Bahadur Sher Jung

Low back pain: a comprehensive review of The Lancet Low Back Pain Series

Lancet low back pain series is a series of three papers published in the Lancet Journal in 2018. The most important message highlighted by these papers, according to the Lancet, is quoted here:

A major challenge will be to stop the use of harmful practices while ensuring access to effective and affordable healthcare for people with low back pain. (THE LANCET)

Here we will discuss each paper in sequence as published in the Lancet journal, starting with the first paper (1) and then proceeding to the second (2) and third paper (3).

In this blog, we will discuss paper number 1: What low back pain is and why we need to pay attention.




Low back pain is the leading cause of disability in children, young individuals, and during mid-life, and in old age and extreme old age. It peaks in mid-life.
There has been an over 50% increase in prevalence, disability, and global burden of low back pain in the last 25 years from 1990 to 2015 (1).
Reproduced from Hartvigsen et al, 2018

More prevalent in high income countries compared to low and middle income countries and women appear to have more pain than men, but there is no difference in rural and urban areas (4).


There is significant social impact on the prevalence and disability of low back pain. We can divide the impact according to different occupational groups, cost and cost variations, healthcare system organization, and social compensation system. No matter from which aspect we look, the costs for low back pain appears to be very high. 


A review of 38 qualitative studies has pulled out four key points relating to the experience of people with persistent low back pain (5). The main question answered by this review is, "What does living with persistent low back pain do to an individual?"

What does living with persistent low back pain do to an individual?

  • Undermining the Influence of Pain. 
    Persistent low back pain can undermine the confidence of an individual. It usually relates to worry and fears about the social consequences of chronic low back pain.
  • A Disempowering Impact on All Levels
    Chronic low back pain can have a potential disempowering impact relating to hopelessness, family strain, social withdrawal, loss of job, and lack of money.
  • Unsatisfying Relationships with Healthcare
    In most cases of low back pain, there may be a lack of confirmation of a diagnosis, disappointment with healthcare encounters, and not feeling listened to. All of these can lead to an unsatisfying relationship with the healthcare system.
  • Learning to Live with Pain
    Lastly, chronic low back pain can influence the individual to come to terms with pain and learn self-management strategies to cope with the pain.


  • In clinics and our society, we mainly focus on the physical or biological component of back pain. According to the biological component, the potential nociceptive sources of back pain can include muscles, facet joints, discs, bones, and ligaments.
  • Recent studies suggest that the central nervous system plays an enormously important role in how pain is perceived and the consequences of pain in the individual. The biological component of back pain is not only in the back but also in the brain. With persistent pain, we see not only physiological but also anatomical changes in the brain. So it is about nociceptive input and pain processing.
  • Comorbidities like asthma, diabetes, poor mental health, poor nutrition, and pain in the other parts of body that can contribute to both the occurrence and to the consequences and disability of the back pain.
  • Social factors such as short education, low income, heavy physical work, and poor access to healthcare can all contribute to persistence and disability related to back pain.
  • Psychological factors and mental health, like depression, anxiety, illness perception and beliefs, low self-efficacy are very important components to consider in the patients with persistence low back pain.
  • Genetic disposition to back pain runs in family. Therefore it is an important contributor to chronic and persistent low back pain.

Reproduced from Hartvigsen, et al, 2018


The degree of pain does not reflect the extent of tissue damage in individual patients. Pain intensity and disability are significantly affected by circumstances and perceptions in our brains. The potential factors related to pain perception, intensity, and disability are:

  • Expectations
  • Experience
  • Fear and worry

These factors influence how we perceive pain and the consequences it has in our lives. Pain intensity and presence do not necessarily indicate any tissue damage in the back.


Persistent and recurrent pain is very common in the population, particularly in people who seek care. If we see people who seek primary care, 6-7 out of 10 people will either have persistent pain after one year or have experienced a recurrence (6). It is a complete paradigm shift in the way we understand back pain.
Reproduced from Itz CJ, Geurts JW, van Kleef M, Nelemans P., 2013

After pooling the data and results from many studies, it became clear that a small proportion of 5-7% will have severe and persistent pain regardless of the treatment they receive. Around 20% or a little more will recover completely and not have pain again. But the majority of patients who receive treatment have an episodic condition that comes and goes (7).
Reproduced from Kongsted A, Kent P, Axen I, Downie AS, Dunn KM, 2016

Patients get frustrated when they have a recurrence when in those cases, it might be the natural course of the condition. So it is better to inform the patients in advance about possible recurrences. Recurrence of back pain is a natural course in those patients, and it does not mean that the condition is worsening.
Whether the pain becomes persistent and disabling depends on how people cope with the pain, their perceived lack of control, whether they expect to recover from pain, negative beliefs, low levels of education, and low social class (8). We can manipulate these factors as clinicians to help the patient. Low back pain has a variable course.


  1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-67.
  2. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368-83.
  3. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-8.
  4. Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-37.
  5. MacNeela P, Doyle C, O'Gorman D, Ruane N, McGuire BE. Experiences of chronic low back pain: a meta-ethnography of qualitative research. Health Psychol Rev. 2015;9(1):63-82.
  6. Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain. 2013;17(1):5-15.
  7. Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC Musculoskeletal Disorders. 2016;17(1):220.
  8. Chen Y, Campbell P, Strauss VY, Foster NE, Jordan KP, Dunn KM. Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain. 2018;159(2):252-60.
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