- Disruptions to sleep may make the experience of back pain worse.
Sleep is increasingly deemed to be an essential component to general health and wellbeing. Growing evidence also suggests that sleep is not only affected by pain, but also influences pain. Poor sleep is a regular feature in chronic pain populations [35; 52], including back pain [4; 19; 22; 31], which is associated with increased pain severity [13; 42; 47], and animal studies have long shown that these sleep effects are mediated through inflammatory mechanisms . Further, restricted or interrupted sleep enhances sensitivity to painful stimuli, impairs pain modulation and increase somatic symptoms in people with and without painful conditions [10; 24; 26; 48].
- Poor quality sleep may increase the risk of back pain development.
Beyond just making back pain worse, some studies have shown poor sleep to be a risk factor for initial back pain development, the transition to chronicity and long-term progression [1; 25; 30; 53]. Luckily, the converse may also be true, with studies showing that improved sleep is associated with reductions in pain [8; 40], highlighting the need to further examine sleep interventions aimed at preventing and managing back pain .
- Work-related factors can contribute to back pain persistence.
Various physical and psychosocial factors related to the work environment have been identified as risk factors for back pain and related disability [18; 29; 39; 45; 49]. In particular, physical factors like repetitive movements and jobs requiring very high physical effort have been associated with low back pain development [9; 20], while psychosocial factors like job dissatisfaction, job insecurity, long working hours, poor relationships with colleagues / employers, and poor work/life balance have all been associated with higher prevalence of back pain [49; 55].
- Worker’s compensation claims are often associated with greater disability and longer time to recover from back pain, but successful intervention is possible.
Unfortunately, the process of obtaining compensation for a work-related injury has historically been associated with worse pain, greater disability and reduced treatment efficacy. This may be due to a need to demonstrate continued pain and disability for the purpose of the claim or may relate to other socioeconomic factors necessitating a compensation claim. Interventions aimed at facilitating return-to-work are, however, proving positive in populations with work-related musculoskeletal pain, suggesting that maintaining effective communication between stakeholders (including engaging the workplace as part of the treatment plan ), and providing early intervention based on risk classifications can lead to improved recovery and return to work success .
- Positional variation may be more important in preventing or managing back pain than correcting “poor” posture
Although ‘poor’ posture has long been believed to cause back pain, there is no consensus on the causal relationship between different postures or specific physical tasks and pain . Instead, it seems that just staying in the same position for long periods of time is associated with the development of at least transient back pain [7; 17]. As well, compared to asymptomatic controls, individuals with back pain tend to show less movement variability [11; 12] and have higher trunk muscle activity levels , suggesting a focus on maintaining the same ‘correct’ posture is likely misguided. It may, thus, be more useful to focus on implementing more frequent breaks with variation in position during sedentary tasks  and addressing other related factors , rather than focusing on correcting ‘poor posture’.
- Regular leisure time physical activity is helpful in preventing the development of back pain.
Physical activity is one of the few factors consistently associated with lower incidence of back pain [2; 44], not to mention obvious beneficial effects on general physical and mental health. Even when back pain is present, continued physical activity also seems protective against the development of more severe symptoms and disability. Despite the overwhelming evidence for the benefits of exercise in preventing and managing back pain, the underlying mechanisms remain surprisingly unclear.
- Stressful life events make pain feel worse and may make it more difficult to cope with.
It is well known from both experimental [16; 51] and clinical work that stress can have a strong effect on the pain experience. In the short-term, acute extreme stress may numb pain perception, but in the longer-term ongoing stress from work or social conflicts may contribute to pain exacerbation and persistence .
- Interactions with others (partners, colleagues, healthcare providers, employers, friends, family, etc.) can have a large impact on how back pain feels and progresses.
Interpersonal communication can have immediate and ongoing effects on pain, with others having the capacity to make a person with back pain feel heard, informed and supported, or isolated, confused and invalidated. Most well studied are perhaps the effects of spousal relationships, showing that criticism or hostility in relationships, possibly related to poor understanding of the pain diagnosis, may lead to greater pain behaviour and disability [5; 6].
- Alcohol consumption and smoking may be associated with greater back pain prevalence.
Although difficult to separate causation from correlation, there seems to be a greater prevalence of back pain in populations with high alcohol consumption and/or smoking history [23; 46; 56]. Alcohol consumption has also been associated with various measures of pain sensitivity among people with acute low back pain though the relationships are complex and likely involve many bio-psycho-social factors. The “alcohol-pain” relationship may also be bi-directional – greater pain may increase alcohol consumption, which may in turn increase pain [27; 58].
- Nutritional supplements are unlikely beneficial for people with low back pain.
Various trials have investigated different dietary supplements, including vitamin D, glucosamine, probiotics, as well as herbal, homeopathic and other complementary interventions for back pain [14; 21; 57]. Supplementation rarely provides significant benefit, though some studies do report effects of herbal compounds to reduce pain more than placebo . Unfortunately, trial quality is often poor with varying control interventions and endpoints, so more high-quality research is needed to determine whether supplementation really is beneficial.
 Agmon M, Armon G. Increased insomnia symptoms predict the onset of back pain among employed adults. PLoS One 2014;9(8):e103591.
 Alzahrani H, Mackey M, Stamatakis E, Zadro JR, Shirley D. The association between physical activity and low back pain: a systematic review and meta-analysis of observational studies. Sci Rep 2019;9(1):8244.
 Amiri S, Behnezhad S. Sleep disturbances and back pain : Systematic review and meta-analysis. Neuropsychiatr 2020;34(2):74-84.
 Axen I. Pain-related Sleep Disturbance: A Prospective Study With Repeated Measures. Clin J Pain 2016;32(3):254-259.
 Burns JW, Post KM, Smith DA, Porter LS, Buvanendran A, Fras AM, Keefe FJ. Spouse criticism and hostility during marital interaction: effects on pain intensity and behaviors among individuals with chronic low back pain. Pain 2018;159(1):25-32.
 Burns JW, Post KM, Smith DA, Porter LS, Buvanendran A, Fras AM, Keefe FJ. Spouse and Patient Beliefs and Perceptions About Chronic Pain: Effects on Couple Interactions and Patient Pain Behavior. J Pain 2019;20(10):1176-1186.
 Christensen SW, Johansson S, Dalgaard M, Eske Jensen A, Høgsted T, Palsson T. The effect of a posture cueing shirt on posture and perceived pain during a computer task in healthy participants, Proceedings of the 11th Congress of The European PAIN Federation EFIC, 2019. p. P084.
 Davies KA, Macfarlane GJ, Nicholl BI, Dickens C, Morriss R, Ray D, McBeth J. Restorative sleep predicts the resolution of chronic widespread pain: results from the EPIFUND study. Rheumatology (Oxford) 2008;47(12):1809-1813.
 Dick RB, Lowe BD, Lu ML, Krieg EF. Trends in Work-Related Musculoskeletal Disorders From the 2002 to 2014 General Social Survey, Quality of Work Life Supplement. J Occup Environ Med 2020;62(8):595-610.
 Edwards RR, Almeida DM, Klick B, Haythornthwaite JA, Smith MT. Duration of sleep contributes to next-day pain report in the general population. Pain 2008;137(1):202-207.
 Falla D, Gizzi L, Parsa H, Dieterich A, Petzke F. People With Chronic Neck Pain Walk With a Stiffer Spine. J Orthop Sports Phys Ther 2017;47(4):268-277.
 Falla D, Gizzi L, Tschapek M, Erlenwein J, Petzke F. Reduced task-induced variations in the distribution of activity across back muscle regions in individuals with low back pain. Pain 2014;155(5):944-953.
 Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain 2013;14(12):1539-1552.
 Gagnier JJ. Evidence-informed management of chronic low back pain with herbal, vitamin, mineral, and homeopathic supplements. Spine J 2008;8(1):70-79.
 Gagnier JJ, Oltean H, van Tulder MW, Berman BM, Bombardier C, Robbins CB. Herbal Medicine for Low Back Pain: A Cochrane Review. Spine (Phila Pa 1976) 2016;41(2):116-133.
 Geva N, Defrin R. Opposite Effects of Stress on Pain Modulation Depend on the Magnitude of Individual Stress Response. J Pain 2018;19(4):360-371.
 Greene RD, Frey M, Attarsharghi S, Snow JC, Barrett M, De Carvalho D. Transient perceived back pain induced by prolonged sitting in a backless office chair: are biomechanical factors involved? Ergonomics 2019;62(11):1415-1425.
 Hallman DM, Holtermann A, Bjorklund M, Gupta N, Norregaard Rasmussen CD. Sick leave due to musculoskeletal pain: determinants of distinct trajectories over 1 year. Int Arch Occup Environ Health 2019;92(8):1099-1108.
 Heffner KL, France CR, Trost Z, Ng HM, Pigeon WR. Chronic low back pain, sleep disturbance, and interleukin-6. Clin J Pain 2011;27(1):35-41.
 Hoogendoorn WE, Bongers PM, de Vet HC, Ariens GA, van Mechelen W, Bouter LM. High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study. Occup Environ Med 2002;59(5):323-328.
 Jensen OK, Andersen MH, Ostgard RD, Andersen NT, Rolving N. Probiotics for chronic low back pain with type 1 Modic changes: a randomized double-blind, placebo-controlled trial with 1-year follow-up using Lactobacillus Rhamnosis GG. Eur Spine J 2019;28(11):2478-2486.
 Kelly GA, Blake C, Power CK, O’Keeffe D, Fullen BM. The association between chronic low back pain and sleep: a systematic review. Clin J Pain 2011;27(2):169-181.
 Klyne DM, Barbe MF, Hodges PW. Systemic inflammatory profiles and their relationships with demographic, behavioural and clinical features in acute low back pain. Brain Behav Immun 2017;60:84-92.
 Klyne DM, Moseley GL, Sterling M, Barbe MF, Hodges PW. Individual Variation in Pain Sensitivity and Conditioned Pain Modulation in Acute Low Back Pain: Effect of Stimulus Type, Sleep, and Psychological and Lifestyle Factors. J Pain 2018;19(8):942 e941-942 e918.
 Klyne DM, Moseley GL, Sterling M, Barbe MF, Hodges PW. Are Signs of Central Sensitization in Acute Low Back Pain a Precursor to Poor Outcome? J Pain 2019;20(8):994-1009.
 Lautenbacher S, Kundermann B, Krieg JC. Sleep deprivation and pain perception. Sleep Med Rev 2006;10(5):357-369.
 Lawton J, Simpson J. Predictors of alcohol use among people experiencing chronic pain. Psychology, Health & Medicine 2009;14(4):487-501.
 Lima M, Ferreira AS, Reis FJJ, Paes V, Meziat-Filho N. Chronic low back pain and back muscle activity during functional tasks. Gait Posture 2018;61:250-256.
 Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro Musculoskeletal Pain Questionnaire. Clin J Pain 2003;19(2):80-86.
 Lusa S, Miranda H, Luukkonen R, Punakallio A. Sleep disturbances predict long-term changes in low back pain among Finnish firefighters: 13-year follow-up study. Int Arch Occup Environ Health 2015;88(3):369-379.
 Marin R, Cyhan T, Miklos W. Sleep disturbance in patients with chronic low back pain. Am J Phys Med Rehabil 2006;85(5):430-435.
 Nicholas MK. Importance of being collaborative for return to work with back pain. Pain 2018;159(8):1431-1432.
 Nicholas MK, Asghari A, Corbett M, Smeets RJ, Wood BM, Overton S, Perry C, Tonkin LE, Beeston L. Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? Eur J Pain 2012;16(1):93-104.
 Nicholas MK, Costa DSJ, Linton SJ, Main CJ, Shaw WS, Pearce G, Gleeson M, Pinto RZ, Blyth FM, McAuley JH, Smeets R, McGarity A. Implementation of Early Intervention Protocol in Australia for ‘High Risk’ Injured Workers is Associated with Fewer Lost Work Days Over 2 Years Than Usual (Stepped) Care. J Occup Rehabil 2020;30(1):93-104.
 O’Donoghue GM, Fox N, Heneghan C, Hurley DA. Objective and subjective assessment of sleep in chronic low back pain patients compared with healthy age and gender matched controls: a pilot study. BMC Musculoskelet Disord 2009;10:122.
 O’Sullivan K, O’Keeffe M, O’Sullivan L, O’Sullivan P, Dankaerts W. Perceptions of sitting posture among members of the community, both with and without non-specific chronic low back pain. Man Ther 2013;18(6):551-556.
 Opp MR. Cytokines and sleep. Sleep Med Rev 2005;9(5):355-364.
 Palsson TS, Travers MJ, Rafn T, Ingemann-Molden S, Caneiro JP, Christensen SW. The use of posture-correcting shirts for managing musculoskeletal pain is not supported by current evidence – a scoping review of the literature. Scand J Pain 2019.
 Parreira P, Maher CG, Steffens D, Hancock MJ, Ferreira ML. Risk factors for low back pain and sciatica: an umbrella review. Spine J 2018;18(9):1715-1721.
 Priebe JA, Utpadel-Fischler D, Toelle TR. Less Pain, Better Sleep? The Effect of a Multidisciplinary Back Pain App on Sleep Quality in Individuals Suffering from Back Pain – a Secondary Analysis of App User Data. J Pain Res 2020;13:1121-1128.
 Puschmann AK, Driesslein D, Beck H, Arampatzis A, Moreno Catala M, Schiltenwolf M, Mayer F, Wippert PM. Stress and Self-Efficacy as Long-Term Predictors for Chronic Low Back Pain: A Prospective Longitudinal Study. J Pain Res 2020;13:613-621.
 Raymond I, Ancoli-Israel S, Choiniere M. Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries. Sleep Med 2004;5(6):551-559.
 Rohling ML, Binder LM, Langhinrichsen-Rohling J. Money matters: A meta-analytic review of the association between financial compensation and the experience and treatment of chronic pain. Health Psychol 1995;14(6):537-547.
 Shiri R, Coggon D, Falah-Hassani K. Exercise for the Prevention of Low Back Pain: Systematic Review and Meta-Analysis of Controlled Trials. Am J Epidemiol 2018;187(5):1093-1101.
 Shiri R, Falah-Hassani K, Heliovaara M, Solovieva S, Amiri S, Lallukka T, Burdorf A, Husgafvel-Pursiainen K, Viikari-Juntura E. Risk Factors for Low Back Pain: A Population-Based Longitudinal Study. Arthritis Care Res (Hoboken) 2019;71(2):290-299.
 Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med 2010;123(1):87 e87-35.
 Sivertsen B, Lallukka T, Petrie KJ, Steingrimsdottir OA, Stubhaug A, Nielsen CS. Sleep and pain sensitivity in adults. Pain 2015;156(8):1433-1439.
 Staffe AT, Bech MW, Clemmensen SLK, Nielsen HT, Larsen DB, Petersen KK. Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants. PLoS One 2019;14(12):e0225849.
 Sterud T, Tynes T. Work-related psychosocial and mechanical risk factors for low back pain: a 3-year follow-up study of the general working population in Norway. Occup Environ Med 2013;70(5):296-302.
 Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech 2020;102:109312.
 Vachon-Presseau E, Martel MO, Roy M, Caron E, Albouy G, Marin MF, Plante I, Sullivan MJ, Lupien SJ, Rainville P. Acute stress contributes to individual differences in pain and pain-related brain activity in healthy and chronic pain patients. J Neurosci 2013;33(16):6826-6833.
 van de Water AT, Eadie J, Hurley DA. Investigation of sleep disturbance in chronic low back pain: an age- and gender-matched case-control study over a 7-night period. Man Ther 2011;16(6):550-556.
 Vinstrup J, Jakobsen MD, Andersen LL. Poor Sleep Is a Risk Factor for Low-Back Pain among Healthcare Workers: Prospective Cohort Study. Int J Environ Res Public Health 2020;17(3).
 Waongenngarm P, Areerak K, Janwantanakul P. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Appl Ergon 2018;68:230-239.
 Yang H, Haldeman S, Lu ML, Baker D. Low Back Pain Prevalence and Related Workplace Psychosocial Risk Factors: A Study Using Data From the 2010 National Health Interview Survey. J Manipulative Physiol Ther 2016;39(7):459-472.
 Yoshimoto T, Ochiai H, Shirasawa T, Nagahama S, Uehara A, Muramatsu J, Kokaze A. Clustering of Lifestyle Factors and Its Association with Low Back Pain: A Cross-Sectional Study of Over 400,000 Japanese Adults. J Pain Res 2020;13:1411-1419.
 Zadro JR, Shirley D, Ferreira M, Carvalho Silva AP, Lamb SE, Cooper C, Ferreira PH. Is Vitamin D Supplementation Effective for Low Back Pain? A Systematic Review and Meta-Analysis. Pain Physician 2018;21(2):121-145.
 Zale EL, Maisto SA, Ditre JW. Interrelations between pain and alcohol: An integrative review. Clin Psychol Rev 2015;37:57-71.
Megan McPhee, MSc
Center for Neuroplasticity and Pain (CNAP)
Aalborg University, Denmark
David Klyne, PhD
Centre of Clinical Research Excellence in Spinal Pain, Injury and Health
School of Health and Rehabilitation Sciences,
The University of Queensland, Australia
Thomas Graven-Nielsen, DMSc, PhD
Center for Neuroplasticity and Pain (CNAP)
Aalborg University, Denmark
Steven J. Linton, PhD
Center for Health and Medical Psychology
School of Law, Psychology and Social Work
Orebro University, Sweden
David Hallman, PhD
Department of Occupational Health Sciences and Psychology
University of Gavle, Sweden