For most people in the public, if you were to tell them that the surgery they were proposing to have or this operation or that operation doesn't actually work, it doesn't sit right, it doesn't make any sense. Like what? Yeah. Why would you do it if it didn't work? So I'm trying to make the public a little bit more skeptical, meaning not cynical, but meaning scientific and more objective, and not just assuming that things work because people do them. So the evidence for what we do as surgeons for musculoskeletal pain is very bad. That was Professor Ian Harris, an orthopedic surgeon, scientist and author. And this is the final episode of our first ever season of the Empowered Beyond Pain podcast, proudly brought to you by Body Logic Physiotherapy. Well, last episode we said we were going to go out with a bang, and if this episode doesn't live up to that, then I'm not sure what will. I consider myself extremely lucky to be in the fortunate position to give voice to the valuable stories from the people who have a lived experience of the conditions we discuss each episode, as well as talk to world-renowned and respected clinical researchers to bring new evidence to your eardrums. And the caliber of today's guest is no exception. We are so lucky that people like you tune in to each episode, and we hope we're giving you value for your time with the knowledge that we're translating. Today, Professor Peter O'Sullivan, Dr. J.P. Caniro and I speak to none other than the Professor Ian Harris, about all things surgery, placebo, research and pain. Ian is a clinician and researcher based in Sydney. He's an orthopedic surgeon with a clinical interest in trauma care, where his practice is based at Liverpool Hospital in Southwest Sydney. He's a professor of orthopedic surgery at the Southwest and Sydney clinical school at the University of New South Wales, Sydney. And an honorary professor at the School of Public Health University of Sydney, where his research is based at the Institute for Musculoskeletal Health. His research interests are in surgical outcomes and the appropriateness of medical care. He conducts randomized trials, systematic reviews, cohort studies and methods studies, and has over 260 publications receiving over 31 million in grant funding since 2012. He's a critic of many aspects of modern medical practice and is a campaigner for more science in medicine and in society. Ian has appeared on many national television programs, including a segment that ABC730 has been kind enough to give us a mission to use, which will play toward the end of this episode. As always, relevant links, including to that ABC segment, Ian's book titled "Certry, the Ultimate Placebo", the references from the scientific articles that we discuss in today's episode, are transcript and much more are available at the show notes page, which can be found at www.bodylogic.physio/podcast. It was such a special chat that we shared with Ian and I hope you enjoy it too. It wouldn't surprise me if you find yourself frequently skipping back to rehear some of the knowledge that Ian drops, just to make sure you understood it correctly. I know I will be. We'll start today's episode with Patient Voice Steve, who actually features in that 730 report that will play towards the end of the episode. Steve will present Facts 10 from the 10 Facts every person should know about Back Pain Paper that we published in the British Journal of Sports Medicine. Then we'll get straight into the chat with Ian. We wish you a fun and safe festive season. We'd like to thank you for your incredible support thus far. Encourage you to share your thoughts with us online at EBP Podcasts on the socials. Leave an iTunes review if you have a spare 20 seconds. And for the final time in this incredible year that has been 2020, remember to ask, is there more to pain than damage? Injections, surgery and strong drugs are usually not a cure. Spine injections, surgery and strong drugs like opioids usually aren't very effective for persistent back pain in the long term. They come with risks and can have unhelpful side effects. So finding low risk ways to put you in control of your pain is the key. To read the full paper for free, search Back Pain Facts BJSM. If you'd like to watch the patient stories behind the facts, click the link in the description. So today on the podcast we have a very esteemed guest, Professor Ian Harris, is an orthopedic surgeon, a scientist, a skeptic, a Sydney cider, a celiburous human and the author of this fantastic book, titled Surgery, the Ultimate Placibo, which I must say is probably caused a lot of stir in the medical and the broader world I suppose. And we're so grateful you can join us today. Welcome to the podcast. Thanks for having me. So it's it's pretty common for people with back pain or any pain of that matter to sort of think that they need surgery that surgery is going to be this the most beneficial thing for them and surgeries at the top of the medical triangle, I guess. But certainly the vast majority, if not most people with back pain probably won't get any extra benefit from surgery, then an alternative intervention like a structured cognitive and functional rehabilitation program. And I suppose as an orthopedic surgeon and our prolific researcher, you're probably one of the best people to ask about when surgery is appropriate. But before we dive into that, can you tell us a little bit about your story, please. Yes, I'm an orthopedic surgeon that trained in locally in Sydney, did some stints overseas and and basically just set myself up as a trauma surgeon, mainly treating fractures. But I also treated backs and used to do back fusions decompressions and things like that as well as spine trauma. But then gradually got into the research side of it wasn't wasn't real comfortable with the evidence for what I was doing, but I didn't have the skills to know what good evidence and bad evidence was. And I really couldn't determine, you know, what I should be doing because I didn't have the critical appraisal skills that I saw that others had. So in pursuing those skills, I ended up sort of in an academic career, which parallels my sort of clinical practice. But I say these days I do most of my work is research. But yeah, so that's how I I ended up where I am. So if you look at your journey in across your career and you look at what you were taught about back pain versus what you know now, how different are they? So it's completely different and and it's different with a lot of fields, but it's probably most different in back pain. So I was taught a lot of them and I worked under. To put it in perspective these days when surgeons wanted to spine surgery, they tend to just do spine surgery. So they'll go off and they'll do specialty fellowships when I did my training. Everybody did spine surgery and everybody did knee surgery and everybody did shoulder surgery. So I saw a lot of spine surgery, I was doing my training and did a fair bit of it. Yeah. And saw how to do fusions and saw the evolution of surgical techniques for fusion starting from no instrumentation, just just putting bone graft in there to early instrumentation to more modern techniques. So I saw all of that happen, which was interesting, but the the thinking around who you operate was you just operated on people when non operative treatment didn't work, you know, it's it's this thing gets ingrained in you as a surgeon. So if non operative treatment doesn't work, then then you do surgery. But then that doesn't answer the question, does the surgery work because if the surgery doesn't work, the failure of non operative treatment doesn't make it any more effective, it still doesn't work. So we didn't ask those questions and so yeah, we did all sorts of things. Now we put people who had back pain into a cast as a test to see whether a fusion would help them. So if you put them in a cast and they said they felt better, then we'd fuse their back. I mean, it just made you know on the surface that makes some inkling of sense, but when you think about it for more than a few seconds, it makes no sense at all. So they were the kinds of things that we were doing. And so when I started practice, I would sometimes fuse people with with back pain. Yeah, that's that's what was done. So if you look at your research journey, how has that changed your understanding of back pain? Yeah, so I guess I haven't given you the rest of my words when I started. So that's where I started the journey. And then once I started looking into the evidence for things and understanding, you know, how evidence is generated and how we can be certain about some things and not others. I quickly started to realize that a lot of the things that we do, and I mean, we're picking on surgery at the moment, but I also realized that a lot of things we do in in in physio in medicine in everywhere didn't really have good evidence and a lot of it actually been shown to be ineffective. And so that really was a, it wasn't I opener and that's one of the things that really swung me into research and learning more and more about it. And really the book kind of came out of my.
frustration with kind of like chipping away at the surgical field and realising that most people in the community weren't aware of these debates. I kind of wrote it looking to appeal to the public, appeal to people in general, because it's probably changing now, but for most people in the public, if you were to tell them that the surgery they were proposing to have or this operation or that operation doesn't actually work, it doesn't sit right, it doesn't make any sense. Whereas people can quite understand that a pill might be ineffective, that they can quite understand that I know those pills are useless and even some other areas especially they might think yeah, that's all pretty useless, but they don't understand the concept that if you go in and mechanically change something and fuse this bad segment together so that it's not there anymore, how can that not work? Surgeons wouldn't be doing it if it didn't work, none of it made any sense, there's all this cognitive dissonance. So I'm trying to make the public a little bit more skeptical, meaning not cynical, but meaning scientific and more objective and not just assuming that things work because people do them, because that's the way I was taught. I was taught that this is the way we treat this condition. Why? That's the way we all treat it and so it must be right and it's only later you realise that the way that everyone's treating it is wrong. Yeah. So if you look at the research work that you've done in the area back pain, what does it tell us about the role of surgery in back pain? I haven't done that much in back pain, but I did do a couple of reviews recently and just in the last year or two, a few of us published a paper looking at the evidence for spine fusion, which is, and just to maybe put it in perspective, for most people there's lots of different operations you can do on the spine and you can do some in the neck and you can do some in the lower back, but the operations are largely broken up into decompression operations where you're taking away pressure from around a nerve or fusion operations where you're fusing two or more vertebrate together to make them solid. And of course you can do a fusion entity compression, but they're roughly, but the spine fusion to me, which is the biggest problem, I think there's two problems with decompression, but fusion is the one where I don't think there's a lot of good indications for it and it's overdone. So we reviewed the evidence, so we just looked at where is the evidence. What good evidence is there for fusing the lumbar spine for various conditions? And we found that there's very little evidence for it. We did find some small areas where it's possibly effective. So for example, we did find a trial that compared spine fusion to know few, not fusing patients who had metastases or secondary cancers in the back. And that often causes the back to be unstable and it can collapse and it can be painful and it can cause nerve problems and then difficulty getting around. And this study showed that if you operated on those people and fused their spine together, they did a lot better. That's quite believable. And it's good that somebody did the trial because now we're a little more certain that it's right. And that kind of surgery probably has a role. But if you look at the proportion of spine fusions being done in the world that are for secondary cancers, it's nothing. I would guess it would be less than 1%. It's not a big number at all. Whereas another thing we looked at is trauma. So fractures of the spine. So again, there may be a role there when there's quite a severe fracture in the spine is dislocated out of place. However, for the most common fractures, which are not like that, they still get treated surgically. But the best evidence we have is the patients don't do any better with surgery than they do without and the costs and complications are high with surgery. So even that, we're kind of, oh, your spine's broken. We'll operate on it. But kind of makes sense. No, it's not that clear. And for the most common fractures, I think surgery is probably not helpful. And then we come to the big ticket items, which is degeneration. It's the, you know, all the different names for it, disc disease, degenerative discs, arthritis, on delosis. And commonly this is treated with back pain. That varies a lot between countries and between geographic regions within countries. And when you see that degree of variation, it normally tells you that there's uncertainty that we don't really know what we should be doing because some people are doing it a lot, some people aren't doing it at all. So there's something wrong there. But I think that's an area where it is overdone. It's quite possible that there is no role for surgery for degenerative conditions in the spine for spine fusion. So this is barring cases that have one-off cases that happen to have a, you know, very unstable spine or something like that. Most of them don't need it. And there's a tendency to find more and more reasons to do it. One of the flavors of the month is this sort of coronal plane instability and people who develop a little bit of collapse and they get a bit of scoliosis. And so people are doing fusions for that. And in the old days we used to fuse two vertebrae together that's called a single level fusion or a single disc fusion. These days they're fusing people from top to tail. You know, they're doing five levels, ten level fusions, which are massive operations, normally in older people. And I am not at all convinced of the evidence that the risks of that kind of surgery are justified by the benefits. And there certainly been no good comparative studies showing that they are. Yeah. I mean, I think that that's what's needed. And I think you've done some research in the work as compensation space as well, looking at the outcomes of people who've had a number of fusions if you have had a workers' compensation injury. Yeah. A lot of my early research and actually my part of my PhD thesis was on, I was fascinated by this compensation effect. We didn't get taught about it at medical school. But once you get into practice, particularly as a surgeon, you see lots of patients who are treated under workers' compensation. And you see, and realize that these are very different people. And often there's lots of psychosocial problems that are interfering with their recovery. And they're often not happy at work or they're having a conflict with their boss or their employer. They're often not motivated to go back to work. And they often have to go to see medical examiners to prove how well they are. Otherwise, they don't get a payment, a payout, and the payout depends on how sick they are. It's a very, very bad system that's right for perverse incentives. And it's, there's perverse incentives for the surgeons as well because the payments that we receive from the workers' compensation system are far outweigh the payments we get from the public system or even from the private system. It's a very generous system for surgeons. And so I think that that's a formula for disaster. So it's common to have spine surgery in workers' compensation situations. And yet we have shown, and others around the world, have, in other countries and jurisdictions have shown, that the outcomes are much worse after surgery if it's performed in a workers' compensation environment. And it's partly for these psychosocial reasons. It's very, it's very difficult to make these people better, particularly when the thing that's causing their problem is not a structural physical problem. If you give a structural physical solution to a psychosocial problem, you're not going to get a good result. And so yeah, we did a meta-analysis on outcomes after different types of surgery. So this was Lumber, Fugian, for instance, but also Carpool Tunnel Syndrome, a bunch of other common shoulder surgery, common operations in the workers' compensation. But the odds of having an unsatisfactory outcome, if you had that operation under a workers' comp situation, was somewhere between three and four. So three to four times the odds of a bad outcome. You're really setting yourself up to failure when you operate on this people and yet it's commonly done. And we're just trying to publish some stuff on that now. We just looked at all the serodata. So in New South Wales, the workers' comp system now is managed under sera, which is the state insurance regulatory agency. And so we've got a whole lot of data from them looking at the rates of surgery and are they increasing and what the costs are and things like that.
And the outcomes are still bad. And we'd previously published on this as well in Workers' Comp in New South Wales. And in fact, one of the numbers I remember from that publication was we looked at patients who had a lumbar fusion. We had about 450, 460 something patients over a few years. And we looked at whether they had, how they were 24 months after the surgery. The probability of returning to pre-injury duties two years after spine fusion was 3%. The probability of still being treated with either ongoing physiotherapy or major opioids, narcotics, two years after your fusion was somewhere between 80 and 90%. So these people did not get one bit better. And that's the focus comp system. It's almost shocking to hear the test looks like that. And I suppose the question then is like, you've got a person who may be highly distressed around the whole work comp space, which could never get in that in itself is incredibly stressful, aren't you? And then you had all the work related issues and then dealing with legal factors, et cetera. And it tells us a little bit about the complexity of the back pain that it's a lot more to do than other factors in some cases than just structure. And but that's a really hard message for someone who has pain to hear. Exactly. And I have to manage that all the time. And you guys have to manage that as well. It's very difficult. I've honed it over the years, but it's not a message you can get across in a single consultation. People have to be believed in one of the things that I stress with people is I do not question in any way the fact that they're having pain. I could be 100% believe they have pain. But what I try to get across to them is that their perception of the pain, the way they react to the pain and their response to the pain and their whole psychological picture around their behavior because of this pain is strongly influenced by many different factors. And yes, it's quite possible there was a physical problem that may even have initiated their pain in the back. But when these other things take over, they take over your brain subconsciously and there's the old ways of thinking about pain. They turn up the volume on your pain and that kind of thing. And so all I try to do in my role, because I'm not a chronic pain specialist or a rehab person or anything like that, is they often come to see me for an opinion regarding surgery in these days because I don't do that surgery anymore. They often get to see me for a second opinion because they've been advised to have surgery. Yeah. So I see lots of patients like that. And so all I try to do is just get them to think that this is perhaps a little bit more complicated than they thought. And there's lots of other factors that are contributing to their current unpleasant experience, which is being expressed by back pain and frustration and anxiety and all the other things that they're feeling. But just to get them thinking that there may be a little bit more complicated than that. And then you have to address the physical, the inevitable physical problems because the patient will always turn up with an MRI scan. Every MRI scan will show an abnormality. So you have to explain to them that the findings that I see on their back are no different than I would see in any other 45-year-old or 55-year-old or whoever all they are. And that those signs are not well correlated with pain. And there are plenty of people with those exact signs who don't have any pain. So it's not, again, it's not their simple thing. Humans love shortcuts. We're evolved to make these heuristic conclusion jumps. As soon as we see something, and we see something that goes along with it, we just put the two together and say that one calls the other. So as soon as we see something on the MRI, regardless of what the evidence tells us, and we've got someone with back pain, and we say, well, whatever it is I can see on the MRI, that's causing your back pain. So I'm going to take it out. It's very appealing. It's very easy to understand. Patients can just stop thinking right there and just say, OK, take it out. I'm done. That's the key to me. So telling people that isn't that simple is hard work. And what kind of response do you get? Because obviously they're coming to you for a second opinion. So you are an off-beat surgeon. You're looking at them here in these stories and looking at their scan. And then in a sense, you're not validating this scan. How does that-- how do people respond to that? Oh, it's completely varied. I mean, I get all into this spectrum and everything in between. So certainly I get the people that, you know, the initial response is, you're telling me it's all in my head and you don't. And I don't know if it's a good response or not. But when people say, you're telling me it's all in your head, I tell them all pain is felt in the head. That's where pain is registered. And I tell them I have people that have no leg, but have foot pain. It's not because they have pain in their foot. They have pain in their head. That's where they're registering it. That's where it all gets controlled. And so I use that as a stepping stone to explain a little bit further. But sometimes people are just very frustrated and you can't get through to them. That's not that often. And it's also not that often I get the other end of the spectrum because quite a lot of people I think don't really want to have surgery. And so they're fairly relieved or happy to know that they don't need to have surgery at least. Then there's the question, well, what am I supposed to do instead? That's difficult. You have that conversation. But some people are relieved. And particularly, maybe it depends on who they've come from. Because spine surgeons-- I've got a lot of friends with spine surgeons. And most of the spine surgeons I know are entirely reasonable, intelligent, good surgeons care a lot about their patients. And don't take these things willy-nilly. But there are surgeons out there that are reasonably aggressive. And sometimes patients feel as if they've been pushed into surgery a little bit. And they're not sure that it's really needed. And sometimes they're happy for an out. Even if it's that I can't do very much to help them, except tell them that surgery will possibly make them worse. Sometimes they're happy with that. So how do you get on with this messaging with your colleagues? Because clearly, as you-- I don't know what the numbers are for a number of fusions in Australia, but I imagine that pretty huge. And particularly in private and work-comp space in my right, compared to the public setting. Yeah, so we're recently-- we're looking at this now, looking at the numbers. And it's been very difficult to interpret, because the rates of spine fusion have increased since 2015, I think, so the last four or five years. But there was a fall before then. And for the-- for a few years, I think, for 2011 and 2015, we can't really quite work out why that is, or whether that's a glitch in the reporting, coding numbers change, and things like that. But we're still working our way through that. We are trying to compare the rates in public versus private versus work-as-comp. Because I think the rates in work-as-comp, I think that's often where it's overdone. But it's difficult because in work-as-comp, you only have a select portion of the population. It's not the denominator isn't everyone in New South Wales or whatever. And the younger people, the rates of spine surgery across the board are much more common in people over 60. So it's people who are 60, 70s that are getting surgery. I think if you look at the rates of surgery of people in their 40s and 50s, then you do see that work-as-comp probably is a little high. But overall, per person, they're not that high. Because outside the work-as-comp situation, not that many people in their 40s and 50s get surgery compared to 60s and 70s, anyway, it's complicated, hard to work out. We did do a study a while back where we looked at the rates simply comparing private versus public. And found that the rates were increasing and very high in the private sector and very low and not increasing at all in the public sector. And we compared that to hip and knee replacements where both hip replacements and knee replacements were increasing and they have been for many years. But they're increasing in the private sector and they're increasing in the public sector. I mean, there's a reasonably big demand for hip and knee replacements. And so they parallel each other. And sometimes it goes up and down. But certainly we're doing much more in the public sector now than we were 10, 20 years ago. And we're doing a lot more in the private sector than we were 10, 20 years ago. The funny thing about spine fusion surgery is that it's been going up and up in the private sector, but it's still largely not done much. Why do you think that is that? I think that I would guess that that reason is because
because we don't really know that it's that effective. So we're fairly sure that someone who has difficulty walking with a very bad R3D Kip will do better, you know, 95% of the time and we'll be able to walk for you, improve their mobility and decrease their pain possibly to nothing. So when someone comes in and sees us with a bad R3D Kip and terrible pain and can't sleep and can't walk around, they'll get a hip replacement. It doesn't matter whether they're public or private because we know it's an effective operation. I think it's different if someone comes in to you with back pain and if someone comes in to you with back pain and they've got in a degenerative changes or whatever and that fail, that course of physio or something and they're not coping very well. You could probably spin it either way. So if I was a surgeon, I could easily say to a public patient for which I'm not going to get much out of it by operating on them. I could easily say, look, you got this problem but this problem isn't really correlated with the findings on the scans. There's lots of complex reasons, reasons why you have pain. The best evidence we have is that surgery will probably not help you. There isn't really very good evidence supporting it at all. So I wouldn't recommend we do such a dangerous procedure for a little gain and I would advise against surgery. Think of a private patient or a workers' patient sitting in front of me, I could have almost the same conversation. So I could say, well, look, the evidence for spine surgery is very good and some people do better, some people don't. We really don't know, there's a lot of controversy out there about spine surgery but we really won't know whether you're the right person for it, whether you respond to it until we try it. You failed everything else so I can't really see you getting better without it. So I think it's worth a go. We'll do a fusion. We'll see how you go. It's the same conversation but with an outcome. Different bias. And so what do you say then to, and this kind of gets to the title of your book around surgeons who say, "I have great outcomes from doing spinal fusion so people were back there." And patients who say, "Look, I had that surgery done and it's changed my life." How do you respond to that? Well, for every one of them, I think there's a patient who says they regretted having the surgery. So, yeah, so that you're getting to really the core of the book, which is this problem that the answer to the question of why do surgeons do operations that I think are not effective based on the evidence? And I'm fairly convinced that the reason why surgeons do these operations is not because they want to make extra money and it's not because they're tapping into a placebo response or anything like that. It's because they honestly believe that it works. The reason why they believe it works is because they see people get better. Now, they may quite selectively see people get better and they might see those people through rose colored glasses and they might not ask those people all the right questions. They might not see them for very long. And that patient may be giving that surgeon a very different answer than they're giving their physio or their GP. But they see people get better and they fall into the logical trap of attributing that improvement to the surgery when that's probably not the case. And it's the same argument I have for, you know, de-briberative osteoarthritis in the knee and the arthroscopy for degenerative changes and things like that is that the improvement you see is probably less than you think. And where it exists, it is probably not attributable to your surgery. It is attributable to other more common things like the natural history and fluctuations of conditions. And shoulder surgery, I think, is a classic for that one as well because I just recently went through in the last say four or five years, went through two long term pain problems. The first one was tennis elbow and the surgeon's out there that will operate on that. But we know statistically that 97% of people with tennis elbow will be all better in 12 months because that's the natural history of the disease. So if you operate on people and you look at your results at 12 months, you're going to think your operation has a 97% success rate. And you'll believe it. But it's a true belief. The other analogy I give is that it's like homeopaths. Homeopaths are classic because homeopaths, homeopathy is true, nothing. Like that is blank treatment. You are giving water in small amounts. So it's nothing. And yet there's a lot of homeopaths out there and they're giving a lot of homeopathic treatment. I don't believe that these people with charlatans, I believe that charlatans, I believe that the homeopaths believe that what they do works because they see people get better and they attribute that improvement to their treatment instead of to the natural history of the condition. The other thing I had was a bad shoulder. I didn't even have it scanned. I don't know what it was, but couldn't lift it for ages. Couldn't reach me on the back. I was using my other arm. I couldn't reach over to the back seat of the car. I tell you were problems and I just had to keep it still a lot and didn't bother having scans and didn't do anything. It took about a year. Now it's 100% again. It's completely normal. So that's a hard thing for patients to accept though when they're distressed, isn't it? So because of your knowledge, you can deal with your own health problems in a completely different way. It has a shorter problem, gets a scan, shows it, it wrote out a cuff tear, which we know are really common and people with no pain at all. That gives them a simple explanation to why they hurt. They then believe they need to fix it. Yeah. Yeah. So you just got to educate them. I mean, and you just say, you know, it depends on the condition, but you guys probably know the figures more than me, but most people with shoulder pain will be better in 12 months. And I suppose the tricky thing there, and this for the, for people we know in back pain, which we know around 25% who don't get better from an episode of back pain. And that, that's the really tough thing is because if we look at the five or seven-year trajectories of that group, they don't tend to do that. Yeah, that's not good. That's what's so tough about this whole conversation is like, well, if I've tried all the stuff and I haven't got better, then surely, and I've got a degenerate disc on his skin and maybe someone stuck an eater when it gave me short-term pain relief, that proves that that's the cause of my pain. And therefore, this is my only option. Yeah. And so compelling. But that's, you've basically outlined the, the argument of a lot of reasonable surgeons. Yeah. They would, they would make that argument. And it's, but it is largely based on their personal experience and, and some not very good evidence. I think we need better evidence to find out if it works. So instead of us all guessing, yeah, we should be doing the studies. And this is another big frustration of mine is that we, we think up these, these things, we, we do them. We think up a new spine operation. We start doing it. We think it works. Nobody tests it. You know, shouldn't we be testing it before we do it? Like, isn't that, isn't that, the drugs aren't allowed to be, yeah, the market for you test them. Why is surgery? Isn't that just a basic principle of learning and science is to, is to find out if things work first and then try them instead of what we did with Neothoscopy is we started doing it in the 70s and 80s. And in 2013, we published a trial showing it doesn't work. Like, shouldn't that trial have been done in 1980? I don't know. It's usually concerning though, but, because for consumers, they put so much trust in the health system. Yeah. And we, yeah, but we abuse that trust. We know and, you know, if the surgeon says you need this, you had to talk people out of it because it's a very authoritative voice in society that often, you know, doesn't often get questioned. And because it doesn't often get questioned, it, I think it gets abused. Yeah, you can, you can just say, no, no, in my experience, you know, you're far better off having this procedure. And you don't have to justify yourself. You don't have to produce the evidence. You don't have to, you know, submit a document to the therapeutic goods association or the medical benefits schedule of Australia to prove that it works. Do you do that culture changing with young surgeons coming through? Yes. I definitely think that the young surgeons are different breed to older surgeons, for sure. Yeah. So things are changing, but I think the change really shouldn't be generational in nature. It should be a little faster than that. But I'm aware that, you know, I think one of the Wiser initiative suggested that, um, that, um,
public funding shouldn't be used for spine surgery and that got rolled because of our cry and so funding has been reinstated. This is the problem is that spine fusion along with most of the other operations on the funding list in Australia were grandfathered in. I mean, they were operations that were already being done in 1983 or whenever it was when the MBS was written on 1985 and that was it. So they were grandfathered in. If you wanted to do a new operation today and get it funded by the government, you'd need a considerable amount of evidence before they would do that. So my argument is that okay, it's a big task. We need to go back through all of those things we're funding and evaluate them the same way as we would with any new procedure that was presented today. And I would even argue that we need to use the public money for that. So Medicare in Australia pays billions and billions of dollars for procedures being done. They should put a little bit of side, you know, two cents in the dollar or something like that for comparative effectiveness studies or trials, finding out whether the things they're paying for work. Then I need to show a couple of things don't work and then they themselves, yeah, millions of dollars a year. So I think that that's something that needs to be done. We shouldn't be doing these things without evidence. It just sounds basic. Yeah. And that's consistent with the most recent guidelines for bad pain is that I think the nice guidelines said, Spongebob said you should only be used as part of a research trial. Yeah. And we ignored guidelines, didn't we? No, we ignored. No. But yeah, it's a very compelling case to say that, and I say this to surgeons as well, they say, oh, well, if you want to test everything, you're going to stymie innovation. Yeah. You know, because I've got a new procedure I want to do. And if I'm going to have to subject it to all your testing, all these patients will miss out. And my answer is what you just said, I say, no, do it. Do it as much as you want, but do it as part of a trial. Yeah. And then we'll know if it works or not, and you won't have to waste your time doing it anymore if it doesn't work. And if it does work, let's go to the government, get this thing reimbursed and you can all get paid to do it. And the government would be more than happy to pay it because they know it's effective. Yeah. And that's what it should work. Yeah. So some of the listeners to this will be kind of shocked, I would think, by what you're saying. But the other thing that you highlighted this, I'll risk benefit thing. And that surgery is not without risk. Can you just talk through what kind of risk might be involved with something like a spinal fusion? Yeah. So a spinal fusion is fairly major surgery. That's another reason why it's more of a target from me than decompression surgery because it's a much bigger operation. It's a longer time under anesthetic. It's more invasive. There's more cutting of the bone and drilling and things like that. There's insertion of devices like screws and plates and rods to hold things together. And so the risks, the complications that it can occur after spine fusion surgery are higher than after simple decompression surgery or an arthroscopic surgery. So for example, a shoulder arthroscopy or knee arthroscopy, it's fairly safe surgery. It's done day only. The patient really doesn't bleed at all. They don't need to stay in hospital. They can walk out of hospital. And the risk of infection, which we often worry about in surgery is extremely low. Most of the risks of arthroscopic surgery, well below 1%, so they're there, but they're very low. But spine fusion surgery is a different story. If you have very close to the nerves, so you can have damage to the nerves. And sometimes some of the screws you put in cannot go in the direction they meant to go. You can get bad bleeding. And probably the biggest complications of spine surgery is that it won't work. It will still have pain afterwards. But it can also cause more problems with the joints next to where you're fused. And so they take more stress and that can cause problems. And often things come loose or they get infected or they're sticking out a little bit or they're rubbing. And all the fusion doesn't take and it needs to be redone. And so the revision operation percent is very high. And that alone I think is not a good sign. So we do have some recent numbers for that. So if you look at say hip or knee replacement, for me that's like super common surgery. Everybody knows somebody's had a hip or knee replacement. The risk of needing another operation within a year or two is pretty low. It's maybe one or two percent that you might need to have something adjusted or taken out or you could get an infection. It's 1%. But it's a couple of percent. You need to take that into account. But once you get over that, the redo rate actually flatens out quite a lot. And the chance of needing another operation even after sort of 10 years is only sort of 4%. It's very low. Spine fusion in the recent workers comp data that we did. We found that the re-operation rate within two years to have another spine operation was 19%. So that's nearly one in five people having another operation on their back within two years of having the first fusion on their back. That means that that in itself tells you this is not a great operation. And if you think of the fact that we actually have a name for it, don't we? Fail back. That's in-dram. Yeah. She's kind of shocking. I don't know if any other orthopedic procedures got that name, has it? No, no, no. So just I'd like that name. I'm very aware that this reasons. I could weigh more of your time. This is such an interesting and important conversation. Anything you guys want to add, because I'd probably have to wrap this up. Yeah, probably a question that I'd like to ask you is what would you tell consumers that they should? What conversation should they have with clinicians when it comes to surgery? Are they key questions they should be asking? That's a very good question that I often get asked. What I normally advise patients to do is to do exactly what I do when I am the patient or my parents or relatives or patients. I just say to the surgeon or the doctor, what is the evidence that having this procedure will be better for me than not having the procedure? That's really boiling it down to nuts and bolts. It's having the procedure compared to not having the procedure. I've asked that question to a surgeon from another specialty once during a family consultation. And he reacted, "Oh, what are you talking about?" Just because we don't have some. I'm kind of saying you don't know is the answer. It really didn't know. He's just saying how safe it was in his hands and how his complication rate was low. That's all great. I said, "But what's the probability of getting a good outcome with this surgery compared to not doing it?" It's the most basic counterfactual way of thinking. And that's a lot of the reviews I do. We just did a review published in Pain, which you can look up and so do you like it. It's a good one. But the journal is Pain and it was published I think just this year. And it's a review of surgery for musculoskeletal pain. So it's back fusion. It's osteoarthritis. It's shoulder surgery. It's carpal tunnel. It's, I think, osteotomies, ankle surgery or all the common. The most common procedures we do for pain, what's the evidence for them? And we looked at all the randomized trials that were done. And less than 1% of all the randomized trials of these musculoskeletal procedures compared the procedure to not doing the procedure. So most of the research we turn out in orthopedics is looking at different ways of doing a spine fusion or looking at how good my results are, but it's not comparing it to not doing it. And in most of the studies, in all except one condition, the majority of trials that compared the procedure to not doing the procedure were not in favor of the procedure. I suppose I have one sort of. - We'll have a final question then. (laughing) And look, excuse me, we'll highlight that study in the show notes of the podcast as well. We'll give a link to it. What is the future hold for us? You talked about some initiatives and some changes that you'd made. Where the wind's going to come from in the future? What's the future for the future for you? And where's this landscape we're going to look like? - Yeah, so we need to change practice. In changing practice is a whole special area of research, almost. And it's, I think it's got to be multi-pronged. So one of my things has been to teach surgeon. So during surgeon training now, you have to learn more about evidence-based medicine and things like that. So it's training surgeons to be more scientific. Training the public to be more scientific and objective and skeptical and asking you right questions as well. And then there's other levers which I haven't ever really pursued, but I'm more and more thinking that they should be used. And that's the external, you know, regulatory, financial levers. People are paying for this. And what's, what gets me is that I'm paying for it. So I'm a little bit, you know, happy for doctors to do it. They think it's best, you know. But what I say is that I don't want to pay for it. So if you want to go doing the answers, if you don't have every patient you see, and the patient believes that what you say is going to work, and you're going to be able to do it. And then you're going to be able to do it. It takes a lot for a person to shift. And we see people like Gordon Waddell and others who have shifted across their career. I think it's a huge testament to you as a person. And as a healthcare practitioner that you've done that. And we're grateful for it. So thanks so much. And I hope you have a wonderful Christmas. Thank you. Thanks, everyone. Thanks, man. Thanks. See you later. Wow. What an unbelievable conversation that was. Ian's knowledge, humility and kindness really shines. There are two things that I want to clarify for our listeners. I think this was pretty clear in the conversation. But I want to make it crystal clear. First, pain from psychosocial reasons or having a psychosocial problem does not mean the pain isn't real, made up, imaginary or exaggerated. As Ian pointed out, pain is always real. Whatever people report is 100% what they feel. And there is a bit of a problem out there where patients don't feel validated, heard, and feel like they have to prove that they have a problem to their healthcare practitioners. It can be pretty hard to improve your pain problem when at the same time you're fighting to prove you have pain. So pain from psychosocial reasons just means that there isn't a structural problem in the back that is contributing to the pain, which is actually a good thing. It does mean the way that people think, feel or respond to their pain or the social environment they live in are more dominant contributors to their pain. Second, we don't think healthcare professionals, including surgeons, homeopas, physios, chiropractors, and so on, that perform treatment that doesn't work are charlatans. The overwhelming majority are good humans who genuinely think that what they're doing works because they've seen people get better. But what we're asking you to consider is the why behind that improvement. As Ian talks about, commonly it's natural history or it may be other phenomena or contextual effects like regression to the mean. A feeling of being listened to looked after, cared for, having a condition made sense of, or a feeling of safety. Okay, so there are a few, well, a lot of question marks around surgery. But that doesn't mean all hope is lost and we should wallow in our question marks and there is nothing you can do if you're considering or have had surgery. The truth is, because there are lots of contributors to pain, it also means there are a lot of potential targets. And I want to highlight a story of hope. Enter, Back Pain Patient Steve, who presented the Back Pain Fact early this episode. Steve first appeared on a radio interview that Professor Peter O'Sullivan did back in 2018. Serendipitously, he was listening and decided to call in to share his story and desperation. Steve had a six-year history of Back Pain was battling in the work his compensation space, was unable to work, had several surgeries, and eventually also had a spinal fusion that unfortunately didn't really help. He was one of the 97% of workers' compensation patients that don't return to pre-injury work within 24 months of a spinal fusion and was most certainly one of the 80 to 90% that are on strong opioids and still requiring ongoing treatment. To cut a long story short, he was eligible for a study that was run through Curtin University where he received a novel three-month intensive structured physiotherapy program. And as you hear, he underwent a huge transformation and he's back to playing hockey. He was back to working within that three-month treatment and now has a new lease on life. That study was my PhD study and part of it has been published in the European Journal of Pain. There's a link to a video abstract of that study, the study itself, in the show notes. So I'll now play the interview of when Steve called Jillian O'Shawna-Sea from ABC back in 2018. And then I'll play the clip from ABC730 program which talks about his journey. And a huge thanks to ABC for granting us permission to use these clips for educational purposes. Stephen is in Padbury. Stephen is 24 and he's had a spinal fusion. Hi, Stephen. Hello, how are you? Yeah, well, thank you. That's good. Yeah, like you said, I've actually told the wrong age. I'm 26 and I've had a problem since I was 21 with chronic pain. I obtained an injury at work. I've had two decompressions of the discs, the L45s. And then last year I received a single level spinal fusion. I've just been to a lot of different sort of specialists and the main thing that I've told me is what you've been saying is going to the cool and just keep moving, but the pain is just really immense. My body gets really tired really quickly. I find that I sleep quite a lot, if I'm not moving a lot. Yeah, but I find that just doing physical activity really, really makes you tired, where's you are? And it's just hard mentally trying to get over that hurdle. It's not only physical pain that you experience when you've got chronic pain is also the mental pain that comes with it as well. My question is about the medication. I'm actually on, I'm not on any opioids. Am I allowed to say the type of drug I'm on? Yeah, go ahead. So I'm on North care and I'm on Alexia, Traumatol, Celerbrics and an antidepressant of Prisbee. Do you think that these drugs will do any benefit for me with my chronic pain? So as you can hear, Steve was in a pretty bad place, physically and mentally. But as I mentioned, he went through a bit of a journey and had a huge turnaround. In fact, he messaged me this week saying he got a best on ground at his hockey grand final and he's doing talks with local schools about positive thinking and overcoming obstacles with pain and injuries. So he really has progressed and he's doing amazing advocacy work. In the next clip, which is a report by Tracy Bowden from ABC730, you'll hear today's guest Ian Harris talking about spinal fusion and then again, you'll hear from Steve talking about his journey. In 2017-18, close to 18,000 fusions were carried out in Australia. It's one of the most common forms of surgery for chronic back pain. But there's a growing debate about where the surgery is the best.
best way to treat most back problems. It's a low level of evidence that we accept and I don't think that's good enough particularly for highly invasive, risky and costly procedures like spine fusion. That whole time that I did have a back pain I was looking for that quick fix. Steve Duhrull is back at hockey training after a tough few years. He hurt his back working on a building site. My back was seizing up and it was quite scary. I wouldn't be able to walk without my leg dragging behind me. In the end Steve had three operations, the final one a spinal fusion. I'm feeling no relief from these operations. Steve Duhrull says a six month physiotherapy program achieved what surgery couldn't, treating his back pain and helping him return to sport and work. If I had my time again and doing this whole process I would definitely explore other options and getting surgery to start off with. So there you have it, our final episode of the inaugural season of the Empowered Beyond Pain Podcast. I'd like to thank Body Logic Physiotherapy for their support in bringing you this podcast free of charge every fortnight. My co-hosts Pete and JP and all of our guests that we've been privileged to speak to this season. But most of all I'd like to thank you, the listeners. Each episode sees thousands of you tune in from more than 80 countries around the world. So it's been a real honour to share these last few months with you. I wish you all the best over the festive season, have a fun time and do get in contact with what you think the podcast. Sharing, rating, reviewing, subscribing are all easy and free ways you can help us, help more people. Do get in contact via eBP podcast on social media. We'll flick us an email with feedback, topic suggestions or just a good day via email, which is
[email protected]. That's it from us. Remember to hug your loved ones and of course, remember to ask, is it there more to pain than damage? Please note what you heard on this episode of Empowered Beyond Pain is strictly for information purposes only and does not substitute personalized high value care from a licence and trusted healthcare practitioner. We are all individuals and need to be assessed and managed as such. Fame Music generously provided by Fervent and Cash.
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