Adrian Traeger, PhD, is a research fellow at the Institute for Musculoskeletal Health, a division of the School of Public Health, University of Sydney. His research centres around developing strategies to improve healthcare for low back pain and other musculoskeletal conditions. He completed his PhD at the University of New South Wales and Neuroscience Research Australia with Professor James McAuley and Professor Lorimer Moseley and has worked as a primary care physiotherapist for over a decade. You can find Traeger on Twitter @adrian_traeger. Traeger recently won the Australian Pain Society’s Rising Star Award for 2022, which showcases up-and-coming pain researchers.
Traeger will deliver a plenary lecture focusing on the overdiagnosis of low back pain at the upcoming 42nd Annual Scientific Meeting (ASM), to be held in Hobart from April 10-13, 2022. As part of the build-up for the ASM, Traeger spoke with Lincoln Tracy, a research fellow from Monash University, Australia, about his passion for evidence-based medicine, how a chance encounter with research students led to him pursuing a PhD, and his work on the overdiagnosis of back pain. Below is an edited transcript of their conversation.
What was your path to becoming a physiotherapist?
My first degree was in exercise science, which I completed at the University of New South Wales in the early 2000’s. Even then I was interested in pain and knew from early on that I wanted to be a physiotherapist. After I completed that degree, I studied a Masters of Physiotherapy before working in private practice for several years. I was a generalist physio working in a family practice, so I saw people of all ages with different musculoskeletal problems. That’s where my interest in pain and research really started.
How did that initial interest in pain spark your transition into research and pursuing a PhD?
When I was studying my physio degree I was very interested in evidence-based practice and this database—the Physiotherapy Evidence Database (PEDro for short)—which is still around today. I was really interested in the concept of how at one end of the scale you could have good research that would be very informative for clinical practice, and on the other end you would have lower quality bits of evidence that you didn’t need to pay as much attention to. I loved the idea of having this information to back up my practice. When you get into clinical practice you have mentors who say things like “You do things this way, or that way”, which means you end up practicing in a way that emulates your mentors. I wanted to know more about why I was doing what I was doing and what the evidence for it was, rather than just doing what has always been done or what keeps patients happy. So, that concept of evidence-based practice came early.
After a few years of practice, I went to the local pub with a colleague for a trivia night. I was introduced to this intelligent group of people and thought, “Who are these people and what are they doing in this daggy pub?” As I was speaking to them, I learned that many of them were PhD students at the University of Sydney some were from Brazil, others from North America, and we got chatting about the research lifestyle. It sounded appealing to me, and I decided it would be something to pursue. I got my chance when I saw a PhD opportunity at the University of New South Wales with Professor James McAuley and Professor Lorimer Moseley. I had read Explain Pain, and it was something I used in my clinical practice. I thought that would be a great way for me to break into research.
Your plenary at the ASM will focus on the overdiagnosis of back pain, why is this such a problem?
Overdiagnosis—which has been the topic of my postdoctoral research—is interesting because it looks at a problem where healthcare doesn’t lead to benefits like you think it should. The natural understanding of healthcare is when people receive healthcare, they are better off and it’s a benefit to society. There are lots of places around the world who don’t have adequate access to healthcare, which is a major global problem—that’s what we call an ‘underuse’ problem. But what’s interesting is there can be overuse problems in healthcare as well. In this situation, you provide health care, but it doesn’t provide any benefit to the patient. Furthermore, it can harm the patient: through their experiences of healthcare, side effects of the drugs, or through lost work and productivity from having to undergo these treatments.
I got really interested in this during my PhD. When I started my postdoc, I worked with a research collaboration called Wiser Healthcare, who had been awarded a big NHMRC Grant to investigate the problem of overdiagnosis or overuse across Australia. I worked on a part of the collaboration, trying to understand the overuse of diagnostic imaging for back pain. If someone has clinical features of a serious condition, they really need the imaging and they need it early to help guide treatment. But most people who hurt their back don’t need imaging.
Despite this, we know 30 to 40% of people who see their GP or go to the ED with back pain get a scan. Ordinarily that wouldn’t really be a problem because you think, “Well, it’s not a costly service, isn’t it better to be sure there isn’t anything serious?” but a lot of people have back pain in Australia and a lot of people go to the doctor for it. So, it all adds up to a lot of wasted money that could be spent on other areas that would improve health. The other problem with the back pain imaging issue is that if someone takes their report home and it has terms like “degenerative changes” or “arthritis”—things we don’t think have a strong association with back pain—it can be very worrying to the individual and can lead them to pursue other types of healthcare that we know aren’t helpful.
What are some of the things we can do to stop the overuse of imaging in back pain?
That’s a great question. The work we’ve been doing in the ED has been trying to quantify the overuse problem, which is a tricky thing to do. We have data collected from our hospitals that tell us how many people who come in with back pain and get a scan. But that number alone—the proportion of people who get imaging—doesn’t tell us whether it was overuse or whether that person needed the scan. To properly measure overuse, you’d need to go through and read a person’s notes, which is very time-consuming if you look at thousands of episodes of care. But we’ve figured out a coding system we can apply to someone’s notes and determine whether this person needed imaging or not, then we can look at whether they had imaging. Using that approach, we can estimate how much of the imaging that’s being done in emergency departments is necessary and how much is overuse.
We can also estimate the underuse problems, as there are people that still go to the ED needing a scan but miss out on one. That’s been interesting to explore because traditionally it’s been thought that imaging is generally done too much for back pain. Which is true but, but when we looked at the data, we found there was an underuse problem as well. This means we need to be careful when we’re intervening. Regardless of what strategy we use, you don’t want to reduce the overuse problem and then increase the underuse problem, which would be catastrophic for some people who miss out on a scan who need it.
A lot of my work has been looking at how to balance those two issues. We recently published a paper looking at the effectiveness of an education strategy in reducing the use of back pain imaging in EDs and discovered it didn’t work very well. So, we’ve been looking at other approaches such as behavioural nudging. These are changes to the doctors’ environment that encourage them to provide a scan when it’s needed and discourage scans when they’re not needed. For example, these can be cues on the computer screen, posters in clinical areas, or having doctors publicly commit to what’s called stewardship and only providing these scans when they’re needed. These cues have been shown to be effective in reducing opioid prescribing in the United States, and we want to try and do something similar in Australia with using imaging for back pain, among other things.
What does winning the APS Rising Star Award mean to you?
It means a lot because it’s recognition of nine years of work. These sorts of prestigious awards don’t come around every day. I’m approaching mid-career status—I’m just under five years post-PhD—and this is the stage where things become more and more competitive, so it’s very meaningful to my career. The other thing that it means is the recognition in the pain research community that overdiagnosis and overtreatment can be a problem. My view with the field of pain research is there has been a lot of focus on undertreatment of pain—which is important as the undertreatment of pain is a key global issue—but the overuse problem us still an issue. I see this award as a way of the APS recognizing the overuse issue. I’m proud of that.
What’s the most interesting study you have been involved in?
I was recently involved in a collaboration with the Federal Department of Health, a nationwide randomised trial to reduce the use of musculoskeletal imaging in Australia. I worked in a team led by Associate Professor Denise O’Connor and Professor Rachelle Buchbinder to recruit over 3,800 GPs who prescribed more musculoskeletal imaging than their peers. We used some of the behavioural nudging strategies I mentioned earlier—we looked at the effect of sending GPs a letter saying, “You’re prescribing more than your peers. This is where you are performing, and this is where your peers are performing.” We found that just a letter could reduce imaging rates and the number of tests orders by the thousands. It was a great example of an interesting and fairly low-cost intervention to improve healthcare.
What’s one important thing you think all early career researchers and trainees should know?
The main thing I’ve learned is the importance of research to human health. Before I became a researcher, I thought of research as just these academics toiling away in their labs and making big discoveries every so often. But in reality, research is this incremental thing where even the smaller studies—when they’re done properly—have the potential to have a broad impact on human health, and different to the impact you would see as a clinician. Unfortunately, it’s easy to lose sight of the potential benefits of research, so I would really encourage people to keep that in mind.
Finally, if you could have a dinner party with anyone from history—dead or alive—who would you want to invite and why?
I would have [late British journalist and critic] A. A. Gill, whose food and travel columns I loved to read. He was a master of language with a clever sense of humour. I’ve learnt a lot from his writing style and observations on living a good life. For some light relief I’d invite Australian comedians Gina Riley and Jane Turner of Kath & Kim fame, which is one of my family’s favourite shows of all time. Though I’ll admit my kids (aged 5 and 8) don’t tend to laugh at it–more look on with a horrified smile! I’d also love to meet some of the researchers involved in developing the Oxford COVID vaccine, like Professor Sarah Gilbert. This is a discovery that has saved many lives already across the world. It was the vaccine my wife Amy received when working as a nurse throughout the pandemic; I remember the gratitude I felt the day she received that vaccine. So I’d love to meet her. And I’d probably have to invite the Obamas. And of course, I’d invite my mum and dad, just so I could introduce them to all my dinner party guests and see their faces. Neither of my parents are academics or went to university—my dad was a joiner, and my mum a homemaker—but they are great conversationalists. I would love to see how they interacted with these guests.
Lincoln Tracy is a postdoctoral research fellow in the School of Public Health and Preventive Medicine at Monash University and freelance writer from Melbourne, Australia. He is a member of the Australian Pain Society and enthusiastic conference attendee. You can follow him on Twitter (@lincolntracy) or check out some of his other writing on his website.
Australian Pain Society 