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Cite as: Archiv EuroMedica. 2025. 15; 5. DOI 10.35630/2025/15/Iss.5.515

Received 09 September 2025;
Accepted 07 October 2025;
Published 12 October 2025

PROGNOSTIC FACTORS IN LOW BACK PAIN: FROM IDENTIFICATION TO STRATIFIED CARE

Wiktoria Mika¹ , Justyna Moszkowicz¹,
Justyna Słowik¹, Daniel Narożniak² ,
Mateusz Mierniczek ² , Anna Rodzeń³

¹Provincial Clinical Hospital No. 2 St. Jadwiga the Queen in Rzeszów, Poland
²St. Raphael’s Voivodeship Specialist Hospital in Czerwona Góra, Poland
³4th Military Clinical Hospital, Wroclaw, Poland

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  wiktoria.m.mika@gmail.com

ABSTRACT

Background:

Low back pain (LBP) is a leading cause of disability worldwide and a major burden on individuals, healthcare systems, and economies. Its prognosis is determined by a multifactorial interplay of psychosocial, demographic, occupational, lifestyle, clinical, and genetic factors, extending beyond biomedical explanations. Previous reviews are now partially outdated, as they did not fully integrate recent findings on systemic comorbidities, genetic predispositions, sleep disturbances, and stress-related disorders. This review addresses this gap by synthesizing evidence up to early 2025, with a particular focus on implications for physical activity and sport participation, an aspect rarely emphasized in earlier literature.

Methods:

This narrative review was conducted in accordance with SANRA guidelines. A comprehensive search of PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar identified publications between 1987 and early 2025. Eligible studies included systematic reviews, meta-analyses, randomized controlled trials, large prospective cohorts, and landmark conceptual papers. A total of 121 publications were included and synthesized thematically across psychosocial, demographic, occupational, lifestyle, clinical, genetic, and systemic domains.

Results:

The analysis confirmed psychosocial determinants as the strongest predictors of chronicity and disability. Occupational exposures, lifestyle behaviors, and comorbid conditions such as hypertension, diabetes, and multisite pain also contributed substantially to prognosis. Emerging evidence highlighted novel domains, including genetic predispositions, biological markers, sleep disturbances, and stress-related disorders such as PTSD. Importantly, this review identified the underexplored relationship between prognostic factors and sport participation: moderate leisure-time activity appears protective, whereas excessive or high-load training may increase risk, underscoring the need for sport-specific prognostic insights.

Conclusion:

LBP prognosis is complex and requires a holistic biopsychosocial approach. The novelty of this review lies in its integration of evidence up to 2025 and its unique emphasis on systemic health indicators, genetic predispositions, and the implications of physical activity and sport participation. These findings expand the scope of prognostic research and highlight domains not adequately addressed in previous reviews. Early risk identification, tailored interventions, and multidisciplinary models of care are essential to improve outcomes and prevent chronicity. Future research should refine prognostic models, incorporate systemic and genetic markers, and develop sport- and activity-specific recommendations to advance prevention, optimize treatment, and support sustained engagement in healthy, active lifestyles.

Keywords:

Low back pain, prognosis, risk factors, chronicity, sport, physical activity, health

INTRODUCTION

Global Burden and Prevalence of Low Back Pain

Low back pain (LBP) remains a formidable global health challenge, consistently ranking as the single largest contributor to years lived with disability (YLDs) worldwide [1]. Its pervasive nature means it affects individuals across all age groups and demographics, with substantial prevalence noted in numerous studies [2, 3]. The sheer scale of LBP's impact extends far beyond individual suffering, deeply affecting healthcare systems and national economies. The economic implications of LBP are immense, encompassing both direct healthcare costs and substantial indirect costs stemming from lost productivity and disability [4, 5]. For example, research by Becker et al. (2010) specifically highlighted the costs of care and the prediction of future healthcare utilization within primary care settings [6]. This extensive economic footprint, combined with its widespread prevalence and contribution to global disability, elevates LBP beyond a mere clinical symptom to a critical public health and economic crisis. This broader perspective underscores that effective LBP management isn't just about alleviating individual discomfort; it's also vital for sustaining healthcare systems, national economies, and preserving individuals' capacity for physical activity and sport.

The Critical Need to Identify Factors Influencing its Course and Chronicity

Despite its high prevalence, LBP often takes a highly variable and unpredictable course. While many acute episodes resolve spontaneously, a significant proportion of individuals transition into persistent or chronic disabling pain [7]. Chou and Shekelle (2010) directly addressed this variability, exploring which patients might develop persistent disabling LBP [8]. This inherent unpredictability poses a significant challenge for both healthcare providers and patients particularly for those whose livelihoods or well-being hinge on physical activity and sport.

The variability in LBP trajectories highlights the critical importance of identifying factors that predict this transition. Such identification is crucial for effective clinical management, enabling early intervention and the application of targeted therapies for individuals deemed at high risk [9]. The PROGRESS framework (Prognosis Research Strategy), for instance, explicitly emphasizes the critical role of prognostic factor research in improving patient outcomes [10]. This represents a fundamental shift in clinical strategy, moving from a reactive approach to symptom treatment towards a proactive stance of risk stratification.

Specific Focus and Original Contribution of the Review

Previous narrative and systematic reviews on prognostic factors in low back pain have provided important insights but are now partially outdated, with most focusing on evidence published up to 2019–2020. They did not fully incorporate recent findings on genetic predispositions, psychosocial stratification models, and implications for sport and physical activity. The present review addresses this gap by synthesizing literature up to early 2025, thereby integrating the most recent evidence and highlighting domains that have emerged as particularly relevant in the last five years. This focus provides added value and novelty, positioning the review as both a current update and a broader perspective that links prognostic research with practical implications for clinical care, public health, and sport participation.

This review also places a unique emphasis on the relationship between prognostic factors in low back pain and their implications for physical activity and sport, an aspect that has been only marginally addressed in previous reviews and remains insufficiently explored in the current literature.

AIM

Therefore, the aim of this review is to provide an updated synthesis of prognostic factors and risk indicators for the development and persistence of low back pain, integrating evidence up to early 2025 and emphasizing recent advances in genetic research, psychosocial stratification, and implications for physical activity and sport participation.

MATERIALS AND METHODS

This review was prepared as a narrative synthesis in accordance with SANRA (Scale for the Assessment of Narrative Review Articles) guidelines. The objective was to provide an integrated and critical overview of prognostic factors in low back pain, with emphasis on studies of high methodological quality and relevance.

Literature Search: A comprehensive search was conducted in PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar for articles published between January 1987 and January 2025. The search strategy combined controlled vocabulary and free-text terms, including “low back pain”, “prognosis”, “risk factors”, “chronicity”, “psychosocial factors”, “stratified care”, and “biopsychosocial model”.

Selection Principles: Studies were considered eligible if they investigated prognostic or risk factors for low back pain in adult populations. Priority was given to systematic reviews, meta-analyses, large prospective cohorts, and randomized controlled trials. Landmark conceptual publications were also included to reflect the historical development of prognostic research. Excluded were case reports, small uncontrolled studies, expert opinions without empirical data, and articles not available in English.

Screening and Data Synthesis: The initial search yielded 1,236 records. After removal of duplicates and title–abstract screening, 121 articles were assessed in full text. Following application of inclusion and exclusion criteria, 121 publications were retained for analysis. Data were extracted on study design, population, prognostic domains assessed, and outcomes reported. The synthesis was thematic and interpretative, with results organized into psychosocial, demographic, occupational, lifestyle, clinical, and genetic domains.

Quality Considerations: While no formal risk-of-bias assessment or PRISMA flow diagram was applied, methodological transparency was maintained through explicit reporting of databases, timeframe, search terms, and selection principles. Emphasis was placed on consistency of findings across study types and on evidence with the greatest clinical and public health relevance. RESULTS

The prognosis of low back pain (LBP) is multifactorial, influenced by a complex interplay of biomedical, psychosocial, and lifestyle factors. The following sections systematically categorize and discuss these various determinants identified in the literature. A comprehensive summary of these key prognostic factors is provided in Table 1.

Psychosocial Factors: The Dominant Predictors of Chronicity

Psychosocial factors consistently stand out as some of the most powerful predictors of persistent LBP and disability, frequently outweighing purely biomedical considerations [17–20]. How patients cognitively and emotionally respond to pain – especially their fear of movement or re-injury (kinesiophobia) and their tendency to catastrophize – significantly contributes to poorer outcomes [21, 22]. These beliefs can lead to reduced activity, deconditioning, and increased disability, creating a vicious cycle. Trinderup et al. (2018) specifically demonstrated a strong link between fear avoidance beliefs and long-term sick leave, disability, and pain [23]. Conditions such as depression, anxiety, and somatization are frequently associated with both the onset and chronicity of LBP [24–26]. Currie and Wang (2005) found that major depression can act as an antecedent risk factor for the first onset of chronic back pain [24]. Furthermore, the impact of anxiety and depression on the outcomes of multidisciplinary pain management has been highlighted by Oliveira et al. (2019), indicating their pervasive influence on treatment effectiveness [27]. The bidirectional relationship between pain intensity and sleep disturbance or poor sleep quality is also a significant factor, as poor sleep can exacerbate pain and vice versa [28]. Beyond common mental health conditions, post-traumatic stress disorder (PTSD) is consistently associated with various chronic pain types [29]. The way individuals cope with their pain profoundly affects their prognosis. Passive coping mechanisms, such as excessive resting or waiting for pain to spontaneously resolve, are identified as risk factors for developing disabling neck or low back pain [30]. Conversely, positive individual recovery expectations are strong prognostic indicators for better outcomes [31]. Resilience, the ability to bounce back from adversity, can also serve as a protective factor against disability in the context of pain [32]. The patient's subjective perception of their LBP can also predict the outcomes of an LBP episode [33]. The concept of "yellow flags" refers to psychosocial risk factors that signal a higher likelihood of long-term disability and work loss in patients with acute LBP [34, 35]. Nicholas et al. (2011) provided a critical reappraisal of the early identification and management of these factors, emphasizing their importance in preventing chronicity [36]. The influential studies that underpin the biopsychosocial model and the development of risk stratification concepts are summarized in Table 2.

While psychosocial factors are dominant, an individual's prognosis is also shaped by their demographic and physical characteristics.

Demographic and Anthropometric Factors

Demographic and anthropometric characteristics also influence LBP prognosis, though their role can be complex and interact with other factors. LBP is a condition that can manifest across the entire life course [46]. While sex and gender differences in pain perception and experience are recognized, age can be a contributing factor, with height loss in older individuals being related to LBP [47, 48]. Obesity is a frequently investigated risk factor for LBP [49, 50]. Heuch et al. (2013) found BMI to be a risk factor for developing chronic LBP in a follow-up study [49]. However, the relationship is not always straightforward, as some research suggests that obesity may not increase the risk of chronic LBP when genetic factors are carefully considered [51]. Excessive weight gain during pregnancy has been linked to persistent low back and pelvic pain after delivery [52]. The association between body height and chronic LBP has also been explored, with some studies indicating a link [53]. Emerging evidence also suggests that family history and underlying genetic factors can influence the prognosis of spinal pain [54, 55].

Beyond these inherent characteristics, daily behaviors and work environment play a significant role in the course of LBP.

Occupational and Lifestyle Influences

Work demands and individual lifestyle choices significantly contribute to LBP risk and prognosis. The nature of one's occupation can be a major determinant of LBP. Physical load at work, perceived physical exertion, and specific repetitive or strenuous work tasks, such as lifting and carrying in healthcare settings, are significant contributors to both the incidence and persistence of LBP [56–61]. The relationship between physical activity and LBP is complex and can be curvilinear. Some research suggests a U-shaped relationship, implying that both insufficient and excessive physical activity may pose risks for LBP [62]. While occupational physical load is consistently identified as a risk factor, leisure-time physical activity can be protective and positively influence the prognosis of chronic LBP [63–65]. Furthermore, sedentary behaviors like television viewing have been associated with LBP [66]. Smoking is a well-established risk factor for LBP, with meta-analyses consistently confirming its association [67, 68]. Adherence to a healthy lifestyle can also positively influence the overall prognosis of LBP [63].

Clinical Characteristics and Comorbidities

The pain's inherent characteristics and the presence of other health conditions are critical in determining LBP's trajectory. Higher baseline pain intensity, a longer duration of pain, and a history of previous LBP episodes are consistent predictors of poorer outcomes and an increased risk of chronicity [69–89]. The "centralization phenomenon," characterized by the migration of pain from a peripheral to a more central location in response to specific movements or postures, has been identified as a positive prognostic factor for chronic LBP and disability [25, 90]. Chronic pain frequently coexists with other health conditions, contributing to a more complex clinical picture [91]. The influence of systemic conditions such as hypertension, diabetes, and abnormal serum lipid levels on LBP risk has been investigated [92–94]. The presence of multisite pain and psychological comorbidity significantly influences the prognosis of chronic LBP, often leading to worse outcomes [95]. Deviations in spinal alignment, such as thoracic hyperkyphosis, have been associated with chronic LBP [96]. Additionally, neuropathic pain can act as an independent risk factor for a lower quality of life in affected individuals [97].

Genetic and Biological Markers

While less extensively covered in the provided references than psychosocial and lifestyle factors, the inclusion of family history and genetic factors points to an emerging and important area of LBP prognosis research [54, 55].

DISCUSSION

This review provides added value compared with earlier syntheses by incorporating evidence published up to early 2025, thereby capturing the most recent developments in prognostic research. In particular, it integrates emerging findings on genetic predispositions, systemic comorbidities, and novel approaches to risk stratification that were not fully considered in earlier reviews. A further unique aspect of this work is its emphasis on the implications of prognostic factors for physical activity and sport participation. This focus remains rarely addressed in previous literature, despite its direct relevance for athletes, physically active individuals, and professionals engaged in sports medicine. By linking prognostic research with outcomes in sport and physical activity, the present review highlights an underexplored dimension that broadens the scope of prognosis studies beyond clinical and public health settings.

Although this review highlights the importance of physical activity and sport participation in the context of low back pain prognosis, practical aspects remain underdeveloped in the current literature. There is still a lack of clear conclusions on how specific types, intensities, and contexts of sport or exercise can positively or negatively influence long-term outcomes in LBP. Evidence suggests that moderate leisure-time activity is protective, whereas excessive or high-load training may increase the risk of persistence or recurrence. However, these relationships are insufficiently defined, and tailored recommendations for athletes or physically active individuals are rarely addressed in previous reviews. By drawing attention to this gap, the present review underscores the need for further research that systematically evaluates how training regimens, sport-specific demands, and recovery strategies can modify the prognosis of LBP.

Additionally, this review emphasizes that low back pain should be understood within a broader systemic context. It frequently coexists with other chronic conditions, including hypertension, diabetes, and multisite pain syndromes, suggesting that prognosis is influenced by overall health status rather than spinal pathology alone. Emerging insights into genetic predispositions and biological markers also highlight that prognosis may be shaped by inherent vulnerabilities in addition to psychosocial and lifestyle factors. Furthermore, the contribution of sleep disturbances and stress-related disorders, such as post-traumatic stress disorder, appears increasingly significant and should be more explicitly integrated into prognostic frameworks and clinical practice.

The consistent and substantial evidence highlighting psychosocial factors as dominant predictors of LBP outcomes, demonstrated across numerous studies [17–20; 98], is more than just an observational finding. It strongly validates the biopsychosocial model of pain, which posits that pain arises from a complex interaction of biological, psychological, and social elements [35]. This review also highlights a more nuanced interplay between genetic predispositions and environmental or lifestyle factors. This points to a deeper complexity, where simple correlations between anthropometric measures and LBP don't provide a full understanding. It highlights a more nuanced interplay between genetic predispositions and environmental or lifestyle factors. The explicit mention of genetic factors signals a shift towards understanding individual predisposition at a deeper biological level, indicating that inherent biological vulnerabilities may also contribute to LBP susceptibility and prognosis. Furthermore, this review reinforces the idea of LBP as part of a more generalized pain experience or systemic health challenge. This implies LBP isn't always an isolated musculoskeletal issue; it can be influenced by, or co-exist with, systemic physiological states. The concept of "multisite pain" further reinforces this idea. This highlights that clinical assessment should extend beyond the spine to include a comprehensive review of a patient's general health.

Implications for Clinical Practice and Public Health

The implication for clinical practice is clear: comprehensive psychosocial screening and interventions–like cognitive behavioral therapy and strategies to reduce fear-avoidance—must become core components of LBP management, particularly for those identified as being at risk of chronicity. Identifying these flags early is central to effective management [30]. The robust evidence base on prognostic factors has directly spurred the development of stratified care models, which aim to match patients to the most appropriate treatments based on their individual risk of developing persistent pain and disability [9, 41, 99, 100]. This approach moves decisively away from a traditional "one-size-fits-all" treatment paradigm.

A prime example of this translation of research into practice is the STarT Back screening tool. This tool is designed to triage patients into low, medium, or high-risk subgroups, thereby guiding the intensity and type of treatment they receive [99, 101]. Hill et al. (2011) provided compelling evidence for the effectiveness of stratified care in family practice, demonstrating improved outcomes compared to usual care [99]. The evolution from merely identifying what factors predict LBP outcomes to developing and rigorously testing "stratified care" models and "clinical decision rules" represents a critical leap in the field [9, 41, 99, 102, 103]. Consequently, healthcare systems should prioritize the widespread adoption and implementation of validated risk stratification tools. Proactive screening for psychosocial "yellow flags" and other key risk factors during the acute phase of LBP is crucial to prevent the transition to chronicity [36, 104–108]. Given the profoundly multifaceted nature of LBP prognosis, multidisciplinary pain management programs are often the most effective approach. These programs typically integrate physical therapy, psychological interventions, and medical management, providing comprehensive care that addresses the diverse determinants of LBP outcomes [109, 110]. This also necessitates a multidisciplinary team approach to address the diverse and interconnected needs of patients, especially those involved in sport and physical activity where psychological resilience and coping are paramount.

For professionals working with athletes, such as coaches and physiotherapists, these findings underscore the need to screen not only for biomechanical issues but also for psychosocial yellow flags. An athlete's fear of re-injury or high stress levels can be a greater barrier to recovery than the physical injury itself, requiring targeted psychological support alongside physical rehabilitation.

Future Research Directions

While significant strides have been made, continued development of more sophisticated and generalizable prognostic models is needed. Future models should aim to incorporate a wider array of biological, psychological, and social factors, moving beyond current limitations [111, 112]. Crucially, research must prioritize the external validation of these models in diverse populations and clinical settings to ensure their generalizability and practical utility. Methodological advancements in prognosis research, such as those outlined by the PROGRESS framework, should be rigorously adopted to improve the quality and interpretability of findings [10]. Translating this knowledge into routine clinical practice remains a significant hurdle. Research is urgently needed to understand the most effective strategies for implementing stratified care models and early intervention programs in real-world clinical settings [99]. This involves identifying and addressing the specific barriers and facilitators to adoption among healthcare providers, patients, and healthcare systems. The trajectory of LBP is dynamic; more long-term prospective cohort studies are essential to better understand the dynamic interplay of prognostic factors [69, 78, 85, 113–120]. Further exploration of genetic predispositions and the identification of objective biological markers (e.g., inflammatory markers, neuroimaging findings) are needed to enhance the accuracy of predictive models and elucidate underlying pathophysiological mechanisms [55]. Beyond merely identifying associations, future research should delve deeper into the neurobiological, psychological, and social mechanisms that drive the transition from acute to chronic LBP. This mechanistic understanding is crucial for developing truly novel, targeted interventions that address the root causes of chronicity, rather than merely managing symptoms [121]. Future research should also focus on designing and rigorously testing highly individualized interventions that are specifically tailored to a patient's unique prognostic risk profile.

Table 3 summarizes the key prognostic factors reported across the analyzed studies, grouped by clinical relevance and strength of evidence.

Limitations

This review should be interpreted in light of several limitations. Although it was prepared in accordance with SANRA guidelines to ensure methodological clarity, its narrative design does not provide the same level of rigor as a systematic review. The choice of databases, the absence of a formal PRISMA flow diagram, and the lack of a structured risk-of-bias assessment reduce reproducibility and transparency to some extent. In addition, study quality was not appraised with standardized tools, and the synthesis was interpretative rather than quantitative, which may limit the strength of the conclusions. These factors do not diminish the value of the presented overview but indicate that the findings should be considered as a comprehensive synthesis of current knowledge rather than a definitive evidence hierarchy.

CONCLUSION

This review confirms that low back pain remains a global health priority, imposing a significant personal, clinical, and economic burden. Its prognosis is determined by a multifactorial interaction of psychosocial, demographic, occupational, lifestyle, clinical, and genetic influences. Among these, psychosocial determinants consistently emerge as the strongest predictors of chronicity and disability, reinforcing the necessity of a holistic biopsychosocial framework in both research and clinical management.

The novelty of this review lies in its inclusion of evidence up to early 2025 and its specific focus on the role of physical activity and sport participation, a dimension rarely emphasized in previous reviews. By integrating recent findings, it also highlights the systemic nature of LBP, which often coexists with conditions such as hypertension, diabetes, and multisite pain syndromes, indicating that prognosis cannot be understood in isolation from overall health. Furthermore, emerging research on genetic predispositions and biological markers, together with the growing recognition of sleep disturbances and stress-related disorders such as PTSD, points to new domains that should be incorporated into prognostic models and future interventions.

The expanding evidence base has already fostered the development of stratified care models and risk-based decision tools, marking a paradigm shift from uniform treatment to personalized, evidence-informed interventions. Early risk identification, tailored care pathways, and multidisciplinary management remain essential for improving outcomes and preventing the transition from acute to chronic pain.

Future work should continue to refine and validate prognostic models, integrate systemic health indicators and genetic markers, and provide sport- and activity-specific recommendations. Such progress will advance prevention, optimize treatment strategies, and ultimately support sustained engagement in healthy, active lifestyles.

The literature on prognostic factors in low back pain is extensive and heterogeneous, ranging from psychosocial and occupational studies to recent genetic and systemic investigations. To provide a clearer overview of the evidence base, we have summarized a selection of representative studies that exemplify the diversity of methodological approaches, populations, and outcomes. These studies were chosen for their relevance, methodological quality, and influence on current understanding of LBP prognosis. Table 1 presents their main characteristics and key findings, organized across different prognostic domains.

DISCLOSURE

Authors’ Contributions

Conceptualization: Wiktoria Mika

Methodology: Daniel Narożniak, Anna Rodzeń, Mateusz Miernicze

Data curation: Wiktoria Mika, Justyna Słowik, Justyna Moszkowicz¹

Formal analysis: Daniel Narożniak, Anna Rodzeń, Mateusz Miernicze

Writing – original draft: Wiktoria Mika, Justyna Słowik, Justyna Moszkowicz¹

Writing – review & editing: all

Supervision: Wiktoria Mika

All authors have read and agreed with the published version of the manuscript.

Use of artificial intelligence

Artificial intelligence tools were used only for language editing of the manuscript. No AI tools were employed for data analysis, interpretation, or writing of the scientific content.

Funding

Conflict of Interest Statement: Authors have declared no conflict of interest.

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