Proposals of population solutions are beset by lack of knowledge

EDITOR,--R M Ellis's editorial on back pain1 does not dig deeply enough into the assumptions underlying the report by the Clinical Standards Advisory Group.2 The report makes important recommendations, based largely on evidence from research, on the clinical management of patients with acute back pain. It also champions an integrated back pain service. Back pain, however, is a public health problem that is unlikely to be resolved by simple clinical measures in individual patients. Proposals of population solutions to the problem of back pain are beset by a lack of knowledge.3 How should a costly epidemic of a medical diagnosis be controlled when the causes of the condition and of the epidemic are poorly understood, the nature of the condition is debated, virtually no primary preventive measures have been shown to work, and “carrying on normal activities” (that is, no treatment) may be among the best treatments available?

Archie Cochrane sat on the United Kingdom Working Party on Back Pain, which reported in 1979 that “unfortunately there is insufficient basis at the moment for formulating advice that could be incorporated into health education directed at the prevention of back pain.”4 Fifteen years on, this conclusion remains substantially unmodified, although Cochrane might have welcomed the fact that the advisory group used evidence from trials in shaping the delivery of services.