Interview with Dr Adrian Traeger

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,

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 unnecessary imaging. But empirical data suggests many chiropractors (and other health professionals) stray from best practice. What are some of the benefits to be gained with better use of guidelines for imaging? What are some of the unintended consequences of using too much imaging?

The benefits of following guidelines are better outcomes for patients and lower risk of harm. We know that routine imaging has no benefits for back pain without features of serious pathology, but substantial risk of harms (e.g. radiation exposure, distress caused by pathoanatomic labelling, further unnecessary tests and procedures). By following guidelines you avoid exposing your patient to these harms.

Q4. And in your opinion, who is the best audience to target? Clinicians? Or the public?

I think both clinicians and patients should know about imaging guidelines, and risks associated with unnecessary imaging. It is a very complex issue though. My feeling is that we need a big cultural shift in how we think about low back pain, if unnecessary imaging rates are to drop. As long as people (clinicians and patients) believe you can see pain on an imaging scan, they are probably going to want the test. There are also medicolegal concerns that drive a lot of imaging, not wanting to miss something. These cases are rare but catastrophic for the patient and the clinician involved. We need to think of new ways to protect both parties without resorting to routine ‘defensive’ imaging.

Q5. You also recently published an article, Lumbar spine fusion: what is the evidence? What should clinicians and the public know about Lumbar spine fusion as an intervention?

Don’t do it for back pain! The available evidence suggests no benefit of spinal fusion, but the costs are huge, and the surgery carries a substantial risk of harm.

Q6. You and Steven Kamper published an article examining the concept of placebo, asking if it is time to abandon the concept. What are some of your thoughts on placebo, contextual effects and the clinical encounter?

That article was a call for researchers to think carefully about what they label “placebo.” The placebo effect itself is not a meaningful way of conceptualizing what happens when one is provided, e.g., a sugar pill. There are all these other factors at play in that intervention: expectations, emotions, the relationship with the practitioner. So if something believed to be inert (e.g. sugar pill) is having an effect on a person’s outcome, rather than label it a placebo, we should try to be explicit and find out exactly what part of that intervention had the effect.

Q7. At the Sydney Musculoskeletal Conference, we briefly discussed some other areas of back pain research which may have less than optimal evidence. Can you mention any of these?

Advice to stay active is not underpinned by a solid evidence base. I think after the PREVENT Trial, it is essential that we do more trials of advice and education to determine what advice, if any, is most effective for people with low back pain.

Q8. What projects are you currently working on or interested in exploring?

I am working on campaign to raise awareness of overdiagnosis. Overdiagnosis occurs when a person is given a diagnosis, for example from a health practitioner, that causes more harm than good. An example of this could be giving a person the diagnosis of a ‘disc bulge.’ There is no robust evidence that providing pathoanatomic diagnoses such as this can improve outcome. However, we do know that such labels can make recovery slower, increase healthcare use, and increase surgery. Overdiagnosis doesn’t just happen in musculoskeletal conditions; there are examples in many other medical fields such as cancer, cardiovascular disease and mental health.

Q10. You seem to be interested in shifting health literacy for the public’s benefit. What ways can we better improve health literacy? How can evidence based chiropractors help?

I am very interested in empowering the public to make informed choices about their healthcare. That is one thing we know patient education can do: reduce fear about illness and reduce healthcare utilisation. Not a great business model for a practitioner in private practice, I know, but I think chiropractors could really set themselves apart from the pack if they could use evidence-based patient education to improve health literacy, and combine that with treatments that we know can reduce pain.

Make sure you have a seat at the National Conference.Early Bird Registration Now Open – www.chiropracticaustralia.org.au