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Back Pain

Bandolier has been asked by a number of readers to seek out information on back pain and its treatment. This is a complex subject of great importance. There are useful publications which are both useful guides into the literature and which also provide useful guidance for purchasers and providers.

The two major publications reviewed are from the Clinical Standards Advisory Group (CSAG) and are available from HMSO. They are complementary: one examines the epidemiology and cost of back pain [1] while the second develops management guidelines [2].

How big is the problem?

Very big. The sheer amount of information presented for the epidemiology of back pain [1] is staggering, but fascinating. Most people with back pain have moderate to severe pain.

The overall numbers, from population prevalence to those having surgery, are shown below.

Getting bigger!

The evidence from Britain and elsewhere is that back pain is becoming a bigger problem - not that there is any evidence of changing pathology, but rather due to changed attitudes and expectations. This trend has been particularly noticeable since the mid '80s. The total number of days in Britain for back incapacity obtained through sickness and invalidity benefit has risen dramatically in recent years:-
The British experience is by no means unusual, with other countries seeing an even steeper rise to higher levels.


The peak incidence of back pain and sciatica occurs at about age 40-60. Age of onset is spread relatively evenly from 16 years to the early 40s, gradually declines thereafter and is uncommon after the mid fifties. In those who continue to have back pain it is more likely to be more frequent or constant with increasing age.


There is little difference in the incidence of back pain in men and women.


Up to 60% of people with low back pain also have some neck symptoms. Back pain is commonly associated with other complaints.

Social class

There is conflicting evidence for a relationship between prevalence of low back pain and disability and lower social class. This may largely be related to manual and non-manual occupations.


There is general though not unanimous agreement that back pain is more common in people in heavy manual occupations who undertake heavy lifting. People in such jobs take significantly more time off work with back pain.


There is considerable evidence of an increased prevalence of low back pain associated with smoking. This may be due to coincide with a complex set of demographic social and lifestyle factors.

Disability and work loss

Surveys show that 6% of employed people with back pain lost at least one working day because of back pain in the previous four weeks. This is equivalent to 1.9% of all employed people losing at least one day in four weeks, and includes 0.3% who were off for the entire four weeks. The estimate of total working days lost in Britain is 52 million (with 95% confidence intervals of 35-69 million days).
Half the total days lost due to back pain are due to the 85% of people who are off work for short periods of less than seven days, and half by the 15% of people who are off work for more than one month. The longer a person is off work with back pain, the lower their chance of returning to work. After six months there is about a 50% chance of returning to work; this has fallen to about 25% at one year and 10% by two years.


The estimated cost to the NHS is £481 million a year (min-max range £356 - 649 million), with non NHS costs (such as private consultations and prescriptions) being an additional £197 million. Costs of DSS benefits is estimated at about £1.4 billion with lost production estimated at £3.8 billion. This breaks down to an annual NHS cost to a purchasing authority of 250,000 people of £2.2 million (range £1.6 - £2.9 million). A typical GP practice with five GPs and 10,000 patients would bear costs of about £88,000 (range £65,000 - £118,000).

Management guidelines for acute back pain

An overview of the management guidelines for acute back pain is given below.
The document from which these are taken [2] develops the background to these ideas and provides two useful algorithms to back this up. The first algorithm is for diagnostic triage, which includes red flags for possible serious spinal pathology and nerve root problems. The second algorithm is for the primary care management of simple backache, which stresses early activity. Both are easy to follow.


The authors of the CSAG report have done some interesting economic modelling of the effect of the management guidelines and service recommendations on NHS resource use. The analysis is based where possible on the results of controlled trials. It is not a straightforward analysis, because there are implications both for savings and for redistribution of resources to obtain more effective treatment. However, they were able to estimate the maximum and minimum sizes of the effects of guideline implementation on some key resources in the NHS:-

Ongoing research

More studies on back pain treatment are continually being published. One good RCT from Finland recently published in the New England Journal [3] compared bed rest, exercise and ordinary activity in acute low back pain. The conclusion was that continuing ordinary activity within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilising exercises.


  1. Epidemiology Review: The Epidemiology and Cost of Back Pain. Clinical Standards Advisory Group. 1994 HMSO £14.00. ISBN 0-11-321889-3.
  2. Back Pain. Report of a CSAG Committee on Back Pain. 1994 HMSO £14.95. ISBN 0-11-321887-7.
  3. A Malmivaara, U Häkkinen, T Aro et al. The treatment of acute low back pain - bed rest, exercises, or ordinary activity? New England Journal of Medicine 1995 332: 351-5.

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