**4.3. Restoring the transverse plane (via the left zone of apposition)**

As we see in right-side dominant posture and in almost every patient with scoliosis, irrespective of curve pattern, the left anterior ribcage is prominent and flared. The anterior left lateral abdominals are lengthened and weak, and the right abdominals are often restricted anteriorly. The left diaphragm is maintained in a position of inhalation. Activities to restore and to achieve greater left diaphragm respiratory effectiveness require a neutral pelvis and relative frontal plane balance. Mobilizing muscles to promote left anterior ribcage internal rotation targets left internal obliques and transverse abdominis. Right and left lower trapezius, left serratus anterior, and right subscapularis are important muscle chain agonists.

Retraining of alternate, reciprocal, upright gait is the ultimate goal. Balanced asymmetry in gait requires sagittal core strength to maintain neutrality of the pelvis and ribcage, with frontal plane competence to achieve *left* AFIR in stance phase and *right* AFER in swing phase, and the ability of the left diaphragm to fully exhale and the right to fully inhale. This exemplifies normalized function of the nondominant *right* AIC (see **Figure 10**). Although not all patients can achieve full-balanced asymmetry, especially in the presence of structural change, balancing triplanar muscle activity will enhance functionality, improve respiration, and in most cases, halt curve progression.

#### **4.4. Examples of exercises**

*90-90 Hip Lift with Right Arm Reach and Balloon:* This is one of the several versions of sagittal plane repositioning activities. In this activity, the patient is able to stabilize the pelvis in a neutral position, via bilateral, isometric hamstring activation, making it easier for many patients to achieve control. The addition of a balloon in any activity will promote active resistance to exhalation and concentric contraction of internal obliques and transverse abdominals. Right reaching in this activity further promotes left abdominal shortening and helps the patient to sense desired left posterior pelvic rotation (see **Figure 15**).

**Figure 15.** *90–90 hip lift with right arm reach and balloon* used with permission from the Postural Restoration Institute®. Copyright 2017, www.posturalrestoration.com

*All Four Belly Lift Walk:* This activity offers greater sensory awareness of position through 4 points of contact with the ground as well as movement against gravity. The patient is asked to "reach" during synchronized breathing with both hands and heels as they "walk" their feet forward, keeping knees bent. This promotes improved thoracic positioning through activation of internal obliques and transverse abdominals as well as diaphragmatic expansion and elongation of the thorax, while paraspinals are inhibited. Ankle dorsiflexion required for posterior weight shifting is an additional valuable component of this activity (see **Figure 16**).

achieve greater left diaphragm respiratory effectiveness require a neutral pelvis and relative frontal plane balance. Mobilizing muscles to promote left anterior ribcage internal rotation targets left internal obliques and transverse abdominis. Right and left lower trapezius, left

Retraining of alternate, reciprocal, upright gait is the ultimate goal. Balanced asymmetry in gait requires sagittal core strength to maintain neutrality of the pelvis and ribcage, with frontal plane competence to achieve *left* AFIR in stance phase and *right* AFER in swing phase, and the ability of the left diaphragm to fully exhale and the right to fully inhale. This exemplifies normalized function of the nondominant *right* AIC (see **Figure 10**). Although not all patients can achieve full-balanced asymmetry, especially in the presence of structural change, balancing triplanar muscle activity will enhance functionality, improve respiration, and in most

*90-90 Hip Lift with Right Arm Reach and Balloon:* This is one of the several versions of sagittal plane repositioning activities. In this activity, the patient is able to stabilize the pelvis in a neutral position, via bilateral, isometric hamstring activation, making it easier for many patients to achieve control. The addition of a balloon in any activity will promote active resistance to exhalation and concentric contraction of internal obliques and transverse abdominals. Right reaching in this activity further promotes left abdominal shortening and helps the patient to

*All Four Belly Lift Walk:* This activity offers greater sensory awareness of position through 4 points of contact with the ground as well as movement against gravity. The patient is asked to "reach" during synchronized breathing with both hands and heels as they "walk" their feet forward, keeping knees bent. This promotes improved thoracic positioning through activation of internal obliques and transverse abdominals as well as diaphragmatic expansion and elongation of the thorax, while paraspinals are inhibited. Ankle dorsiflexion required for posterior weight shifting is an additional valuable component of this activity (see **Figure 16**).

**Figure 15.** *90–90 hip lift with right arm reach and balloon* used with permission from the Postural Restoration Institute®.

serratus anterior, and right subscapularis are important muscle chain agonists.

cases, halt curve progression.

154 Innovations in Spinal Deformities and Postural Disorders

Copyright 2017, www.posturalrestoration.com

sense desired left posterior pelvic rotation (see **Figure 15**).

**4.4. Examples of exercises**

**Figure 16.** *All four belly lift walk* used with permission from the Postural Restoration Institute®. Copyright 2017, www. posturalrestoration.com

*Left Sidelying, Left Flexed Femoral Acetabular Adduction with Right Lowered Extended Femoral Acetabular Abduction:* This frontal plane sidelying exercise is a progression following the acquisition of sagittal plane neutral pelvic position. The sidelying position offers support and sensory reference to help the patient find and recruit the proper muscles. Activation of the left hip adductor helps to maintain sagittal plane neutral pelvic position. The left lateral abdominals are concomitantly activated with a right lower extremity reach to correct the left lumbar scoliosis in the frontal plane. The sidelying position offers gravitational resistance to right hip abduction, strengthening the right gluteus medius and maximus in the corrected position (see **Figure 17**).

**Figure 17.** *Left sidelying, left flexed femoral acetabular adduction with right lowered extended femoral acetabular abduction* used with permission from the Postural Restoration Institute®. Copyright 2017, www.posturalrestoration.com

*Right Sidelying Right Apical Expansion with Left Femoral Acetabular Internal Rotation (AFIR):* A higher-level challenge for control of a right thoracic curvature is presented in this activity. The loaded right arm facilitates right scapular depression and retraction of the thoracic prominence toward the midline with beneficial elongation of the right lumbar spine. The left reach promotes right trunk rotation and left posterior mediastinal expansion. The pelvic position further encourages the corrective left lateral abdominals, left acetabular femoral adduction, and internal rotation (AFIR) with right acetabular femoral abduction and external rotation (AFER). Without sufficient right thoracic control, this activity can result in patients "dropping into" their thoracic curve, making this an advanced activity (see **Figure 18**).

**Figure 18.** *Right Sidelying Right Apical Expansion with Left Femoral Acetabular Internal Rotation (AFIR)* used with permission from the Postural Restoration Institute®. Copyright 2017, www.posturalrestoration.com

*Standing Supported Left Acetabular Femoral Internal Rotation (AFIR) with Right Femoral Acetabular Abduction:* This frontal plane, upright, supported activity is a natural progression of a left sidelying program. For patients with left lumbar scoliosis, activation of left internal obliques and transverse abdominals creates a stabilizing triplanar force on the lumbar spine, a region clinically associated with instability in these patients. Frontal plane control of the pelvis is highlighted as the patient attempts to abduct their right leg and maintain triplanar pelvic corrections. Bringing this familiar frontal plane challenge to the upright position allows the patient to carry over sensations and control established in left sidelying to a more functional integration of postural correction (see **Figure 19**).

**Figure 19.** *Standing supported left acetabular femoral internal rotation (AFIR) with right femoral* used with permission from the Postural Restoration Institute®. Copyright 2017, www.posturalrestoration.com

*Four Point Gait with Mediastinum Expansion:* Efficient gait requires the pelvis to move over the stance limb with the trunk counterrotating. Patients with scoliosis are commonly challenged during left stance due to limited left pelvic rotation and right trunk counterrotation. The use of walking poles is an effective method to achieve "all 4" sensory awareness of the ground when upright. The patient is guided into a movement pattern for left pelvic orientation over the left stance limb as they simultaneously expand the left posterior mediastinum via left arm reach as they advance the left pole, promoting right trunk counterrotation (see **Figure 20**).

**Figure 20.** *Four-point gait with mediastinum expansion* used with permission from the Postural Restoration Institute®. Copyright 2017, www.posturalrestoration.com

*Standing Supported Left Acetabular Femoral Internal Rotation (AFIR) with Right Femoral Acetabular Abduction:* This frontal plane, upright, supported activity is a natural progression of a left sidelying program. For patients with left lumbar scoliosis, activation of left internal obliques and transverse abdominals creates a stabilizing triplanar force on the lumbar spine, a region clinically associated with instability in these patients. Frontal plane control of the pelvis is highlighted as the patient attempts to abduct their right leg and maintain triplanar pelvic corrections. Bringing this familiar frontal plane challenge to the upright position allows the patient to carry over sensations and control established in left sidelying to a more functional

**Figure 18.** *Right Sidelying Right Apical Expansion with Left Femoral Acetabular Internal Rotation (AFIR)* used with permission

from the Postural Restoration Institute®. Copyright 2017, www.posturalrestoration.com

*Four Point Gait with Mediastinum Expansion:* Efficient gait requires the pelvis to move over the stance limb with the trunk counterrotating. Patients with scoliosis are commonly challenged during left stance due to limited left pelvic rotation and right trunk counterrotation. The use of walking poles is an effective method to achieve "all 4" sensory awareness of the ground when upright. The patient is guided into a movement pattern for left pelvic orientation over the left stance limb as they simultaneously expand the left posterior mediastinum via left arm reach as they advance the left pole, promoting right trunk counterrotation (see **Figure 20**).

**Figure 19.** *Standing supported left acetabular femoral internal rotation (AFIR) with right femoral* used with permission from the

integration of postural correction (see **Figure 19**).

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*Seated, Supported Left Acetabular Femoral Internal Rotation (AFIR) with Right Psoas and Iliacus and Right Femoral Acetabular External Rotation (AFER):* In scoliosis, spinal compression is problematic because it increases spinal torsion. Sitting is likely the most common posture associated with increased spinal compression. Effective seated postural corrections are, therefore, an important skill requiring advanced, tri-planar control of the pelvis and thorax. This advanced, integrated activity positions the pelvis in left rotation with counterrotation of the thoracic spine into right trunk rotation. The lengthened right psoas is shortened and strengthened in its role as a hip flexor (see **Figure 21**).

**Figure 21.** *Seated, supported left acetabular femoral internal rotation (AFIR) with right Psoas and iliacus and right femoral acetabular external rotation* (AFER) used with permission from the Postural Restoration Institute®. Copyright 2017, www. posturalrestoration.com
