Pain Physician 2014; 17:379-391 • ISSN 1533-3159

Systematic Review

Prevalence of Low Back Pain in Latin America:

A Systematic Literature Review

Joao B.S. Garcia, PhD1, John J. Hernandez-Castro, PhD2, Rocio G. Nunez, MD1,
Maria A.R. Pazos, MD1, Jorge O. Aguirre, PhD1, Asisa Jreige, MD1, Willian Delgado, MD1,
Manuel Serpentegui, MD1, Maria Berenguel, MD1, and Alberto F. Cantisani, MD1

Background: Chronic low back pain is considered as a high-impact condition that affects the working
From: 1Change Pain Latin
American Panel, Federal population of Latin America, with long reaching social and economic repercussions. Its true frequency
University of Maranhao, is unknown due to the absence of well-designed clinical trials that use standardized definitions and
Sao Luis, Maranhao, Brazil; criteria.
2Clinic of Pain and Palliative
Care, Universidad del Objectives: To evaluate the prevalence of chronic non-specific low back pain among the Latin
Rosario - MEDERI, Bogotá,
American population.
Colombia

Sociedade Brasileira de Study Design: A systematic review of chronic non-specific low back pain in Latin America.
Estudo da Dor, São Paulo,
SP, Brazil Setting: Meeting of Change Pain Latin America, Mexico.
b Universidade Federal
do Maranhão, São Luís, Methods: Data sources included relevant literature identified through searches of published studies
MA, Brazil c Instituto between August 30, 2002, and August 30, 2012, in 7 electronic databases: Cochrane BVS, Pubmed,
Maranhense de Oncologia
Medline, Lilacs, Scielo, Hinari, and MedCarib. Publications dealing with low back pain of a post-
Aldenora Belo, São
Luís, MA, Brazi traumatic, infectious, or malignant origin were excluded. Two reviewers selected in an independent
manner all eligible studies using the MOOSE checklist and extracted data on both prevalence and risk
Address Correspondence: factors associated with low back pain. A narrative synthesis of the results was drafted, which was later
Joao B S Garcia, PhD validated by a panel of clinical experts on pain.
Federal University of
Maranhao
Sao Luis, Maranhao, Brazil
Results: Twenty-eight studies were included in the review, comprising a total of 20,559 subjects
E-mail: from 7 countries in the region. Four of these studies, with significant methodological differences
jbgarcia@uol.com.br between them, measured the frequency of chronic low back pain with results that varied from 4.2%
to 10.1%. Four studies are part of the Community Oriented Program for Control of Rheumatic
Disclaimer: Change Pain
Diseases (COPCORD) program reports, and were pooled and analyzed separately because of their
Latin America is supported
by an educational grant particular design. Their prevalence estimations varied between 1.8% and 11.3%. The remaining 20
from Grünenthal. studies evaluated a total population of 6,992 subjects, and found a prevalence of low back pain of
Conflict of interest: Each 31.3%. Based on an epidemiological model constructed on both times to resolution and low back pain
author certifies that he or recurrence rates, the prevalence of chronic low back pain in Latin America was estimated to be around
she, or a member of his or
her immediate family, has 10.5%. Some risk factors reported by the authors are long working hours with the worker in the sitting
no commercial association position, obesity and overweight, pregnancy, smoking, advanced age, lifting and carrying heavy loads,
(i.e., consultancies, domestic work, sedentary lifestyles, and duration of current employment. A subgroup analysis of the
stock ownership, equity population under study yielded an estimated prevalence of low back pain of 16.7% for the population
interest, patent/licensing
arrangements, etc.) that exposed to a lower number of risk factors and 65% for the higher risk subgroup. In this review, we
might pose a conflict of made an exhaustive search of studies evaluating the epidemiology of chronic low back pain in the Latin
interest in connection with America region.
the submitted manuscript.
Limitations: The large topographic and chronologic variability in definitions of low back pain,
Manuscript received:
interviewer bias, and subject selection bias.
06-23-2013
Revised manuscript
received: Conclusions: Despite the sparse information and the methodological heterogeneity of the studies,
03-16-2014 pooled results allowed for an indirect estimation of the prevalence of low back pain in the region that
Accepted for publication: was pretty consistent with the published results obtained from other settings. New studies need to be
04-08-2014 carried out to supplement and overcome the methodological weaknesses of those previously conducted.
Free full manuscript:
www.painphysicianjournal.
Key words: Prevalence, epidemiology, low back pain, Latin America, chronic pain
com
Pain Physician 2014; 17:379-391
www.painphysicianjournal.com
 Pain Physician: September/October 2014; 17:379-391

A lthough there are many publications

concerning the incidence and prevalence
of chronic low back pain (CLBP), this
information is difficult to interpret because of the
different definitions used to outline the symptoms
up than patients who had not been receiving Workers’
Compensation at baseline, which configures an addi-
tional problem in cases of LBP.
The prevalence of CLBP seems to be increasing of
late. A crossover study (7) based on telephone surveys in-
and their duration (1). CLBP is sometimes defined as cluding a representative sample of households in North
low back pain (LBP) that lasts for more than 7 – 12 Carolina (US) was conducted in 1992 and then repeated
weeks (1). Other authors define it as pain that outlasts in 2006. A total of 4,437 households were contacted in
the expected healing period, and acknowledge that 1992 and 5,357 in 2006 to identify non-institutionalized
chronic pain may have several ill-defined pathological adults 21 years of age and older with chronic cervical
causes (2). According to the American Society of or lumbar pain (> 3 months) limiting daily life activities.
Interventional Pain Physicians (ASIPP), chronic pain is a The prevalence of LBP increased significantly during this
pain that persists 6 months after an injury and beyond 14-year interval, from 3.9% in 1992 to 10.2% in 2006.
the usual course of an acute disease or a reasonable Increases were observed in all adult age strata, in both
time for a comparable injury to heal, that is associated men and women, and in all ethnic groups (7).
with chronic pathologic processes that cause continuous Low back pain is considered as a high-impact
or intermittent pain for months or years, that may condition that affects the working population of Latin
continue in the presence or absence of demonstrable America, with far reaching social and economic reper-
pathologies; may not be amenable to routine pain cussions. For example, official figures from the Mexican
control methods; and healing may never occur. This government show that between 10% and 15% of all
is a combination definition considering that chronic disability claims are due to CLBP (8). In Argentina LBP is
pain is a complex phenomenon and multifactorial third among the most common causes of employment-
(3). Databases pertaining to insurers and health care associated disability, with a relevant contribution to
systems only include those cases for which the symptoms labor absenteeism (9). In Brazil, LBP was the diagnosis
result in the loss of working days or on some other used to grant 3,102 retirement pensions in account of
kind of disability; therefore, very little is known on the permanent disability, in 2007 alone (10).
epidemiology of CLBP that is not associated with labor Due to the evident effect of CLBP on the health and
absenteeism or with employment benefits (1). wellbeing of the Latin American population, it is man-
The most relevant symptoms of LBP are pain and datory to estimate its true frequency in order to design
disability (2). General practitioners are expected to see public policies and interventions more in keeping with
at least a one patient with LBP per week in their prac- the real magnitude of the problem. However, the lack
tices (4). of well-designed clinical trials aimed at assessing the
Most human beings are expected to experience at epidemiology of CLBP with standardized definitions
least one episode of LBP during their lifetime because and criteria, as well as the difficulties in both sampling
lifetime prevalence varies between 49% and 70% (2). In and quality of the observational studies available thus
high income countries, back pain is a medical diagnosis far, make this task even more daunting. Thus, a more
commonly associated with work. In the United King- expedient alternative was pursued in the present work,
dom, for example, it is one of the most common causes consisting of estimating the prevalence of CLBP from
of labor absenteeism, accounting for 12.5% of all sick an epidemiological model constructed with data on the
leaves (5). CLBP is the most common cause of physical overall frequency of LBP published in the literature.
limitation in adults 45 years of age and younger (1) Additionally, with this study we intended to cat-
and is the second cause of sick leaves (3). Every year egorize the available publications, identifying those
between 2% and 4% of the whole labor force of the that, due to their design, could become useful refer-
United States receives medical compensations related ences for clinicians and investigators of the region.
to LBP (1). In a prospective, observational study (6) of
patients who had sciatica and who had been receiv-
Methods
ing Workers’ Compensation at baseline, patients were
more likely to be receiving disability benefits and were Definitions
less likely to report relief from symptoms and improve- For the purposes of the present study, LBP was de-
ment in quality of life at the time of the 4-year follow- fined as pain localized below the lower edge of the last

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 Prevalence of Low Back Pain in Latin America

rib and above the lower gluteal folds, with or without a Spanish MeSH Terms: “Low back pain” [Majr]) AND
neuropathic component. “Epidemiology” [Mesh]) OR “Prevalence” [Mesh]) AND
In medical literature, LBP is usually classified as “Latin America” [Majr] OR “Brazil” [Majr] OR “Mexico”
acute, subacute, and chronic, according to its duration [Majr] OR “Cuba” [Mesh]) OR “Costa Rica” [Mesh])
(11,12). LBP is said to be acute when it persists for less OR “República Dominicana” [Majr]) OR “El Salvador”
than 6 weeks, subacute when it persists from 6 weeks to [Majr]) OR “Honduras” [Mesh]) OR “Panamá” [Mesh])
3 months, and chronic when it persists for more than 3 OR “Colombia” [Majr] OR “Paraguay” [Majr]) OR “Uru-
months (2). guay” [Majr]) OR “Venezuela” [Majr]) OR “Bolivia”
Data search was restricted to the following CIE-10 [Majr]) OR “Ecuador” [Majr]) OR “Argentina” [Majr]
codes: M544 (low back pain with a neuropathic compo- OR “Chile” [Majr] OR “Guatemala” [Majr]) OR “Nicara-
nent) and M545 (non-specified LBP). gua” [Majr]) OR “Peru” [Mesh]

Inclusion Criteria Quality Assessment of the Included

Studies included in this review were crossover tri- Publications
als, systematic literature reviews, or meta-analyses, Although systematic literature reviews and meta-
published in biomedical journals of any country of the analyses of controlled clinical trials are considered
world in English, Spanish, or Portuguese. Their main as very useful tools to synthesize the best available
goal needed to be the evaluation of the prevalence evidence, systematic reviews of epidemiological studies
of LBP and/or CLBP, either alone or with some other have major limitations and methodological particulari-
epidemiological measures (incidence, risk factors, and/ ties, owing to the observational studies from which they
or burden of disease). Only studies conducted with the originate (13). For this reason, the Meta-Analysis of Ob-
population of Latin American countries were included. servational Studies in Epidemiology (MOOSE) checklist
was selected for this review (14). The items of this check-
Exclusion Criteria list were used as part of the prior quality assessment of
Studies conducted or published before August 30, the studies to be included in the review. The verification
2002, studies including patients with LBP of a post- process included aspects related to the quality of the
traumatic or infectious origin, or those with a prior his- antecedents, the description of the methodology used,
tory of a known or suspected malignancy were excluded the presentation and discussion of the results, as well as
from the review. of the final conclusions drawn by the authors.

Search Strategy Synthesis

Since the information was to be obtained spe- Since the studies included are extremely heteroge-
cifically from the Latin American population, a system- neous, a narrative synthesis was used for most studies,
atic search was carried out in the following electronic and the analyses of the pooled results were only carried
databases: out in those cases where it was necessary to facilitate
Cochrane BVS, Pubmed, Medline, Lilacs, Scielo, Hi- data presentation and analysis.
nari, MedCarib.
The following search criteria were used: Expert Panel
Publication period: Between August 30, 2002, and In order to validate the consistency of the findings
August 30, 2012. of the present review, an expert panel composed of
English MeSH terms: “Low Back Pain” [Majr]) AND “Ep- clinical specialists in CLBP and public health was con-
idemiology” [Mesh]) OR “Prevalence” [Mesh]) AND “Latin vened, with the objective that the synthesis and conclu-
America” [Majr] OR “Brazil” [Majr] OR “Mexico” [Majr] OR sions of the work were as objective as possible.
“Cuba” [Mesh]) OR “Costa Rica” [Mesh]) OR “Dominican
Republic” [Majr]) OR “El Salvador” [Majr]) OR “Honduras”
Results
[Mesh]) OR “Panama” [Mesh]) OR “Colombia” [Majr] OR As a result of the systematic search, and once ad-
“Paraguay” [Majr]) OR “Uruguay” [Majr]) OR “Venezuela” mission and quality criteria had been applied, 28 stud-
[Majr]) OR “Bolivia” [Majr]) OR “Ecuador” [Majr]) OR “Ar- ies were included in the review, with a total of 20,559
gentina” [Majr] OR “Chile” [Majr] OR “Guatemala” [Majr]) subjects from 7 countries of the region (Table 1).
OR “Nicaragua” [Majr]) OR “Peru” [Mesh] Of the 28 studies reviewed only 4 evaluated the

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 Pain Physician: September/October 2014; 17:379-391

prevalence of CLBP, 3 of them conducted in Brazil and is, their measurements combine both acute and CLBP
one in Colombia (15,20,24,29), with the remaining 24 cases in the same figure.
measuring the frequency of LBP making no distinction Three Brazilian studies measured the prevalence
as to the cases found by duration of the symptoms, that of LBP at specific times of life: adolescents, pregnant
women, and the elderly (21,25,28).
Table 1. Studies included in the review, categorized by country Four studies included in the review form part of the
of origin. Community Oriented Program for Control of Rheumat-
Country No. of studies Total patients References ic Diseases (COPCORD) program reports (34,36,37,40).
This program is aimed at determining the prevalence of
Brazil 14 11,998 (15-28)
diverse classes of musculoskeletal pain and rheumato-
Colombia 5 1,050 (29-33)
logic diseases in different adult populations. Due to the
Cuba 1 300 (34)
homogeneous and particular design of these studies,
Ecuador 1 83 (35) their results were pooled and analyzed separately from
Mexico 3 3,361 (36-38) all other studies.
Peru 3 3,465 (39-41) Seventeen studies assessed the prevalence of LBP
Venezuela 1 302 (42) in different populations, including miners, oil workers,
Total 28 20,559 sawyers, homemakers, nurses, seamstresses, and drivers
(Fig. 1).

Observational
studies
n = 28

Prevalence of General
chronic LBP prevalence of
n=4 LBP n = 24

In the general During specific In different General

population periods of life populations COPCORD
LBP n=3 n = 17 population n = 4
n=2

Public healthcare Pregnant women Cuba

system users n=1 n=1
n=1

Mexico
University Adolescents n=2
students of n=1
Medicine and
related careers
Peru
n=1
Elderly patients n=1
n=1

Fig. 1. Type of population included in the studies reviewed.

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 Prevalence of Low Back Pain in Latin America

Studies Conducted Using the COPCORD aspects such as the time definition of CLBP and the type
Methodology and Questionnaire of population observed could explain the heterogene-
All 4 COPCORD studies used a standardized meth- ity of their results (Table 3).
odology: The patient completed a questionnaire on The study conducted by Silva et al (24) was a cross-
health and musculoskeletal disturbances and in case of over population study with 3,182 patients (1,374 men
any affirmative answer, a specialized assessment was and 1,808 women), all of them 20 years of age and
made by a rheumatologist, who finally decided the older, residing in urban areas in the south of Brazil.
diagnosis to be recorded. CLBP was defined as pain lasting 7 weeks or more; the
Although the same methodology was utilized for patients had to indicate the site of pain on a human fig-
all 4 studies, there is significant heterogeneity in both ure depicting in different colors the cervical, thoracic,
size and type of the populations selected, as well as in and lumbar regions of the spine. The mean age of the
the wide differences in the results reported, even be- patients was 44 years (SD ± 16.3 years). The reported
tween studies conducted in the same country (Table 2). prevalence of CLBP was 4.2%. The study included a rep-
A remarkable finding was the large number of resentative sample of the city population, with a low
subjects enrolled in these 4 studies, equivalent to one percentage of lost and withdrawn subjects (5.6%). In
fourth of all subjects included for this whole review. general the study had a good methodological design
Unfortunately, the results reported from the COPCORD
studies can be neither compared with nor interpreted Table 2. Subjects in the studies conducted using the COPCORD
methodology and questionnaire.
as the other prevalence studies because the reported
numbers do not necessarily correspond to the preva- Study
Patients Prevalence Author
lence of LBP in the population observed, but to the population
frequency with which participating rheumatologists Reyes Llerena et al,
Cuba 300 11.3%
made this particular diagnosis in their patients (Fig. 2). 2000 (34)
Peru 1,965 7.1% Gamboa et al, 2009 (40)
Observational Studies Evaluating the Cardiel and Rojas-
Mexico 1 2,500 6.3%
Prevalence of Chronic Low Back Pain Serrano, 2002 (37)
Four studies reported the prevalence of CLBP; 3 of Mexico 2 761 1.8% Álvarezet al, 2005 (36)
them were conducted in Brazil and one in Colombia. Pooled
5,526 6.2%
The significant differences between them in crucial results

Fig. 2. Prevalence of low back pain in the studies conducted with the COPCORD methodology and questionnaire.

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 Pain Physician: September/October 2014; 17:379-391

Table 3. Observational studies on the prevalence of chronic low back pain.

Author Patients Prevalence Mean age (DE) Country
Silva et al (24) 3,182 4.2% 44 years (16.3 years) Brazil
Almeida et al (15) 2,281 7.1% 40.9 years (14.7 years) Brazil
Cordeiro et al (20) 2,341 5.12% 30 years (ND) Brazil
Camargo et al (29) 237 10.12% 20.6 years (2.2 years) Colombia
Total 8,041

and its setbacks are mostly related to the definition of low physical activity, and with the female gender.
of CLBP that could be overestimated, and to a reverse A statistically significant association between
causality bias potentially incurred by attempting to es- smoking and CLBP was found in the studies carried out
tablish risk factors for CLBP with the use of a crossover by Almeida et al (15) and Silva et al (24). Both stud-
study. ies demonstrated a higher frequency of CLBP among
Almeida et al (15) conducted a crossover observa- smokers. For Almeida, the odds ratio (OR) was 1.47
tional study with a representative sample of the adult (95% confidence interval [CI] 1.11 – 1.96) and for Silva
population residing in urban areas of Brazil. The study 1.78 (95% CI 1.15 – 2.75).
enrolled 2,281 patients (1,016 men and 1,265 women), One difference between the results reported by
between 20 and 94 years of age. The mean age was these studies is that for Almeida, the association be-
40.9 years (SD ± 14.7 years). The prevalence reported tween tobacco and CLBP was also a significant finding
for CLBP was 17.4%. Six months or more duration was among former smokers, that is, those who had quit
set forth as a cutting point to establish the chronicity of smoking one year or more ago, OR 1.59 (95% CI 1.17
LBP, which reflects an underestimation of the condition – 2.17), whereas for Silva this association had no statisti-
in view of the usually accepted definition of CLBP (3). cal significance among former smokers, OR 1.58 (95%
The study published by Cordeiro et al (20) corre- CI 0.92 – 2.72). The studies conducted by Camargo et al
sponds to a joint initiative of 2 universities, the Brazil- (29) and Cordeiro et al (20) did not include the associa-
ian Ministry of Health, and Maranhão State Govern- tion of smoking and CLBP in their analyses.
ment, aimed at determining the prevalence of CLBP
and chronic headache among the users of the public Observational Studies Assessing the
health care system. The study included 2,341 patients Prevalence of Non-specified Low Back Pain
(829 men and 1,512 women), between 16 and 98 years A total 20 publications assessed the prevalence of
of age. The mean age was 30 years. Around 50% of the LBP in different types of populations. Most of them (17
patients were residents of urban areas and the remain- studies) were focused on the occurrence of LBP in dif-
ing were residents of the rural area of the state. The ferent types of jobs, whereas the other 3 reported the
prevalence reported for CLBP was 5.12%. These results frequency of LBP in adolescents, (21), the elderly (28),
could be explained by the inclusion of a significantly and pregnant women (25), respectively. Table 4 and Fig.
younger population, a substantial percentage of which 3 describe the most important aspects of these studies.
resides in rural areas. Fig. 3 summarizes the results reported by 20 ob-
One of the Colombian studies evaluated the preva- servational crossover studies that evaluated the preva-
lence of CLBP. Camargo et al (29) conducted a crossover lence of LBP in Latin America. In order to facilitate the
study to characterize the frequency and location of presentation of the studies and the analysis of their
chronic back pain among students of medicine and results, they have been subdivided into 3 strata, with
related careers, namely graduate students of physical this division not reflecting a probabilistic criterion but
therapy, medicine, nutrition, nursing, and bacteriology. an intuitive classification to facilitate the presentation
The study included 237 students (88 men and 149 wom- of the results:
en), with a mean age of 20.6 years (SD ± 2.2 years), all of
whom were at the first 10 semesters of their academic Stratum 1 (Low Risk)
programs. CLBP was reported by 24 of the 237 patients This stratum includes populations at a low risk of
(10.12%) and was associated with the number of years LBP. The prevalence of LBP is in the range of 9.1% to
the student had been at the university, with the hours 20.3%. This stratum includes adolescents (21), miners, and

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 Prevalence of Low Back Pain in Latin America

Table 4. Observational studies on the prevalence of non-specified low back pain.

Study Population N. of cases Prevalence
Bazán et al, 2007 (39) 260 210 80.8%
Duque Vera et al, 2011 (30) 233 158 67.8%
Guzmán et al, 2007 (32) 114 75 65.8%
Martins and Silva, 2005 (25) 203 130 64.0%
Zavala-González et al, 2010 (38) 100 63 63.0%
Barros et al, 2011 (17) 239 146 61.1%
Mayworm et al, 2008 (26) 200 122 61.0%
Andrusaitis et al, 2006 (16) 410 242 59.0%
Pereira et al, 2007 (27) 12 6 50.0%
Neil et al, 2004 (42) 302 85 28.0%
Reis et al, 2008 (28) 203 68 33.6%
Ferreira et al, 2006 (23) 78 26 33.4%
Brito and Bezerre, 2010 (18) 264 88 33.3%
Silva et al, 2007 (19) 180 59 33.0%
Loyola, 2010 (35) 83 23 27.7%
Pinto and Frias, 2010 (33) 346 70 20.3%
De Vitta et al, 2011 (21) 1,236 241 19.5%
Palomino et al, 2005 (41) 1,240 205 16.5%
El Khouri et al, 2008 (22) 1,169 160 13.7%
Gómez Ramirez, 2012 (31) 120 11 9.1%
Total 6,992 2,188

Fig. 3. Prevalence of non-specified low back pain reported in observational studies from different types of populations.

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 Pain Physician: September/October 2014; 17:379-391

oil workers (22,31,41) (possibly working for companies the figures reported in most studies for the general
having a well-designed program to prevent professional population. This stratum includes the results of studies
diseases), and university administrative officials (33). conducted with the employees of a university (drivers,
The studies pooled in this stratum included 4,111 janitors, and other similar employments) (35), transit
patients among which 687 cases of LBP were reported. bus drivers (23), senior citizens (28), nurses (mostly reg-
A pooled analysis of all the studies in this stratum istered nurses) (30), and workers enrolled in a physical
yielded a prevalence of 16.7% (Fig. 4). rehabilitation program (18). The pooled studies in this
stratum included 1,110 patients among which 349 cases
Stratum 2 (Medium or “Usual” Risk) of LBP were reported. The pooled results of the studies
The prevalence reported by these studies var- in this stratum yielded a prevalence of LBP of 31.5%
ies between 27.7% and 36.3%%, i.e., pretty close to (Fig. 5).

Fig. 4. Prevalence of non-specified low back pain in the studies of the stratum 1.

Fig. 5. Prevalence of non-specified low back pain in the studies of the stratum 2.

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 Prevalence of Low Back Pain in Latin America

Stratum 3 (High Risk) and the intriguing differences in their results. These
This stratum includes the studies conducted with difficulties in estimating the prevalence of CLBP are
populations at high risk of LBP, that is, people working not exclusive of our region. Rather, the comparison of
long hours in the sitting position (truckers, seamstress- the results obtained from different populations or at
es, and technicians) (16,17,26), jobs that require lifting different times from the same population has posed a
and/or carrying heavy loads (sawyers, truck loaders, true methodological challenge due to the lack of in-
homemakers, and assistant nurses) (27,30,32,39), and formation, the marked methodological heterogeneity,
people carrying physical overloads such as pregnant differences in the temporal definitions of chronicity,
women (25) and people who are overweight or obese and the difficulty in obtaining reliable estimations as
(38) (Fig. 6). references (1,43-45).
This category grouped 9 studies, with a total of The most immediate alternative to estimate the
1,771 patients and 1,152 cases of LBP reported. The prevalence of CLBP is a statistic approach encompassed
pooled results of the 9 studies in this stratum yielded a within the frame of the prevalence of LBP in general
prevalence of LBP of 65%. (1). Methodologically sound estimations of the preva-
lence of LBP in other regions yield figures very close to
Discussion 30% (1,46-48).
None of the COPCORD studies seems to report an Although separately none of the 20 observational
LBP prevalence figure consistent with what has been studies included in the review could, due to the specif-
previously reported either on a global or a regional ics of their populations, provide a reliable estimation
basis. The pooled results of the 4 studies (34,36,37,40) of the prevalence of LBP in the general Latin American
yield a figure pretty removed from the expected preva- population, and although the aggregation of epidemi-
lence of LBP in the general population (Table 2). ological studies is not often recommended due to the
Only 4 of the 28 studies in the review evaluated the lack of thoroughness of these studies, it is evident that
prevalence of CLBP in the Latin American population the pooled results of the 20 studies that measured the
(15,20,24,29). In spite of the large number of patients prevalence of LBP provide a privileged point of view on
(8,041), the results cannot be combined to obtain a the frequency of the condition in the region.
pooled result due to the large heterogeneity of their These pooled results comprise 6,992 patients that
designs, the different definitions of chronicity used, include homemakers, adolescents, pregnant women,

Fig. 6. Prevalence of non-specified low back pain in the studies of the stratum 3.

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 Pain Physician: September/October 2014; 17:379-391

seniors, workers and operators, administrative officials, could have been affected by both interviewer bias and
seamstresses, truckers, transit bus drivers, miners, obese subject selection bias.
subjects, and others. This consideration is confirmed Another noteworthy finding is the difference in
by the pooled result of prevalence of 31.3%, a figure the prevalence of LBP reported in 2 different studies
pretty close to the expected prevalence of LBP in the conducted with nurses (30,42). Both studies coincide
general population. in indicating that LBP is strongly associated with the
Additionally, the analysis of these studies by risk efforts made when bathing and mobilizing patients,
strata showed that the 6 studies categorized in stratum a fact that could explain the differences reported be-
2, where the medium or “usual” risk of the general cause the study conducted by Neil et al (42), where the
population is located, yield a pooled prevalence rate prevalence of LBP was of only 28%, just 49% of the
of 31.5%. This means that, in spite of the theoretical patients were assistant nurses whereas in the study
difficulties surrounding the aggregation of the results performed by Duque et al (30), with a reported preva-
of these studies, the pooled analysis provides very con- lence of 67.8%, the percentage of assistant nurses was
sistent estimations, close to 31%. of 85.4%.
Notwithstanding the undeniable limitations of the Importantly, the number of continuous hours a
available evidence on the epidemiology of CLBP at the patient remains in the sitting position is a common
global level, several findings can be drawn: The studies determinant of the prevalence of LBP in several of the
show that the majority of the episodes of LBP are mild reviewed publications (16,17,23,26). This could explain
in severity and rarely disabling, and that only a few why transit bus drivers, who often have resting periods
of the affected individuals go to the doctor (45). It is between their daily route assignments, have a preva-
known that 90% of the cases of LBP will resolve within lence of LBP far lower than truck drivers, who often
the first 90 days after their onset, that is, only 10% of drive longer periods of time and have less resting peri-
all new cases of LBP go on to enlarge the prevalence ods during their working day (16,23).
rate of CLBP (1,49), a percentage that should be added A remarkable finding is the high impact of LBP
to the 24% of expected annual recurrence for the cases among women (21,25,28,39). This could be attributed
initially resolved (1,45). This means that up to 34% of not only to differences in musculoskeletal constitution
the prevalence observed of LBP could be expected between men and women, but also to differences in
to correspond to cases of CLBP. By applying these as- both roles and tasks women undertake on a daily basis.
sumptions to our observations (31% * 0.34), an indirect It is not a coincidence that the higher prevalence of
estimation of 10.54% is obtained as an approximate LBP observed in this review was found in a group of
prevalence of CLBP in the region. homemakers (39) because it is at their own home where
Many biases and methodological limitations af- women are more exposed to long working hours that
fect the validity of these results. One of them is the include caring for young children, frequent lifting and
potentially large topographic and chronologic vari- carrying of heavy loads, performing tasks in uncomfort-
ability (most of which has not been described in an able postures, and the use of inadequate tools. Addi-
explicit manner) in the definitions of LBP used in each tionally, homemakers’ work may be poorly recognized
one of the studies included. Multiple factors that affect or rewarded, which generates an environment laden
the prevalence of LBP have been identified (ethnicity, with frustration and complex emotional states.
educational level, urban vs. rural living, body weight, LBP also affected significantly older workers, or
job satisfaction, wage issues, type of employment people who perform the same activity for longer pe-
contract, stress management, secondary income, and riods of time (31,33,35), a finding that should call the
under-registration), most of which are absent from the attention of interdisciplinary work groups interested in
considerations of the reviewed studies. The vast major- the prevention and timely management of LBP, for the
ity of the studies were conducted with the patients at design of programs specifically targeted to this particu-
their work places, which generates a “healthy worker” lar population.
bias, even with the possibility that the interviewed A strong association was reported between LBP
population is the less affected one because people with and obesity, overweight, and sedentary lifestyles (17,
disabling LBP may be absent from work, and those with 26, 38). This brings to light a true time bomb, given the
CLBP may have been moved to other worksites with growing epidemics of overweight and obesity currently
lower risk activities. Most studies included in this review plaguing the Western world.

388 www.painphysicianjournal.com
 Prevalence of Low Back Pain in Latin America

LBP and its employment, social, and economic the body (15). Some other factors associated with the
consequences could complicate the already worrisome smoker could involve, for example, the fact that smok-
picture of cardiovascular risk in the region. ers tend to be more sedentary or less concerned with
The high prevalence of LBP reported among preg- their own health than non-smokers (16).
nant women (25) is explained, among other causes,
by the mechanical overload women bear during preg-
Conclusions
nancy, hormonal changes, body water redistribution, This systematic literature review allowed us to find
increased blood viscosity due to a deficit in fibrinolysis, and process valuable information on the behavior of
relative ischemia of spinal structures, changes in body LBP in the Latin American region. In spite of the paucity
posture, and the occurrence of compartment syn- of data and of the methodological heterogeneity of
dromes (50-52). The fact that doctors and registered the studies, the pooled results of 20 carefully selected
nurses rarely, if ever, ask pregnant women about their studies provided a significant sample of 6,992 patients,
musculoskeletal system during prenatal visits is trouble- pertaining to a wide variety of occupations and age
some. It is also important to highlight the few pharma- groups, which allows for an indirect estimation of the
cological alternatives there are for the management of approximate prevalence of LBP in the Latin American
LBP during pregnancy. region that is pretty consistent with what has been
The association reported between smoking and reported in other regions of the world.
CLBP suggests that the use of tobacco contributes to The present work confirms the need to undertake
the development of CLBP (15,24), even among those crossover studies that overcome the methodological de-
who have quit smoking more than one year ago (15). ficiencies previously discussed. Some recommendations
Although the literature has confirmed the association to attain this goal would be: to include representative
between smoking and CLBP, the causal mechanism has samples of the general population, more particularly
not been completely elucidated (16). Some explana- in countries where this type of study has never been
tions described in the literature state that smoking pro- conducted; to develop a harmonized measurement
duces changes in the pH and perfusion of intervertebral instrument; to publish the results in indexed journals;
discs, while debilitating the paravertebral muscles and to use indicators and variables previously agreed
that provide support to the spine, which may lead to upon that allow for reliable comparisons being made
a decreased resistance to tension and delayed healing between the different countries of the region, between
processes. Nicotine can also impact the central nervous Latin America and other regions of the world, or be-
system with a change in the perception of pain, which tween the results of the same region in the course of
could explain musculoskeletal pains in other regions of time.

References
1. Andersson GB. Epidemiological fea- disability and return to work among pa- low back pain in Argentina. J Rheumatol
tures of chronic low-back pain. Lancet tients who have a herniated lumbar disc: 2002; 29:1029-1033.
1999; 354:581-585. The effect of disability compensation. J 10. Meziat Filho N, Silva GA. Disability pen-
2. Koes BW, Van Tulder MW, Thomas S. Di- Bone Joint Surg Am 2000; 82:4-15. sion from back pain among social secu-
agnosis and treatment of low back pain. 7. Freburger JK, Holmes GM, Agans RP, rity beneficiaries, Brazil. Revista de Saúde
BMJ 2006; 332:1430-1434. Jackman AM, Darter JD, Wallace AS, Cas- Pública 2011; 45:494-502.
3. Manchikanti L, Singh V, Datta S, Co- tel LD, Kalsbeek WD, Carey TS. The rising 11. Hasenbring MI, Hallner D, Klasen B,
hen S, Hirsch J. Comprehensive review prevalence of chronic low back pain. Arch Streitlein-Böhme I, Willburger R, Rus-
of epidemiology, scope, and impact Intern Med 2009; 169:251-258. che H. Pain-related avoidance versus
of spinal pain. Pain Physician 2009; 8. Noriega-Elío M, Barrón Soto A, Sierra endurance in primary care patients with
12:E35-E70. Martínez O, Méndez Ramírez I, Pulido subacute back pain: Psychological char-
4. Last AR, Hulbert K. Chronic low back Navarro M, Cruz Flores C. The debate acteristics and outcome at a 6-month
pain: Evaluation and management. Am on lower back pain and its relationship follow-up. Pain 2012; 153:211-217.
Fam Physician 2009; 79:1067-1074. to work: A retrospective study of workers 12. Hiebert R, Campello MA, Weiser S,
5. Frank A. Low back pain. BMJ 1993; on sick leave. Cadernos de Saúde Pública Ziemke GW, Fox BA, Nordin M. Pre-
306:901-909. 2005; 21:887-897. dictors of short-term work-related dis-
6. Atlas SJ, Chang Y, Kammann E, Keller 9. Soriano ER, Zingoni C, Lucco F, Catog- ability among active duty US Navy per-
RB, Deyo RA, Singer DE. Long-term gio LJ. Consultations for work related sonnel: A cohort study in patients with

www.painphysicianjournal.com 389
 Pain Physician: September/October 2014; 17:379-391

acute and subacute low back pain. Spine 23. Ferreira B, Vanessa, da S, Marco Antônio Bogotá DC, Colombia, 2010.
J 2012; 12:806-816. Guimaraes, Guilherme B, Luís, Enrique 34. Reyes Llerena GA, Guibert Toledano M,
13. Vandenbroucke JP, Von Elm E, Altman MD, Estélio. Lombalgia e fatores psicos- Hernández Martínez AA, González Otero
DG, Gøtzsche PC, Mulrow CD, Po- sociais em motoristas de ônibus urbano. ZA, Alcocer Varela J, Cardiel MH. Preva-
cock SJ, et al. {Need all authors listed.} Fit Perform J 2006;:295-299. lence of musculoskeletal complaints
Strengthening the Reporting of Ob- 24. Silva MC da, Fassa AG, Valle NCJ. and disability in Cuba. A community-
servational Studies in Epidemiology Chronic low back pain in a Southern based study using the COPCORD core
(STROBE): Explanation and elaboration. Brazilian adult population: Prevalence questionnaire. Clin Exp Rheumatol 2000;
Ann Intern Med 2007; 147:W163-W194. and associated factors. Cad Saude Pu- 18:739-742.
14. Stroup DF, Berlin JA, Morton SC, Olkin blica 2004; 20:377-385. 35. Loyola F. Prevalencia del dolor lumbar
I, Williamson GD, Rennie D, Moher D, 25. Martins RF, Silva JLP. Back pain is a ma- en el personal de conserjería, conduc-
Becker BJ, Sipe TA, Thacker SB. Meta- jor problem for many pregnant women. tores y editorialistas de la UTPL en el
analysis of observational studies in epi- Rev Ass Med Bras 2005; 51:144-147. periodo diciembre 2008 - febrero 2009
demiology: A proposal for reporting. 26. Mayworm SH, Pereira JS, Silva MAG [Thesis]. 2010.
Meta-analysis of Observational Studies da. Prevalence of low back pain in 36. Álvarez J, Nuño B, Alcocer J. Enferme-
in Epidemiology (MOOSE) group. JAMA dressmakers of women’s underwear in dades reumáticas y discapacidad laboral
2000 ;283:2008-2012. Nova Friburgo/RJ. Fisioter Bras 2008; en población adulta rural. Rev Med IMSS
15. Almeida ICGB, Sá KN, Silva M, Baptista 9:205-209. 2005; 43:287-292.
A, Matos MA, Lessa Í. Chronic low back 27. Pereira JE, Pinto MC, De Souza RA. Pre- 37. Cardiel MH, Rojas-Serrano J. Commu-
pain prevalence in the population of the valência de lombalgias em transporta- nity based study to estimate prevalence,
city of Salvador. Rev Bras Ortop 2008; dores de sacos de café. Motriz Rev Ed Fis burden of illness and help seeking be-
43:96-102. UNESP 2007; 12:229-238. havior in rheumatic diseases in Mexico
16. Andrusaitis SF, Oliveira RP, Barros Filho 28. Reis LA dos, Mascarenhas CHM, Marin- City. A COPCORD study. Clin Exp Rheu-
TEP. Estudo da prevalência e fatores de ho Filho LEN, Borges PS. Low back pain matol 2002 ;20:617-624.
risco da lombalgia em caminhoneiros at the third age: Distribution and prev- 38. Zavala-González MA, Cruz RC-D la, Po-
do estado de São Paulo, Brasil. Clinics alence at the Physical Therapy School poca-Flores A, Posada-Arévalo SE. Low
2006; 61:503-510. Clinic from the Southwestern Bahia back pain in residents of Comalcalco,
17. Barros SS de, Ângelo R di C de O, Uchôa State University, Brazil. Rev Bras Geriatr Tabasco, Mexico: Prevalence and associ-
ÉPBL. Occupational low back pain Gerontol 2008; 11:93-103. ated factors. Arch Med 2010; 2:90-96.
and the sitting position. Rev Dor 2011; 29. Camargo Lemos DM, Orozco Vargas 39. Bazán C, Fernández J, Dávila K. Preva-
12:226-230. LC, Hernández Sánchez J, Niño Cruz lencia y los factores asociados al dolor
18. Brito A, Bezerre C. Prevalência de lom- GI. Dolor de espalda crónico y activi- lumbar en amas de casa mayores de 18
balgia em trabalhadores submetidos ao dad física en estudiantes universitarios años en el Asentamiento Humano Dan-
programa de Reabilitação Profissional de áreas de la salud. Rev Soc Esp Dolor iel A. Carrión del Distrito de San Martín
do Instituto Nacional do Seguro Social 2009; 16:429-436. de Porres; en el año 2007.
(INSS), São Luís, MA. Acta Fisiatr 2010; 30. Duque Vera IL, Zuluaga D, Pinilla A. 40. Gamboa R, Medina M, Acevedo E, Pas-
17:148-152. Prevalencia de lumbalgia y factores de tor C. Prevalencia de enfermedades
19. Silva C, Silva AT, Gervásio F. Prevalên- riesgo en enfermeros y auxiliares de la reumatológicas y discapacidad en una
cia e aplicação da classificação de Mck- ciudad de Manizales. Promocion Salud comunidad urbano-marginal: Resulta-
enzie para lombalgia em funcionários 2011; 16:27-38. dos del primer estudio COPCORD en el
do Centro Universitário UniEvangé- 31. Gómez R MM. Determinación de facto- Perú. Rev Per Reumatol 2009; 15:40-46.
lica. 2007; Retrieved from: http://uni- res de riesgo generadores de lumbalgia: 41. Palomino JC, Ruiz F, Navarro G, Dongo
evangelica.edu.br/gc/imagens/file/ En trabajadores contratistas de ECO- F, Llap C, Gomero R. El trabajo a turnos
anais_pbic/2006/fisioterapia/IC%20 PETROL, estación Puerto Salgar, Cun- como factor de riesgo para lumbago en
09.02.06%20subp2.pdf. dinamarca. Rev Arb Sent Vida 2012; 1. un grupo de trabajadores peruanos. Rev
20. Cordeiro Q, El Khouri M, Ota D, Ciam- 32. Guzmán A, Borjas L, Muñoz B. Determi- Med Hered 2005; 16:184-189.
pi D, Corbett CE. Lombalgia e cefaleia nación de factores de riesgo ocupacio- 42. Neil M, Víctor L, Aismara B. Lumbalgia
como aspectos importantes da dor nal generadores de lumbalgia mecánica ocupacional en enfermeras venezolanas.
crônica na atenção primária à saúde em en trabajadores cosecheros de madera. Salud Trab 2004; 12:19-32.
uma comunidade da região amazônica Facultad Ciencias de la Salud de la Uni- 43. Hoy D, Brooks P, Blyth F, Buchbinder
brasileira. Acta Fisiatr 2008; 15:101-105. versidad del Cauca 2007; 9. {Please check R. The epidemiology of low back pain.
21. De Vitta A, Martinez MG, Piza NT, that the title of the journal is italicized Best Pract Res Clin Rheumatol 2010;
Simeão SF de AP, Ferreira NP. Preva- correctly and provide page numbers.} 24:769-781.
lence of lower back pain and associated 33. Pinto L, Frias O. Prevalencia de dolor 44. Hoy D, March L, Brooks P, Woolf A,
factors in students. Cad Saude Publica lumbar y su relación con la condición Blyth F, Vos T, Buchbinder R. Measur-
2011; 27:1520-1528. física: Estudio en trabajadores del área ing the global burden of low back pain.
22. El Khouri M, Corbett CE, Cordeiro Q, administrativa de una institución edu- Best Pract Res Clin Rheumatol 2010;
Ota D. Prevalência de lombalgia em cativa en la ciudad de Bogotá, 2008 24:155-165.
garimpeiros de Serra Pelada, Pará / Bra- [Trabajo de Grado]. Universidad Colegio
45. Buchbinder R, Pransky G, Hayden J.
sil. Acta Fisiatr 2008; 15:82-86. Mayor de Nuestra Señora del Rosario,
Recent advances in the evaluation and

390 www.painphysicianjournal.com
 Prevalence of Low Back Pain in Latin America

management of nonspecific low back resentative sample of Greek population: 51. Noon ML, Hoch AZ. Challenges of the
pain and related disorders. Best Pract Analysis according to personal and so- pregnant athlete and low back pain. Curr
Res Clin Rheumatol 2010; 24:147-153. cioeconomic characteristics. Spine 2004; Sports Med Rep 2012; 11:43-48.
46. Hoy D, Toole MJ, Morgan D, Morgan 29:1355-1360. 52. Majchrzycki M, Mrozikiewicz PM, Kocur
C. Low back pain in rural Tibet. Lancet 49. Shekelle PG, Markovich M, Louie R. An P, Bartkowiak-Wieczorek J, Hoffmann
2003; 361:225-226. epidemiologic study of episodes of back M, Stryła W. Low back pain in pregnant
47. Skovron ML, Szpalski M, Nordin M, pain care. Spine 1995; 20:1668-1673. women. Ginekol Pol 2010; 81:851-855.
Melot C, Cukier D. Sociocultural factors 50. Katonis P, Kampouroglou A, Aggelopou-
and back pain. A population-based study los A, Kakavelakis K, Lykoudis S, Makri-
in Belgian adults. Spine 1994; 19:129-137. giannakis A, AlpantakiK. Pregnancy-re-
48. Stranjalis G, Tsamandouraki K, Sakas lated low back pain. Hippokratia 2011;
DE, Alamanos Y. Low back pain in a rep- 15:205-210.

www.painphysicianjournal.com 391