It is perhaps fitting that the last guideline produced by the National Collaborating Centre for Primary Care prior to its merger with related NICE guidelines groups, should cover the same disorder that the RCGP published as its first comprehensive evidence based guideline over a decade ago: the early management of non-specific low back pain.

Longer-term non-specific back pain remains a common problem for practitioners to deal with, particularly in primary care, occupational health and musculo-skeletal services. It still represents a major cause of sickness absence from work- remaining the largest single cause in Scandinavia, only exceeded by mild to moderate mental health problems in the UK.

It is gratifying to observe how dramatically the number of high quality RCTs on interventions for NSLPB has increased over the last ten years. At last we are able to make treatment recommendations for people with continuing back pain that are likely to generate real patient benefits. Building on this, the authors of this guideline have produced a simple care pathway for those with back pain that will reduce the multiplicity of different treatment approaches, many unproven, that are in use by the NHS.

However, whilst these guidelines demonstrate the quality and extent of evidence covering a wide range of interventions, covering most day to day clinical queries and decisions within the field, much of the detail remains unanswered, highlighted in the evidence to recommendations sections at the end of the chapters. The group have identified six key research questions: screening, education, sequential v single interventions, psychological therapy, invasive procedures, and TENS. Robust evidence is increasingly sought by NHS commissioners to underpin significant investment. Whilst a lack of evidence of effectiveness doesn’t equate with evidence of ineffectiveness, it is only sensible that, investment in back pain treatments should support those interventions for which effectiveness is supported by good quality research.

Professor Mark B Gabbay, MD, FRCGP, National Collaborating Centre for Primary Care Board