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Low back pain among the working-age population: from the global burden of disease study 2021

BMC Musculoskeletal Disorders volume 26, Article number: 441 (2025) Cite this article

Abstract

Background

The burden of low back pain in the global working-age population (WAP) is substantial and exhibits unique characteristics. This study aimed to evaluate global, regional, and national trends in low back pain prevalence among the WAP over a 32-year period.

Methods

We utilized data from the 2021 Global Burden of Disease (GBD) study to evaluate the global impact of low back pain in the WAP from 1990 to 2021. A secondary analysis focused on temporal trends and a decomposition analysis of low back pain.

Results

From 1990 to 2021, there was a continuous decrease in the rate of low back pain among the global WAP. The age-standardized incidence rate (ASIR) decreased from 4,111 (95% uncertainty interval [UI]: 2,682–5,619) to 3,676 (95% UI: 2,563–5,021), with an annual average percentage change (AAPC) of -0.36. The age-standardized prevalence rate (ASPR) decreased from 9,731 (95% UI: 7,061–12,970) to 8,632 (95% UI: 6,296–11,517), with an AAPC of -0.39. The age-standardized disability-adjusted life years (DALYs) rate (ASDR) decreased from 1,108 (95% UI: 686–1,650) to 982 (95% UI: 608–1,460), with an AAPC of -0.39. However, the number of low back pain cases in the global WAP continued to increase. Regions with a middle Socio-demographic Index (SDI), South Asia, China, and India carried a heavier burden of low back pain in the WAP. The burden was also greater among females, with the gender gap continuing to widen. Decomposition analysis revealed that population growth and population aging were the predominant driving factors.

Conclusions

Despite the overall reduction in the ASIR, ASPR, and ASDR of low back pain among WAP, it remained a leading cause of disability worldwide. More attention needs to be paid to the low back pain burden among WAP in middle-SDI regions, countries with a large population base, and females. Significant gender and regional disparities persist within WAP, highlighting the necessity for targeted preventive and therapeutic interventions to alleviate the burden of low back pain and reduce the risks of disability.

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Introduction

Over 600 million individuals globally were affected by low back pain, a condition that stood as the foremost cause of disability worldwide [1]. The condition exerted a profound impact on individuals, families, and society, particularly within the working-age population (WAP), where it impaired productivity, led to loss of work capacity [2], and contributed to increasing poverty [3]. Low back pain may affect workers'mental health [4], work capacity [5], and income [6, 7]. Studies have also shown that both acute and chronic low back pain can lead to higher disability rates [8]. The economic burden caused by low back pain is substantial [9]. Meanwhile, poverty exacerbated symptoms of low back pain. Therefore, low back pain in WAP is a complex issue that may have an impact on social and economic development. Previous studies have not specifically focused on the working-age population. This study aims to analyze the epidemiological characteristics of low back pain in this group, calling for attention from individuals and relevant authorities to the health status of this age group. This study provides new insights into the global burden of low back pain in WAP, filling a critical gap in this field with potential clinical and translational value.

Implementing targeted interventions for low back pain patients reduced global disability, enhanced public health, and contributed to the sustainable development of social security systems [10], particularly in low- and middle-income countries (LMICs) [11]. However, studies had investigated the global burden of low back pain across all age groups [1], but research specifically focused on the WAP remained limited.

Using data from the GBD study, this research analyzed trends in low back pain incidence, prevalence, and disability-adjusted life years (DALYs) among WAP in 204 countries and regions from 1990 to 2021, stratified by gender, region, country, and Socio-demographic index (SDI). Countries in high SDI regions have higher incidence rates and various economic costs associated with low back pain compared to those in low SDI regions [12, 13]. There are gender differences in the incidence and prevalence of low back pain, with a higher prevalence in women than in men [14, 15]. These findings offered valuable insights for the intervention and treatment of low back pain, providing a foundation for future actions by national and relevant departments to help reduce the burden and health influence of low back pain on the global WAP. The results had significant implications for the WAP and the enhancement of socio-economic productivity.

Methods

Data sources

This study utilized data from the GBD 2021 study, which covered the disease burden in 204 countries and regions from 1990 to 2021. We collected data on patients aged 15–64 with low back pain, including incidence, prevalence, DALYs, and their respective rates, to quantify the burden of low back pain. In the GBD study, years lived with disability (YLDs) are considered equivalent to DALYs, as low back pain is not associated with mortality within the study's statistical framework. The GBD algorithm provides rates per 100,000 population and offers 95% uncertainty intervals (UIs) for each rate. The methodology underlying the GBD study has been extensively detailed elsewhere [16]. Since this study is based on the GBD, detailed information regarding data imputation and handling of missing data can be found in the relevant studies. This study was approved by the Medical Ethics Committee of Shanxi Provincial People's Hospital. Informed consent was waived due to the anonymous, aggregated, and publicly available nature of the analyzed data.

The case definition for low back pain was specified as pain in the posterior aspect of the body, extending from the lower margin of the 12 th ribs to the low gluteal folds, with or without pain radiating to one or both lower limbs, lasting for at least one day. In the International Classification of Diseases, Tenth Revision (ICD-10), low back pain is classified under codes M54.3, M54.4, and M54.5, and as code 724 in the Ninth Revision (ICD-9) [1]. This study included 10 age groups, from 15–19 years to 60–64 years, with each group spanning 5 years [17]. The age-standardized rates (ASRs) were calculated based on the age-standardized population from the GBD 2019 study [1].

The temporal trends in the burden of low back pain were assessed by calculating the annual average percentage change (AAPC), with analyses conducted across global, regional, and national levels, as well as by sex and the SDI. SDI is an indicator that reflects the impact of social and economic factors on health outcomes. Its calculation method was the geometric mean of the lagged distribution of total fertility rate for individuals under 25 years old, average years of education and per capita income for those aged 15 and above. For example, if the SDI value was higher, it meant that the average years of education were longer, the per capita income was higher, and the fertility rate was lower. SDI could be used to divide countries and regions into the high, high-middle, middle, low-middle, and low SDI groups [16]. In the GBD 2021 study, SDI values range from 0 to 1, with higher values indicating better socio-economic conditions and improved health outcomes. Based on 2021 SDI, regions are divided into five quintiles: low (0–0.466), low-middle (0.466–0.619), middle (0.619–0.712), high-middle (0.712–0.810), and high (0.810–1) [18].

Statistics analysis

The absolute values of incidence, prevalence, and DALYs were obtained by summing the corresponding values across all relevant age groups. Age-standardized methods were used to eliminate the influence of age differences on the results. Time trends were evaluated using Joinpoint software (version 5.0.2) from the National Cancer Institute (NCI). Joinpoint regression is a statistical method used to analyze trends in time-series data, such as the incidence, prevalence, mortality, and DALYs. This method partitions the continuous time-series data's linear regression model into several statistically significant trend segments, with each portion described by a linear model to identify the optimal number of turning points. The method uses a Monte Carlo permutation test to determine the optimal number of joinpoints and their locations based on the statistical significance of the change in trend [19]. The AAPC and its 95% confidence interval (CI) were calculated using a linear regression model. A negative upper limit of 95% CI for the AAPC indicates a downward trend, while a positive lower limit indicates an upward trend [20]. Decomposition analysis was performed to determine the driving factors behind changes in the burden of low back pain during this period. This method, developed by Das Gupta and widely applicable in epidemiological research, offers a principled dissection of how each component uniquely contributes to the overall trend [21]. It summarizes the contribution of various factors to observed changes by algebraically isolating the standardized impact of each contributing multiplicative factor. Epidemiological change involves changes in the incidence or prevalence of disease due to various factors, such as improvements in healthcare, the introduction or evolution of risk factors, the effectiveness of prevention strategies, advancements in treatment, or changes in environmental or lifestyle factors. ASRs were reported per 100,000 population, with data presented as values with 95% UIs.

Results

Global trends

Table 1 presents a detailed account of the prevalence, incidence, and DALYs associated with low back pain in the WAP. In 2021, an estimated 453 million (95% UI: 330–604) individuals in the WAP suffered from low back pain globally, compared to 297 million (95% UI: 215–395) in 1990. During this period, the global age-standardized prevalence rate (ASPR) in the WAP exhibited a declining trend, decreasing from 9,731 per 100,000 (95% UI: 7,061–12,970) in 1990 to 8,632 per 100,000 (95% UI: 6,296–11,517) in 2021. The number of cases increased, with 193 million (95% UI: 134–263) reported in 2021, compared to 126 million (95% UI: 88–172) in 1990. However, the global age-standardized incidence rate (ASIR) in the WAP decreased from 4,111 per 100,000 (95% UI: 2,682–5,619) in 1990 to 3,676 per 100,000 (95% UI: 2,563–5,021) in 2021. Likewise, DALYs increased from 33.77 million (95% UI: 20.9–50.3) in 1990 to 51.51 million (95% UI: 31.9–76.6) in 2021, while age-standardized DALYs rate (ASDR) showed a downward trend, from 1,108 per 100,000 (95% UI: 686–1,650) in 1990 to 982 per 100,000 (95% UI: 608–1,460) in 2021.

Table 1 Incidence, prevalence, and DALYs of low back pain among WAP in 1990 and 2021, and AAPC from 1990 to 2021, by global, gender, SDI, and regional levels
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Joinpoint regression analysis showed a consistent decline in the global ASIR, ASPR, and ASDR for low back pain from 1990 to 2021. Specifically, the AAPC for ASIR was −0.36 (95% CI: −0.39 to −0.33), while prevalence and DALYs followed similar trends, with AAPCs of −0.39 (95% CI: −0.42 to −0.36) and −0.39 (95% CI: −0.41 to −0.37), respectively. The steepest decline in ASIR was observed between 1990 and 1993 [average percentage change (APC)] = −1.14, 95% CI: −1.27 to −1.01], followed by a deceleration from 1993 to 2000 (APC = −0.58, 95% CI: −0.62 to −0.53). A further reduction was seen from 2000 to 2004 (APC = −0.14, 95% CI: −0.27 to −0.01), with a more pronounced decline from 2004 to 2010 (APC = −0.29, 95% CI: −0.35 to −0.24). The rate of decline leveled off from 2010 to 2015 (APC = −0.05, 95% CI: −0.13 to 0.04), before accelerating again from 2015 to 2021 (APC = −0.20, 95% CI: −0.24 to −0.15). Similar trends were discovered for the prevalence and DALYs in the WAP, with a marked decline from 1990 to 1993, followed by a deceleration in the rate of decline from 1993 to 2000. The reduction rate then slowed significantly from 2000 to 2005, increased from 2005 to 2010, decelerated again from 2010 to 2015, and finally, accelerated from 2015 to 2021(Fig. 1).

Fig. 1
figure 1

Joinpoint regression analysis of the global ASIR (A), ASPR (B), and ASDR (C) for low back pain in WAP from 1990 to 2021. Abbreviations: WAP, working-age population; AAPC, average annual percent change; APC, annual percentage change; DALYs, disability-adjusted life-years; ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASDR, age-standardized DALYs rate

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Sex trends

Globally, the prevalence, incidence, and DALYs associated with low back pain are consistently higher in females within the WAP compared to males. In 2021, the ASPR was 10,743 per 100,000 females (95% UI: 7,838–14,264) versus 6,528 per 100,000 males (95% UI: 4,737–8,764), a decline from 1990 figures of 12,026 per 100,000 females (95% UI: 8,726–15,969) and 7,476 per 100,000 males (95% UI: 5,405–10,040). In 2021, the ASIR was 4,529 per 100,000 females (95% UI: 3,171–6,167) and 2,827 per 100,000 males (95% UI: 1,961–3,867). In 1990, the ASIR was 5,001 per 100,000 females (95% UI: 3,498–6,823) and 3,238 per 100,000 males (95% UI: 2,243–4,437). Similarly, in 2021, the ASDR were higher in females, at 1,213 per 100,000 (95% UI: 752–1,801), compared to males, at 752 per 100,000 (95% UI: 464–1,124). In 1990, the ASDR was higher in females, at 1,361 per 100,000 (95% UI: 844–2,025), compared to males, at 860 per 100,000 (95% UI: 529–1,286). From 1990 to 2021, the ASPR declined more rapidly in males than in females (females: AAPC = −0.37, 95% CI: −0.38 to −0.35; males: AAPC = −0.44, 95% CI: −0.49 to −0.39). These gender-specific incidence and DALYs trends are consistent with the results of prevalence. The number of female cases was also higher than that of male cases in 1990 and 2021. Further gender-stratified details of low back pain in the WAP can be found in Table 1 and Fig. 2.

Fig. 2
figure 2

Joinpoint regression analysis of the global ASIR, ASPR, and ASDR for low back pain by gender in WAP, for males (A, C, E) and females (B, D, F), from 1990 to 2021. Abbreviations: WAP, working-age population; AAPC, average annual percent change; APC, annual percentage change; DALYs, disability-adjusted life-years; ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASDR, age-standardized DALYs rate

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SDI, regional, and national trends

Across SDI regions, the ASIR, ASPR, and ASDR exhibited a declining trend from 1990 to 2021. Notably, in 2021, the high SDI region recorded the highest ASIR, ASPR, and ASDR, at 4,874 per 100,000 (95% UI: 3,548–6,455), 11,662 per 100,000 (95% UI: 8,953–14,956), and 1,327 per 100,000 (95% UI: 851–1,928), respectively. In contrast, the middle SDI region exhibited the lowest ASIR at 3,220 per 100,000 (95% UI: 2,215–4,430), ASPR at 7,480 per 100,000 (95% UI: 5,345–10,096), and ASDR at 853 per 100,000 (95% UI: 522–1,277). In high-middle SDI regions, the AAPC decrease for ASIR, ASPR, and ASDR was the fastest, while in low-middle SDI regions, the AAPC decrease for ASIR and ASPR was slowest, and for ASDR, the AAPC decrease was slowest in low-SDI regions. In addition, the high SDI region had the highest number of incident cases, prevalent cases, and DALYs in 1990 and 2021, indicating it had the highest burden. Specific values can be found in Table 1 and Fig. 3.

Fig. 3
figure 3

Correlations between ASIR, ASPR, and ASDR of global low back pain among WAP and SDI at the regional level. Notes: ASIR of low back pain among WAP at the global level and 21 regions, by SDI, from 1990 to 2021 (A). ASDR of low back pain among WAP at the global level and 21 regions, by SDI, from 1990 to 2021 (B). ASPR of low back pain among WAP at the global level and 21 regions, by SDI, from 1990 to 2021 (C). Abbreviations: SDI, socio-demographic index; DALYs, disability-adjusted life-years; ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASDR, age-standardized DALYs rate

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At the regional level, from 1990 to 2021, the largest declines in the ASIR, ASPR, and ASDR were observed in East Asia. (ASIR: AAPC = −0.63, 95% CI: −0.67 to −0.58; ASPR: AAPC = −0.65, 95% CI: −0.70 to −0.60; ASDR: AAPC = −0.65, 95% CI: −0.70 to −0.60). Among all regions, only Central Latin America and Tropical Latin America exhibited increasing trends, with Central Latin America experiencing the largest increases. (ASIR: AAPC = 0.05, 95% CI: 0.03 to 0.07; ASPR: AAPC = 0.06, 95% CI: 0.05 to 0.07; ASDR: AAPC = 0.05, 95% CI: 0.04 to 0.07). The region with the highest number of DALYs in 1990 was East Asia and South Asia, while in 2021, it was South Asia and East Asia. The region with the highest number of incidence cases in 1990 was East Asia and South Asia, while in 2021, it was South Asia and East Asia. The region with the highest number of prevalence cases in 1990 was East Asia and South Asia, while in 2021, it was South Asia and East Asia. Oceania has consistently had the lowest numbers across all three data sets (Table 1 and Fig. 3).

Sweden exhibited the highest AAPC in ASIR, ASPR, and ASDR, all showing an upward trend.(ASIR: AAPC = 0.91, 95% CI: 0.84 to 0.98; ASPR: AAPC = 0.86, 95% CI: 0.80 to 0.93; ASDR: AAPC = 0.87, 95% CI: 0.80 to 0.94). Conversely, China showed the most significant decline in AAPC across these indicators.(ASIR: AAPC = −0.66, 95% CI: −0.71 to −0.61; ASPR: AAPC = −0.69, 95% CI: −0.74 to −0.64; ASDR: AAPC = −0.68, 95% CI: −0.74 to −0.63). The three countries with the highest ASDR in 1990 were Hungary, Czechia, and Romania; for ASIR, they were Hungary, New Zealand, and Poland; and for ASPR, they were Hungary, Romania, and Czechia. In 2021, the three countries with the highest ASDR were Hungary, Czechia, and Albania; for ASIR, they were Hungary, Poland, and Czechia; and for ASPR, they were Hungary, Czechia, and Albania. The three countries with the lowest ASDR, ASIR, and ASPR in both 1990 and 2021 were Maldives, Myanmar, and Thailand. By 2021, China had the highest number of incident cases and DALYs globally, followed closely by India, which recorded the highest number of prevalent cases. Specific numerical values can be found in Table 2 and Fig. 4.

Table 2 Incidence, prevalence, and DALYs of low back pain among WAP in 1990 and 2021, and AAPC from 1990 to 2021, by nations
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Fig. 4
figure 4

Correlations between ASIR, ASPR, and ASDR of low back pain among WAP and SDI at the national level. Notes: In 2021, ASIR of low back pain among WAP in 204 countries, by SDI, the total population (A), males (B), and females (C). In 2021, ASDR of low back pain among WAP in 204 countries, by SDI, the total population (D), males (E), and females (F). In 2021, ASPR of low back pain among WAP in 204 countries, by SDI, the total population (G), males (H), and females (I). Abbreviations: SDI, socio-demographic index; DALYs, disability-adjusted life-years; ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASDR, age-standardized DALYs rate

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Decomposition analysis

From 1990 to 2021, the changes in the number of incident cases, prevalent cases, and DALYs for low back pain in the WAP were attributed to population growth, population aging, and epidemiological changes. Population growth and population aging led to an increase in numbers, while epidemiological changes resulted in a decrease, partially offsetting the overall increase. For detailed information, please refer to Fig. 5. For example, the number of prevalent cases of low back pain in the WAP increased by 52.7%, with 55.8% attributable to population growth, 12.1% to population aging, and −15.2% due to epidemiological changes. For most regions, epidemiological changes were the primary drivers of the decline in the burden of low back pain in the WAP, whereas population growth was the main factor contributing to the increase. At the regional level, Central Sub-Saharan Africa experienced the most significant increases in the total number of incident cases, prevalent cases, and DALYs, with respective increases of 159.0%, 158.4%, and 160.8%. Among the SDI regions, the most significant increases occurred in the low SDI region (incident cases: 126.0%; prevalent cases: 124.6%; DALYs: 125.8%), whereas the smallest increases were observed in the high SDI region (incident cases: 19.6%; prevalent cases: 19.4%; DALYs: 18.9%). Specific numbers can be found in Table 3.

Fig. 5
figure 5

Decomposition analysis of changes in low back pain among WAP incident cases (A), prevalent cases (B), and DALYs (C) at global level, SDI level, and regional level, 1990 to 2021. Notes:The black dots denote the sum of contribution to the changes in all 3 components. For each component, the magnitude of a positive value indicated a positive contribution; the magnitude of a negative value indicates a negative contribution. Abbreviations: WAP, working-age population; DALYs, disability-adjusted life-years; SDI, socio-demographic index

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Table 3 Changes in incidence, prevalence, and DALYs number for low back pain among WAP according to population-level determinants and causes from 1990 to 2021
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Discussion

This study offered a comprehensive overview of the global burden of low back pain in the WAP from 1990 to 2021. Our analysis provided the most current and comprehensive description of the prevalence, incidence, and DALYs of low back pain at the global, regional, and national levels, along with their rates of change. Research indicated that the burden of low back pain within the WAP exhibited both gender-specific and regional heterogeneity. Decomposition analysis suggested that these changes were primarily driven by population growth, although there were some regional exceptions. Population aging also contributed to these changes, while epidemiological changes had a mitigating impact.

In 2021, the number of individuals in the WAP affected by low back pain exceeded 450 million, with severe cases significantly impacting quality of life and work. Currently, low back pain has persisted as the leading cause of global disability, exerting a substantial impact on public health worldwide [22]. The widespread prevalence of low back pain across global regions may contribute to an increased disease burden at regional and national levels. For example, in Spain, the cost associated with low back pain was approximately €8.945 billion in 2017 [12]. In China, low back pain was strongly linked with a high prevalence of anxiety symptoms [23]. The opioid burden among low back pain was significant, with 27% of spinal fusion patients continuing long-term prescribed opioid use 12 months post-surgery [24]. Opioid use led to serious health risks, such as high rates of addiction and mortality [25]. Studies showed that low back pain was common in the US, frequently accompanied by the serious issue of prescription opioid misuse [26]. In 2018, opioid overdoses claimed approximately 47,000 lives in the United States alone [27]. Improving low back pain through non-pharmacological treatments may help mitigate some of the impacts of opioid abuse.

Due to the specificity of the population we analyzed, the WAP population is closely linked to various types of work. High workloads are likely to contribute to low back pain, which may further affect work efficiency, increase work burdens, and create a vicious cycle. Occupations involving heavy physical labour were linked to low back pain [28]. Warehouse workers frequently reported experiencing low back pain [29]. Incorrect work posture and job content could also cause lower back pain. Tailors who worked in static forward-bent postures for long hours faced an increased risk of low back pain, a condition that similarly remained prevalent among drivers [30,31,32]. Furthermore, healthcare workers were notably susceptible to high rates of low back pain because of their jobs [33].

The results of the gender analysis are consistent with those of existing studies, showing a notably higher prevalence of low back pain among female hospital staff, particularly nurses, compared to their male counterparts [34]. Women may have taken on more important roles in the nursing and education industries, as well as in office work. Apart from the gap in occupational factors compared to men, females exhibited increased susceptibility to chronic low back pain [35] due to ergonomic factors [15], pregnancy [36], physiological structure [37], and family responsibilities [38]. Additionally, gender bias in medical practice by healthcare professionals could lead to misdiagnosis and undertreatment [39]. Occupational factors seemed to exert a stronger influence on low back pain in females [40]. For women, low back pain was associated with occupational activity involving frequent heavy lifting, standing position leaning forward, sitting position leaning forward, and sitting at the computer three or more days a week. Similarly, another study on low back pain in New Zealand found that womenexperienced higher rates of working in awkward or tiring positions, dissatisfaction with contact and cooperation with management, and perceiving their job as very or extremely stressful [41]. A study conducted in the Paris region indicated that although women appeared to have less exposure to known risk factors, these risk factors were predominant among female workers, leading to a higher incidence and severity of low back pain in women [42].

The analysis of SDI revealed that in high SDI regions such as Australia, Canada, and France, these indicators were the highest, potentially due to work practices, job types, and industrial distribution. In middle SDI regions such as China, Albania, and Brazil, the indicators were the lowest, possibly related to shifts in industrial structure and developments in healthcare systems. At the regional level, East Asia had the largest average decline in age standardization indicators. This may have been attributed to the changes in industrial structure and the improvement of medical service capabilities in East Asia in recent years. Central Latin America and Tropical Latin America exhibited increasing trends, which may have been attributed to inadequate local healthcare conditions [43, 44], work practices, and job types [45]. At the national level, Sweden exhibited the highest of these indicators, whereas China had the lowest. However, due to their large population bases, China and India had high numbers of individuals in the WAP affected by low back pain. Recent studies in India have also confirmed this [46]. Different races may have differences in their perception of lower back pain due to cultural differences [47]. Existing studies have shown that after adjusting for potential confounding factors, the cultural dimensions of power distance and collectivism are negatively correlated with the prevalence of chronic low back pain [48]. When analyzing regional differences, cultural and lifestyle variations may have contributed significantly. For example, in regions characterized by heavy lifting or manual labor, particularly among females, the incidence, prevalence, and DALYs of low back pain may have been elevated. In contrast, in high and high-middle-income countries, higher incidence, prevalence, and DALYs may have been due to the increased use of computers and smartphones, as well as more comprehensive healthcare services. Additionally, due to COVID-19, sedentary behaviour, decreased activity, and extended periods of working from home may have exacerbated low back pain [49]. During the COVID-19 pandemic, working from home and remote work increased the incidence of low back pain among workers [50, 51]. Additionally, studies have confirmed that remote work is associated with the worsening of low back pain [52]. Other research has pointed out that during COVID-19, activity limitations and pain intensity due to low back pain were higher [53]. However, our data did not reflect this trend. This may be due to the impact of healthcare policies or a reduction in demand for medical care due to safety concerns. Previous studies have confirmed this, showing a decrease in patients visiting the emergency department due to low back pain [54]. Nonetheless, the living and working environments, content, and methods, as well as access to healthcare services and awareness of diseases, differ for the WAP across various SDI regions and countries.

According to our analysis and previous research, there were three risk factors for low back pain patients in WAP [1]. Among these, occupational ergonomics appeared to be the most significant factor. A study conducted among healthcare workers in northeastern Poland demonstrated that a sedentary lifestyle significantly increased the recurrence of low back pain, while increased physical activity helped alleviate symptoms [55]. Interventions targeting occupational ergonomic factors, such as incorporating active rest breaks or changing postures, were shown to reduce low back pain symptoms in high-risk office workers [56]. Furthermore, research indicated that smoking and a high body mass index (BMI) were also risk factors for low back pain [1]. However, the causal mechanisms linking these factors to low back pain remain unclear. Nevertheless, studies on these risk factors remain significant. Interventions targeting these factors may influence the condition of low back pain.

For the WAP, taking active rest breaks and changing postures positively affected low back pain, and rest did not negatively impact work efficiency [57]. Replacing one hour of sitting with one hour of vigorous activity per week alleviated low back pain [58]. Well-designed jobs, combined with a'fitness for work'approach that aligned worker capabilities with job demands, had beneficial effects on low back pain and may have helped shorten the time to return to work and reduce short-term absenteeism [59]. Studies demonstrated that implementing participatory ergonomics methods to improve working conditions reduced low back pain by approximately 12% and increased productivity by an average of 42% [30]. Ergonomic structures, work formats, back care programs, and the use of assistive devices helped mitigate such occupational hazards [33]. Research conducted in Brazil linked work-related stress to a higher incidence of low back pain, along with more frequent episodes and increased severity of the condition [60].

In the past few decades, clinical guidelines for low back pain have undergone significant changes. In the past, medication and surgery were the primary treatments, but now there is more focus on self-management, physical therapy, psychological therapy, and other medical approaches. These changes reflect a shift in the understanding of low back pain treatment, emphasizing the improvement of patients'function and quality of life through non-pharmacological treatments such as exercise, massage, acupuncture, and others [61]. However, the implementation of specific policies has not been very effective. In this regard, individualized strategies [62] and the effective implementation of guidelines seem to be important [63]. For example, the United States and the United Kingdom have successfully reduced unnecessary imaging tests by using specific imaging request forms and adding educational information in MRI reports [64, 65]. Denmark has improved the implementation of guidelines through multiple strategies, reducing secondary referrals and saving healthcare costs [66].

For high SDI regions and countries, optimization and improvement may be the main focus of various policies. Studies have shown that stratified care is more effective and cost-efficient than traditional best care methods [67, 68]. Reconfiguring the entire clinical pathway from initial contact to specialty care to improve low back pain is also one of the directions for future exploration. Another promising direction could be through integrated healthcare and occupational interventions, targeting both the healthcare system and, more broadly, public health. Combining healthcare and occupational health interventions for treating low back pain [61]. Early interventions in Sweden have shown that addressing workplace issues can help patients return to work earlier and reduce healthcare costs [69]. At the same time, high SDI regions also face issues of inappropriate and excessive use of medical examinations [70], medications [71], and surgeries [72]. Changing compensation and disability policies may bring potential benefits, especially in reducing work disability and welfare applications due to low back pain. These policies should encourage workplace interventions and support early return to work through more flexible disability benefit policies.

In low SDI regions and countries, the primary issue to address is the allocation of basic healthcare resources and the integration of relevant information due to insufficient health resources. The lack of or inadequate monitoring of occupational musculoskeletal health policies [73] and the scarcity of high-quality low back pain data [74] are evident issues. The direct and indirect costs at the individual, social, and healthcare system levels in most low SDI regions remain unclear [22]. Additionally, more research and practice are needed to evaluate the actual effects of these public health interventions. Public health resources in low SDI regions and countries are typically focused on the prevention of infectious diseases, but low back pain should also be a key area of concern. Therefore, more targeted interventions need to be designed and implemented for low-income populations to reduce health disparities, eliminate barriers to returning to work, and help them escape poverty [61]. At the same time, it should be noted that spreading high-cost healthcare models to low- and middle-income countries will exacerbate, rather than alleviate, the burden [22]. Healthcare resource allocation and policy development should be tailored to the specific circumstances.

Due to their unique status, screening for related diseases in the working-age population helps improve overall well-being and productivity [75]. Treating individual low back pain patients may not be sufficient to address one of the most disabling global health issues [76, 77]. As mentioned, low back pain is very common and is strongly influenced by patients'beliefs and expectations, in addition to social events such as compensation and disability policies. Back pain is also often poorly managed [78]. Social-level interventions to improve low back pain health outcomes include mass media campaigns to increase public understanding of low back pain [79, 80], addressing people's fears and expectations about health—care providers [81, 82], eliminating compensation and disability policies that encourage disability, and implementing research to address the significant evidence-practice gap [59].

Several limitations were encountered in this study. First, heterogeneity in data sources was observed, primarily due to sparse and uneven data distribution, challenges in obtaining representative samples, and restrictions on data exchange across countries. Much of the data in the study relied on retrospective reports, with a broad definition of low back pain that lacked precise criteria. Although analytical methods could be adjusted to enhance comparability between different datasets, such adjustments introduced uncertainty and might not have fully captured actual differences. Furthermore, much of the data relied on models rather than on observational data. Ideally, primary data from each country would have been available, and standardized methods would have been used for analysis; however, achieving this was challenging. Obtaining country-level raw data in the WAP remained challenging, particularly in low-income countries. These countries might not have reported low back pain, and their populations might have engaged in more physically demanding labour. Inequality in data could magnify the impact of data from high-income regions, distorting the accuracy of global assessments. The absence of primary data hindered the ability to draw accurate conclusions about regional and national differences. Second, the study did not account for the actual impact of COVID-19 on the burden of low back pain, particularly in regions most severely affected by the pandemic and in many LMICs. This included factors such as worsening occupational ergonomic conditions, reduced access to medical treatment, and increased mortality among older adults. Third, manual calculation of ASRs of low back pain was employed. Although this method helped alleviate the impact of age differences, it also affected the accuracy of the calculated UIs. This method might have influenced the original data quality, availability, and statistical uncertainty, potentially hindering full integration into the estimation results. Finally, the results of this study might have been disproportionately influenced by data from countries with large populations. This could have resulted in conclusions that might not have directly applied to or accurately reflected the unique circumstances of specific regions.

The results of this study will help promote countries and their relevant departments to adopt relevant policies to address back pain. Meanwhile, developing a more accurate definition for lower back pain can more accurately reflect the burden of lower back pain in different regions of WAP. In addition, further research is needed using more representative data. To alleviate this burden, collaboration among multiple departments and disciplines was essential, such as improving work-related factors, physical exercise, and treatment, etc. [76].

Conclusions

Over the past three decades, the global ASIR, ASPR, and ASDR for low back pain in the WAP showed a continuous downward trend. However, the absolute number of cases continued to rise, driven by population growth and aging, particularly in densely populated regions such as Asia. The burden of low back pain among females in the WAP remained higher than that among males, with significant regional heterogeneity. As a leading cause of global disability, low back pain in the WAP poses a significant threat to healthy aging. National and organizational policies are needed to mitigate the burden of low back pain exacerbated by population growth and population aging. Considering gender-specific and regional heterogeneities, multifaceted measures should be implemented to strengthen international cooperation and prevent the further widening of disparities. Simultaneously, sharing healthcare information on low back pain could generate more accurate country-specific or estimated data, facilitating the statistical tracking of changes in incidence, prevalence, and DALYs over time, thereby providing a more precise picture. Our findings underscore the need for more high-quality data and research to enhance analysis and statistics. The objective is to implement patient-centered interventions that mitigate potential risk factors, identify and prevent the onset and progression of low back pain, and alleviate its disease burden.

Data availability

The data used in this study came from a public database that everyone can access through the link provided in this article (https://www.healthdata.org/research-analysis/gbd).

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Acknowledgements

We appreciate the outstanding work by the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 collaborators.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. The Orthopedic Department of Shanxi Provincial People’s Hospital, Shanxi Medical University, Taiyuan, 030012, China

    Yao-kan Zhang, Yi-zhou Ge, Ze-bin Wang & Feng Chang

  2. Fifth Clinical Medical College, Shanxi Medical University, Taiyuan, 030012, China

    Yao-kan Zhang, Yi-zhou Ge & Ze-bin Wang

  3. First Clinical Medical College, Changzhi Medical College, Changzhi, 046000, China

    Jia-xuan Wang

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Contributions

Yaokan Zhang (First Author): Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Writing-original draft, Writing-review & editing, Visualization. Jia-xuan Wang: Software, Validation, Formal analysis, Investigation, Visualization, Writing- review & editing. Yi-zhou Ge: Software, Validation, Formal analysis, Data curation, Investigation, Visualization. Ze-bin Wang: Data curation, Validation, Formal analysis, Methodology, Investigation. Feng Chang (Corresponding Author): Conceptualization, Resources, Writing review & editing, Supervision, Project administration.

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Correspondence to Feng Chang.

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Zhang, Yk., Wang, Jx., Ge, Yz. et al. Low back pain among the working-age population: from the global burden of disease study 2021. BMC Musculoskelet Disord 26, 441 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08704-x

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08704-x

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BMC Musculoskeletal Disorders

ISSN: 1471-2474

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