The Doctor Briefing for The Upright Protocol

For the clinician. Handed to you by your patient. Two sides.

Patient name
Date
Known vertebral fracture, site and date if known
Most recent imaging or DEXA, date
Sites scanned and T-scores, if known
Current medication for bone

What she is asking you about

Your patient is considering a twelve-week programme called The Upright Protocol. She was asked to bring you this page before she starts. I designed the programme. I am not her clinician, and this is not a treatment recommendation. It is a plain description of exactly what she would be doing, so that you can tell her whether she should.

She reached this programme because our screening refused her from our loading programme. That refusal is the point of this document. A reported vertebral fracture, a T-score at or below -3.0, stenosis, spondylolisthesis or a spinal fusion all route a woman here instead, because supervised high-intensity loading trials were not run in her, and running her through one unsupervised is the thing most likely to hurt her.

What is in it, precisely

Two sessions a week. About twenty-five minutes each. Twelve weeks.

There is no barbell in this programme. Not in week one, not in week fifty-two. No axial loading of the spine at any point, no external load held above or across the shoulders, no weighted flexion, no impact work of any kind, and no floor-to-standing lift of a loaded object.

Every session contains three things:

1. Extension endurance. Prone extension, progressed by time held and by repetitions rather than by added weight. It is in every session and it is the centre of the programme.

2. Lower limb strength, unloaded. Chair rises, sit to stand, step work. Progressed by chair height and by repetitions.

3. Balance and fall avoidance. Static and dynamic standing balance, progressed by base of support and by removing visual reference. Roughly half of each session.

Alongside those: getting up from the floor, taught as a skill in week nine rather than assumed at the start. Patients who cannot lie prone follow a standing variant set, chosen in the app and reversible: wall-supported extension holds in place of prone extension, counter-supported single-leg abduction in place of side-lying abduction, and a counter-supported anti-rotation hold in place of quadruped work, progressed on the same schedule.

What is permanently excluded

• Loaded or repeated spinal flexion. Sit-ups, weighted crunches, the finish of a rowing stroke where the back rounds.
• Standing toe touches and any forward bend under load.
• Combined flexion and rotation.
• Impact loading. No hopping, no drop landings, no jumping.
• Any axial load through the spine.

Sinaki and Mikkelsen reported a substantially higher rate of vertebral fracture among postmenopausal women performing flexion exercise than among those performing extension exercise. Arch Phys Med Rehabil 1984;65(10):593-596. That finding is the reason for the exclusions above and it is forty years old.

The three things it claims, and the one it does not

It claims she will be stronger in extension, steadier on her feet, more upright, and better at getting off a floor in twelve weeks. Those four are measured at week one and week twenty-four, by her, at home: an extension hold in seconds, the lowest chair she can rise from without hands, time to get from the floor to standing, and a single-leg stand in seconds.

It does not claim to change bone mineral density, and nothing in the product implies that it does. The honest position is that the evidence for extensor training changing a scan number is thinner than the evidence for it changing what happens to her. If she has come away believing otherwise, please correct her, and tell me.

What would make you say no, and what we do about it

She is screened twice. A question in front of the payment form names every reason below, so any of them stops the sale before her card is touched and sends her to you instead of into the programme. The fuller health screen, the same one the heavier programme uses, is completed before her first session:

• New or changed back pain that nobody has assessed
• Having been told not to exercise, not to lift, or given a limit on what she may lift
• Surgery in the last six months
• Blood pressure that is not yet controlled
• Pregnancy, for which this programme has not been reviewed at all

Inside the programme, the following stop her and put this page in front of her: new sudden back pain, pain at night that wakes her, any symptom down a leg, any change in bladder or bowel control, fever or unexplained weight loss, and any sudden change in height or a new curve.

If her fracture is recent, the question I would most like her to ask you is whether it is stable, and when it is, whether extensor endurance and balance work without any axial load is appropriate for her. She may not know to ask it in those words. It is in her programme material, but four minutes is four minutes.

Three questions she has been asked to put to you

1. Is her fracture stable, and is unloaded extensor endurance and balance work appropriate for her now, or should she wait, and until when?

2. Is there anything in the exclusions above that does not go far enough for her specifically, given her imaging?

3. When is her next scan due, and can it be booked at the same facility on the same scanner as the last one?

If you would rather she did not

Tell her, and she stops. There is a full refund at any point and no argument attached to it. She is not being sold something she has to defend to you.

If it would help to see the actual sessions, or if something above is wrong or badly put, I would genuinely like to hear it. The address is on the site she came from.