Resources for General Practitioners
Ask a question and we'll frequent it...
The simple answer to this is yes. Although we hope that you will be able to integrate FREE into your normal consultation, if there are elements which you think are important to cover, which you do not have time for in one consult, it is better for the person to return to you and continue to receive a consistent and coherent package of care, rather than seeking an opinion elsewhere. This will obviously also give you more time to practise FREE, which has to be a good thing.
Although pathology incredibly rarely presents as back pain, screening for it is an important part of a GP's role. It must be remembered, however, that screening can also result in a number of unwanted side effects. These include anxiety, increased perceptions of spine vulnerability, incidental findings, radiation exposure, and unnecessary subsequent interventions. For this reason we recommend that only cauda equina syndrome, infection, and abdominal aortic aneurysms are screened at the first consultation. There is more information regarding this on the Red Flags page.
We think that the best time to ask Red Flags questions is at the end of the history, after having Researched the Threat. This is because we do not think it should be the focus of the history, but rather some simple (casual from the perspective of the patient) screening questions at the end of the history before commencing the physical exam. This way screening will not be seen by the patient as being the most important element of the consultation (which it may be if these questions are prioritised to the start of the consultation), nor will they be the thing which stays in the patient's mind (which they may be if they are screened as the end of the consultation).
Inside the back cover of the patient booklet there is a list of reasons to return to the doctor, this means that you do not need to stress these potential signs of pathology to your patients.
It is not expected that all of the movements will help all of your patients, so the key thing is to try a different movement. Often movements performed in lying will be helpful even when the same movements have not been as useful in standing. This is usually because there is less muscle guarding (a protective response) when someone is lying and feels more in control.
Remember that not improving is not necessarily a negative finding. If someone can repeat a movement several times and not get any worse, this still indicates that they are not making an injury any worse, so the movement does not need to be avoided.
If someone does feel worse after repeating a movement, it is worth explaining that there is nothing wrong with the movement itself, but they may not be ready to push it yet. They can try again in a couple of days when things have settled/pain relief has taken effect. In the meantime, they can focus on other movements, or moving in the same direction but not to their current limit.
The effectiveness and best way of implementing FREE is currently being investigated through clinical research trials.
You can still use FREE confidently as it is based upon the best available evidence, and is consistent with current low back pain clinical guidelines.