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. 2025 Jul 14;50(19):1363–1373. doi: 10.1097/BRS.0000000000005447

Changing Burden, Risk Factors, and Projections of Low Back Pain in Adolescents and Young Adults

Insights From the Global Burden of Disease Study 2021

Yanbin Zhang a, Chaoqun Yang b, Jing Bai c, Bin Xiao a, Jianguo Zhang d, Rongyin Sun e,✉, Da He a,✉
PMCID: PMC12410083  PMID: 40662292

Abstract

Study Design.

Ecological study.

Objective.

To illustrate the spatiotemporal trends, attributable risk factors, and the projected burden of LBP among adolescents and young adults (AYAs) aged 15 to 39 years.

Summary of Background.

Low back pain (LBP) poses a considerable challenge to individuals and society, and current epidemiological trends in AYAs experiencing LBP remain to be explored.

Materials and Methods.

Data extracted from the Global Burden of Disease 2021 study were utilized to examine the LBP burden among AYAs on global, regional, and national scales between 1990 and 2021. This ecological study also investigated global age-sex differences and the percentage of the burden linked to risk elements, while employing the Bayesian age-period-cohort model to project worldwide trends until 2036.

Results.

Between 1990 and 2021, the worldwide counts of incident, prevalent, and years lived with disability (YLDs) cases of LBP in AYAs rose. The calculated estimated annual percentage changes and relevant 95% CIs indicated decreasing trends in age-standardized incidence rate, age-standardized prevalence rate, and age-standardized YLDs rate throughout the study period. The highest counts of prevalent, incident, and YLDs cases were found in regions with middle SDI in 2021, whereas high SDI areas experienced the maximum age-standardized rates. Females carried a heavier burden compared with males on a global scale. Occupational ergonomic factors contributed to the most significant percentage of YLDs globally in 2021, accounting for 26.93%. Predictions for the period 2022 to 2036 suggested a decline in the age-standardized rates of females worldwide, while the burden of females was predicted to remain higher than that of males.

Conclusion.

To tackle the current and possibly rising burden of LBP among AYAs, comprehensive and suitable interventions should be tailored to meet regional and sex disparities.

Key Words: adolescents and young adults, disease burden, low back pain, projection, risk factors

Low back pain (LBP), a representative musculoskeletal disorder, is considered to develop from the combination of psychological, biological, and social factors.1 Over 600 million individuals globally experienced LBP in 2020, and it was forecast that this number would exceed 800 million in 2050.2 LBP constitutes a critical contributor to disability; based on the Global Burden of Disease (GBD) 2019 and 2021 studies, it was identified as the foremost cause of years lived with disability (YLDs) globally.3,4 In addition to pain and disability, the adverse effects due to LBP also involve work limitations, increased social inequality, and a substantial economic impact.5 The epidemiological burden of LBP has exerted significant pressure on individuals and society.

The age range encompassing adolescents and young adults (AYAs) is approximately 15 to 39 years. This period is recognized as a crucial time for physical, emotional, and psychosocial variations, during which significant life events such as access to higher education and career advancement typically take place.6,7 These changes may be unfavorable for the health of AYAs and diminish their motivation to seek treatment for diseases.8 A previous study has demonstrated that LBP usually initiates in adolescence and affects this whole stage, becoming particularly common in 14-year-old individuals.9 An evaluation of information obtained from the Western Australian Pregnancy Cohort study indicated that the reported percentage of LBP within the past month was 32% and 45% for individuals aged 17 and 22 years, respectively.10 Therefore, it is vital to identify epidemiological patterns of LBP among AYAs and establish strategies to alleviate the relative burden.

A current study focused on the LBP burden in AYAs using data from the GBD 2019 study, which did not include an analysis of the burden attributable to risk factors.11 To fulfill this gap and to update epidemiological insights regarding LBP in AYAs by utilizing the most current data provided by the GBD 2021 study, the present study illustrated global, regional, and national changes in LBP among AYAs between 1990 and 2021, explored age and sex variations in the global burden, clarified the share of the burden linked to related risk elements, and projected global patterns by sex between 2022 and 2036.

MATERIALS AND METHODS

Data Sources and Definitions

The GBD 2021 study presented extensive estimates of health metrics covering 204 countries and territories, as well as 811 subnational locations between 1990 and 2021.12 It also assessed the impact of 88 risk factors on specific health outcomes.13 The estimation of disease burden was accomplished using a Bayesian meta-regression tool (DisMod-MR 2.11), coupled with bias adjustment utilizing MR-BRT, and the corresponding modeling information can be found in the prior study.12 Input sources associated with LBP in AYAs include published literature, health surveys, and other data.2

We extracted the counts of incidence, prevalence, and YLDs of LBP along with the age-standardized YLDs rate (ASYR), age-standardized incidence rate (ASIR), and age-standardized prevalence rate (ASPR) from the GBD 2021 results tool, and the related 95% uncertainty intervals (UIs) were also obtained. 15 to 39 years was the selected age group in this study. In the GBD 2021 study, the Sociodemographic Index (SDI) is an integrated metric for comparing levels of social development within the GBD study framework. SDI values span from 0 to 100, categorizing all countries and territories into 5 quartiles.12

The definition of LBP has been expressed in the previous study.14 Three important attributable risk factors, including high body mass index (BMI), occupational ergonomic factors, and smoking, were examined in this study to clarify their contributions to the burden of LBP in AYAs. In the GBD 2021 study, occupational ergonomic factors represent the percentage of working people with exposure to work leading to LBP according to the distributions of the population in 9 occupational groups.13 The definition of high BMI for people aged over 20 years is a BMI above 20 to 23 kg/m2, with high BMI for individuals of 2 to 19 years defined as overweight or obesity.13

Statistical Analysis

The current study represented an ecological analysis according to data sets from the GBD 2021 study, employing the estimated annual percentage change (EAPC) to determine patterns of ASPR, ASIR, and ASYR of LBP in AYAs from 1990 to 2021. The relevant EAPC values and 95% confidence intervals could be derived through the linear regression model, with the calculational formula presented as y = α + βx + ε and EAPC = 100 × (e β − 1). Here, β corresponds to the natural logarithm of ASPR, ASIR, and ASYR, and x represents the calendar year.6 ASPR, ASIR, and ASYR exhibited increasing trends when the lower bound of the 95% CIs was over zero, while they displayed decreasing trends if the upper bound of the 95% CIs was under zero.15

The Bayesian age-period-cohort (BAPC) model accomplishes the prediction of the burden of disease using the second-order random walk for prior smoothing; however, implementing Markov Chain Monte Carlo within a traditional Bayesian framework leads to associated convergence and mixing problems.16 The Integrated Nested Laplace Approximation (INLA), joint with the BAPC model for approximating the posterior marginal distributions, can effectively avoid the above challenges and improve the accuracy of projections.17 We utilized the R packages INLA (version 24.06.27) and BAPC (version 0.0.36) in the R Studio software (version 4.4.2) to project global LBP trends among AYAs over the upcoming 15 years, with population data also obtained from the GBD 2021 study.

RESULTS

Global Burden of LBP in AYAs

Compared with 1990, the global rises in prevalent, incident, and YLDs cases of LBP in AYAs were recorded in 2021 (Table 1, Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/BRS/C771 and Supplemental Table 2, Supplemental Digital Content 2, http://links.lww.com/BRS/C772). Specifically, the associated prevalent cases and incident cases were 173,391,354.65 and 76,477,359.86 worldwide in 2021, respectively, with YLDs cases caused by LBP in AYAs reaching 19,764,376.99. The global ASPR, ASIR, and ASYR declined to 5828.62 per 100,000 (95% UIs: 4773.25 to 6985.72), 2570.82 per 100,000 (95% UIs: 2074.27 to 3094.23), and 664.39 per 100,000 (95% UIs: 442.93 to 904.3) in 2021, respectively. Between 1990 and 2021, the EAPC values and their 95% CIs for ASPR, ASIR, and ASYR were calculated to be negative, suggesting that the age-standardized rates of LBP in AYAs presented noticeable downward patterns during this period.

TABLE 1.

Global and Regional Prevalent Cases, ASPR, and EAPC of LBP in Adolescents and Young Adults, 1990–2021

Location Prevalent Cases ASPR EAPC
1990 (95% UI) 2021 (95% UI) 1990 (Per 100,000, 95% UI) 2021 (Per 100,000, 95% UI) 1990–2021 (%, 95% CI)
Global 138353912.63 (113358435.68 to 164950012.57) 173391354.65 (141995917.66 to 207813093.24) 6312.35 (5171.94 to 7525.79) 5828.62 (4773.25 to 6985.72) −0.21 (−0.26 to −0.16)
SDI regions
 High SDI 33654140.49 (28148365.35 to 40025923.52) 31722961.51 (27009600.79 to 37007508.79) 9699.59 (8112.75 to 11536.03) 8980.55 (7646.23 to 10476.57) −0.23 (−0.27 to −0.2)
 High-middle SDI 28893628.47 (23666497.57 to 34705481.63) 26770760.51 (21863350.81 to 32342501.88) 6384.8 (5229.73 to 7669.09) 6080.57 (4965.93 to 7346.11) −0.09 (−0.18 to 0.01)
 Middle SDI 38806459.35 (31534305.84 to 46734522.81) 47554286.74 (38472967.71 to 57249773.11) 5156.1 (4189.87 to 6209.48) 5127.2 (4148.07 to 6172.55) 0.05 (−0.01 to 0.11)
 Low-middle SDI 26556061.94 (21715459.08 to 31940300.18) 43923089.59 (35670732.92 to 53070845.12) 5857.09 (4789.47 to 7044.61) 5473.33 (4444.99 to 6613.25) −0.23 (−0.29 to −0.17)
 Low SDI 10296517.78 (8437246.9 to 12380382.12) 23266415.31 (18965092.19 to 28025189.69) 5586.57 (4577.78 to 6717.21) 5181.12 (4223.27 to 6240.83) −0.24 (−0.27 to −0.21)
GBD regions
 Andean Latin America 713410.45 (588616.05 to 851489.65) 1290860.84 (1047112.66 to 1542507.79) 4613.46 (3806.44 to 5506.38) 4766.92 (3866.8 to 5696.21) 0.12 (0.08 to 0.15)
 Australasia 1008241.96 (834671.57 to 1201914.86) 1169830.13 (969491.08 to 1420287.63) 12365.19 (10236.5 to 14740.41) 11172.2 (9258.9 to 13564.13) −0.25 (−0.3 to −0.2)
 Caribbean 750571.89 (608741.21 to 903071.55) 932001.35 (760504.77 to 1116542.73) 5049.38 (4095.23 to 6075.3) 5120.13 (4177.98 to 6133.94) 0.04 (0.02 to 0.06)
 Central Asia 1847976.6 (1512763.8 to 2222959.57) 2556164 (2101293.74 to 3092693.71) 6494.67 (5316.57 to 7812.54) 6837.07 (5620.41 to 8272.14) 0.07 (0.01 to 0.14)
 Central Europe 5160135.31 (4250558.5 to 6172118.02) 3855100.88 (3177441.12 to 4649758.68) 11014.54 (9073.01 to 13174.66) 11008.36 (9073.29 to 13277.54) 0.04 (−0.01 to 0.09)
 Central Latin America 4530142.28 (3694222.44 to 5459694.83) 7145315.56 (5873338.62 to 8552502.94) 6635.89 (5411.41 to 7997.53) 7063.2 (5805.84 to 8454.22) 0.16 (0.11 to 0.21)
 Central Sub-Saharan Africa 1131986.99 (921696.45 to 1359225.93) 2870218.78 (2335249.79 to 3449190.11) 5452.16 (4439.3 to 6546.64) 5305.78 (4316.85 to 6376.04) −0.12 (−0.15 to −0.1)
 East Asia 25269842.78 (20376046.92 to 30405992.49) 18883123.56 (15444960.31 to 23014849.43) 4466.95 (3601.88 to 5374.87) 3941.8 (3224.09 to 4804.29) −0.28 (−0.46 to −0.11)
 Eastern Europe 7465736.73 (6142614.84 to 9074073.91) 5757512.08 (4714330.87 to 6968463.64) 8704.52 (7161.85 to 10579.73) 8700.66 (7124.22 to 10530.63) 0.06 (−0.05 to 0.16)
 Eastern Sub-Saharan Africa 3779602.88 (3080029.63 to 4576698.01) 9056289.91 (7367470.28 to 10949896.09) 5331.66 (4344.81 to 6456.07) 5169.55 (4205.53 to 6250.46) −0.1 (−0.11 to −0.1)
 High-income Asia Pacific 6971474.82 (5760216.57 to 8376564.62) 4906520.16 (4030586.48 to 5932493.24) 10328.84 (8534.26 to 12410.6) 9708.31 (7975.14 to 11738.35) −0.1 (−0.15 to −0.05)
 High-income North America 12410895.33 (10369412.42 to 14787792.28) 12258458.38 (10824104.95 to 13692252.21) 10952.51 (9150.92 to 13050.1) 9951.33 (8786.93 to 11115.27) −0.23 (−0.3 to −0.16)
 North Africa and Middle East 10545301.85 (8765582.79 to 12569465.95) 20493757.2 (16718972.7 to 24644556.83) 7879.65 (6549.81 to 9392.15) 8059.96 (6575.38 to 9692.42) 0.1 (0.08 to 0.11)
 Oceania 121045.05 (98227.49 to 146647.72) 263033.88 (213806.75 to 318549.66) 4556.76 (3697.79 to 5520.58) 4668.34 (3794.65 to 5653.64) 0.08 (0.07 to 0.1)
 South Asia 24512936.65 (19954230.13 to 29487156.42) 38435668.18 (30952617.66 to 46603205.5) 5679.33 (4623.14 to 6831.8) 4859.56 (3913.45 to 5892.21) −0.53 (−0.67 to −0.4)
 Southeast Asia 8396599.42 (6823247.67 to 10081248.24) 12428216.57 (10027229.95 to 15110175.64) 4262.13 (3463.5 to 5117.26) 4481.44 (3615.68 to 5448.52) 0.17 (0.16 to 0.18)
 Southern Latin America 1680908.09 (1375036.96 to 2022568.9) 2294943.69 (1884481.81 to 2752634.67) 8810.14 (7206.98 to 10600.89) 8896.62 (7305.41 to 10670.91) 0.04 (−0.01 to 0.09)
 Southern Sub-Saharan Africa 895848.69 (724240.98 to 1067882.5) 1471268.03 (1194257.14 to 1783137.46) 4144.51 (3350.59 to 4940.4) 4322.68 (3508.8 to 5238.97) 0.1 (0.04 to 0.17)
 Tropical Latin America 5073781.99 (4145176.15 to 6132778.16) 7384418.29 (6091172.12 to 8908276.75) 7889.19 (6445.3 to 9535.81) 8361.96 (6897.52 to 10087.55) 0.14 (0.12 to 0.17)
 Western Europe 12594229.07 (10545856.12 to 14979656.03) 10927856.24 (9028639.99 to 13177352.41) 8738.71 (7317.41 to 10393.87) 8420.77 (6957.27 to 10154.18) −0.12 (−0.14 to −0.1)
 Western Sub-Saharan Africa 3493243.78 (2852629.96 to 4185074.31) 9010796.95 (7316738.89 to 10815417.84) 4880.6 (3985.57 to 5847.2) 4712.55 (3826.57 to 5656.35) −0.12 (−0.17 to −0.07)
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ASPR indicates age-standardized prevalence rate; EAPC, estimated annual percentage change; LBP, low back pain; SDI, sociodemographic index.

Regional Burden of LBP in AYAs

The greatest number of YLDs, prevalent, and incident cases of LBP in AYAs were recorded in regions recognized as middle SDI in 2021, followed by regions with low-middle SDI (Table 1, Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/BRS/C771 and Supplemental Table 2, Supplemental Digital Content 2, http://links.lww.com/BRS/C772). However, regions identified as high SDI experienced the maximum ASPR, ASIR, and ASYR, which were 8980.55 per 100,000, 3886.76 per 100,000, and 1023.05 per 100,000, respectively. Regarding GBD regions, South Asia recorded the highest counts of incident, prevalent, and YLDs cases in 2021. In 2021, the maximum ASPR and ASIR were observed in Australasia, while Central Europe recorded the maximum ASYR.

There were nonlinear yet definite positive correlations between the SDI and the ASPR (Figure 1A), ASIR (Figure 1B), and ASYR (Figure 1C) of LBP in AYAs worldwide and across the 21 GBD regions. When the SDI fell below 0.8, the age-standardized rates rose alongside increasing SDI levels; conversely, this trend reversed when the SDI exceeded 0.8. Australasia exhibited notable downward trends of LBP burden in AYAs.

Figure 1.

Figure 1

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Associations between SDI and age-standardized prevalence rate (A), age-standardized incidence rate (B), age-standardized YLDs rate (C) of LBP in AYAs globally and across 21 GBD regions in 2021. Expected values for SDI and age-standardized rates based on all sites are displayed as black lines. SDI indicates sociodemographic index; YLDs, years lived with disability; LBP, low back pain; AYAs, adolescents and young adults; GBD, Global Burden of Disease.

National Burden of LBP in AYAs

In 2021, Hungary reported the highest ASPR (Figure 2A) and ASYR (Figure 2C) of LBP in AYAs at 11,914.62 per 100,000 and 1371.54 per 100,000, respectively. The maximum ASIR (Figure 2B) was observed in New Zealand (4943.58 per 100,000). In 2021, Eswatini had the lowest ASPR, ASIR, and ASYR across 204 countries and territories. On the national scale, more than 40% of countries and territories experienced rising patterns in age-standardized rates of LBP in AYAs. The largest EAPCs for ASPR (Figure 2D), ASIR (Figure 2E), and ASYR (Figure 2F) were detected in Sweden over the study period, with values of 0.84%, 0.96%, and 0.85%, respectively. Conversely, India demonstrated the most significant downward trends in ASPR, ASIR, and ASYR. Supplemental Table 3 (Supplemental Digital Content 3, http://links.lww.com/BRS/C773) provides detailed values for metrics related to LBP burden in AYAs across 204 countries and territories.

Figure 2.

Figure 2

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ASPR (A), ASIR (B), and ASYR (C) of LBP in AYAs in 2021, as well as EAPC for ASPR (D), ASIR (E), and ASYR (F) between 1990 and 2021 across 204 countries and territories. A positive value of EAPC represents an increasing trend in the corresponding age-standardized rate during the study duration, while a negative value indicates the opposite situation. ASPR indicates age-standardized prevalence rate; ASIR, age-standardized incidence rate; ASYR, age-standardized YLDs rate; YLDs, years lived with disability; LBP, low back pain; AYAs, adolescents and young adults; EAPC, estimated annual percentage change.

Age and Sex Patterns in LBP Burden in AYAs

Over the study period, the global number of prevalent cases of LBP for males and females among AYAs grew over time, with the ASPR showing a slight declining trend (Figure 3A). Similar patterns were observed in incidence and YLDs (Figure 3B, C). Females markedly exceeded males across all metrics of LBP burden in AYAs. As displayed in Supplemental Table 4 (Supplemental Digital Content 4, http://links.lww.com/BRS/C774), the burden indicators for both sexes increased with age in 2021, and the burden of females was consistently greater than that of males across all age groups.

Figure 3.

Figure 3

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The global counts and age-standardized rates of prevalence (A), incidence (B), and YLDs (C) of LBP in AYAs by sex from 1990 to 2021. The bar plots and their error bars denoted the counts and the related 95% UIs; the line plots and their shade represented the rates and the related 95% UIs. YLDs indicates years lived with disability; LBP, low back pain; AYAs, adolescents and young adults; UIs, uncertainty intervals.

Attributable Risk Factors Analysis

In 2021, the attributable risk factor that accounted for the greatest percentage of YLDs due to LBP in AYAs worldwide was occupational ergonomic factors (26.93%; Figure 4A). The percentage of YLDs attributed to occupational ergonomic factors was higher in lower SDI regions, while high BMI and smoking emerged as more significant contributors in regions identified as higher SDI. In High-income North America, high BMI (18.14%) surpassed occupational ergonomic factors to become the element causing the highest percentage of YLDs. In terms of sex, the proportion of YLDs due to smoking in males was notably greater compared with females globally and across all regions (Figure 4B, C). Worldwide and in most regions, the YLDs burden caused by occupational ergonomic factors was higher in males, whereas the YLDs burden due to high BMI was heavier in females.

Figure 4.

Figure 4

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Percentage of YLDs attributable to risk factors of LBP for overall (A), male (B), and female (C) populations among AYAs globally, across 5 SDI regions, and 21 GBD regions, 2021. The risk factors in each section are, in turn, occupational ergonomic factors, high body mass index, and smoking, with the values following the horizontal bars representing specific percentiles. YLDs indicates years lived with disability; LBP, low back pain; AYAs, adolescents and young adults; SDI, sociodemographic index; GBD, Global Burden of Disease.

Projections of LBP Burden in AYAs

For males, the global ASPR of LBP in AYAs was predicted to grow from 4350.25 per 100,000 in 2022 to 4372.13 per 100,000 in 2036 (Figure 5A), while it would decline from 7225.24 per 100,000 to 7130.36 per 100,000 for females (Figure 5B). The projected global ASIR of males would increase from 1953.64 per 100,000 in 2022 to 1989.11 per 100,000 in 2036 (Figure 5C), whereas it would decrease slightly from 3150.65 per 100,000 to 3141.92 per 100,000 for females (Figure 5D). Regarding ASYR, males were predicted to exhibit a stable trend over the forecast period (Figure 5E), with females experiencing a downward pattern (Figure 5F). Moreover, females were forecast to experience higher age-standardized rates than males between 2022 and 2036. Notably, the number of incident, prevalent, and YLDs cases would present upward trends in both sexes globally during the forecast period. Detailed values concerning the predicted cases and age-standardized rates of LBP in AYAs can be found in Supplemental Table 5 (Supplemental Digital Content 5, http://links.lww.com/BRS/C775).

Figure 5.

Figure 5

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Predicted trends of age-standardized prevalence rate (A: males, B: females), age-standardized incidence rate (C: males, D: females), and age-standardized YLD rate (E: males, F: females) of LBP in AYAs by sex from 2022 to 2036. The sector shape represents the distribution of projections between the 2.5% and 97.5% quartiles, with the solid line indicating the projected mean value. The vertical dashed line corresponds to the starting year of the projection. YLDs indicates years lived with disability; LBP, low back pain; AYAs, adolescents and young adults.

DISCUSSION

Based on what we know, this represents the most recent ecological study demonstrating the evolving burden, risk elements, and predictions of LBP in AYAs according to the GBD 2021 public database. Although declining patterns in age-standardized rates of LBP in AYAs were noted within the study period, counts of all metrics increased in 2021 compared with 1990, rising more than 25%. Furthermore, compared with the middle-aged population aged 45 to 59 years, AYAs experienced a higher negative EAPC for ASYR of LBP, reflecting a relatively smaller decline in ASYR of AYAs within the study duration.18 The present study emphasizes the identification of the aggravated LBP burden of AYAs to avoid more adverse effects while growing into advanced age.

Occupational ergonomic factors have been identified as the most significant contributors to the LBP burden among AYAs in this study. A cohort study indicated that physical workload factors, including awkward work postures and physically demanding work, were associated with LBP among adolescents.19 Besides, rapid socioeconomic developments have led to more sedentary occupations, and sedentary behavior during work has been found to moderately elevate the LBP risk for adolescents and adults.20 Notably, the burden of LBP due to high BMI increased from 1990 to 2021,21 with our findings suggesting that the global share of the LBP burden caused by high BMI among AYAs was substantial in 2021. High BMI is a direct manifestation of overweight and obesity, which has been confirmed as a critical risk element for LBP, even among young adults.22 Besides, the risk and the likelihood of persistence or recurrence of LBP rise with increasing BMI values.23 Obesity may aggravate LBP by adding more stress to the intervertebral discs (IVD) and joints.24 The obesity burden within the younger population presents a concerning trend,25 highlighting the necessity for AYAs to reduce obesity to alleviate the LBP burden. Furthermore, smoking plays an influential role in the burden of LBP among AYAs. It was estimated that 82.6% of smokers began their habit between 14 and 25 years of age.26 A bidirectional Mendelian randomization study has shown that smoking elevates the risk of IVD degeneration, and IVD degeneration may lead to LBP.27 The specific biological mechanisms by which smoking affects LBP in AYAs remain to be investigated. In addition to the previous attributable risk factors, LBP in AYAs may be influenced by psychological factors, as LBP is considered an emotional reaction that may be affected by feelings of anxiety and fear.1 Moreover, it has been demonstrated that a lack of physical activity and overactivity may elevate the risk of LBP in adolescents.28

Significant regional variations were identified in the burden of LBP among AYAs. First, low-middle and middle SDI areas shared higher amounts of prevalent, incident, and YLDs cases. An earlier review indicated that a higher LBP burden in low-income and middle-income countries was linked to the population being more exposed to hard physical work.29 Similarly, our study revealed that AYAs faced a heavier LBP burden attributable to occupational ergonomic factors in lower SDI regions. Incorrect or harmful procedures and care regarding LBP may lead to more iatrogenic disability in lower-income countries,30 thereby potentially exacerbating the LBP burden. Moreover, low education and low income, and their associated limited health care resources and unhealthy lifestyles, also have a negative impact on the burden of LBP in AYAs in lower SDI areas.5 Second, the maximum age-standardized rates were detected in areas with high SDI, possibly linked to local lifestyles. In the present study, higher SDI areas experienced a higher proportion of LBP burden caused by high BMI and smoking among AYAs. Considering that LBP poses a severe clinical and economic challenge in high-income countries,31 reducing the exposure of AYAs to unhealthy lifestyles could effectively reduce their LBP burden.

Regarding differences between both sexes, compared with males, the global burden of LBP was more severe in females among AYAs throughout the study period. The ages between 15 and 39 years are the primary period for females to experience pregnancy. A meta-analysis study has found that the global LBP prevalence in pregnancy reaches up to 40.5%, with the prevalence increasing as the pregnancy progresses.32 During pregnancy, the heightened forces exerted on the lumbar spine, changes in hormone levels, and laxity of the pelvic ligaments all contribute to the likelihood of LBP.33 Psychologically, the heavier burden of females may be linked to their greater sensitivity to pain.34 Projections in this study indicated that the global age-standardized rates in females would continue to exceed those observed in males. Consequently, there is a pressing need for more targeted interventions for females aged 15 to 39 years to mitigate the negative effects of LBP, such as maintaining a standard level of BMI. Young males faced a greater burden of LBP caused by occupational ergonomic factors and smoking in this study, and the reduction in smoking rates and adverse work postures should be acknowledged as beneficial actions. Furthermore, when considering the overestimates or underestimates of the number of cases due to differences in health-seeking behavior, differences in the LBP burden between the sexes need to be interpreted cautiously.

The present study demonstrated that the global prevalent, incident, and YLDs cases of LBP in AYAs would increase during the forecast period, suggesting a potential worsening burden in the future. The previous study has predicted an increase in life expectancy and an elevated tendency toward population aging patterns in the future,35 with population aging potentially affecting the LBP burden of AYAs by indirectly increasing competition for health care resources and changing the workforce structure of society. Managing risk factors is a fundamental preventive strategy that can be implemented according to the characteristics of different regions. For example, encouraging AYAs in low SDI areas to maintain correct postures while working, and efforts to reduce obesity rates would be beneficial in high SDI areas. Besides, enhancing educational attainment has been revealed to mitigate the risk of LBP.36 To narrow the sex disparities in the future burden of LBP in AYAs, it is recommended that young females appropriately increase their exercise, with moderate-quality evidence supporting that exercise programs, combined with education or not, may reduce the harms of LBP.37 Public health strategies are also significant, which seek to reshape the cognition and behaviors of the public regarding LBP,38 and these measures mainly include changing the priority of LBP, implementing interventions in conjunction with other chronic diseases for prevention, along with public health programs for health care resource optimization and lifestyle interventions.39

Limitations

Several limitations are present in this study. First, the data collected by the GBD 2021 study may contain omissions because of potential differences in diagnostic criteria and the amount of self-reported data for LBP in AYAs across different countries and territories, which may lead to an underestimation of the corresponding burden reported in this study. Second, influenced by the ecological fallacy, this study could illustrate the correlation between attributable risk factors available in the GBD 2021 database and the LBP burden of AYAs, unable to infer individual characteristics.40 Third, the GBD 2021 study does not provide a broader range of related risk factors for LBP among AYAs, which limits the analysis of the burden associated with other elements. Fourth, a more in-depth epidemiological burden analysis could not be performed in this study because the GBD 2021 database does not contain data on the corresponding LBP subcategories.

CONCLUSIONS

The LBP burden in AYAs has been severe throughout the study period, exhibiting notable sex and regional differences. Furthermore, the burden is expected to present an upward trend until 2036, emphasizing the necessity of managing this disease. To alleviate the LBP burden among AYAs, comprehensive LBP prevention and control policies are recommended for development in each country and territory considering their respective socioeconomic and cultural contexts. On an individual scale, AYAs should limit exposure to relevant attributable risk factors, establish healthy lifestyles, and strengthen the management of LBP, particularly for females.

Key Points

  • The worldwide counts of incident cases, prevalent cases, and years lived with disability (YLDs) cases of low back pain (LBP) in adolescents and young adults (AYAs) have escalated between 1990 and 2021.

  • High sociodemographic index (SDI) regions reported the highest age-standardized rates in 2021, while the highest number of prevalent, incident, and YLDs cases were found in regions with middle SDI.

  • Females in AYAs bear a heavier LBP burden globally during the study and projection duration.

  • Occupational ergonomic factors represent the foremost contributor to LBP burden in AYAs, accounting for the relevant YLDs proportion of 26.93% worldwide.

Supplementary Material

SUPPLEMENTARY MATERIAL
brs-50-1363-s001.docx (22.5KB, docx)
brs-50-1363-s002.docx (21.9KB, docx)
brs-50-1363-s003.docx (65.5KB, docx)
brs-50-1363-s004.docx (16.7KB, docx)
brs-50-1363-s005.docx (19.7KB, docx)

Footnotes

Y.Z., C.Y., and J.B. are co-first authors.

This work was supported by the Beijing Natural Science Foundation (L242164).

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

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Jianguo Zhang, Email: jgzhang_pumch@yahoo.com.

Rongyin Sun, Email: sunry24@mails.jlu.edu.cn.

Da He, Email: heda_jst@aliyun.com.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

SUPPLEMENTARY MATERIAL
brs-50-1363-s001.docx (22.5KB, docx)
brs-50-1363-s002.docx (21.9KB, docx)
brs-50-1363-s003.docx (65.5KB, docx)
brs-50-1363-s004.docx (16.7KB, docx)
brs-50-1363-s005.docx (19.7KB, docx)

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