Back problems

What are back problems?

'Back problems’ describes a range of conditions related to the bones, joints, connective tissue, muscles and nerves of the back. These conditions can affect the neck (cervical spine), upper back (thoracic spine) and lower back (lumbar spine) as well as the sacrum and tailbone (coccyx). Back problems are a significant cause of disability and lost productivity.

Back problems reported on these webpages include:

• disc disorders (such as herniated discs or disc degeneration)
• sciatica and curvature of the spine
• back pain/problems not elsewhere classified.

Note: back problems associated with another condition, such as osteoporosis are not included. For this reason, the total prevalence of back problems is likely to be underestimated.

Back problems include:

• episodes of ‘non-specific’ pain in the lower, middle and upper back that are sometimes associated with injury but often may arise and settle for no apparent reason
• ‘sciatica’ – a back problem with pain shooting down one leg often accompanied by tingling, numbness or weakness in that leg. A similar problem in the neck will cause arm symptoms
• narrowing in the canal of the lumbar spine through which the spinal cord passes. This is more common in older people and causes difficulty walking as well as symptoms in both legs
• less common conditions such as infection or fracture that are managed differently to the more common back problems
• ‘whiplash’ following a motor vehicle accident.
   

Back problems can have many causes, relating to work, sport and lifestyle issues, injuries, diseases such as arthritis, disc disease and osteoporosis. Sometimes back pain is the result of a health condition beyond the spine such as a kidney stone or shingles. Factors that may increase the risk of developing back problems include age, physical fitness, smoking, being overweight, and the type of work a person does (ABS 2019).

Pain is the main symptom in most back problems. Back problems are a common reason for pain among younger and middle-aged adults, but can start in childhood (Raspe et al. 2004). Back problems are often recurrent and may need to be managed as a long-term health condition.

How common are back problems?

About 4.0 million Australians (16% of the total population) have back problems, based on self-reported data from the Australian Bureau of Statistics (ABS) 2017–18 National Health Survey (NHS).

Back problems are least common among people from birth to age 24 (Figure 1). The overall prevalence of back problems, after accounting for differences in age, is similar for males (16%) and females (15%).

Figure 1: Prevalence of back problems, by age and sex, 2017–18

Note: refers to people who self-reported having back pain and problems (current and long term).

Source: AIHW analysis of ABS 2019a (Data table).
 

Aboriginal and Torres Strait Islander people

According to self-reported data from to the ABS 2018–19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), the prevalence of back problems among Aboriginal and Torres Strait Islander people was 12.6%, affecting about 102,000 people – including about 14,000 who live in remote areas (9.4% of the remote Indigenous population).

After adjusting for age, males (17.0%) and females (17.3%) had similar rates of back pain and problems. The proportion of Indigenous Australians (17.1%) and non-Indigenous Australians (15.7%) affected was also similar (Figure 2).

Figure 2: Prevalence of back problems by Indigenous status, 2018–2019

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: ABS 2019b (Data table).

Inequalities

According to self-reported data from the 2017–18 National Health Survey, prevalence of back problems was similar in Major cities (16%), Inner regional (17%) and Outer regional and Remote (15%) areas of Australia. Those living in the lowest socioeconomic areas were 1.4 times as likely to have back problems compared with those living in the highest socioeconomic areas (18% and 13%) (Figure 3).

Figure 3: Prevalence of back problems, by remoteness and socioeconomic area, 2017–18

Note: Rates are age-standardised to the Australian population as at 30 June 2001.
Source: AIHW analysis of ABS 2019b (Data table).

Impact of back problems

Burden of disease

In 2022, back problems was the third leading cause of burden and accounted for 4.2% of total burden (DALY); 8.2% of non-fatal burden (YLD), and less than 1% of fatal burden (YLL). Within the musculoskeletal condition disease group, back problems accounted for 34% of total burden (DALY); 34% of non-fatal burden (YLD); and 5.8% of fatal burden (YLL).

Variation by age and sex

• Back problems was the leading cause of burden for people aged 35–54, increasing with age from 10.4 DALY per 1,000 population for those aged 35–39, peaking at 13.5 for those aged 50–54.
• Males and females had similar rates of burden from back problems (9.0 and 9.1 DALY per 1,000 population, respectively).

Figure 4: Burden of disease due to back problems by sex, age and year

Trends over time

The rate of burden from back problems increased slightly from 8.0 to 8.6 DALY per 1,000 population between 2003 and 2022 – or 0.4% per year on average, after adjusting for changes in age structure.

Further detail is available in the Australian Burden of Disease Study 2022.

Variation between population groups

In 2018, after adjusting for age:

• The rate of burden from back problems was highest in Inner regional areas compared with those in Remote and very remote areas (9.3 and 5.9 DALY per 1,000 population, respectively).
• The rate of burden from back problems increased with decreasing socioeconomic group – for example, the lowest group (people living in areas with the highest level of disadvantage) was 1.4 times higher than the rate for the highest group (9.6 and 7.0 DALY per 1,000 population) (AIHW 2021).

Further detail is available in the Australian Burden of Disease Study 2018: Interactive data on disease burden.

Figure 5: Burden of disease due to back problems by sex, remoteness area, socioeconomic group and year

Health system expenditure

In 2019–20, an estimated $3.4 billion of expenditure in the Australian health system was for back problems, representing 2.4% of total health expenditure and 23% of expenditure for all musculoskeletal conditions (AIHW 2022b).

Where is the money spent?

Figure 6 presents a detailed breakdown of estimated expenditure for back problems by area of the health system, showing that:

• Hospital services represented 62% ($2.1 billion) of back problems expenditure which was similar to the proportion of total health expenditure for hospital services (63%). However, the private hospital proportion of back problems expenditure was relatively high, at more than double that for total health expenditure (37 compared with 16%).
• Primary care accounted for 21% ($723.6 million) of back problems spending, which was less than the primary care portion of total health expenditure (28%).
• Referred medical services represented 17% ($565.8 million) of back problems expenditure, nearly double the proportion of total health expenditure (9%). The medical imaging proportion of back problems expenditure was especially large in comparison to the average, at nearly 5 times the proportion for total health expenditure (14 compared with 3%).

Figure 6: Amount and proportion (%) of back problem expenditure attributed to each area of the health system, compared to expenditure for all disease groups, 2019–20

Figure 7 presents the component (%) that back-problems expenditure makes up for each area of the health system, showing that in 2019–20, back problems accounted for:

• 12% ($464.8 million) of all medical imaging expenditure – ranking third of all diseases/ conditions
• 5.6% ($1.3 billion) of all private hospital service expenditure – ranking third of all diseases/ conditions.

Figure 7: Proportion of expenditure attributed to back problems, for each area of the health system, 2019–20

Who is the money spent on?

In 2019–20:

• the age distribution of spending on back problems reflects the prevalence distribution of the condition, with most spending being for older age groups (74% for people aged 45 and over)
• more back problems expenditure was attributed to females than males ($1.7 billion and $1.5 billion, respectively with a remainder $162.0 million (4.7%) not specified.

Further detail is available in Disease expenditure in Australia 2019–20.

In 2018–19, it was estimated that:

• Back problems expenditure per case was 1.1 times greater for females than males ($860 and $760 per case, respectively).
• Back problems expenditure per case was 32% lower than musculoskeletal conditions as a group ($820 and $1200 per case, respectively) (AIHW 2022c).

Further detail is available in Health system spending per case of disease and for certain risk factors.

Perceived health status

People aged 15 and over with back problems were less likely to perceive their health as excellent compared with those without the condition according to the 2017–18 National Health Survey (NHS). After adjusting for age, people with back problems were 2.4 times as likely to rate their health as poor (6.5%) compared with those without back problems (2.7%) (Figure 8).

Figure 8: Self-assessed health of people aged 15 and over with and without back problems, 2017–18

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Psychological distress

Overall, people aged 18 and over with back problems were 2.5 times as likely to report experiencing very high levels of psychological distress (8.1%) than those without the condition (3.2%) after adjusting for age (Figure 9).

Figure 9: Psychological distress^(a) experienced by people aged 18 and over with and without back problems, 2017–18

(a) Psychological distress is measured using the Kessler Psychological Distress Scale (K10), which involves 10 questions about negative emotional states experienced in the previous 4 weeks. The scores are grouped into Low: K10 score 10–15, Moderate: 16–21, High: 22–29, Very high: 30–50.

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Pain

People with back problems were 2.6 times as likely to experience severe (11%) and very severe (3.1%) bodily pain compared with those without the condition (4.6% and 1.0%, respectively) according to self-reported data from the 2017–18 NHS (Figure 10).

Figure 10: Pain^(a) experienced by people aged 18 and over with and without back problems, 2017–18

(a) Bodily pain experienced in the 4 weeks prior to interview.

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Impact on activity

In 2017–18, 38% of people with back problems said that bodily pain interfered with their daily activities at least 'moderately', compared with 17% of people without back problems. Of people with back problems, 5.8% said bodily pain had an 'extreme' impact on their activity, compared with 2.4% of people without back problems (Figure 11).

Figure 11: Extent that bodily pain interferes in daily activities in people with and without back problems, 2017–18

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Workforce participation

According to self-reported data from the 2017–18 NHS, people aged 15–64 with back problems are less likely to be employed (73%) compared with people without back problems (77%) and more likely to not be in the labour force (22% compared with 19%). There is little difference in the proportion of people who were unemployed with (5%) and without (4%) back problems (Figure 12).

Figure 12: Workforce participation of people aged 15–64 with and without back problems, 2017–18

Note: Rates are age-standardised to the Australian population as at 30 June 2001.

Source: AIHW analysis of ABS 2019 (Data table).

Deaths

How many deaths were associated with back problems?

Back problems was recorded as an underlying or associated cause for 1,024 deaths or 4.0 deaths per 100,000 population in Australia in 2021, representing 0.6% of all deaths and 11% of all musculoskeletal deaths. Back problems was the underlying cause for 111 deaths (11% of back problem deaths) and an associated cause only, for 913 deaths (89% of back problem deaths).

Variation by age and sex

In 2021, back problem mortality (as the underlying and/or associated cause) was concentrated amongst:

• older people (59% aged 75 and over), which was slightly less than the proportion of people aged 75 and over for total deaths (67%)
• females (52% of back problems deaths were female compared with 48% of total deaths).

Figure 13: Age profile of back problems mortality statistics, by sex

Trends over time

Age standardised mortality rates for back problems (as the underlying and/or associated cause) between 2011 and 2021:

• increased from 2.0 to 3.2 per 100,000 population
• remained stable over time with the mortality rate for males always higher than females. During this period mortality rates were 1.1 to 1.4 times higher among males compared with females.  

Figure 14: Historical back problems mortality statistics, by sex, 2011–2021

Variation between population groups

Remote and very remote areas had 1.8 times more back problem deaths per population when compared with Major cities.

The lowest socioeconomic group (people living in areas with the most disadvantage) had 1.8 times more back problem deaths per population than the highest socioeconomic group (people living in areas with the least disadvantage) in 2021.

Further detail on mortality data is available in the Chronic musculoskeletal condition mortality data tables 2023.

Treatment and management of back problems

Pain is the main symptom of most back problems and treatment can be complex. This can be further complicated by comorbid conditions. Some general treatment strategies for chronic diseases, for example, lifestyle modifications such as diet, exercise, weight control, and reducing smoking, may benefit people with back problems (Bauer et al. 2014).

The most common back problem is non-specific low back pain. The most recent Australian clinical practice guidelines for management of non-specific low back pain encourages reassurance, self-management and physical therapy as first line care, supplemented by non-pharmacological therapies such as heat, massage, acupuncture and mindfulness where appropriate (Almeida et al. 2018). Medications are discouraged except where first and second-line non-pharmacological interventions are unsuccessful, and when they are prescribed, the lowest effective dose for the shortest amount of time possible is advised (Almeida et al. 2018).

Non-steroidal anti-inflammatory drugs (NSAIDS) should be the first-line medication when non-pharmacological management is inadequate (Almeida et al. 2018). Opioids should only be used when other treatments have failed after cautious assessment of risk versus benefits for the individual (Almeida et al. 2018). Paracetamol and surgery are no longer recommended for non-specific low back pain (Almeida et al. 2018).

Reliable and up to date information on how to manage back pain is provided at MyBackPain.org.au, a resource funded by Australia’s National Health and Medical Research Council, and developed by Arthritis Australia, the University of Queensland and Cochrane Back and Neck.

General practitioners and back pain treatment

General practitioners (GPs) are usually the first point of contact with the health care system for people with back problems. Back problems are among the most commonly managed conditions in general practice (Almeida et al. 2018). In 2015–16, 3.1 of every 100 GP-patient encounters for chronic conditions were for the management of back problems. This has increased significantly from 2.6 of every 100 GP-patient encounters in 2006–07 (Figure 15).

There is currently no nationally consistent primary health care data collection monitoring provision of care by GPs. The statistics on general practice activities are based on Bettering the Evaluation and Care of Health (BEACH) data, which are derived from a sample survey of GPs and their encounters with patients and should be interpreted with caution.

 Figure 15: Rate of back complaints managed by GPs, 2006–07 to 2015–16

Source: Britt et al. 2016 (Data table).

Hospitalisation and the treatment of back problems

Data from the AIHW National Hospital Morbidity Database (NHMD) show that in 2020–21:

• There were 192,000 hospitalisations with a principal diagnosis of back problems.
• The rate of hospitalisations was greater for females than males (820 per 100,000 compared with 680 per 100,000). This was true for all age groups from 45–49 years and over.
• The rate of hospitalisation for back problems increased with age.
• The average length of stay for overnight hospitalisations showed a similar pattern for males and females across age groups (Figure 16).

Figure 16: Age profile of back problems hospitalisation statistics, by sex

Back problem hospitalisations were composed of:

• back or spine pain (53%), of which lower-back-pain (27% of all back problem hospitalisations), neck-pain (6.3%), and radiculopathy (5.9%) were the most common
• vertebrae and disc disorders (41%), of which spinal stenosis (12%), lumbar and other intervertebral disc disorders with radiculopathy (8.9%), and spondylosis (7.3%) are common examples
• deforming dorsopathies (4.3%)
• other dorsopathies (1.4%).

Note: all percentages above represent proportion of total back problems hospitalisations.

From 2015–16 to 2020–21, the hospitalisation rate for back problems among Australians remained relatively stable with the exception of 2019–20 when there was a dip in the hospitalisation rate. This is likely due to widespread public health mandates to pause elective surgery due to the COVID-19 pandemic. The hospitalisation rate was higher for females compared with males across all years. Just under half of all hospitalisations with a principal diagnosis of back problems stay overnight in hospital. Of these, the average length of stay in hospital was 5.5 days in 2020–21 (Figure 17). Data prior to 2015–16 are not presented because rehabilitation hospitalisations were coded differently before this year.

Figure 17: Historical back problems hospitalisation statistics, by sex, 2010–11 to 2020–21

Comorbidities of back problems

People with back problems often have other chronic diseases and long-term conditions. These are referred to as 'comorbidities' – 2 or more health problems occurring at the same time. Comorbidities often share common risk factors, and may interact to determine the health status of individuals. As people age, they are more likely to develop more than one chronic condition.

This information is based on self-reported data from the Australian Bureau of Statistics (ABS) 2017–18 National Health Survey (NHS), and was last updated in March 2019.

Selected comorbidities

An estimated 2.5 million Australians aged 45 and over have back problems, based on self-reported data from the 2017–18 National Health Survey. Of these, almost 3 in 4 people (74% of the total population of people with back problems) report also having one or more of the following selected chronic conditions (Figure 19):

• heart, stroke and vascular disease
• kidney disease
• arthritis
• mental and behavioural conditions
• asthma
• diabetes
• chronic obstructive pulmonary disease (COPD)
• osteoporosis
• cancer.

In addition, almost 1 in 2 (46%) have two or more other chronic conditions (Figure 18).

Figure 18: Number of selected chronic conditions in people aged 45 years and over with back problems, 2017–18

Note: the 9 other selected chronic conditions are heart, stroke and vascular disease, asthma, arthritis, cancer, COPD, diabetes, kidney disease, mental and behavioural conditions, and osteoporosis.

Source: AIHW analysis of ABS 2019 (Data table).

Types of comorbid chronic conditions in people with back problems

Among people aged 45 years and over with back problems:

• 48% have arthritis, compared with 29% without back problems
• 34% have mental and behavioural conditions, compared with 18% without back problems
• 17% have asthma, compared with 11% without back problems
• 16% have heart, stroke and vascular disease, compared with 10% without back problems (Data table).

These proportions remained similar even after accounting for differences in the age structure of the populations (Figure 19).

Figure 19: Prevalence of other chronic conditions in people aged 45 years and over with and without back problems, 2017–18

Notes:

Source: AIHW analysis of ABS 2019 (Data table).

1. Age-standardised to the 2001 Australian population.
2. Proportions do not total 100% as one person may have more than one additional diagnosis.