Podcast: Low back pain

Low back pain is the number one cause of disability in the world. We speak with Professor Manuela Ferreira, Dr. Jaimie Steinmetz, and Dr. Garland Culbreth, who recently published a study exploring the contributing risk factors and impacts of low back pain.

Key takeaways:

• Low back pain is the leading cause of disability globally and has been since 1990. The number of cases is expected to increase as the population ages, with the greatest number occurring in people around 80-85 years old.
• What risk factors contribute to low back pain?
  • Occupational ergonomics like poor workplace setups
  • Obesity, which can be associated with less physical activity and lead to inflammation in the body
  • Smoking, which could be a confounder for low activity and other risk factors, or contribute to reduced circulation in the spinal column, making it more prone to injuries
• What are the policy and treatment recommendations for low back pain? 
  • Focus on prevention strategies that involve physical activity
  • Reduce reliance on opioid prescriptions and surgical treatments
  • Bust myths that people with back pain should stay sedentary

Read the research

This transcript has been lightly edited for clarity.

PAULINE CHIOU: Welcome to the Global Health Insights podcast. I’m Pauline Chiou in Media Relations at the Institute for Health Metrics and Evaluation. In this podcast, we’re going to be talking about low back pain. It’s the leading cause of disability globally, and we are fortunate to have the research team of a recent study that has been published in The Lancet Rheumatology.

With us we have Professor Manuela Ferreira of Sydney Musculoskeletal Health at the University of Sydney. We also have Dr. Jaimie Steinmetz, who’s managing research scientist at IHME, and Dr. Garland Culbreth, who’s also a research scientist at IHME. So, thank you all for joining us on this very important topic. Professor Ferreira, let me start with you as the first author of this paper. 

The team looked at 30 years of data of low back pain around the world. What are some of the key points that we should take away from the paper? 

DR. MANUELA FERREIRA: Thank you so much, Pauline. And thank you for having me. I think that the number one key point would be that low back pain is still the main cause of disability around the world. It has been since 1990, and the absolute number of cases has been increasing over the years and is projected to increase even further. 

So I think that the main message would be that for the first time we actually established that the peak prevalence of back pain is in the older age population. It’s around 85 years of age, which contradicts what we used to believe. We used to believe that the peak prevalence of back pain was around 45 to 55 years of age.

This is alarming because as we know, the population is aging and the older person affected by back pain will usually present other comorbidities that will impact their health even further. And at the moment, I don’t think we have the right strategies to address that problem. So, to me, those were the key messages of the paper.

PAULINE CHIOU: So we will talk about some strategies and policy recommendations in a little bit. But first, let’s break down the issue of low back pain. Dr. Steinmetz, in terms of risk factors, what are some of the key risk factors that are causing low back pain as we see this increase in the peak age going from 40 to 45 now to 80 to 85?

DR. JAIMIE STEINMETZ: For the Global Burden of Disease study, we’ve looked at three risk factors for low back pain and found that they all contribute to lower back pain prevalence. Those are occupational ergonomics, smoking, and obesity, and together combined, about 39% of low back pain burden is attributed to those risk factors. We know it’s really important to think about them and prevention around those different areas.

PAULINE CHIOU: And what are some other risk factors? Dr. Culbreth, I know you not only looked at ergonomics but some other modifiable risk factors. 

DR. GARLAND CULBRETH: We also considered high BMI and smoking because those are also good risk factors. So, we considered their contributions as well and we looked at the patterns and how they also impacted. 

PAULINE CHIOU: So a lot of people will say, okay, smoking, like, what exactly is it about smoking that could possibly cause low back pain?

DR. GARLAND CULBRETH: So there’s a few theories. One of them is that circulation can become aggravated in discs and that makes the spinal column more prone to injuries. That’s one theory. It also can be a confounder for behavioral risks like low activity and things like that. So sort of a situation where there’s a lot of working theories. 

PAULINE CHIOU: Okay. And then in terms of high BMI, or obesity, is it what we would sort of logically conclude that if you’re carrying around more weight, it might put more stress on your low back? Or are there more reasons to this? 

DR. GARLAND CULBRETH: Well, that’s one component, that’s part of it. But there’s also other parts, like association with inflammation, for example, like a whole body inflammation in the case of a really high BMI. 

PAULINE CHIOU: All right, Professor Ferreira, another interesting takeaway from the research is that you found that low back pain globally seems to impact women more than men. Why is that? 

DR. MANUELA FERREIRA: A very good question. We can’t say the exact reason why, yet there are some studies being conducted at the moment. We actually looked at twins, and a population of monozygotic twins and dizygotic twins, to see if gender actually drives the difference that we observe.

And we couldn’t see any difference in those studies, meaning that it might not be biological. So that difference might not be because of biological differences between genders. It could be because women tend to seek care more often than men. This has been observed in other conditions as well. So what we can assume with the data that we found was that women probably report to and seek care for back pain more often than men. And this is what we are observing in the prevalence as well. 

PAULINE CHIOU: And, if that’s the case, Professor Ferreira, if women are reporting more than men, is that going to be a problem in terms of men being undiagnosed or untreated? 

DR. MANUELA FERREIRA: It could be. It’s again a very good question. It depends on how we define under-treatment for back pain, because at the moment I think we are over-treating back pain.

So, I think a lot of people with back pain are actually seeking care without having to seek care because they don’t have the right knowledge and message out there. So, is it possible that women are being more treated than men? Yes. Is it possible that men are being under-treated? I’m not sure I agree with that. 

PAULINE CHIOU: Mmm, okay.

All right. And one of the statistics that we saw from this paper is the projection into 2050. Dr. Steinmetz, I’d love your take on this, because if we’re aware of low back pain as a leading disability globally, why do we need to prepare for this 36% increase 30 years from now? 

DR. JAIMIE STEINMETZ: So, as you say, 36% increase.

Right now we’re estimating that there’s about 620 million people worldwide who experience low back pain. And so, if we have these kinds of estimate of progression, then we’re thinking around 843 million people in the year 2050. So that’s just an enormous number of individuals have crossed the age span. Of course, you know, we do see this kind of higher prevalence or rates in all this ages, but we are estimating more back pain in children all the way through.

So, a lot of the reason that we’re projecting this increase is due to changes in population structure and, in particular, an aging population. So, as we’ve talked about, we do see higher rates as people get older: as we have a larger proportion of the population that is older, we’re going to start to see more cases.

And so I think just thinking about that absolute number, it’s so important to think about preventive strategies and really education around protection of population.

PAULINE CHIOU: Yeah, yeah, absolutely. Absolutely. Before we get to those preventive strategies, I’d love to look at regional numbers and the trends that you saw there. Dr. Culbreth, in the paper, you looked at where you saw the highest occurrence of low back pain and the lowest.

And Dr. Steinmetz had mentioned aging as well as population growth. How does that all play into some of the countries that popped up in your paper, like high occurrence in Hungary and the Czech Republic, low occurrence of back pain in the Maldives and in Myanmar, for example. 

DR. GARLAND CULBRETH: So, this is actually a bit complicated. If you look at just the number of cases and then you compare that to the population structure in those locations, you’ll see that in Myanmar, in the Maldives, the population skews a little bit younger.

And so it’s not picking up that age pattern that hits that high peak toward the upper end of the age range and prevalence. However, if you then look at the age-standardized rates, you see the same locations high and low on the high and low end. So you have to dig a little bit deeper and it comes down to, we also estimate uncertainty not just the plain numbers.

So the regions have their uncertainty bands and each of these locations has an estimated uncertainty band as well. And these are the highest and the lowest locations, but they’re well within their regional sort of band. And they’re very close to other neighboring locations bands as well. So they’re not proper outliers. There’s no special underlying thing pushing them up there, following the data we have; those just happen to be the highest and lowest ones.
  
PAULINE CHIOU: Okay. And Dr. Culbreth, when we look ahead at the projection up to 2050, are there certain regions of the world we should be paying attention to where you’re projecting certain trends? 

DR. GARLAND CULBRETH: Well, we certainly saw the biggest increases in sub-Saharan Africa and again, due to population structure changes, aging and growth, etc.

PAULINE CHIOU: All right. It’s a fascinating paper.

Dr. Ferreira, let’s dive into policy recommendations and treatment. You had mentioned earlier that you believe that many people are not treated properly and are not receiving preventive guidance. Flesh out what the problem is and what some of your recommendations would be. 

DR. MANUELA FERREIRA: So we published a series of three papers a couple of years ago calling for global action on how to manage back pain, and some of the points that we highlight are that people with back pain seem to be getting a lot more passive types of therapy, such as analgesics, for example, or even physical agents or physical therapies that are very passive and that are less likely to get them more active, and therapeutics, which would be, for example, exercise. And this is even more accentuated in the older population. So, there is of course, the opioid crisis. In Australia, for example, back pain is the number one reason for an opioid prescription, and we see this across the globe. So, there is this emphasis on medication and less emphasis on exercise.

The problem is a patient with a new episode of back pain who doesn’t get better. They will develop surgery. We do know that a number of the surgical procedures offered for people with back pain are not supported by high-quality evidence. So it is actually a very complex answer to probably a complex question.

We are not offering evidence-based treatments for people with back pain and they tend to get more chronic and they tend to use more complex and costly interventions. Going back to prevention again, our prevention strategies overall are not very effective and we are not very good actually at implementing them across the globe. And these would be improving knowledge and beliefs around back pain for the general population, for clinicians, for patients.

These would actually also be getting people to become more active, trying to bust that myth. That if you have back pain, you have to sit, you have to be quiet. You cannot move, you have to lie down in bed. So, all of those beliefs actually have been shown not to be true. So trying to change the way people perceive back pain, it is okay to move.

Even if you have pain in the back, it’s okay to stay at work. It’s okay to return to work. You might have to need to change your activities and modify the extent, the duration and the type of activities. But it’s okay to move. 

PAULINE CHIOU: All right. And Dr. Steinmetz and Dr. Culbreth, do you have anything to add? Because either we’ve all had low back pain, or we know somebody who’s had low back pain. So this is of high interest to people around the world. 

DR. JAIMIE STEINMETZ: I mean, I think also maybe on the occupation side, you know, just emphasizing that this is really important both in terms of workplace and workplace policy, but also, for employees, and really thinking about that, and maybe the setup that they have, and the importance of considering that for their own health.

So we’re happy to be able to provide or shed some light on that risk factors.

PAULINE CHIOU: Dr. Culbreth?

DR. GARLAND CULBRETH: Mostly echoing similar sentiments because this is such a huge cause, then we need to be paying attention so that we can make sure everybody’s able to live their lives well. 

PAULINE CHIOU: Yeah. And, you know, you brought up an interesting point about physical activity, because as you say, Dr. Ferreira, if you’re suffering from pain, your instinct is to go and rest.

But what you’re saying is you actually might need a little bit more activity. Can you just explain why it took so many reasons? 

DR. MANUELA FERREIRA: Again, some of them are related to how you interpret your body. And, you know, the more psychological aspects of pain. But also, if you look at the spine, there are a lot of small joints in the spine.

This spine was made to move. It provides stability to the trunk, but it was really made to move. Our body was made to move. So, I’m saying when you actually stay in the same position, whether it is sitting down the whole day, standing the whole day, or lying in bed the whole day, that actually contradicts what your spine is supposed to be doing.

So, not only movement is important because of how you perceive pain and how you perceive your body, not only the psychological aspects of pain, but also the biological aspects of pain. It needs to move, your body needs to move. 

PAULINE CHIOU: It’s a fascinating conversation. And thank you so much for your research. Dr. Manuela Ferreira, Dr. Jaimie Steinmetz, and Dr. Garland Culbreth.

It's been a pleasure. Thank you. 

DR. MANUELA FERREIRA: Thank you so much for having me.