Prevalence of chronic low back pain: systematic review

Meucci, Rodrigo Dalke; Fassa, Anaclaudia Gastal; Faria, Neice Muller Xavier

doi:10.1590/S0034-8910.2015049005874

Abstracts

OBJECTIVE

To estimate worldwide prevalence of chronic low back pain according to age and sex.

METHODS

We consulted Medline (PubMed), LILACS and EMBASE electronic databases. The search strategy used the following descriptors and combinations: back pain, prevalence, musculoskeletal diseases, chronic musculoskeletal pain, rheumatic, low back pain, musculoskeletal disorders and chronic low back pain. We selected cross-sectional population-based or cohort studies that assessed chronic low back pain as an outcome. We also assessed the quality of the selected studies as well as the chronic low back pain prevalence according to age and sex.

RESULTS

The review included 28 studies. Based on our qualitative evaluation, around one third of the studies had low scores, mainly due to high non-response rates. Chronic low back pain prevalence was 4.2% in individuals aged between 24 and 39 years old and 19.6% in those aged between 20 and 59. Of nine studies with individuals aged 18 and above, six reported chronic low back pain between 3.9% and 10.2% and three, prevalence between 13.1% and 20.3%. In the Brazilian older population, chronic low back pain prevalence was 25.4%.

CONCLUSIONS

Chronic low back pain prevalence increases linearly from the third decade of life on, until the 60 years of age, being more prevalent in women. Methodological approaches aiming to reduce high heterogeneity in case definitions of chronic low back pain are essential to consistency and comparative analysis between studies. A standard chronic low back pain definition should include the precise description of the anatomical area, pain duration and limitation level.

Low Back Pain, epidemiology; Pain Measurement; Prevalence; Review

OBJETIVO

Estimar a prevalência mundial de dor lombar crônica, segundo idade e sexo.

MÉTODOS

Foram consultadas as bases de dados eletrônicas Medline (PubMed), Lilacs e Embase. A estratégia de busca utilizou os seguintes descritores:back pain, prevalence_,musculoskeletal diseases_,chronic musculoskeletal pain_,rheumatic_,low back pain_,musculoskeletal disorders e chronic low back pain . Foram selecionados os estudos de base populacional de delineamento transversal ou coortes que avaliaram dor lombar crônica como desfecho. A qualidade dos estudos selecionados foi avaliada, assim como a prevalência de dor lombar crônica, segundo idade e sexo.

RESULTADOS

Foram incluídos 28 estudos nesta revisão. De acordo com a avaliação qualitativa, cerca de um terço dos estudos tiveram pontuação baixa, principalmente em decorrência das altas taxas de não respondentes. A prevalência de dor lombar crônica foi de 4,2% em indivíduos com idade entre 24 e 39 anos e 19,6% entre aqueles de 20 a 59 anos. Dentre nove estudos com indivíduos com 18 anos ou mais, em seis a prevalência de dor lombar crônica variou entre 3,9% a 10,2%, e nos outros três estudos a prevalência foi entre 13,1% e 20,3%. Entre idosos brasileiros, a prevalência de dor lombar crônica foi de 25,4%.

CONCLUSÕES

A prevalência de dor lombar crônica aumenta linearmente a partir da terceira década de vida até os 60 anos de idade, sendo mais prevalente nas mulheres. Questões metodológicas visando a reduzir a alta heterogeneidade nas definições de casos nos estudos sobre dor lombar crônica são fundamentais para permitir análises comparativas e de consistência entre diferentes estudos. A definição de dor lombar crônica deve incluir a descrição precisa da área anatômica, período de duração da dor e nível de limitação.

Dor Lombar, epidemiologia; Medição da Dor; Prevalência; Revisão

INTRODUCTION

Low back pain is a common condition affecting many individuals at some point in their lives.⁴4 Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354(9178):581-5. DOI:10.1016/S0140-6736(99)01312-4 The estimation is that between 5.0% and 10.0% of cases will develop chronic low back pain (CLBP), which is responsible for high treatment costs, sick leave, and individual suffering,²⁶26 Liao ZT, Pan YF, Huang JL, Huang F, Chi WJ, Zhang KX, et al. An epidemiological survey of low back pain and axial spondyloarthritis in a Chinese Han population. Scand J Rheumatol. 2009;38(6):455-9. DOI:10.3109/03009740902978085

27 Loisel P, Lemaire J, Poitras S, Durand MJ, Champagne F, Stock S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occup Environ Med . 2002;59(12):807-15. DOI:10.1136/oem.59.12.807^-²⁸28 Melloh M, Röder C, Elfering A, Theis JC, Müller U, Staub LP, et al. Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol. BMC Musculoskelet Disord. 2008;9:81. DOI:10.1186/1471-2474-9-81 in addition to being one of the main reasons for people to seek health care services.¹³13 Esteban-Vasallo MD, Domínguez-Berjón MF, Astray-Mochales J, Genova-Maleras R, Pérez-Sania A, Sánchez-Perruca L, et al. Prevalencia de enfermedades crónicas diagnosticadas en población inmigrante y autóctona.Gac Sanit . 2009;23(6):548-52. DOI:10.1590/S0213-91112009000600012^,²⁸28 Melloh M, Röder C, Elfering A, Theis JC, Müller U, Staub LP, et al. Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol. BMC Musculoskelet Disord. 2008;9:81. DOI:10.1186/1471-2474-9-81 Although CLBP is highly disabling, information about its prevalence and associated factors are scattered in the literature. Most results are presented in a secondary way in studies evaluating several musculoskeletal outcomes simultaneously. Moreover, we found great variability among studies as to the characterization of chronic and low back pain. A systematic review of the global prevalence of low back pain included a summary prevalence of chronic low back pain.²¹21 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. DOI:10.1002/art.34347 However, the prevalence estimates found by the authors were based on studies with great variability concerning anatomical characterization of the low back region. Thus, the included studies have definitions according to which back and/or neck pain were considered low back pain.²¹21 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. DOI:10.1002/art.34347 This lack of standardization disregard specificities of the cervical, thoracic and lumbar spine as well as the attempts in the literature to standardize low back pain studies.¹¹11 Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R,. Walker BF, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976). 2008;33(1):95-103. DOI:10.1097/BRS.0b013e31815e7f94

The objective of this review was to estimate the worldwide chronic low back pain prevalence according to age and sex.

METHODS

We consulted electronic databases without any restrictions regarding language or year of publication, and the final database search took place on June 8, 2014. We searched terms as words to broad the number of references retrieved.

The search strategy varied according to the database, as follows:

Medline: back pain [Mesh] AND prevalence [Mesh], chronic musculoskeletal pain prevalence, rheumatic low back pain, musculoskeletal disorders low back pain prevalence, chronic low back pain AND prevalence;

LILACS: back pain AND prevalence, chronic musculoskeletal pain prevalence, rheumatic low back pain, musculoskeletal disorders low back pain prevalence, chronic low back pain AND prevalence;

EMBASE: back pain AND prevalence, chronic musculoskeletal pain prevalence, rheumatic low back pain, musculoskeletal disorders low back pain prevalence, "chronic low back pain" AND "prevalence".

All references retrieved from the databases were exported to EndNote^®. To identify duplicated studies, we used the EndNote^® "find duplicates" tool configured to compare titles and authors from the retrieved references, and manually excluded duplicates not identified by the program.

In the review, we excluded publications with titles that enabled the identification of studies conducted with specific populations such as students, occupational groups or individuals with specific illnesses as well as literature reviews. In the following stage, we read the abstracts. Those that enabled the identification of literature reviews or studies assessing musculoskeletal outcomes other than chronic low back pain and studies using convenience samples were also excluded.

After the abstracts, the studies selected were read and excluded if they assessed occupational groups, used convenience samples, or if they lack definition on the anatomical location of low back pain or the period of time determining pain as being chronic. Studies assessing chronic low back pain in individuals with low back pain, which provide insufficient information to calculate the prevalence of this outcome in the entire sample, were also excluded.

The searches focused on population-based or cohort studies evaluating CLBP prevalence. Only studies with a clear definition of low back pain and time criteria for pain chronicity were selected.

We identified the following characteristics of the selected studies: country, response rate, number of individuals evaluated/interviewed, age group, low back pain definition, use of human body drawings, and chronic pain definition. CLBP prevalence was then extracted and the confidence interval was calculated for those studies without information about it.

The studies were evaluated according to a quality tool adapted from Hoy et al,²¹21 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. DOI:10.1002/art.34347 which included eight items: sample representativeness, sample size estimates, census or random sampling process, non-respondent bias probability, primary data collection, validated questionnaire instrument, standardized data collection, and human body drawings (Table 1). A score index was built whereby a weighting of 0.2 was attributed to sample representativeness, census or random sample, and non-respondent bias probability. A weighting of 0.08 was attributed to the remaining five items, thus enabling a maximum score of 1. More weighting was attributed to those characteristics with greater potential of causing bias in chronic low back pain prevalence estimates.

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Table 1
Chronic low back pain according to population-based studies.

We reported this systematic review according to the PRISMA Statement.³⁰30 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting Items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097. DOI:10.1371/journal.pmed.1000097

RESULTS

We found twenty-eight studies that fulfilled the inclusion criteria, which were thus included in this review (Figure 1). Of the twenty-five original population-based cross-sectional studies, 13 were European,³3 Altinel L, Köse KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. [The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey]. Acta Orthop Traumatol Turc. 2008;42(5):328-33. Turkish.^,⁵5 Andersson HI. The epidemiology of chronic pain in a Swedish rural area. Qual Life Res . 1994;3 Suppl 1:S19-26.

6 Bjorck-van Dijken C, Fjellman-Wiklund A, Hildingsson C. Low back pain, lifestyle factors and physical activity: a population based-study.J Rehabil Med . 2008;40(10):864-9. DOI:10.2340/16501977-0273^-⁷7 Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden.Pain . 1989;37(2):215-22.^,¹⁸18 Heuch I, Hagen K, Nygaard O, Zwart JA. The impact of body mass index on the prevalence of low back pain: the HUNT study. Spine (Phila Pa 1976). 2010;35(7):764-8. DOI:10.1097/BRS.0b013e3181ba1531

19 Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA. Prevalence of low back pain in the community: implications for service provision in Bradford, UK. J Epidemiol Community Health. 1996;50(3):347-52. DOI:10.1136/jech.50.3.347^-²⁰20 Hoddevik GH, Selmer R. [Chronic low back pain in 40-year olds in 12 Norwegian counties]. Tidsskr Nor Laegeforen. 1999;119(15):2224-8. Norwegian^,²²22 Jacobsson L, Lindgärde F, Manthorpe R. The commonest rheumatic complaints of over six weeks' duration in a twelve-month period in a defined Swedish population: prevalences and relationships. Scand J Rheumatol. 1989;18(6):353-60. DOI:10.3109/03009748909102096^,²³23 Jiménez-Sánchez S, Fernández-de-Las-Peñas C, Carrasco-Garrido P, Hernández-Barrera V, Alonso-Blanco C, Palacios-Ceña D, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit . 2012;26(6):534-40. DOI:10.1016/j.gaceta.2011.10.012^,³¹31 Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90.^,³³33 Oostrom SH, Verschuren M, Vet HC, Boshuizen HC, Picavet HSJ. Longitudinal associations between physical load and chronic low back pain in the general population: the Doetinchem Cohort Study. Spine (Phila Pa 1976). 2012;37(9):788-96. DOI:10.1097/BRS.0b013e31823239d1

34 Palmer KT, Calnan M, Wainwright D, Poole J, O'Neill C, Winterbottom A, et al. Disabling musculoskeletal pain and its relation to somatization: a community-based postal survey. Occup Med (Lond). 2005;55(8):612-7. DOI:10.1093/occmed/kqi142^-³⁵35 Park CH, Wagener DK, Winn DM, Pierce JP. Health conditions among the currently employed. Vital Health Stat Series 10. 1993;(186):1-67. five were North American (USA and Canada),¹1 Alkherayf F, Agbi C. Cigarette smoking and chronic low back pain in the adult population. Clin Invest Med . 2009;32(5):E360-7.^,⁸8 Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine (Phila Pa 1976) . 1995;20(3):312-7.^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,³²32 Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007 four were South American (Brazil),²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,⁹9 Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML Dor crônica em idosos residentes em São Paulo, Brasil: prevalência, características e associação com capacidade funcional e mobilidade (Estudo SABE). Cad Saude Publica. 2013;29(2):325-34. DOI:10.1590/S0102-311X2013000200019^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁷37 Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.Pain . 2003;102(1-2):167-78. DOI:10.1016/s0304-3959(02)00372 two were Asian (Japan and China)¹⁵15 Fujii T, Matsudaira K, Oka H. The association between compensation and chronic disabling back pain. J Orthop Sci. 2012;17(6):694-8. DOI:10.1007/s00776-012-0282-0^,²⁶26 Liao ZT, Pan YF, Huang JL, Huang F, Chi WJ, Zhang KX, et al. An epidemiological survey of low back pain and axial spondyloarthritis in a Chinese Han population. Scand J Rheumatol. 2009;38(6):455-9. DOI:10.3109/03009740902978085 and one was African (Nigeria)³¹31 Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90. (Table 1). The response rate was greater than 75.0% in fifteen studies. Two articles did not report the response rate (Table 1).

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Figure 1
Selection process for studies of chronic low back pain prevalence.

Regarding studies using a population-based cohort design, a Norwegian study performed a census of the population aged over 20 in a given province and did not report the proportion of males and females.¹⁶16 Hagen K, Linde M, Heuch I, Stovner LJ, Zwart JA. Increasing prevalence of chronic musculoskeletal complaints: a large 11-year follow-up in the general population (HUNT 2 and 3). Pain Med . 2011;12(11):1657-66. DOI:10.1111/j.1526-4637.2011.01240.xThe other studies used random sampling of individuals of both sexes aged between 20 and 65.³⁸38 Shiri R, Solovieva S, Husgafvel-Pursiainen K, Taimela S, Saarikoski LA, Huupponen R, et al. The association between obesity and the prevalence of low back pain in young adults: the Cardiovascular Risk in Young Finns Study.Am J Epidemiol . 2008;167(9):1110-9. DOI:10.1093/aje/kwn007^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 The follow-up rates of the cohort studies varied between 53.0% and 79.0% (Table 1).

Thirteen of the population-based cross-sectional studies defined chronic pain as a period of continuous pain lasting more than three months; seven used a "over six months" criterion, two used continuous pain, two others used pain lasting for more than seven weeks, and one used pain lasting for more than six weeks. All three population-based cohort studies used the same criterion (pain lasting more than three months).

Regarding the qualitative analysis of the reviewed papers, all studies achieved scores in their description of a census or random sampling process, primary data collection, and standardized data collection; 27 studies had representative samples of the target population; 19 studies had small non-respondent bias probability; only four articles described the sample size estimates; three papers evaluated the study questionnaire reliability; and 10 studies used human body drawings to locate low back pain (Table 2).

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Table 2
Qualitative evaluation of the assessed studies.

According to the score index, nine studies scored between 0.56 and 0.64. The main reason for the low scores found by these studies were their high non-response rates. Eleven studies scored between 0.72 and 0.76. Most of these did not obtain scores for instrument validation, use of human body drawings, and sample size calculation. Eight studies scored between 0.84 and 0.92, and the items that resulted in these high scores were "use of medical manikin" or "human body drawing", and "sample size calculation" (Table 2).

Considering only cross-sectional population-based studies with response rates above 75.0%, CLBP prevalence was 4.2% in individuals aged 24 to 39³⁸38 Shiri R, Solovieva S, Husgafvel-Pursiainen K, Taimela S, Saarikoski LA, Huupponen R, et al. The association between obesity and the prevalence of low back pain in young adults: the Cardiovascular Risk in Young Finns Study.Am J Epidemiol . 2008;167(9):1110-9. DOI:10.1093/aje/kwn007 years and 19.6% in those aged 20 to 59.¹1 Alkherayf F, Agbi C. Cigarette smoking and chronic low back pain in the adult population. Clin Invest Med . 2009;32(5):E360-7. In six out of nine studies²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,³3 Altinel L, Köse KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. [The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey]. Acta Orthop Traumatol Turc. 2008;42(5):328-33. Turkish.^,⁷7 Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden.Pain . 1989;37(2):215-22.^,⁸8 Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine (Phila Pa 1976) . 1995;20(3):312-7.^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³¹31 Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90.^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 with individuals aged 18, 19, 20, 21 years or above, CLBP varied between 3.9% and 10.2%.⁸8 Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine (Phila Pa 1976) . 1995;20(3):312-7.^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³¹31 Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90.^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 Three reported higher prevalence rates (13,1%, 14.7%, and 20.3%).²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,³3 Altinel L, Köse KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. [The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey]. Acta Orthop Traumatol Turc. 2008;42(5):328-33. Turkish.^,⁷7 Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden.Pain . 1989;37(2):215-22. CLBP prevalence was 23.3% in individuals aged 25 to 74⁵5 Andersson HI. The epidemiology of chronic pain in a Swedish rural area. Qual Life Res . 1994;3 Suppl 1:S19-26. (Table 1) and 25.4% among older adults (≥ 60 years old).⁹9 Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML Dor crônica em idosos residentes em São Paulo, Brasil: prevalência, características e associação com capacidade funcional e mobilidade (Estudo SABE). Cad Saude Publica. 2013;29(2):325-34. DOI:10.1590/S0102-311X2013000200019 We found no difference in relation to CLBP prevalence at different periods of the year or in different places.

Five studies with high response rates presented CLBP prevalence according to specific age groups.²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 Figure 2 shows that CLBP prevalence rates are lower in younger individuals (aged 20 to 30 years), increasing from the third decade of life on, reaching the highest proportions between 50 and 60 years of age, and stabilizing in the seventh decade of life.

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Figure 2
Chronic low back pain prevalence (CLBP) according to age (six estimates).

Two studies (Figure 2) showed that CLBP occurrence has doubled in recent years in North Carolina and in Pelotas in all age groups analysed.¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155

In five²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 of nine²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,³3 Altinel L, Köse KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. [The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey]. Acta Orthop Traumatol Turc. 2008;42(5):328-33. Turkish.^,⁷7 Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden.Pain . 1989;37(2):215-22.^,⁸8 Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine (Phila Pa 1976) . 1995;20(3):312-7.^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³¹31 Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90.^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 studies with individuals (or older than) 18, 19, 20, or 21 years old and response rates above 75.0%, CLBP prevalence was around 50.0% higher in women than in men (Figure 3).

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Figure 3
Chronic low back pain (CLBP) according to sex (nine estimates).

Only eight studies¹1 Alkherayf F, Agbi C. Cigarette smoking and chronic low back pain in the adult population. Clin Invest Med . 2009;32(5):E360-7.^,²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,¹⁵15 Fujii T, Matsudaira K, Oka H. The association between compensation and chronic disabling back pain. J Orthop Sci. 2012;17(6):694-8. DOI:10.1007/s00776-012-0282-0^,²³23 Jiménez-Sánchez S, Fernández-de-Las-Peñas C, Carrasco-Garrido P, Hernández-Barrera V, Alonso-Blanco C, Palacios-Ceña D, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit . 2012;26(6):534-40. DOI:10.1016/j.gaceta.2011.10.012^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³²32 Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 evaluated CLBP prevalence using other independent variables. One study showed that CLBP prevalence is higher in white and black non-Hispanic individuals in relation to Hispanic individuals.¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543 Four studies showed that individuals with less schooling have more CLBP than those with more schooling.¹⁵15 Fujii T, Matsudaira K, Oka H. The association between compensation and chronic disabling back pain. J Orthop Sci. 2012;17(6):694-8. DOI:10.1007/s00776-012-0282-0^,²³23 Jiménez-Sánchez S, Fernández-de-Las-Peñas C, Carrasco-Garrido P, Hernández-Barrera V, Alonso-Blanco C, Palacios-Ceña D, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit . 2012;26(6):534-40. DOI:10.1016/j.gaceta.2011.10.012^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 Two studies found that individuals of lower economic status had higher CLBP prevalence than those of higher economic status.²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 Six studies assessed CLBP prevalence using smoking as a variable. In all six studies, smokers had more CLBP than non-smokers.¹1 Alkherayf F, Agbi C. Cigarette smoking and chronic low back pain in the adult population. Clin Invest Med . 2009;32(5):E360-7.^,²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,¹⁵15 Fujii T, Matsudaira K, Oka H. The association between compensation and chronic disabling back pain. J Orthop Sci. 2012;17(6):694-8. DOI:10.1007/s00776-012-0282-0^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³²32 Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 Three studies²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³²32 Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 found that obese individuals have more CLBP than eutrophic individuals (Table 3).

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Table 3
Chronic low back pain according to other variables in population-based studies, except age and sex.

According to the population-based cohort studies, CLBP prevalence was of 6.3% in England and 23.0% in Norway.¹⁶16 Hagen K, Linde M, Heuch I, Stovner LJ, Zwart JA. Increasing prevalence of chronic musculoskeletal complaints: a large 11-year follow-up in the general population (HUNT 2 and 3). Pain Med . 2011;12(11):1657-66. DOI:10.1111/j.1526-4637.2011.01240.x^,³²32 Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007^,⁴⁰40 Waxman R, Tennant A, Helliwell P. A prospective follow-up study of low back pain in the community. Spine (Phila Pa 1976). 2000;25(16):2085-90. CLBP incidence in at least one follow-up session was 10.8%, whereas persistence in all three follow-up sessions was 5.6% (Table 1).³²32 Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007

DISCUSSION

Almost half the studies included in this systematic review had a response rate lower than 75.0%. The criteria for chronic low back pain case definition are heterogeneous. The most common criterion was continuous pain for a period equal to or greater than three months. Based on our qualitative evaluation, around one third of the studies obtained low scores, mainly due to high non-response rates. CLBP prevalence varied according to the age ranges in the studies and was around three to four times higher in individuals aged over 50 compared to those aged 18 to 30. Females, people of lower economic status, those with less schooling, and smokers had higher CLBP prevalence compared to males, people with higher economic status, those with more schooling, and non-smokers, respectively.

In relation to the quality of the studies, the instrument used showed that the main characteristic that reduced their score was the high rate of non-respondents. This limitation makes clear the challenge to reduce the proportion of non-respondents in population-based studies, especially in countries where postal surveys are used. The instrument used included eight evaluation questions contemplating most items applicable to observational studies on the checklist proposed by Downs and Black,¹²12 Downs SH, Black N. The feasibility of creating a check list for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. DOI:10.1136/jech.52.6.377 mainly concerning sample representativeness. In this review, we attributed more weight to these items.

Two studies indicated that CLBP prevalence doubled over time.¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155 This might reflect important changes in lifestyle and in the world of work. The intensive use of computers at work and at home as well as other technologies has increased sedentariness – a risk factor for chronic and acute low back pain due to muscle weakness.¹⁷17 Heneweer H, Vanhees L, Picavet HS. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143(1-2):21-5. DOI:10.1016/j.pain.2008.12.033^,²⁵25 Knuth AG, Bacchieri G, Victora CG, Hallal PC. Changes in physical activity among Brazilian adults over a five-year period. J Epidemiol Community Health. 2009;64(7):591-5. DOI:10.1136/jech.2009.088526 Obesity is also related to lifestyle and is a known risk factor for CLBP as it promotes overloading of the articular structures of lumbosacral spine, which become predisposed to degeneration.²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155

The increase in CLBP prevalence among individuals aged 30 to 60 may also be related to occupational and domestic exposures that overload the low back along with the degenerative articular process shown after 30 years of age. Although CLBP stabilizes or reduces from the seventh decade of life on, its prevalence remains high when compared to younger individuals (aged 20-30). This reduction among older people may be due to reduced exposure to occupational and everyday activities that increase the risk for CLBP.²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 The literature also suggests that older adults are more resilient to pain due to factors related to ageing, such as cognitive impairment and decreased pain perception.²¹21 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. DOI:10.1002/art.34347

The mechanism whereby females have consistently higher CLPB prevalence is partially known.²2 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Prevalência de dor lombar crônica na população da cidade de Salvador. Rev Bras Ortop. 2008;43(3):96-102. DOI:10.1590/S0102-36162008000200007^,³3 Altinel L, Köse KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. [The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey]. Acta Orthop Traumatol Turc. 2008;42(5):328-33. Turkish.^,⁵5 Andersson HI. The epidemiology of chronic pain in a Swedish rural area. Qual Life Res . 1994;3 Suppl 1:S19-26.^,¹⁴14 Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543^,²⁴24 Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002^,²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁸38 Shiri R, Solovieva S, Husgafvel-Pursiainen K, Taimela S, Saarikoski LA, Huupponen R, et al. The association between obesity and the prevalence of low back pain in young adults: the Cardiovascular Risk in Young Finns Study.Am J Epidemiol . 2008;167(9):1110-9. DOI:10.1093/aje/kwn007^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 This might be related to women's exposure to musculoskeletal loads due to pregnancy, child care, and double workday (domestic tasks plus paid work). Furthermore, physiological characteristics such as less muscle and bone mass as well as psychological factors may contribute to higher CLBP prevalence among them.²¹21 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. DOI:10.1002/art.34347

Higher CLBP prevalence in individuals with less income and less schooling may be related to inferior living and working conditions, which can lead them to jobs that have greater risk to the lumbar spine.²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155 Regarding the higher proportion of CLBP among smokers, this is caused by the systemic effects of nicotine on the joints of the spine, accelerating the joint degeneration process, and increasing the potential of transmission of pain impulses in the central nervous system.²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005 According to the literature, overweight or obese individuals are subject to greater loads on the lumbar spine, thus favoring the development of chronic pain in this region.²⁹29 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155^,³⁹39 Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005

Hoy et al²¹21 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. DOI:10.1002/art.34347 made a valuable contribution to low back pain studies and estimated a summary prevalence of CLBP of 20.1% (SD = 9.8). However, these results should be critically evaluated given that this prevalence estimation included inaccurate outcome definitions such as back and neck as synonyms for low back.²¹21 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. DOI:10.1002/art.34347Our systematic review used a stricter definition of CLBP for low back location. Moreover, having CLBP as a primary focus of interest allowed more in-depth discussion on its specificities, which are usually dispersed among time periods of varying durations estimating how recently pain occurred.

Although this systematic review only included studies with a precise definition of low back pain regarding its anatomical location, heterogeneity in chronic pain definition may have influenced the prevalence rates reported, and this is therefore a limitation to our study. Similarly, since CLBP is frequently a secondary outcome, little information are available about its prevalence to other covariables and this is a significant gap in knowledge regarding CLBP.

Moreover, the lack of standardized methods between studies about the subject hinders the evaluation of occurrence measurements and CLBP associated factors in observational studies, as well as the evaluation of the treatment efficacy for this problem. Therefore, methodological approaches aiming to reduce high heterogeneity are key to provide consistency and comparative analysis between different studies, systematic reviews, and meta-analysis. A standard CLBP definition should include the anatomical area of reference, period of pain evaluation, limitation level, and proper differentiation between acute and CLBP. These recommendations are in keeping with the recent National Institute of Health (NIH) Pain Consortium Task Force on research standards for CLBP, which defined this outcome as a back pain problem that has persisted for at least three months and has resulted in pain on at least half the days in the past six months. NIH suggested a minimum data set for evaluating CLBP, which includes a human body drawing showing the lumbar spine, as well as studying limitations in everyday activities arising from CLBP.¹⁰10 Deyo RA, Dworkin SF, Amtmann D, Andersson G, Borenstein D, Carragee E, et al. Report of the NIH Task Force on research standards for chronic low back pain. Spine (Phila Pa 1976). 2014;39(14):1128-43. DOI:10.1097/brs.0000000000000434

Moreover, CLBP studies need some improvement in developing countries and other regions, given that the large concentration of studies in European countries shows higher CLBP prevalence in older populations, mainly in Caucasian individuals with better living conditions.

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¹
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²
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³
Altinel L, Köse KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. [The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey]. Acta Orthop Traumatol Turc. 2008;42(5):328-33. Turkish.
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Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML Dor crônica em idosos residentes em São Paulo, Brasil: prevalência, características e associação com capacidade funcional e mobilidade (Estudo SABE). Cad Saude Publica. 2013;29(2):325-34. DOI:10.1590/S0102-311X2013000200019
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Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R,. Walker BF, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976). 2008;33(1):95-103. DOI:10.1097/BRS.0b013e31815e7f94
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Downs SH, Black N. The feasibility of creating a check list for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. DOI:10.1136/jech.52.6.377
¹³
Esteban-Vasallo MD, Domínguez-Berjón MF, Astray-Mochales J, Genova-Maleras R, Pérez-Sania A, Sánchez-Perruca L, et al. Prevalencia de enfermedades crónicas diagnosticadas en población inmigrante y autóctona.Gac Sanit . 2009;23(6):548-52. DOI:10.1590/S0213-91112009000600012
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Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543
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Fujii T, Matsudaira K, Oka H. The association between compensation and chronic disabling back pain. J Orthop Sci. 2012;17(6):694-8. DOI:10.1007/s00776-012-0282-0
¹⁶
Hagen K, Linde M, Heuch I, Stovner LJ, Zwart JA. Increasing prevalence of chronic musculoskeletal complaints: a large 11-year follow-up in the general population (HUNT 2 and 3). Pain Med . 2011;12(11):1657-66. DOI:10.1111/j.1526-4637.2011.01240.x
¹⁷
Heneweer H, Vanhees L, Picavet HS. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143(1-2):21-5. DOI:10.1016/j.pain.2008.12.033
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Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA. Prevalence of low back pain in the community: implications for service provision in Bradford, UK. J Epidemiol Community Health. 1996;50(3):347-52. DOI:10.1136/jech.50.3.347
²⁰
Hoddevik GH, Selmer R. [Chronic low back pain in 40-year olds in 12 Norwegian counties]. Tidsskr Nor Laegeforen. 1999;119(15):2224-8. Norwegian
²¹
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. DOI:10.1002/art.34347
²²
Jacobsson L, Lindgärde F, Manthorpe R. The commonest rheumatic complaints of over six weeks' duration in a twelve-month period in a defined Swedish population: prevalences and relationships. Scand J Rheumatol. 1989;18(6):353-60. DOI:10.3109/03009748909102096
²³
Jiménez-Sánchez S, Fernández-de-Las-Peñas C, Carrasco-Garrido P, Hernández-Barrera V, Alonso-Blanco C, Palacios-Ceña D, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit . 2012;26(6):534-40. DOI:10.1016/j.gaceta.2011.10.012
²⁴
Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002
²⁵
Knuth AG, Bacchieri G, Victora CG, Hallal PC. Changes in physical activity among Brazilian adults over a five-year period. J Epidemiol Community Health. 2009;64(7):591-5. DOI:10.1136/jech.2009.088526
²⁶
Liao ZT, Pan YF, Huang JL, Huang F, Chi WJ, Zhang KX, et al. An epidemiological survey of low back pain and axial spondyloarthritis in a Chinese Han population. Scand J Rheumatol. 2009;38(6):455-9. DOI:10.3109/03009740902978085
²⁷
Loisel P, Lemaire J, Poitras S, Durand MJ, Champagne F, Stock S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occup Environ Med . 2002;59(12):807-15. DOI:10.1136/oem.59.12.807
²⁸
Melloh M, Röder C, Elfering A, Theis JC, Müller U, Staub LP, et al. Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol. BMC Musculoskelet Disord. 2008;9:81. DOI:10.1186/1471-2474-9-81
²⁹
Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155
³⁰
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting Items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097. DOI:10.1371/journal.pmed.1000097
³¹
Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90.
³²
Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007
³³
Oostrom SH, Verschuren M, Vet HC, Boshuizen HC, Picavet HSJ. Longitudinal associations between physical load and chronic low back pain in the general population: the Doetinchem Cohort Study. Spine (Phila Pa 1976). 2012;37(9):788-96. DOI:10.1097/BRS.0b013e31823239d1
³⁴
Palmer KT, Calnan M, Wainwright D, Poole J, O'Neill C, Winterbottom A, et al. Disabling musculoskeletal pain and its relation to somatization: a community-based postal survey. Occup Med (Lond). 2005;55(8):612-7. DOI:10.1093/occmed/kqi142
³⁵
Park CH, Wagener DK, Winn DM, Pierce JP. Health conditions among the currently employed. Vital Health Stat Series 10. 1993;(186):1-67.
³⁶
Picavet HSJ, Schouten JSAG. Physical load in daily life and low back problems in the general population: the MORGEN Study. Prev Med . 2000;31(5):506-12. DOI:10.1006/pmed.2000.0737
³⁷
Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.Pain . 2003;102(1-2):167-78. DOI:10.1016/s0304-3959(02)00372
³⁸
Shiri R, Solovieva S, Husgafvel-Pursiainen K, Taimela S, Saarikoski LA, Huupponen R, et al. The association between obesity and the prevalence of low back pain in young adults: the Cardiovascular Risk in Young Finns Study.Am J Epidemiol . 2008;167(9):1110-9. DOI:10.1093/aje/kwn007
³⁹
Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005
⁴⁰
Waxman R, Tennant A, Helliwell P. A prospective follow-up study of low back pain in the community. Spine (Phila Pa 1976). 2000;25(16):2085-90.

Publication Dates

Publication in this collection
20 Oct 2015

History

Received
25 Sept 2014
Accepted
31 Jan 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Esteban-Vasallo MD, Domínguez-Berjón MF, Astray-Mochales J, Genova-Maleras R, Pérez-Sania A, Sánchez-Perruca L, et al. Prevalencia de enfermedades crónicas diagnosticadas en población inmigrante y autóctona.Gac Sanit . 2009;23(6):548-52. DOI:10.1590/S0213-91112009000600012

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Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med . 2009;169(3):251-8. DOI:10.1001/archinternmed.2008.543

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[16] ¹⁶
Hagen K, Linde M, Heuch I, Stovner LJ, Zwart JA. Increasing prevalence of chronic musculoskeletal complaints: a large 11-year follow-up in the general population (HUNT 2 and 3). Pain Med . 2011;12(11):1657-66. DOI:10.1111/j.1526-4637.2011.01240.x

[17] ¹⁷
Heneweer H, Vanhees L, Picavet HS. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143(1-2):21-5. DOI:10.1016/j.pain.2008.12.033

[18] ¹⁸
Heuch I, Hagen K, Nygaard O, Zwart JA. The impact of body mass index on the prevalence of low back pain: the HUNT study. Spine (Phila Pa 1976). 2010;35(7):764-8. DOI:10.1097/BRS.0b013e3181ba1531

[19] ¹⁹
Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA. Prevalence of low back pain in the community: implications for service provision in Bradford, UK. J Epidemiol Community Health. 1996;50(3):347-52. DOI:10.1136/jech.50.3.347

[20] ²⁰
Hoddevik GH, Selmer R. [Chronic low back pain in 40-year olds in 12 Norwegian counties]. Tidsskr Nor Laegeforen. 1999;119(15):2224-8. Norwegian

[21] ²¹
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. DOI:10.1002/art.34347

[22] ²²
Jacobsson L, Lindgärde F, Manthorpe R. The commonest rheumatic complaints of over six weeks' duration in a twelve-month period in a defined Swedish population: prevalences and relationships. Scand J Rheumatol. 1989;18(6):353-60. DOI:10.3109/03009748909102096

[23] ²³
Jiménez-Sánchez S, Fernández-de-Las-Peñas C, Carrasco-Garrido P, Hernández-Barrera V, Alonso-Blanco C, Palacios-Ceña D, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit . 2012;26(6):534-40. DOI:10.1016/j.gaceta.2011.10.012

[24] ²⁴
Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey.J Pain . 2010;11(11):1230-9. DOI:10.1016/j.jpain.2010.07.002

[25] ²⁵
Knuth AG, Bacchieri G, Victora CG, Hallal PC. Changes in physical activity among Brazilian adults over a five-year period. J Epidemiol Community Health. 2009;64(7):591-5. DOI:10.1136/jech.2009.088526

[26] ²⁶
Liao ZT, Pan YF, Huang JL, Huang F, Chi WJ, Zhang KX, et al. An epidemiological survey of low back pain and axial spondyloarthritis in a Chinese Han population. Scand J Rheumatol. 2009;38(6):455-9. DOI:10.3109/03009740902978085

[27] ²⁷
Loisel P, Lemaire J, Poitras S, Durand MJ, Champagne F, Stock S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occup Environ Med . 2002;59(12):807-15. DOI:10.1136/oem.59.12.807

[28] ²⁸
Melloh M, Röder C, Elfering A, Theis JC, Müller U, Staub LP, et al. Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol. BMC Musculoskelet Disord. 2008;9:81. DOI:10.1186/1471-2474-9-81

[29] ²⁹
Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155. DOI:10.1186/1471-2474-14-155

[30] ³⁰
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting Items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097. DOI:10.1371/journal.pmed.1000097

[31] ³¹
Omokhodion FO. Low back pain in a rural community in South West Nigeria. West Afr J Med . 2002;21(2):87-90.

[32] ³²
Oostrom SH, Verschuren M, Vet HC, Picavet HSJ. Ten year course of low back pain in an adult population-based cohort: the Doetinchem cohort study.Eur J Pain . 2011;15(9):993-8. DOI:10.1016/j.ejpain.2011.02.007

[33] ³³
Oostrom SH, Verschuren M, Vet HC, Boshuizen HC, Picavet HSJ. Longitudinal associations between physical load and chronic low back pain in the general population: the Doetinchem Cohort Study. Spine (Phila Pa 1976). 2012;37(9):788-96. DOI:10.1097/BRS.0b013e31823239d1

[34] ³⁴
Palmer KT, Calnan M, Wainwright D, Poole J, O'Neill C, Winterbottom A, et al. Disabling musculoskeletal pain and its relation to somatization: a community-based postal survey. Occup Med (Lond). 2005;55(8):612-7. DOI:10.1093/occmed/kqi142

[35] ³⁵
Park CH, Wagener DK, Winn DM, Pierce JP. Health conditions among the currently employed. Vital Health Stat Series 10. 1993;(186):1-67.

[36] ³⁶
Picavet HSJ, Schouten JSAG. Physical load in daily life and low back problems in the general population: the MORGEN Study. Prev Med . 2000;31(5):506-12. DOI:10.1006/pmed.2000.0737

[37] ³⁷
Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.Pain . 2003;102(1-2):167-78. DOI:10.1016/s0304-3959(02)00372

[38] ³⁸
Shiri R, Solovieva S, Husgafvel-Pursiainen K, Taimela S, Saarikoski LA, Huupponen R, et al. The association between obesity and the prevalence of low back pain in young adults: the Cardiovascular Risk in Young Finns Study.Am J Epidemiol . 2008;167(9):1110-9. DOI:10.1093/aje/kwn007

[39] ³⁹
Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad Saude Publica . 2004;20(2):377-85. DOI:10.1590/S0102-311X2004000200005

[40] ⁴⁰
Waxman R, Tennant A, Helliwell P. A prospective follow-up study of low back pain in the community. Spine (Phila Pa 1976). 2000;25(16):2085-90.

Author (year)	Country	Design	Response rate	N	Male		Female		Age or age group	Definition of chronic pain	Prevalence	95%CI
Author (year)	Country	Design	%	N	n	%	n	%	Age or age group	Definition of chronic pain	%	95%CI
Hoddevik et al²⁰ (1999)	Norway	CS	63.4	67,338	31,846	47.3	35,492	52.7	40-42	> 3 months	2.0	1.9;2.1
Shiri et al³⁸ (2008)	Finland	CS	76.0	2,575	1,185	46.0	1,390	54.0	24-39	Continuous pain in the last year	4.2	3.4;5.0
Picavet et al³⁶ (2000)	Netherlands	CS	50.0	22,415	10,132	45.2	12,283	54.8	20-59	> 3 months	19.1	18.6;19.6
Palmer et al³⁴ (2005)	England	CS	53.0	2,632	Not reported	Not reported	Not reported	Not reported	25-64	> 6 months	11.0	9.8;12.2
Hillman et al¹⁹ (1996)	England	CS	72.0	3,184	1,437	45.1	1,747	54.9	25-64	> 3 months	10.2	9.1;11.3
Alkherayf et al¹ (2009)	Canada	CS	78.9	73,507	35,242	47.9	38,265	52.1	20-59	Continuous pain > 6 months	19.6	19.3;19.9
Picavet et al³⁷ (2003)	Netherlands	CS	50.0	3,664	1,640	44.8	2,024	55.2	≥ 25	> 3 months	21.2	19.9;22.5
Heuch et al¹⁸ (2010a)	Norway	CS	69.0	63,968	30,102	47.1	33,866	52.9	≥ 20	> 3 months	23.6	23.3;23.9
Bjorck-Van Dijken et al⁶ (2008)	Sweden	CS	69.3	5,798	Not reported	Not reported	Not reported	Not reported	25-79	> 6 months	16.4	15.5;17.4
Johannes et al²⁴ (2010)	USA	CS	75.7	27,035	10,357	38.3	16,678	61.7	≥ 18	> 6 months	8.1	7.5;8.7
Carey et al⁸ (1995)	USA	CS	79.0	8,067	Not reported	Not reported	Not reported	Not reported	≥ 21	> 3 months/or 24 episodes of pain in the last year	3.9	3.5;4.3
Freburger et al¹⁴ (2009)	USA	CS	86.0	9,924	Not reported	Not reported	Not reported	Not reported	≥ 21	> 3 months/or 24 episodes of pain in the last year	10.2	9.6;10.8
Meucci et al²⁹ (2013)	Brazil (Pelotas)	CS	89.6	2,732	1,151	42.1	1,581	57.9	≥ 20	≥ 7 weeks in the last 3 months	9.6	8.3;10.8
Andersson⁵ (1994)	Sweden	CS	90.0	1,609	817	50.8	792	49.2	25-74	> 3 months	23.3	21.2;25.4
Silva et al³⁹ (2004)	Brazil (Pelotas)	CS	94.4	3,182	1,374	43.2	1,808	56.8	≥ 20	≥ 7 weeks in the last 3 months	4.2	3.5;5.0
Almeida et al² (2008)	Brazil (Salvador)	CS	97.1	2,281	1,016	44.5	1,265	55.5	≥ 20	Continuous pain > 6 months	14.7	13.3;16.2
Dellaroza et al⁹ (2013)	Brazil (Sao Paulo)	CS	89.9	1,271	513	40.4	758	59.6	≥ 60	Continuous pain > 6 months	25.4	23.0;27.8
Omokhodion³¹ (2002)	Nigeria	CS	100	900	450	50.0	450	50.0	20-85	> 3 months	7.0	5.3;8.7
Brattberg et al⁷ (1989)	Sweden	CS	82.0	857	391	47.3	436	52.7	18-84	> 6 months	20.3	17.6;23.0
Altinel et al³ (2008)	Turkey	CS	100	2,035	841	41.3	1,194	58.7	≥ 19	Continuous pain	13.1	11.6;14.6
Park et al³⁵ (1993)	USA	CS	87.0	44,233	18,562	42.0	25,671	58.0	≥ 18	> 3 months	6.7	6.4;7.0
Fujii et al¹⁵ (2012)	Japan	CS	Not reported	52,650	26,779	50.9	25,871	49.1	20-79	4^th degree low back pain lasting > 3 months at some time in life	3.9	3.7;4.1
Jacobsson et al²² (1989)	Sweden	CS	49.4	445	230	51.7	215	48.3	50-69	Pain > 6 weeks Rheumatologist's diagnosis	6.3	4.0;8.6
Liao et al²⁶ (2009)	China	CS	88.7	10,921	5,687	52.1	5,234	47.9	≥ 16	> 3 months	1.0	0.8;1.2
Jimenez-Sanchez et al²³ (2012)	Spain	CS	Not reported	12,190	5,742	47.1	6,448	52.9	≥ 16	> 3 months	11.1	10.5;11.7
Hagen et al¹⁶ (2011)	Norway	C	HUNT 2: 53.0	49,483	Not reported	Not reported	Not reported	Not reported	≥ 20	> 3 months	–	–
			HUNT 3: 54.0	50,839							HUNT 2: 22.7	22.4;23.0
			Wave II:90 WI	1,671							HUNT 3: 23.4	23.0;23.9
Van Oostrom et al³² (2011)	Netherlands	C	Baseline: 62.0	12,405	2,686	47.1	3,020	52.9	26-65	> 3 months or "pain always present" Definitions changed during follow-ups T1-T2	Follow-up I: 17.4%
			Follow-up I: 79.0	6,118							Follow-up II: 17.4%
			Follow-up II: 75.0	4,917							Follow-up III: 19.9%
			Follow-up III: 78.0	4,520							Incidence: No/No/No: 62.4% No/Yes/Yes or No/No/Yes: 10.8%
			For analyses with data from all follow-ups	5,706							Recurrence/Persistence: Yes/Yes/No or Yes/No/No: 10.3% Yes/No/Yes or No/Yes/No: 10.9% Yes/Yes/Yes: 5.6%
Waxman et al⁴⁰ (2000)	England	C	Baseline: 76.0	3,184	–		–		25-64	> 3 months	Baseline: 6.3% Follow-up: 11.1%
Waxman et al⁴⁰ (2000)	England	C	Follow up: 70.0	1,455	615		840		25-64	> 3 months	Baseline: 6.3% Follow-up: 11.1%

Study	Score weight								Total score
	0.2	0.08	0.2	0.2	0.08	0.08	0.08	0.08

	Was the sampling frame a true or close representation of the target population?	Was the sample size estimated?	Was some form of random selection used to select the sample, OR, was a census undertaken?	Was the likelihood of non-response bias minimal?	Were data collected directly from the subjects (as opposed to a proxy)?	Had the study instrument that measured the parameter of interest (e.g., CLBP prevalence) been tested for reliability and validity (if necessary)?	Was data collection standard ized?	Was a human body drawing used?
Hoddevik et al²⁰ (1999)	Yes	No	Yes	No	Yes	No	Yes	No	0.56
Shiri et al³⁸ (2008)	Yes	No	Yes	Yes	Yes	No	Yes	Yes	0.84
Picavet et al³⁶ (2000)	Yes	No	Yes	No	Yes	No	Yes	Yes	0.64
Palmer et al³⁴ (2005)	Yes	No	Yes	No	Yes	No	Yes	No	0.56
Hillman et al¹⁹ (1996)	Yes	No	Yes	No	Yes	Yes	Yes	Yes	0.72
Alkherayf et al¹ (2009)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Picavet et al³⁷ (2003)	Yes	No	Yes	No	Yes	No	Yes	Yes	0.64
Heuch et al¹⁸ (2010a)	Yes	No	Yes	No	Yes	No	Yes	No	0.56
Bjorck-Van Dijken et al⁶ (2008)	Yes	No	Yes	No	Yes	No	Yes	No	0.56
Johannes et al²⁴ (2010)	Yes	No	Yes	No	Yes	No	Yes	No	0.76
Carey et al⁸ (1995)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Freburger et al¹⁴ (2009)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Meucci et al²⁹ (2013)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	0.92
Andersson⁵ (1994)	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	0.92
Silva et al³⁹ (2004)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	0.92
Almeida et al² (2008)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	0.84
Dellaroza et al⁹ (2013)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Omokhodion³¹ (2002)	Yes	No	Yes	Yes	Yes	No	Yes	Yes	084
Brattberg et al⁷ (1989)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Altinel et al³ (2008)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	0.84
Park et al³⁵ (1993)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Fujii et al¹⁵ (2012)	Yes	No	Yes	Yes	Yes	No	Yes	Yes	0.84
Jacobsson et al²² (1989)	Yes	No	Yes	No	Yes	No	Yes	No	0.56
Liao et al²⁶ (2009)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Jimenez-Sanchez et al²³ (2012)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Hagen et al¹⁶ (2011)	Yes	No	Yes	Yes	Yes	Yes	Yes	No	0.64
Van Oostrom et al³² (2011)	Yes	No	Yes	Yes	Yes	No	Yes	No	0.76
Waxman et al⁴⁰ (2000)	Yes	No	Yes	Yes	Yes	No	Yes	Yes	0.84

Author (year)	Variable	Prevalence
Author (year)	Variable	%	95%CI	%	95%CI
Alkherayf et al¹ (2009)	Smoking status	Daily smokers (present or former): 23.3 Occasional smokers (present or former): 17.2 Non-smokers: 15.7 Analysis stratified by smoking status: CLBP prevalence was higher in daily smokers (present or former) in comparison to occasional smokers (present or former) and non-smokers in all variables assessed: sex, age, BMI, education and occupational status

Freburger et al¹⁴ (2009)	Race/Ethnicity	1992		2006
		Non-Hispanic white: 4.1	3.5;4.7	Non-Hispanic white: 10.5	9.4;11.5
		Non-Hispanic black: 3.0	2.0;4.0	Non-Hispanic black: 9.8	8.2;11.4
		Other:4.1	1.4;6.8	Hispanic: 6.3	3.8;8.9
				Other: 9.1	6.2;12.0

Meucci et al²⁹ (2013) & Silva et al³⁹ (2004)	Education (years)	2002		2010
		0: 6.9	6.0;7.8	0: 14.3	9.7;18.9
		1-4: 6.3	5.5;7.2	1-4: 13.0	10.2;15.7
		5-8: 4.4	3.7;5.2	5-8: 9.7	7.5;11.9
		9-11: 2.7	2.2;3.3	9-11: 8.1	5.9;10.2
		≥ 12: 2.0	1.5;2.6	≥ 12: 6.8	4.7;8.8
	Economic status	A or B: 2.8	2.3;3.4	A or B: 7.8	5.0;10.5
		C: 4.6	3.9;5.4	C: 9.0	7.4;10.5
		D or E: 4.6	3.9;5.4	D or E: 11.3	9.0;13.6
	Smoking	Never: 3.2	2.6;3.9	Never: 8.0	6.6;9.4
		Former smoker: 5.0	4.3;5.8	Former smoker: 11.3	8.5;14.1
		Smoker: 5.5	4.7;6.3	Smoker: 11.5	9.2;13.9
	BMI (kg/m²)	≤ 19.9: 2.7	2.1;3.3	≤ 19.9: 4.3	0.5;8.0
		20-24.9: 3.4	2.8;4.1	20-24.9: 8.0	6.1;9.8
		25-29.9: 4.1	3.4;4.9	25-29.9: 8.4	6.5;10.2
		≥ 30.0: 6.2	5.7;7.1	≥ 30.0: 14.2	11.5;16.9

Almeida et al² (2008)	Smoking	Never: 12.2
		Former smoker: 19.7
		Smoker: 17.6
	Marital status	Married or partner: 15.9
		Single: 9.5
		Widow or divorced: 20.6

Fujii¹⁵ (2012)	Smoking	No CLBP		CLBP
	Smoking	Ever smoked: 52.4		Ever smoked: 42.6
	Education	College: 49.4		College: 40.8

Jimenez-Sanchez et al²³ (2012)	Education	Male		Female
		No studies: 9.7	6.9;13.5	No studies: 20.1	16.7;24.0
		Primary: 9.9	8.7;11.2	Primary: 17.1	15.7;18.6
		Secondary:6.6	5.4;7.9	Secondary: 10.7	9.3;12.3
	Marital status	Single: 4.3	3.4;5.4	Single: 7.7	6.5;9.1
		Married: 9.5	8.6;10.6	Married: 15.5	14.3;16.8
		Divorced or widowed: 10.5	7.2;15.1	Divorced or widowed: 20.4	18.0;23.0

Van Oostromet al³² (2011)		Analysis stratified by 3 patterns of low back pain: never long-standing LBP; persistent LBP over 10 years; varying LBP. Individuals with persistent LBP were less educated, have less paid job, were more obese, and predominantly smokers.

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Prevalence of chronic low back pain: systematic review

Prevalência de dor lombar crônica: revisão sistemática

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