Spinal Stabilization Program
at Progressive Physical Therapy & Spine Center
Preface
The name Progressive Physical Therapy is no accident. It was named that in 1986 by
myself, Barry Fitch, DPT, its founder and owner. It was named that in an effort to
capture the spirit of its purpose: To never be satisfied with the status quo, to continually
improve the quality of our service and patient outcomes, to embrace innovation and
technology and the construction of new evidence-based effective treatment protocols.
While remaining in the mainstream, we lead the charge in Physical Therapy to construct
more effective treatment techniques. We seek to elevate Physical Therapy through
competence and effectiveness and to emerge as the primary rehab providers in our area.
Back injuries represent a problem of epidemic proportions in the U.S. It is one of the
most common and costly musculoskeletal disorders experienced in the U.S. Back
injuries account for 10% of all chronic health conditions and visits to a doctor.
Approximately 80% of all Americans will suffer at least one occurrence of low back pain
in their lifetimes.(4,5,6) Four to five percent of the population has an acute low back
pain episode every year.(4,7) Occupational injuries represent an enormous problem in
the U.S. They are second only to the common cold for lost workdays and account for a
disproportionate share of workers compensation costs. While diagnoses related to LBP
account for 16-19% of workers compensation claims, they represent as much as 50% of
costs.(8) “Accident Facts:, a publication of the National Safety Council, reported that
there were 770,000 disabling injuries to the back in the U.S. in 1993. The average cost
per disabling injury was $27,000. Estimates of annual costs for LBP in the U.S. have
been as high as $100 Billion.(4,7,8,9,10, 11,12) These costs continue to rise. According
to the American Society of Orthopedic Surgeons, back injuries are the most costly
medical condition in America.
Most patients who have experienced ongoing back problems don’t have to be told that
there exists a great big gaping hole in healthcare concerning effective treatment of the
back and neck. Most conventional treatment practices whether by physical therapists,
chiropractors or medical doctors, simply do not work very well. A study completed in
2003 concluded the following: “Certainly, the historical lack of success of the
rehabilitation and medical professions in treating low back pain should serve as sufficient
motivation to look to more evidence based models.”(1)
Philosophy
Most problems of the spine originate from a localized instability. The cause of the
instability is generally not from a single incident trauma. Studies show that as little as
4% of spinal problems are caused by a single incident trauma.(2) The vast majority of
spinal problems are caused by accumulated micro-trauma.
The source of the micro-trauma may be from repetitive stress injuries or from what we at
Progressive Physical Therapy call “Creep”. “Creep” is generally caused by poor postural
habits, which stretch the supportive ligaments and muscles of the spine. This produces
areas in the spine, which are hypermobile (have too much motion). Hypermobility and
instability are not one and the same. Instability is the inevitable consequence of hypermobility if not addressed. Eventually, the supportive tissues of the spine stretch to the
point that aberrant (abnormal or unwanted) motion occurs. This is the defining moment
of instability, when aberrant motion occurs.
Aberrant motion, left untreated, causes a progressive deterioration of spinal components
and leads to what Dr. Stanley Paris calls a “cascade of symptoms”.(3) The further down
the cascade, the worse the problem and the less likely that conservative intervention can
be effective.
Poor
Posture
Accumulated
Microtrauma
Single Incident
Trauma
Hyper-mobility
Instability
Deterioration of the disc
Osteophyte formation
Arthritis in facet joints
He
Multilevel disc
Herniation / Stenosis
The cascade of symptoms illustrated on the previous page follows the general course
as outlined below:
1.
2.
3.
4.
5.
6.
7.
Poor posture causes transition zones at the apex of the spinal curves.
Hypermobility then develops at these apexes.
The hypermobility, if left alone, progresses to a local instability
Instability allows aberrant motion.
Aberrant motion initially causes pain and inflammation
Aberrant motion causes progressive wear and tear on the spine.
Wear and tear manifests itself as bony spurs or osteophytes and/or disc
degeneration.
8. Progressive wear and tear leads to lateral foramen stenosis (narrowing) and/or
herniated discs.
9. Continued progression can lead to stenosis of the central canal and/or multiple
disc herniations,
Note: It should be mentioned that there are a number of healthcare providers including
some physical therapists that deny the existence of spinal instability. There is an even
larger group of physical therapists that acknowledge its existence, but really don’t
understand it adequately. This is where we at Progressive excel. We understand spinal
instability and the problems that develop as a result. We have developed evidence-based
and effective protocols for the conservative treatment of most neck and low back
problems.
Note: It must be mentioned that there are other musculoskeletal changes that occur as
the result of poor posture that affect shoulder and even hip function. This will not be
discussed further in this section.
Causes of Instability
Repeated or Accumulated Micro-trauma, as indicated previously, is a consequence of
wear and tear. Many in the medical community feel that this is normal wear and tear
associated with age.
Our view at Progressive is that it is abnormal wear and tear caused by ergonomically and
anatomically incorrect repeated stresses over time. These stresses gradually stretch and
tear the supporting structures of the spine until they can no longer provide adequate
support.
A good example of this is a bulldozer operator.
The constant vibration and jolting of this occupation, compounded by sitting which
places twice the force on the spine as standing, fatigues the supporting tissues of the spine
and gradually inflicts micro-trauma faster than the body can repair it.
Poor Posture is really a subclass of accumulated micro-trauma. Back problems caused
from poor posture are especially prevalent in Americans. We have become a relatively
sedentary society. We sit more than anyone. We sit to watch television. We sit at our
computers. We sit when we drive and Americans, in general, drive more than the rest of
the world.
This excessive sitting is not without consequence, especially, in clerical or other ‘desk’
jobs where we sit virtually all day, only to leave and get in our car and sit again.
In this case, we literally ‘mold to our sitting posture’. Our heads move forward. Our
shoulders round forward. Our upper back humps back. Our hamstrings tighten up. Our
hip flexors tighten and our low back may increase or decrease its natural curve. Our
muscle fiber orientation is skewed and thus less effective. We gradually “Creep” into
what we call a ‘little old lady posture’. Yes, indeed, “Creep” as a result of poor posture
even makes us look older.
Phases of Postural Creep
As a result of our devotion to the computer, our backs are deteriorating at younger and
younger ages and we are looking older, sooner. There are many cosmetic problems that
are caused at least in part to “Creep”. A turkey neck, for example, is mostly the result of
the head moving forward over time and the excess skin hanging down like a turkey’s
neck. This unsightly skin flap is but the fingerprint of severe and destructive changes that
are occurring in the spine.
By the time a person’s posture has deteriorated to Phase 2 shown below, 3 transition
zones have developed at the apex of the spinal curves. Problems may occur at any of the
3 or at multiple transitions zones simultaneously, but problems in the neck region are
most common in females and problems in the low back are most common in males.
Neck problems most commonly manifest themselves as bony arthritic changes. Low
back problems most commonly manifest themselves as disc degeneration. However
either or both may manifest themselves at any or all of the transition zones.(3)
The Fitch-O’Reilly Protocol
Our philosophy and treatment protocol for spinal instability be it neck or back is, we
believe, to be superior in every way to the philosophy and treatment of our competitors,
whether physical therapists, chiropractors or whomever. Rather than just treating the
symptoms, we strive to treat the origin of the problem. The supporting muscles of the
spine require endurance or slow twitch strength. Hence, that is the way we treat them. If
postural creep is a problem then we address it. If ergonomics are a problem, then we
address that as well. Unlike most of our competitors, we don’t just guess at important
objective measurements such as range of motion and strength. We actually measure
them. Our treatment protocol follows the 10 principles outlined below:
1) Stability before mobility: Chiropractors manipulate, physical therapists stretch,
and medical doctors prescribe muscle relaxors. It is our view at PPT that all 3
may be wrong with respect to spinal instability. Manipulation may further the
instability, indiscriminate stretching may do the same. Muscle relaxors impede
the only support the patient has left. At PPT, we endeavor to strengthen the
surrounding musculature to help support the spine and stop aberrant motion as our
first priority.
2) Stop Creep: Poor postural habits are identified and addressed early on.
Realizing that creep did not occur over a short time, it is not expected to resolve
over a short time. The initial goal is to stop its progression and then subsequently
reverse what we can over time.
Posture Measurements
We first establish a baseline of individual postures by taking a lateral view picture. From
the picture, we measure approximate spinal curves. Published normative values vary,
but here at PPT we use 30 degrees as normal for all curves. Our method of measurement
is not an exact science such as from radiographs, so we utilize pre and post rehabilitation
pictures to verify our findings.
For more information on posture go to:
http://www.apta.org/AM/Template.cfm?Section=Publications&CONTENTID=20457&T
EMPLATE=/CM/HTMLDisplay.cfm
3) Discriminate Stretching Only: It is the view of PPT that indiscriminate
stretching of the cervical spine or anywhere in the spine for that matter is
contraindicated and may exacerbate an instability. We do, however recognize
that stretching is a valuable and essential tool in spinal rehabilitation. It is
absolutely necessary that only shortened tissues that interfere with normal
movement be stretched. Careful here. Therapists frequently mistake muscle
guarding for muscle tightness. They are not the same. In the case of whiplash,
the guarding is an effort of the musculature to stabilize the spine. In effect, the
neck is ‘too loose’, yet many, even most PT’s elect to stretch this. We at PPT
believe this to be ABSOLUTELY WRONG and we trust that none of our
therapists will practice this.
4) Manual Therapy (myofacial release and discriminate joint mobilization): These
manual therapy techniques can be very helpful in improving posture and spinal
function, but just as in stretching below, care must be taken to ensure that
mobilization is used only in areas of tightness.
5) SlowTwitch over Fast twitch: It is our belief that many of the exercises used by
our colleagues in physical therapy are appropriate, but often are not applied
optimally and are of limited use as such. Where we differ is that we utilize these
exercises in a sustained contraction format in an effort to strengthen the more
functional slow twitch properties of associated musculature.
6) Technology: Unlike most of our competitors, we at Progressive Physical
Therapy don’t just guess at important objective measurements such as Range of
Motion (ROM), strength and posture. We actually measure them. In order to
accurately measure these variables, we utilize the most advanced technology
available. Currently, we use the MCU or Multi-Cervical Unit for the neck and the
Monitored Rehab Systems Back Extension machine and the BTE Vector for the
low back. This technology is valuable for assessing range of motion and strength.
It is also useful for isometrically and isotonically exercising spinal musculature.
Additionally, the technology does an excellent job identifying the specific areas of
tightness which need stretch.
The Multi-Cervical Unit
For more information on the MCU go to http://www.btetech.com/
The Monitored Rehab Systems Back Extension
The Monitored Rehab Systems Back Extension has been developed in close cooperation
with practitioners of physical and manual therapy. The unique chair construction
guarantees optimum adjustment for training of the intrinsic back muscles and the
collagen interstitial tissue in the lumbar and lumbosacral regions. With use of special
software, the reconditioning and strengthening of the lumbosacral regions can be
optimally adjusted.
For more information go to http://www.monitoredrehab.com/
BTE Vector Robotic Spine
For more information go to http://www.btetech.com/
7) Modalities as needed: We at PPT do utilize and recommend the use of various
modalities for both palliative and restorative purposes during rehabilitation.
These modalities include, but are not limited to various kinds of electrical
stimulation, ultrasound, dry stick injection, heat , ice, phonophoresis, and
inotophoresis. Many modern physical therapists especially those with manual
therapy certifications such as mine, (IOC) vilify their use. We at PPT could not
disagree more. We continue to believe that modalities are a valuable tool in the
rehabilitation of the spine.
8) Ergonomics: Patients are taught basic ergonomic principles and how to
implement these concepts to save their backs from unnecessary wear and tear.
The ‘Back Saver’ chair was invented and patented by myself, Barry E. Fitch,
DPT and is an extremely useful tool is preventing and even reversing postural
creep.
9) Follow-up: After successful rehabilitation, patients with progressive spinal
deterioration are encouraged to schedule with their physical therapist for a
recheck every 6 months for 3 years. This is much like routine preventative care at
the dentist and is felt to be necessary to monitor the condition of the spine and to
proactively adjust a patient’s home program as indicated.
10) Research: We at Progressive Physical Therapy realize that research is often a
Catch 22 situation. That is to say that most researchers are poor clinicians and
conversely, most clinicians are poor researchers. Therefore, much of the available
published research has limited practical use. At PPT we are continually involved
in in-house clinical research which is implemented by seasoned clinicians with
consultation of qualified researchers. Much of this research is in the form of
tracking outcomes of treatment interventions to verify the efficacy of our
treatment protocols and methods. Results of this research are used as a feedback
mechanism to improve our treatment methods and outcomes.
**Our spinal stabilization program generally runs from 6 to 12 weeks (18-36
treatments).
Anecdotal Evidence
As bad as the statistics were in the previously cited article in 1993, I fear that is just the
tip of the iceberg. We already have an epidemic of back problems in the U.S,, but unless
we utilize more effective interventions, the epidemic is going to grow exponentially. I
have been practicing physical therapy for 25 years. During that time, I have focused
mostly on the spine. Twenty five years ago, I routinely saw patients with ‘hunched over’
postures in their 50’s and 60’s and older. Now, I am seeing those same postures in
patients in their 20’s. The reasons, I believe, are clear. Americans, have become more
sedentary. Personal computers didn’t even exist 25 years ago and have become a major
culprit in facilitating poor posture. Couple that with the fact that Americans are
becoming more and more obese and a mega epidemic is born. When we first began to
use the Fitch-O’Rielly protocol, it was our goal to just stop the progression of “Creep”.
We have since found that in many instances, we can reverse the effects of “Creep”. At
Progressive Physical Therapy, we almost routinely reverse patients in stages 2, 2 ½, and
even 3 to stage 1.
Note: There are several problems of the spine that are not directly related to instability.
For all but the most serious we have other programs for these that may or may not
include components of the stabilization program. These problems include, but are not
limited to the following:
Congenital deformities
 Scoliosis
 Spondylisthesis
 Osteoporosis
 Cancer
 Painful entrapment
 Stuck Facet joint
There are others that are a direct consequence of instability, but have progressed to the
extent that a stabilization program may be of little value and even contraindicated. These
include, but are not limited to the following:
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Multilevel disc herniation
Stenosis
Still, as stated earlier, the vast majority of back problems of Americans today originate
from a localized instability. One group of researchers concluded that the human spine is
inherently unstable.(3) While we at Progressive feel that this may be overstated, the take
home message is that the spine is more dependent on its surrounding musculature for
stability than any other joint in the body.
Hypothetical Case to Illustrate the Cascade of Symptoms
Single –Incident Trauma, while not as common a culprit as accumulated micro-trauma,
does exist. Whether produced in a micro-second in a single-incident trauma or slowly
from postural creep, the results are the same. Let’s consider the following hypothetical
scenario: A young woman, aged 28 was sitting at a stoplight when her car was hit in the
rear by another driver. The next morning she has a stiff and sore neck. Lets assume that
the damage done by this whiplash injury is not severe enough to cause an instability, but
has stretched the long ligaments of the neck sufficient to cause hypermobility of one of
her neck joints. She seeks medical help from one of the following practitioners.
Which one/s is correct?
Treatment
Results
Chiropractor
Medical Doctor
Physical Therapist
Manipulation
Medications:
Anti-inflamatories
Muscle relaxers
Analgesics
Moist Heat
Electric Stim
Stretching exercises
better after 2 wks
better after 2 weeks
better after 2 wks
Again, Which is correct?
It is the opinion at Progressive Physical Therapy that they are all wrong. While they may
treat the symptoms paliatively (they feel better for a little while), they do nothing at all to
treat the underlying problem of instability. In fact in many cases they do more harm than
good and even facilitate the hastening of the downward cascade for they following
reasons:
-Chiropractors because they manipulate into an instability and thus, further exacerbate the
instability.
-Physical Therapists because they stretch into an instability and thus, further exacerbate
the instability.
-Medical Doctors because they prescribe muscle relaxers which inhibit the only
supporting structures that are left and thus, further exacerbate the instability.
So, What happens to the young lady?
She is a legal assistant. Everything goes well for about 5 years with only intermittent
bouts of neck pain that last a day or two. Then she wakes up one morning with a stiff
and sore neck. After 2 weeks she is no better. Over-the-counter Ibuprofen no longer is
effective. The hyermobility in her neck joint has progressed to the point where an
instability has developed. The aberrant motion borne out of this instability has further
traumatized the supporting tissues of the neck and caused inflammation and pain until her
neck is chronically stiff and sore. Her posture has deteriorated in that her head has
moved forward and her upper back has begun to hunch over. What does she do? Go
back to the Chiropractor or Medical Doctor or Physical Therapist? No. No. No and Yes.
Not the Chiro, not the MD, and not your average PT, but to Progressive Physical Therapy
where we understand and treat the source of problem, not just the symptoms.
Treatment
The good news is that spinal instability and its consequential problems can be treated
effectively so long as it has not cascaded down too far. In most cases, we at Progressive
can reverse the process or at least stop its progression. Like any treatable progressive
disease, the earlier the process is identified and treated, the better.
How we at Progressive Physical Therapy will treat the young lady: The Fitch - O’Reilly
Protocol.
Other Helpful Links
The Whiplash Center: http://www.whiplashcentre.com/
The American Academy of Physical Medicine: http://www.aapmr.org/
Academy of Orthopaedic Manual Therapy: http://www.aaompt.org/
The American Physical Therapy Association: http://www.apta.org
http://www.spine.org/Documents/spine_rehab_2006.pdf
www.spine.org
http://www.spine-health.com/topics/conserv/physrelief/physrelief01.html
http://www.spineuniverse.com/
About the Author
Barry E. Fitch, PT
MBA, DPT, IOC.
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President of Progressive Physical Therapy
Doctor of Physical Therapy (DPT) from the University of St. Augustine
Master of Business Administration (MBA) from Brenau University
Bachelor of Science (BS) from the Medical University of S.C.
Bachelor of Arts (BA) in Biology From Francis Marion College
Integrated Orthopedics Certified (IOC) specialty certification
Physical Therapist since 1984
Administrator since 1987
Served honorably in the U.S. Army
Member of the American Physical Therapy Association
Past member of Board of Physical Therapy Examiners
Board Member S C Association of Medical Professionals
Farmer
Member of Saluda Baptist Church
About the Contributing Program Developer
Jerry S. O’Reilly, PTA, CSHE, CWT,CPT,SSC
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Director of Industrial Programs for Progressive Physical Therapy
Licensed Physical Therapist Assistant since 1998
Bachelor of Science (BS) from the university of South Carolina
Associate of Science (AS) from Midlands Technical College
Certified specialist in health ergonomics (CSHE)
Certified Weight Trainer (CWT)
Certified personal trainer (CPT)
Specialist in Sports Conditioning (SSC)
Member of the American Physical Therapy Association
Member of the South Carolina Association of Medical Professionals
References
1. Jemmett, RS, Br J Sports Med, 2003;37:91
2.
3. Paris, S, FCO Notes,
4. ByrnesG, Bierma T, Agnew B, et. Al. A new direction in low-back pain research.
AIHA Journal. 2002; 63; 1: 55-61.
5. Donajkowski K. Back Injury: Causes, Prevention, Treatment, Professional Safety.
Sep 1993; 38; 9:21-30.
6. Muir T. Back injury prevention in health care requires training techniques,
exercise. Occ Health & Safety. June 1994; 63; 6: 66-71.
7. Gates S. Muscle weakness is leading cause for Nurses Low Back Pain. OH&S.
1988: 4: 57-60.
8. Marras W. Occupational Low Back Disorder Causation and Control. Ergonomics.
Jul 2000; 43: 880-902.
9. McReynolds M. Managing the High Cost of Back Injury. Occupational Health
and Safety. 1992: 61; 4: 58-62.
10. Evans C, Gilbert J, Taylor W, Hiderrand A. A Randomized Controlled Trial of
Flexion Exercised Education and Bedrest for Patients with Acute Low Back Pain.
Physiother Can. 1987; 39: 96-101.
11. Seeds R, Levene J, Goldberg M, Shirka A. Electronic equipment Provides
Accuracy in Back injury Analysis. OH&S. 1988; 5: 38-42.
12. Leonard B. Lower back pain hits emplouers in the bottom line. HR Magazine. Jan
1994.