Global, regional, and national burden of low back pain, and associated risk factors from 1990 to 2021, with projections of incidence to 2050: A systematic analysis for the Global Burden of Disease Study 2021

Global, regional, and national burden of low back pain, and associated risk factors from 1990 to 2021, with projections of incidence to 2050: A systematic analysis for the Global Burden of Disease Study 2021 | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 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Data may be preliminary. 1 December 2025 V1 Latest version Share on Global, regional, and national burden of low back pain, and associated risk factors from 1990 to 2021, with projections of incidence to 2050: A systematic analysis for the Global Burden of Disease Study 2021 Authors : Liangyuan Tan 0009-0008-8595-6226 , Peipei Yang , Xiaofeng Gan , Hongliang Tang , Peng Yang , Xiongjiang Wang , and Kailong Wang 0000-0002-7069-9107 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.176459971.13506346/v1 351 views 147 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Low back pain (LBP) is the leading cause of years lived with disability (YLDs) worldwide. This study aimed to update the incidence, prevalence, and disability-adjusted life years (DALYs) of LBP from 1990 to 2021, stratified by age, sex, and sociodemographic index (SDI) at global, regional, and national levels. Data were obtained from the 2021 Global Burden of Disease (GBD) study. Estimated annual percentage changes (EAPCs) were calculated to assess temporal trends in age-standardized incidence (ASIR), prevalence (ASPR), and YLD rates (ASYR). Analyses were conducted by sex, year, 20 age groups, 204 countries, 21 regions, five SDI quintiles, and major risk factors. In 2021, the global burden of LBP remained high, with 628,838,475 cases and an age-standardized prevalence (ASPR) of 7,463.13 per 100,000 people. The ASIR was 3,176.63, and the age-standardized YLD rate (ASYR) was 832.18 per 100,000. High-SDI regions showed the highest ASPR, ASIR, and ASYR, while middle-SDI regions had the lowest. At the country level, Hungary had the highest rates, whereas the Maldives had the lowest. Occupational risks, high body mass index, and tobacco use were the largest contributors to YLDs. Population growth, aging, and epidemiological changes significantly influenced ASIR, ASPR, and ASYR trends across SDI regions. The ASPR, ASIR, and ASYR of LBP remain elevated in high-SDI regions, with Hungary and the Czech Republic showing the greatest national burden. Introduction As one of the most common musculoskeletal disorders worldwide, low back pain (LBP) is a major public health concern because of its high incidence, frequent recurrence, and substantial social burden [1; 2] . LBP is characterized not only by soreness, stabbing pain, or dull pain in the lumbar and sacral regions but also by radiating pain and numbness in the lower limbs [3; 4] . In severe cases, it can restrict basic movements such as bending and turning, directly impairing an individual’s ability to perform self-care and reducing work productivity [5] . From urban office workers to farmers, and teenagers to the elderly, LBP crosses the boundaries of age, occupation, and region [6] . The lifetime prevalence of LBP is as high as 84%, and a proportion of patients may develop disability [7] . Importantly, the number of patients affected by LBP is expected to increase significantly in the future with population aging [8; 9; 10] . Given its prevalence and burden worldwide, updated epidemiological data are important for researchers and health care decision-makers. The Global Burden of Disease (GBD) study provides systematic measurements of health impairments caused by diseases and injuries by age, gender, year, and geographical location, and allows comparison of the burden of different diseases [11; 12] . Previous assessments of LBP within the GBD framework have confirmed that it is the leading cause of disability in most countries and regions [13; 14; 15] . The total burden of disability and disease-related costs is expected to continue rising over the coming decades [16; 17; 18] . However, no comprehensive analysis of the burden of LBP has yet been conducted using the latest GBD 2021 data worldwide. The objective of this research is to provide an updated evaluation of the incidence, prevalence, and disability-adjusted life years (DALYs) of LBP from 1990 to 2021 for 204 countries and regions. The analysis is categorized by age, gender, and sociodemographic index (SDI) at the regional, global, and national levels. This research also identifies the attributable risk factors of LBP and includes projections of cases from 2021 to 2050. This study will offer more targeted guidance for public health policies and help reduce the impact of LBP on society in the coming decades. Methods Data obtention The GBD study included data from 204 countries and regions spanning 1990 to 2021, along with information from the first-level administrative divisions of 22 countries. It also conducted comparative assessments of health impairments associated with 369 medical conditions and 88 risk factors. GBD research can be accessed through the GHDx online platform. GBD data were primarily derived from censuses, surveys, hospital records, and administrative records, and adhered to the Guidelines for Accurate and Transparent Health Estimation Reporting in a standardized and repeatable manner [19] . Because no relevant mortality rate reports are available, the number of years of life lost (YLLs) can be disregarded. Therefore, DALYs are equivalent to years lived with disability (YLDs) [20] . In this study, YLD was used as the indicator of disease burden [20] . According to the GBD 2021 dataset, statistical data on the prevalence, incidence, and YLDs of LBP and their corresponding 95% uncertainty intervals (UI) from 1990 to 2021 were extracted. The detailed data were prepared as follows: (a) Demographic characteristics: gender (male, female) and age (20 age groups: 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, 80–84, 85–89, 90–94, and ≥95 years, with 5 years as one age cycle), year (1990–2021), 204 countries and regions, and SDI [21] . Based on SDI, all 204 countries and regions were stratified into five development levels: low (0.805). (b) Disease burden indicators: prevalence, incidence, YLD rate, age-standardized prevalence (ASPR), age-standardized incidence (ASIR), and age-standardized YLD (ASYR) [21] . The 95% UI represents the range of values determined by the 25 th and 975 th ordered values from 1,000 samples of the posterior distribution obtained using the GBD algorithm, which was applied to evaluate uncertainty caused by variation in time period, location, and data heterogeneity. Informed consent was unnecessary because the Institutional Review Board granted an exemption for this study, given its reliance on publicly available data without personally identifiable or confidential information. Statistical analyses This study examined the temporal trends in the incidence, prevalence, and YLD rate of LBP from 1990 to 2021. Age-standardized rates (ASR) were used to quantify these trends within the study period using the following formula:\(\text{ASR}=\frac{\sum_{i=1}^{n}{r_{i}w_{i}}}{\sum_{i=1}^{n}\ w_{i}}\times 100,000\)(\(r_{i}\): the specific rate for the i age group [e.g., prevalence or incidence rate], n is the total number of age groups, and wᵢ is the standard population weight for the i age group). It was assumed that the natural logarithm of ASR and time follow a linear correlation. The regression line fitting rate was calculated using the formula: Y=α+βX+ε, where Y is ln(ASR), X represents the calendar year, β indicates the direction of the ASR trend (negative or positive), and ε is the error term. The estimated annual percentage change (EAPC) was calculated using the formula: EAPC=100*(exp(β)-1), and the 95% confidence interval (CI) of the EAPC was obtained from the linear regression model. If the EAPC estimate and the lower bound of its 95% CI are both positive, the ASR is interpreted as showing an increasing trend. If the EAPC estimate and the upper bound of its 95% CI are both negative, the ASR is interpreted as showing a decreasing trend. Otherwise, the ASR is considered stable [22] . To describe the temporal trend and distribution of the LBP burden across countries and regions, the EAPC was applied to generate a heat map of annual changes in LBP from 1990 to 2021 and to plot the global rate of YLD and the corresponding ASR for LBP during the same period. Differences by gender and age group were also assessed [23] . To evaluate the effect of SDI classification on the LBP burden in countries and regions worldwide from 1990 to 2021, and specifically in 2021, changes in ASR by SDI category were calculated. First, the ASR of different SDI regions and countries was determined, and the global SDI dataset was integrated. Spearman correlation analysis was performed to measure the association between SDI and ASR in each region and country, and a fitted curve was generated to evaluate the relationship between SDI and ASR of LBP [22] . All statistical analyses were performed using R software. Risk factors The GBD 2021 study estimated that the LBP burden is associated with three modifiable risk factors: environmental/occupational risks, metabolic risks, and behavioral risks. Within metabolic risk factors, high body mass index (BMI) was evaluated. For environmental/occupational risk factors, occupational exposures were assessed, and for behavioral risk factors, tobacco use was considered. The results were presented as the effect of these risk factors on the ASYR (age-standardized YLD rate) across different age groups [22; 23] . Decomposition analysis \begin{equation} {I\text{ncidences}}_{m,P,r}=\sum_{j=1}^{k}{(b_{j,t}\ \times P_{t}\times f_{j,t})}\nonumber \\ \end{equation} \({I\text{ncidences}}_{m,P,r}\) represents the number of incidences, based on population size, age structure, and incidence rates in year t ; \(b_{j,t}\ \)denotes the proportion of the j-th age group in year t , representing the share of that age group within the total population. \(P_{t}\) indicates the total population in year t ；\(f_{j,t}\) refers to the incidence for the j-th age group in year t [25] . Prediction of the disease burden linked to LBP spanning 2021 to 2050 In this study, the ARIMA model was applied to forecast the disease burden associated with LBP from 2021 to 2050 [23] . Global level The global burden of LBP remained high in 2021, with 628,838,475 total cases (95% UI: 551,834,407–700,881,341), representing a 62.59% increase compared with 1990 (386,731,361). Although the absolute number of cases rose substantially, the ASPR decreased from 8,391.58 per 100,000 persons in 1990 to 7,463.13 in 2021. The EAPC for ASPR was –0.31742% (95% CI: –0.35103 to –0.2838) (Table 1 and Figure 1). In 2021, the global ASIR of LBP was 266,873,321 cases (95% UI: 235,369,489–299,406,380), a 61.72% increase from 1990. However, the ASIR declined slightly from 3,534.99 per 100,000 persons in 1990 to 3,176.63 in 2021. The EAPC for ASIR was –0.28945% (95% CI: –0.32112 to –0.25777) (Table 1 and Figure 1). The global DALYs for LBP in 2021 were 70,156,962 (95% UI: 50,194,205–94,104,688), a 61.71% increase from 1990. However, the ASYR declined slightly from 937.34 per 100,000 persons in 1990 to 832.18 in 2021. The EAPC for ASYR was –0.31552% (95% CI: –0.34919 to –0.28183) (Table 1 and Figure 1). Regional level In 2021, the global LBP burden showed clear regional differences that were closely associated with SDI level. ASPR varied significantly across regions. The prevalence rate in high-SDI regions was the highest, at 9,783.64 per 100,000 persons (95% UI: 8,876.62–10,734.23), while it was lowest in middle-SDI regions, at 6,421.04 per 100,000 persons (95% UI: 5,616.75–7,199.09) (Table 1 and Figure 1). The temporal trends of ASPR revealed distinct patterns by SDI level, which may reflect different stages of epidemiological transition. The decline in high-middle SDI regions was the most pronounced [EAPC 95% CI: –0.42672% (–0.47394 to –0.37948)], whereas the decrease in low-middle SDI regions was the smallest [EAPC 95% CI: –0.18396% (–0.23139 to –0.1365)] (Table 1). Across continents, ASPR showed that Europe had the highest prevalence, at 10,304.71 per 100,000 persons (95% UI: 9,092.62–11,495.90), while Asia had the lowest, at 6,510.48 per 100,000 persons (95% UI: 5,690.10–7,286.61). The Africa region showed the smallest decline [EAPC 95% CI: –0.10136% (–0.12721 to –0.0755)], whereas the Asia region exhibited the largest decrease, with an EAPC of –0.32155% (95% CI: –0.37971 to –0.26336). Among WHO regions, ASPR revealed that the prevalence was highest in the European region, at 10,200.08 per 100,000 persons (95% UI: 8,988.30–11,382.99), and lowest in the Western Pacific region, at 5,984.04 per 100,000 persons (95% UI: 5,235.61–6,694.87). The Eastern Mediterranean region showed the greatest increase [EAPC 95% CI: 0.04242% (0.0258–0.05904)], while the Western Pacific region experienced the largest decrease, with an EAPC of –0.47896% (95% CI: –0.55358 to –0.40429). At the GBD regional level, ASPR demonstrated that Central Europe had the highest prevalence, at 12,831.04 per 100,000 persons (95% UI: 11,293.99–14,267.18), whereas East Asia had the lowest, at 5,418.74 per 100,000 persons (95% UI: 4,746.47–6,045.66). The Tropical Latin America region showed the most notable increase, with an EAPC of 0.06862% (95% CI: 0.04097–0.09627), whereas East Asia experienced the greatest decline [EAPC 95% CI: –0.46517% (–0.56698 to –0.36326)]. The global burden of LBP in 2021 showed marked regional variation, closely associated with SDI levels. ASIR differed significantly, with high-SDI regions reporting the highest incidence at 4,118.80 per 100,000 persons (95% UI: 3,695.02–4,589.31), while middle-SDI regions reported the lowest at 2,770.57 per 100,000 persons (95% UI: 2,435.96–3,119.83) (Table 1 and Figure 1). Temporal trends in ASIR displayed distinct patterns across SDI levels, suggesting different stages of the epidemiological transition. The decline in high-middle-SDI regions was the most pronounced [EAPC 95% CI: –0.37959% (–0.42478 to –0.33438)], whereas the decrease in low-middle-SDI regions was the smallest [EAPC 95% CI: –0.17577% (–0.21932 to –0.1322)] (Table 1). Across the four continents, ASIR indicated that incidence was highest in Europe, at 4,306.38 per 100,000 persons (95% UI: 3,814.69–4,841.36), and lowest in Asia, at 2,805.88 per 100,000 persons (95% UI: 2,474.38–3,155.81). The European region experienced the smallest decline [EAPC 95% CI: –0.0864% (–0.10199 to –0.07081)], whereas the Asian region showed the largest decline [EAPC 95% CI: –0.29615% (–0.34893 to –0.24335)]. In the WHO regions, ASIR revealed that incidence was highest in the European region, at 4,267.07 per 100,000 persons (95% UI: 3,781.73–4,794.32), and lowest in the Western Pacific region, at 2,591.59 per 100,000 persons (95% UI: 2,280.61–2,916.55). The Eastern Mediterranean region displayed the most notable increase, with an EAPC of 0.03023% (95% CI: 0.01837–0.04208), while the Western Pacific region demonstrated the greatest decline [EAPC 95% CI: –0.44172% (–0.50978 to –0.37361)]. Across the GBD regions, ASIR showed the highest incidence in Central Europe, at 5,181.24 per 100,000 persons (95% UI: 4,595.33–5,834.52), and the lowest in East Asia, at 2,369.25 per 100,000 persons (95% UI: 2,088.98–2,663.65). The Andean Latin America region displayed the most notable increase [EAPC 95% CI: 0.03845% (0.01489–0.06201)], whereas East Asia showed the greatest decline [EAPC 95% CI: –0.44419% (–0.53403 to –0.35427)]. In 2021, the global LBP burden exhibited marked regional differences that were closely associated with the level of SDI. ASYR varied significantly, with high-SDI regions showing the highest YLDs at 1,094.34 per 100,000 persons (95% UI: 792.26–1,459.42), whereas middle-SDI regions reported the lowest values at 717.45 per 100,000 persons (95% UI: 512.59–962.53) (Table 1 and Figure 1). Temporal trends in ASYR displayed distinct patterns across SDI levels, suggesting different stages of the epidemiological transition. The decline was most pronounced in high-middle SDI regions [EAPC 95% CI: –0.41377% (–0.4613 to –0.36622)], while the smallest decrease occurred in low-middle SDI regions [EAPC 95% CI: –0.1688% (–0.21585 to –0.12173)] (Table 1). Across the four continents, Europe had the highest YLDs, at 1152.36 per 100,000 persons (95% UI: 825.94–1,552.13), whereas Asia reported the lowest, at 727.55 per 100,000 persons (95% UI: 519.40–976.38). Among the continents, Africa showed the smallest decline [EAPC 95% CI: –0.08807% (–0.1141 to –0.06203)], while Asia experienced the largest decline [EAPC 95% CI: –0.31624% (–0.37349 to –0.25896)]. In the WHO regions, ASYR indicated that the European region had the highest YLDs, at 1,140.84 per 100,000 persons (95% UI: 817.42–1,536.72), while the Western Pacific region reported the lowest, at 675.49 per 100,000 persons (95% UI: 480.00–906.37). The Eastern Mediterranean region showed the most notable increase [EAPC 95% CI: 0.03455% (0.01601–0.05308)], whereas the Western Pacific region experienced the largest decline [EAPC 95% CI: –0.47598% (–0.54975 to –0.40216)]. At the GBD regional level, ASYR revealed that Central Europe had the highest YLDs, at 1,439.39 per 100,000 persons (95% UI: 1,027.23–1,934.40), while East Asia recorded the lowest, at 611.77 per 100,000 persons (95% UI: 433.79–820.52). Tropical Latin America exhibited the most significant increase [EAPC 95% CI: 0.07471% (0.05093–0.09850)], whereas East Asia experienced the greatest decline [EAPC 95% CI: –0.46227% (–0.56293 to –0.36151)]. National level In 2021, the ASPR of LBP ranged from approximately 5,020.83 to 14,024.64 per 100,000 persons. Among all countries, Hungary (14,024.64 per 100,000 persons; 95% UI: 12,361.13–15,712.34), the Czech Republic (13,298.59 per 100,000 persons; 95% UI: 11,720.80–14,874.21), and the Republic of Albania (13,011.72 per 100,000 persons; 95% UI: 11,468.98–14,627.03) showed the highest ASPR. By contrast, the Republic of Maldives (5,020.83 per 100,000 persons; 95% UI: 4,401.32–5,671.95), the Republic of the Union of Myanmar (5,056.85 per 100,000 persons; 95% UI: 4,441.86–5,710.22), and the Kingdom of Thailand (5,169.73 per 100,000 persons; 95% UI: 4,487.19–5,814.51) exhibited the lowest ASPR (Figure 2A; Supplementary Table S1). The ASIR of LBP ranged from approximately 2,215.56 to 5,408.81 per 100,000 persons. Among all countries, Hungary (5,408.81 per 100,000 persons; 95% UI: 4,788.39–6,085.51), the Republic of Poland (5,274.09 per 100,000 persons; 95% UI: 4,671.11–5,936.96), and the Czech Republic (5,240.01 per 100,000 persons; 95% UI: 4,603.17–5,944.22) reported the highest ASIR. By contrast, the Republic of Maldives (2,215.56 per 100,000 persons; 95% UI: 1,944.53–2,490.89), the Republic of the Union of Myanmar (2,246.83 per 100,000 persons; 95% UI: 1,987.45–2,538.18), and the Kingdom of Thailand (2,284.91 per 100,000 persons; 95% UI: 1,998.55–2,581.55) showed the lowest ASIR (Figure 2B; Supplementary Table S1). The ASYR of LBP ranged from approximately 564.98 to 1,573.52 per 100,000 persons. Hungary (1,573.52 per 100,000 persons; 95% UI: 1,118.61–2,089.53), the Czech Republic (1,488.41 per 100,000 persons; 95% UI: 1,068.88–2,002.20), and the Republic of Albania (1,465.12 per 100,000 persons; 95% UI: 1,042.24–1,978.49) exhibited the highest ASYR. In contrast, the Republic of Maldives (564.98 per 100,000 persons; 95% UI: 396.39–750.07), the Republic of the Union of Myanmar (565.48 per 100,000 persons; 95% UI: 396.38–750.32), and the Kingdom of Thailand (581.13 per 100,000 persons; 95% UI: 413.21–789.10) showed the lowest ASYR (Figure 2C; Supplementary Table S1). The changes in age-standardized ASPR varied substantially across countries between 1990 and 2021. The most pronounced decreases were observed in the Kingdom of Denmark [EAPC: −0.71111% (95% CI: −0.8168 to −0.6053)], the Republic of India [EAPC: −0.49875% (95% CI: −0.5564 to −0.4411)], and the People’s Republic of China [EAPC: −0.49686% (95% CI: −0.5744 to −0.4193)]. In contrast, Taiwan (Province of China) [EAPC: 0.64171% (95% CI: 0.5432–0.7402)], the Kingdom of Sweden [EAPC: 0.60490% (95% CI: 0.5106–0.6992)], and the Islamic Republic of Pakistan [EAPC: 0.43598% (95% CI: 0.3384–0.5336)] showed increases (Figure 3A; Supplementary Table S1). The changes in age-standardized ASIR also showed considerable cross-country variation. The steepest declines were recorded in the Kingdom of Denmark [EAPC: −0.47714% (95% CI: −0.55546 to −0.39876)], the Republic of India [EAPC: −0.45899% (95% CI: −0.56930 to −0.34855)], and the People’s Republic of China [EAPC: −0.46729% (95% CI: −0.56086 to −0.37363)]. By contrast, Taiwan (Province of China) [EAPC: 0.37326% (95% CI: 0.30885–0.43771)], the Kingdom of Sweden [EAPC: 0.61104% (95% CI: 0.45893–0.76337)], and the Islamic Republic of Pakistan [EAPC: 0.36208% (95% CI: 0.30718–0.41701)] exhibited increasing trends (Figure 3B; Supplementary Table S1). The changes in age-standardized ASYR showed considerable variation across countries. The steepest declines were observed in the Kingdom of Denmark [EAPC: −0.6965% (95% CI: −0.82847 to −0.56434)], the Republic of India [EAPC: −0.47778% (95% CI: −0.59773 to −0.35769)], and the People’s Republic of China [EAPC: −0.49382% (95% CI: −0.59830 to −0.38922)]. In contrast, Taiwan (Province of China) [EAPC: 0.63549% (95% CI: 0.54292–0.72815)], the Kingdom of Sweden [EAPC: 0.62396% (95% CI: 0.47235–0.77579)], and the Islamic Republic of Pakistan [EAPC: 0.43535% (95% CI: 0.36057–0.51019)] exhibited increases (Figure 3C; Supplementary Table S1). Age and sex patterns The global ASPR of LBP in 2021 showed a gradual increase in individuals aged 10–14 years and followed a zigzag upward trend, peaking at 80–84 years with a corresponding prevalence rate of 27,970.7 (95% UI: 21,366.2−35,617.5). The overall prevalence rate and the number of affected females were higher than those of males. Among females aged 50–54 years, the highest number of cases was 37,462,591.51 (95% UI: 27,061,745.79−50,874,702.05), after which the number decreased with increasing age (Figure 4A). The ASIR of LBP reached its highest level of 10,533.81 (95% UI: 10,618,004.62−20,782,300.28) in individuals aged 75–79 years, and it was higher among females in all age groups. The largest number of cases in the 50–54 age group was 15,315,569.57 (95% UI: 10,618,004.62−20,782,300.28), and this number decreased with increasing age (Figure 4B). The ASYR of LBP reached its highest level of 2825.86 (95% UI: 1865.65−4051.94) in the 80–84 age group and was consistently higher among females in all age groups. The quantity of YLDs in the 55–59 age group was the highest, at 42,151,796.7 (95% UI: 26,462,543.71−61,840,076.4). The global number of YLDs increased until the 55–59 age group and then decreased with increasing age, while both the number and YLD rate were consistently higher in females than in males (Figure 4C). Correlation with the SDI At the regional level, there was a clear positive relationship between the SDI and the ASPR, ASIR, and DALY rates of LBP from 1990 to 2021. For example, the ASPR first showed an exponential increase and then decreased as the SDI rose, with a correlation coefficient of R = 0.599 (0.549–0.644) and P < 0.001. From 1990 to 2021, the ASPR in Central Europe, Eastern Europe, Australasia, North Africa and the Middle East, Tropical Latin America, and Central Sub-Saharan Africa was higher than the expected growth for their sociodemographic indices. In contrast, the burdens in East Asia, Andean Latin America, Southern Sub-Saharan Africa, the Caribbean, and Oceania were lower than anticipated during the same period (Figure 5A). The ASIR also showed an exponential increase at first and then decreased as the SDI rose, with a correlation coefficient of R = 0.607 (0.558–0.651) and P < 0.001. From 1990 to 2021, the ASIR in Central Europe, Eastern Europe, Australasia, North Africa and the Middle East, Central Asia, Tropical Latin America, and Central Sub-Saharan Africa was higher than the expected growth for their sociodemographic indices. In contrast, the burdens in East Asia, Andean Latin America, Southern Sub-Saharan Africa, the Caribbean, and Oceania were lower than anticipated during the same period (Figure 5B). The ASYR also showed an exponential increase at first and then decreased as the SDI rose, with a correlation coefficient of R = 0.613 (0.564–0.657) and P < 0.001. From 1990 to 2021, the ASYR in Central Europe, Eastern Europe, Australasia, North Africa and the Middle East, Central Asia, Tropical Latin America, and Central Sub-Saharan Africa was higher than the expected growth for their sociodemographic indices. In contrast, the burdens in East Asia, Andean Latin America, Southern Sub-Saharan Africa, the Caribbean, and Oceania were lower than anticipated during the same period (Figure 5C). At the national level, there was a significant positive correlation between the SDI and the ASPR, ASIR, and DALY rates of LBP. For example, the ASPR showed an exponential decrease at first and then increased with higher levels of social and economic development, with a correlation coefficient of R = 0.412 (0.29–0.52) and P < 0.001. From 1990 to 2021, the ASPR in Albania, Hungary, Czechia, Romania, and Montenegro was higher than the expected growth for their sociodemographic indices (Supplementary Figure S1). The ASIR showed an exponential decrease at first and then increased with higher levels of social and economic development, with a correlation coefficient of R = 0.43 (0.31–0.536) and P < 0.001. From 1990 to 2021, the ASPR in Albania, Hungary, the Czech Republic, Romania, and Montenegro was higher than the expected growth, while the ASPR in Timor-Leste, Myanmar, the Maldives, Thailand, and Malaysia was lower than the expected growth (Supplementary Figure S2). The ASYR showed an initial exponential decrease and then increased with rising social and economic development, with a correlation coefficient of R = 0.423 (0.302−0.53, P < 0.001). From 1990 to 2021, the ASPR in Albania, Hungary, the Czech Republic, Romania, and Montenegro was higher than the expected growth, while in Timor-Leste, Myanmar, the Maldives, Thailand, and Malaysia it was lower than the expected growth (Supplementary Figure S3). Risk factors Globally, in 2021, occupational risks were the largest contributor to YLDs. Other significant factors included high BMI and tobacco use (Figure 6). In High-income North America, North Africa and the Middle East, and Oceania, however, high BMI was the leading contributor to YLDs. The proportion of LBP-related YLDs linked to high BMI in 2021 varied across SDI regions. Globally, 11.7% of LBP-related YLDs were attributed to high BMI. In high-SDI regions, the proportion was 14.8%, compared with only 6.2% in low-SDI regions. In 2021, 12.3% of LBP-related YLDs worldwide were attributed to tobacco use, representing a declining trend compared with previous years. In high-SDI regions, 15.9% of LBP-related YLDs were attributed to tobacco use, whereas only 6.7% in low-SDI regions were linked to high BMI. Occupational risks accounted for 22.1% of LBP-related YLDs globally in 2021, slightly lower than in prior years. In high-SDI regions, 15.1% of LBP-related YLDs were attributed to occupational risks, reflecting a modest decrease. By contrast, in low-SDI regions, as much as 33% of LBP-related YLDs were attributed to occupational risks. Decomposition analysis The decomposition analysis showed that population growth, aging, and epidemiological changes significantly contributed to trends in incidence, prevalence, and YLDs of LBP across the five SDI regions (Figure 7). Globally, population growth, aging, and epidemiological changes accounted for 40.66%, 145.38%, and −86.04% of the increase in incidence, with prevalence rising by −6.51%, 94.76%, and 11.75%, and YLDs by −53.68%, 177.19%, and −23.5%. Population growth remained the main driver of the global LBP burden. By sex, females consistently experienced a higher burden than males. At the regional level, population growth had the most notable effect across all SDI groups. Among them, prevalence was most prominent in the low SDI region, contributing 91.7%, while incidence and YLDs were highest in the middle SDI region at 112.84% and 93%, respectively. In the high-middle SDI region, aging had a relatively major effect on the LBP burden, with prevalence, incidence, and YLDs at 74.05%, 187.82%, and 149.48%, respectively. Epidemiological change had a minor negative effect, especially on incidence, with the middle SDI region most affected (−85.49%). Overall, population growth and aging drove a significant increase in LBP burden across SDI regions. When stratified by sex, females in all SDI regions faced a higher burden than males. Future forecasts of global burden of LBP From 2021 to 2050, the LBP burden is projected to change significantly, with ASPR, ASIR, and ASYR showing overall declines. However, in females, ASPR, ASIR, and ASYR may rise slightly, while in males, they are expected to fall. Female ASYR is projected to increase from 1,022 in 2021 to 1,029 per 100,000 in 2050, a rise of about 0.69% over 30 years. Male ASYR will drop from about 635 in 2021 to 537 per 100,000 in 2050, a decline of 15.44% over 30 years. Overall ASYR across both sexes will decrease from about 832 in 2021 to 777 per 100,000 in 2050, a reduction of 6.61% (Figure 8A). Female ASPR is forecasted to rise from 9,212 in 2021 to 9,766 per 100,000 in 2050, an increase of 60.26% over 30 years. Male ASPR will fall from 5,640 in 2021 to 4,914 per 100,000 in 2050, a decline of 12.88%. Overall ASPR across sexes will drop from 7,463 in 2021 to 6,795 per 100,000 in 2050, a decline of 8.95% (Figure 8B). Female ASIR is projected to rise from 3,880 in 2021 to 4,133 per 100,000 in 2050, an increase of 6.52%. Male ASIR will fall from 2,451 in 2021 to 2,159 per 100,000 in 2050, a decrease of 11.92%. Overall ASIR across sexes will decline from 3,177 in 2021 to 2,975 per 100,000 in 2050, a reduction of 6.36% (Figure 8C). Discussion This study provides a comprehensive analysis of the global LBP burden across 204 countries and regions from 1990 to 2021. It examines the disease burden from global, regional, and national perspectives, as well as age and sex distributions, risk factors, SDI, and future projections, highlighting the differences and complex patterns among regions and SDI levels. These findings offer valuable reference information for decision-making and health care planning. Globally, the ASPR, ASIR, and ASYR of LBP declined from 1990 to 2021. These findings are consistent with earlier GBD research, which also reported a downward trend in age-standardized annual rates of LBP [26] . At the regional level, high-SDI regions had the highest ASPR, ASIR, and ASYR rates, while middle-SDI regions had the lowest. This highlights ongoing socioeconomic inequalities in the global LBP burden. The higher burden in high-SDI regions may result from factors such as physical inactivity, obesity, and unhealthy diets [27; 28] . Moreover, the largest declines in ASPR, ASIR, and ASYR rates occurred in high-middle-SDI regions, whereas the smallest declines were observed in low-middle-SDI regions. Limited healthcare access, weak secondary prevention, and poor risk factor control may explain the slight decrease in low-middle-SDI regions [15] . Research has also shown that factors such as poor quality of life, low income, and limited education can worsen the LBP burden [29] . In contrast, high-middle-SDI regions may benefit from effective public health interventions, established healthcare systems, and better awareness of LBP risk factors and symptoms [30; 31] . Additionally, high rates of incidence, prevalence, and YLDs were observed in Europe, while lower rates occurred in Asia. The elevated burden in Europe may stem from occupational risks, high smoking rates, and population aging [32; 33] . Overall, LBP is a common condition with substantial global burden, making it critical to prioritize its management, prevention, and treatment. The risk analysis showed that occupational risks, tobacco use, and high BMI are the main contributors to the global LBP burden. In 2021, 11.7% of YLDs were linked to high BMI, 12.3% to tobacco, and 22.1% to occupational risks worldwide. The effects of these risk factors varied across SDI quintiles and regions. For example, in high SDI areas, 14.8% of YLDs were linked to high BMI compared with only 6.2% in low SDI areas. Likewise, 15.9% of YLDs were attributed to tobacco in high SDI, while only 6.7% were due to high BMI in low SDI. Occupational risks accounted for 15.1% of YLDs in high SDI but 33% in low SDI. Thus, a targeted prevention strategy is needed. For example, in middle- and low-income countries, occupational exposure is the main risk factor, and interventions targeting it could reduce the LBP burden [34; 35] .high-income countries, rising smoking rates and high BMI suggest more emphasis should be placed on healthy diets, physical activity, and smoking reduction to ease the obesity- and smoking-related burden [20; 36] . Multiple approaches are required to address these risks. In high-income nations, promoting healthier diets and workplace fitness initiatives may help foster regular activity. In low- and middle-income countries, tobacco control efforts such as smoke-free laws, higher taxes, and expanded cessation support should be strengthened. These targeted strategies could help reduce and prevent the global LBP burden. Furthermore, population growth, aging, and epidemiological changes significantly contributed to the trends of ASIR, ASPR, and ASYR of LBP in the five SDI regions. Globally, aging, population growth, and epidemiological changes accounted for 40.66%, 145.38%, and −86.04% of the rise in incidence rates; prevalence increased by −6.51%, 94.76%, and 11.75%; and YLDs changed by −53.68%, 177.19%, and −23.5%. Population growth was identified as the primary driver of the global LBP burden. The elevated burden among older people may reflect cumulative exposure to risk factors, reduced physical activity, and sedentary lifestyles [37; 38] . The increasing burden in older age groups could stem from these cumulative effects, alongside decreased activity levels that intensify the risk. Additionally, population aging has increased the proportion of individuals with spinal degeneration, such as lumbar disc herniation, thereby raising LBP prevalence [39] . In addition, population growth may coincide with accelerated urbanization, promoting widespread adoption of unhealthy lifestyles that further increase the LBP burden [40] . Addressing challenges from both aging and population growth is therefore essential. Pension systems should be strengthened, elderly care services improved, and balanced population development pursued through optimized distribution and greater investment in education. This study forecasts that ASYR, ASPR, and ASIR of LBP in females may rise slightly over the next 30 years, while rates in males are expected to decline. Countries should implement more efficient preventive measures targeting major causes of LBP. However, limitations in the data model and future socioeconomic changes may affect these projections. Thus, continuous monitoring and flexible adjustments to prevention strategies remain necessary. This research has several limitations. First, because changes in diagnostic criteria over time were estimated through modeling, some deviation from actual GBD data may have occurred, potentially leading to bias. Second, differences in data reporting standards and completeness across countries may have introduced uncertainty into the results. Third, as LBP cases were reported using diverse definitions and recall periods, the input data remain heterogeneous. Future studies should adopt more advanced analytical models and integrate more field-based survey data to strengthen prediction reliability. Conclusion In summary, although this study forecasts a decline in ASIR, ASPR, and ASYR of LBP from 2021 to 2050, the absolute burden remains substantial, with clear disparities across countries, regions, and SDI levels. These findings highlight the need for targeted prevention and treatment strategies tailored to different populations, especially in low- and middle-income countries. Promoting healthier diets, workplace fitness programs, and stronger tobacco control measures are essential steps to reduce the global burden of LBP. Author Contributions LYT: Conceptualization, Methodology, Data curation, Visualization, Validation, Writing – Original Draft, and Writing – Review & Editing. PPY, XFG and HLT: Data analysis, Literature investigation and interpretation, Data cleaning and verification. PY and XJW: Application and parameter optimization of data analysis tools, Statistical analysis implementation. KLW: Overall research supervision, Funding acquisition and management, Writing – original draft, Writing – review & editing, and Final manuscript approval. Acknowledgements The authors would like to thank all collaborators involved in GBD2021 study. The information, the results, or interpretation of the current study do not represent any opinion of the GBD. Conflicts of Interest Not applicable. Data Availability Statement The Global Burden of Disease (GBD) data used in this study are publicly accessible via the GHDx online platform (https://vizhub.healthdata.org/gbd-results/) and served as the primary data source for the analysis of low back pain burden in this research. Ethics approval Not applicable. References [1] Y. Wu, S. Wulf Hanson, G. Culbreth, C. Purcell, P. Brooks, J. Kopec, L. March, A.D. Woolf, M. Pasovic, E. Hamilton, D. Santomauro, and T. Vos, Assessing the impact of health-care access on the severity of low back pain by country: a case study within the GBD framework. The Lancet. Rheumatology 6 (2024) e598–e606, https://doi.org/10.1016/s2665-9913(24)00151-6. [2] D.G. Borenstein, and F. Balagué, Low Back Pain in Adolescent and Geriatric Populations. Rheumatic diseases clinics of North America 47 (2021) 149–163, https://doi.org/10.1016/j.rdc.2020.12.001. [3] A. Anselmo, M. Pagano, I. Cappadona, D. Cardile, R.S. Calabrò, and F. 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Trends in low back pain (LBP) prevalence, incidence, and years lived with disability (YLDs) from 1990 to 2021. Figure 2. The global disease burden of LBP for both sexes in 204 countries and territories. (A) Prevalence rate. (B) Incidence rate. (C) YLDs rate. Figure 3. The global disease burden of LBP for both sexes in 204 countries and territories. (A) Estimated annual percentage change (EAPC) for prevalence. (B) EAPC for incidence. (C) EAPC for YLDs. Figure 4. The global burden of LBP by age and sex in 2021. (A) Prevalent cases and prevalence rate per 100,000 population. (B) Incident cases and incidence rate per 100,000 population. (C) YLDs burden per 100,000 population. Figure 5. Association with the sociodemographic index (SDI) at the regional level. Age-standardized rate of prevalence (ASPR) (A), incidence (ASIR) (B), and years lived with disability (ASYR) (C) of LBP for the 21 Global Burden of Disease regions by SDI, 1990–2021. Thirty points are plotted for each region and show the observed ASPR/ASIR/ASYR from 1990 to 2021 for that region. Expected values, based on SDI and disease rates in all locations, are shown as a solid line. Regions above the solid line represent a higher-than-expected burden, and regions below the line show a lower-than-expected burden. Figure 6. Percentage of age-standardized YLDs rates of LBP attributable to risk factors. Figure 7. Decomposition analysis of LBP in working-age group changes from 1990 to 2021 at the global level by SDI quintile and sex. (A) Prevalence. (B) Incidence. (C) YLDs. Figure 8. Future forecasts of the global burden of LBP. (A) ASYR. (B) ASPR. (C) ASIR. Supplementary files Supplementary Figure S1 . ASPR of LBP for the 21 GBD countries by SDI, 1990–2021. Thirty points are plotted for each country and show the observed ASPR from 1990 to 2021 for that country. Expected values, based on SDI and disease rates in all locations, are shown as a solid line. Countries above the solid line represent a higher-than-expected burden, and countries below the line show a lower-than-expected burden. Supplementary Figure S2 . ASIR of LBP for the 21 GBD countries by SDI, 1990–2021. Thirty points are plotted for each country and show the observed ASIR from 1990 to 2021 for that country. Expected values, based on SDI and disease rates in all locations, are shown as a solid line. Countries above the solid line represent a higher-than-expected burden, and countries below the line show a lower-than-expected burden. Supplementary Figure S3 . ASYR of LBP for the 21 GBD countries by SDI, 1990–2021. Thirty points are plotted for each country and show the observed ASYR from 1990 to 2021 for that country. Expected values, based on SDI and disease rates in all locations, are shown as a solid line. Countries above the solid line represent a higher-than-expected burden, and countries below the line show a lower-than-expected burden. Supplementary Table S1 . Table 1. Global and regional trends in LBP burden: prevalence, incidence and YLDs (1990-2021). Supplementary Material File (figure 1.tif) Download 3.81 MB File (figure 3.tif) Download 5.09 MB File (figure 4.tif) Download 2.95 MB File (figure 5.tif) Download 11.33 MB File (figure 6.tif) Download 6.36 MB File (figure 7.tif) Download 9.56 MB File (figure 8.tif) Download 7.58 MB Information & Authors Information Version history V1 Version 1 01 December 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords disability-adjusted life years global burden of disease incidence low back pain prevalence Authors Affiliations Liangyuan Tan 0009-0008-8595-6226 The First Affiliated Hospital of Guangxi University of Chinese Medicine View all articles by this author Peipei Yang The First Affiliated Hospital of Guangxi University of Chinese Medicine View all articles by this author Xiaofeng Gan GuangXi University of Chinese Medicine View all articles by this author Hongliang Tang Fangchenggang Hospital of Chinese Medicine View all articles by this author Peng Yang Fangchenggang Hospital of Chinese Medicine View all articles by this author Xiongjiang Wang GuangXi University of Chinese Medicine View all articles by this author Kailong Wang 0000-0002-7069-9107 [email protected] The First Affiliated Hospital of Guangxi University of Chinese Medicine View all articles by this author Metrics & Citations Metrics Article Usage 351 views 147 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Liangyuan Tan, Peipei Yang, Xiaofeng Gan, et al. Global, regional, and national burden of low back pain, and associated risk factors from 1990 to 2021, with projections of incidence to 2050: A systematic analysis for the Global Burden of Disease Study 2021. Authorea . 01 December 2025. DOI: https://doi.org/10.22541/au.176459971.13506346/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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