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Low back pain: prevalence, causes, and management

Low back pain: prevalence, causes, and management

Low back pain: prevalence, causes, and management

Author: Dr. Faisal Hayat, MBBS

What is low back pain?

Low back pain is a symptom, not a disease, resulting from several different abnormalities or diseases. By definition, it is a sensation of pain, typically between the lower rib margins and the buttock creases. Usually, it is of musculoskeletal origin. It can be acute, sub-acute, or chronic.

  • The most commonly accepted definitions for the acute, subacute, and chronic types are, respectively, less than one month, between 2 and 3 months, and more than three months since the onset of the symptoms. Low back pain is called non-specific if the specific nociceptive source remains unidentified.

What is the prevalence of low back pain?

Low back pain (LBP) is the most common type of back pain.[2] It is a prevalent symptom. It is more common in women than in men. It is the most common cause of disability globally. Its prevalence mainly depends on factors such as sex, age, education, and occupation. An increase in age and low educational status are associated with a higher prevalence of low back pain.

  • Worldwide, activity-limiting low back pain prevalence was 7·3% in 2015.[1]
  • The lifetime prevalence of low back pain (LBP) with at least one episode of LBP in a lifetime is reported to be up to 85% in developed countries [3].
  • It involves high-income, middle-income, and low-income countries and all age groups from children to the elderly. [4]
  • An estimated 149 million days of work per year are lost because of low back pain. The low back pain prevalence of 39% was reported in the material workers, whereas 18.3% in the workers whose job responsibilities were classified as sedentary. Generally, it is associated with sedentary occupations, smoking, obesity, and low socioeconomic status.

What causes the low back pain?

Generally, it is not possible to identify a specific nociceptive cause for low back pain. Only in a small proportion of people we can identify a specific pathological cause. Individuals with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at the greatest risk.

  • Musculoskeletal causes like low back sprain, strain, and muscle spasm are the common causes of low back pain.
  • Lumbar disk disease is a common cause of low back and leg pain. It mainly occurs at the level of L4-L5 or L5-S1.
  • Lumbar spinal stenosis (LSS) is another common cause of low back pain. In more than 75% of cases, the cause of LSS is acquired. Factors for the LSS are degenerative conditions (spondylosis, scoliosis, and spondylolisthesis), Paget’s disease, surgery to spine, trauma, and endocrine disorders.
  • Spondylosis primarily involves the cervical and lumbosacral spine. Back pain increases with movement and gets better with inactivity.
  • The most common neurologic symptom in patients with systemic cancer is back pain. Cancer-related back pain is constant, dull, unrelieved by rest, and gets worse at night. By contrast, LBP improves with rest if there is a mechanical cause.
  • The hematogenous spread of the staphylococci and some other bacteria to the vertebrae causes vertebral osteomyelitis. Tuberculosis is also involved in vertebral infections.
  • Must rule out the trauma or any other injury to the vertebrae.
  • Low back pain may be a referred pain from the abdomen or pelvis.

How should a clinician manage low back pain?

Low back pain and other spine disorders are the most expensive medical problems to treat in the United States. The clinical course of the low back pain is primarily benign, and almost 95% of the patients recover within a few months of the onset of symptoms.

Acute low back pain (ALBP) is a self-limited condition and usually resolves without any treatment in less than a period of one month.

On the other hand, CLBP is a persistent form of low back pain that needs proper evaluation and management. A variety of interventions have been described for the management of LBP. It is believed that early physical therapy may reduce the risk of conversion from acute to chronic symptoms.

Initial assessment

The initial assessment excludes serious causes of spine pathology that require urgent intervention. Serious causes include infection, cancer, or trauma. Primary care clinicians should be aware of these red flag signs and symptoms associated with serious medical conditions that may cause low back pain.

  • He should develop a system to continually screen for these symptoms. It includes administering medical screening questionnaires that query patients regarding the nature, onset, and progression of these symptoms, specific movements or positions that make the symptoms better or worse, and any 24-hour pattern of symptom behavior.
  • In addition, a neurological status examination should be included for these patients. The clinician should evaluate psychological and social factors that may contribute to a patient’s persistent pain and disability. When a potentially serious medical condition is suspected, clinicians should refer the patient to an appropriate medical practitioner.

Role of diagnostic imaging

Low back pain is treated as a homogeneous entity once these red flags and nerve root compression are excluded.

  • The initial use of diagnostic imaging, specialty consultation, and prescription of opioid medications in the absence of red flags are not recommended as first-line. And routine ordering of imaging for low back pain should be discouraged.

ALBP without radiculopathy

  • The patient should be reassured and educated about the disease.
  • Bed rest should be avoided, and recommend an early resumption of routine physical activity. Strenuous manual labor should be avoided.
  • Blankets and heating pads are sometimes helpful.
  • NSAIDs and acetaminophen are proven to be the best first-line options for ALBP. The use of skeletal muscle relaxants is useful but causes sedation.[5]

CLBP without radiculopathy

  • The same treatment guidelines recommended in ALBP are also helpful in CLBP.
  • Exercise is the mainstay of treatment for CLBP.
  • NSAIDs, acetaminophen, and TCAs are helpful.
  • Depression is common among CLBP patients, so it should be appropriately treated. Cognitive behavior therapy is also beneficial.
  • Massage therapy and various injections are proven to be beneficial.[5]

Low back pain with radiculopathy

  • A herniated disk is a common cause of back pain with radiculopathy. Resumption of regular physical activity is recommended.
  • NSAIDs, acetaminophen, and opioid analgesics are useful. Epidural glucocorticoid injections are helpful.
  • Surgical intervention is recommended in cauda equina syndrome, spinal cord compression, or patients with progressive motor weakness due to nerve root injury.[5]

Electromagnetic fields therapy

The use of electromagnetic fields (EMFs) has increased in the last decade in rehabilitation treatment. It provides a non-invasive, safe, and easy method to directly treat the site of injury, the source of pain and inflammation, and other types of disease.

  • A randomized, patient-blinded, clinical trial on pulsed electromagnetic field (PEMF) therapy effectiveness in non-specific low back pain patients published in 2018-19 concludes that PEMF therapy has relieved the pain intensity and has improved functionality in individuals with non-specific low back pain. [6]


  1. Global Burden of Disease, Injury Incidence, Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1545–602.
  2. 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. Published 2013 Jan 26. doi:10.1186/1471-2431-13-14
  3. Louw QA, Morris LD, Grimmer-Somers K. The prevalence of low back pain in Africa: a systematic review. BMC Musculoskeletal Disorder 2007; 8: 105.
  4. Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., . . . Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356-2367. doi:10.1016/s0140-6736(18)30480-x.
  5. Jameson J.L., Fauci A.S., Kasper D.L., Hauser S.L., Longo D.L., and Loscalzo J., Harrison’s Principles of Internal Medicine. 20th McGraw-Hill Education.
  6. Elshiwi AM, Hamada HA, Mosaad D, Ragab IMA, Koura GM, Alrawaili SM. Effect of pulsed electromagnetic field on nonspecific low back pain patients: a randomized controlled trial. Braz J Phys Ther. 2019;23(3):244-249. 2018.08.004

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