures for studying and lounging (i.e., avoiding prone on elbows and sitting in her curve pattern).

*Sagittal plane*: Supported supine activities to reposition pelvis were initiated by concomitant strengthening of hamstrings and lateral abdominals focusing on exhalation to bring her rib cage down anteriorly, restoring her respiratory zone of apposition. A left hip shift bias was used to help anchor her left femoral-pelvic position with her left lateral abdominals as in the *90/90 Hip Lift with Right Arm Reach and Balloon* (see **Figure 15**). Improved sagittal plane position was maintained throughout her program while addressing other planes of correction and progressing positional challenges against gravity.

*Frontal plane*: Exercises focusing on balancing left lumbar curve were implemented in left sidelying with a right leg reach, and by PRI left-side plank activities to lengthen her right lateral abdominals and shorten/strengthen the left. Her right thoracic curve was addressed with left sidelying activities to allow gravity to assist with centralization, as well as with positioning and muscle activation to direct air for right apical and left thoracic concavity expansion. Right upper extremity retraction/shoulder extension in external rotation was implemented to help activate her right low and middle trapezius to help reposition her right scapula toward the midline. Position was progressed from sidelying to sitting to standing. Examples of these PRI nonmanual techniques are *the Left Sidelying Left Flexed Femoral Acetabular Adduction with Right Lowered Extended Femoral Acetabular Abduction* (see **Figure 17**), and the *Standing Supported Left Acetabular Femoral Internal Rotation (AFIR) with Right Femoral Acetabular Abduction* (see **Figure 19**).

*Transverse plane*: Once the left respiratory zone of apposition was achieved to anchor left anterior rib flare, activities to strengthen right low trapezius and triceps were used to assist with thoracic spine derotation and rib cage balancing. Likewise, right iliacus and psoas were used for lumbar spine derotation in sitting and standing. The left serratus anterior and low trapezius were activated concomitantly to bring the left rib cage posteriorly (to expand the left thoracic concavity). Exercises were progressed from supine to seated to supported standing to freestanding, followed by the addition of resistance (dynamic stabilization) in standing for strengthening and maintenance of this correction.

*Final Clinical Findings*: Height—5′6 & 5/8″ (2½ years later, almost 4″ of growth), X-rays - right thoracic: T5–T12 = 35°, left lumbar: T12–L4 = 29.1°, Risser 4. Menses began summer of 2016. Her growth has stabilized, and we are hopeful to prevent progression requiring surgical correction/fixation. Spirometry (FEV)—2700 cc, which is age-appropriate. Single limb stance—more symmetrical and balanced on each leg with good observable pelvofemoral position bilaterally.

*Summary*: Working with teenagers can be challenging as well as rewarding due their very busy lives and neurodevelopmental immaturity to realize consequences. When trying to prevent curve progression, over a long period of time during growth, the process can become repetitive and laborious and it is easy for an adolescent to lose belief and/or motivation in the process. School and extracurricular activities can override exercise programs, especially if the patient has no pain. However, RM was diligent with her program and was able to implement concepts of correction and to perform challenging exercises while away at summer camp. Her case is an excellent example of the possibility to hold a curve that began to rapidly progress (10° in 6 months), with a starting point >25°, during a period of growth. She was able to avoid the need for surgical correction and now has a "tool bag" of exercises and positions she can use to thwart potential discomfort, as well as to maintain balanced asymmetry, throughout her lifetime. At recent follow-up, she proudly offered that she has less pain than her peers and teammates following exercise classes and games "because I now know how to take care of my spine!"
