**5.1. Case 1**

*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 conservative treatment.

*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 due to restlessness.

#### *5.1.1. Clinical reasoning and treatment progression*

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 spine migrated right. She remained in hyperextension.

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 help her learn how to breathe diaphragmatically.

*Frontal plane*: Left AFIR was introduced with a hip hinge standing activity that simultaneously facilitated left posterior mediastinal (concavity) expansion.

The lateral spinal curve was eliminated in five physical therapy sessions of 1 hour each, over a 3-month period by addressing sagittal plane and respiratory dysfunction. MD's mother helped her with daily exercises. Due to her extreme hypermobility, MD is continuing physical therapy check-ins at 3–6-month intervals to maintain alignment, to stabilize, and strengthen her structure and to assure a neutral baseline. Scoliosis has not recurred. She continues her intensive ballet.

*Summary*: At age 9, when MD began PT, no spinal structural changes were evident, and there was no countertilt. However, her curve had progressed over a year, at Risser 0, from 13° to 27° with a rapid growth period ahead of her. Without intervention, structural change and curve progression were inevitable. This case highlights the importance of early detection and treatment. In the US, the current medical approach to juvenile and adolescent scoliosis is "wait and see." Once exaggerated curvatures in sagittal or frontal planes progress to structural change, rehabilitation is significantly more challenging and often less successful.
