**4.2. Balancing the frontal plane**

Findings from this test must be correlated with the ADT for accurate assessment. If the ADT demonstrates a bilaterally neutral pelvic position, the rotational range to right and left should be equal. If the ADT reveals left or bilateral anterior pelvic rotation, the legs should have a greater range of motion to the right. The rationale for this test assumes a right-side dominant pattern unless the ADT demonstrates neutral balance. In a right-side dominant person, the lumbar spine will be right-oriented; therefore, the legs will appear to turn further to the right. If the legs move farther to the left, it indicates that the right iliolumbar ligament is compro-

These few examples give an idea of how the findings from PRI clinical tests correlate with one another to give an understanding of the patient's position and biomechanical function. These

Exercises, termed "nonmanual techniques" in PRI, are powerful tools for proprioception and physiological transformation for patients with scoliosis of all ages. Based on the model of rightside dominance due to human asymmetry, and taking into consideration the patient's unique configuration and function revealed by the evaluation tests, exercises are carefully chosen to most appropriately meet the tri-planar needs of that patient. Some of the greatest similarities between the methodology of Schroth Barcelona and PRI are in the application of exercises. Both place emphasis on exercise position, breath, and stabilization in the corrected tri-planar position [8, 9]. Exercise progression begins in fully supported positions to isolate and recruit underused or misused muscles. Supported positions are also favored for the introduction of multimuscle integration. When the patient demonstrates competence in activating correct muscle chain activity while supported, challenge is intensified by progression to more upright activities. Repetition of challenging positions, held through multiple breathing cycles, promotes proprioceptive familiarity with new alignment and stabilization in new muscle patterns. Increased self-awareness and more precise muscle and breath control enable the patient to self-correct in activities of daily living. Achieving true alternating, reciprocal movement, as

The PRI protocols begin with establishing the patient's ability to achieve sagittal plane neutral position of the pelvis and the ribcage. As previously described, this means that in a position of rest, their musculoskeletal system is in a state of relative muscle balance following a "repositioning" activity. Sagittal plane repositioning is most easily achieved in supported positions. Gravity is thereby eliminated and underused muscles can be positionally isolated and challenged.

Recruitment of the hamstring muscles is the most common starting point for repositioning exercises. The hamstring muscles insert proximally on the ischial tuberosity and distally on the medial tibial condyle and on the head of the fibula and the lateral tibial condyle. When

physiological details are otherwise hard to assess and factor into treatment protocols.

**4. Exercise progressions for restoration of musculoskeletal balance**

mised and does not maintain lumbopelvic stability.

152 Innovations in Spinal Deformities and Postural Disorders

required in gait, is a final challenge.

**4.1. Repositioning for sagittal plane neutrality**

As the patient becomes stronger and more proficient at maintaining sagittal plane ribcage and pelvic alignment via hamstring and lateral abdominal integration, work begins on balancing muscles of the frontal plane. The pelvis and hips are key components. For example, in the stance phase of gait, the femur should be internally rotated relative to the acetabulum to insure stability. The right leg is typically better positioned to achieve stable stance. The pelvis is typically oriented right, positioning the right femur in stance and the left femur in swing phase of gait. Muscle chain activity supporting left stance is weak. Exercise progressions to recruit, strengthen, and integrate the left nondominant muscle chain are initiated. Target muscles to promote frontal plane balance include, but are not limited to the left adductor, the left anterior gluteus medius, the right gluteus maximus, and right serratus anterior.

Frontal plane exercise progressions often begin with sidelying to assist isolation, strengthening, and neural encoding of underused muscles. More upright positions challenge the patient's ability to maintain sagittal control with the addition of appropriate abduction and adduction movements. Exercise complexity and challenge increases as isolated muscles are integrated together in activities that require frontal plane muscle chain activity. Isolated left nondominant muscles are gradually integrated together in increasingly complex and challenging exercises in the frontal plane.

Muscle inhibition is another powerful technique utilized by PRI to rebalance patterned systems. Recruitment of an antagonist to an overactive muscle will neurologically inhibit that muscle's firing. Overactive and overused muscles are inhibited by the exercise position as well as by the action of the exercise.
