Abstract
Study Design.
This was an observational study.
Objective.
Assessing the global burden of disease for low back pain (LBP) using the 2021 GBD (Global Burden of Disease) database.
Summary of Background Data.
LBP is a leading cause of workforce loss and disability. With societal aging and changes in lifestyle and work habits, the incidence of LBP is expected to rise. This study comprehensively analyzes the epidemiological trends of global LBP from 1990 to 2021.
Methods.
Data publicly available from the 2021 GBD study were utilized, and a systematic analysis was conducted to assess the global burden and epidemiological trends of LBP.
Results.
From 1990 to 2021, the age-standardized prevalence, incidence, and Years Lived with Disability (YLD) rates of LBP have slightly declined globally. However, the number of affected individuals, new cases, and YLD numbers have significantly increased, making LBP a leading cause of YLD in 2021. The number of affected individuals increases with age, peaking in both men and women between the ages of 50 and 54. Worldwide, women have a higher prevalence of LBP than men, and this increases with age, with both sexes reaching peak prevalence between 80 and 84 years in 2021. Overall, over the past 3 decades, age-standardized YLD rates have shown a positive correlation with the Socio-demographic Index (SDI). In terms of region and nation, Tropical Latin America and Kingdom of Sweden have seen the greatest increase in age-standardized prevalence rates from 1990 to 2021.
Conclusion.
Globally, LBP remains a notable public health concern, carrying a consistently high burden. To alleviate the future impact of this disease, it is imperative to increase public awareness regarding its risk factors and to implement preventive measures.
Key Words: low back pain, global burden, years lived with disability, socio-demographic index
Low back pain (LBP) is pain below the rib cage, primarily in the lumbar, lumbosacral, and buttock areas, and can present as localized, diffuse, radiating, or referred pain.1,2 LBP is a common musculoskeletal disorder prevalent in both developed and developing nations. It is a leading cause of disability and ranks sixth in overall disease burden.3 Approximately 60% to 80% of people will experience LBP at some stage in their lives, nearly every age group, from children to the elderly.4–6 According to reports, the prevalence of LBP in the general adult population in the United States is 10% to 30%, with a lifetime prevalence as high as 65% to 80%.1 LBP has become a major contributor to Years Lived with Disability (YLD) globally, representing not only a common health issue but also a significant financial and health care burden amid rising health care expenditure rates in many countries.6,7
A study in 2020 revealed that musculoskeletal diseases are the second leading cause of non-fatal disabilities worldwide,8,9 affecting over 1.63 billion people. The Global Burden of Disease (GBD) database includes five specific musculoskeletal conditions: rheumatoid arthritis, osteoarthritis, LBP, neck pain, and gout. However, particular emphasis on LBP has been lacking.10 Using the GBD 2019 data, the research analyzed the global, regional, and national prevalence, incidence, and YLD of LBP across various ages, sexes, and SDI categories.11 This study updates and expands on those findings with publicly available model data from the GBD 2021, offering the latest and most comprehensive information on the global burden of LBP.
MATERIALS AND METHODS
Overview
The Global Burden of Disease Study 2021 estimated the prevalence and YLD due to LBP in 204 countries from 1990 to 2021, categorized by age and sex. The study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).12 This study examines global data from 1990 to 2021 from GBD 2021, the most comprehensive source on worldwide disease and injury trends, maintained by the Institute for Health Metrics and Evaluation (IHME). It evaluates the burden of 371 diseases and 88 risk factors13 across 204 countries using diverse health metrics. The GBD 2021 methodology for estimating disease burden is consistent with GBD 2019, but improvements have been made by analyzing data from more countries, introducing new LBP triggers, refining measurement methods and redistribution algorithms, and expanding uncertainty intervals. Data are presented as counts and age-standardized rates per 100,000 population within the UI population.
Case Definition and Input Data
In the GBD 2021 study, low back pain is defined as pain in the lower back, from the bottom of the 12th rib to below the hips, lasting at least one day and possibly accompanied by leg pain.14
The data used in this article are derived from the GBD 2021 data set, which evaluates the age-specific and sex-specific incidence, prevalence, and mortality rates of over 300 diseases and injuries across 204 countries and regions.8,15 We extracted relevant data on lower back pain, categorized by country and region, from the Global Health Data Exchange query tool((https://ghdx.healthdata.org/gbd-2019/data-input-sources), spanning from 1990 to 2021.
Data Processing and Disease Modeling
Before fitting the model, it is essential to stratify prevalence estimates by sex and age. In studies examining sex differences among older age groups or the prevalence of both sexes within specific age cohorts, the sex ratio and associated uncertainty range from the study can be used to present the data. When reporting prevalence for both sexes, stratification should be based on the sex ratio derived through Meta-Regression with Bayesian Regularized Trimming (MR-BRT),15 using a female-to-male ratio of 1.19 (95% Uncertainty Interval: 1.03–1.40). Data for individuals aged over 25 should be stratified into 5-year age intervals, and case definitions must be refined to correspond with the GBD estimates for LBP. The MR-BRT method is utilized to correct for bias, excluding exceptionally high prevalence values (those 1.5 times or more above the mean). DisMod-MR 2.11 is applied to estimate incidence rates, under the assumption that lower back pain does not occur before the age of 5. Uncertainty intervals (UIs) are derived from the 2.5th and 97.5th percentiles of the distribution, based on 1000 model iterations after convergence.16
Severity and Years Lived with Disability
In the Medical Expenditure Panel Surveys and analyses of U.S medical claims data, LBP is classified into six distinct severity levels, encompassing conditions both with and without leg pain, each assigned a specific disability weight (Supplemental Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597). YLD are determined by multiplying the disability weight by the prevalence rate specific to age, sex, location, and year, with adjustments made to account for comorbid conditions.
In the current model, The GBD methodology does not assign any rise in mortality to LBP. Although LBP may be part of a pathway leading to death (e.g., an overdose of opioids), each death in the GBD methodology is only recorded once and is due to other causes. Therefore, our modeling maintains the same estimates for Disability-Adjusted Life Years (DALYs) and YLDs. Consequently, the disability burden is reported as YLDs.
Sociodemographic Index
We also conducted a correlation analysis on the SDI for the year 2021. The SDI is an indicator that assesses a country’s per capita income distribution, average education years, and fertility rate among women under 25.15 A smooth spline model was developed to examine the relationship between LBP burden (measured by YLDs) and SDI across 204 countries from 1990 to 2021, using GBD 2021 data mapped with ArcMap 10.2.
Estimate Projections
ARIMA (Autoregressive Integrated Moving Average), ES (Exponential Smoothing) and BAPC (Bayesian age–period–cohort analysis) models are statistical models used for time series analysis and forecasting, predicting future trends from past data.17–19
RESULTS
Global Burden of Low Back Pain
In 2021, there were an estimated 628.8 million individuals globally suffering from LBP, with a 95% Uncertainty Interval (UI) of 551.8 to 700.8 million. The age-standardized annual prevalence rate (ASPR) was estimated at 7463.0 cases per 100,000 people (95% UI 6575.7–8321.8), marking a decline of −0.3806% (95% UI −0.4063% to −0.3548%) from 1990 to 2021. In addition, in 2021, there were 266.8 million new cases of LBP globally (95% UI 235.3–299.4 million), with an age-standardized annual incidence rate (ASIR) of 3176.6 cases per 100,000 people (95% UI 2811.8–3562.3), which has decreased by -0.3468% (95% UI −0.3712 to −0.3224) from 1990 to 2021. LBP resulted in 70.16 million Years Lived with Disability (YLD) (95% UI 50.19–94.10 million), with an age-standardized YLD rate of 832.2 per 100,000 people (95% UI 595.9–1115.2). Despite the age-standardized YLD rate for LBP declining by −0.3834% (95% UI −0.404 to −0.3628) from 1990 to 2021, LBP remains a leading cause of age-standardized YLD rates globally (Table 1).
TABLE 1.
Percentage Changes in Prevalent Cases, Incident Cases, and Years Lived With Disability (YLD) Due to Low Back Pain in 2021, As Well As in the Age-Standardized Rates for the Global Burden of Disease Regions
| Prevalence (95% Uncertainty interval) | Incidence (95% uncertainty interval) | YLDs (95% uncertainty interval) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Locations | Number (2021) | Age-standardized prevalence rate (2021) | Percentage change in age-standardized rates between 1990 and 2021 | Number (2021) | Age-standardized incidence rate (2021) | Percentage change in age-standardized rates between 1990 and 2021 | Number (2021) | Age-standardized ylds rate (2021) | Percentage change in age-standardized rates between 1990 and 2021 |
| Global | 628,838,475 (551,834,407–700,881,341） | 7463.0 (6575.7–8321.8) | −0.3806 (−0.4063 to −0.3548) | 266,873,321 (235,369,489–299,406,380) | 3176.6 (2811.8–3562.3) | −0.3468 (−0.3712 to −0.3224) | 70,156,962 (50,194,205–94,104,688) | 832.2 (595.9–1115.2) | −0.3834 (−0.404 to −0.3628) |
| High-income North America | 49,456,310 (46,021,985–525,984,989） | 13,360.3 (9747.7–11,177.3) | −0.2148 (−0.2644 to −0.1652) | 20,525,968 (18,564,440–22,433,456) | 4430.7 (4019.9–4856.3) | −0.1931 (−0.2177 to − 0.1684) | 5,425,099 (3,944,504–7,058,790) |
1159.5 (843.8–1514.0) |
−0.262 (−0.3077 to −0.2163) |
| High-income Asia Pacific | 27,054,791 (23,812,392–30,032,356) | 10,041.1 (8876.2–11,287.7) | −0.339 (−0.4568 to −0.2211) | 11,053,079 (9,710,908–12,353,921) | 4236.8 (3745.6–4769.3) | −0.3019 (−0.4201 to −0.1835） | 3,027,728 (2,147,702–4,085,674) |
1140.1 (814.6–1534.1) |
−0.3243 (−0.4089 to −02396) |
| Central Europe | 20,610,737 (18,182,273–22,911,380) | 12,831.0 (11,294.0–14,267.2) | −0.091 (−0.0937 to −0.0883) | 8,079,891 (7,097,942–9,076,612) | 5181.2 (4595.3–5834.5) | −0.0597 (−0.0629 to −0.0565） | 2,290,522 (1,634,308–3,088,294) | 1439.4 (1027.2–1934.4) | −0.0783 (−0.0912 to −0.06550 |
| Central Asia | 8,445,849 (7,373,427–9,503,998) | 9188.5 (8032.3–10,254.5) | −0.0379 (−0.0435 to −0.0323) | 3,627,338 (3,190,645–4,122,873) | 3908.4 (3443.9–4408.1) | −0.0318 (−0.0343 to −0.0292） | 952,839 (682,011–1,286,067) |
1029.9 (732.9–1385.7) |
−0.0406 (−0.0451 to −0.0362) |
| Oceania | 674,940 (591,101–768,285) | 6322.2 (5498.3–7093.7) | −0.0326 (−0.0436 to −0.0215) | 297,549 (259,577–339,195) | 2728.3 (2394.4–3098.4) | −0.0378 (−0.0583 to −0.0172） | 76,195 (54,394–102,628) | 705.1 (504.1–943.4) | −0.0338 (−0.0474 to −0.0203) |
| Australasia | 4,389,558 (3,843,185–4,905,996) | 11,327.0 (9980.8–12,746.4) | −0.2735 (−0.2972 to −0.2499) | 1,793,375 (1,584,866–1,997,436) | 4715.6 (4181.4–5288.9) | −0.2359 (−0.3101 to −0.1617） | 488,387 (349,002–661,173) |
1268.2 (904.8–1709.0) |
−0.2702 (−0.2968 to −0.2437) |
| Eastern Europe | 31,818,730 (28,084,336–35,390,254) | 11,189.9 (9858.3–12,447.2) | −0.1294 (−0.142 to −0.1169) | 12,839,596 (11,238,456–14,387,501) | 4619.1 (4112.2–5173.3) | −0.0905 (−0.0971 to −0.0839） | 3,508,059 (2,503,644–4,720,036) | 1241.4 (889.7–1666.4) | −0.125 (−0.1335 to −0.1165) |
| Western Europe | 58,122,167 (51,179,306–64,598,752) | 9533.0 (8439.7–10,690.6) | −0.1118 (−0.1237 to −0.0999) | 23,987,309 (21,198,828–26,893,840) | 4040.7 (3579.6–4541.6) | −0.1099 (−0.1203 to −0.0994） | 6,444,977 (4,566,679–8,666,045) |
1069.0 (766.3–1441.3) |
−0.1138 (−0.1259 to −0.1018) |
| Central Latin America | 19,673,938 (17,310,811–22,160,905) | 7487.1 (6597.8–8413.6) | 0.0411 (0.032–0.0502) | 8,328,520 (7,336,429–9,409,867) | 3173.3 (2801.6–3585.8) | 0.0332 (0.0189–0.0475) | 2,204,585 (1,574,612–2,963,661) |
837.4 (597.9–1127.0) |
0.0396 (0.0317–0.0476) |
| Andean Latin America | 3,735,038 (3,274,646–4,209,857) | 5769.8 (5050.6–6502.9) | 0.0051 (−0.0152 to 0.0254) | 1,646,434 (1,458,880–1,844,797) | 2537.3 (2248.5–2847.9) | 0.0167 (0.0018–0.0317) | 419,827 (298,545–559,565) |
646.9 (458.2–863.7) |
0.0001 (−0.169 to 0.017) |
| North Africa and Middle East | 50,601,960 (44,810,213–57,246,491) | 8713.5 (7713.0–9767.2) | −0.0812 (−0.0812 to −0.1025) | 21,554,211 (18,949,089–24,589,228) | 3686.1 (3259.3–4157.6) | −0.0614 (−0.0756 to −0.0471) | 5,661,667 (4,030,973–7,583,353) |
967.4 (696.7–1297.0) |
−0.0949 (−0.1138 to −0.076) |
| Caribbean | 3,086,535 (2,735,228–3,457,070) | 6007.0 (5348.9–6726.1) | −0.0436 (−0.0489 to −0.0383) | 1,338,623 (1,184,999–1,505,225) | 2618.9 (2316.5–2943.0) | −0.0387 (−0.0459 to −0.0315） | 344,542 (247,890–462,391) |
670.9 (483.4–901.2) |
−0.0613 (−0.0753 to −0.0753) |
| Tropical Latin America | 23454673 (20450315-26355944） | 9303.5 (8187.7–10,456) | 0.1031 (0.0931–0.1132) | 9,654,115 (8,506,642–10,873,405) | 3857.4 (3402.3–4336.3) | 0.0645 (0.0495–0.0796) | 2,598,774 (1,862,649–3,499,223) |
1029.6 (741.5–1382.1) |
0.0979 (0.0821–0.1136) |
| Southern Latin America | 7,546,942 (6,657,534–8,456,318) | 9741.1 (8600.8–10,945.8) | −0.072 (−0.2006 to −0.0569) | 3,175,959 (2,802,991–3,549,723) | 4138.3 (3660.7–4648.2) | −0.0673 (−0.1745 to 0.0399) | 843,277 (596,115–1,134,514) |
1090.8 (772.1–1464.4) |
−0.0747 (−0.1986 to 0.0493) |
| Eastern Sub-Saharan Africa | 20,671,419 (18,268,068–23,441,517) | 7607.2 (6640.3–8512.4) | −0.1189 (−0.1239 to −0.1139) | 9,141,988 (8,019,263–10,354,866) | 3240.0 (2855.2–3641.3) | −0.1075 (−0.1142 to −0.1008) | 2,317,834 (1,643,306–3,112,636) |
844.4 (602.7–1135.4) |
−0.104 (−0.1108 to −0.0972) |
| Central Sub-Saharan Africa | 6,759,109 (5,963,457–7,709,322) | 7619.3 (6670.3–8565.2) | −0.1104 (−0.1342 to −0.0867) | 2,999,484 (2,638,593–3,421,283) | 3259.0 (2879.7–3674.3) | −0.1016 (−0.125 to −0.0783) | 754,976 (536,134–1,006,808) |
842.6 (603.1–1136.4) |
−0.0829 (−0.1015 to −0.0642) |
| Western Sub-Saharan Africa | 21,532,804 (18,994,996–24,407,091) | 6911.7 (6024.0–7750.4) | −0.0882 (−0.1036 to −0.0729) | 9,583,990 (8,386,342–10,870,298) | 2974.3 (2616.3–3351.9) | −0.09 (−0.107 to −0.0729) | 2,419,519 (1,712,962–3,244,286) |
770.6 (549.4–1039.0) |
−0.0685 (−0.0809 to −0.0562) |
| Southern Sub-Saharan Africa | 4,577,210 (3,987,735–5,172,963) | 6510.4 (5661.4–7303) | −0.155 (−0.1657 to 0.1444) | 2,000,245 (1,750,711–2,271,266) | 2810.6 (2465.1–3178.5) | −0.1492 (−0.1554 to −0.143) | 505,036 (361,967–678,388) |
712.9 (510.7–955.0) |
−0.1936 (−0.2054 to −0.1819) |
| South Asia | 119,421,340 (104,121,215–135,119,660) | 6919.7 (6023.4–7778.7) | −0.3584 (−0.3853 to −0.3315) | 51,725,612 (45,244,519–58,532,118) | 2970.3 (2606.5–3335.0) | −0.3154 (−0.3389 to −0.2918) | 13,247,628 (9,487,458–17,842,551) |
762.3 (544.5–1022.8) |
−0.3482 (−0.3743 to −0.3221) |
| East Asia | 105,135,609 (91,895,083–118,365,184) | 5418.7 (4746.5–6045.7) | −0.6462 (−0.6966 to −0.5959) | 45,417,237 (39,382,941–51,288,188) | 2369.2 (2089.0–2663.6) | −0.5995 (−0.6389 to − 0.5601) | 11,867,556 (8,333,735–16,052,098) | 611.8 (433.8–820.5) | −0.6469 (−0.6944 to −0.5993) |
| Southeast Asia | 42,068,815 (36,528,833–47,513,123) | 5859.2 (5118.4–6584.8) | −0.0423 (−0.0514 to −0.0332) | 18,102,798 (15,777,830–20,544,107) | 2518.3 (2218.5–2844.1) | −0.0598 (−0.0693 to −0.0503) | 4,757,936 (3,371,946–6,410,456) | 658.0 (468.0–885.6) | −0.0345 (−0.045 to −0.0241) |
Regional Burden of Low Back Pain
In 2021, the age-standardized annual prevalence rate (ASPR) of LBP, per 100,000 population, reached its peak in high-income North America [13,360.3 (95% UI 9747.7–11177.3)], Central Europe [12,831.0 (95% UI 11,294.0–14,267.2)], and Australasia [11,327.0 (95% UI 9980.8–12,746.4)]. In contrast, the lowest ASPR was observed in Andean Latin America [5769.8 (95% UI 5050.6–6502.9)], East Asia [5418.7 (95% UI 4746.5–6045.7)], and Southeast Asia [5859.2 (95% UI 5118.4–6584.8)] (Table 1). For age-standardized annual incidence rates (ASIR) of LBP, Central Europe [5,181.2 (95% UI 4595.3–5834.5)], Australasia [4715.6 (95% UI 4181.4–5288.9)], and Eastern Europe [4619.1 (95% UI 4112.2–5173.3)] had the highest rates (Table 1). The regions with the highest ASPR for LBP also had the highest age-standardized YLD rates, whereas those with the lowest ASPR had the lowest ASIR and YLD rates (Table 1). Supplemental Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597 displays the annual average percentage change in age-standardized prevalence, incidence, and YLD rates for all GBD regions from 1990 to 2021. As can be seen it, most regions showed a declining trend, with the East Asia exhibiting the highest decline. The age-standardized prevalence rate decreased from 6652.2 (95% UI 5797.6–3229.7) in 1990 to 5418.7 (95% UI 4746.5–6045.7) in 2021, a decrease of −0.6462% (95% UI −0.6966 to −0.5959). The age-standardized incidence rate dropped from 2866.2 (95% UI 2520.5–5216.5) in 1990 to 2369.2 (95% UI 2089.0–2663.6) in 2021, a decrease of −0.5995% (95% UI −0.6389 to −0.5601). The age-standardized YLD rate declined from 751.0 (95% UI 532.5–1,014.9) in 1990 to 611.8 (95% UI 433.8–820.5) in 2021, a decrease of −0.6469% (95% UI −0.5993 to −0.6944). However, Tropical Latin America showed the most significant increase, with the age-standardized prevalence rate rising slightly from 9009.3 (95% UI 7876.5–10,155.8) in 1990 to 9303.7 (95% UI 8187.7–10,456.0) in 2021, an increase of 0.1031% (95% UI 0.0931–0.1132). The age-standardized incidence rate increased from 3780.7 (95% UI 3331.8–4274.2) in 1990 to 3857.4 (95% UI 3402.3–4336.4) in 2021, an increase of 0.0645% (95% UI 0.0495–0.0796). The age-standardized YLD increased from 998.4 (95% UI 712.2–1339.0) in 1990 to 1029.6 (95% UI 741.5–1382.1) in 2021, an increase of 0.0979% (95% UI 0.0821–0.1136).
National Burden of Low Back Pain
In 2021, the age-standardized annual prevalence rate (ASPR) for LBP per 100,000 people was estimated to range from 4401.3 to 15,712.3 (Fig. 1, Supplemental Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597). On the basis of the ASPR data for 2021, Hungary [14,024.6 (95% UI 12,361.1–15,712.3)], Czech Republic [13,299.0 (95% UI 11,720.8–14,874.2)], and Albania [13,011.7 (95% UI 11,469.0–14,627.0)] had the highest ASPRs. In contrast, Maldives [5020.8 (95% UI 4401.3–5672.0)], Myanmar [5056.8 (95% UI 4441.9–5710.2)], and Thailand [5170.0 (95% UI 4487.2–5814.5)] had the lowest ASPRs. Meanwhile, the age-standardized annual incidence rate (ASIR) for LBP per 100,000 people in 2021 ranged from 1944.5 to 6085.5 (Supplementary Digital Figure S1, Supplemental Digital Content 2, http://links.lww.com/BRS/C598, Supplementary Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597). According to the ASIR data for 2021, Hungary [5408.8 (95% UI 4788.4–6085.5)], Poland [5274.1 (95% UI 4671.1–5937.0)], and Czech Republic [5240.0 (95% UI 4603.2–5944.2)] had the highest ASIRs. According to Supplemental Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597 the three countries with the highest ASPR for LBP also had the highest age-standardized YLD rates, whereas the three with the lowest ASPR had the lowest ASIR and YLD rates (Fig. 2). Supplementary Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597 show notable differences in the annual average percentage change in age-standardized prevalence, incidence, and YLD rates across countries from 1990 to 2021. Notably, the Kingdom of Sweden experienced the largest increases in age-standardized prevalence [0.64 (95% UI 0.59–0.69)], incidence [0.61 (95% UI 0.55–0.67)], and YLD rate [0.64 (95% UI 0.59–0.69)]. In contrast, the People’s Republic of China showed the smallest increases, with declines in age-standardized prevalence [−0.68 (95% UI −0.73, −0.64)], incidence [−0.63 (95% UI −0.67, −0.58)], and YLD rate [−0.68 (95% UI −0.73, −0.64)].
Figure 1.
Estimated age-standardized annual prevalence rates of low back pain per 100,000 people by country/region in 2021.
Figure 2.
Estimated age-standardized YLD rates of low back pain per 100,000 people by country/region in 2021.
Age and Sex Patterns of Low Back Pain
Global data results indicate that globally, women have higher prevalence, incidence, and YLD rates for LBP compared with men (Fig. 3, Supplementary Digital Figure S2, Supplemental Digital Content 3, http://links.lww.com/BRS/C599 and S3, Supplemental Digital Content 4, http://links.lww.com/BRS/C600, Supplementary Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597). However, more significant differences are observed in the older age groups (i.e., >75 yr). In 2021, the prevalence, incidence, and YLD rates for women peaked at ages 80 to 84. In addition, the number of prevalent cases, incident cases, and YLDs peaked in the 50 to 54 age group and then showed a declining trend with increasing age, extending through to the oldest age group. Among all age categories, there were no statistically notable disparities in prevalence, incidence, and YLD rates between women and men.
Figure 3.
Global age-standardized prevalence and incidence rates of low back pain per 100,000 people, stratified by age and sex, in 2021.
Burden of Low Back Pain Stratified by Sociodemographic Index
From 1990 to 2021, a positive correlation was observed between the age-standardized YLD rates for LBP and the Sociodemographic Index (SDI). Regionally, the age-standardized YLD rates of LBP showed a declining trend with increasing SDI levels. However, in Central Europe, Australasia, and Eastern Europe, the estimated prevalence of LBP exceeded the anticipated levels based on SDI during the 1990 to 2021 period (Fig. 4). At the national level in 2021, a positive correlation was also observed between the age-standardized YLD rates of LBP and SDI across 204 countries and territories. Furthermore, countries including Hungary, the Czech Republic, and Albania had age-standardized YLD rates that exceeded the expected levels (Fig. 5).
Figure 4.
Age-standardized YLD rates for low back pain from 1990 to 2021, across 21 Global Burden of Disease (GBD) regions stratified by Sociodemographic Index (SDI).
Figure 5.
Age-standardized YLD rates for low back pain in 2021, across 204 countries and territories in relation to the Socio-demographic Index (SDI).
Global Forecasts for Low Back Pain
The ARIMA model forecasts a sustained increase in the global prevalence of LBP from 2022 to 2050, projecting that ~890 million individuals will be affected, with 380 million incidences anticipated by 2050 (Fig. 6A-D, Supplementary Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597). Throughout this period, the projected number of cases is expected to rise consistently for both males and females, with females consistently exhibiting higher prevalence rates than males, underscoring the disproportionate burden of this health issue on women. Despite the rising cases, the age-standardized incidence rate (ASR) for LBP is gradually declining, indicating a decrease relative to population age changes. The ES and BAPC models support this (Fig. 6E-H, Supplementary Tables, Supplemental Digital Content 1, http://links.lww.com/BRS/C597, Supplementary Digital Figure S4, Supplemental Digital Content 5, http://links.lww.com/BRS/C601), aligning with ARIMA model findings, suggesting that although LBP is still a global concern, its relative impact may be diminishing.
Figure 6.
Predictions for lower back pain from 2022 to 2050 based on ARIMA (Autoregressive Integrated Moving Average) and ES (Exponential Smoothing) models. (A) DALYs for low back pain based on the ARIMA model. (B) YLDs for low back pain based on the ARIMA model. (C) Prevalence for low back pain based on the ARIMA model. (D) Incidence for low back pain based on the ARIMA model. (E) DALYs for low back pain based on the ES model. (F) YLDs for low back pain based on the ES model. (G) Prevalence for low back pain based on the ES model. (H) Incidence for low back pain based on the ES model.
DISCUSSION
This provided the most recent data on LBP prevalence, incidence, and YLD from 1990 to 2021 for 204 countries and regions. Our research analyzes the disease burden of LBP from the perspectives of global, regional, and national levels, age and sex patterns, sociodemographic indices, and future projections. This will provide valuable information on policymaking and health care practices.
In 2021, there were ~628.8 million cases of LBP globally, with 223.6 million new cases and 70.16 million cases of YLD. Although the age-standardized rates of prevalence, incidence, and YLD for LBP have slightly decreased from 1990 to 2021, the absolute number of affected individuals, new cases, and YLD have significantly increased, making LBP the primary cause of global YLD in 2021. Furthermore, the prevalence of LBP continues to rise in certain regions and countries, with the most significant increases noted in tropical Latin America and Sweden. Our data analysis indicates variability in morbidity and incidence rates across different regions and countries, potentially attributable to factors such as the strength of health care systems, the implementation of effective preventive measures, and the severity of the condition in these areas. Regions with high morbidity rates may need more medical resources, whereas those with high incidence rates should enhance preventive measures to reduce disease occurrence.
This study demonstrates that in 2021, Women bore a heavier burden of LBP compared with men, consistent with findings from 2017 and 2019 studies. Research indicates20–22that hormonal changes in women, particularly during menopause and perimenopause, significantly contribute to the prevalence of LBP. In addition, psychological, social, and sociocultural factors also play a role.23,24 Age significantly impacts LBP-related disability, with all ages at risk, and the likelihood of disability increasing as people get older. In 2021, the global prevalence, incidence, and YLD trends for LBP all increased with age, peaking in both men and women between the ages of 50 and 54. Similarly, the global trends in prevalence, incidence, and YLD rates rose with age, reaching a peak in both men and women in the 80 to 84 age group. This study observes age and sex patterns in LBP, highlighting that women generally experience a higher burden of LBP than men, due to several potential factors. Firstly, Women’s physiological traits, like menstruation and pregnancy, can heighten back strain due to hormonal shifts and relaxed pelvic ligaments.25–27 In addition, Lifestyle factors like women’s larger share of household chores, activities involving prolonged bending,28 and long-term high heel29 use contribute to the risk and worsening of lower back pain. In contrast, aging is also a significant factor in the burden of LBP. Studies show30,31 that the prevalence of LBP is considerably higher among older adults than in younger populations, likely due to degenerative changes in the musculoskeletal system and a decrease in function, which further increases the risk of LBP. This indicates an association between pain and aging.32 In conclusion, enhancing LBP prevention and treatment for women and the elderly is essential to reduce pain and improve their quality of life.
The SDI level is a key factor influencing the health loss and mortality of patients with LBP. Between 1990 and 2019, age-standardized YLD rates decreased, suggesting that economic growth and education help lower LBP-related YLD rates. This study found that when the SDI exceeds 0.7, the burden of LBP gradually decreases with increasing SDI. The burden of LBP is not limited to countries with higher SDI levels, it can also be observed in countries with lower SDI levels, suggesting that influencing factors may differ by region.
Because of factors like sex, cultural setting, and geographical circumstances,33–35 reduced physical activity and sedentary lifestyles may lead to an increase in YLD rates for LBP. Compared with areas or countries with lower income levels, previous studies have indicated that the prevalence and incidence of insufficient physical activity may be higher in high-income areas or countries. However, as living standards improve, YLD rates indicate that there is a correlation between living standards and the burden of LBP. Research also shows that factors such as low income, poor quality of life, and lower educational levels can have a significant negative impact on the burden of LBP disease.6 Given these findings, more detailed and precise LBP prevention strategies should be developed based on the relationship involving age-standardized YLD rates and SDI. Furthermore,
Our forecasts suggest that global LBP cases will rise over the next 30 years, increasing the health burden for both men and women worldwide. Countries should implement broader, more effective prevention strategies targeting the common causes of LBP.
Limitations
This study has certain limitations. First, annual variations in diagnostic criteria for diseases can introduce biases into the data collected by the GBD, which are not measured directly but are derived through computational models, potentially leading to biased outcomes. Second, the completeness and standard of data reporting may vary across different countries, leading to potential underestimation of the prevalence, incidence, and YLD rates linked to LBP. Furthermore, the risk factors contributing to LBP, such as environmental, occupational, metabolic influences, tobacco use, and high body weight, have not been assessed.
CONCLUSIONS AND IMPLICATIONS
Over the past 3 decades, although there has been no significant change in the occurrence of LBP, the burden remains high. It is projected that by 2050, the number of LBP cases will continue to rise, and its burden will further increase, making it a major global public health issue. The burden of disease related to LBP may continue to rise. with significant variations between countries. The socioeconomic status and lifestyles of different regions and countries also impact on the YLD rates associated with LBP. In addition, middle-aged women and the elderly population are the main contributors to the burden of LBP. Therefore, targeted prevention, intervention, and management measures should be considered, considering the sociocultural contexts and sex differences of various countries, to mitigate the disease burden of LBP.
Key Points
Globally, from 1990 to 2021, the age-standardized prevalence, incidence, and YLD (years lived with disability) proportion of Low back pain (LBP) have declined slightly, but the number of people affected, new cases, and YLDs have all increased significantly. LBP remains a major cause of YLDs globally in 2021.
The Prevalence, incidence, and YLD rates for women globally are higher than those for men. In addition, the number of prevalent cases, incident cases, and YLD cases peak in the 50 to 54 age group.
SDI (Sociodemographic Index) level is a crucial factor influencing the health loss and mortality rates among patients with LBP. From 1990 to 2021, a positive correlation can be observed between the age-standardized YLD rate of LBP and SDI.
It is projected that by 2050, the number of LBP cases will continue to rise, and its burden will continue to increase, remaining a major global public health issue. There is a need to raise public awareness of its risk factors and implement preventive measures to reduce the future burden of this disease.
Supplementary Material
Footnotes
M.C., Y.X., and M.C. are co-first authors.
This manuscript is original and has not been submitted elsewhere in part or in whole.
No IRB or equivalent approval was sought for this manuscript as it solely utilizes public information that is freely available online.
This study was supported by grants from the financial support of the National Science Foundation of China (NSFC, 81974349, 82202766), 2022 In-Hospital Free Innovation Pre-Research Fund of the Scientific Research Office (F016.01003.22003.138) and Department of Science and Technology of Hubei Province General Foundation of Natural Science (2024AFB664, 2022CFB686).
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal's website, www.spinejournal.com.
Contributor Information
Mei Cheng, Email: Chengmei0126@hotmail.com.
Yinkai Xue, Email: xueyinkai@126.com.
Min Cui, Email: cm95588@hust.edu.cn.
Xianlin Zeng, Email: zxl69222@163.com.
Cao Yang, Email: caoyangunion@hust.edu.cn.
Fan Ding, Email: Spine_dingfan@163.com.
Lin Xie, Email: linxie@hust.edu.cn.
References
- 1.Urits I, Burshtein A, Sharma M, et al. Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Curr Pain Headache Rep. 2019;23:23. [DOI] [PubMed] [Google Scholar]
- 2.Delitto A, George SZ, Van Dillen L, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42:A1–A57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389:736–747. [DOI] [PubMed] [Google Scholar]
- 4.Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013;13:14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Manek NJ, Macgregor AJ. Epidemiology of back disorders: prevalence, risk factors, and prognosis. Curr Opin Rheumatol. 2005;17:134–140. [DOI] [PubMed] [Google Scholar]
- 6.Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391:2356–2367. [DOI] [PubMed] [Google Scholar]
- 7.Knezevic NN, Candido KD, Vlaeyen JWS, et al. Low back pain. Lancet. 2021;398:78–92. [DOI] [PubMed] [Google Scholar]
- 8.Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1789–1858. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Jin Z, Wang D, Zhang H, et al. Incidence trend of five common musculoskeletal disorders from 1990 to 2017 at the global, regional and national level: results from the global burden of disease study 2017. Ann Rheum Dis. 2020;79:1014–1022. [DOI] [PubMed] [Google Scholar]
- 10.Global, regional, and national burden of other musculoskeletal disorders, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5:e670–e682. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Chen S, Chen M, Wu X, et al. Global, regional and national burden of low back pain 1990-2019: A systematic analysis of the Global Burden of Disease study 2019. J Orthop Translat. 2022;32:49–58. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Stevens GA, Alkema L, Black RE, et al. Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement. Lancet. 2016;388:e19–e23. [DOI] [PubMed] [Google Scholar]
- 13.Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403:2162–2203. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:968–974. [DOI] [PubMed] [Google Scholar]
- 15.Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–1222. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Safiri S, Kolahi AA, Smith E, et al. Global, regional and national burden of osteoarthritis 1990-2017: a systematic analysis of the Global Burden of Disease Study 2017. Ann Rheum Dis. 2020;79:819–828. [DOI] [PubMed] [Google Scholar]
- 17.LI Y, Ning Y, Shen B, et al. Temporal trends in prevalence and mortality for chronic kidney disease in China from 1990 to 2019: an analysis of the Global Burden of Disease Study 2019. Clin Kidney J. 2023;16:312–321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Yang W, Su A, Ding L. Application of exponential smoothing method and SARIMA model in predicting the number of admissions in a third-class hospital in Zhejiang Province. BMC Public Health. 2023;23:2309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Ji X, Chen J, Ye J, et al. Epidemiological analysis of global and regional lung cancer mortality: based on 30-year data analysis of global burden disease database. Healthcare (Basel). 2023;11:2920. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Adera T, Deyo RA, Donatelle RJ. Premature menopause and low back pain. A population-based study. Ann Epidemiol. 1994;4:416–422. [DOI] [PubMed] [Google Scholar]
- 21.Wáng YX, Wáng JQ, Káplár Z. Increased low back pain prevalence in females than in males after menopause age: evidences based on synthetic literature review. Quant Imaging Med Surg. 2016;6:199–206. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Wang YXJ. Menopause as a potential cause for higher prevalence of low back pain in women than in age-matched men. J Orthop Translat. 2017;8:1–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol. 2002;70:678–690. [DOI] [PubMed] [Google Scholar]
- 24.Fillingim RB, King CD, Ribeiro-Dasilva MC, et al. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10:447–485. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Kesikburun S, Güzelküçük Ü, Fidan U, et al. Musculoskeletal pain and symptoms in pregnancy: a descriptive study. Ther Adv Musculoskelet Dis. 2018;10:229–234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Thabah M, Ravindran V. Musculoskeletal problems in pregnancy. Rheumatol Int. 2015;35:581–587. [DOI] [PubMed] [Google Scholar]
- 27.Weis CA, Padkapayeva K, Smith P, et al. Relationship between location of pregnancy-related and postpartum-related back pain and limitations of daily activities and work participation. J Manipulative Physiol Ther. 2023;46:143–151. [DOI] [PubMed] [Google Scholar]
- 28.Habib RR, El Zein K, Hojeij S. Hard work at home: musculoskeletal pain among female homemakers. Ergonomics. 2012;55:201–211. [DOI] [PubMed] [Google Scholar]
- 29.Weitkunat T, Buck FM, Jentzsch T, et al. Influence of high-heeled shoes on the sagittal balance of the spine and the whole body. Eur Spine J. 2016;25:3658–3665. [DOI] [PubMed] [Google Scholar]
- 30.Dionne CE, Dunn KM, Croft PR. Does back pain prevalence really decrease with increasing age? A systematic review. Age Ageing. 2006;35:229–234. [DOI] [PubMed] [Google Scholar]
- 31.Tamcan O, Mannion AF, Eisenring C, et al. The course of chronic and recurrent low back pain in the general population. Pain. 2010;150:451–457. [DOI] [PubMed] [Google Scholar]
- 32.Blyth FM, Noguchi N. Chronic musculoskeletal pain and its impact on older people. Best Pract Res Clin Rheumatol. 2017;31:160–168. [DOI] [PubMed] [Google Scholar]
- 33.Bento TPF, Genebra C, Maciel NM, et al. Low back pain and some associated factors: is there any difference between genders?. Braz J Phys Ther. 2020;24:79–87. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Henschke N, Lorenz E, Pokora R, et al. Understanding cultural influences on back pain and back pain research. Best Pract Res Clin Rheumatol. 2016;30:1037–1049. [DOI] [PubMed] [Google Scholar]
- 35.Ferreira GE, Herbert R, Machado GC, et al. Low back pain presentations to New South Wales emergency departments: Trends over time and geographical variation. Emerg Med Australas. 2021;33:868–874. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.