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Annals of Translational Medicine logoLink to Annals of Translational Medicine
. 2020 Mar;8(6):299. doi: 10.21037/atm.2020.02.175

Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017

Aimin Wu 1, Lyn March 2,3,✉, Xuanqi Zheng 1, Jinfeng Huang 1, Xiangyang Wang 1, Jie Zhao 4, Fiona M Blyth 5, Emma Smith 2,6, Rachelle Buchbinder 7, Damian Hoy 2,3
PMCID: PMC7186678  PMID: 32355743

Abstract

Background

Low back pain (LBP) is a common musculoskeletal problem globally. Updating the prevalence and burden of LBP is important for researchers and policy makers. This paper presents, compares and contextualizes the global prevalence and years lived with disability (YLDs) of LBP by age, sex and region, from 1990 to 2017.

Methods

Data were extracted from the GBD (the Global Burden of Disease, Injuries, and Risk Factors Study) 2017 Study. Age, sex and region-specific analyses were conducted to estimate the global prevalence and YLDs of LBP, with the uncertainty intervals (UIs).

Results

The age-standardized point prevalence of LBP was 8.20% (95% UI: 7.31–9.10%) in 1990 and decreased slightly to 7.50% (95% UI: 6.75–8.27%) in 2017. The prevalent numbers of people with LBP at any one point in time in 1990 was 377.5 million, and this increased to 577.0 million in 2017. Age-standardized prevalence of LBP was higher in females than males. LBP prevalence increased with age, and peaked around the ages of 80 to 89 years, and then decreased slightly. Global YLDs were 42.5 million (95% UI: 30.2 million–57.2 million) in 1990 and increased by 52.7% to 64.9 million (95% UI: 46.5 million–87.4 million) in 2017. YLDs were also higher in females than males and increased initially with age; they peaked at 35–39 years of age in 1990, before decreasing, whereas in 2017, they peaked at 45–49 years of age, before decreasing. Western Europe had the highest number of LBP YLDs.

Conclusions

Globally, LBP is the leading global cause of YLDs. Greater attention is urgently needed to mitigate this increasing burden and the impact it is having on health and social systems.

Keywords: Low back pain (LBP), prevalence, years lived with disability (YLDs), Global Burden of Disease Study

Introduction

Low back pain (LBP) is the most common musculoskeletal problem globally (1-4). It is the leading cause of activity limitation and absenteeism from work (5-7), and results in a huge medical burden and economic cost (2,8). It is consequently one of the major global public health problems (9-11).

The Global Burden of Disease (GBD) Study is updated every one to two years (6,12-15). LBP is included as one of the musculoskeletal conditions in GBD study—the last article describing the global burden of LBP in detail was based upon the GBD 2010 (10) analysis. However, since then, there have been a number of methodological changes made and updated data (6). These include: an updated DisMod-MR tool; construction of a Socio-Demographic Index (SDI); further research to establish disability weights (DWs); and adjustment for comorbidity (6). Therefore, it is important to present these changes and highlight the resulting update on the prevalence and global burden of LBP.

Methods

All of the data analysed and presented in this article were obtained from the updated GBD 2017 (the Global Burden of Disease, Injuries, and Risk Factors Study) (http://www.healthdata.org/gbd/data). The GBD 2017 data were derived from the GBD repository of population health data, including World Health Surveys and National Health Surveys, literature reviews, and claims data. Literature review for LBP was conducted in October 2017. The electronic databases of Ovid Medline, EMBase, and CINAHL were searched and eight studies were included. In addition, USA claims data for 2000, 2010, 2012, and 2014 by state, and Taiwan claims data from 2016 were included.

In brief, Bayesian meta-regressions by DisMod-MR 2.1 were used to synthesize sparse and heterogeneous, epidemiological data to estimate the point prevalence and YLD outcomes. In GBD 2010, DisMod-MR 1.0 was used to pool all data by world region. This was updated to DisMod-MR 2.0 in GBD 2013, which increased the computational speed allowing consistent computations between all disease parameters at the country level. DisMod-MR 2.1 was used in GBD 2016 and 2017, and enables estimates down to the sub-national level. Results were stratified by five-year age groups from birth up to 95+. The detailed methods of the systematic analysis for GBD 2017 by the IHME (Institute for Health Metrics and Evaluation) have been published elsewhere (6).

LBP was defined as pain that lasts for at least one day (with/without pain referred into one or both lower limbs) in the area on the posterior aspect of the body from the lower margin of the 12th ribs to the lower gluteal folds (10,16,17).

DWs represent the magnitude of health loss associated with BP. DWs were measured on a scale from zero to one, with zero representing a state of full health, and one representing a state equivalent to death. The DWs used in GBD 2010 were based on face to face surveys conducted in five countries as well as an internet survey (10). The DWs used in GBD 2017 have been described previously (18), and also included data from the European Disability Weights Measurement Study that took place in Hungary, Italy, the Netherlands and Sweden.

A total of six sequelae were used to represent the different levels of LBP severity: (I) most severe BP with leg pain (DW: 0.384, 95% CI: 0.256–0.518); (II) most severe BP without leg pain (DW: 0.372, 95% CI: 0.250–0.506); (III) severe BP with leg pain (DW: 0.325, 95% CI: 0.219–0.446); (IV) severe BP without leg pain (DW: 0.272, 95% CI: 0.182–0.373); (V) moderate BP with/without leg pain (DW: 0.054, 95% CI: 0.035–0.079); and (VI) mild BP with/without leg pain (DW: 0.020, 95% CI: 0.011–0.035).

There is no mortality from LBP, therefore, the YLDs and DALYs (Disability-adjusted life years) values are the same. In this paper, we have only used the term YLDs. The unadjusted YLDs of each sequela were calculated using the formula:

YLDsequela = Prevalencesequela × DWsequela (17).

The SDI was originally constructed in GBD 2015; it is a composite indicator of development status correlated with health outcomes. Briefly, it is the geometric mean of 0 to 1 indices of total fertility rate under the age of 25 (TFU25), mean education for those aged 15 and older (EDU15+), and lag-distributed income (LDI) per capita.

A comorbidity correction involving a micro-simulation performed for each age-sex-location-year, was used to calculate the comorbidity-adjusted YLDs at the final stage. The co-occurrence of different diseases was estimated by simulating 40,000 individuals in each age-sex-location-year combination based on disease prevalence. A flow chart describing the process for estimating the YLDs is shown in Figure 1.

Figure 1.

Figure 1

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The flow chart of the YLDs estimation. Map SF-12 to GBD DW: the data were first collected from the short form-12 (SF-12), then, the individual SF-12 summary scores were mapped to an equivalent disability weight (DW); Nonfatal database: low back pain is one type of nonfatal disease, therefore, the data are input into the GBD nonfatal database; The “year” under the prevalence by location/year/age/sex represents the years 1990–2017.

Uncertainty intervals (UIs) were calculated using a propagating technique also described elsewhere (15,19,20). Briefly, the distribution of every computed step was stored in 1,000 draws; the final estimate is the mean estimate across all 1,000 draws, and the 95% UI is the 25th and 975th ranked values.

Results

Prevalence

The age-standardized point prevalence of LBP in the 21 world regions by gender at 1990 and 2017 is summarized in Table 1.

Table 1. The age-standardized point prevalence of low back pain in 1990 and 2017, by region and gender.

Region Gender 1990 (%) 2017 (%) Difference** (%)
Mean LUI UUI Rank* Mean LUI UUI Rank*
Andean Latin America Male 7.65 6.89 8.44 8.31 7.45 9.19 0.66
Female 7.36 6.61 8.22 7.87 7.08 8.77 0.50
Both 7.50 6.76 8.33 13 8.08 7.26 8.94 13 0.58
Australasia Male 11.60 10.52 12.79 11.99 10.73 13.38 0.39
Female 13.11 11.86 14.54 13.84 12.41 15.31 0.73
Both 12.38 11.22 13.63 3 12.94 11.63 14.32 4 0.56
Caribbean Male 5.32 4.79 5.89 5.28 4.77 5.85 −0.04
Female 6.15 5.49 6.81 6.03 5.51 6.65 −0.12
Both 5.75 5.15 6.36 19 5.67 5.16 6.26 19 −0.08
Central Asia Male 9.21 8.27 10.23 9.14 8.22 10.17 −0.07
Female 9.11 8.16 10.18 9.11 8.11 10.18 0.01
Both 9.17 8.24 10.21 10 9.13 8.16 10.20 10 −0.04
Central Europe Male 12.40 11.16 13.79 12.51 11.34 13.77 0.11
Female 12.47 11.15 13.89 12.57 11.37 13.86 0.10
Both 12.46 11.18 13.86 2 12.57 11.38 13.85 5 0.11
Central Latin America Male 4.68 4.15 5.24 4.88 4.37 5.41 0.20
Female 6.43 5.73 7.17 6.28 5.61 6.95 −0.15
Both 5.59 4.97 6.20 20 5.62 5.02 6.23 20 0.03
Central Sub-Saharan Africa Male 8.78 7.78 9.82 8.94 7.95 9.99 0.16
Female 7.75 6.90 8.69 7.87 6.99 8.82 0.12
Both 8.24 7.30 9.23 11 8.40 7.48 9.39 12 0.16
East Asia Male 4.16 3.61 4.72 3.44 3.02 3.85 −0.72
Female 5.70 4.91 6.56 4.38 3.87 4.89 −1.32
Both 4.94 4.27 5.63 21 3.92 3.46 4.37 21 −1.02
Eastern Europe Male 11.56 10.26 12.95 10.52 9.37 11.78 −1.04
Female 11.40 10.10 12.74 10.59 9.47 11.79 −0.81
Both 11.48 10.20 12.77 6 10.57 9.40 11.79 8 −0.91
Eastern Sub-Saharan Africa Male 8.10 7.23 8.99 8.52 7.60 9.49 0.43
Female 6.43 5.74 7.20 6.65 5.90 7.42 0.22
Both 7.25 6.46 8.09 15 7.56 6.73 8.42 15 0.31
High-income Asia Pacific Male 10.25 9.12 11.51 11.45 10.19 12.83 1.20
Female 14.42 12.80 16.18 14.90 13.27 16.80 0.48
Both 12.36 11.02 13.84 4 13.16 11.74 14.73 2 0.80
High-income North America Male 10.39 9.37 11.49 9.80 9.20 10.42 −0.59
Female 12.21 11.03 13.44 11.55 10.85 12.28 −0.66
Both 11.36 10.24 12.54 7 10.71 10.06 11.39 7 −0.65
North Africa and Middle East Male 8.96 8.06 9.90 9.09 8.14 10.01 0.13
Female 10.75 9.62 11.94 10.74 9.61 11.97 −0.01
Both 9.85 8.84 10.90 9 9.90 8.86 10.98 9 0.06
Oceania Male 5.89 5.21 6.57 6.20 5.50 6.98 0.31
Female 6.89 6.10 7.75 7.23 6.41 8.11 0.34
Both 6.37 5.67 7.11 18 6.70 5.95 7.53 16 0.33
South Asia Male 5.72 5.06 6.43 5.05 4.50 5.65 −0.67
Female 7.44 6.62 8.33 7.07 6.31 7.89 −0.37
Both 6.54 5.81 7.32 17 6.06 5.40 6.75 18 −0.48
Southeast Asia Male 7.33 6.61 8.10 7.72 7.05 8.42 0.39
Female 7.52 6.79 8.29 7.78 7.07 8.52 0.25
Both 7.43 6.71 8.21 14 7.76 7.08 8.49 14 0.32
Southern Latin America Male 11.98 10.59 13.54 13.25 11.86 14.64 1.27
Female 12.64 11.22 14.11 13.66 12.26 15.18 1.02
Both 12.33 10.97 13.85 5 13.47 12.09 14.89 1 1.13
Southern Sub-Saharan Africa Male 8.11 7.25 9.03 7.40 6.62 8.25 −0.70
Female 5.97 5.32 6.65 5.53 4.95 6.11 −0.44
Both 6.99 6.25 7.75 16 6.42 5.75 7.12 17 −0.57
Tropical Latin America Male 10.55 9.42 11.80 11.37 10.14 12.69 0.82
Female 12.02 10.71 13.43 11.51 10.29 12.78 −0.52
Both 11.32 10.11 12.60 8 11.45 10.22 12.74 6 0.13
Western Europe Male 12.29 11.08 13.63 12.02 10.82 13.31 −0.27
Female 14.05 12.69 15.49 14.13 12.74 15.62 0.08
Both 13.24 11.95 14.63 1 13.12 11.81 14.50 3 −0.13
Western Sub-Saharan Africa Male 8.79 7.86 9.78 9.31 8.36 10.32 0.52
Female 7.65 6.86 8.50 8.27 7.42 9.12 0.62
Both 8.23 7.40 9.18 12 8.76 7.89 9.70 11 0.53
Globally Male 7.47 6.67 8.31 6.94 6.24 7.67 −0.53
Female 8.86 7.90 9.82 8.01 7.22 8.84 −0.85
Both 8.20 7.31 9.10 – 7.50 6.75 8.27 – −0.70
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*, rank: the rank of LBP prevalence among the above 21 regions. **, difference: calculated by subtracting the 1990 prevalence (%) from the 2017 prevalence (%). LUI, lower uncertainty interval; UUI, upper uncertainty interval.

Globally, the age-standardized point prevalence of LBP was 8.20% (95% UI: 7.31–9.10%) in 1990, and this decreased to 7.50% (95% UI: 6.75–8.27%) in 2017. Prevalence was higher in females than males. For females, this was 8.86% (95% UI: 7.90–9.82%) in 1990 and 8.01% (95% UI: 7.22–8.84%) in 2017, whereas for males, prevalence was 7.47% (95% UI: 6.67–8.31%) in 1990 and 6.94% (95% UI: 6.24–7.67%) in 2017 (Figure 2A). The estimated prevalent numbers of people with LBP was 377.5 million in 1990, and this increased to 577.0 million in 2017, due to the considerable increased population globally from 1990 to 2017 (Figure 2B).

Figure 2.

Figure 2

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The prevalence trend of low back pain. (A) The age-standardized point prevalence of low back pain from 1990 to 2017, by gender. (B) The estimated prevalent number of people with low back pain from 1990 to 2017, by gender.

LBP prevalence increased with age, peaking around the ages 80 to 89 years old, and then slightly decreased. This pattern was observed in both females and males, in 1990 and 2017 (Figure 3A,B).

Figure 3.

Figure 3

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The age-specific prevalence of low back pain. (A) The age-specific point prevalence of low back pain in 1990, by gender. (B) The age-specific point prevalence of low back pain in 2017, by gender.

In 2017, the highest LBP prevalence was Southern Latin America (13.47%), followed by high-income Asia Pacific (13.16%), while the lowest was East Asia (3.92%), followed by Central Latin America (5.62%). The highest prevalent number of people with LBP was South Asia (96.3 million), followed by East Asia (67.7 million), while the lowest prevalent number of people with LBP was Oceania (0.7 million), followed by Caribbean (2.7 million).

Years lived with disability (YLDs)

LBP was the leading cause of YLDs for both 1990 and 2017 out of the all conditions studied in GBD 2017. In both time points, LBP was the leading cause of YLDs in 13 out of the 21 world regions (Table 2).

Table 2. Years lived with disability (YLDs), age-standardized YLD rate (per 100,000 persons) and rank (in all causes) of low back pain in 1990 and 2017, by region and sex.

Regions Gender YLDs (1,000s) Age-standardized YLD rate (per 100,000 persons) Rank**
1,990 2,017 Difference* 1,990 2,017 Difference* 1,990 2,017
Mean LUI UUI Mean LUI UUI Mean LUI UUI Mean LUI UUI
Andean Latin America Male 123 88 165 262 186 165 140 844 607 1,140 904 644 1,215 60 1 1
Female 125 89 169 259 184 169 135 815 584 1,100 865 615 1,163 50 2 1
Both 247 176 337 522 371 337 274 829 595 1,113 884 630 1,183 55 1 1
Australasia Male 127 90 172 202 145 172 75 1,170 830 1,580 1,198 863 1,628 29 1 1
Female 153 109 206 250 179 206 97 1,345 957 1,810 1,406 1,006 1,889 61 1 1
Both 280 200 377 453 324 377 173 1,259 898 1,702 1,304 937 1,759 45 1 1
Caribbean Male 90 64 123 138 99 123 48 584 415 793 576 414 776 −8 1 2
Female 108 78 146 166 120 146 58 672 484 904 657 475 872 −15 3 2
Both 198 142 269 304 219 269 105 629 452 851 618 446 830 −11 3 3
Central Asia Male 259 187 349 400 286 349 140 993 716 1,332 973 698 1,307 −20 1 1
Female 301 216 407 450 321 407 149 990 705 1,324 985 706 1,327 −5 2 1
Both 560 404 752 850 607 752 290 993 712 1,330 979 704 1,314 −13 1 1
Central Europe Male 864 616 1,170 966 694 1,170 101 1,311 939 1,762 1,306 934 1,755 −5 2 1
Female 997 708 1,343 1,139 825 1,343 142 1,341 959 1,805 1,343 963 1,801 2 1 1
Both 1,861 1,319 2,505 2,104 1,530 2,505 243 1,329 949 1,787 1,328 949 1,772 −1 1 1
Central Latin America Male 317 225 432 633 453 432 316 511 368 695 521 374 707 9 2 2
Female 471 334 637 902 643 637 431 705 503 952 681 485 928 −24 2 2
Both 788 559 1,066 1,535 1,096 1,066 747 611 437 828 604 430 818 −7 2 2
Central Sub-Saharan Africa Male 165 118 227 391 279 227 226 961 691 1,293 977 696 1,310 16 3 1
Female 151 108 204 354 251 204 203 840 608 1,125 857 620 1,150 17 5 3
Both 317 226 434 746 532 434 429 898 648 1,201 917 658 1,230 19 4 1
East Asia Male 2,719 1,936 3,735 3,316 2,342 3,735 597 456 324 620 366 259 494 −90 1 4
Female 3,478 2,445 4,696 4,394 3,134 4,696 916 623 437 837 471 336 633 −152 2 3
Both 6,197 4,397 8,384 7,709 5,453 8,384 1,513 539 381 730 419 300 565 −120 1 3
Eastern Europe Male 1,356 971 1,840 1,321 950 1,840 −35 1,212 873 1,639 1,095 783 1,482 −117 1 1
Female 1,814 1,318 2,432 1,767 1,288 2,432 −47 1,206 864 1,615 1,115 804 1,498 −91 1 1
Both 3,170 2,305 4,274 3,089 2,236 4,274 −82 1,208 868 1,622 1,106 793 1,497 −102 1 1
Eastern Sub-Saharan Africa Male 499 356 678 1,125 801 678 626 894 645 1,202 934 674 1,265 40 3 1
Female 396 284 535 892 635 535 496 707 511 946 731 526 988 23 5 4
Both 895 642 1,215 2,017 1,437 1,215 1,122 799 577 1,070 830 599 1,120 31 3 2
High-income Asia Pacific Male 1,007 717 1,368 1,489 1,067 1,368 481 1,060 754 1,444 1,166 829 1,600 106 1 1
Female 1,535 1,091 2,090 1,930 1,378 2,090 395 1,530 1,091 2,091 1,567 1,117 2,126 37 1 1
Both 2,543 1,811 3,441 3,419 2,423 3,441 876 1,294 923 1,758 1,361 970 1,863 67 1 1
High-income North America Male 1,581 1,131 2,124 2,171 1,554 2,124 589 1,054 756 1,424 988 709 1,313 −66 1 1
Female 2,105 1,510 2,820 2,801 2,027 2,820 695 1,270 910 1,707 1,191 858 1,572 −79 1 1
Both 3,687 2,635 4,931 4,972 3,590 4,931 1,285 1,167 837 1,575 1,091 786 1,445 −75 1 1
North Africa and Middle East Male 1,281 916 1,734 2,822 2,014 1,734 1,541 971 698 1,308 972 699 1,308 2 1 2
Female 1,442 1,030 1,934 3,062 2,197 1,934 1,620 1,162 833 1,546 1,155 825 1,555 −6 2 2
Both 2,723 1,953 3,685 5,884 4,211 3,685 3,161 1,064 763 1,430 1,062 761 1,429 −3 1 1
Oceania Male 16 11 22 35 25 22 19 649 461 883 678 488 910 29 2 2
Female 17 12 23 38 27 23 21 754 541 1,023 785 563 1,045 32 3 3
Both 33 23 45 74 53 45 41 700 500 952 730 524 980 30 3 3
South Asia Male 2,774 1,987 3,769 4,547 3,239 3,769 1,773 633 457 848 553 397 746 −79 2 2
Female 3,236 2,315 4,363 6,248 4,454 4,363 3,012 812 581 1,085 771 553 1,028 −41 3 3
Both 6,010 4,291 8,156 10,795 7,689 8,156 4,785 718 514 961 661 476 889 −56 3 3
Southeast Asia Male 1,448 1,033 1,964 2,758 1,983 1,964 1,310 816 588 1,101 843 605 1,125 27 1 1
Female 1,554 1,112 2,102 2,911 2,096 2,102 1,357 832 592 1,116 849 611 1,131 17 2 1
Both 3,002 2,146 4,061 5,669 4,078 4,061 2,668 825 589 1,109 847 610 1,128 22 1 1
Southern Latin America Male 292 209 402 473 336 402 181 1,263 904 1,736 1,367 972 1,847 104 1 1
Female 340 243 465 543 392 465 203 1,351 962 1,848 1,438 1,027 1,949 87 1 1
Both 632 453 866 1,016 724 866 384 1,309 941 1,786 1,404 1,002 1,896 95 1 1
Southern Sub-Saharan Africa Male 158 113 214 256 183 214 98 885 635 1,197 791 565 1,060 −93 1 2
Female 127 90 170 214 154 170 87 648 468 872 593 428 795 −56 5 5
Both 285 204 385 470 336 385 186 762 549 1,026 688 498 919 −74 1 3
Tropical Latin America Male 738 527 1,012 1,402 1,002 1,012 664 1,154 824 1,567 1,227 872 1,662 73 1 1
Female 877 625 1,191 1,521 1,088 1,191 644 1,310 936 1,775 1,246 891 1,679 −65 1 1
Both 1,615 1,149 2,215 2,924 2,085 2,215 1,308 1,235 885 1,675 1,237 884 1,670 2 1 1
Western Europe Male 2,754 1,960 3,733 3,302 2,383 3,733 548 1,269 901 1,730 1,229 872 1,676 −39 1 1
Female 3,555 2,533 4,801 4,273 3,085 4,801 718 1,478 1,051 2,000 1,479 1,051 2,011 0 1 1
Both 6,309 4,513 8,491 7,575 5,476 8,491 1,266 1,379 983 1,870 1,356 964 1,851 −23 1 1
Western Sub-Saharan Africa Male 642 464 867 1,459 1,039 867 817 971 704 1,307 1,024 733 1,384 53 2 2
Female 530 379 709 1,363 972 709 834 838 605 1,120 906 641 1,210 68 4 3
Both 1,172 839 1,575 2,822 2,015 1,575 1,650 906 653 1,207 962 684 1,292 57 3 2
Globally Male 19,210 13,729 26,153 29,467 21,020 26,153 10,257 813 580 1,094 748 538 1,008 −65 1 1
Female 23,313 16,598 31,184 35,479 25,357 31,184 12,167 966 687 1,293 869 624 1,165 −97 1 1
Both 42,523 30,176 57,224 64,947 46,512 57,224 22,424 892 637 1,195 810 582 1,089 −82 1 1
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*, difference: calculated by subtracting the 1990 YLDs/age-standardized YLD rate from the 2017 YLDs/age-standardized YLD rate. **, rank: the rank of the number of YLDs caused by LBP compared to all other conditions in GBD 2017. LUI, lower uncertainty interval; UUI, upper uncertainty interval.

The global YLDs for LBP were 42.5 million (95% UI: 30.2 million–57.2 million) in 1990, and increased 52.7% to 64.9 million (95% UI: 46.5 million–87.4 million) in 2017 (Table 2). YLDs were higher for females than males in both 1990 (23.3 million, 95% UI: 16.6 million–31.2 million, compared to 19.2 million, 95% UI: 13.7 million–26.2 million, respectively) and 2017 (35.5 million, 95% UI: 25.4 million–47.7 million, compared to 29.5 million, 95% UI: 21.0 million–40.0 million, respectively) (Table 2). The age-standardized YLD rate (per 100,000 population) decreased slightly from 892 (95% UI: 637–1,195) in 1990 to 810 (95% UI: 582–1,089) in 2017, although this was not statistically significant at the 0.05 level. The age-standardized YLD rate was also higher in females than males (Table 2).

Total YLDs for LBP also increased initially with age; they peaked at 35–39 years of age in 1990, before decreasing (Figure 4A), whereas in 2017, they peaked at 45–49 years of age, before decreasing (Figure 4B). Both females and males had similar trends.

Figure 4.

Figure 4

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The age-specific number of years lived with disability. (A) The age-specific number of low back pain years lived with disability (with uncertainty intervals) in 1990, by age and gender. (B) The age-specific number of low back pain years lived with disability (with uncertainty intervals) in 2017, by age and gender.

In 2017, the region with the highest number of YLDs was South Asia (10.8 million, 95% UI: 7.7 million–14.7 million), followed by East Asia (7.7 million, 95% UI: 5.53 million–10.4 million). The region with the lowest number of YLDs was Oceania (73,589, 95% UI: 52,501–100,281), followed by the Caribbean (303,867, 95% UI: 219,393–408,488). The region with the highest age-standardized YLD rate (per 100,000 persons) was Southern Latin America [1,404], followed by high-income Asia Pacific [1,361]. The region with the lowest age-standardized YLDs rate was East Asia [419], followed by Central Latin America [604].

Discussion

In this article, data analysed in GBD 2017 are presented. The prevalence (in %) of LBP had decreased between 1990 and 2017, whereas the prevalent number of people with LBP and the number of YLDs had increased substantially. LBP remains the leading global cause of YLDs in 2017. It should be noted that with each GBD study iteration, new data are being added to the models that derive the estimates over time. This consequently alters and strengthens the model outputs—as a result, and for example, prevalence estimates from GBD 2010 may differ from those from GBD 2017. Other factors that may influence prevalence changes between iterations are changes to the DWs, the DisMod-MR tool, construction of the SDI, and adjustments for comorbidity.

The gender disparity of LBP prevalence was different in GBD 2017 compared to GBD 2010 (10). In GBD 2010, prevalence was reportedly higher in males (10.1%) compared to females (8.1%); however, prevalence was higher in females in GBD 2017. This difference between GBD 2010 and GBD 2017 is mainly attributed to the improved data coverage and methods in GBD 2017 rather than any real changes over this period. Other studies have reported a similar gender trend (21-24). Possible explanations for this are likely to be complex and may include biological, psychological and sociocultural factors (22,25,26). However, another interesting finding is that males in Central, Eastern, Western and Southern Sub-Saharan Africa had a higher prevalence than females—further research is needed to better understand this.

The prevalence trends by age observed in GBD 2017 were similar to GBD 2010 (10). Prevalence was high in all age groups from 18 years onwards, and peaked at around 80–89 years old (Figure 3). There are many factors that may increase the prevalence of LBP with age. Aging is associated with pain, which may restrict social and physical function (27); consequently, this restriction may result in further deterioration of the musculoskeletal system and further pain. Degeneration of the lumbar spine as a potential contributor to LBP continues to be a subject of debate (28-32).

There was a slight decrease in the point prevalence (%) of LBP from 1990 to 2017, although this was not significant at the 0.05 level. The number of prevalent cases of LBP and number of YLDs has increased dramatically in this period, although, again, this was not significant at the 0.05 level. If these are real increases, they are likely to be mainly driven by aging and increasing population numbers (19)—having said this, the influence of this will vary from region to region, and there may also be other contributing factors such as obesity, increased motorization (1,4), and willingness to report pain. Of note, the point prevalence and age-standardized YLDs rate (per 100,000 persons) in Southern Latin America, high-income Asia Pacific, Andean Latin America, Australasia and Western Sub-Saharan Africa have all increased suggesting that factors beyond aging and population increase may be at play.

The age trend for YLDs was different to that of prevalence. YLDs peaked in the middle-aged population, and thus the working-age population is most greatly affected by the burden of LBP. Figure 4 shows YLDs peaked around the ages 35 to 39 years old in 1990. However, consistent with the aging population and increasing global life expectancy, this peak was delayed to 45 to 49 years old in 2017 (19).

Strengths and limitations

The updated GBD 2017 has been improved compared to GBD 2010. More up-to-date data were included from World Health Surveys and National Health Surveys, the European Disability Weights Measurement Study, additional systematic reviews, and claims data from the USA Taiwan. Methodological changes included (I) updating the DisMod-MR tool, (II) having greater granularity in reporting of results for the oldest age groups (80–84, 85–89, 90–94 and 95+ years), (III) construction of a SDI, and (IV) adjustment for comorbidity. These changes increase confidence in the accuracy of results.

Despite some improvements since GBD 2010, sufficient population-based prevalence and burden estimates on LBP are still lacking from many regions and countries. Consequently, burden estimates were heavily reliant on models. While these models have been improved, it should be noted that they are models rather than original data. Further, of the studies that were included in the analysis, substantial heterogeneity remains between the case definitions used. This has made it difficult to compare the data across countries and over time. Additionally, it is difficult to determine with confidence the impact of changes to LBP policy and practice. Hence, this is the key limitation in estimating and understanding the global burden of LBP. Standardisation of data collection would be an important first step. The Global Alliance for Musculoskeletal (MSK) Health and the Global Burden of Disease 2010 Study MSK Expert Group have developed a standardized survey questionnaire for measuring the population prevalence of LBP and other MSK conditions (24). The tool can be found online at: http://bjdonline.org/msk-survey-module/. The case definitions are aligned to those of the GBD. The intention for the questionnaire is for it to be integrated within pre-existing and planned surveys such as National Health Surveys, and not being used as a stand-alone tool. This will help to minimize the burden from having to conduct multiple surveys in the local communities, and, subsequently, will save the required resources. It also encourages LBP and other musculoskeletal disorders to be viewed as being integrated within broader health initiatives rather than being seen as a separate issue. It is hoped this publicly-available module will be widely adopted to increase the availability of comparable data on LBP and other MSKs (24).

The DWs used also have some limitations. The DWs were based on surveys that were conducted in a limited number of countries (Bangladesh, Indonesia, Peru, Tanzania, the USA, Hungary, Italy, The Netherlands and Sweden) prior to 2013 as well as a global web-based survey (18). The surveys rely on perceptions of respondents to often brief descriptions of a complex health problem. More recent surveys in a greater number of countries will increase the generalizability of the DWs.

Implications for policy and practice

From 1990 to 2017, LBP continued to be the leading cause of YLDs globally. Many countries and health-related organizations continue to prioritize communicate diseases over non-communicable diseases such as LBP. The Lancet Low Back Pain Series recently made a call for action on the management of LBP burden from governments, policy makers and the broader society (8,9,33). However, there continues to be a gap between evidence for effective management of LBP and current practice and policy, as outlined in the recent Lancet Series (8,9,33). Greater attention is needed to bridge this gap. A biopsychosocial framework could be used to guide the management including education, self-management, resumption of usual activities and exercise, and psychological measures for those with persistent symptoms. Management guidelines for different stages of BP and for different contexts should also be recommended. The recent Lancet Series documented high level of the inappropriate investigations and treatments that are contributing to the LBP burden for both individuals and society. Key recommended principles for LBP would be to reduce unnecessary imaging and treatment, support people to be active and stay at work, and to only use medication, imaging, and surgery prudently (33). For high-risk cases, prevention and early intervention could be considered. Linton et al. reported a stepped, stratified, and matched care approach might reduce wastage of clinical time and resources (34).

Hartvigsen et al. (8) concluded that the cost and disability from LBP vary substantially between countries, and would increase in the coming decades. Many of the risk factors (such as obesity, increased motorization and work-related issues) associated with LBP identified in those high-income countries are also present in developing countries (1,4,35,36). High-income countries are likely to have better developed health systems to manage this increasing burden. For these low-income and middle-income countries, health systems are most likely not as well developed, and, therefore, will face greater challenges in managing the impact of the growing LBP burden.

Given that many of the risk factors for LBP are shared by other non-communicable diseases, it is imperative that integrated, collaborative approaches are established and built upon to ensure affordable solutions to the growing burden of LBP (37), especially, in low- and middle-income countries (38). Greater efforts are urgently needed to expand the amount of comparable data on the prevalence of LBP at national and sub-national levels. Future investigation should also include the effectiveness, cost-effectiveness of preventive and therapeutic strategies.

Conclusions

The global prevalence and YLD rates from LBP decreased slightly from the 1990 to 2017, but the number of LBP sufferers and YLDs increased substantially. Prevalence and YLDs were higher in females than males. Prevalence increased with age, and YLDs peaked at around 35 to 49 years of age. Globally, LBP remains the leading global cause of YLDs, yet it continues to be inadequately recognized as a disease burden in the population with the major disparity continuing between the level of burden, and the policy, research and health services response. This will continue to be an urgent need for governments and other donors (33,38).

Acknowledgments

We would like to thank the Global Burden Disease 2017 Study for the data.

Funding: A Wu is supported by the National Natural Science Foundation of China (No. 81501933), the Wenzhou Municipal Science and Technology Bureau (Y20170389), the Wenzhou leading talent innovative project (RX2016004), and the Zhejiang Provincial Medical Technology Foundation of China (2018KY129).

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. No identified patient information was included in this study, therefore, the ethical approval was not needed. To download the original full data used in these analyses, please visit the Global Health Data Exchange at http://ghdx.healthdata.org/gbd-2017.

Footnotes

Conflicts of Interest: The authors have no conflicts of interest to declare.

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