Elsevier

The Spine Journal

Volume 14, Issue 10, 1 October 2014, Pages 2299-2319
The Spine Journal

Clinical Study
Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis

https://doi.org/10.1016/j.spinee.2014.01.026Get rights and content

Abstract

Background context

Great effort has been made toward limiting low back pain (LBP). Recent focus has included factors involved with secondary and tertiary prevention, with less attention given to primary prevention.

Purpose

This review provided a current estimate of the incidence of LBP and risk factors associated with either first-time LBP or transition to LBP from a baseline of a pain-free state.

Study design

A systematic review and meta-analyses were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Patient sample

Studies included subjects aged 18 years or older, from longitudinal, observational, cohort designs that included baseline risk factors to an outcome of either first-time LBP or transition to LBP from a baseline of a pain-free state.

Outcome measures

Risk factors and incidence rates were reported using descriptive analysis and the PRISMA guidelines.

Methods

Electronic search strategies in PubMed, CINAHL/SPORTDiscus, and Cochrane Central Register of Controlled Trials were combined with a hand search to identify articles for inclusion. Studies were classified based on the population studied (community vs. occupational based) and type of LBP outcome (first ever vs. transition from a baseline pain-free state).

Results

A total of 41 studies were included for review. Meta-analytical incidence rates for first-time LBP and transition to pain from a pain-free state were similar (∼25%), regardless of community or occupational populations. Risk factors for first-time LBP or transition to LBP from a baseline of a pain-free state were psychosocial and physically related. No consistent risk factor emerged as predictive of first-time LBP, although prior LBP was a consistent predictor of future incident LBP. Significant heterogeneity was found across studies in most models, which limits these findings.

Conclusions

The results of this study suggest that incidence of LBP is similar in community and occupational settings regardless of LBP definition. There were multiple diverse physical and psychosocial risk factors for first-time LBP. A history of LBP was the most consistent risk factor for transition to LBP from a baseline of a pain-free state.

Introduction

Evidence & Methods

Low back pain is one of the most frequent conditions for which patients seek medical care. There is little information regarding risk factors that predispose to the development of low back pain.

The authors performed a systematic review of the literature and performed a meta-analysis to describe the incidence of, and risk factors for, low back pain. The pooled incidence of low back pain was 26% for both community-based and occupational populations. Psychosocial and physical factors both appeared to play a role, although firm conclusions were limited by between-study heterogeneity.

The integrity of a meta-analysis rests solely on the quality of data presented in the studies selected for inclusion. The substantial heterogeneity between the papers selected for the meta-analysis presented here clearly impairs any broad conclusions, as the authors correctly state in their limitations section. At a minimum, this effort highlights the poor quality of the literature with respect to primary prevention of low back pain and identifies the need for further research in this regard.

The Editors

Low back pain (LBP) is a common injury in the general adult population. A recent systematic review published mean lifetime, annual, and point prevalence rates of 38.9%, 38.0%, and 18.3%, respectively [1], whereas individual epidemiologic cross-sectional surveys point to lifetime prevalence rates as high as 70% to 80% [2], [3]. The prevalence of LBP symptoms peaks between the ages of 40 and 69 years, is higher among females than males in all age groups, and is more common in countries with high-income economies [1]. Whether acute or chronic, LBP can lead to functional limitations and disability and is a prominent complaint of individuals seeking medical care [3], [4], [5], [6].

Clinicians and researchers focus on reducing the physical, psychological, and financial costs associated with episodes of LBP. Although secondary (stopping the progression of disease-oriented deterioration) and tertiary (returning of a patient to a status of maximum usefulness with a minimum risk of recurrence of the disorder) prevention measures are important, incorporating primary prevention strategies in the current health-care model may also be impactful [7]. Primary prevention incorporates reducing the occurrence of first-time LBP or the transition to LBP from a pain-free state [8], which are dedicated measures of incident LBP. To initiate effective primary prevention programs, it is essential to identify predictive risk factors for the first incident LBP in longitudinal studies. Prevalence estimates and factors associated with prolonged pain and disability in cross-sectional studies are not helpful for the design of primary prevention programs. Discovered predictive risk factors from longitudinal studies can be classified as individual, physical, or psychosocial [9], and those that have a strong association with the development of LBP and are modifiable should be targeted in primary prevention settings.

Previous systematic reviews and meta-analyses of first-onset LBP have focused on only a subset of risk factors [10], [11], [12], [13], [14] or an adolescent population [15]. Although helpful, these reviews fail to provide a comprehensive view of the incidence and baseline risk factors for LBP. Consequently, the objective of this manuscript was to meta-analyze the incidence estimates of LBP in community-dwelling and occupational populations with no history of LBP and in those purely asymptomatic at baseline. Secondarily, our goal was to identify the individual, physical, and psychosocial risk factors predictive of these episodes for use in primary prevention settings.

Section snippets

Study design

A systematic review and meta-analysis was carried out in accordance to the 27-item PRISMA Statement for Reporting Systematic Reviews [16]. The study was exempt from review of the Institutional Review Board at High Point University and subsequent university affiliations from all authors.

Search strategy

The PubMed, CINAHL, SPORTDiscus, and Cochrane Central Register of Controlled Trials databases were accessed on May 25, 2012, with the following search terms: incidence[tiab], prognost*[tiab], risk factor[tiab],

Search results

The electronic database search of PubMed, Cochrane Central Register of Controlled Trials, CINAHL, and SPORTDiscus provided a total of 2,867 citations. After removing duplicate manuscripts, 2,172 studies remained. Of these, 2,111 were excluded based on the title and abstract review, leaving 61 for full-text review (kappa agreement, 0.45; 95% CI, 0.34–0.55). The full text of the 61 remaining studies were retrieved and reviewed for eligibility, of which 32 more were excluded based on study design,

Discussion

The primary objective of this manuscript was to meta-analyze the incidence of new LBP within adult community-dwelling and occupational populations. Secondarily, predictive risk factors of LBP were described. We identified 41 longitudinal studies that met our inclusion criteria and were able to divide incidence rates and risk factors by definition of pain free at baseline (eg, either never had experienced LPB or were pain free at baseline), then further into population-based or occupational

Conclusions

There are multiple recognized risk factors for LBP; however, most are not robust or replicable, and many are not modifiable. Based on these findings, we believe that the potential success of primary prevention studies needs further evaluation. There is considerable heterogeneity in individual studies but when pooled incident LBP in community and occupational settings was about 25% for those who report first-ever LBP and those who report transfer from a pain-free state at baseline.

References (79)

  • E.L. Gheldof et al.

    Development of and recovery from short- and long-term low back pain in occupational settings: a prospective cohort study

    Eur J Pain

    (2007)
  • S. Luoto et al.

    Static back endurance and the risk of low-back pain

    Clin Biomech (Bristol, Avon)

    (1995)
  • M.N. van Poppel et al.

    Risk factors for back pain incidence in industry: a prospective study

    Pain

    (1998)
  • J.A. Verbunt et al.

    Cause or effect? Deconditioning and chronic low back pain

    Pain

    (2010)
  • N.E. Foster et al.

    Subgrouping patients with low back pain in primary care: are we getting any better at it?

    Man Ther

    (2011)
  • J.C. Hill et al.

    Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial

    Lancet

    (2011)
  • D. Hoy et al.

    A systematic review of the global prevalence of low back pain

    Arthritis Rheum

    (2012)
  • F. Biering-Sorensen

    A prospective study of low back pain in a general population. I. Occurrence, recurrence and aetiology

    Scand J Rehabil Med

    (1983)
  • R.A. Deyo et al.

    Cost, controversy, crisis: low back pain and the health of the public

    Annu Rev Public Health

    (1991)
  • W.F. Stewart et al.

    Lost productive time and cost due to common pain conditions in the US workforce

    JAMA

    (2003)
  • L.G. Hart et al.

    Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey

    Spine

    (1995)
  • J.W. Frank et al.

    Disability resulting from occupational low back pain. Part I: what do we know about primary prevention? A review of the scientific evidence on prevention before disability begins

    Spine

    (1996)
  • J. Winkel et al.

    Assessment of physical work load in epidemiologic studies: concepts, issues and operational considerations

    Ergonomics

    (1994)
  • W.E. Hoogendoorn et al.

    Systematic review of psychosocial factors at work and private life as risk factors for back pain

    Spine

    (2000)
  • S.J. Linton

    Occupational psychological factors increase the risk for back pain: a systematic review

    J Occup Rehabil

    (2001)
  • H. Heneweer et al.

    Physical activity and low back pain: a systematic review of recent literature

    Eur Spine J

    (2011)
  • A. Liberati et al.

    The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration

    PLoS Med

    (2009)
  • J.R. Landis et al.

    The measurement of observer agreement for categorical data

    Biometrics

    (1977)
  • J.P. Higgins et al.

    Quantifying heterogeneity in a meta-analysis

    Stat Med

    (2002)
  • J. Higgins et al.

    Cochrane handbook for systematic reviews of interventions

    (2011)
  • J.P. Higgins

    Commentary: heterogeneity in meta-analysis should be expected and appropriately quantified

    Int J Epidemiol

    (2008)
  • S.G. Thompson et al.

    Explaining heterogeneity in meta-analysis: a comparison of methods

    Stat Med

    (1999)
  • P.R. Croft et al.

    Psychologic distress and low back pain: evidence from a prospective study in the general population

    Spine

    (1995)
  • P.R. Croft et al.

    Short-term physical risk factors for new episodes of low back pain. Prospective evidence from the South Manchester Back Pain Study

    Spine

    (1999)
  • G.J. Macfarlane et al.

    Employment and physical work activities as predictors of future low back pain

    Spine

    (1997)
  • D.P. Symmons et al.

    A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings

    Ann Rheum Dis

    (1991)
  • S.Z. George et al.

    Predictors of occurrence and severity of first time low back pain episodes: findings from a military inception cohort

    PLoS One

    (2012)
  • D.F. Masset et al.

    Relation between functional characteristics of the trunk and the occurrence of low back pain. Associated risk factors

    Spine

    (1998)
  • F. Pietri et al.

    Low-back pain in commercial travelers

    Scand J Work Environ Health

    (1992)
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    FDA device/drug status: Not applicable.

    Author disclosures: JBT: Nothing to disclose. APG: Grant: Agency for Health Care Research and Quality (E, K-12 Comparative Effectiveness Career Development Award grant number HS19479-01, Paid directly to institution). SZG: Board membership: American Physical Therapy Association (Honorarium for Editorial Board Service); Grants/grants pending: National Institutes of Health; Brooks Health (F, Paid directly to institution). CEC: Other: Editor-in-chief of a journal.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

    No funding was used in this study. The authors claim no conflicts of interest, although APG has received funding from the Agency for Health Care Research and Quality and SZG has received funding from the National Institutes of Health and Brooks Health.

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