We need to know who will benefit from which intervention

Spinal pain is not a new problem. Back strain is mentioned in the oldest surviving surgical text, the Edwin Smith papyrus from 1500 BC. However, the place of mechanical spinal pain in medicine has changed dramatically over the centuries. As life expectancy and general health conditions have improved, neck and back pain have become major causes of morbidity and health expenditure.1 Back pain was recently estimated to affect around 17.3 million people in the United Kingdom at an annual cost of £1bn ($1.9bn; € 1.4bn) to the NHS and an additional £565m to private healthcare providers.1 The recent publication of three papers in the BMJ, including one in this issue, addressing the physiotherapeutic and manipulative treatment of spinal pain is therefore timely (p 75).2^–4 It also coincides with the release of guidance from the Arthritis and Musculoskeletal Alliance.5

The alliance has brought together a multidisciplinary group to evaluate systematically the evidence for various interventions in spinal pain and determine clinical standards for their delivery. The guidance emphasises conservative management in the community by a variety of health professionals including physiotherapists, chiropractors, osteopaths, and musculoskeletal physicians. Only a small proportion of patients with so called red flag signs indicating serious underlying pathology should be referred without delay to …