Low back pain

What it is

How research defines it

The Global Burden of Disease 2021 analysis counted pain from the 12th ribs down to the gluteal folds (the creases under the buttocks)¹. To count, the pain had to last for at least a day¹.

Research also sorts it by duration^2,3:

• Acute: under 6 weeks, in a 2024 systematic review (a study that gathers the research on a question in a set, checkable way)².
• Subacute: 6 weeks to under 12 weeks, in the same review².
• Persistent: 12 weeks to under 52 weeks, in the same review².
• Chronic: over 12 weeks, in a 2021 Cochrane review (a systematic review done to the Cochrane Collaboration’s standards)³.

What “non-specific” means

A 2017 Lancet seminar describes non-specific low back pain as having no known pathoanatomical cause, meaning no known cause in a body structure⁵. It notes that guidelines back sorting patients to find the rare cases caused by serious disease⁵. A 2018 Lancet series review reports that in almost everyone with low back pain, no specific nociceptive (pain-signalling) cause can be found⁶. It adds that a small share have a well understood cause, such as a broken spinal bone, cancer or infection⁶.

Who it affects

How many people

A systematic review pooled 165 general-population studies from 54 countries⁷. It put the prevalence (the share of people in a group with a condition at a given time) at 11.9% at one time point⁷. Over a one-month period, it was 23.2%⁷.

Age and sex

• Sex. In the Global Burden of Disease analysis, prevalence was higher in females than males at each age¹.
• Age. The same analysis found prevalence rose with age and peaked at about 85 years¹.

What goes with it

A 2018 Lancet series review reports that some groups carry the greatest risk of reporting this pain⁶. They are people with physically demanding jobs, people with other physical or mental conditions, smokers, and people with obesity⁶. The same review reports that people with low socioeconomic status (lower income and social standing) are over-represented among those with disabling low back pain⁶.

The Global Burden of Disease analysis linked 38.8% of years lived with disability from low back pain to three risk factors that can change¹:

Risk factor	Share of years lived with disability
Ergonomic factors at work (physical demands of the job)	22.0%1
Smoking	12.5%1
High body mass index (a measure of weight for height)	11.5%1

What studies found

How episodes tend to go

A 2018 Lancet series review reports that most people with a new episode recover quickly⁶. It adds that the pain often comes back, and in a small share it becomes persistent and disabling⁶. The 2016 NICE guideline states that episodes usually do not last long⁸. It adds that one year on from an acute episode that needed care, up to one-third report ongoing pain of at least moderate intensity⁸.

A 2024 meta-analysis (a study that pools the results of several earlier studies) tracked mean pain on a 0 to 100 scale²:

Type at study entry	At start	At 6 weeks	At 52 weeks	Certainty of evidence
Acute2	56	26	21	Moderate
Subacute2	63	29	31	Moderate
Persistent2	56	48	40	Very low

Disability followed a slightly more favourable course than pain².

When pain comes back

A 2017 systematic review of eight studies found the research did not give robust estimates of how often low back pain recurs⁹. In that review, a history of earlier episodes was the one factor that predicted recurrence consistently⁹.

A cohort study (a study that follows a group of people over time) enrolled 250 people who had recently recovered from low back pain¹⁰. Within 12 months, 69% had a recurrence, and 40% had one that limited their activity¹⁰. Frequent awkward postures, sitting more than 5 hours a day and more than two past episodes predicted a recurrence within 12 months in this cohort¹⁰.

A 2018 Lancet series review names three factors that raise the risk of persistent disabling pain⁶. They are high pain at the start, psychological distress and pain in several body sites⁶.

What scans show

A systematic review of 33 studies looked at CT and MRI scans of 3,110 people without back pain¹¹. CT is a scan that builds detailed pictures of the inside of the body from X-rays. Disc degeneration (wear-type changes in the discs between the spinal bones) was seen in 37% of 20-year-olds and 96% of 80-year-olds¹¹. Its authors concluded that many of these features are likely part of normal ageing and not linked to pain¹¹.

A meta-analysis of 14 studies compared MRI (a scan that shows soft tissue in detail) in 3,097 adults aged 50 or younger¹². Disc bulges and disc degeneration, among other findings, were more common in those with back pain than in those without¹². A disc bulge is a disc that spreads out past the edges of the spinal bones around it. Other findings, including annular fissures (cracks in a disc’s outer ring), were not associated with low back pain¹².

What guidelines say about imaging

An overview looked at 15 clinical guidelines for non-specific low back pain in primary care⁴. The guidelines support imaging when serious disease is suspected, but discourage its routine use⁴.

Six randomised trials (studies that assign people to groups by chance) were pooled in one meta-analysis¹³. They included 1,804 people with low back pain¹³. Pain and function did not differ significantly between imaging the lower back straight away and usual care¹³. This held at up to 3 months and at 6 to 12 months¹³.

A 2018 Lancet series review reports gaps between evidence and practice around the world¹⁴. It describes limited use of recommended first-line approaches¹⁴. It also describes high use of scans, rest, opioids, injections into the spine and surgery¹⁴.

What exercise trials found

A 2021 Cochrane review pooled randomised trials in adults with chronic non-specific low back pain³:

• Against no intervention, usual care or placebo. Exercise reduced pain by about 15 points out of 100 at the first follow-up, on moderate-certainty evidence. This was a clinically important difference (a change big enough to matter to patients)³.
• Function. In the same comparison, exercise gave a gain in function that fell short of the authors’ threshold for a clinically important difference³.
• Against other non-surgical approaches. Exercise did better for pain and function, but the effects fell short of the authors’ threshold for a clinically important difference³.
• Against manual therapy. No difference was observed³.

Most of the review’s 249 trials were judged at risk of bias, and 79% were at risk because exercise is hard to blind³. Among trials reporting them, adverse effects occurred in 33% of exercise groups and 29% of comparison groups³. In the exercise groups of the 12 trials that measured them systematically, they were mostly minor, such as muscle soreness³.

A 2022 Cochrane review looked at yoga in chronic non-specific low back pain¹⁵. Against no exercise, yoga gave small improvements in function and pain that were not clinically important¹⁵. Against back-focused exercise, there was little or no difference in back-specific function at three months, on moderate-certainty evidence¹⁵. Yoga was linked to more adverse events than no exercise at 6 to 12 months, mainly more back pain, on low-certainty evidence¹⁵. It may carry a similar risk to other exercise¹⁵.

Studies of acute pain

A 2010 Cochrane review looked at advice for people with acute low back pain¹⁶. On moderate-quality evidence, advice to stay active may give small gains in pain and function over advice to rest in bed¹⁶. Three trials of 931 people gave low-quality evidence of little or no difference between exercises, bed rest advice and stay-active advice¹⁶.

Studies of new episodes

A 2016 meta-analysis of 21 randomised trials (30,850 people) looked at the risk of an episode of low back pain¹⁷. On moderate-quality evidence, exercise combined with education lowered that risk¹⁷. The evidence that exercise alone may lower it was low to very low quality¹⁷. The same analysis found evidence of no effect from education alone, back belts or shoe insoles, with certainty from moderate to very low¹⁷.

In a randomised trial of 701 adults recently recovered from non-specific low back pain, one group had an individualised, progressive walking and education programme¹⁸. The median time to a recurrence that limited activity was 208 days in that group, against 112 days with no intervention¹⁸. The share with any adverse event over 12 months was similar in the two groups¹⁸. The programme group had more lower-limb (leg) adverse events, 100 against 54¹⁸.

Work

A 2014 meta-analysis looked at workers with back pain¹⁹. It estimated that 68% had returned to work at 1 month, 86% at 1 to 6 months, and 93% at 6 months or more¹⁹. Estimates varied widely between studies¹⁹.

Connections

The back muscles

The erector spinae makes up most of the back’s muscle mass and is the main muscle that straightens the spine²⁰. A meta-analysis of imaging studies found no differences in the size or make-up of the lumbar (lower back) erector spinae linked to low back pain²¹. The same analysis found the multifidus (a deep muscle running along the spine) somewhat smaller and fattier with low back pain²¹. A systematic review of 25 studies found the evidence on erector spinae size conflicting²².

Studies of back-muscle endurance and later low back pain disagree^23,24. A systematic review of 26 prospective cohort studies found strong evidence of no link between trunk muscle endurance and later low back pain²³. Its authors warned that the studies varied, so results need caution²³.

An observational Danish study of 928 adults differed²⁴. Its author concluded that good back-muscle endurance “may prevent first-time occurrence” of low back trouble in men²⁴.

The back extension and the Sorensen test

The Sorensen test, a timed hold covered on the back extension page, is named after a 1984 study by Biering-Sorensen²⁵. It times how long a person can hold the upper body level and unsupported, face down, with the lower body fixed to a table²⁵. A reliability and case-control study tested 63 people²⁶. Those without low back pain held the position significantly longer than those with current or past non-specific low back pain²⁶.

The bird-dog

In the bird-dog, a person on hands and knees lifts one leg and the opposite arm²⁷. In 13 outpatients with non-specific low back pain, people tolerated each of the core exercises tested well, apart from the lateral plank, or side plank²⁷.

In a randomised trial of 40 people with non-specific low back pain (30 finished), a 6-week home programme included the bird-dog and the plank²⁸. Disability fell from the start in both groups, whether the programme came as a game or as a take-home packet²⁸. The change did not differ significantly between the two groups²⁸.

Sources

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Every source the library cites

Changes

• September 29, 2026 First published.