INTERVIEWS
Interview with Dr Adrian Traeger By: Matthew Bulman BHSc, MChiro
Dr Adrian Traeger is a postdoctoral research fellow at the Institute for Musculoskeletal Health, a division of the School of Public Health, University of Sydney. He is a physiotherapist who has worked in primary care for over 10 years. He completed his doctorate at NeuRA, UNSW, which focused on how best to reassure patients with low back pain, and has been actively researching and publishing in the area of back pain. He was kind enough to find some time within his busy schedule to answer a few questions for our membership. Q1. You have been publishing some fascinating and influential research in the area of back pain, and most recently, “Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain A Randomized Clinical Trial.” in JAMA Neurology This trial investigated the question, “Is intensive patient education effective as part of first-line care for patients with acute low back pain?”. Guidelines suggest this to be an intervention strategy. What did you find in your trial? And what are the implications and recommendations for practice? It was certainly an interesting trial to be part of. Up to this point we really had no robust evidence that patient education could influence outcomes in people with acute low back pain. We felt patient education was the most likely treatment to work; we had evidence it was reassuring, and hypothesised that high quality reassurance was the key to recovering. Other physical and psychological treatments hadn’t shown much promise for these patients. Patient education was the one thing we felt could change the trajectory of acute low back pain, through two pathways: a direct pathway (reducing threat of pain, therefore reducing pain intensity) and an indirect pathway (encouraging gradual return to activity and work). In the trial we had 2 groups of 101 patients with acute low back pain. The intervention group received 2 x 1hour sessions of patient education based on the book Explain Pain. The control group received placebo patient information, which was everything the intervention group received – time with practitioner, empathy – minus the information and advice-giving component. What did we find? To our surprise, the intervention had no effect on our primary outcome, which was pain intensity 3-months after the onset of pain. This was really challenging to accept. Many believed, including me,
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CA NEWS MARCH 2019
that what you say to a patient can have important impact on outcomes, whether that be indirectly through encouraging positive behaviors (e.g. taking an active approach to recovery) or directly, by changing the threat of pain. Our trial really turned those theories on their head. Q2. This trial has caused a lot of uproar on social media, as well as in different clinical and scientific corners of the world. What is your perspective of social media for clinicians, researchers and health consumers? I think social media is a great way to amplify the messages coming from research. Some of the detail and nuance of the science is inevitably lost in short-form, which can be problematic, but in general it seems like a useful way for clinicians and researchers to keep up with research. With regard to the uproar about our trial, it wasn’t wholly unexpected. We tested a popular treatment, one that is taught around the world. Nobody likes to think that the approach they advocate for, with the very best of intentions for their patient, is ineffective. The beauty of science is that the results of our trial are not a matter of opinion–they are a simple fact. The question now is what can we do with this new knowledge to improve patient care? Q3. Another area of research you are involved in is reducing unnecessary imaging for low back pain. Chiropractors are very split in this area, with the research community and evidence based chiropractors aligned with best practice, hoping to reduce
