An historical perspective on low back pain and disability.

This review of low back pain and sciatica over the past 3500 years tries to put our present epidemic of low back disability into historical perspective. Backache has affected human beings throughout recorded history (Table 1). What has changed is how it has been understood and managed. Two key ideas in the nineteenth century laid the foundation for our modern approach to backache: that it came from the spine and that it was due to injury. Backache had always previously been considered a rheumatic condition. Only from that time were backache and sciatica considered and treated together. Their management was increasingly dominated by the new orthopedic principle of therapeutic rest. What is new is chronic disability due to simple backache. Apart from rare cases, this only began to appear in the late nineteenth century. It escalated after World War II. It appears to be closely related to changed understanding and management of backache: specifically to the idea that backache is due to serious spinal injury or degeneration and to medical prescription of rest. This is reinforced by the improved social support which makes rest possible. Sadly, we must conclude that much low back disability is iatrogenic.