Guest: Professor Mark Hancock
Presenter: Wayne Bucklar
Guest Bio: Mark Hancock is an Associate Professor of Physiotherapy, Faculty of Medicine and Health Science, Macquarie University. He has 20 years of clinical experience as a musculoskeletal physiotherapist working in a primary care setting. Mark now works full time as an academic/researcher. His research focuses on the diagnosis and management of back pain. He has published over 70 peer reviewed papers and received over 2.7 million dollars in funding. He has published in leading medical journals (e.g. Lancet, BMJ and Annals of Internal Medicine) and discipline specific journals (e.g. Spine, Physical Therapy).
Segment overview: For our Health Academy Series today, our guest is Associate Professor of Physiotherapy Mark Hancock from the Faculty of Medicine and Health Science at the Macquarie University. He has a particular research interest in better understanding the causes of low back pain and identifying subgroups of patients who respond best to specific interventions. Today he will be sharing his thoughts about the different approaches which may lead to better outcomes. Many believe in better matching of treatment to individuals but how we do this is controversial and interesting.
Health Professional Radio
Wayne Bucklar: You’re listening to Health Professional Radio with Wayne Bucklar. This is the Health Academy, our regular chat with academics who are working in medicine and research as in clinicians both who are working in particular areas and today our guest is Mark Hancock. Mark is with Macquarie University Hospital and as a specialist in musculoskeletal physiotherapy, and I think Mark a particular interest in the lower back?
Mark Hancock: Yes, that’s correct Wayne.
W: Now Mark thanks for your time in talking to us on Health Professional Radio. We like to get our ears into the academic sphere from time to time to hear what’s going on. Tell us about your research and what’s been happening.
M: Sure. Wayne most of my research covers pretty much all aspects of back pain involved in diagnosis, prognosis and treatment study. But I guess I have a particular interest in a better understanding of the causes of back pain and how we identify what we might call sub groups of patients who respond best to a particular intervention. So to give you a little bit of background, for the last 15 or 20 years pretty much all guidelines around the world are recommended that back pain is manage with the diagnostic triage, so this involves identifying patients who have serious cause of back pain, so things such as fracture or cancer. And also identifying patients who have no nerve involvement, what we might commonly call “sciatica.” And then it’s recommended that the rest of the patients which is pretty much 85 to 90% are considered to have nonspecific or simple back pain. And I guess it’s been argued that its need a possible all necessarily important to identify the cause of this patient’s pain and then we can treat them without that. But we’ve been following this approach for quite a long time now and what we’ve found with a lot of big trials that we’ve run is that most treatment have small effect on these patients but we’re really not getting a good outcome that we’ve like to. It’s I guess…
W: It does seem Mark from a lay man’s perspective that back pain is very common but the treatments are very different.
M: Exactly. There’s just a huge range of treatments that are out there and at the moment there’s not a really good reason, I guess I’d argue that many patients they’re getting the particular treatment that they get. So what we’ve really become more and more interested in this kind of work out which patients require which type of treatment, and if we do then hope for the outcomes be much better. So when you talk to clinicians or patients, they’ll often say “Look, a certain person done very well with one type of treatment,” that other patient do really well with the different type of treatment. And that would think pretty obvious, but it’s actually not the way most of the big trials we’ve tried, so on the big trials you take this group of nonspecific back pain patients and they will all get manual therapy or manipulation or they’re all get a certain medication. And as we said we’re getting disappointing results to that, so broadly speaking may interest is in trying to better target the right treatment for the right patient.
W: Now I see on your bio that you’ve published over 70 journal articles and including some of the big names – Lancet, BMJ, Archives in internal medicine so I’m assuming that evidence based medicine is very much in your focus. How should this trial be conducted if what we’re doing is not working now?
M: Sure. Look what we’re trying to do I guess develop trials that within the trial design try to answer this question of whether the patient will do better with specific types of treatment. And there are some of those trials that have started to come out recently. So as an example there is a trial that was called the “STarT Back” trial that was published in Lancet a couple of years ago from Jonathan Hill and some colleagues at Keele University. And so they looked at a targeted, or stratified care approach where they use a simple tool to identify initially patients that are likely to recover well without much intervention, a patient who have a poor prognosis. And then based from this information they’ve then targeted both the type of treatment but also the amount of treatment for those different individuals. And what they found in their trial is that by doing this – they do produce better outcomes, but interestingly in the patient who had a good prognosis, the outcome was just as good if they go some very little treatment. So basically they’re saving money in that group of patients and then I guess using that money to provide more and better treatment for the patients in that room more likely to go on develop chronic pain.
W: So is it your view Mark that there is a lot available treatment of simple back pain?
M: Absolutely. I think we’ve got really strong evidence, we’ve done quite a few big prognosis studies looking at the cause of back pain. And we know that the vast majority of people will have simple pain and haven’t had it for very long you know just a week or two, a lot of those patients will recover very well with minimum treatment. And there’s really strong evidence for that now. So again that’s one of the challenge it leads to – clearly identify those people who need simple treatment, just good advice, good reassurance, possibly simple medicines and then really just monitoring those people over the first couple of weeks. But some of those big studies which show that probably 80-90 percent of those people will recover within 2 to 3 months, if they’re pretty much left alone.
W: Is there room to suspect that some of this back pain is kind of chronic lifestyle issues that really ought to be prevented rather than treated?
M: Yeah, it’s a very interesting question. We’ve become more and more interested in prevention at the moment because whilst I told you that many people with back pain recover, well we also know that a huge proportion of those patients will have recurrence, so some of our best studies would say about 50% of patients will have a recurrence of their pain within a year. So prevention is really an area we need to look at more. It’s actually an area that there’s surprisingly little research in back pain, there would be 10 times many trials on treatment as there are on prevention probably far more. With regards to lifestyle factors again we don’t know enough about it and I think that’s the challenge we need to go back and better understand which variables and lifestyle factors are critical for back pain. And then as we better understand those things, then we’ll be able to target the treatments more effectively.
W: And I guess funding is always an issue here. It’s always easier I think in Australia particularly to get funding for ambulances than to get funding for road traffic signs. We seem as a culture there is much more interested in the end of the process rather than the beginning. Is funding difficult to get for these studies which are about prevention?
M: Absolutely, that’s pretty much been our experience. We’ve had a prevention trial with bunch been trying to get funded for a while now. We’ve got small amounts of funding but really not the funding to do the big trial we’d like to. And that’s exactly right, it seems to be easier to get funding you know for patient with pain rather than to prevent it. But really long term I think prevention is probably gonna be arguably more important in back pain. And generally speaking, back pain and musculoskeletal conditions whilst they’re responsible for a huge amount of the burden of health conditions, they don’t tend to get the funding some of the other annual life threatening conditions.
W: Yeah, I can see how a funding body would be influenced that way. Mark do you think there’s an increasing prevalence of back pain? Is it something that’s been growing? In my head I think well generally work has become less manual and work … become more conscious of safe processes. Is the incidence increasing or decreasing?
M: I think the best evidence we have is that it’s probably fairly stable, but if anything increasing rather than decreasing. Obviously one of the challenges is are we reporting the pure incidence or the incidence that people are reporting their back pain -going to see, seek health care etc. So we see that its influence by different countries, different cultures etc. But broadly speaking the reduction in manual labor it doesn’t seem to be reducing the incidence of back pain and arguably the increase in sitting in our community and the decrease physical activity maybe contributing to an increase. So physical activities an interesting one, people have been looking at this for a while and sometimes with different findings but a common finding seems to be that very low levels of physical activity may increase your risk of back pain and very high levels of activity may also increase and somewhere in the middle it’s maybe more protected.
W: From my point of interview it’s interesting, I as you can imagine lots of the media area bout health related things in this job and the two things that keep cropping up in my reading at present sugar and sitting has been big villains in health.
M: Absolutely. Now sitting is definitely a popular thing at the moment with regards to the potential risks independent of actual physical activity. But look, many patients will tell you and they do believe that sitting is something that causes that pain and some colleague of mine have just done a study where they looked at what would patients doing right before they’ve got their back pain and compared that to a window of time, maybe a week or a month before. So using the patients as their own control and trying to look at practice that were associated with back pain and sitting is something that does seem to come up in these studies. Again it’s that challenge that for different people, it’s different. So for some people sitting is the problem, and for other people it’s seems to be something quite different.
W: Mark many of our listeners are clinicians in acute care settings. What’s the message you’d like them to take away from chatting today?
M: Well with regards to managing back pain, I think at the moment we need to provide simple treatments. The treatments with the best evidence in patients who had short term back pain are very much encouraging patients to remain active, giving patients reassurance that they’ve got a good prognosis. And then if patients aren’t responding to those treatments then it’s appropriate to go and get further investigation for further treatment. There’s pretty strong evidence at the moment that imaging patients with back pain is not helpful, and that touches another issue that I’m interested in that I think we need to image patients in a research sense to better understand back pain which may lead to better treatments in the future. But at the moment there’s strong evidence that imaging patients doesn’t improve their outcome, it doesn’t guide treatment. So our nest patients are very small group of patients where we’re can see during surgery and that really is a very very small group.
W: Uh huh.
M: But imaging is not recommended at the moment.
W: That’s an interesting perspective Mark. I’ve been talking this morning with Professor Mark Hancock from Macquarie University Hospital. Mark is an expert in back pain and musculoskeletal physiotherapy. Mark one of my favorite questions is about misconceptions, are there misconceptions in your field that drives you nuts and keeps you awake at night?
M: Well I guess we’ve touched on it in some ways.
M: Misconceptions that having imaging is really important and without that your back pain can’t be manage. So one of my recent PhD student actually did a survey where she asked patients all turning up to a GP or any health condition, how important they though it would be for them to have imaging if they have back pain. And the vast majority of them thought that it was really important to be able to get that. And at the moment as I said that’s not the case so we’re wasting money doing that and we’re also actually not helping patients. So I guess that’s something and I guess the other frustration is that everybody’s got their own story. They had some treatment often some quite alternative treatment that they think is the cure to all back pain but we know that that’s not. It’s just not that simple, you know when we test any of this intervention in big groups of people they really don’t have big effect across a group of people which brings us back to that issue that we’ve got to find out which patients need which treatment and that’s where our focus is.
W: That would be intriguing research to see as it develops Mark. That I idea of anecdotal self-diagnosis which kind of use to occur unlimited basis now with Dr. Google on hand as being boosted astronomically. And I do in this job, hear story all the time of people who’ve got a kind of case study of one with no rigor who bring enthusiastically promote it because that’s what worked for them.
M: Exactly, yeah.
W: Mark it’s been a pleasure having you on Health Academy with us this morning, I’ve enjoyed our chat, however we’ve run out of time, once again as we often do when we talk to academics because of all the people around, clinical academics are people who know their stuff inside and out and happy to talk about it -o it’s been a pleasure having you on. For people who’ve have just missed our chat, the good news is that we have a transcript on our website at www.hpr.fm and you can also catch the interview both on SoundCloud and on YouTube. Professor Mark Hancock, thank you very much for your time this morning.
M: Thank you Wayne, it’s been a pleasure.
W: This is the Health Academy on Health Professional Radio.