James is Manager of the BiM research group at NeuRA. James is a veritable expert at this sort of thing – having been Manager of the Back Pain Research Group at Sydney University and the George Institute. His research interests are in back pain and clinical pain.
James is possibly the most interesting manager in the world – former club promoter, bar/restaurant and night club operator, underground house music connoisseur, psuedo-vegetarian (for the most interesting of reasons), moped rider and psychologist (yes – that does make him interesting). James has a PhD from Brunel Uni, UK on cultural influences in back pain.
In 2004 he moved to Australia to the Universty of Sydney and George Institute, managing research groups. His personal research is in identifying and treating risk factors for chronic back pain and developing approaches to improve management of chronic low back pain. Recently he has become interested in novel strategies for managing clinical pain in the real world. Link to James’ published research here and here is James talking more about what he does:
James – thanks for the intro and info. I currently am involved in treating low back pain patients in the acute setting (average duration of symptoms ~ 5 days) and its interesting to see their Fear Avoidance scores. For the Physical Activity sub scale they average about 17-18 points and the work sub scale around 8 points. Upon discharge we are seeing approximately a 70% change in these scores over the span of about a week as well as at least a 50% improvement on their Oswesrty. The tx approach is mainly manual therapy based (manipulation) and / or ther ex with education and reassurance to remain active. We hint about the pain as the driver for the painful experience but no where near go into the amount of depth that a formal pain neurophysiology approach would take. It will be interesting to see what happens to these people 1 month, 3 months, 6 months and a year out.
I’m curious as to what are your thoughts about prognostic indicators for recurrent disability? What have you seen or found recently…
Thanks again look forward to your response,
Mike
[Reply]
Michael Leal Reply:
September 16th, 2011 at 11:02 pm
Hello again, meant to say “we hint about the brain as the driver for the painful experience”. Speaking along those same lines any thoughts about bringing in this education early and not just in the chronic population? I have done this in the past but haven’t seen any evidence to support its usefulness in the acute state? If changes in the cortical mass are being seeing relatively early on and the chance of laterality, 2 point discrimination, and pain pressure thresholds being altered it would make since that the education component would be crucial to help walk them through the healing process even starting within the acute phase….thoughts?
[Reply]
Please can you send me details on the PHd scholarship for the CRPS recovery.
Thank you
[Reply]
James Reply:
September 19th, 2011 at 11:23 am
Hi Alison, do you want to drop me an email and I will send you the details.
thanks,
James
[Reply]
Hi Michael,
I think that you have brought up a number of really interesting issues about treating patients with acute low back pain.
When we test most treatments for acute low back pain in well-designed RCTs, there is usually no effect (e.g. Hancock et al (2007) or Machado et al (2010)). This might be because the treatments that we have are no good, but it is probably because many patients get better without any intervention. For these people perhaps the main treatment goal should be to try to get them better a little quicker. Ideally this should be as cheap and as effective as possible and we are conducting an RCT at the George Institute to see whether good management with simple analgesics like paracetamol can achieve this (Williams et al (2010)).
I reckon the more problematic group of patients are those who recover slowly, if at all. Our best estimates are they are about 30% of acute low back pain patients (Henschke et al (2008)). Many, but not all, of these patients have certain psychological characteristics that are evident pretty soon after they develop back pain, characteristics that those who recover quickly don’t have.
The question is how do you identify these patients and then what do you do with them if you can identify them? It doesn’t look like clinicians are that good at identifying them (Hill et al (2010) or Hancock et al (2009)) so some tools have been developed to help (e.g. the Orebro – 21 items or the STARTBACK tool (Hill et al (2008)) – actually we are just waiting for the results of treating patients on the basis of their scores on this tool), but these aren’t great either.
My feeling is that if we can refine these tools and we get better at identifying these patients they probably require some management which is more than simple advice, paracetamol or physiotherapy. I’d bet that proper pain education would be a good place to start, I certainly don’t’ think that this can hurt. This is untested though and just my feeling.
Williams, C.M. et al., 2010. PACE–the first placebo controlled trial of paracetamol for acute low back pain: design of a randomised controlled trial. BMC musculoskeletal disorders, 11(1), p.169.
Henschke, N. et al., 2008. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ (Clinical research ed.), 337(jul07 1), pp.a171–a171.
Hancock, M.J. et al., 2007. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet, 370(9599), pp.1638–1643.
Hill, J.C. et al., 2008. A primary care back pain screening tool: Identifying patient subgroups for initial treatment. Arthritis and rheumatism, 59(5), pp.632–641
Hill, J.C. et al., 2010. Comparing the STarT back screening tool’s subgroup allocation of individual patients with that of independent clinical experts. The Clinical journal of pain, 26(9), pp.783–787
Hancock, M.J. et al., 2009. Can rate of recovery be predicted in patients with acute low back pain? Development of a clinical prediction rule. European journal of pain (London, England), 13(1), pp.51–55.
Machado, L.A.C. et al., 2010. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC medicine, 8(1), p.10
[Reply]