My next patient: looking hopeful, hobbling in. Six weeks of pain and no respite. Referral to physiotherapy was the obvious option for such patients, but now I know from a paper in this issue that providing routine physiotherapy in the NHS is no better than advice to remain active (p 708).1 Six weeks is a long time to be in pain, unable to work, and relatively immobile. Most patients will still be experiencing low back pain and related disability one year after their first consultation, and unfortunately we can do little about it.^w1 Although in this study patients felt better, objective outcomes did not improve—and, in a resource limited health service, can we make referral decisions based on subjective measures?1

What are the implications for physiotherapy? Not all interventions can stand up to critical appraisal,2 and this paper shows that our traditional model of physiotherapy for back pain is ineffective. But let us …