Functional restoration

It’s a Wednesday afternoon in a gym in a leafy Birmingham suburb, and nine people are lying on the floor with their eyes closed, having completed a half-hour exercise session. Lulled by a calm, low voice in the background, some of them have taken themselves off to a tropical beach or their favourite garden chair, and one or two – as some gentle snoring suggests – have drifted off completely. They are all patients at the city’s Royal Orthopaedic Hospital (ROH), and they’re in the physiotherapy gym here as participants in an innovative programme to treat their persistent back pain.

It’s the hospital’s functional restoration programme, led by physiotherapist Dave Rogers and supported by an orthopaedic physician and a pain counsellor. Functional restoration is a 12-hour combined physical and psychological programme of treatment, which aims ‘to train patients to become experts at understanding their persistent low back pain, to manage flare-ups in pain effectively, to set goals to improve function, to reduce reliance on analgesic medication, and to engage in healthy behaviours’. 

This is week three of the four week-programme. The session start with participants sitting in a semi-circle facing a flip chart that lists their self-set goals. They mostly feature some kind of activity – the golf driving range, for example, walking 6,000 steps a day, or swimming – apart from one that says ‘stop at 8pm every day’ set by someone who feels they need more relaxation. Each session starts by reviewing these goals, discussing progress and how people feel. Group members talk one at a time, listening to each other, nodding in agreement when someone says ‘I’m really suffering the last few days but I can feel the exercise is really helping me’ or ‘it’s hard to do certain moves but I try to push myself a bit more’. They feel informed, confident, comfortable as a group, and buoyed by the knowledge they’ve acquired over the previous sessions.

Understanding flare-ups

The focus for this session is on managing flare-ups and reducing the risk of them occurring. One of the group describes a flare-up: ‘My body goes into slow mode. My whole body hurts not just my back. Everything builds up in me. I’m in a vicious circle – when I feel like this I get stressed about feeling like this.’

Everyone experiences flare-ups but their triggers vary, and Rogers encourages the group to recognise their triggers, saying: ‘Sometimes with flare ups it’s helpful to think if there’s a pattern.’ They all agree that stress is a consistent trigger, and Rogers concurs: ‘It’s one way of your body saying ‘enough’s enough’’. His solution is a plan to follow when a flare-up occurs. It’s a combination of awareness, acceptance, mindfulness and activity. He explains: ‘Your pain system is designed to attract your attention, so when you get a flare-up you will feel pain. It can overwhelm you, but the plan is there to manage that and stop it taking over.’

The way Rogers speaks is a conscious approach and part of the programme. ‘We use helpful and careful language,’ he says, ‘Developed through the principles of cognitive behavioural therapy (CBT), using metaphors and visual analogies.’ This contributes to the demystification and aids understanding.

Pain psychotherapist Abigail Darling applies the same approach. Her first contribution to this session comes at the midway point when she encourages the group off their chairs for some mindful walking. (‘Next week,’ she teases, ‘we’ll do some mindful chocolate eating.’) They spend a few minutes walking around the gym, focussing on the movement of their bodies before regrouping for a short anatomy lesson about how the brain works. This, also, is aimed at promoting understanding of the processes going on when their back pain strikes. Darling explains the flight or fight impulse, and demonstrates breathing techniques to manage pain response. ‘Slow breathing,’ she says, ‘tells the brain it’s time to relax.’ 

Suitably relaxed, it’s time to move. The chairs are stacked away and the exercise equipment comes out. ‘They do 30 minutes of exercise in the gym, in simple circuits, using gym equipment plus stretches and weights,’ Rogers explains, ‘and I see myself as a coach. At the first session, they were all a bit nervous, and tended to stick to just one thing. Now they’re working their way round the room having a go at different kinds of exercise.’

Developing the programme

Rogers originally worked at the ROH earlier in his career as a specialist MSK advanced practice physiotherapist. Working predominantly with back-pain patients, he became disillusioned, saying: ‘I realised the model to treat chronic back pain wasn’t working. So I left.’ 

Keen to learn more about what would work, over the next few years he was introduced to group-based cognitive behavioural therapy (CBT) techniques, and worked with an occupational health provider managing people with MSK issues back to work. He also completed a Masters in Pain Science and Management at Keele University. 

The ROH’s functional restoration programme, the hospital’s first combined physical and psychological treatment for back pain, started off as a CQUIN (Commissioning for Quality and Innovation) project in 2011. Back at the ROH by then, Rogers developed the model with clinical colleagues, and gained support from the trust board and medics.

He explains: ‘At the time, NICE guidelines were recommending that such programmes run over 100 hours but we weren’t going to get funding for that, so to make it affordable and get agreement from commissioners, we put together a programme that ran twice a week for four weeks – 12 hours in total. And we got the funding.’

Patients are referred to the programme from spinal clinics, physiotherapy departments, and from their GP. There are around 40 referrals a month, and up to 12 people are accepted for each group. Typically these will be adults of any age who have suffered with persistent back pain for at least 12 weeks, which has not responded to routine primary care management, such as GP advice or medication. They will be working people, possibly off work due to their condition, but motivated to improve. 

‘We do screening to assess people’s motivation for change before we accept them on to the programme,’ says Rogers. ‘It looks at their goals around quality of life. If they can’t set a goal, they can’t join the programme. They have to want to do this.’

‘There is a physical assessment to rule out other issues or causes and make sure there aren’t underlying conditions that could mean they shouldn’t participate in the physical exercise. But, generally, when the diagnosis is non-specific back pain, this treatment can work, and data shows us that surgery, injections and drugs don’t necessarily work.’

Impressive results

The four-week timetable involves a mix of education, exercise and relaxation. ‘We’ll look at how they do activity and give reassurance throughout,’ Rogers says, ‘We explain the biology of pain. It’s logical to feel pain and it’s logical to protect yourself from pain, but understanding that what they’re experiencing is more to do with the nervous system than with tissue, helps people to manage it.’

The service has been evaluated and the results are impressive, with clear evidence of its effectiveness in reducing back disability and pain self-efficacy. It is low cost with wide potential for savings. Rogers points out: ‘As well as the positive outcomes for patients, there’s a financial incentive for services. Long-term this could provide huge savings for the NHS. It’s a no-brainer.’

After a couple of years of successful results with the programme, Rogers and his colleague Dr Grahame Brown developed their study into a book, Back to Life.

‘It’s a great title,’ says Rogers, ‘Because that’s exactly what this treatment does – brings people back to life. It has major health and lifestyle benefits.’

The book is part of the team’s push to promote the programme and its outcomes more widely, and to demonstrate the crucial role physiotherapists have played in its success. A report on the service is included on the Innovations in Physiotherapy Database, with one of the learning points noted as ‘physiotherapists can play a key role in redesigning musculoskeletal services to improve health outcomes for patients’.

‘Physiotherapy is the lead on this, and more physiotherapists can be doing it.’ Rogers says. As well as his role at the ROH, Rogers is a first contact physio and he has used the same approach to treat some of the patients he’s seen at the surgery. 

He firmly believes that combined physical and psychological approach is the key to successfully treating and managing persistent back pain. ‘We’ve got to get this right when we’re training physios,’ he says, suggesting that both undergraduate and post-graduate students should be learning about the psychosocial approach and being taught the principles of CBT. 

‘It has multiple applications. It could work for lots of other conditions – not just back pain – and it could enhance both rehabilitation and prehab,’ he says.

As the two hours comes to a close, Rogers observes the group finishing up and leaving the gym: ‘Two and a half weeks into the programme, some people are making really good progress. As long as you’ve got a focus on where you’re going, you can get there.’

Rachel’s story

‘I’ve suffered with back pain since I was in my early 20s, so about 25 years now. I don’t know exactly what caused it but a few things may have contributed: I had a car accident and I fell off a stage and down some steps.

Over the last 10 years it’s become more and more painful. There’s been times when I’ve nearly passed out with the pain. I was on 32 tablets a day. Doctors would give you a tablet for the pain, another one to treat the side effects of that, then they caused other things and you got more tablets. 

Through all this I was still functioning. I won’t stop work – that’s one of my things. If I do, my pain’s taking over me and I want to take over the pain.

It was getting to the stage where it was affecting our life and I didn’t want the family to be suffering just because I was. I wanted to achieve a pain-free, normal life, so I went back to the doctor and asked if there was another way to do this. By then tramadol, wasn’t working so I was having morphine and diazepam. I had a really good doctor who listened to me, and we worked together to get me off the tablets, and went from there to where I am now. I want to try and be medication-free and I am at the moment.  

Last December I had a really bad flare-up so I went back to the doctor, and then I got referred to the Royal Orthopaedic Hospital. They told me about various options, injections, an operation, or this programme. I was told it would help me change my behaviour towards the pain, and it interested me because I felt that I’m not quite there myself. Also I thought it would be great to do it with other people and speak to them about their experiences. 

The first week we paired up and had to learn what the chronic pain was from the other person and then explain it to the group. From that we all had an equal understanding of each other, and that bonds you and brings you together.

Three weeks in, it’s making me more aware of when the pain is hitting in, now I’m ‘what are my thought processes around it? I know the pain is real but am I making it worse?’ When you’re stressed you tense your body, that’s what gives you the spasms, and this is helping deal with that. It’s the mindset, the breathing, thinking about things like that. That last 20 minutes of the Wednesday session where we’re lying down doing the relaxation – that’s really helped.

My job is demanding and can be quite stressful. I’m a HR co-ordinator, dealing with all sorts of things, sometimes welfare issues, and you have to try and help other people. It can be quite challenging and distressing. The relaxation is helping with that pressure. I’ve found an app with relaxation techniques, including a lunch break one that I’ve started to do at work. They’re only six minutes and really good.

This programme is not for everybody. To do it you’ve got to be in that mindset of wanting to live your life. But it’s giving me confidence in my body again, confidence that I can do more things than I was allowing myself to do. And that makes a huge difference.’

Further resources

• A 12‐h combined physical and psychological treatment programme for patients with persistent back pain
• Functional Restoration Service 
• Cognitive Behavioural Skills to Treat Back Pain: The Back Skills Training (BeST) Programme  

Author : Lucie Culkin