Elsevier

The Lancet

Volume 354, Issue 9178, 14 August 1999, Pages 581-585
The Lancet

Review
Epidemiological features of chronic low-back pain

https://doi.org/10.1016/S0140-6736(99)01312-4Get rights and content

Summary

Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain, partly because of a lack of agreement about definition. Chronic back pain is sometimes defined as back pain that lasts for longer than 7–12 weeks. Others define it as pain that lasts beyond the expected period of healing, and acknowledge that chronic pain may not have well-defined underlying pathological causes. Others classify frequently recurring back pain as chronic pain since it intermittently affects an individual over a long period. Most national insurance and industrial sources of data include only those individuals in whom symptoms result in loss of days at work or other disability. Thus, even less is known about the epidemiology of chronic low-back pain with no associated work disability or compensation. Chronic low-back pain has also become a diagnosis of convenience for many perople who are actually disabled for socioeconomic, work-related, or psychological reasons. In fact, some people argue that chronic disability in back pain is primarily related to a psychosocial dysfunction. Because the validity and reliability of some of the existing data are uncertain, caution is needed in an assessment of the information on this type of pain.

Section snippets

Back pain in society

The prevalence of chronic back pain should be placed in the context of the prevalence of back pain in general. Many studies attest to the high frequency of back complaints in society. 70–85% of all people have back pain at some time in life. The annual prevalence of back pain ranges from 15% to 45%, with point prevalences averaging 30%.1 In the USA, back pain is the most common cause of activity limitation in people younger than 45 years, the second most frequent reason for visits to the

Chronic back pain

Praemer and colleagues2 used the 1988 National Health Interview Survey (1985–88) to estimate the frequency of chronic or permanent impairment in the USA. Musculoskeletal impairment was the most prevalent impairment in people aged up to 65 years, and back and spine impairments the most frequently reported subcategory of musculoskeletal impairment (51·7%). The annual rates varied significantly by sex and age (table 2). Back and spine impairments were more common in women (70·3 per 1000

Psychological distress and psychiatric disorders

Various cross-sectional studies indicate an association between psychological factors and the occurrence of low-back pain.1 These factors include anxiety, depression, somatisation symptoms, stressful responsibility, job dissatisfaction, mental stress at work, negative body image, weakness in ego functioning, and poor drive satisfaction. The experience of stress, anxiety, and depression is sometimes, but not always, secondary to back pain. In a few prospective studies, various symptoms that

Recovery from back pain

Most patients with back pain recover quickly and without residual functional loss. Table 4 shows the similarities in recovery rates between studies and countries. Overall, 60–70% recover by 6 weeks, 80–90% by 12 weeks (figure 1). Recovery after 12 weeks is slow and uncertain. Fewer than half of those individuals disabled for longer than 6 months return to work and, after 2 years of absence from work, the return-to-work rate is close to zero.22 Diagnosis has been found to affect recovery;

Predictive models of return to work

There have been various attempts to develop models to predict the duration of absence from work due to low-back pain. These models are difficult to compare because of differences in the population studied, time of the evaluation, and socioeconomic differences between countries. Rossignol and colleagues19 used a logistic-regression model to analyse factors that influence the risk of work-related sickness absence for longer than 6 months. Age and location of symptoms were the most important

Recurrence

The recurrence rate of low-back pain is so high that it seems to be part of its natural history. Table 5 shows data from different studies. Lifetime recurrences of up to 85% were reported by Valkenburg and Haanen,17 whereas in Sweden, the 1-year recurrence of sick-listing for low-back pain was 44% in 1987.6 Data from Canada show recurrence rates of 20% in 1 year and 36% over 3 years.19, 36 Men had a higher risk of recurrence than women, and people aged 25–44 years had the highest rate of

Office visits to physicians

In 1990, there were about 15 million office visits to physicians in the USA for mechanical low-back pain, which accounts for about 2·8% of all office visits.4 Since Hart and colleagues4 did not include visits to allied health professionals, such as chiropractors, the actual number of office visits was probably more than 30 million per year. Among physicians and osteopaths, the number of visits in 1989–90 was only slightly higher than in 1980–81 (when it was 12·2 million). Another US study

Rates of hospital admission and surgery

Volinn and colleagues45 examined the US National Hospital Discharge Survey for time trends (1979–87), and Taylor and colleagues3 extended the study to include data up through 1990. During the 11 years surveyed, operations among adults for low-back pain increased by 55% from 147 500 in 1979 to 279 000 in 1990. This rise corresponds to an increase from 102 to 158 per 100 000 adults. This increase was particularly great for fusions that increased by 100% from 13 to 26 per 100 000 adults. In 1990,

Conclusion

Back pain of at least moderate intensity and duration has an annual incidence in the adult population of 10–15%, and a point prevalence of 15–30%. The prevalence rises with increasing age up to 65 years, after which age it drops off for unknown reasons. The outlook for patients with back pain is generally excellent with 90% or greater recovery over 3 months. Unfortunately, for individuals who did not recover within this time the recovery process is slow and their demand on the health-care

References (45)

  • SZ Nagi et al.

    Social epidemiology of back pain in a general population.

    J Chronic Dis

    (1973)
  • JW Frymoyer et al.

    An overview of the incidence and costs of low back pain.

    Orthop Clin North Am

    (1991)
  • GBJ Andersson

    The epidemiology of spinal disorders.

  • A Praemer et al.
  • VM Taylor et al.

    Low-back pain hospitalization: recent United States trends and regional variations.

    Spin

    (1994)
  • LG Hart et al.

    Physician office visits for low back pain.

    Spine

    (1995)
  • A Frank

    Low back pain.

    BMJ

    (1993)
  • AL Nachemson

    Back pain. Causes, diagnosis and treatment.

    (1991)
  • F Biering-Sorensen

    Low back trouble in a general population of 30-, 30-, 50-, and 60-year old men and women. Study design, representativeness and basic results.

    Dan Med Bull

    (1989)
  • JW Frymoyer et al.

    Risk factors in low back pain: an epidemiological survey.

    J Bone and Joint Surg

    (1983)
  • F Gyntelberg

    One year incidence of low back pain among male residents of Copenhagen aged 40–59.

    Dan Med Bull

    (1974)
  • C Hirsch et al.

    Low back pain symptoms in a Swedish female population.

    Clin Orthop

    (1969)
  • L Hult

    Cervical, dorsal and lumbar spinal syndromes.

    Acta Orthop Scand

    (1954)
  • A Magora

    Investigation of the relation between low back pain and occupation. 2. Work history.

    Ind Med Surg

    (1970)
  • AC Papageorgiou et al.

    Estimating the prevalence of low back pain in the general population.

    Spine

    (1995)
  • HO Svensson et al.

    A retrospective study of low back pain in 38- to 64-year-old women. Frequency and occurrence and impact on medical services.

    Spine

    (1988)
  • HO Svensson et al.

    Low back pain in forty to forty-seven year old men. 1. Frequency of occurrence and impact on medical services.

    Scand J Rehab Med

    (1982)
  • HA Valkenburg et al.

    The epidemiology of low back pain.

  • K Walsh et al.

    Low back pain in eight areas of Britain.

    J Epidemiol Community Health

    (1992)
  • M Rossignol et al.

    Working disability due to occupational back pain: three-year follow-up of 2300 compensated workers in Quebec.

    J Occup Med

    (1988)
  • TWC van Doorn

    Low back disability among self-employed dentists, veterinarians, physicians and physical therapists in the Netherlands.

    Acta Orthop Scand

    (1995)
  • PB Polatin et al.

    Psychiatric illness and chronic back pain. The mind and the spine—which goes first?

    Spine

    (1993)
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