Jared Powell:
Today's guest is Harrison Hansford Harrison is an accredited exercise physiologist and PhD student at the University of New South Wales and Neuroscience Research Australia. Harrison's current research focuses on using big data to identify whether treatments for musculoskeletal conditions are safe, effective, and to whom these findings apply. I spoke with Harrison about his recent publication in the Journal of Physiotherapy about the smallest worthwhile effect of exercise for chronic low back pain. The smallest worthwhile effect is being touted as an important patient-centered metric to convey the minimal effect a patient would consider worthwhile for different treatment approaches. Listen on to hear Harrison expertly explain what this means and how it might or might not apply to clinicians Without any further delay, I bring to you my conversation with Harrison Hansford. Harrison Hansford, welcome to the show.
Harrison Hansford:
Thank you.
Jared Powell:
Thanks for coming on, mate. We've got a really interesting study to talk about today that is fairly dense, but certainly very interesting, and I think a lot of clinicians will be interested to hear a ton about it. However, before we get into that, tell me who are you, Harrison, and what do you like to do? What does a normal work week look like for you?
Harrison Hansford:
So, I, I mean, fundamentally I'm, I trained at an exercise physiologist, and so everything I do comes, comes at things from a clinical standpoint. And I work two years in a specialist clinic treating people with chronic fatigue syndrome, which is fascinating. But I guess I only did that one day a week. And primarily I'm a, a PhD student focusing on trying to improve the care of people with musculoskeletal conditions and, and primarily through understanding what treatment effects matter to patients, which is sort of we're gonna focus on today, but also as well as whether existing treatments are safe and effective and making sure that people are getting the best sort of care they can.
Jared Powell:
That sounds like a very noble research question or research program that, that you're involved in there. Kudos to you. So, normal working week. Are you you, full-time, PhD, you're in the, in the lab, in the study every day smashing out statistics. What are you doing? Yeah,
Harrison Hansford:
I think that's what most PhDs look like, but I, I'm lucky to be able to do mine completely remotely. I've just moved up to the Gold Coast do my p PhD based in Sydney. And so at the moment I just sit at home and, and analyze data and crunch numbers, mix in a surf or two throughout the day as well. And so a normal working week is, is pretty relaxed. I can do what I want whenever I want. Hopefully my supervisor doesn't listen to this too much, but outside of like my PhD I guess my other work is I also work as a boundary umpire in the A FL. So playing the women's a FL and the state league a FL as well, which means also do a lot of running, a lot of gym work to stay fit and be able to run around an noble and do that on the weekend.
Jared Powell:
Yeah, absolutely. Are you, are you Victorian originally or a FL? No, just,
Harrison Hansford:
Just grew up playing a FL in Sydney and then realized I was no good at playing, playing footy and so decided to stay involved and get umpiring.
Jared Powell:
Yeah. Good. Do you support an A FL team?
Harrison Hansford:
I do. I'm not sure I'm allowed to say who I support, but I'm from Sydney, so that might give it away a little bit.
Jared Powell:
Well, there's two teams now there, Harrison, so it's a 50 50. I assume you're a swan.
Harrison Hansford:
Yes, definitely, definitely more swans. Yeah, yeah,
Jared Powell:
Yeah. Well they're, they've been a pretty good team support over the last 20 years it feels like. So, is Lance, is buddy still playing or is he retired? There was a whole fanfare last year, wasn't it about Yeah,
Harrison Hansford:
He's retired, but yeah, no, obviously had a huge career, so that's good in Sydney.
Jared Powell:
Good that you signed him up for a 10 year trillion dollar contract, so, nice mate. Exactly. All right, so let's let's get into the chat here. So a paper that I have read from yours multiple times actually to try and understand it. And that's no disrespect to your writing, but more so to the, to the, the actual stuff that you're covering is about the smallest worthwhile effect. And this was, this paper was published in the Journal of Physiotherapy, I believe, was it last year? 2023?
Harrison Hansford:
Yep. Last year. Middle of last year. Which is good to see you get up finally.
Jared Powell:
Yeah, yeah, yeah, for sure. These things are, are a labor of love and, and, and quite hard to do. So I'll hand it over to you straight up because you know it intimately. You said to me before you were, it is all you were thinking about for a good 12 months of your life, and that's time you won't ever get back. So I hope you remember it. So just Harrison, if you don't mind starting with what is a smallest worthwhile effect and then maybe what it isn't, and then how does a smallest worthwhile effect differ from something maybe people know a little bit more, which is that of a, a clinically meaningful effect?
Harrison Hansford:
Yeah, I think to understand the small cell effect and, you know, clinical importance in general, you know, I guess the way most people sort of think about it is it's how much better someone has to get to make doing something worth it, essentially. And in the context of, of patients and, and research as well, it really comes down to comparing two treatments like we would in a, a randomized trial where you're trying to see if one is better than the other. Because when you, you're treating a patient, you, you've got generally a few different treatments that that might be appropriate for them, and it's up to you and, and the patient as well to, to figure out which one is gonna be the, the best for me given what the research says about. And so the smallest worthwhile effect is a number that tells us on average the amount of benefit that a patient needs from a specific intervention. So exercise or a drug or a surgery compared to something else. So a control that could be doing nothing, it could be, you know, a different intervention to make the, the intervention we're interested in worthwhile, essentially. So you're gonna have to pull me up if, if anything becomes a little bit complex because it, it gets very nuanced very quickly simple.
Jared Powell:
It's all simple so far. Well done.
Harrison Hansford:
Okay, cool. So yeah, in our paper, what it, what it was is looking at how much better does someone's paying you to get. 'cause We were looking at people with acute and chronic low back pain to make doing exercise worthwhile compared to doing nothing. And the, the fact I'm keep saying compared is actually really, really important because the way most people think about or most measures of, of clinical importance are determined like the minimum clinically important difference or there's a million different terms for the same construct, is the smallest of effects focuses on the difference. So the effect of a treatment compared to something else, whereas all the other ones focus on just what happens within a group. And I listened to Steve Camper's podcast with you and he also focused on, on this sort of difference as well as, you know, it's really important that we always compare things and look at a between group difference, not just a change within group.
Harrison Hansford:
And, and the reason for that is because a change could be due to anything, you know, it could just be that they were gonna get better anyway. It could be that they started doing something else which made 'em get better. Whereas if you compare it to something, both groups will naturally get better, they'll have natural history, and the only thing that'll differ in an ideal trial will be the intervention. And so the small scale effect is, is that difference, but how big it has to be in order for the intervention to be considered worth it by patients. Is that making sense, ?
Jared Powell:
Yeah, yeah, absolutely. So I'll just highlight a couple of key points there, mate. So it's a between group difference, not a within group change. That's key. So it's always in on the background of comparing it to a control group that'll sort of ring out and resonate with listeners when I ask you a question a little bit later on in the conversation. So that's super important to, we're gonna clarify that a few times throughout and keep saying, compared to Harrison, I like it. You don't need to be sorry for that. So that, that all makes absolutely perfect sense. And you, you and you, your study investigated exercise and non-steroidal anti-inflammatory drugs. Do you wanna go through what that smallest worthwhile effect was for both of those treatments?
Harrison Hansford:
Yeah, and before I do that, I might just highlight one extra little thing is or, or two other things that I think unique to the smallest worthwhile effect and, and why we use that language rather than the other terms that often get used that are that calculated slightly differently is it's intervention specific. So the MCID I'm gonna start abbreviating that because saying minimum clinically important difference is an absolute mouthful of we're talking for two hours, but that is just, you know, you'd have the MCID for pain for people with back pain. And so that's the same number, the same D or yeah, the same difference between treatments, that's for every intervention. So that could be a pain education booklet, it could be a surgery, could be opioids, could be exercise. You know, it's that same one number applied to all those treatments to say, well, if the effect is more than than one or two or, or whatever it is, then it's meaningful.
Harrison Hansford:
But that's not really appropriate because obviously patients that can consider a a pain education booklet, a very different type of intervention to a surgery on their back. And so we'll probably need a different benefit because of that. And so the small cell effect really takes into account the the risks and, and harms of a treatment. And that's what goes into, into calculating it. And relatedly, it's, it's also just determined by patients, you know, the other, all the other variables have some sort of an input by researchers who can sort of influence a little bit how, what the number is and who knows why they do that. But and it's mostly unintentional, but there's really no way that we can change what the answer is with the smallest flow effect. And actually to really, you can tell me if this is gonna take too long, but we could run through what, what's known as the benefit harm trade off method, which is what we use in the paper, which is how you determine the method. And I think that might help listeners understand a little bit about what this actually is and, and why it's UA little bit unique. Yeah,
Jared Powell:
Give gimme a back harm and trade off method Ted talk in two minutes. Harrison, go.
Harrison Hansford:
Yeah, I'll try and do it less. So we'll do it for an opioid. We'll, we'll do it, you know, something everyone knows and imagine you've got, you've got back pain. And so first of all, I, I'd explain to all the risks of opioids. So, you know, there's a risk, you could get addicted to it. You could have some side effects, you know, constipation, all that kind of stuff. It might cost about 10 bucks a week or so, so not too expensive because it's covered on the PDS. But yeah, the main thing to note is that you got this side effects and so making you did nothing, nothing else from now, your back pain's probably gonna get a little bit better, about 20% or so. How much of a benefit would you need from the opioid to be better than doing nothing considering the fact that there are some side effects effects?
Harrison Hansford:
And so, you know, you might say, oh, I might wanna get 40% better, you know, because about 60% better in total, maybe that's worth it. And then the next thing the process asks is, okay, well you said 40%. What if that was 30% better? So a little bit less than what you said. And you might think, oh, prob 30% more is okay, you know, that's still about getting 50% better in total and that that's all right. And I say, cool, all right, now what about 20% on top of the 20% from doing nothing? And you may then say, oh, no, no, no, that's not enough. And so the smallest worthwhile effect is 30% for that person because that's the amount, the minimum amount they would need on top of doing nothing, our comparator to make that the opioids worthwhile. And that would be different for surgery and different for a pain education booklet. Does that make sense?
Jared Powell:
Yeah, absolutely. So you are asking patients this who are recruited to your trial and then you're just averaging the, the answers. Yeah.
Harrison Hansford:
Yeah. So we took the median, but yeah, just pretty much averaging it and then aggregating it over, you know, I think we had about 200 people or so, so
Jared Powell:
Cool. No, that makes perfect sense. I think that was important to get in there upfront. Now tell me the results. This is the stuff we all want to hear. So what, what are our patients with acute and chronic low back pain? What, what is their smallest worthwhile effect of exercise versus NSAIDs?
Harrison Hansford:
So we didn't look at it at ex the, the smallest effect of exercise for acute back pain because the guidelines sort of say, oh, well maybe in the acute phase of back pain exercise isn't the best thing, you know, remaining active and things, but you know, you're probably not gonna go to someone and start lifting two days after you, your back's gotten really bad. And so we looked at it for chronic back pain and the smallest well effect wast a 20% additional reduction to the, the 20%. We, we said was natural history, but the, the main thing is it's 20% difference that's required. And then for NSAIDs it was a little bit, bit, little bigger, which we found quite interesting. And we did that for acute and chronic because that's sort of what NSAIDs are recommended for. And that was, yeah, 30% reduction.
Harrison Hansford:
Yeah, so we said over six weeks.
Jared Powell:
Okay, so a 20% reduction for exercise and a 30% reduction for NSAIDs. Yeah.
Harrison Hansford:
And those numbers don't really mean much at the moment because like, you know,
Jared Powell:
From what? Yeah,
Harrison Hansford:
Yeah. From what?
Jared Powell:
So let's, so let's go straight to that. So let's, can we, can we anchor it to a, let's say, pain on a zero to 10 NPRS scale?
Harrison Hansford:
Yeah. And so we put this, the table of this in the paper because we found ourselves, you know, when I was explaining the results to our collaborators, getting very confused about what these numbers all actually meant and how you use them to interpret a trial. And so if you can access it, then looking at the paper is gonna be really helpful. But I think the, the typical one and, and what's most relevant for our sample, and I guess these trials in general is a baseline pain of five. So if someone with, with pretty bad pain, but it's not, you know, they're probably not gonna be presenting to the ed, but it is bothering them. And four NSAIDs, that 30% reduction or difference, that's a 1.5 point difference between groups. And then for exercise that,
Jared Powell:
So that's compared to a control group, right? So that's compared to doing nothing or usual care or something like that. Yep. Yeah.
Harrison Hansford:
So imagine you have a trial of, of NSAIDs versus nothing and the nothing group, let's say. Yeah, you know, they get a little bit better like, like most people do. But then NSAIDs, the NSAIDs group would have to get 1.5 points better than the other group, but they, it is not just getting 1.5 points better overall.
Jared Powell:
Cool.
Harrison Hansford:
Yeah.
Jared Powell:
And then the exercise
Harrison Hansford:
Exercise is one point, so that's 20% of, of five. And so they'd need to get one point better than a control group. And that's what the p people may or may not have seen the, the paper. We sort of did a trial for graded sensory motory training, which is exercise on steroids with a whole bunch of other things. And there was about a one point difference there. And so that's similar to what we found.
Jared Powell:
So exercise would need to outperform a control intervention by, let's say one point if their baseline pain was five in order for a patient to think that's a, a, a worthwhile treatment to do for like the smallest effect, right?
Harrison Hansford:
Yeah. So if they got only a little bit more better, like say 0.5, then they probably wouldn't think that's worth, you know, going to the gym or going for a walk five times a week or, or whatever it is, the exercise they would've been doing. And if it's more than that, then they would.
Jared Powell:
Cool. So notably there's a difference between exercise and NSAIDs. Can you speculate as to why?
Harrison Hansford:
Yeah, so we've had a few people talk to us about this because intuitively for me that doesn't, I mean, I may be a little bit biased, but it doesn't really make sense. 'cause Taking an nsaid, like neurophin is really easy. It's basically like, it's like $5 for a packet and you don't have to do anything for it. And there aren't really many side effects. It's pretty safe for most people. But people said that actually we'd prefer to do exercise over an NSAID indirectly, but by having a smallest, a lower smallest worthwhile effect for exercise. And I find that really interesting. But I think part of the reason we think that was the case is because the people who were recruited to this survey, they were people who were reason reasonably active. And so exercise is probably something they enjoyed already and there's a whole bunch of other benefits of exercise. And so doing exercise wasn't a big burden for them, even if it did take time. And so they were happy to, to do exercise rather than nothing for a smaller, smallest worthwhile effect.
Jared Powell:
Yeah, interesting. Again, yeah, like exercise is, is especially if someone exercises right, it seems like a much more healthier and generally good intervention to participate in relative to a nonsteroidal anti-inflammatory. And within that, I assume when you said NSAIDs, you mentioned the harms of, of NSAIDs. Yeah,
Harrison Hansford:
So we mentioned the harms. We said, you know, that low risks of you know, things going on with your gut, sometimes you can get a bit of stomach upset, and then really rarely you can get slightly worse side effects like cardiovascular or heart, heart adverse effects. And we sort of explained that these were relatively rare, but were possible, whereas for exercise, the main thing we we mentioned was that you, you might get a little bit worsened pain in the short term, which we know some people, people get, but outside of that, there's probably not too many risks unless you're doing something extreme.
Jared Powell:
Yeah. And so this got me thinking, Harrison, we, there's been a little bit of pushback and scrutiny directed towards exercise lately, which has been good because exercise is occupied a fairly privileged position in the treatment of musculoskeletal pain for some time. And lots of people are saying there's questions of efficacy and there's certainly consistent very modest effect sizes with exercise that we're seeing in a bunch of pain conditions from the lumbar spine to the shoulder, to the knee to the hip with osteoarthritis, et cetera, et cetera. And so there's been a bunch of sort of hip piece editorials that have come out challenging the role of exercise for musculoskeletal pain owing to the, the consistently small and modest effect sizes. Does your paper challenge this at all or does it add any nuance or does it support exercise at all, or is it just a different lens that we're looking into it with?
Harrison Hansford:
Yeah, I, I think it's a really good point. And I think, you know how I was saying that, you know, part of the reason that, that the exercise smallest effects might have been smaller than NSAIDs is because of all those other benefits. I think that's probably the way, and, and why this might, our paper might be slightly helpful to interpret these effect sizes because you can't really disentangle those other effects from the effects on pain, but it does change the sort of treatment decision making about it is you, you know, you might say, well, you know, I think we know that exercise probably reduces pain about one to 1.5 points compared to doing nothing or, or not much else. And so our paper shows that most people will consider that worthwhile. And that's aside from the whole argument about exercise compared to placebo and what the active ingredient for exercise is and, and what's actually reducing pain, but using our results, it, it does seem that most people will consider the benefit that most people will get worth doing.
Harrison Hansford:
But it, it really comes down to an individual and, and you can sort of present that, you know, if you do this for your pain, you're probably gonna get about, you know, a small amount better, do you wanna do that? And if that comes with seeing a physio for three times a week for six weeks, maybe that's not worthwhile if they know that only there's this modest effect. But if you say, actually, I'm only gonna see you once as a clinician and then I want you to, so, you know, just try to keep active and do a little bit more, then maybe that's, that then is worthwhile because you're still getting exercise in, it's just a bit different.
Jared Powell:
Yeah. So this sounds like this smallest worthwhile effect sounds like it fits really nice into the shared decision making paradigm where you're like, okay, this is all the treatment options you have available. They're all somewhat equally effective, but within those treatments, there might be a different benefit of harm risk profile trade off that we might need to consider. Would you invoke, when you are speaking to a patient, so this is on the front line, would you invoke the literature and say, well, we've done studies and we, we we've seen that in chronic low back pain most people would accept a 30% or 20% improvement with exercise for their chronic low back pain, or would you sort of just say, ah, it might help you by one point out of 10 relative to doing nothing over over six weeks? Like, how would you approach that clinical interaction? Would you, would you try and break it down into more digestible, less theoretical points, or would you go to the literature?
Harrison Hansford:
Yeah, I mean, that's the million dollar question. It's, it's really tricky to, I think, convey research patients. You know, it's one, it's tricky enough to understand research yourself and then try to convey that understanding to a patient who then has to make a decision based on that is really, really tricky. And, and interestingly, it's something we've, we've thought a lot about is how how should this smaller SW profile effect be used by people? And, and we as a team sort of came to the conclusion that it, it might not actually be very useful for a clinician, and that might sound a little bit odd, but the reason for that is because you can just ask them, you know, how much better would you need to get? And that could, the answer could come in a whole different bunch of forms if it's probably not gonna come as a between group difference, because people don't really think about between group differences.
Harrison Hansford:
We've found with, when people are in pain, they just wanna know where they're gonna get to. And so they may say, I, I want to get, like, I, I want, I'm happy, I wanna get a lot better. And you can try and disentangle that into a number. And so that could, you know, they say, all right, you know, I want to get 50% better. And you are like, okay, well, you know, from from our paper, we, we know that the natural history, most people are probably gonna get about 20% better or so. And so in your head you could say, all right, well they're smallest worthwhile effect is, is 30% their baseline pain is about, you know, five, let's say. So we need about a 1.5 point difference, and that's what exercise produces on average. So I reckon this person will like it. And you can say that to them and, and explain your sort of thought process.
Harrison Hansford:
But I think that the main takeaway for, for clinicians is, well, you can ask them their smallest worthwhile effect, you don't need our paper to, to do that. And then you can discuss, you know, well, you know, that exercise produces about 1.5 out of 10 differences compared to doing nothing. And so if they'll consider that worthwhile, then that's probably a, a good treatment for them. But if they want to, you know, get massively better and, and be cured in two weeks, then, or I mean, you might have to say that there's, there's nothing that we know that will do it, but exercise appears to be the, the most promising one. Yeah. Does that sort of
Jared Powell:
Make it Yeah, for sure. So, so do you see this smallest worthwhile effect as being more of a, a research academic construct as opposed to a clinical use?
Harrison Hansford:
Yeah, I do. And it can be used by clinicians to interpret research. And I think that's probably one of the more important parts of it is how do you know what results are meaningful in, in a trial or a meta-analysis? And particularly also for policy makers, you know, people who are saying, all right, these are the things that are getting funded by Medicare and these are the things that are going into hospitals and, and these are the guidelines. It allows them to interpret research and, and treatment effects using something that's informed by patients and patient's opinion rather than, you know, expert opinion, which is what's often been done in the past, or just picking a number and saying, yep, I like that, that treatment effect. Or I, I'm, you know, I used to be a physio, so I love bit of manual therapy and we'll just recommend that. It gives me more structure to interpreting the results of, of trials and meta-analysis.
Jared Powell:
Yeah, it's, it's funny 'cause in a lot of research papers, something might be statistically significant, but there might not be a clinical meaningful difference or A-M-C-I-D or whatever you wanna call it. Mm-Hmm. And there's an editorial that I have read recently who you, you probably aware of, is it the, the Shahid editorial, which says like, who gets to decide what a, what a clinically important change is? Mm-Hmm. And you sort of, you think about it and you go, you are trying to make these decisions in concert with a patient when they present to you about what, what we should do. And as physical therapists or eps or we have a limited amount of tools mainly exercise based, and that's certainly what the clinical practice guidelines tell us what to do. And then we're consistently seeing there's these small effect sizes that might not be clinically meaningful for using exercise for a bunch of musculoskeletal conditions.
Jared Powell:
But then, like that sort of speaks to your point about the limited value of this arbitrary MCID of one point out of 10 or two points out of 10 or 15 points on a dash scale or a spatty scale or whatever you wanna say. Like, how relevant is that to this patient? Like what might be their minimal clinically important change or difference for this treatment? And it might be 10% for one person in terms of a pain reduction, it might be 50%. Now this is within group, because again, we're not comparing, there's no counterfactual in, in, in real life, unfortunately. So like how, how do we, how do we take all of these abstract constructs for clinicians, let alone patients, and then try and make a decision? It's, it's really challenging and it, and it, we're gonna simplify it and say it just comes back to what the patient in front of you really wants or what they expect. And you have have to have a conversation about that.
Harrison Hansford:
Yeah. And I think particularly, you know, I think our roles as EPS and, and physios and, you know, all, all our sort of health pressures to deal with with exercise, it's not just delivering exercise. I don't think it ever has been. And so I think starting the discussion about, well, what do you expect from treatment? And, you know, do you just wanna walk away from here feeling a bit better? In which case, you know, a bit of manual therapy might, might be the way to go, but, you know, do you want to, you know, get a little bit better over the long term or do you want to be able to do some sort of functional activity? You know, I think those conversations are arguably more important than, than worrying about an NRS because, and you know, this is a challenge when you go from research to practice is it is what's easy in research, which is a zero to 10 NRS is not always what's relevant in practice.
Harrison Hansford:
And so, you know, it is sort of a bit tangential to our paper, but I think it is really about that shared decision making and, and figuring out what does the patient in front of you actually want? And, and that might be a pain reduction, it might be an improvement in, in their, you know, functional impairment. It may be just actually they're really distressed from it and they wanna talk to you about it first and then, you know, you can slowly do a few exercises. And I think that, yeah, our paper sort of helps interpret research and, and know whether one treatment is more worthwhile than another. And it is challenging at the moment because there aren't many estimates of the small s sw bowel effect, and we're working on changing that. But when there are, and you know, we've got a smaller s sw bowel effect for opioids and surgeries and pain education and all these different treatments, we can then sort of make it a bit more of a hierarchy in our own heads of which ones do patients on average consider worthwhile? And that can then bleed into your clinical practice a bit as well.
Jared Powell:
Yeah. Awesome. Do, do you envisage the smallest worthwhile effect replacing the MCID at all? I
Harrison Hansford:
Think it definitely should. I think it's quite challenging because it takes a bit more work than the to estimate than the MCID and whereas the MCID, you know, to calculate it, you just need to ask people sort of two questions. You know, what's your pain intensity at baseline and follow up, and then how much have you changed on a, you know, seven point like a scale or something? Whereas this, you know, requires people to understand things and then answer a series of questions. And so I hope it replaces it and I think that's something we're working to try and get greater acknowledgement of, of the smallest web effect as potentially a slightly more valid way of determining whether an intervention is clinically important based on its effect. And so I hope it does, but I think it'll be slow. Like everything is, it'll take time.
Jared Powell:
Yeah. Good luck, mate. It's tough to change these things when they're being instantiated in the system for so long. But mate, I, I reckon you can do it. You stand passionate about it, Harrison, and you've got a solid team that you're, you're working with as well who are very influential. So I'm sure you'll, you'll make inroads if you don't change it by the end of your PhD, which is no pressure, mate. What else are you working on, mate? Or do you, do you actually have anything else you'd like to add in terms of like maybe some, some key talking points or, or too long didn't read or too long didn't listen? What can, what can the listeners take out of your paper?
Harrison Hansford:
Yeah, I, I think the main, the main thing is that to interpret whether a treatment A works and is then b worthwhile a it, you always look at the between group difference. And I think exercise literature is very guilty of sort of saying, oh, well, well both people, both groups got better. And that's a, that's a good thing, but that doesn't tell you that either of them work, and therefore it's really hard to tell whether that the benefit of of one of the treatments is, is worthwhile because you're not comparing between the two. So the key is to always look at the between group difference and then use an index of, of clinical importance, like the smallest survival effect to inform, you know, your interpretation of, of that research. And for us that was for most people about a, a one point difference for exercise for, for chronic low back pain and you know, about 1.5 a little bit more for people with well taking NSAIDs for acute or chronic. So that would be the main takeaways I think from this is always look at the between group difference.
Jared Powell:
Well said mate. Well said. What else are you working on, Harrison? What can we expect to see from you published in the near future?
Harrison Hansford:
So a couple we're working on a couple more smallest with effect papers for, for different interventions. Like I saw it already sort of hinted at a couple actually related to, to shoulder pain, which is yeah,
Jared Powell:
Good man, because I was gonna ask you about that, but I just didn't wanna make it all about me
Harrison Hansford:
up your alley. And, and looking at the, the effectiveness of different surgeries and the smallest worthwhile effect of those surgeries for rotator cuff pain. And so that's really exciting. But unfortunately that's not what makes up my PhD and my PhD's. Yeah. Using a couple of different complex methods that I'm well outta my depth to deal with. But looking at the generalizability of randomized trial results for, for acute low back pain and, and medicines in particular, because one thing I, I didn't realize, my PhD is all the trials of, of medicines. So you've got paracetamol, you've got NSAIDs, you've got now opioids have been done in Sydney and comparing to placebo for acute low back pain, there's really not many other trials out there. And so the guidelines that say these are the medicines that should be re recommended for people are all based on results from Sydney . And, and you know, Sydney's a great place. We all, we all love Sydney, but you know, maybe those results don't apply to people in the US or or the uk. And so we're using sort of these new methods to, to formally generalize those studies outside of the context they're in and, and hopefully better inform the guidelines in the US and in the UK and and beyond. And yeah, I think that's really exciting
Jared Powell:
Mate. As a Queenslander, I can relate to the fact that we would respond very differently to things than people in Sydney in New South Wales. So I, I can fully get on board with the lack of generalizability there,
Harrison Hansford:
. Yeah. And then because I'm a psycho punishment, that's not the only thing I'm doing. We're also really looking to try and yeah, there's a few different things we're doing with, with people with hip fractures and, and different medicines and the safety for that and as well as different surgeries spinal stenosis, which I think most people know as a sort of different little subsection of, of back pain where, where surgery is one of the actual things that, that is recommended at the moment. And we're also looking at to try and improve the reporting of the studies that, that we're sort of doing and, and the people doing across the world so that people can understand them better and the, the information that can be used a little bit more and head into the US in the middle of the year to, to organize all of that and, and make it all happen. So that's a really exciting project as well. It's not just about the, the clinical side of things, it's also about improving research as well.
Jared Powell:
So yeah mate, nice to see you dipping into your PhD budget there as well. In order to get a trip to the US well done
Harrison Hansford:
The best thing. Best thing about a PhD .
Jared Powell:
Yeah, exactly. Good. That's, that's awesome mate. Thanks. Thanks for the chat. Are you on the socials? Where, where can people find you? Are you active on Twitter or anything?
Harrison Hansford:
Yep, I'm relatively active on Twitter. I think that's probably the best place is, and it's just HJ Hansford and then Harrison answered on LinkedIn and not as active on there. But I think if people are interested in this sort of stuff, it's also probably worth following our, our groups page on Twitter, which is the Center for Pain Impact. And you should be able to find us. And we're also looking for PhD students, so if people, if particularly clinicians, I think clinicians clinical practice is hard work. And so if you want a bit of a break and really, you know, find your podcast interesting because I know you really focus on the research, then reach out to us on the Center of Pain Impact or me. And I think we're really looking for, for more really passionate clinicians about pain and all different types of pain, you know phantom limb pain pelvic pain now and back pain as well. And so all different sort of things and if people are interested then reach out and we're always keen to take on more people.
Jared Powell:
Yeah, I can, I can attest to your group's stature. I know a bunch of the guys there really good people, solid researchers, always producing research at the vanguard of pain management. And so yeah, shout out. And so if anyone anyone's listening that is thinking of it, that they want to just torture themselves for five years, three years, four years. For me it's seven years 'cause I'm doing it part-time. Oh it's go to a PhD. You won't regret it. If you wanna get a free trip to the US by the sounds of it too, go do a PhD as well.
Harrison Hansford:
Yeah. Come to a PhD with us. But yeah, it's been great chatting.
Jared Powell:
Alright mate, that's been awesome. Thanks Harrison.
Harrison Hansford:
Cheers.
Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with Harrison Hansford. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
