Low back pain is simultaneously one of the most common and vexing pain conditions physicians treat. According to the International Association for the Study of Pain (IASP), low back pain (LBP) is the leading cause of years lived with disability and is a major public health concern worldwide. Physicians who change how they frame the condition, specifically, not as an injury, may reduce healthcare expenditures as well as improve patient outcomes, based on a recent study.¹

Intervention for Low Back Pain is Often Too Early

However, these guidelines are not as widely followed as might be ideal.² “Despite these recommendations, current practice commonly involves an overuse of opioid medications for pain relief, inappropriate spinal imaging, and potentially harmful interventional procedures, including surgery,” wrote Wilson et al in their Applied Health Economics and Health Policy paper.¹

Among common barriers to the implementation of recommended practices, Wilson et al found inadequate knowledge of or confidence in best practices on the part of clinicians, patient requests for more interventional treatments, and inadequate time for more personalized care.

FREE Approach Calms Fear, Promotes Self-Care

In their study, the team, based in the UK and New Zealand, assessed the effectiveness of an LBP intervention known as the Fear Reduction Exercised Early (FREE). This approach includes five hours of education and training for primary care physicians; resources for patient support, such as education, advice, and reassurance; and support for electronic consultation to help ensure adherence to guidelines.

“Guideline recommendations and the FREE approach aim to help clinicians and patients to reduce the perceived need for medical intervention to manage LBP,” thus reducing the need for future care, they wrote. This is accomplished by helping patients develop both the skills and confidence to self-manage their pain. “The FREE approach,” they added, “emphasises that LBP can occur without injury and that framing it as an injury risks unnecessarily medicalising LBP and may have negative consequences on the patient’s perception of fragility and willingness to return to physical activity.”

FREE Approach Reduces Injury Insurance Claims, Healthcare Costs

The researchers analyzed data drawn from nationwide injury insurance claims records in New Zealand over a 33-month period. They analyzed the association of FREE training with injury insurance claims, healthcare utilization, and costs by comparing LBP claims and associated activity with non-musculoskeletal injury claims for the same periods, before and after the physicians underwent FREE training. They then compared that data with the same data for physicians who were not trained in the FREE method.

By referring patients less often to other medically unnecessary and potentially harmful health services, Wilson et al stated in their paper, FREE-trained doctors can have a positive impact on the cost and effectiveness of patient care.

FREE Approach Adoption in the US

Padma Gulur, MD, professor of anesthesiology in the pain medicine division at Duke University School of Medicine, pointed out that Wilson’s study highlights aspects of care that are well-established in the US. “Though still not universal,” she said, “implementation of these methods is growing and is in place in most large medical centers.”


  1. Wilson R, Pryymachenko Y, Abbott JH, et al. A guideline-implementation intervention to improve the management of low back pain in primary care: A difference-in-difference-in-differences analysis. [published online ahead of print, 2022 Dec 6]. Appl Health Econ Health Policy. 2022;1-10. doi:10.1007/s40258-022-00776-3
  2. Foster NE, Anema JR, Cherkin D et al. Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions. Lancet. March 21, 2018. doi:10.1016/S0140-6736(18)30489-6.
  3. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Annals Int Med. 2017 Apr 4;166(7):514-530.