Course Notes: Advanced Integration Day 4 – Curvature of the Spine

Today we get wild and crazy and talk about scoliosis and the like; the last day of AI.

For day 1, click here

For day 2, click here

For day 3, click here

Scoliosis Variations

The entire day focused predominately on treating scoliosis, which oftentimes amounts to exaggerations of the common patterns PRI discusses.

Because scoliosis is an exaggerated PRI pattern, one must beget the question if the pattern or scoliosis came first? This question obviously cannot be answered, but for our intents and purposes we ought to assume pattern precedes curve. That way we may be able to alter the impairment.

The scoliosis we can alter is often functional aka rotational. These types are ones that everyone has; the question is to what degree.

Nonpathological Curve

The nonpatho curve is an exaggerated version of the LAIC/RBC pattern, oftentimes with superior T4 syndrome involved. In this pattern the left ribs are externally rotated and right internally rotated. This reason is why 98% of scoliosis has right sided rib humps. A rib hump is akin to excessive rib internal rotation.  In this case, the spine looks like so…

Yep, he's still got it.
Yep, he’s still got it. [Adapted from PRI manual]
Here we can see how the spine excessively right orients up to T8-T9, then rotates left superior to that.

These patients will present with typical Left AIC and Right BC test results along with typical right lateralization. One difference may be the right shoulder is not as low as typical with most patterned individuals. This change is due to compensating for the excessive curve.

When treating, these people like most everyone need a ZOA. The steps to treat are as follows:

  1. Get neutral at the pelvis
  2. Get right apical expansion 
  1. Get right low trap and right tricep

Pathological Curve

With a pathological curve, we see basically a RAIC/LBC pattern, which amounts to a body in left stance with a brain that is right lateralized

My drawing ability is patho.
My drawing ability is patho. [adapted from PRI manual]
Here we see the opposite of the non-patho curve; a left oriented lumbar spine from L3-5 and right oriented thorax. What makes this curve pathological is because the pelvis is still right facing. Thus, the spine below T8 stays rotated to the left. This patient may present with a rib hump on the right upper thorax and possibly on the left lower thorax.

The hypothetical reason for this curve’s occurrence is to achieve a pseudo-left stance. A patterned individual will have difficulty getting into left stance; in particular left acetabulo-femoral internal rotation (AFIR) on the left hip. So to compensate, the lumbar spine curves left; essentially becoming the left hip.

This patient will present as a left AIC with or without typical right BC test results.  Because testing may be inconsistent, it is very difficult to tell if one has a pathological curve unless you have an x ray.  Their center of gravity is shifted to the left because the spine is shifted as such.

Our treatment goals will essentially involve aligning the pelvis with the lumbar spine, but the progression is different from normal PRI style. Reason being is due to these patients not presenting “normally” per PRI standards.

With the lumbar curve compensating for a left hip, top priority is getting the hip back via AFIR

From here, we progress in the following manner:

  1. Alternating activity via left femoral-acetabular (FA) IR & adduction with with FA abduction 
  2. Upright left AFIR with right trunk rotation


People who have excessive kyphosis in the upper and lower thoracic regions love using their low back a little too much. Therefore, this issue is mostly a sagittal plane problem.

These folks will usually present with inability to perform a toe touch. This impairment results from short and weak hamstrings combined with overactive pecs and lats. Oftentimes the SCM will be overactive too, thus creating a forward headed posture.

We see other influences that may contribute to one developing excessive kyphosis:

  1. Hyperactive iliacus that pulls the pelvis anterior.
  2. Long active psoas.
  3. Short serratus anterior to contribute to rounded shoulders.
  4. Decreased apical expansion bilaterally.
  5. Hyperactive anterior temporalis
  6. Compensatory overactive pterygoids.

Therefore, when treating, our goal is to get the spine frontal and transverse planes. The way we do this is by inhibiting the lats while getting us some activity on elongated hamstrings

A Q&A Tidbit

Once the course material was finished, we had a great Q&A session with Ron, James, and Mike. Many points were clarified, and we got a big gem from Mike regarding the infrasternal angle.

Using this angle is a great way to cue ZOA. Assuming 90 degrees is “normal” and what we want to shoot for, there may be two ways to achieve this number depending on one’s starting point.

–          Wide infrasternal angle: Tell the patient to exhale and make their angle 0 degrees (they can’t obviously).  Keep the angle at that value while breathing.

–          Narrow infraternal angle: Put the patient in sidelying to further bias the obliques and shut off rectus abdominis.

Final Thoughts

Whew.  So there you have it. Four days of some of PRI’s finest material. I will definitely have to retake this course to fully grasp it, but assimilating the bit of info I had seems to be making a difference in how I practice this methodology.

Moreover, I am so excited to continue learning more from them next year. I cannot recommend this information enough.

(In)famous Ron Quotes and Great James Quotes

  • “The best orthotic you have is your brain.”
  • “The more you put on somebody, the more unstable they are.”
  • There’s an orthotic I’d never want on my spine. It’s called a rod, brace, or jacket.”
  • “The brain is the big kahuna.”
  • [regarding the rules of the Hruska Adduction lift test] “You’re breaking kindergarten rules. Your nap is over. You’re in first grade.”
  • “Fixing stuff in swing is the show. It’s feed forward.”
  • “It’s not a neocortex. It’s a paleocortex.”
  • “Don’t take me literally, but take me literally.”
  • “Modify one’s passions to be successful.”
  • “People don’t get their hands overhead enough.”
  • “Running is not alternating activity; running is momentum.”
  • “When you reach, you risk. But you must reach without losing a reference center.”
  • “[Shoulder] Internal rotation is a party trick at best if you aren’t alternating and reciprocating.”
  • “[James on geriatric patients] If you don’t integrate you won’t get the baked goods.”
  • “Cobb method has nothing to do with respiration.”
  • “The orientation of the vestibular system drives everything.”

    1. So should get better with time? Or do I need aggressive manual? 🙂

      Thanks for the kind words. Hopefully I see you at a few courses.

  1. Wow do you have a busy schedule! Reminds me of mine before I had a family! I would say your drawing will get better with time, only if you are compliant….. or maybe you’re like a chronic whiplash.

  2. Hi,Zac.I’d like to ask what kind of posture is called neutral.Is it right or neutral to have ADT – on both sides?Or It’s neutral to have ADT – on the left and ADT on the right?

      1. And if I have a client who has a Left AIC or PEC with a RBC or BBC problem.After treating the Left AIC or PEC,he still has a pelvis problem,then what should I focus on ?The RBC(BBC) or the pelvis?

          1. I mean the pelvis floor probem,like left PADT, R HALT<3/5.Then what should be treated in the following step?The Brachial chain or the pelvis floor?

          2. It really depends on the patient. Personally I try to clear all passive ROM tests first before progressing the HALT, but oftentimes you will see ROM improve in all chains simultaneously.

            Hope this helps,


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