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Study objective -To assist a purchasing district in the planning of services for low back pain by assessing the prevalence of symptoms and the current involvement of primary, secondary, and complementary care in the treatment of low back pain. In the light ofthese findings, to assess further the potential impact of a new system of open access to physical therapy, as recommended by the British Clinical Standards Advisory Group (CSAG).Design -A two-stage cross sectional survey approach using postal questionnaires. Subjects -Altogether 1437 men and 1747 women aged 25-64 years, randomly selected from the family health services association register in Bradford. Main results -An annual incidence of4 7% for low back pain was found, with lifetime, 12 month period, and point prevalences of 59%, 39%, and 19% respectively. Over a one year period, 50 3% of episodes were acute (<2 weeks), 21% were subacute (2 weeks-3 months), and 26% were chronic (over 3 months) in duration. Altogether 17*8% of the population in this age range experienced referred pain, numbness, or tingling, and 6-4% took time off work as a result of low back pain. In the same year, 20% of the population in the same age range consulted no-one about their pain, 13-7% were treated at the primary care level, 4% received secondary care, and 3% visited a complementary therapist. One fifth of those who did not consult a professional experienced severe pain during episodes. Prevalence estimates indicate that an emphasis on early intervention and primary care management of simple low back pain as recommended by the CSAG could generate a 131% surge in demand for physical therapy. Conclusions -Local prevalence estimates may allow purchasers to estimate the potential effects of a shift in management policy for low back pain and to highlight areas of unmet need in terms of resources and patient education. (J Epidemiol Community Health 1996;50:347-352) Low back pain (LBP) continues to present a major challenge to industrialised societies. Its associated disability is a problem which some suggest has reached epidemic proportions,' and its effects on industry and health services are increasingly felt. During the past decade, the number of days of certified incapacity due to back pain has tripled to an estimated 106 million,2 and the number of patients referred to hospital has increased fivefold.3 At a total social cost to Britain of nearly 6 billion in 1993, the price of LBP continues to rise by an estimated £500 million each year.3 A recent British report issued by the Clinical Standards Advisory Group (CSAG) has recommended purchaser specific contracts for LBP, with an emphasis on primary care management of the problem. In particular, it recommends that general practitioners have open access to physical therapy.3 However, previous studies have demonstrated that regional differences exist in rates of general practice consultation for LBP.4 If purchasers are to plan effectively and improve standards of care for those with LBP, local baseline estimates ofneed an...

Total knee replacement has until recently been considered unreliable and often seen as a last resort for many with severe knee problems. Advances in prosthesis design and surgical and anaesthetic techniques have transformed this procedure into a reliable option with a potential for reducing disability and dependency in a large number of people in the community. Understandably, the prevalence pool of those who may benefit is large; health authorities and, increasingly, general practitioners should consider purchasing more total knee replacement surgery to offer real choice to those in need.

For many years, the Stanford Health Assessment Questionnaire (HAQ) has provided an effective measure of disability. Recently, some debate has emerged about whether or not the HAQ is an "ordinal' or "interval' scale. The opportunity to test its level of measurement arose when the scale was applied in a community survey which undertook a two-stage random sample using postal questionnaires to ascertain the health care needs of those with arthritis. The HAQ data are fitted to the Rasch model which tests for the presence of certain desirable characteristics of measurement, e.g. unidimensionality. The fit of the data to the model for those self-reporting rheumatoid arthritis (RA) was adequate. The transformed HAQ score, derived from the Rasch analysis, is compared with the ordinary HAQ (raw) score. This shows that, for those with RA, incremental units of the raw score at the margins of the scale reflect an increasing level of (dis)ability compared to similar units in the centre of the scale. Thus, the traditional HAQ score (range 0-3) is an ordinal score. The findings also indicate that scoring all 20 items may lead to greater sensitivity. Questions are also raised about the construct validity for those with other types of arthritis. For osteoarthrosis, the grip item does not appear to belong to the same underlying construct as the other items.