A Physical and Behavioral Approach to Rehabilitating an Injured Back
For nearly three weeks, five to six hours per day Monday through Friday, seven patients were coaxed through a variety of stretches, lifts, and exercises. Each time, clinicians nudged the patients a bit closer to their goals. They also guided the patients through a daily counseling and education session that included active discussions among the patients.
Welcome to the Functional Rehabilitation Program (FRP) at the Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, a boot camp of sorts for people with chronic and disabling back pain. The patients were diverse in age and lifestyle. Some had experienced severe trauma; for others, the pain had no obvious cause. Almost all participants achieved the goals they had set for themselves early in the program. Many went on to tell Rowland Hazard, MD, the program’s creator and leader, that the program transformed their lives and livelihoods.
An episode of low-back pain is a commonplace experience, one that will affect most adults at some point. The majority of those affected recover in short order, with or without intervention. A small minority may learn they have a specific and identifiable problem that can be addressed through surgery. One such condition is spinal stenosis, a narrowing of the bone channel occupied by the spinal cord.
All other patients—those with chronic pain but no specific diagnosis—face a confusing array of choices. They may be offered surgery, injections, or opioid medications, for example. These approaches may or may not work; the evidence base supporting them is thin. Many patients will continue to suffer. They might accept that their pain and limited function are permanent. They may even exit the workforce with disability compensation.
The fundamental premise underlying Hazard’s program is that for these patients, the “find-and-fix” approach modern medicine favors is misguided. Their problems cannot be “fixed.” Nonetheless, their function can be substantially restored through physical activity and behavior change.
Functional restoration has been Hazard’s preoccupation throughout his medical career. He was first introduced to the newly invented approach during his fellowship at the University of Texas in the mid-1980s. Hazard went on to develop an experimental offering at the University of Vermont and to gather data that demonstrated its effectiveness. Jim Weinstein, an orthopedist at DHMC who was building an innovative approach of his own to spine care, was a natural ally, so Hazard made the move to DHMC in 2003. By 2016, the program’s design reflected nearly three decades of evolution, guided by feedback from patients, a constant quality monitoring program, and reimbursement policies.
In Hazard’s recollection, one of the most fundamental changes in philosophy over these years was the abandonment of any definition of “normal” function. In the early years, the program was guided by data that established strength, flexibility, and endurance norms for peers without back pain. Program success was defined by how close patients were to these standards at the end of the program. There was a mismatch, however, between this assessment and patient satisfaction. Hazard elaborated:
I spent a lot of time interviewing patients over a year after they had gone through the program to figure out why they were or were not satisfied with their results. In retrospect, it’s a little bit embarrassing that it took us so long to conclude that what we defined as “normal” simply had no relevance for patients. Their hopes and expectations were not tied to our data tables; they were tied to the activities that they wanted to be able to engage in. Those activities might vary dramatically. Consider, for example, the difference between a computer programmer and a soldier hoping to return to active duty.
As such, early in the program all patients set goals for themselves and those goals become the standard by which the program was assessed. Patient satisfaction scores have risen. Though roughly one patient in 10 drops out of the program before completing it, almost all patients who complete the program achieve their goals.
Hazard has learned over the years to trust the goals that patients set for themselves. While patients who have suffered a recent acute injury tend to expect a complete recovery, patients who have lived with chronic pain tend to think quite differently. Their goals are more conservative. In general, they do not expect to fully restore function or completely eliminate pain. They also are wary of failure; that is, they do not want to complete a rigorous three-week program and find they have fallen short of their hopes.
Often, patients not only are pleased with the results but astonished by them. For example, on average patients triple their lifting capacity by the end of the program.
Patients often set aggressive goals. Nonetheless, the FRP staff has seen that it is nearly impossible to predict what is possible. They make no effort to persuade patients to moderate their expectations.
The formation of social bonds between patients can be a powerful part of the FRP. Many patients have similar experiences prior to coming to the program. They have suffered for a long time but they typically have no specific diagnosis, or perhaps have multiple competing diagnoses. They have no cast or brace, so to their peers in day-to-day life they can only say, “My back hurts.” Many of those peers have experienced acute back pain of their own and thus think they know what it is all about. Since most have readily recovered, the instinctive reaction, whether vocalized or not, can be, “Well, I got over it. What’s wrong with you?”
Participants in the FRP may also feel they have been treated dismissively by their doctors. They may have been given a pseudo diagnosis, such as “back strain,” which was intended to make them feel better but from the patient’s perspective only seemed to diminish the problem’s seriousness. Alternatively, after providing an ineffective treatment, the doctor might suggest applying for social security disability, believing all that can be done has been done.
Hazard sees particular harm in offhand remarks that doctors make all too often to patients: If [a certain activity] causes pain, then avoid it. Such comments can have life-altering consequences. Patients give up on activities that are critical to their occupation or otherwise meaningful in their lives. Inactivity subsequently may bring about feelings of helplessness and depression or secondary deconditioning, including stiffness, weakness, and loss of endurance. The spiral continues downward from there.
Early in the program, the FRP staff reassures patients by explaining that the only person who can fully understand the patient’s pain is the patient. Such reassurance from a clinician, however, is only a start. It is only when the patients start sharing their stories with each other that they begin to accept that their own experiences are truly legitimate. They see that they are not alone. It is a catharsis for many.
Although interactions among patients are generally a positive force within the program, patients who dwell too long on negative emotions can drag down the group as a whole. A crucial challenge for the staff has been figuring out how to maintain positive attitudes throughout the program. The team has learned to avoid either asking patients to stop complaining or rewarding complaints with sympathy. Instead, they focus attention on objective measures of progress towards the goals each patient sets. “Steady Eddie” is the common refrain. The aim is to create a safe environment in which patients can discover for themselves, individually and one step at a time, what they are capable of and what works for them.
In addition to Hazard, the program staff includes a nurse practitioner, a physical therapist, an occupational therapist, a physical/occupational therapy assistant, and a medical social worker. Although the staff have other responsibilities within DHMC, all are able to make the FRP their first priority when the monthly program is in session.
Reimbursement has always been a challenge for the FRP, one that has perpetually frustrated Hazard. He elaborated:
It’s tough. In the current fee-for-service world, our service is difficult to provide because it takes a team. The results are outstanding but they are not the kinds of results that most payers are interested in. They want clear diagnoses and interventions matched to those diagnoses. They do not, by and large, care about what matters most to patients: the physical capacity for desired work, play, and activities of daily living.
The FRP billed as much as it could for its services, limited by rules regarding the number of units of physical therapy that could be charged in a single day or the number of units patients could accumulate in a single year. Workers’ compensation programs tended to be the most generous in reimbursing the FRP. Their aims were in line with that of the FRP—achieving functional improvements that allowed patients to fully return to work.
Hazard felt fortunate to have found a home at DHMC, an institution he felt had progressive values and was pushing as best it could towards new models of care. (At the same time, he lamented the realities of fee-for-service medicine, which led to staffing levels that were incongruous with those progressive values. DHMC had far more surgeons than non-surgeon physicians in spine care.) Weinstein, who in 2011 rose to the position of CEO, believed in the FRP. Indeed, DHMC admitted patients into the program regardless of ability to pay and even arranged inexpensive dorm-like accommodations for patients who traveled a great distance to participate.
Based on best estimates of the program’s revenues and expenses and an objective of at least breaking even, Hazard and DHMC had agreed to a goal of 7 program graduates per month, a goal the FRP had met in 8 of the past 10 years. The analysis showed that profitability was closely tied to the volume of patients per month. Due to both practical and regulatory constraints, the program could not be offered to more than 9 patients at a time. Hazard felt frustrated by the opacity of the accounting system and the difficulty in fixing a precise number on the program’s profitability.
DHMC’s willingness to support the FRP did not imply a blank check. Indeed, the program has operated under financial pressures throughout its existence. Hazard has responded by systematically working to eliminate the least impactful elements of the program and reduce it to its minimum viable format. In its original incarnations in Texas and Vermont, the program had been much longer and more expensive.
In the middle of his medical career, Hazard founded and became CEO of a company that manufactured and sold his inventions in the U.S., Europe, and Asia. That experience guided his approach to perfecting the program through continuously monitoring outcomes and their response to program changes. He gathered data and experimented with removing various elements. He saw that results did not noticeably change when the program was shortened or when aqua therapy was removed or when psychiatric assessments and counseling were removed. (Hazard assessed both functional outcomes and depression scores.) As such, these elements were eliminated.
Beyond the intensive physical exercise, what remains is education and counseling aimed at enabling patients to take better care of themselves and building their confidence that they are better positioned than any medical professional to understand and manage their pain. For example, one counseling session focuses on the wide range of drugs prescribed for back pain and the benefits, risks, and side effects of each. In particular, the session encourages patients to reflect on their personal experiences with each prescription. Afterwards, patients feel empowered to identify the prescriptions most helpful for them and to avoid the rest.
Hazard was eager to see programs like the FRP spread, believing there was an enormous opportunity nationwide. The trends in spine care were clear and alarming. Volumes for diagnostics, pills, and procedures were growing strongly. Nonetheless, disability rates were going up at the same time. In his view, it was symptomatic of an enormous public health problem. A different approach like functional restoration was needed, yet only a small fraction of patients who could benefit from functional restoration had access to it.
Hazard wasn’t sure he had the desire to head a nationwide expansion effort, however, even if he could partner with a payer with motivation and money to spend. He wished to stay as close as he could to the patients he treated and to remain actively engaged in the ongoing process of perfecting the program. He felt that running a large organization would remove him from both.
That said, Hazard had endeavored to spread the program locally. He approached the VA hospital in nearby White River Junction, Vermont, for example, noting that the VA system was one of the few in the country that was not subject to volume-based (fee-for-service) incentives and that it had a large number of patients who could benefit from the FRP. Though he made some progress in Washington, the local VA to date has not come up with the funding needed to launch the program or even to compensate Hazard for the time he was prepared to invest. Hazard later pursued a partnership with a second nearby hospital, but became frustrated with what he saw as administrative inertia at DHMC.
Though much of his time was dedicated to the FRP, Hazard was hardly immune from the pressures of fee-for-service medicine. His clinical schedule was jammed. New patients booked appointments several months out. Free time to think about spreading the FRP was scarce. Nonetheless, he frequently hosted visitors who were curious and wanted to learn more about the program’s specifics.
He highlighted to all visitors what he believed were the two biggest barriers to success: First, it’s hard to make a profit under fee-for-service reimbursement. Second, it’s hard to find good people to work within such a program, and it takes time to deconstruct habits that may have been acquired in volume-driven or “find-and-fix” environments or that may be idiosyncratic to a particular medical profession.
Furthermore, functional restoration requires a team mindset. Hazard elaborated:
We all have our skills, but part of the job of running this program is nudging people from different disciplines—doctors, nurse practitioners, physical therapists, occupational therapists, and social workers—to adopt a shared set of beliefs about how to help patients achieve their life goals.