**5.3. Case 3**

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

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

*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

*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

*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

hand propping on her right hip. She was *pain-free*.

*5.2.1. Treatment progression and clinical reasoning*

160 Innovations in Spinal Deformities and Postural Disorders

on elbows and sitting in her curve pattern).

progressing positional challenges against gravity.

strengthening and maintenance of this correction.

**Figure 19**).

*History*: JP is a 66-year-old female with primary complaint of loss of upright function for the past 10 years due to debilitating left leg sciatica. JP was able to stand and/or walk for only 10 min at a time, and this was greatly affecting her ability to participate in her choir practice and in her ability to play actively with her grandson. The patient was diagnosed with scoliosis as a teenager but was not offered any intervention. X-rays reveal right thoracic convexity between T2 and T11 (apex T8) with a Cobb angle of 26°. There is a larger, left lumbar convexity between T11 and L4 (apex L2) with a Cobb angle of 51° and clear evidence of rotary instability with moderate lateral listhesis of L4 on L5.

#### *5.3.1. Initial evaluation findings*

Standing posture—anterior translation of the pelvis. There is a notable, fixed left thoracolumbar kyphosis deformity and an associated left trunk imbalance with a right pelvic orientation in the frontal and transverse planes. JP is noted to have a flat thoracic spine and anterior rib flares bilaterally. Gait—elevated thorax with no appreciable right arm swing, the pelvis remains rightoriented throughout right and left stance phases. Clinical tests—*ADT* (see **Figure 12**) reveals the right hemipelvis is in neutral position and the left hemipelvis in anterior rotation. *HGIR* (see **Figure 13**) reveals restriction of right glenoid-humeral internal rotation due to restrictions of right apical chest expansion with elevation and external rotation of the left anterior ribcage. Palpation reveals limited expansion for both the right *Apical Chest Expansion Test* and the left *Posterior Mediastinum Expansion* Test. Spirometry (FEV) measures were 2100 cc, 1800 cc, and 1800 cc, respectively, over three trials consistent with hyperinflation and likely reduced FEV for age and gender (norms for 65-year-old woman, 2160 cc). *Functional outcome measure—*Roland Morris Self-Report Low Back Pain Disability Questionnaire (RMDQ) was 9/24 or 37.5% selfreport disability.

### *5.3.2. Treatment progression and clinical reasoning*

*Sagittal*: Treatment began with sagittal plane control of pelvis and thorax to improve critical respiratory core muscle control. JP started in hooklying and supine 90–90 postures to begin activities like supine 90–90 with balloon blowing versions (see **Figure 15**). Once postural testing indicated adequate sagittal plane control, she moved to a left sidelying program.

*Frontal*: For this patient, the left sidelying position was felt to be best to help her begin to control frontal and transverse plane forces particularly in the region of her left lower lumbar spine, which were the most likely source of her debilitating sciatica. As JP gained control of the left abdominal wall in left sidelying and to obtain a ZOA, she began to integrate that control with combined muscular efforts culminating in left acetabular femoral internal rotation as with *Left Sidelying Left Flexed Femoral Acetabular Adduction with Right Lowered Extended Femoral Acetabular Abduction* (see **Figure 17**). JP was severely challenged with kinesthetic awareness of muscle activation and "carry over" to alternative postures. In her case, it was very helpful to have her stand up after a left sidelying activity to try to reproduce the same movement pattern in upright—her most challenging posture. Adding activities like *Standing Supported Left Acetabular Femoral Internal Rotation with Right Femoral Acetabular Abduction* (see **Figure 19**) were, therefore, quite a good challenge for improved upright control.

*Transverse and alternating, reciprocating movement*: As JP demonstrated further capacity for trunk control with left acetabular femoral internal rotation, we added challenges to coordinate with right trunk rotation as with gait. The use of walking poles was tremendously helpful for this patient to help with her balance, core muscle activation, kinesthetic sense of the ground and weight shifting, as well as to offer additional support for spinal elongation, a critical element in scoliosis treatment. Activities depicted like Four Point Gait with Mediastinal Expansion were further developed (see **Figure 20**).

*Summary*: Over the course of her last few visits (21 visits total), JP was consistently reporting dramatic and steady improvement in her function. She was playing with her grandson more than 2 hours at a time and able to stand through 3-hour choir rehearsals. Her walking progression was up to 34 min. The last RMDQ score was 3/24 or 12.5% self-report disability. All physical therapy goals were met. She was highly compliant and motivated throughout the course of her care, which no doubt, contributed to her strong outcomes.
