Back program succeeds without medication

Exercise and education are key components

Karen Bricker, MS, OTR/L, knows first hand about the effectiveness of her hospital’s back pain treatment program.

"I went through other programs and had to keep coming back. This was the first program that broke the cycle for me," says Bricker, who is director of rehab services at D.T. Watson Rehabilitation Hospital in Sewickley, PA.

The Watson Back Center program uses no modalities or medication but relies on a combination of exercise and education to help patients manage their own back pain.

For Bricker, the success of the program was due in part to learning she could manage her own back problems, rather than "going through a scenario where I was in treatment for months on end and building up a sick image in my mind."

The program uses little equipment, reinforcing the staff’s belief that back patients need to be involved in home exercises that don’t require elaborate equipment.

The results are dramatic. The average number of treatment sessions is 9.1, including the initial evaluation and two follow-up visits, over a 60-day period.

Pain reductions are considerable

The last 200 patients have reported an average initial pain rating of 6.5 on a 10-point scale when they started the program and an average pain rating of 1.5 at discharge.

"This is a system that is perfect for the ‘90s and beyond. It’s a very inexpensive, integrated model that makes the patient the focus," says William J. Somerset, DO, the hospital’s senior vice president for medical affairs, who developed the program.

In 20 years of dealing with musculoskeletal problems, Somerset lost faith in traditional treatment methods such as ultrasound, hot packs, and passive modalities.

Instead, he has found that getting the patient involved in his or her own care is the best way to get the muscular skeletal system back to a normal state of well-being.

"Our primary goal is to make the patients independent in self-management. This gives them a lifetime cure," Somerset explains.

The approach works, even for patients who might have tried other programs that didn’t help them.

"I have found that if you approach patients on the front end with consistent positive messages, you can be surprised at the outcomes you can get," Somerset says.

Patients typically come to the Watson Back Center over a two-month period, which gives them time to practice at home and come back for monitoring, Somerset says.

"We’re teaching them a skill, and we can’t just load them up in a week and assume they’ve got it all," he explains.

New patients are jointly evaluated by a physician and either a physical therapist or exercise physiologist.

"We make sure everyone is working on the same page at the same time. We have physicians working directly with the therapists from day one," Somerset says.

The physician makes a diagnosis and develops an individual exercise prescription.

Doses of exercise

"Exercise is the same as medicine; it has to be dosed. The type and frequency of the exercise varies according to the patient’s basic problem. We try to fine-tune our diagnoses," Somerset says.

The evaluation generally takes about two hours. The first hour-long therapy session, takes place in a small closed room with no distractions.

"We spend a lot of time educating patients about what their condition is and what it is not. People with soft tissue injury are fearful that something is seriously wrong, and they often are afraid to do anything," Somerset says.

All therapy is one-on-one, except when two staff members work with one patient, says Peter Chase, business manager and director of operations.

Patients are expected to perform a home-based exercise program from the first therapy session. The length of the home program varies from patient to patient but usually involves routines that can be done in a few minutes but must be done several time a day, Chase says.

"We try to put them in charge of their own back pain. We don’t view ourselves in the role of healers but in the role of teachers who can help educate patients to take charge of their back pain for the rest of their lives," Chase says.

Because education is a vital part of the success of the program, Somerset has recruited physical therapists and exercise physiologists with teaching experience.

Teaching background

"Unfortunately, therapists aren’t trained to teach. They are trained to get someone up and moving. Teaching psychomotor skills is a complicated art form. The people we’ve recruited all have teaching backgrounds, and that makes a big difference in a program that emphasizes education," he says.

The back center has developed its own outcomes measuring system, which runs on Fox Pro, an off-the-shelf software program and tracks objective and subjective outcomes measures.

Objective measures tracked include flexibility parameters, such as the resting length of key muscle groups, medication use, how often patients see other practitioners, and work status.

Patients are asked to rate their pain on a scale of zero to 10 and to take the center’s Physical Activity Restriction Scale that rates how much the patient feels the pain restricts his or her lifestyle.

Used together, the subjective and objective measures give practitioners a total picture of the patient’s status.

"There is a linear relationship between improving flexibility and decreasing pain," Somerset says. (For an illustration of this relationship, see charts, p. 48.)

Continuing pain indicates other problems

If a patient’s flexibility improves but the pain ratings stay the same, it’s a red flag that there may be other issues involved.

For workers’ compensation patients, this may be pending insurance settlements or problems with a boss at work.

For other patients, a disparity in the two scales can point to psychological issues such as depression, Somerset explains.

For the first 21¼2 years, referrals to the back center came by word-of-mouth from primary care physicians, orthopedic surgeons, and eurosurgeons.

Now, armed with successful outcomes data, the hospital’s marketing staff is making sales calls on physicians, workers compensation case managers, and acute rehabilitation hospitals.

Private pay insurers and workers’ compensation cover the back program, Chase says.

"Because we empower the patient to take care of their own back, in the long term, they are consuming fewer resources," Chase says.