Explaining Pain for Acute Back Pain – reflections on Traeger et al. part 2

4. Why am I excited?

First up, one of the great liberators of being a scientist is that we are not just permitted to change our minds, we are actually required to do so when the data say so. The Very Excellent Kevin Vowles uses the phrase ‘dance to the data’ and I like it. So, I have changed my mind about the likely benefit of just adding a two session didactic Pain Ed session to usual care for high risk acute back pain – let’s not do it.

Second – I am interested in the potential of harnessing these results to develop better pathways. The potential I see lies in the secondary outcomes but critically, secondary outcome findings are exactly that – they are NOT confirmatory results but they give us ideas for the next phase. That is, they are not used to make a finding but to generate a hypothesis for testing. That consistent and synergistic benefits were observed in secondary findings seems to suggest that a shift in direction is warranted and potentially valuable.

Here is the list of aligned results ALL OF WHICH ARE TOO SMALL TO SAY THE INTERVENTION WE DID WORKED: The Pain Ed group were:

  • Less disabled at 1 week and 3 months – 1.6 and 1.7 points on a 24 point scale (not a clinically important shift).
  • Less affected by their pain at 3 months – this small effect corroborates the above, perhaps suggesting neither are statistical artefacts, but we are not sure how much of a shift is important to people on this scale.
  • Lower proportion of people in the Pain Ed group were seeking health care at 3 months. I love the potential this kicks up – thinking $$ saved.
  • Less likely to have a recurrence of back pain in the next year. The risk of recurrence was 29% in the Pain Ed group and 47% in the other group. Thinking $$ saved again.
  • More convinced that nothing was seriously wrong in their back at 1 week (although see Point 3 above).

BUT WAIT! Beware the full picture – it is really important to concede that, at 12 months, the groups are pretty much identical. There is a lesson here and we are not the only ones learning it – better long term outcomes might (though also might not) need ongoing engagement with patients, or a ‘booster’, but a booster of what? We clearly need some fresh direction here.

5. My speculation and pitch to funders:

There is probably no point in just adding two hours of pain ed to otherwise good care. The outcomes in this high risk group were completely what we would expect of high risk patients who are participating in a trial (no matter what treatment they receive) and a bit better than if they weren’t participating in a trial. Even if all those secondaries that were different between groups were in fact primary outcomes of a trial with a massive sample size and we ended up with a whole lot of significant effects on targets we care about, the size of the effects would not be worth getting excited about (with the really interesting exception of recurrence and health care seeking),

So how will we respond to this discovery? Well, we have already responded because we have known this result a lot longer than you have! We have started by shifting our focus toward whole of community education, toward identifying the key concepts that actually do promote recovery and not fussing with those that don’t, toward better integrating self-management strategies, and focussing more on getting everyone – public, clinicians of all stripes and funders – onto the same page. A consistent and contemporary message may be a key missing piece of this puzzle.

My sincere hope is that this trial will trigger us all to (i) redouble our efforts to bring the best care as we currently know it to people in pain (‘do better’), and (ii) work more closely with clinicians, consumers and researchers innovating to improve best care as we know it. I suspect we need a coordinated community-driven and community focussed approach to this problem – I have ranted on this already – ‘whole of community education’. I still think education is going to be the critical piece we can get better, but this trial is sending our team and collaborators and consumer and clinician networks back to the fundamental question – what should education look like: the model we tested here is not it.

** In case you haven’t heard, I have a substantial conflict of interest when it comes to this subject matter. I stand to gain significantly, primarily in reputation but also in royalties for books, if pain science education is seen to be important. I co-authored the key texts “Explain Pain”, “Explain Pain Supercharged”, “Explain pain handbook: protectometer”, and “Painful Yarns”. I helped develop the curriculum for this trial.

About Lorimer Moseley

Lorimer Moseley Body In MindLorimer is Foundation Chair in Physiotherapy and Professor of Clinical Neurosciences at the University of South Australia, and Senior Principal Research Fellow at Neuroscience Research Australia. He has published over 300 scholarly works. His H-index is 71. He leads the Body in Mind Research Group, which investigates the role of the brain and mind in chronic pain.

Reference

Traeger AC, Lee H, Hübscher M, et al. Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain. A Randomized Clinical TrialJAMA Neurol. Published online November 05, 2018. doi:10.1001/jamaneurol.2018.3376