Low back pain continues to be one of the most common health conditions worldwide and remains the leading cause of years lived with disability. A major new review published in JAMA provides an updated overview of the epidemiology, diagnosis, prognosis, and treatment of low back pain, offering important insights for clinicians and patients alike.

According to the review, approximately 619 million people worldwide were living with low back pain in 2020. The condition affects people of all ages, becomes more common with advancing age, and is more prevalent among women than men.

The review emphasizes that while low back pain is extremely common, most cases are not caused by serious disease. Instead, about 90% of patients have nonspecific low back pain, meaning no single anatomical structure can be reliably identified as the source of symptoms.

Low back pain is defined as pain located below the rib cage (costal margin) and above the gluteal folds, with or without associated leg pain.

The condition is typically classified according to symptom duration:

• Acute low back pain: less than 6 weeks
• Subacute low back pain: 6 to 12 weeks
• Chronic low back pain: longer than 12 weeks

Most patients seen in primary care do not have a serious underlying spinal disorder. Specific causes such as vertebral fracture, spinal infection, malignancy, inflammatory disease, or cauda equina syndrome are relatively uncommon.

Researchers note that low back pain is a complex biopsychosocial condition.

Rather than being caused by a single damaged structure, symptoms often arise from an interaction between:

• Biological factors
• Psychological factors
• Social influences
• Occupational demands
• Lifestyle factors

Several factors increase the likelihood of developing low back pain.

• Obesity
• Tobacco use
• Diabetes
• Asthma
• Previous episodes of low back pain
• Depressive symptoms

• Heavy lifting
• Repetitive physical work
• High workplace demands
• Low job control

• Increasing age
• Female sex

The prevalence rises steadily with age and peaks around 85 years.

Patients typically report:

• Pain in the lower back
• Difficulty bending
• Difficulty lifting objects
• Problems walking
• Reduced tolerance for sitting
• Reduced tolerance for standing
• Functional limitations at home and work

Pain may radiate into the buttock or thigh but often does not follow a specific nerve-root distribution.

Many patients experience symptom fluctuations, with pain worsening during certain activities and improving after movement modification or rest.

• History of cancer
• Fever
• Recent spinal infection
• Intravenous drug use
• Significant trauma
• Osteoporosis
• Long-term corticosteroid use
• Progressive neurological deficits
• New bowel dysfunction
• New bladder dysfunction
• Saddle anesthesia

One of the strongest messages from the review is that routine imaging should not be performed for most patients with nonspecific low back pain.

Researchers note that MRI and X-ray findings frequently reveal age-related degenerative changes even in people without symptoms.

Common findings include:

• Disc degeneration
• Disc bulges
• Facet arthropathy
• Endplate changes

These findings can lead to:

• Increased anxiety
• Unnecessary testing
• Inappropriate treatments
• Misattribution of symptoms

The review therefore recommends reserving imaging for patients with red-flag symptoms or specific clinical indications.

The outlook is generally favorable.

Approximately:

• 72% of patients recover within 12 months
• Most improvement occurs within the first 6 weeks

The prognosis is less optimistic.

Researchers found that:

• Only 42% recover within 12 months
• Many continue to experience persistent symptoms beyond one year

However, meaningful improvements in function and quality of life remain achievable even when pain persists.

The review highlights several evidence-based treatments for acute nonspecific low back pain.

Patients should be informed that:

1. Serious disease is unlikely.
2. Recovery is usually favorable.
3. Remaining active is important.
4. Bed rest should be avoided.

Self-management strategies include:

• Heat application
• Activity pacing
• Continuing daily activities
• Maintaining work participation when possible

Recommended options include:

• Superficial heat
• Spinal manipulation
• Massage
• Acupuncture

Recommended medications include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Skeletal muscle relaxants

Examples cited in the review include ibuprofen, naproxen, celecoxib, cyclobenzaprine, and tizanidine.

Several commonly used treatments showed limited benefit.

Not routinely recommended:

• Acetaminophen (paracetamol) alone
• Benzodiazepines
• Systemic corticosteroids

Not recommended because of limited efficacy or increased risks:

• Long-term opioids
• Antiepileptic medications
• Routine corticosteroids
• Routine skeletal muscle relaxants
• Transcutaneous electrical nerve stimulation (TENS)
• Lumbar supports
• Therapeutic ultrasound

For chronic low back pain, the emphasis shifts away from medication and toward active rehabilitation.

Researchers found benefits from:

• Strength training
• Aerobic exercise
• Pilates
• Flexibility programs
• Combined exercise approaches

Importantly, no single exercise type appears superior.

The best program is often the one patients enjoy and can consistently perform.

Evidence supports:

• Cognitive behavioral therapy (CBT)
• Pain education
• Mindfulness-based approaches
• Cognitive functional therapy

These therapies help patients address fear of movement, maladaptive beliefs, and behavioral patterns that contribute to persistent disability.

Integrated programs combining:

• Exercise
• Psychological treatment
• Vocational support
• Medical management

appear to provide the greatest overall benefit for many patients with chronic symptoms.

The review found little evidence supporting invasive procedures for nonspecific chronic low back pain.

• Epidural steroid injections
• Facet joint injections
• Routine spinal cord stimulation
• Routine spinal fusion surgery
• Disc replacement surgery

These interventions should only be considered in carefully selected patients after extensive conservative treatment has failed.