Darlow B, Stanley J, Dean S, et al. The Fear Reduction Exercised Early (FREE) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial. PLoS Med. 2019 Sep 9;16(9):e1002897. doi: 10.1371/journal.pmed.1002897. eCollection 2019 Sep. (Original study)

BACKGROUND: Effective and cost-effective primary care treatments for low back pain (LBP) are required to reduce the burden of the world's most disabling condition. This study aimed to compare the clinical effectiveness and cost-effectiveness of the Fear Reduction Exercised Early (FREE) approach to LBP (intervention) with usual general practitioner (GP) care (control).

METHODS AND FINDINGS: This pragmatic, cluster-randomised controlled trial with process evaluation and parallel economic evaluation was conducted in the Hutt Valley, New Zealand. Eight general practices were randomly assigned (stratified by practice size) with a 1:1 ratio to intervention (4 practices; 34 GPs) or control group (4 practices; 29 GPs). Adults presenting to these GPs with LBP as their primary complaint were recruited. GPs in the intervention practices were trained in the FREE approach, and patients presenting to these practices received care based on the FREE approach. The FREE approach restructures LBP consultations to prioritise early identification and management of barriers to recovery. GPs in control practices did not receive specific training for this study, and patients presenting to these practices received usual care. Between 23 September 2016 and 31 July 2017, 140 eligible patients presented to intervention practices (126 enrolled) and 110 eligible patients presented to control practices (100 enrolled). Patient mean age was 46.1 years (SD 14.4), and 46% were female. The duration of LBP was less than 6 weeks in 88% of patients. Primary outcome was change from baseline in patient participant Roland Morris Disability Questionnaire (RMDQ) score at 6 months. Secondary patient outcomes included pain, satisfaction, and psychosocial indices. GP outcomes included attitudes, knowledge, confidence, and GP LBP management behaviour. There was active and passive surveillance of potential harms. Patients and outcome assessors were blind to group assignment. Analysis followed intention-to-treat principles. A total of 122 (97%) patients from 32 GPs in the intervention group and 99 (99%) patients from 25 GPs in the control group were included in the primary outcome analysis. At 6 months, the groups did not significantly differ on the primary outcome (adjusted mean RMDQ score difference 0.57, 95% CI -0.64 to 1.78; p = 0.354) or secondary patient outcomes. The RMDQ difference met the predefined criterion to indicate noninferiority. One control group participant experienced an activity-related gluteal tear, with no other adverse events recorded. Intervention group GPs had improvements in attitudes, knowledge, and confidence compared with control group GPs. Intervention group GP LBP management behaviour became more guideline concordant than the control group. In cost-effectiveness, the intervention dominated control with lower costs and higher Quality-Adjusted Life Year (QALY) gains. Limitations of this study were that although adequately powered for primary outcome assessment, the study was not powered for evaluating some employment, healthcare use, and economic outcomes. It was also not possible for research nurses (responsible for patient recruitment) to be masked on group allocation for practices.

CONCLUSIONS: Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.


Discipline Area Score
Psychologist 6 / 7
Physician 5 / 7
Comments from MORE raters

Physician rater

Low back pain is certainly a very common complaint seen by primary care practitioners. The physician's approach is typically based on professional society standards and past clinical experience. This study compares a specific clinical approach to one that varies by practitioner. Clinical outcomes included not only pain reduction but also return of physical function and decrease in fear and anxiety. Although the clinical outcomes did not differ significantly between the 2 groups, cost and follow up visit frequency decreased. Perhaps making such standardized training available more broadly might be better received by primary care practitioners now.

Psychologist rater

The research is valuable because t indicates the benefits to GP's when trained in the FREE approach that takes into consideration psychosocial and similar aspects affecting recovery. It may also lead to similar research in the area that may be aid patients in shortening their recovery time, using less medication and less invasive tests, for example. Even though there was no benefit directly to patients when using FREE, indirectly it may, as it allows to have GP's with more knowledge and adhere to guidelines recommendations. Overall, as a psychologist, I found it to be informative since it points to the need to have GP having a better understanding of their population in order to choose best alternatives that hopefully help the patient and reduces unnecessary health care costs. I am not clear as to why the benefits of FREE did not helped in recovery of LBP individuals. I'm unsure if it was related to the design of the study, or that it does not really matter if GP's receive such training .
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