Low back pain in China and the role of traditional Chinese medicine: findings from the global burden of disease study 2021 and a meta-analysis

Abstract

Introduction To quantify the burden of low back pain (LBP) and its risk factors in China from 1990 to 2021 and to assess the efficacy of traditional Chinese medicine (TCM) interventions. Methods The incidence, prevalence, and years lived with disability (YLDs) of LBP in China were searched. Trends from 1990 to 2021 were assessed using estimated annual percentage changes, stratified by age and sex, and joinpoint regression evaluated temporal patterns in LBP burden attributable to risk factors. Then, we searched ten electronic databases (up to April 2025) for randomized controlled trials (RCTs) of TCM interventions. The primary outcomes were pain intensity and physical function. Results In 2021, China had the highest absolute incidence, prevalence, and YLDs of LBP among G20 countries, although its age-standardized YLD rate had decreased significantly since 1990. An estimated 3.31 million YLDs (95% UI: 2.28, 4.53) were attributable to occupational ergonomic factors, 1.85 million (95% UI: 1.08, 2.70) to smoking, and 1.06 million (95% UI: 0.11, 2.23) to high body mass index. The systematic review identified 137 eligible trials involving 11 936 participants. Moderate-confidence evidence showed reduced post-intervention pain intensity with acupuncture plus physiotherapy care (standardized mean difference [SMD] = −1.59, 95% CI [−2.10, −1.09]), acupressure (SMD = −0.87, [−1.17, −0.57]), and acupuncture plus moxibustion (SMD = −2.44, [−2.72, −2.16]) versus physiotherapy care. Improved physical function had moderate-to-very-low confidence with acupuncture (SMD = −1.50, [−2.44, −0.57]) and Tai Chi (SMD = −1.84 [−2.30, −1.37]) compared with physiotherapy care and Western medicine. Conclusion Despite the decline in age-standardized YLD rates since 1990, the absolute burden remains substantial. Incorporating TCM into management may help address this burden but requires risk-stratified, large-scale, high-quality RCTs with extended follow-up.

Keywords

low back pain / traditional Chinese medicine / global burden of disease study / China

Electronic Supplementary Material

The online version contains supplementary material available at https://doi.org/10.26599/eCMTA.2026.9570039.

Funding

This work was supported by grants from the High Level Traditional Chinese Medicine Key Subject Construction Project of the National Administration Of Traditional Chinese Medicine—Evidence-based Traditional Chinese Medicine (grant no.: zyyzdxk-2023249); the Hebei Administration of Traditional Chinese Medicine (grant no.: B2025019); the National Health Commission (grant no.: YLZLXZ24G033); the Special Fund of Basic Scientific Research Business Expenses for Central Public Welfare Scientific Research Institutes (grant no.: 2022-JYB-PY-013).

Author Contribution Statement

Man-ci Zhou: Data curation, methodology, software, visualization, formal analysis, and writing - original draft. Xiu-mei Wang: Data curation, software, validation, and writing - original draft. Jun-yan Zeng: Data curation, methodology, visualization, and writing - review & editing. Guo-lin Guo: Investigation, resources, formal analysis, and writing - review & editing. Mitchell Levine: Methodology, formal analysis, and writing - review & editing. Jian Li: Supervision and writing - review & editing. Hong-guo Rong: Conceptualization, supervision, project administration, funding acquisition, and writing - review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this study.

Data Availability

Data will be made available by the corresponding author upon reasonable request.

Use of AI statement

None.

References

[1] GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the global burden of disease study 2021. Lancet Rheumatol. 2023; 5(6):e316-e329.

[2] Xu S, Qi J, Liu C, et al. Evaluation of three decades of the burden of low back pain in China before COVID-19: estimates from the Global Burden of Disease Database 2019. J Glob Health. 2024; 14:04006.

[3] Wallwork SB, Braithwaite FA, O’Keeffe M, et al. The clinical course of acute, subacute and persistent low back pain: a systematic review and meta-analysis. Can Med Assoc J. 2024; 196(2):E29-E46.

[4] Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain. 2013; 17(1):5-15.

[5] Wong CK, Mak RY, Kwok TS, et al. Prevalence, incidence, and factors associated with non-specific chronic low back pain in community-dwelling older adults aged 60 years and older: a systematic review and meta-analysis. J Pain. 2022; 23(4):509-534.

[6] World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. https://www.who.int/publications/i/item/9789240081789.2023. Accessed June 7, 2025.

[7] Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018; 391(10137):2368-2383.

[8] Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018; 391(10137):2356-2367.

[9] Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. Lancet. 2018; 391(10137):2384-2388.

[10] Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American college of physicians. Ann Intern Med. 2017; 166(7):514-530.

[11] Zhang X, Ren J, Liu C, He M, Ren L, Lv Z. Evaluating traditional Chinese medicine interventions on chronic low back pain using goal attainment scaling. Evid Based Complementary Altern Med. 2020; 2020(1):8854927.

[12] Luo Y, Wang CZ, Sawadogo R, Tan T, Yuan CS. Effects of herbal medicines on pain management. Am J Chin Med. 2020; 48(1):1-16.

[13] Patel M, Urits I, Kaye AD, Viswanath O. The role of acupuncture in the treatment of chronic pain. Best Pract Res Clin Anaesthesiol. 2020; 34(3):603-616.

[14] Zhou T, Salman D, McGregor AH. Recent clinical practice guidelines for the management of low back pain: a global comparison. BMC Musculoskelet Disord. 2024; 25(1):344.

[15] Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis. PLoS One. 2015; 10(2):e0117146.

[16] Zhang Z, Pasapula M, Wang Z, Edwards K, Norrish A. The effectiveness of cupping therapy on low back pain: a systematic review and meta-analysis of randomized control trials. Complementary Ther Med. 2024; 80:103013.

[17] Wei Y, Xie Y, Xuan A, et al. Analysis and comparison of the trends in burden of low back pain in China and worldwide from 1990 to 2021. J Health Popul Nutr. 2025; 44(1):39.

[18] Jia N, Zhang M, Zhang H, et al. Prevalence and risk factors analysis for low back pain among occupational groups in key industries of China. BMC Public Health. 2022; 22(1):1493.

[19] Liu Q, Liu X, Lin H, et al. Occupational low back pain prevention capacity of nurses in China: a multicenter cross-sectional study. Front Public Health. 2023; 11:1103325.

[20] Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study 2021. Institute for Health Metrics and Evaluation Web site. https://ghdx.healthdata.org/gbd-2021. Accessed March 4, 2025.

[21] Oliveira CC, Charalampous P, Delaye J, et al. A systematic review of studies that estimated the burden of chronic non-communicable rare diseases using disability-adjusted life years. Orphanet J Rare Dis. 2024; 19(1):333.

[22] GBD 2021 Risk Factors Collaborators. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 403(10440):2162-2203.

[23] Stevens GA, Alkema L, Black RE, et al. Guidelines for accurate and transparent health estimates reporting: the GATHER statement. Lancet. 2016; 388(10062):e19-e23.

[24] Jahn A, Andersen JH, Christiansen DH, Seidler A, Dalbøge A. Occupational mechanical exposures as risk factor for chronic low-back pain: a systematic review and meta-analysis. Scand J Work Environ Health. 2023; 49(7):453-465.

[25] Schönnagel L, Hoehl BU, Taheri N, et al. The impact of smoking on low back pain and disability. Eur J Pain. 2025; 29(6):e70041.

[26] De Simone M, Choucha A, Ciaglia E, et al. Discogenic low back pain: anatomic and pathophysiologic characterization, clinical evaluation, biomarkers, AI, and treatment options. J Clin Med. 2024; 13(19):5915.

[27] Lim TK, Ma Y, Berger F, Litscher G. Acupuncture and neural mechanism in the management of low back pain: an update. Medicines. 2018; 5(3):63.

[28] Zhu X, Jia Z, Zhou Y, et al. Current advances in the pain treatment and mechanisms of traditional Chinese medicine. Phytother Res. 2024; 38(8):4114-4139.

[29] Müller A, Laskowski NM, Thomas TA, et al. Update on treatment studies for compulsive buying-shopping disorder: a systematic review. J Behav Addict. 2023; 12(3):631-651.

[30] Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

[31] Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 336(7650):924-926.

[32] Rücker G. Network meta-analysis, electrical networks and graph theory. Res Synth Meth. 2012; 3(4):312-324.

[33] Run CS. Observation of the effect of traditional Chinese medicine nursing intervention on pain and health related quality of life in non specific lower back pain. Diet Health. 2019; 6(49):208-209.

[34] Yao LH, Chen F, Feng DD. Clinical effect of suspension exercise training combined with Tongdu Wenyang acupuncture on chronic non-specific low back pain. Henan Med Res. 2021; 30(31):5884-5887.

[35] Liu J, Yeung A, Xiao T, et al. Chen-style Tai Chi for individuals (aged 50 years old or above) with chronic non-specific low back pain: a randomized controlled trial. Int J Environ Res Public Health. 2019; 16(3):517.

[36] Zhang AB, Wang TG, Dong M, Yu XD, Chen GS, Wang J. Treatment of 60 cases of chronic nonspecific low back pain with acupuncture and moxibustion and intramuscular plaster. Chin Med Mod Distance Educ China. 2018; 16(17):123-124.

[37] Su LX, Liao XR, Lin Q, et al. Clinical study on modified Cassia twig and Pueraria decoction in the treatment of non-specific low back pain patients with cold - dampness syndrome. Yunnan J Tradit Chin Med. 2021; 42(7):29-32.

[38] Xie LN, Liu MY, Su ZS. Clinical effect of core muscle group training combined with acupuncture on chronic low back pain. Smart Health. 2020(14):133-134,144.

[39] An Y, Duan YF, Chen JX. Puncture cupping plus McKenzie therapy improving lumbar flexion and extension function of patients suffering lower back pain. Acta Chin Med. 2020; 35(5):1115-1119,1130.

[40] Chen JX, An Y, Duan YF. Clinical observation of acupuncture and cupping combined with Mckenzie therapy for the treatment of chronic non specific lower back pain in elderly patients. Mod J Integr Tradit Chin West Med. 2021; 30(13):1442-1446.

[41] Xiao BE, Chen YY, Fan WF, et al. Clinical observation of core muscle group training combined with balance tank in the treatment of chronic non specific lower back pain of qi stagnation and blood stasis type. China Naturop. 2023; 31(11):46-50.

[42] Zou L, Zhang Y, Liu Y, et al. The effects of Tai Chi Chuan versus core stability training on lower-limb neuromuscular function in aging individuals with non-specific chronic lower back pain. Medicina. 2019; 55(3):60.

[43] Liu J, Zhao WN, Yuan YH. Effects of Tai Chi on the event-related potential of patients with chronic non-specific low back pain. Chin J Sports Med. 2018; 37(10):826-832.

[44] Chen Z, Long DY, Wang JQ, et al. The study on the rehabilitation benefits of Ai-Chi in elderly patients with nonspecific low back pain by ICF rehabilitation set. Chin J Rehabil Med. 2022; 37(10):1341-1346.

[45] Qi JQ, Ding W, Ren HT, Guan T, Wang JY. Clinical observation of acupoint application combined with eight section brocade in the treatment of non specific lower back pain of cold dampness type. China Naturop. 2020; 28(1):45-48.

[46] Yang D, Huang H, Xu DD, Zhao Y. Effects of Baduanjin exercise on patients with chronic nonspecific low back pain and surface electromyography signs of erector spinal muscle: a randomized controlled trial. Medicine. 2023; 102(43):e35590.

[47] Liang B, Wei Y, Pei H, Liang X, Chen G, Pei L. Temporal trends of low back pain burden and joinpoint and age-period-cohort analysis in China from 1990 to 2021. BMC Public Health. 2025; 25(1):1598.

[48] Chen K, Ling J, Zhou X, Zhang M, Long Q, Huang L. Deciphering the anti-senescence immune paradigm: Kidney Yin-Yang equilibrium in traditional Chinese medicine. J Holist Integr Pharm. 2024; 5(2):77-89.

[49] Zhang J, Tian Y, Li Y, et al. Time trends in the burden of low back pain and its associated risk factors in China from 1990 to 2019. J Orthop Transl. 2024; 45:256-265.

[50] Lancet T. Improving occupational health in China. Lancet. 2019; 394(10197):443.

[51] Li Q, Peng L, Wang Y, Yang Y, Wang Z. Risk factors for low back pain in the Chinese population: a systematic review and meta-analysis. BMC Public Health. 2024; 24(1):1181.

[52] Mohd Isa IL, Teoh SL, Mohd Nor NH, Mokhtar SA. Discogenic low back pain: anatomy, pathophysiology and treatments of intervertebral disc degeneration. Int J Mol Sci. 2023; 24(1):208.

[53] Wang F, Yang Y, Xu J, Zhao M, Ma H, Xu Q. The shifting global landscape of low back pain attributable to high body mass index: burden, growth, and inequalities. Prev Med Rep. 2025; 53:103031.

[54] Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015; 2015(9):Cd001929.

[55] Qin J, Zhang Y, Wu L, et al. Effect of Tai Chi alone or as additional therapy on low back pain: systematic review and meta-analysis of randomized controlled trials. Medicine. 2019; 98(37):e17099.

[56] Qiao L, Guo M, Qian J, Xu B, Gu C, Yang Y. Research advances on acupuncture analgesia. Am J Chin Med. 2020; 48(2):245-258.

[57] Wang JH, van Haselen R, Wang M, et al. Acupuncture for smoking cessation: a systematic review and meta-analysis of 24 randomized controlled trials. Tob Induc Dis. 2019; 17:48.

[58] Zhang YY, Su YZ, Tian ZY, et al. Acupuncture and related acupoint therapies for smoking cessation: an umbrella review and updated meta-analysis. Tob Induc Dis. 2024; 22:186147.

[59] Chen M, Liu J. Effects of traditional Chinese medicines on weight management among adults with overweight or obesity: a systematic review and network meta-analysis. Obes Sci Pract. 2024; 10(3):e763.

[60] Kim G, Kim D, Moon H, et al. Acupuncture and acupoints for low back pain: systematic review and meta-analysis. Am J Chin Med. 2023; 51(2):223-247.

[61] Yan WX, Lin HZ, Wang X, et al. Acupuncture for low back pain: reevaluation of systematic reviews and meta-analyses. Curr Pain Headache Rep. 2023; 27(9):351-369.

[62] Zhang K, Lin X, Liu Z, et al. Therapeutic effects of different acupuncture methods on chronic nonspecific low back pain: a network meta-analysis. J Orthop Surg Res. 2024; 19(1):615.

[63] Liu XX, Guo YY, Fei YT, et al. World federation of acupuncture-moxibustion societies clinical practice guideline on acupuncture-moxibustion: non-specific low back pain recommendation summaries. World J Acupunct Moxibust. 2024; 34(3):213-221.

[64] Li H, Ge D, Liu S, et al. Baduanjin exercise for low back pain: a systematic review and meta-analysis. Complementary Ther Med. 2019; 43:109-116.

[65] Zhang X, Liang F, Lau CT, et al. STandards for reporting interventions in clinical trials of Tuina/massage (STRICTOTM):extending the CONSORT statement. J Evidence Based Medicine. 2023; 16(1):68-81.

[66] Boutron I, Guittet L, Estellat C, Moher D, Hróbjartsson A, Ravaud P. Reporting methods of blinding in randomized trials assessing nonpharmacological treatments. PLoS Med. 2007; 4(2):e61.

[67] Yu H, Wang H, Ma T, Huang A, Lu Z, Zhang X. TCM nonpharmacological interventions for chronic low-back pain: a protocol for systematic review and network meta-analysis. Medicine. 2020; 99(40):e22547.

[68] Zhang C, Zi S, Chen Q, Zhang S. The burden, trends, and projections of low back pain attributable to high body mass index globally: an analysis of the global burden of disease study from 1990 to 2021 and projections to 2050. Front Med. 2024; 11:1469298.