ARTHRITIS & RHEUMATISM
Vol. 64, No. 6, June 2012, pp 2028–2037
A Systematic Review of the Global Prevalence of
Low Back Pain
Damian Hoy,1 Christopher Bain,1 Gail Williams,1 Lyn March,2 Peter Brooks,3 Fiona Blyth,4
Anthony Woolf,5 Theo Vos,1 and Rachelle Buchbinder6
Objective. To perform a systematic review of the
global prevalence of low back pain, and to examine the
influence that case definition, prevalence period, and
other variables have on prevalence.
Methods. We conduced a new systematic review of
the global prevalence of low back pain that included
general population studies published between 1980 and
2009. A total of 165 studies from 54 countries were
identified. Of these, 64% had been published since the
last comparable review.
Results. Low back pain was shown to be a major
problem throughout the world, with the highest preva-
lence among female individuals and those aged 40–80
years. After adjusting for methodologic variation, the
mean ⴞ SEM point prevalence was estimated to be
11.9 ⴞ 2.0%, and the 1-month prevalence was estimated
to be 23.2 ⴞ 2.9%.
Conclusion. As the population ages, the global
number of individuals with low back pain is likely to
increase substantially over the coming decades. Investi-
Supported by the Bill and Melinda Gates Foundation (to
Dr. Hoy and Prof. Vos), the Australian Commonwealth Department
of Health and Ageing (to Prof. March), and 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).
1
Damian Hoy, BAppSc, MPH, PhD, Christopher Bain,
MBBS, MPH, Gail Williams, PhD, MSc, Theo Vos, PhD, MSc: Uni-
versity of Queensland, Herston, Queensland, Australia; 2Lyn March,
MBBS, PhD, MSc: Royal North Shore Hospital, North Sydney Public
Health Unit, Institute of Bone and Joint Research, and University
of Sydney, Sydney, New South Wales, Australia; 3Peter Brooks, MD,
FRACP: University of Melbourne, Melbourne, Victoria, Australia;
4
Fiona Blyth, MBBS, PhD, MPH, FAFPHM: University of Sydney,
Sydney, New South Wales, Australia; 5Anthony Woolf, MBBS, FRCP:
Peninsula College of Medicine and Dentistry, Plymouth, UK; 6Ra-
chelle Buchbinder, MBBS, PhD, MSc, FRACP: Cabrini Medical Centre,
Malvern, Victoria, Australia, and Monash University, Melbourne,
Victoria, Australia.
Address correspondence to Damian Hoy, PhD, MPH, Uni-
versity of Queensland, School of Population Health, Herston Road,
Herston, Queensland 4006, Australia. E-mail: d.hoy@uq.edu.au.
Submitted for publication May 10, 2011; accepted in revised
form December 15, 2011.
2028
DOI 10.1002/art.34347
© 2012, American College of Rheumatology
gators are encouraged to adopt recent recommendations
for a standard definition of low back pain and to consult
a recently developed tool for assessing the risk of bias of
prevalence studies.
Low back pain is one of the most common health
problems and creates a substantial personal, community,
and financial burden globally (1–4). As part of estimat-
ing the global burden of low back pain, with low back
pain defined as “activity-limiting low back pain (⫹/⫺
pain referred into 1 or both lower limbs) that lasts for at
least 1 day” (5), country-specific prevalence data were
required.
The most recent global review of the prevalence
of low back pain in the adult general population was
published in 2000 and showed point prevalence of
12–33% and 1-year prevalence of 22–65% (6). Since
then, 2 additional global reviews have been conducted,
one of which focused on the elderly (2) and the other on
adolescents (7). A key finding from these reviews was
the extent of methodologic variation between studies,
especially regarding the case definition and prevalence
period used, and the nature and extent of measures
taken to minimize bias (2,6–10).
Although these previous reviews made a major
contribution to our understanding of low back pain, a
large number of prevalence studies have been published
subsequently. The specific aim of the current study was
to perform an up-to-date systematic review of the global
prevalence of low back pain for informing the Global
Burden of Disease (GBD) study, and in doing so, to
examine the influence that case definition, prevalence
period, and other variables have on prevalence.
METHODS
The methods used conformed to the Meta-analysis of
Observational Studies in Epidemiology (11) and the Cochrane
Collaboration (12) recommendations.
Selection criteria. All population-based studies pub-
lished from 1980 to 2009 in which the prevalence of low back
GLOBAL PREVALENCE OF LOW BACK PAIN
pain was reported were considered for inclusion. Studies were
excluded if they clearly were not representative of the general
population (e.g., clinic patients, pregnant women, miners),
were limited to a subset of individuals with low back pain (e.g.,
those with spondylolisthesis), had a sample size of ⬍150, or
were reviews.
Search strategy. The Ovid Medline, EMBase, and
CINAHL electronic databases were searched. There were no
age, sex, or language restrictions. The terms “back pain,”
“lumbar pain,” “back ache,” “backache,” and “lumbago” were
used individually and combined with each of the following:
“prevalence,” “incidence,” “cross-sectional,” and “epidemiol-
ogy.” Reference lists of included studies were inspected to
identify additional relevant studies. One reviewer (DH) as-
sessed the titles and abstracts of all retrieved references to
identify studies that appeared to fulfill the inclusion criteria,
and all potentially eligible articles were retrieved in full text.
Data extraction and management. The relevant study
information was extracted (by DH) into a Microsoft Excel
database (13). If a study presented age- and/or sex-specific
estimates, the total counts were not extracted. If data were
stratified by age and sex separately, the total and sex-specific
data were not extracted. Age/sex bands with sample sizes of
⬍50 were merged with one or more adjacent age/sex bands in
the study. If a study presented both raw and standardized data,
standardized data were ignored; if a study presented only
standardized data, these were extracted. Case definitions were
partitioned as follows: anatomic area, minimum episode dura-
tion, and whether or not cases had to have activity limitation.
Variables extracted included the following: region,
country, year of publication, citation, study type, data ascer-
tainment, sample size, case definition (overall), case definition
(anatomic), case definition (minimum episode duration), case
definition (activity limitation), coverage, urbanicity, each item
from the risk-of-bias tool, year start of data collection, year end
of data collection, prevalence period, age, sex, denominator
(number of cases at risk), numerator (number of cases with low
back pain), prevalence, standard error (SE), design effect, and
whether data were standardized. Double entry of data took
place for a randomly selected sample of the studies (10% [n ⫽
16]) and demonstrated a high level of accuracy (99.4%). The 8
inaccuracies related to text fields (e.g., incorrect spelling) did
not influence the numerical data.
Risk of bias assessment. One reviewer (DH) assessed
the risk of bias for each included study, using a tool that was
developed for this purpose and was shown to be reliable (14).
The tool includes 10 items that assess measurement bias,
selection bias, and bias related to the analysis (all rated as
either high or low risk) and an overall assessment of risk of bias
rated as either low, moderate, or high risk (see Appendix 1,
which is available at the Arthritis & Rheumatism web site at
http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1529-
0131).
A second reviewer (RB) assessed the risk of bias on a
sample of 16 studies (10%) to ensure that the criteria were
applied consistently and that consensus could be reached, as
recommended by the Cochrane Handbook for Systematic Re-
views of Interventions (15). Overall agreement between the
reviewers was 78% with a kappa value of 0.69 (95% confidence
interval 0.55, 0.79), indicating moderate agreement (kappa
values from 0.41 to 0.60 indicate moderate agreement, and
values from 0.61 to 0.80 indicate substantial agreement).
2029
Following discussion, agreement was reached for all differ-
ences. In the majority of instances, the initial assessment by
DH was confirmed by the consensus.
Data preparation. Uncertainty for each estimate was
recorded as a standard error. If an estimate was not reported,
it was calculated from the reported confidence interval or
sample size, as described in Appendix 2 (available at the
Arthritis & Rheumatism web site at http://onlinelibrary.
wiley.com/journal/10.1002/(ISSN)1529-0131). The database
was screened for outliers, inconsistencies, and unexpected and
missing values. Scatterplots were used to inspect the outliers.
Outliers were subjectively defined as prevalence estimates that
appeared to be substantially outside the plausible range.
Outliers were excluded from the analysis if the study risk of
bias was moderate or high, and if data were available from
another study in the same country with an equal or lower risk
of bias.
Assessment of heterogeneity. Heterogeneity between
estimates was assessed using the I2 statistic (16). A value of
zero indicates true homogeneity, while values of 25%, 50%,
and 75% indicate low, moderate, and high heterogeneity,
respectively (17).
Statistical analysis. Statistical analysis was performed
using Stata version 10.1 (18). The influence that individual and
summary risk-of-bias items, case definition, prevalence period,
sex, age, year of data collection, urbanicity, and economy have
on prevalence was assessed using pairwise correlations for
continuous variables, t-tests for independent samples for bi-
nary variables, and one-way analysis of variance for variables
with multiple categories to detect differences between groups.
In a multivariate regression analysis, data were log trans-
formed to achieve normality, using the following formula:
log(prevalence ⫹ 0.2). The value 0.2 was chosen, because it
provided the best approximation to normality. The outcome
variable was “overall prevalence of low back pain” and was
unrestricted by prevalence period. The standard error was
calculated using the formula (19): SE(log[prevalence ⫹ 0.2]) ⫽
(SE[prevalence])/(prevalence ⫹ 0.2). Linear, quadratic, and
cubic associations of prevalence with age were assessed by
including the midpoint of the age group, centered age squared,
and centered age cubed in the multivariate model.
The centered age squared and centered age cubed
were calculated by taking the average of all midpoints of the
age groups and subtracting this value from each midpoint of
the age group to derive a centered age value, which was then
squared and cubed, respectively. Midpoints of the age groups
were categorized as follows: 0–9, 10–19, . . . , and 90–99.
Prevalence trends over time were assessed using a pairwise
correlation t-test for independent samples to compare data
collected before 1998 with data collected during or after 1998.
The influence of economic status on prevalence was assessed
by grouping countries according to the World Bank income
group classification system (20) and performing a t-test for
independent samples. A pairwise comparison was undertaken
to compare the Human Development Index with prevalence
(21).
The quality of the overall evidence from the systematic
review was summarized using the GRADE (Grading of Rec-
ommendations Assessment, Development and Evaluation) sys-
tem (15,22), which has the following options: 1) high quality—
further research is very unlikely to change our confidence in
the estimate, 2) moderate quality—further research is likely to
2030 HOY ET AL

moval of estimates with a prevalence period of ⬎1 year. In

addition, to attempt to control for some of the methodologic
heterogeneity, a prediction of the overall mean prevalence
estimate was made by including the following variables in a
multivariate regression model: sex, midpoint of age group,
centered age squared, centered age cubed, prevalence period,
anatomic case definition, minimum episode duration, activity
limitation, coverage, urbanicity, and the 10 individual risk-of-
bias items. The resulting estimates were for the national-level
mean point and 1-month prevalence of activity-limiting low
back pain lasting for more than 1 day on the “posterior aspect
of the body from the lower margin of the twelfth ribs to the
lower gluteal folds” (5).

Figure 1. Search strategy and exclusion process for studies of the
prevalence of low back pain. ⴱ ⫽ study not representative of the
national population (n ⫽ 331), study focused on a specific subset of low
back pain (n ⫽ 16), sample size less than 150 (n ⫽ 15), or review article
(n ⫽ 15). † ⫽ Article did not exist (n ⫽ 2) or journal was no longer in
circulation, and attempts to retrieve the article through a document
delivery service and/or directly from the author were unsuccessful (n ⫽
7).
have an important impact on our confidence in the estimate
and may change the estimate, 3) low quality—further research
is very likely to have an important impact on our confidence in
the estimate and is likely to change the estimate, and 4) very
low quality—any estimate is very uncertain.
Sensitivity and predictive analyses. Three prespecified
sensitivity analyses were undertaken to assess their impact on
the estimates, as follows: 1) removal of high risk-of-bias
estimates, 2) removal of standardized estimates, and 3) re-
RESULTS
Search results. The electronic database search
yielded 8,727 studies (Figure 1). Irrelevant titles (n ⫽
8,211) were excluded, leaving 516 eligible titles. Of
these, 139 abstracts met the inclusion criteria. An addi-
tional 20 eligible studies were identified from inspection
of the reference lists of included studies. Nine full-text
articles could not be located, leaving 150 studies that
met the inclusion criteria. Two German studies (one
with a high risk of bias and one with a moderate risk of
bias) (23,24) were excluded, because their prevalence
estimates were considered to be outliers (point preva-
lence ranged from 76% to 92% in elderly Germans).
Two other German studies (one with a moderate risk of
bias and one with a low risk of bias) had estimates (point
prevalence ranging from 20% to 50%) that were more in
keeping with those of most other studies (25,26). Of the
remaining studies, one contained data from studies in 17
countries (27), and the other contained data from stud-

Table 1. Prevalence of low back pain according to prevalence period and case definition variations
Quantile
No. of
Prevalence estimates 10% 25% 50% 75% 90% Mean ⫾ SD%
Prevalence period
Point 243 6.3 10.3 15.0 24.2 35.5 18.3 ⫾ 11.7
1 month 145 14.8 21.3 32.1 38.0 49.0 30.8 ⫾ 12.7
1 year 271 14.3 21.0 37.4 53.0 64.8 38.0 ⫾ 19.4
Lifetime 133 6.2 15.1 42.0 60.4 66.4 38.9 ⫾ 24.3
Anatomic
Back 268 9.9 15.8 26.6 36.4 53.6 28.5 ⫾ 16.4
Low back 302 7.2 12.8 26.1 43.1 56.0 29.1 ⫾ 18.8
R12 to lower GFs* 254 11.0 17.4 35.2 52.0 63.7 35.5 ⫾ 19.7
Minimum episode duration
Not specified 661 8.7 15.0 31.5 48.8 62.5 33.2 ⫾ 20.3
1 day 146 14.1 22.1 34.0 44.0 56.4 33.8 ⫾ 15.8
3 months/“chronic” 86 8.7 12.8 19.2 24.3 33.6 20.1 ⫾ 9.8
Activity limitation
With or without activity limitation 912 9.1 15.8 29.1 45.5 58.2 31.8 ⫾ 19.0
Activity-limiting only 54 5.0 8.1 12.2 18.8 30.8 17.0 ⫾ 15.4

* Posterior aspect of the body from the lower margin of the twelfth ribs (R12) to the lower gluteal folds (GFs).
GLOBAL PREVALENCE OF LOW BACK PAIN 2031

Table 2. Results of multivariate regression analysis*

Regression
Covariate coefficient 95% CI P
Constant ⫺1.58 ⫺1.75, ⫺1.41 ⬍0.001
Sex
Female 0
Unspecified ⫺0.06 ⫺0.11, ⫺0.01 0.011
Male ⫺0.11 ⫺0.15, ⫺0.07 ⬍0.001
Age
Midpoint ⬍0.01 ⬍0.01, 0.01 ⬍0.001
Centered age squared ⬍0.01 ⬍0.01, ⬍0.01 ⬍0.001
Centered age cubed ⬍0.01 ⬍0.01, ⬍0.01 0.147
Prevalence period
Point 0
1 month 0.30 0.24, 0.36 ⬍0.001
1 year 0.45 0.40, 0.49 ⬍0.001
Lifetime 0.49 0.43, 0.55 ⬍0.001
Anatomic case definition
Back 0
Low back 0.06 0.01, 0.11 0.029
R12 to lower GFs† 0.56 0.45, 0.67 ⬍0.001
Minimum episode duration
Not specified 0
1 day ⫺0.10 ⫺0.15, ⫺0.04 ⬍0.001
3 months/“chronic” ⫺0.28 ⫺0.37, ⫺0.19 ⬍0.001
Activity limitation
With or without activity limitation 0
Activity-limiting only ⫺0.20 ⫺0.29, ⫺0.10 ⬍0.001
Coverage
Community 0
Regional ⫺0.02 ⫺0.10, 0.05 0.510
National ⫺0.19 ⫺0.29, ⫺0.08 ⬍0.001
Urbanicity
Rural 0
Urban 0.04 ⫺0.03, 0.12 0.256
Risk of bias item 1, target population
Low risk 0
High risk ⫺0.07 ⫺0.14, 0.01 0.071
Risk of bias item 2, sampling frame
Low risk 0
High risk 0.03 ⫺0.05, 0.12 0.457
Risk of bias item 3, random selection
Low risk 0
High risk 0.11 ⫺0.01, 0.23 0.066
Risk of bias item 4, nonresponse bias
Low risk 0
High risk ⫺0.04 ⫺0.08, 0.00 0.079
Risk of bias item 5, was a proxy used?
Low risk 0
High risk ⫺0.51 ⫺0.62, ⫺0.40 ⬍0.001
Risk of bias item 6, case definition
Low risk 0
High risk 0.44 0.35, 0.53 ⬍0.001
Risk of bias item 7, study instrument
Low risk 0
High risk 0.12 0.07, 0.16 ⬍0.001
Risk of bias item 8, data collection mode
Low risk 0
High risk 0.47 0.34, 0.60 ⬍0.001
Risk of bias item 9, prevalence period
Low risk 0
High risk ⫺0.07 ⫺0.15, 0.00 0.050
Risk of bias item 10, numerator/denominator
Low risk 0
High risk 0.01 ⫺0.18, 0.20 0.913
* Values were log transformed to achieve normality (see Methods). 95% CI ⫽ 95% confidence interval.
† Posterior aspect of the body from the lower margin of the twelfth ribs (R12) to the lower gluteal folds (GFs).
2032
Figure 2. Median prevalence of low back pain, with interquartile
range, according to prevalence period.
ies in 2 countries (23). Thus, a total 165 studies provided
966 age- or sex-specific prevalence estimates for 54
countries.
Description of included studies. An overview of
the included studies is provided in Appendix 3 (available
at the Arthritis & Rheumatism web site at http://
onlinelibrary.wiley.com/journal/10.1002/(ISSN)1529-
0131). All of the included studies had cross-sectional
designs and ascertained data through an interview or
self-completed questionnaire. The majority of studies
included both sexes, a broad age range in the adult
population, and both urban and rural populations. Of
the 966 estimates, 161 were standardized by age, sex,
and/or some other factor. The mean year of publication
was 1999 (median 2000 [range 1982–2009]), and 64% of
the studies had been published since the last comparable
systematic review (6). Overall, 36 studies (22%) were
rated as having a low risk of bias (353 estimates), 82
(50%) were rated as having a moderate risk of bias (434
estimates), and 47 (28%) were rated as having a high risk
of bias (179 estimates). High risk-of-bias ratings were
most common for item 1 (national representativeness/
target population), item 4 (nonresponse bias), item 6
(case definition), and item 7 (study instrument) (see
Appendix 4 and Appendix 5 [which shows the risk of bias
ratings for all included studies], available at the Arthritis
& Rheumatism web site at http://onlinelibrary.wiley.com/
journal/10.1002/(ISSN)1529-0131).
Key results. The mean overall prevalence of low
back pain, which was defined as all prevalence regardless
of prevalence period, was 31.0%. The mean point prev-
alence was 18.3%, and 1-year prevalence was 38.0%
(Table 1). For prevalence plotted by age, I2 ⫽ 99.6%,
HOY ET AL
indicating high heterogeneity, and additional stratifica-
tion by prevalence period and varying case definitions
had only a minor impact on reducing the I2 value (to
99.1%). Multivariate regression showed that several
study-level variables had a significant influence on prev-
alence (Table 2).
Risk of bias. Five of the 10 individual risk-of-bias
items were shown to significantly influence prevalence
(Table 2). A high risk of bias for 3 items (case definition
[item 6], whether the study instrument had been tested
for reliability and validity [item 7], and comparability of
mode of data collection [item 8]) was associated with a
higher prevalence, while high risk of bias for 2 items
(whether the data were collected directly from subjects
as opposed to a proxy [item 5] and prevalence period
[item 9]) was associated with a lower prevalence.
Case definition. Most estimates (n ⫽ 661) did not
specify the minimum episode duration required for a
case to be counted (Table 1). Of those that did specify
the minimum duration, the most common durations
were 1 day (n ⫽ 146), 3 months (n ⫽ 38), and 1 week
(n ⫽ 34). In addition, 48 estimates specified that disease
“chronicity” was required for inclusion. For estimates in
which the minimum episode duration was not specified,
the mean prevalence was significantly higher than that
for estimates for which durations were specified as 1 day
(T ⫽ ⫺3.73, P ⬍ 0.001) and 3 months/“chronic” (T ⫽
⫺6.61, P ⬍ 0.001).
For anatomic locations, the “low back” was the
most common category (n ⫽ 302), followed by the
“back” (n ⫽ 268), and the “posterior aspect of the body
from the lower margin of the twelfth ribs to the lower
gluteal folds” (n ⫽ 254) (Table 1). Prevalence differed
significantly across anatomic definitions (F ⫽ 20.91, P ⬍
0.001); the definitions of “low back” (T ⫽ 2.05, P ⫽
0.041) and “posterior aspect of the body from the lower
margin of the twelfth ribs to the lower gluteal folds”
(T ⫽ 10.52, P ⬍ 0.001) were associated with significantly
higher mean prevalence compared with the “back.”
Only a small proportion of the estimates were
restricted to activity-limiting cases (n ⫽ 54) (Table 1).
The mean prevalence of activity-limiting low back pain
was approximately half that of low back pain with or
without activity limitation (T ⫽ 5.63, P ⬍ 0.001). Activity
limitation continued to be significantly related to prev-
alence in the multivariate regression analysis (T ⫽
⫺4.02, P ⬍ 0.001).
Prevalence period. The most common prevalence
periods were point (n ⫽ 243), 1 month (n ⫽ 145), 1 year
(n ⫽ 271), and lifetime (n ⫽ 133) (Table 1). Prevalence
differed significantly according to prevalence period
(F ⫽ 29.15, P ⬍ 0.001). The mean point prevalence
GLOBAL PREVALENCE OF LOW BACK PAIN 2033

with males (T ⫽ 2.31 [P ⫽ 0.022] and T ⫽ 2.26 [P ⫽

Figure 3. Median prevalence of low back pain, with interquartile
range, according to sex and midpoint of age group. Midpoint ⫽ (lower
limit of age group ⫹ [upper limit of age group – lower limit of age
group]/2).
(18.3%) was significantly lower than the 1-month prev-
alence (30.8%) (T ⫽ ⫺9.8, P ⬍ 0.001), and the 1-month
prevalence was significantly lower than the 1-year prev-
alence (38.0%) (T ⫽ ⫺4.0, P ⫽ 0.001) (Figure 2). There
was no significant difference between the 1-year preva-
lence and the lifetime prevalence (38.9%). Regression
analysis demonstrated that 1-month, 1-year, and lifetime
prevalences were all significantly higher than the point
prevalence (Table 2).
Sex and age. The median overall prevalence of
low back pain was higher among females than among
males across all age groups (Figure 3). The overall mean
prevalence of low back pain was significantly higher
among females compared with males (Table 3) (T ⫽ 4.1,
P ⬍ 0.001), and this difference continued to be evident
in the regression analysis (T ⫽ 6.04, P ⬍ 0.001). Both the
mean point prevalence and the mean 1-month preva-
lence were significantly higher among females compared
0.025], respectively), but there was no significant differ-
ence between the sexes for 1-year prevalence and life-
time prevalence.
A cubic representation of the age curve provided
the best fit to prevalence. Both the mean prevalence and
the median prevalence were high during adolescence,
declined among those ages 20–29 years, progressively
increased until peaking somewhere between 40 and 69
years (this peak occurred earlier for men than women),
and then progressively declined (Figure 3). However, the
difference in mean prevalence between adolescents and
individuals ages 20–29 years was not significant, whereas
there were significant differences between those ages
20–29 years and those ages 40–69 years (T ⫽ ⫺3.18, P ⫽
0.002) and between individuals ages 40–69 years and
those ages 80–99 years (T ⫽ 3.14, P ⫽ 0.002).
The regression analysis showed that the quadratic
association with age was more significant than the cubic
and linear associations. That is, the association charac-
terized by increasing prevalence until middle age fol-
lowed by a decline during older age was more significant
than those characterized by gradually increasing preva-
lence across all ages (T ⫽ 4.36, P ⬍ 0.001) and increas-
ing prevalence in adolescence, followed by a decline in
the 20s, an increase during middle age, and a decline
during the oldest ages (T ⫽ 1.45, P ⫽ 0.147). This
remained so when the analysis was limited to point
prevalence estimates.
Year, urbanicity, and economy. The prevalence
of low back pain increased very slightly over the past 3
decades (r ⫽ 0.096, P ⫽ 0.003). There was no significant
difference in the mean prevalence between urban and
rural areas (Table 3). The mean prevalence in countries
with high-income economies was higher than estimates
from countries with middle-income (T ⫽ 5.09, P ⬍
0.001) and low-income economies (T ⫽ 3.03, P ⫽ 0.003).
There was no significant difference in mean prevalence

Table 3. Prevalence of low back pain according to sex, urbanicity, and economy
Quantile
No. of
Prevalence estimates 10% 25% 50% 75% 90% Mean ⫾ SD%
Sex
Female 344 12.5 21.0 33.7 48.1 64.0 35.3 ⫾ 18.8
Male 323 7.8 15.0 25.9 40.0 56.5 29.4 ⫾ 18.5
Urbanicity
Rural 62 1.8 13.1 31.1 45.2 63.0 31.9 ⫾ 21.8
Urban 270 7.2 14.2 25.3 44.3 62.1 30.7 ⫾ 20.4
Economy
Low income 13 0.5 0.8 18.2 21.7 25.9 16.7 ⫾ 15.7
Middle income 216 5.2 10.6 21.4 38.6 52.0 25.4 ⫾ 18.3
High income 737 10.3 16.9 30.3 46.6 60.9 32.9 ⫾ 19.0
2034
between middle-income and low-income economies.
There was a strong positive correlation between a coun-
try’s Human Development Index and overall mean
prevalence (r ⫽ 0.088, P ⬍ 0.001), and this continued to
be significant when the analysis was limited to point
prevalence estimates (r ⫽ 0.122, P ⫽ 0.023).
Quality of overall evidence. The quality of the
overall evidence from this review was moderate; that is,
further research is likely to have an important impact on
our confidence in the estimate and may change the
estimate.
Sensitivity and predictive analyses. Excluding
high risk-of-bias estimates from the analysis resulted in a
significant increase in the overall mean prevalence, from
31.0% to 32.7% (T ⫽ 2.64, P ⫽ 0.008) and a nonsignif-
icant increase in point prevalence, from 18.3% to 18.7%.
Excluding standardized data resulted in nonsignificant
increases in overall prevalence (to 31.1%) and point
prevalence (to 18.7%). If estimates associated with
prevalence periods longer than 1 year (5 years and
lifetime) were excluded, the overall prevalence de-
creased significantly to 29.7% (T ⫽ ⫺2.02, P ⫽ 0.044).
When the regression analysis results were used to
adjust the overall mean ⫾ SD prevalence (31.0 ⫾ 0.6%)
to reflect our GBD 2010 study case definition for low
back pain (activity-limiting low back pain lasting more
than 1 day on the “posterior aspect of the body from the
lower margin of the twelfth ribs to the lower gluteal
folds”), point prevalence was reduced to 11.9 ⫾ 2.0%,
and 1-month prevalence was reduced to 23.2 ⫾ 2.9%.
These values were also lower than the unadjusted
mean ⫾ SD estimates for point prevalence (18.3 ⫾
0.8%) and 1-month prevalence (30.8 ⫾ 1.1%). P values
less than 0.05 were considered significant.
DISCUSSION
Our updated systematic review of the global
prevalence of low back pain showed that low back pain
is a major problem throughout the world and is most
prevalent among females and persons ages 40–80 years.
After adjusting for methodologic variation, the mean ⫾
SD point prevalence of activity-limiting low back pain
lasting more than 1 day was estimated to be 11.9 ⫾ 2.0%,
and the 1-month prevalence was estimated to be 23.2 ⫾
2.9%. Due to significant methodologic heterogeneity
between the included studies, single summary measures,
such as mean prevalence, should be interpreted with
caution.
This systematic review of the global prevalence of
low back pain is the first to assess the risk of bias in the
included studies and is the first study in which a sensi-
HOY ET AL
tivity analysis was performed to assess the impact of
including estimates with a high risk of bias (11,12,28).
The sensitivity analysis showed that the overall mean
prevalence would have been significantly higher if esti-
mates with a high risk of bias had been excluded. In
addition, 5 of the 10 individual items on the risk of bias
tool had a significant influence on prevalence. These
findings provide empirical data about the direction of
the bias and its potential effect.
We observed a substantial increase in the number
of studies of low back pain prevalence since the last
comparable review (6). Similar to other reviews, we
observed considerable methodologic variation between
studies, which particularly related to the prevalence
period and case definition (2,6,9,29). A standardized
definition of low back pain will assist future reviews,
enable greater comparisons between countries, and ul-
timately lead to a far-improved understanding of low
back pain.
Dionne et al (30) recommended using the follow-
ing questions in prevalence studies of low back pain: 1)
In the past 4 weeks, have you had pain in your low back?
and 2) If yes, was this pain bad enough to limit your
usual activities or change your daily routine for more
than one day? Those investigators emphasized the im-
portance of describing the specific anatomic area and,
when possible, using a diagram of the body with the low
back area shaded. The area they recommend for the low
back is “the posterior aspect of the body from the lower
margin of the twelfth ribs to the lower gluteal folds”
(30). Given that low back pain is quite common, point
prevalence estimates are also useful to capture and are
easily interpreted by policy-makers.
In addition, a detailed description of the study
population aids the validity of comparisons between
populations. Factors of interest include age, sex, history
of low back pain, occupation, job satisfaction, educa-
tional status, stress, anxiety, depression, social support in
the workplace, body mass index, and family history of
low back pain (31).
Consistent with other research, we observed a
higher mean and median prevalence of low back pain
among females compared with males (9,32). Possible
explanations for this difference include 1) pain related to
osteoporosis (33), menstruation (34–36), or pregnancy
(37–39), 2) individual or societal influences resulting in
sex differences in the likelihood of reporting somatic
symptoms (32,40,41), and 3) the divergent growth pat-
terns between the sexes during adolescence, which may
influence pain in this period (7).
We observed that the prevalence of low back pain
was high during adolescence, which concurs with a
GLOBAL PREVALENCE OF LOW BACK PAIN
previous review showing that the prevalence of low back
pain increases throughout adolescence, and this peak
often appears earlier in girls than in boys, possibly as a
result of an earlier onset of puberty (7). In our review,
the prevalence of low back pain was highest during
middle age, which represents some of the most produc-
tive years of a person’s working life. This results in a
major economic impact for many individuals, families,
businesses, and governments (42–44).
A curvilinear distribution of the prevalence of
low back pain over age was also reported in a review by
Dionne et al (2). Those investigators demonstrated that
this was apparent for all low back pain; however, when
they restricted their analysis to more severe forms of low
back pain, they observed that the prevalence kept in-
creasing in the older age groups. Consistent with these
findings, there is some evidence that older individuals
have a greater threshold for lower levels of pain but a
reduced tolerance to more severe pain (45).
Dionne et al (2) suggested that many factors
could explain the decrease in the prevalence of less
severe low back pain that occurs with aging, including
cognitive impairment, depression, decreased pain per-
ception, and increased tolerance to pain. In addition,
surveys often exclude persons living in institutions such
as nursing homes (9), and these individuals may have a
higher prevalence of low back pain compared with older
persons living in the community.
Despite an increase in the amount of data since
earlier reviews (6,10), there continues to be a paucity of
information on low back pain in countries with low-
income and middle-income economies. Our data are
consistent with a previous review showing that low back
pain was less prevalent in countries with low-income and
middle-income economies compared with countries with
high-income economies (10). The lower prevalence of
low back pain in developing countries has been specu-
lated to be attributable to higher levels of exercise,
shorter height, higher pain thresholds, and less access to
industrial insurance compared with countries with high-
income economies (10).
Methodologic issues are also likely to explain
some of this difference, including survey planning meth-
ods and differing case definitions and sample population
age and sex structures. Related to this, researchers from
countries with low-income and middle-income econo-
mies may, in some cases, experience greater barriers in
trying to publish studies. For example, the majority of
peer-reviewed journals accept submissions only in Eng-
lish. Moreover, difficulties in constructing accurate sam-
pling frames and accessing remote regions and villages
2035
can greatly add to the challenge of publishing academi-
cally rigorous studies.
The mean lifetime prevalence of low back pain
(38.9%) was much lower than expected and was partic-
ularly influenced by low rates from studies conducted in
China (46–48), Nepal (49), Cuba (50), and Pakistan
(51). The low prevalence of low back pain observed in
these countries with low-income and middle-income
economies may have several influences, some of which
were discussed earlier. In addition, chronic low back
pain may make up a larger proportion of all low back
pain in these countries, making the ratio of lifetime
prevalence to other prevalence periods lower in these
countries compared with countries with high-income
economies. Although no data support this, a study in
Tibet showed a relatively low ratio of 1-year–to–point
prevalence (42%:34%), suggesting that a high propor-
tion cases of low back pain are chronic in nature (52).
The relatively low lifetime prevalence observed in these
studies may also be attributable to selection, measure-
ment, and recall bias.
Similar to most systematic reviews, our study is
likely to be subject to publication bias that may have
inflated the prevalence estimates of low back pain (53).
We attempted to limit the potential for publication bias
by conducting an extensive search for potentially rele-
vant studies and placing a specific focus on capturing
information from countries with low-income or middle-
income economies. In addition, we carefully examined
the risk of bias for each included estimate.
Based on the results of this systematic review, low
back pain continues to be a very common problem
globally. With aging populations, the absolute number of
people with low back pain is likely to increase substan-
tially over the coming decades. Further research is
needed to identify risk factors and culturally appropriate
interventions to prevent and treat low back pain. Re-
searchers are encouraged to adopt recent recommenda-
tions on defining low back pain in epidemiologic studies
to assist future reviews, enable comparisons between
countries, and improve our understanding of low back
pain. Furthermore, the tool for assessing the potential
risk of bias of included estimates could be used to
improve the design of future epidemiologic studies.
ACKNOWLEDGMENTS
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. In addition, we are
thankful to Dr. Emma Smith for her work on the GBD 2010
study, Dr. Karla Meursing for translating a number of the
2036
articles, Dr. Rungthip Puntumetakul, Melinda Protani, and Dr.
Rumna De for their involvement in testing of the risk-of-bias
tool, and Karen Carter and Dr. Linda Cobiac for their useful
insights.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors approved
the final version to be published. Dr. Hoy had full access to all of the
data in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Study conception and design. Hoy, Bain, Williams, March, Brooks,
Blyth, Woolf, Vos, Buchbinder.
Acquisition of data. Hoy, March, Blyth.
Analysis and interpretation of data. Hoy, Bain, Williams, March,
Brooks, Blyth, Woolf, Vos, Buchbinder.
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