Back pain is a top cause of chronic pain in the U.S.
Now, for patients who have been unsuccessful with typical treatments such as surgery and narcotic pain pills, some doctors are trying an innovative approach to help patients cope and heal called functional restoration. The idea is to teach patients to manage back pain, even if it isn’t eliminated, and get them back to work, sports, and other daily tasks and activities.
Patients learn exercises they can do daily to build strength and endurance. A big component is psychological and behavioral counseling to teach coping skills and help them get over the fear of movement that comes with “pain catastrophizing,” which is the tendency to magnify the threat of pain and feel helpless to do anything about it.
Many patients join such programs as a last resort, frustrated by surgeries that didn’t work. After multiple tests, they may never get a firm diagnosis of the cause of their pain, leading to depression and anxiety. And the drugs doctors often prescribe have side effects and risk becoming addictive.
Americans spend an estimated $90 billion annually on diagnostic tests, surgery and other treatments, and back pain is also the leading cause of disability for people under 45. Researchers say functional-restoration programs could help reduce such costs and end the cycle of drugs and narcotic medications for many patients.
At Dartmouth-Hitchcock Medical Center in Lebanon, N.H., the Functional Restoration program offers a three-week boot camp of sorts for chronic back-pain sufferers who have had disabling pain that lasts more than three months. They are often referred to the center after surgery and other treatments have failed or surgery isn’t an option, says Rowland G. Hazard, director of the program and a professor at the Geisel School of Medicine at Dartmouth College.
Many have tried injections, drugs, chiropractic treatments and acupuncture “but at the end of the day they still have their symptoms back and can’t do the things that are important to them,” Dr. Hazard says. They undergo a medical evaluation to see if the program is safe for them as well as goal-setting interview to determine their personal functional aims.
Sessions take place in a large sunlit room with exercise equipment and floor space for drills, with up to eight patients at a time under the constant supervision of staff including a doctor, occupational and physical therapists, and a nurse practitioner. In addition to strengthening and cardio exercises, there are relaxation exercises to help patients for future pain-flare-ups.
Roy D. Hunter, 60, of Claremont, N.H., was a carpenter and house builder, and had suffered several injuries that left him in terrible pain, including one where he was knocked down by a bull on a farm, resulting in bone and tissue damage. He had four operations on disks in his spine, cortisone injections, anesthetic patches, and has taken the prescription narcotic oxycodone.
Once a high school basketball player who did rigorous farm chores and liked to ski, “40 years later I was on a couch and couldn’t do anything,” he says. He completed the program last Friday. During the three weeks, he says, he learned how to bend, stretch and move properly.
He lifted crates with different weights inside to simulate things he would have to do to return to work. He also was assigned exercises to help strengthen his stomach muscles. The Dartmouth team helped teach him coping skills. He had become afraid to do anything that might trigger pain, Mr. Hunter says. “I still have back pain but I am learning how to dismiss it in my mind and get back to what I could do before.”
Melissa Soendergaard, 46, of White River Junction, Vt., injured her lower back in February 2012, and was later diagnosed with sciatica, pain along a nerve that extends to the legs from the back. She was injured again last February, and tests suggested other issues including disk degeneration and cracked vertebrae. She tried physical therapy, cortisone injections and medications to no avail, and doctors said surgery wasn’t an option. She says her body “became gradually more deconditioned as I would try to find a position to alleviate the pain and stay in it as long as possible.” She struggled emotionally and gained about 100 lbs.
Different doctors she saw persuaded her to try Dr. Hazard’s program. The group model at first reminded her of “The Biggest Loser” TV series, she says. Soon she came to see the program as “a safe place to find out what I was capable of.”
Ms. Soendergaard, who also completed the program last Friday, started her days with warm-ups, stepping and low-impact aerobics, moving on to strengthening, weight-bearing exercises and endurance training. She and her husband have a business, and in the program she learned how to properly lift things like cases of paper and put them on a shelf. To simulate pushing a vacuum cleaner, she pushed and pulled a sled-like device.
The program staff also taught her how to “separate the mind from the body,” so she can deal with soreness and pain and “acknowledge what’s going on in the body without giving it a lot of power,” she says. “The point is how you live with it because there may not be a fix.”
On average, patients in the Dartmouth program have modest improvement in pain and self-assessed disability over the three weeks “but they make quite dramatic improvements in mood, flexibility, strength and endurance,” tripling their lifting capacity on average, Dr. Hazard says. They come back a week after completion to review a home regimen, are checked again at one and three months, and at a year they are surveyed on their status. Though the hospital doesn’t ask them to stop drugs while on the program, if drugs would interfere with their goals, such as driving a truck, they are asked to stop either before or after completion.
The Dartmouth-Hitchcock program costs about $17,000. It can be covered by insurance, depending on the policy, and the hospital offers assistance programs.
“The key is helping people change the way they think about pain,” from “it’s only going to get worse and there is nothing I can do about it,” to “I have pain, but there are some things I can do about it,” says Kelli Allen, a professor at the University of North Carolina Chapel Hill School of Medicine. Dr. Allen, who is also a researcher for the U.S. Department of Veterans Affairs in Durham, N.C., is conducting a study for the VA to determine if a 12-week home-based physical activity program combined with cognitive behavioral counseling could help older veterans with chronic low back pain restore function, versus physical activity alone.
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