Back pain is so common its impact is often under-estimated. Chronic back pain is a seriously disabling condition, which causes much distress (Smith et al., 2001; Sprangers et al., 2000). A survey of Scottish adults (Smith et al., 2001) showed that 14% reported continuous or intermittent pain for at least 3 months, for which they had taken analgesics and sought treatment. Nearly half of these people reported severe functional limitations in direct proportion to the severity of their pain. Chronic pain, of which back pain usually constitutes the largest category, was also associated with poorer physical and mental health.

Much back pain is dealt with in the United Kingdom in primary care and often involves physiotherapeutic intervention. If the back pain does not resolve or the individual does not adapt, referrals are often made to orthopaedics, rheumatology, or in some cases to neurosurgery. Optimal treatment consists of explanation and reassurance, with minimal rest, and encouragement to return to activities despite continuing pain. This contrasts with traditional advice, which tends towards prolonged rest and a cautious approach to physical activity. Any delay in referral for investigation and expert diagnosis tends to leave the patient in limbo with neither reassurance nor advice, thereby contributing to disability.

There are many possible causes and mechanisms of low back pain (Waddell, 2004). Some symptoms or physical signs indicate urgent and often operable conditions, such as tumours. These symptoms and physical signs are labelled ‘red flag’ indicators and suggest referral onto specialist services is appropriate.