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What Causes Lower Back Pain? What the Research Says
In a 2018 Lancet review, Hartvigsen and colleagues report that for nearly all people with low back pain it is not possible to identify a specific nociceptive cause. The authors say only a small proportion of people with low back pain have a well understood pathological cause, such as a vertebral fracture, malignancy, or infection. A 2026 JAMA review by Cashin and colleagues states that about 90% of patients presenting for care with low back pain have nonspecific low back pain, defined as pain not associated with a specific spinal disorder. For patients with low back pain of any duration, the review says initial management includes reassurance that serious underlying disease is unlikely. Brinjikji and colleagues' 2015 review of CT and MRI found that degenerative findings often occur in people with no pain.
Hartvigsen and colleagues' 2018 Lancet review says that, for nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Cashin and colleagues' 2026 review in JAMA says about 90% of patients who present for care with low back pain have nonspecific low back pain, pain not associated with a specific spinal disorder.
I had low back pain for about ten years and have no medical credentials. Every research figure below comes from a source listed at the end of the page.
What the research and guidelines found
| Source | Finding | Source type |
|---|---|---|
| Hartvigsen 2018, Lancet | Among people with low back pain, only a small proportion have a well understood pathological cause, such as a vertebral fracture, malignancy, or infection. | Review |
| Cashin 2026, JAMA | Acute nonspecific low back pain is usually self-limited, and approximately 72% of individuals with acute nonspecific low back pain recover by 12 months. | Review |
| Downie 2013, BMJ | Downie and colleagues' 2013 review included 14 studies of patients presenting with low back pain in primary, secondary, or tertiary care. Pooling was not possible because the tests differed. Many red flags in guidelines provide virtually no change in probability of fracture or malignancy for those patients, or have untested diagnostic accuracy. Only a small subset has evidence of being informative for those patients. | Systematic review |
| Brinjikji 2015, AJNR | Across CT and MRI studies totaling 3,110 people with no pain, estimated disc degeneration was 37% at age 20 and 96% at age 80. | Systematic review |
| NICE NG59, updated 2026 | The guideline covers assessment and management of low back pain and sciatica in people aged 16 and over. | Guideline |
Hartvigsen and colleagues' 2018 review says most people with new episodes of low back pain recover quickly, though recurrence is common. In a small proportion of people with a new episode of low back pain, it becomes persistent and disabling. In people with low back pain, the authors say, initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increase the risk of persistent disabling pain. People with physically demanding jobs, physical and mental comorbidities, smokers, and people with obesity are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. The review says that, in people with low back pain, increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain.
Cashin and colleagues' 2026 review classes low back pain as acute when it is shorter than 6 weeks, subacute from 6 to 12 weeks, and chronic when it is longer than 12 weeks. The review says prognosis is less favorable for patients with chronic nonspecific low back pain, but 42% of those patients recover within 12 months. WHO's 2023 guidance defines chronic primary low back pain in adults as pain lasting more than 3 months that is not due to an underlying disease or other condition.
What to do in practice
- For patients with low back pain of any duration, Cashin and colleagues' 2026 review says initial management includes reassurance that serious underlying disease is unlikely.
- For patients with low back pain of any duration, Cashin and colleagues' 2026 review recommends remaining physically active, continuing usual activities including work, and avoiding prolonged rest.
- Brinjikji and colleagues' 2015 review of CT and MRI in people with no pain estimated disc bulge at 30% at age 20 and 84% at age 80, and says those imaging findings must be interpreted in the context of the person's clinical condition.
- WHO's 2023 guidance recommends non-surgical interventions for adults with chronic primary low back pain. These include education programs, exercise programs, some physical therapies such as spinal manipulative therapy and massage, psychological therapies such as cognitive behavioural therapy, and medicines such as NSAIDs.
- WHO's 2023 guidance outlines 14 interventions not recommended for most people in most contexts, such as lumbar braces, belts or supports, traction, and opioid painkillers. They should not be routinely offered to adults with chronic primary low back pain, because potential harms likely outweigh benefits.
Where the program in the app fits
Low Back Pain Coach uses a required 45-degree back-extension bench. Floor Foundations is a starting point until you have one, and it is not an equipment-free version of the program. The program is not written for a vertical 90-degree Roman chair. It is for people with chronic pain who have been cleared to exercise. Recent workouts and pain logs help set the next session. The first guided session is free, and the pain log, calendar, 30-day graph, CSV export, lessons, and flare help. Later guided sessions require a plan. The app does not diagnose your back or identify the cause of your pain. The exact bench progression has not been tested in a trial. Details are on the app page.
When to get care
Go to emergency care now for any of these:
- New numbness, tingling or change in feeling in the saddle area: around the groin, inner thighs, genitals or anus, or when you wipe
- New trouble getting or keeping an erection, not being able to orgasm, or a change in feeling during sex
- New bladder or bowel changes: trouble starting or stopping pee, a weak stream, not feeling when you need to go, or leaking pee or poo
- New pain, tingling, numbness or weakness in both legs
- Leg or foot weakness that is getting worse (tripping, a foot that slaps down)
- Back pain that started after a recent serious accident, like a car crash or a bad fall
See a clinician today (urgent care if no appointment today) for any of these:
- Other new weakness or numbness in one leg or foot
- Fever or chills alongside the back pain
- New pain after a recent smaller fall or knock
- Unexplained weight loss, or a history of cancer
- Pain that is rapidly getting worse
- Pain that is constant at rest and worse at night, not tied to movement
More on those signs is on back pain red flags.
Common questions
What causes most lower back pain?
Hartvigsen and colleagues' 2018 Lancet review says it is not possible to identify a specific nociceptive cause for nearly all people with low back pain. Cashin and colleagues' 2026 JAMA review says about 90% of patients presenting for care with low back pain have nonspecific low back pain, pain not associated with a specific spinal disorder.
How well do red flags screen for fracture or cancer?
Downie's 2013 review of 14 studies of patients with low back pain found that many red flags in guidelines provide virtually no change in probability of fracture or malignancy, or have untested diagnostic accuracy. Only a small subset had evidence of being informative for those patients.
Can a scan show the cause of lower back pain?
Brinjikji and colleagues' 2015 review of CT and MRI, across imaging studies totaling 3,110 people with no pain, estimated disc degeneration at 37% at age 20 and 96% at age 80. Many of these findings in people with no pain are likely part of normal aging and unassociated with pain.
Why does lower back pain last in some people?
Hartvigsen and colleagues' 2018 review says that in people with low back pain, initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increase the risk of persistent disabling low back pain. Cashin and colleagues' 2026 review says prognosis is less favorable for patients with chronic nonspecific low back pain, but 42% of those patients recover within 12 months.
When should I stop and see a doctor?
Go to emergency care now for any of these: New numbness, tingling or change in feeling in the saddle area: around the groin, inner thighs, genitals or anus, or when you wipe; New trouble getting or keeping an erection, not being able to orgasm, or a change in feeling during sex; New bladder or bowel changes: trouble starting or stopping pee, a weak stream, not feeling when you need to go, or leaking pee or poo; New pain, tingling, numbness or weakness in both legs; Leg or foot weakness that is getting worse (tripping, a foot that slaps down); Back pain that started after a recent serious accident, like a car crash or a bad fall. See a clinician today (urgent care if no appointment today) for any of these: Other new weakness or numbness in one leg or foot; Fever or chills alongside the back pain; New pain after a recent smaller fall or knock; Unexplained weight loss, or a history of cancer; Pain that is rapidly getting worse; Pain that is constant at rest and worse at night, not tied to movement.
Sources
- Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X. PMID: 29573870. link
- Cashin AG, Chou R, Weimer MB, McAuley JH. Low back pain: a review. JAMA. 2026;336(2):144-158. doi:10.1001/jama.2026.9631. PMID: 42295944. link
- Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347:f7095. doi:10.1136/bmj.f7095. PMID: 24335669. link
- Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173. PMID: 25430861. link
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59. Published 30 November 2016, last updated 29 July 2026. link
- World Health Organization. WHO releases guidelines on chronic low back pain. 7 December 2023. link
The app
Low Back Pain Coach runs a guided strength program on a 45-degree back-extension bench: floor work until you have a bench, then four stages from short holds to weighted reps. You log your pain the next morning, and that log sets the next session. A voice counts the holds, reps and rest.
Your first guided session is free. Then $59.99 a year or $9.99 a month, renewing until you cancel, with a 7-day free trial for eligible new subscribers. US prices. iPhone and Android. The 45-degree bench is required. What the app does.
The program on one page
The printable program card has the four stages, the next-morning rule, and the stop signs on one sheet.
If you want an email when the program or the app changes, leave your address. A few emails a year at most, and a reply to any of them takes you off the list.