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EXTENDED REPORT
The global burden of low back pain: estimates from
the Global Burden of Disease 2010 study
Damian Hoy,
1
Lyn March,
2
Peter Brooks,
3
Fiona Blyth,
4
Anthony Woolf,
5
Christopher Bain,
6,7
Gail Williams,
8
Emma Smith,
9
Theo Vos,
10,11
Jan Barendregt,
8
Chris Murray,
11
Roy Burstein,
11
Rachelle Buchbinder
12,13
Handling editor Tore K Kvien
▸Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
annrheumdis-2013-204428).
For numbered affiliations see
end of article.
Correspondence to
Dr Damian Hoy, University of
Queensland, School of
Population Health, Herston Rd,
Herston, QLD 4006, Australia;
damehoy@yahoo.com.au
Received 9 August 2013
Revised 10 January 2014
Accepted 24 January 2014
Published Online First
24 March 2014
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204344
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204627
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204631
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204647
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204680
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204763
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204431
▸http://dx.doi.org/10.1136/
annrheumdis-2013-204320
To cite: Hoy D, March L,
Brooks P, et al.Ann Rheum
Dis 2014;73:968–974.
ABSTRACT
Objective To estimate the global burden of low back
pain (LBP).
Methods LBP was defined as pain in the area on the
posterior aspect of the body from the lower margin of
the twelfth ribs to the lower glutaeal folds with or
without pain referred into one or both lower limbs that
lasts for at least one day. Systematic reviews were
performed of the prevalence, incidence, remission,
duration, and mortality risk of LBP. Four levels of severity
were identified for LBP with and without leg pain, each
with their own disability weights. The disability weights
were applied to prevalence values to derive the overall
disability of LBP expressed as years lived with disability
(YLDs). As there is no mortality from LBP, YLDs are the
same as disability-adjusted life years (DALYs).
Results Out of all 291 conditions studied in the Global
Burden of Disease 2010 Study, LBP ranked highest in
terms of disability (YLDs), and sixth in terms of overall
burden (DALYs). The global point prevalence of LBP was
9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2
million (M) (95% CI 39.9M to 78.1M) in 1990 to
83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence
and burden increased with age.
Conclusions LBP causes more global disability than
any other condition. With the ageing population, there is
an urgent need for further research to better understand
LBP across different settings.
INTRODUCTION
Low back pain (LBP) is well documented as an
extremely common health problem
1–4
; it is the
leading cause of activity limitation and work
absence throughout much of the world,
5
and it
causes an enormous economic burden on indivi-
duals, families, communities, industry and govern-
ments.
6–8
As part of the Global Burden of Disease
2010 Study (GBD 2010),
9
the global burden of
musculoskeletal conditions was estimated using
updated methods that address methodological lim-
itations of previous GBD studies.
10–12
Burden was
expressed in disability-adjusted life years (DALYs).
This paper details the methods and results for
estimating the global burden of LBP for GBD
2010. It is one of a series of articles. The overall
capstone GBD 2010 papers were published in the
Lancet,
913–16
and the papers that report the
methods and results for the MSK conditions are
published in Annals of Rheumatic Diseases.
17–25
One of these papers describes in detail the methods
used for estimating the global burden of the MSK
conditions
22
and should be read in conjunction
with the current paper.
METHODS
Figure 1 outlines the steps taken in estimating the
burden of LBP. The GBD LBP expert group per-
formed steps 1 to 3, and the GBD core team per-
formed the remaining steps.
Established case definition
The initial case definition for LBP was ‘activity-
limiting LBP (± pain referred into one or both
lower limbs) that lasts for at least one day’.
12
The
‘low back’was defined as the area on the posterior
aspect of the body from the lower margin of the
twelfth ribs to the lower glutaeal folds. For the
final analysis, ‘activity-limiting’was removed from
the case definition because: (1) this provided a
more robust analytical model given that relatively
few data points from the systematic review con-
formed to the case definition of LBP that was
activity-limiting and (2) this definition aligned
better with the LBP definition used in national
health surveys that were included in the final
analysis.
Established health states
A series of sequelae were developed to characterise
the different levels of severity and take into
account the variation in functional loss associated
with acute and chronic LBP with or without leg
pain (table 1).
12
Each sequela was defined in lay
terms.
Performed systematic reviews
The systematic reviews have been described else-
where
26–28
—see online supplementary file 1 for further
details. For incidence, a small number of studies were
found, but all counted the number of people as the
numerator rather than the number of incident episodes.
This number could not be converted to episode inci-
dence as no data were found on the average number of
episodes a person with LBP experiences over time.
Thus, incidence could not be used as a parameter in the
burden estimates.
26
For duration and remission, no
population-based studies were found, and for mortality,
there was no consistent and conclusive evidence that
LBP is associated with an increased risk of mortality.
26
For prevalence, 170 published studies were iden-
tified. These reported 1139 age and/or sex-specific
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estimates. All included studies were assessed for risk of bias
using a tool specifically developed for GBD 2010.
28
High risk
of bias estimates (n=242) and estimates with a prevalence recall
period greater than 1 year (n=105) were excluded, leaving a
total of 792 estimates from 118 studies (101 papers). One
German study
29
was excluded, as it contained outlier data
(point prevalence ranging from 77% to 92% in elderly
Germans), and estimates more consistent with most other
studies (point prevalence ranging from 20% to 50%) were avail-
able in two other German studies of equal or lower risk of
bias.
30 31
This left a total of 117 studies and 780 estimates, with
data available from 47 countries and 16 of the 21 GBD world
regions.
There was substantial heterogeneity between studies with
respect to prevalence period and case definition (ie, the
minimum episode duration), anatomical location, and whether
or not cases had to experience activity limitation. To make data
points more comparable, adjustments were made in
DisMod-MR, a Bayesian meta-regression tool developed for
GBD 2010 by predicting the value of a data point as if the
study had used the reference definition. To do so, DisMod-MR
estimates coefficients for study-level covariates by comparing the
values of prevalence measured by various methods in the global
dataset. For the purpose of these analyses, it was necessary to
reduce the number of categories of case definition and preva-
lence period. This was done by merging some of the categories
on the basis of overlapping CIs or expert opinion (on the basis
of proximity to overlapping CIs) for prevalence and/or regres-
sion coefficients. To determine how best to reduce the number
of categories, a multivariate regression was done with preva-
lence (log transformed plus 0.2 to achieve normality) as the
dependent variable and the following independent variables:
age, sex, prevalence period, minimum episode duration, ana-
tomical location, activity limitation, coverage, urbanicity and
risk of bias (see online supplementary file 2).
Three groups were formed for prevalence recall period: (1)
point (including one day); (2) short-term (one week to two
months); and (3) longer-term (three months to one year). Three
groups were formed for anatomical case definition: (1) back,
low back, ‘posterior aspect of the body from the lower margin
of the twelfth ribs to the lower glutaeal folds’, and
‘thoraco-lumbo-sacral’; (2) lumbar, ‘lumbar or sacro-iliac joint
(s)’, and ‘neck or back’; and (3) ‘posterior aspect of the body
from the seventh cervical vertebra to the lower glutaeal folds’,
and ‘thoracic or lumbar’. For the minimum episode duration
definition variations, two groups were formed: (1) ‘not speci-
fied’,‘>1 day’,‘>3 days’,‘>1 week’, and ‘>7 weeks’; and (2)
‘>3 months’,‘>6 months’,‘chronic’, and ‘frequent’. Note, the
first category in each of the above groups is considered the refer-
ence category.
Established disability weights
Surveys were conducted in five countries for GBD 2010 and
complemented by an open access internet survey; pair-wise com-
parison questions were used, in which respondents were asked
to indicate which of two health states presented as brief lay
descriptions they considered ‘the healthier’. Results were used
to derive DWs.
15
Added information from National Health Surveys
Additional information on prevalence of LBP was derived from
the World Health Surveys (50 countries; 1495 data points)
32
;
Australian National Health Surveys (1995, 2001, 2003/2004
and 2007/2008; 43 data points)
33
; Australian Surveys of
Disability, Ageing and Carers (2003 and 2009; 41 data
points)
34
; and the US National Health Information surveys
(2001–2008; 168 data points)
35
and NHANES (2009; 20 data
Figure 1 Steps taken in estimating
the global burden of low back pain,
GBD 2010.
Table 1 Sequelae for low back pain in GBD 2010
Sequela Lay description Disability weight
Severe acute low
back pain without
leg pain
This person has severe low back
pain, which causes difficulty
dressing, sitting, standing,
walking and lifting things. The
person sleeps poorly and feels
worried
0.269 (0.184–0.373)
Severe acute low
back pain with leg
pain
This person has severe low back
and leg pain, which causes
difficulty dressing, sitting,
standing, walking and lifting
things. The person sleeps poorly
and feels worried
0.322 (0.219–0.447)
Severe chronic low
back pain without
leg pain
This person has constant low back
pain, which causes difficulty
dressing, sitting, standing,
walking and lifting things. The
person sleeps poorly, is worried
and has lost some enjoyment in
life
0.366 (0.248–0.499)
Severe chronic low
back pain with leg
pain
This person has constant low back
and leg pain, which causes
difficulty dressing, sitting,
standing, walking and lifting
things. The person sleeps poorly,
is worried and has lost some
enjoyment in life
0.374 (0.252–0.506)
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points).
36
Data from these surveys were not included in the sys-
tematic review as they did not fulfil our inclusion criteria at that
time.
Bayesian metaregression
DisMod-MR is a Bayesian metaregression tool that has a
number of functions, including: (1) pooling heterogeneous data
and adjusting data for methodological differences; (2) checking
data on incidence, prevalence, duration, remission and mortality
risk for internal consistency and (3) predicting values for coun-
tries and regions with little or no data using disease-relevant
country characteristics and random effects for country, region
and super-region. In the absence of usable incidence and remis-
sion data, a ‘prevalence-only’model was run (see online supple-
mentary file 3).
Severity distribution
To estimate the distribution of LBP cases across the GBD 2010
health states, the US Medical Expenditure Panel Survey (MEPS)
from 2000 to 2009 was used. This had information on the
prevalence of 156 disorders included in the GBD as well as
health status information provided by all individuals using the
Short Form-12 (SF-12) questionnaire.
37
In order to provide a translation of SF-12 values into a scale
comparable with that used by the GBD 2010 DWs, the GBD
core team conducted a small study on a convenience sample of
respondents who were asked to fill in SF-12 to reflect 62 lay
descriptions covering a wide range of severity that were used in
the GBD DW surveys. With regression methods, the proportion
of an individual’s SF-12 score, translated into a GBD DW, that
could be attributed to LBP was calculated, while controlling for
any comorbid other condition.
Cases were then grouped in categories of disability based on
the midpoints between DWs reflecting successive levels of sever-
ity. It was assumed that those with no disability in MEPS were
cases that had remitted since their diagnosis of LBP was
reported. As the case definition was for ‘point prevalence’, this
proportion of cases was excluded from the calculation of the
average DW for all LBP and the remaining proportions were
scaled to add up to 100%.
MEPS respondents with LBP were partitioned into levels of
severity for LBP with leg and another four for LBP without leg
pain. The mild acute and chronic neck pain DWs were used as
proxy DWs for the lowest LBP disability classes given that no
mild LBP health states were available from the household and
on-line surveys used to derive DWs (tables 2 and 3). An age dis-
tribution of the proportions of LBP with and without leg pain
was derived from the prevalence figures in MEPS. The propor-
tions for males and females combined were calculated after
finding little difference by sex. From these proportions, the
average DWs were calculated by age.
Final burden estimates
The Disability-Adjusted Life Year (DALY) is the standard metric
used to quantify burden.
38
DALYs are calculated by combining
years of life lost (YLL) due to premature mortality, and years
lived with disability (YLD). As there is no mortality from LBP,
YLDs and DALY estimates are the same. The average DW was
multiplied by the age/sex/region-specific prevalence for the years
1990, 2005 and 2010 to derive YLDs. The uncertainty interval
(UI) around each quantity of interest was calculated from SEs
around all data inputs and the uncertainty from all steps of data
manipulations, including the use of country and region fixed
effects in DisMod-MR and the severity distributions.
Uncertainty ranges are presented as the 2.5 and 97.5 centile
values, which can be interpreted as a 95% UI. Further detail on
how uncertainty was calculated can be found elsewhere.
9
Prevalence estimates were standardised using the 2001 WHO
standard population.
39
As disability weights were derived for single health states,
simple addition of YLDs for all conditions would assume that
disability is additive if a person has comorbid health states.
Thus, a person with a number of more severe health states
could be awarded a cumulative disability weight that exceeds 1,
which equates to greater health loss than ‘being dead’. Assuming
a multiplicative function between DWs for comorbid health
states assures that a combined DW can never be greater than
1. To make a correction for comorbidity, hypothetical popula-
tions were simulated for each age, sex, country and year.
Individuals in these hypothetical populations were assigned to
have no, one or more health states based on the prevalence
figures for each health state. The multiplicative function was
applied to any individual with comorbid health states and the
DW for each component health state reduced proportionately.
This allowed an estimate of the reduction in DW for any health
state in an age and sex group by country and year: the
comorbidity correction.
RESULTS
Description of included data
There were 2566 data points included in the final DisMod-MR
models. These were from 85 countries, and 20 of the 21 GBD
2010 regions. The majority of studies used for these data
included both sexes, a broad age range in the adult population,
and urban and rural populations.
Prevalence
The global age-standardised point prevalence of LBP (from 0 to
100 years of age) in 2010 was estimated to be 9.4% (95% CI
9.0 to 9.8). It was higher in men (mean: 10.1%; 95% CI 9.4 to
10.7) compared with women (mean: 8.7%; 95% CI 8.2 to 9.3).
The age and sex distribution across regions was similar.
DisMod-MR assumes a similar age pattern for all regions unless
there are sufficient data points in a region to indicate a variation
from the global age pattern. The large heterogeneity in the LBP
dataset meant that there was no departure from the default of a
common age pattern (figure 2). Prevalence peaked at around
80 years of age.
Table 2 The eight sequela categories used for calculating the
severity distribution of low back pain (with disability weights, and
proportional distributions), GBD 2010
Category DW Proportion
Low back pain without leg pain
Mild acute low back pain 0.040 (0.023–0.064) 49.8% (42.1–57.1)
Mild chronic low back pain 0.101 (0.067–0.149) 22.7% (16.9–28.8)
Severe acute low back pain 0.269 (0.184–0.373) 10.5% (8.1–13.4)
Severe chronic low back pain 0.366 (0.248–0.499) 17.0% (11.8–23.2)
Low back pain with leg pain
Mild acute low back pain 0.040 (0.023–0.064) 36.1% (28.3–43.7)
Mild chronic low back pain 0.101 (0.067–0.149) 26.1% (20.4–33.0)
Severe acute low back pain 0.322 (0.219–0.447) 12.0% (9.3–15.3)
Severe chronic low back pain 0.374 (0.252–0.506) 25.8% (18.1–33.8)
The two milder classes of low back pain disability weights used the mild acute and
chronic neck pain weights.
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Age-standardised prevalence in 2010 was highest in western
Europe (mean: 15.0%; 95% CI 14.1 to 16.0) followed by North
Africa/Middle East (mean: 14.8%; 95% CI 13.8 to 15.9), and
lowest in the Caribbean (mean: 6.5%; 95% CI 5.6 to 7.4) fol-
lowed by central Latin America (mean: 6.6%; 95% CI 5.8 to 7.4).
Prevalence did not change significantly from 1990 to 2010.
YLD and DALYs
Globally, and out of the 291 conditions studied, LBP was
ranked as the greatest contributor to global disability (measured
in YLDs), and the sixth in terms of overall burden (measured in
DALYs)—table 4. It was ranked as the greatest contributor to
disability in 12 of the 21 world regions and the greatest
contributor to overall burden in two of the 21 world regions
(western Europe and Australasia).
DALYs increased from 58.2 million (M) (95% CI 39.9M to
78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010.
Population increase contributed 30% of the 43% increase in DALYs
between 1990 and 2010 while ageing was responsible for the
remaining 13%. DALYs were highest in mens (44.2M; 95% CI
30.3M to 60.1M) compared with women (38.9M; 95% CI 26.5M
to 52.9M). DALYs were highest between ages 35 and 50 years.
DISCUSSION
New estimates of the global burden of low back pain
The process for estimating the global burden of LBP has been
extensive, and has taken almost 6 years. The results show that
Table 3 Age-standardised prevalence and DALYs (with 95% CIs) for low back pain in the age range 0–100 years, by region and sex, 2010,
GBD 2010
----------------(in thousands)---------------
Country Sex Prevalence Prevalence LL Prevalence UL DALYs DALY LL DALY UL
Asia-Pacific high income Male 9.4 6.9 12.5 1388 859 2117
Female 8.6 6.4 11.5 1385 885 2125
Australasia Male 12.9 10.6 15.5 252 167 364
Female 11.5 9.3 13.9 235 156 342
Caribbean Male 7.0 5.8 8.3 183 119 260
Female 6.0 4.9 7.2 165 111 229
Central Asia Male 9.1 7.5 11.2 417 269 590
Female 7.8 6.4 9.5 396 268 560
Central Europe Male 12.6 10.5 15.1 1126 739 1582
Female 10.3 8.6 12.5 1050 688 1490
East Asia Male 7.1 5.3 9.3 7390 4710 11 018
Female 6.2 4.7 8.2 6210 3766 9069
Eastern Europe Male 12.2 10.2 14.6 1744 1179 2493
Female 10.4 8.6 12.3 1942 1331 2701
Latin America Andean Male 8.0 5.8 10.8 247 151 379
Female 6.7 5.0 9.2 213 133 325
Latin America central Male 7.0 5.8 8.3 942 613 1343
Female 6.2 5.2 7.4 887 586 1265
Latin America southern Male 8.8 6.0 12.2 347 207 538
Female 7.2 5.0 10.0 316 190 484
Latin America tropical Male 12.3 9.7 15.2 1542 1007 2288
Female 10.1 7.9 12.6 1360 854 1973
North Africa/Middle East Male 15.7 14.2 17.5 4179 2845 5773
Female 13.9 12.6 15.3 3550 2446 4898
North America high income Male 7.7 6.2 9.4 1914 1231 2743
Female 7.7 6.1 9.5 2012 1304 2887
Oceania Male 8.6 5.9 12.3 44 26 69
Female 7.6 5.2 11.0 38 23 62
South Asia Male 11.1 9.3 13.2 10 406 7014 14 704
Female 9.2 7.8 10.9 8258 5585 11 631
Southeast Asia Male 8.7 7.5 10.0 3165 2156 4376
Female 7.1 6.2 8.2 2723 1839 3805
Sub-Saharan Africa central Male 8.9 6.1 12.6 365 212 574
Female 7.6 5.3 10.5 324 193 498
Sub-Saharan Africa east Male 9.7 8.5 11.1 1514 1018 2107
Female 7.6 6.6 8.7 1220 840 1677
Sub-Saharan Africa southern Male 8.3 6.8 9.8 300 201 416
Female 6.7 5.5 8.0 260 169 374
Sub-Saharan Africa west Male 11.7 10.3 13.5 1759 1230 2416
Female 9.5 8.2 10.9 1419 963 1977
Western Europe Male 15.5 14.2 16.9 4964 3417 6806
Female 14.5 13.3 15.8 4915 3361 6652
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the prevalence and burden from LBP is very high throughout
the world. Out of the 291 conditions studied in GBD 2010,
LBP was found to have the sixth highest burden. LBP caused
more disability globally than any other condition. The study has
also enhanced our understanding of LBP. It suggests that preva-
lence peaks in older age groups. As a consequence, in regions
with higher life expectancies, burden of LBP was ranked higher.
With ageing populations throughout the world, but especially in
low and middle-income countries, the number of people living
with LBP will increase substantially over coming decades.
Previous estimates of the global burden of low back pain
For the original GBD study (GBD 1990), no estimates were
made for LBP. For the GBD 2000–2004 updates, separate esti-
mates were made for three LBP health states: (1) Acute episode
of LBP resulting in moderate or greater limitations to mobility
and usual activities; (2) Episode of intervertebral disc displace-
ment or herniation; and (3) Chronic intervertebral disc dis-
order.
11
The global burden of LBP in 2004 was estimated to be
2.5 million DALYs, representing just 0.09% of the overall global
disease burden. Overall, LBP ranked 105th out of 136 condi-
tions studied.
The previous approach for estimating the burden of LBP had
a number of limitations. First, the assumptions used to derive
the incidence and duration of a LBP episode led to significant
underestimation. Duration of acute LBP episodes was assumed
to be four days, and incidence was derived from period preva-
lence figures (‘in the last 2 weeks did you have back pain?’).
Other factors explaining the low estimates for 2004 were lower
DWs and the exclusion of mild non-specific LBP, which is
common and has a substantial global impact.
40–43
There were
also limitations due to methodological heterogeneity between
LBP prevalence studies and a paucity of suitable data.
Intervertebral disc pathology was a defining factor for two of
the health states in GBD 2004, yet the presence of intervertebral
disc pathology requires imaging, and most population-based
studies do not have the resources to perform these investiga-
tions. More importantly, the presence of intervertebral disc
pathology correlates poorly with clinical symptoms, and is
therefore unlikely to be a good indicator of functional
disability.
44
Strengths and limitations of the new estimates
GBD 2010 provided an opportunity to ensure that LBP is quan-
tified more accurately. There were several improvements on pre-
vious methods, including: (1) the development of a new case
definition and set of functional health states, which are more in
line with the natural history of LBP, and include mild LBP; (2)
the development of a new set of DWs for these health states,
which were derived through community-based and health pro-
fessional surveys in a number of countries; (3) more in-depth
systematic review methods to capture country-specific informa-
tion; (4) substantial attempts at dealing with risk of bias and the
methodological heterogeneity between studies; and (5) use of a
new, more advanced version of DisMod that can (a) pool all
data rather than rely on a ‘pick and choose’method, (b)
perform meta-regression to make data points from different
studies more comparable, (c) use data to fill in missing informa-
tion and (d) carry forward uncertainty throughout the analysis.
Figure 2 DisMod-MR-generated prevalence (per 1) of low back pain by age, sex, year and region, GBD 2010.
Table 4 Regional low back pain YLD and DALY rankings in 2010
(out of 291 conditions), GBD 2010
Region YLD ranking DALY ranking
Globally 1 6
Central Asia 2 7
East Asia 1 5
Asia-Pacific high income 1 2
South Asia 1 10
Southeast Asia 2 7
Australasia 1 1
Caribbean 4 13
Central Europe 1 3
Eastern Europe 1 3
Western Europe 1 1
Andean Latin America 2 5
Central Latin America 2 7
Southern Latin America 1 2
Tropical Latin America 1 3
North Africa/Middle East 1 2
North America high income 1 3
Oceania 2 14
Central sub-Saharan Africa 3 23
Eastern sub-Saharan Africa 3 17
Southern sub-Saharan Africa 4 15
Western sub-Saharan Africa 2 13
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Despite these strengths, there were limitations. The functional
domains in GBD 2010 refer to body functions and structures
(eg, vision) as well as more complex human operations (eg,
mobility). They do not refer to broader aspects of life such as
participation, well-being, carer burden and economic impact. It
is important that burden of disease estimates are supplemented
with this information to consider the full impact of a condition
in a population.
There was considerable methodological variation between
studies, especially relating to the prevalence period and case def-
inition used. Researchers are encouraged to adopt recent recom-
mendations on defining LBP in epidemiologic studies to assist
future reviews, enable comparisons between countries, and
improve our understanding of LBP.
12 45
While using the MEPS study had the advantage of estimating
the distribution of severity while taking comorbidity into
account, it also had limitations. There is likely to have been
some level of recall bias despite there being three follow-up
points per year. Also, MEPS may not be representative of the
health state experience for LBP across the globe. In low-income
and middle-income countries, where services for the prevention
and management of LBP are less extensive as in the USA, the
health state experience could be different.
Suggested further research
There is a clear need for further research on the natural history
of LBP. Long-term longitudinal studies that include people from
the general population would provide important information on
the average duration, and severity of disability over the course
of an episode of LBP. Incorporating this research with pain
diaries to track the daily patterns of pain and disability would
add greater depth to this research. With expanding and ageing
populations in many low-income and middle-income countries,
the enormous burden from LBP in these areas will grow signifi-
cantly over coming decades. There is an urgent need to increase
our understanding, and attempt to mitigate the growing burden
of LBP in these areas.
CONCLUSION
Globally, LBP causes more YLD than any other condition.
Governments, health service and research providers and donors
need to pay far greater attention to the burden that LBP causes
than what they have done previously. Further research is
urgently needed to better understand the predictors and clinical
course of LBP across different settings, and the ways in which
LBP can be prevented and better managed.
Author affiliations
1
University of Queensland, School of Population Health, Herston, Queensland,
Australia
2
Department of Rheumatology, University of Sydney Institute of Bone and Joint
Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
3
Australian Health Workforce Institute, University of Melbourne, Parkville, Victoria,
Australia
4
University of Sydney, School of Public Health, Camperdown, New South Wales,
Australia
5
Department of Rheumatology, Royal Cornwall Hospital, Truro, UK
6
National Centre for Epidemiology and Population Health, The Australian National
University, Canberrra, Australian Capital Territory, Australia
7
Genetics and Population Health Division, Queensland Institute of Medical Research,
Brsibane, Queensland, Australia
8
School of Population Health, University of Queensland, Herston, Queensland,
Australia
9
Department of Rheumatology, Northern Clinical School, Sydney Medical School,
University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales,
Australia
10
School of Population Health, University of Queensland, Seattle, Washington, USA
11
Institute for Health Metrics and Evaluation, University of Washington, Seattle,
Washington, USA
12
Department of Epidemiology and Preventive Medicine, School of Public Health and
Preventive Medicine, Monash University, Mebourne, Victoria, Australia
13
Monash Department of Clinical Epidemiology, Cabrini Institute and Monash
University, Mebourne, Victoria, Australia
Acknowledgements We would like to thank the following individuals who were
kind enough to provide us with data upon request: Professor Fereydoun Davatchi,
Dr Arash Tehrani, Dr Rowsan Ara, and Professor Atiqul Haq. Additionally, we are
thankful to Dr Rungthip Puntumetakul, Melinda Protani, and Dr Rumna De for their
involvement in testing of the risk of bias tool. The MSK LBP Expert Group was
comprised of the following individuals: Rachelle Buchbinder, Damian Hoy, Peter
Brooks, Lyn March, Anthony Woolf, and Fiona Blyth. The GBD Core Team members
included on this paper are: Christopher Murray and Theo Vos.
Contributors All authors had substantial contribution to: conception and design,
or analysis and interpretation of data; drafting the article or revising it critically for
important intellectual content; and final approval of the version to be published.
Funding Supported by the Bill and Melinda Gates Foundation (to Dr Hoy and Prof
Vos), the Australian Commonwealth Department of Health and Ageing (to Dr Smith
(University of Sydney, Institute of Bone and Joint Research) and Prof March), the
Australian National Health and Medical Research Council (Postgraduate Scholarship
569772 to Dr Hoy and Practitioner Fellowships 334010 (2005–2009) and 606429
(2010–2014) to Prof Buchbinder, and the Ageing and Alzheimers Research
Foundation (Asst Prof Blyth).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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