The curse of low back pain.

For those of us who have had back pain, this year's Journal special series relates not only to our professional experiences, but also to our personal experiences--experiences that can be life altering.

The title of this note was not designed to evoke images of suffering, however. It was designed to serve as a recognition that back pain is not just an impairment that can cause disability, but a battleground on which patients war with employers and insurers, and various health care practitioners fight with one another for tuff. Low back pain is a curse not only because it causes suffering and disability and disrupts people's lives, but also because it brings out some of the worst in human behavior. Few who care about the subject remain untainted.

The term "low back pain" rarely stimulates thoughtful dialogue. Consider our profession's almost hysterical response to the woefully inadequate Agency for Health Care Policy and Research guidelines on acute low back pain. The publication of those guidelines was not the finest hour for AHCPR--or for the physical therapists who were reactionary rather than responsive. Similarly, the willingness of some practitioner groups to play loose with the facts as they promoted themselves was at best unseemly and at worst an example of why society often views those who treat low back pain with skepticism and disdain. To many in our society, those who have back pain are automatically suspect, and those who treat them for profit are seen as irresponsible money grubbers rather than as caring practitioners trying to eliminate someone's pain.

In an ideal world, the special series that begins this month would be filled with articles detailing the success rates of various treatments. In an ideal world, we would be discussing which of many viable treatments have the best evidence for various types of patients. We also would be talking about cost and strategies to provide effective care even under the constraints of managed care initiatives. As will become clear when you read the articles in the series, however, we are not practicing in an ideal world.

Some people would have you believe that they have the secret recipe--treatments they have discovered, management protocols they are marketing, or techniques they are willing to teach--but such people are masters of the evidence-free argument. There are ideas on how we can best treat patients with low back pain, and some tentative and tantalizing pieces of evidence suggest that some interventions do work for certain types of patients. But that evidence is preliminary and should be carefully evaluated. If we insist on repeating dogmas and arguing from bias, we will do no one any good. Instead, we will diminish our credibility and our potential to help people in pain.

In putting together this special series, Dr Anthony Delitto cast a wide net. In addition to physical therapists, a variety of other heath care professionals and biomechanists are represented here. Through their carefully crafted articles they have much to offer us, with many ideas that can influence how practitioners manage their patients. Some articles border on exposes. They remind us of the extent to which many assertions--assertions that often are tied to the self-interests of those who purvey evaluation and treatment methods--go unchallenged in the back care arena. Through systematic review of the literature and other credible sources, we find that work capacity evaluations and assessments of effort, widely heralded by some people, are in reality poorly documented.

This is a series about low back pain. It also is an illustration of how professionals can set aside their biases and defensiveness in order to critically examine an issue that is relevant to patients, payers, employers, and society as a whole. This series should be read not just by those who care about low back pain, but by anyone who believes that through conscious, concerted effort and the application of science to clinical practice we can regain the respect that we may have lost due to rhetorical excess and fierce interprofessional battle.