Back pain is the most commonly reported physical symptom, after headache and tiredness 1. It results in a great deal of disability and distress especially in industrialised countries. Attitudes and beliefs about its course and management play an important role: they impact on the severity and extent of disability and distress reported. Evidence based treatment for non-specific low back pain includes brief educational interventions, short term painkillers, supervised exercise and counselling 2. To maximise the chances of successful treatment and minimise variation in care, it is important that all healthcare professionals understand the basic principles of back pain management. They also need to be confident that an active management strategy is the best approach as recommended in international guidelines 3. Family physicians (known in the UK as general medical practitioners: GPs) are often the first port of call for people with back pain, but community pharmacists and nurses are important sources of advice for many people.

Community pharmacists can be consulted without appointment in a large number of convenient locations. They are in an ideal position to give timely advice to patients at the onset of low back pain and also reinforce advice given by other healthcare professionals. For example they can:

• provide over-the-counter (OTC) analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), when it is safe to do so

• reassure and provide appropriate information and/or advice

• advise those with "red flags" to seek medical care

In fact, community pharmacists and their staff do all these things, but there is little specific information about the quality of care provided in the pharmacy for people with back pain. The quality of this care will be determined by factors that are professional, patient related and environmental. The main professional factors are the knowledge, skills and attitudes of individual practitioners. Most importantly, it would be helpful to be sure that bed rest is not being recommended, since this is considered harmful in most cases. The attitudes and practice of specialist physicians, family physicians and physical therapists have been previously investigated 4567.

Campaigns to make patients and professionals more aware of current guidelines have taken place in the UK and Australia. In Australia, a large public health campaign was successful in improving attitudes to back pain. The campaign also reduced functional disability related to back pain in the general population and the economic impact of back pain 8. In Scotland, there has been a campaign to try to bring about change in the attitudes lay public and health professionals have about back pain and how to cope with it. Population surveys show that this campaign achieved 60% penetration and a 20% positive shift in public attitudes towards keeping active 9.

In England, a new National Health Service (NHS) contract for community pharmacists was implemented in April 2005. This gives them an expanded role in which they are expected to take a more central position managing patients with long term conditions and supporting self-care 10. It is therefore timely to carry out a survey to determine how prepared pharmacists are to take up this role in relation to back pain. Additionally, information from a survey can be used to design appropriate educational resources if required for pharmacists, their staff and people with back pain. The survey objectives were to:

• determine the attitudes, knowledge and reported practice of community pharmacists advising people who present with acute or chronic low back pain

• compare current reported practice with evidence-based clinical guidelines

• make recommendations about the pharmacists' role and training needs in relation to self-management of back pain

This survey represents a first attempt to understand the nature and variety of advice that patients with back pain in England are likely to receive in the community pharmacy setting. Due to the method of distribution, the sample was not totally representative of community pharmacists in general. It contained more middle aged, female and part-time workers than expected. Some facilitators chose not to distribute the questionnaire and the total number of pharmacists given the opportunity to complete it is unknown. The method of distribution, which was judged to be the most efficient way to obtain a sufficiently large and diverse sample, made it impossible to know what the response rate was. The responses obtained are likely to represent pharmacists in England who were more motivated and interested in the topic. It is noteworthy that even in this self-selected group somewhat maladaptive beliefs were often reported and many did not feel confident to provide the best advice to customers with back pain.

About 72% of the respondents had some personal experience of back pain, which was a relatively high percentage given their age profile and the known epidemiology. It may be that people who have suffered from back pain were more likely to respond. However, the respondents' experience of back pain was not inconsistent with published data from international studies reporting that 59–84% suffer back pain at some stage in their lives 18.

The mean BBQ score (31.37) was slightly more positive than that found in similar surveys of lay people. At baseline in the UK BEAM trial the mean BBQ scores in the randomised groups (patients with low back pain) were about 28, and the highest score achieved by any group post-intervention was 31.3 19. Following a population based public health intervention in Australia (designed to alter attitudes towards back pain) the highest BBQ score achieved was 29.7 13. Pharmacists' responses to the WBS questions (approximately 60% agreement with activity statements) were similar to those in the Scottish general public after a public health campaign 9. The BBQ has not previously been used in studies of healthcare practitioners. It was originally designed for use with people in industrial settings rather than patients.

The positive attitudes identified in this survey may be due to the nature of the sample, or a general change over time. Pharmacists who have had (and perhaps recovered from) short term back pain were more positive than the sample in general. The respondents may have been more knowledgeable and positive than the average pharmacist, because they were (a) attending a continuing education event in their own time and (b) motivated enough to respond to this survey. Unfortunately, because of the method of distribution there was no information about education session attendees and no further way to assess response bias.

Finding a more positive attitude among sufferers of back pain contrasts with the findings from a survey of public perceptions about back pain carried out in the UK ten years ago 20. Those who had experienced back pain were less positive and especially those who had consulted a GP had more cautious or negative attitudes. Furthermore, in this public perceptions survey, those who were in older age groups and who were in social classes A-C were slightly more likely to agree with positive statements from the Back Book. The responding pharmacists in this present study would largely belong to these categories.

There seemed to be majority support for an active management approach to back pain: positive attitude towards back pain, positive attitude towards working when not pain free and agreement about using painkillers. Pharmacists' attitudes about working when not pain free were similar to those found in Australian and UK studies of GPs 1314. Promoting greater awareness of The Back Book among pharmacists is one obvious way to make evidence based information directly available to their staff and customers 1521.

Vignettes are reported to be a valid way to collect information about the quality of clinical practice when compared with standardised patients (the gold standard method) 22. However, actual practice has not been assessed in this survey, only possible practice based on existing knowledge. Personal experience of back pain seemed to influence the advice pharmacists say they would give, which has implications for the quality and consistency of advice given. The impact of attitudes on practice has previously been demonstrated in physiotherapists 4 and family physicians 5.

The survey showed that pharmacists were willing and able to provide evidence based advice to people with low back pain. However, the representativeness of the results was unclear and further research would be useful. Those sampled were generally positive in their approach to the condition and, importantly, unlikely to recommend rest. Yet, in contrast, they also exhibited caution regarding movement that may cause pain, which could cause some confusion and lead to undue restriction of activity. Similar issues have been identified for family physicians and physical therapists 7. Most pharmacists agreed that they would benefit from more training and education about back pain. Training to improve the confidence and ability of pharmacists to provide advice about the management of back pain may provide a useful model for improving other aspects of supported self-care, especially for conditions involving some chronic pain. This would support UK Government policy for making support for self-care in long term conditions widely available via pharmacies 23.

The author(s) declare that they have no competing interests.

JS, JKM and HE conceived and developed the study. JS conducted the data analysis. JKM, GW and AKB provided advice on the evidence based treatment of back pain. GW and AKB acted as expert consultants at all stages of study design and data analysis. JS prepared the draft manuscript. All the authors contributed to, reviewed and approved the final manuscript.