Elsevier

The Lancet

Volume 391, Issue 10137, 9–15 June 2018, Pages 2356-2367
The Lancet

Series
What low back pain is and why we need to pay attention

https://doi.org/10.1016/S0140-6736(18)30480-XGet rights and content

Summary

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause—eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Introduction

Low back pain is an extremely common symptom experienced by people of all ages.1, 2, 3 In 2015, the global point prevalence of activity-limiting low back pain was 7·3%, implying that 540 million people were affected at any one time. Low back pain is now the number one cause of disability globally.4 The largest increases in disability caused by low back pain in the past few decades have occurred in low-income and middle-income countries, including in Asia, Africa, and the Middle East,5 where health and social systems are poorly equipped to deal with this growing burden in addition to other priorities such as infectious diseases.

Rarely can a specific cause of low back pain be identified; thus, most low back pain is termed non-specific. Low back pain is characterised by a range of biophysical, psychological, and social dimensions that impair function, societal participation, and personal financial prosperity. The financial impact of low back pain is cross-sectoral because it increases costs in both health-care and social supports systems.6 Disability attributed to low back pain varies substantially among countries, and is influenced by social norms, local health-care approaches, and legislation.7 In low-income and middle-income countries, formal and informal social-support systems are negatively affected. While in high-income countries, the concern is that the prevalent health-care approaches for low back pain contribute to the overall burden and cost rather than reducing it.8 Spreading high-cost health-care models to low-income and middle-income countries will compound rather than alleviate the burden. Low back pain is therefore an urgent global public health concern.

Key messages

  • Low back pain is an extremely common symptom in populations worldwide and occurs in all age groups, from children to the elderly population

  • Low back pain was responsible for 60·1 million disability-adjusted life-years in 2015, an increase of 54% since 1990, with the biggest increase seen in low-income and middle-income countries

  • Disability from low back pain is highest in working age groups worldwide, which is especially concerning in low-income and middle-income countries where informal employment is common and possibilities for job modification are limited

  • Most episodes of low back pain are short-lasting with little or no consequence, but recurrent episodes are common and low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences

  • Low back pain is a complex condition with multiple contributors to both the pain and associated disability, including psychological factors, social factors, biophysical factors, comorbidities, and pain-processing mechanisms

  • For the vast majority of people with low back pain, it is currently not possible to accurately identify the specific nociceptive source

  • Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes

  • Costs associated with health care and work disability attributed to low back pain vary considerably between countries, and are influenced by social norms, health-care approaches, and legislation

  • The global burden of low back pain is projected to increase even further in coming decades, particularly in low-income and middle-income countries

Against this backdrop, we present a series of two papers and a Viewpoint. The aim of this paper is to present a current understanding of what low back pain is, its burden and global impact, as well as an overview of causes and the course of low back pain. The evidence for the effectiveness of current treatments and promising new directions for managing low back pain is presented in paper two,9 and the Viewpoint is a worldwide call to action.10

The approach for this Series involved the constitution of a team of leading international experts on back pain from different professional backgrounds and from countries around the globe who convened for a workshop in Buxton, UK, in June, 2016, to outline the structure of each paper. For this paper, we identified scientific studies using broad search terms in MEDLINE (PubMed) and Scopus. To identify potentially relevant papers from low-income and middle-income countries, we also searched Google Scholar and the African Index Medicus Database. To minimise selection bias and to ensure high-quality evidence was selected, systematic reviews were preferred and sought when possible. However, we also used information from large population-based cohorts, international clinical guidelines, and the Global Burden of Disease (GBD) 2015 study. Primary research from low-income and middle-income regions excluded from systematic reviews was also referenced where appropriate.

Section snippets

What is low back pain?

Low back pain is a symptom not a disease, and can result from several different known or unknown abnormalities or diseases.

It is defined by the location of pain, typically between the lower rib margins and the buttock creases.11 It is commonly accompanied by pain in one or both legs and some people with low back pain have associated neurological symptoms in the lower limbs.

For nearly all people presenting with low back pain, the specific nociceptive source cannot be identified and those

Causes of low back pain

Although clinical tests are unable to accurately identify the tissue source of most low back pain, several structures are innervated and have been shown to produce pain when stimulated. In some cases local anaesthetic relieves the pain (panel 1).14, 15 Many imaging (radiography, CT scan, and MRI) findings identified in people with low back pain are also common in people without such pain, and their importance in diagnosis is a source of much debate.22 Nevertheless, at least in people younger

Radicular pain and radiculopathy

Radicular pain occurs when there is nerve-root involvement; commonly termed sciatica. The term sciatica is used inconsistently by clinicians and patients for different types of leg or back pain and should be avoided.29 The diagnosis of radicular pain relies on clinical findings, including a history of dermatomal leg pain, leg pain worse than back pain, worsening of leg pain during coughing, sneezing or straining,30 and straight leg raise test. Radiculopathy is characterised by the presence of

Specific pathological causes of low back pain

Potential causes of low back pain that might require specific treatment include vertebral fractures, inflammatory disorders (eg, axial spondyloarthritis), malignancy, infections, and intra-abdominal causes (panel 2). A study of 1172 new presentations of acute (<2 weeks) episodes of low back pain in primary care in Australia found specific causes of back pain in 0·9% of participants, with fracture being by far the most common (eight of 11 cases), followed by inflammatory disorders (two of 11

How common is low back pain?

Low back pain is uncommon in the first decade of life, but prevalence increases steeply during the teenage years; around 40% of 9–18-year olds in high-income, medium-income, and low-income countries report having had low back pain.55, 56 Most adults will have low back pain at some point.57 The median 1-year period prevalence globally in the adult population is around 37%, it peaks in mid-life, and is more common in women than in men (figure 2).1 Low back pain that is accompanied by activity

Overall disability

The GBD 2015 study calculated disease burden for 315 causes in 195 countries and territories from 1990 to 2015 and provides a comprehensive assessment of the patterns and levels of acute and chronic diseases and burden and disability of those worldwide.61 Low back pain was responsible for around 60·1 million years lived with disability (YLD) in 2015, an increase of 54% since 1990.4 It is the number one cause of disability globally, as well as in 14 of the 21 GBD world regions.4 Less than 28% of

Natural history

Low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences.87 Around half the people seen with low back pain in primary care have a trajectory of continuing or fluctuating pain of low-to-moderate intensity, some recover, and some have persistent severe low back pain.88 A systematic review89 (33 cohorts; 11 166 participants) provides strong evidence that most episodes of low back pain improve substantially within 6

Multifactoral contributors to persistent disabling low back pain

In recent decades, the biopsychosocial model has been applied as a framework for understanding the complexity of low back pain disability in preference to a purely biomedical approach. Many factors including biophysical, psychological, social and genetic factors, and comorbidities (figure 1) can contribute to disabling low back pain (table 2). However, no firm boundaries exist among these factors and they all interact with each other. Thus, persistent disabling low back pain is not merely a

Limitations

Despite advances in many aspects of understanding low back pain, including the burden, course, risk factors, and causes, some important limitations exist. Most evidence comes from high-income countries, and may or may not generalise to low-income and middle-income countries. Although many factors are associated with both the development of low back pain and the transition to persistent disabling pain, the underlying mechanisms, including the effect of co-occurring non-communicable diseases, are

Conclusion

Low back pain is now the number one cause of disability globally. The burden from low back pain is increasing, particularly in low-income and middle-income countries, which is straining health-care and social systems that are already overburdened. Low back pain is most prevalent and burdensome in working populations, and in older people low back pain is associated with increased activity limitation. Most cases of low back pain are short-lasting and a specific nociceptive source cannot be

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