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How to reduce low back pain from the burden of noncommunicable diseases in Iran? A policy brief from evidence generation to practical application in the Iranian health system
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Ali Ahmadi *    |
| SKUMS , aliahmadi2007@gmail.com |
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Abstract: (32 Views) |
Non-communicable diseases (NCDs), particularly musculoskeletal disorders, represent one of the most significant challenges facing health systems worldwide and in Iran. According to global estimates, NCDs account for approximately 82–83% of all deaths globally and more than 90% of deaths in Iran. Within this group, musculoskeletal disorders contribute an increasing share of the overall disease burden, with their rank rising from ninth place in 1990 to fourth place in 2023. Low back pain (LBP), as the most prevalent condition in this category, ranks first in the burden of musculoskeletal disorders and is a leading cause of disability, work absenteeism, and reduced quality of life. It is also among the main contributors to years lived with disability, second only to mental and behavioral disorders.
In Iran, low back pain represents a major public health problem and consistently ranks among the leading causes of disease burden and disability. The high prevalence of LBP in the general population, substantial direct and indirect diagnostic and treatment costs, overuse of imaging, and social and occupational consequences such as work absenteeism underscore the urgent need for a systematic, evidence-based response. Despite this considerable burden, until recently there was no integrated national clinical guideline for managing patients with low back pain across different levels of care, particularly within primary health care (PHC) settings and health houses. Referral indications, diagnostic approaches, and treatment pathways were inconsistently applied.
In response to this gap, and at the request of the Non-Communicable Diseases Management Center of the Ministry of Health, a national guideline for low back pain care was developed. The process began with a structured review of existing international clinical guidelines to identify those most relevant to Iran’s epidemiological profile, cultural context, health system structure, and available resources. These global recommendations were then adapted and integrated with the requirements of Iran’s PHC system, population characteristics, and service delivery capacities. A multidisciplinary expert panel contributed to the guideline, which addressed 20 key clinical and policy questions related to the diagnosis, treatment, referral, and follow-up of patients with low back pain using an evidence-based approach. Ultimately, a care flowchart, defined roles and responsibilities for different levels of care, and standardized service packages aligned with the national health network were developed and proposed.
To assess feasibility and real-world performance, a pilot implementation was conducted in Chaharmahal and Bakhtiari Province. Approximately 295,896 individuals covered by comprehensive health service centers were randomly selected as the target population. Of these, 264,984 individuals were aged over 7 years, and a total of 133,496 participants (mean age approximately 48 years, 62% female) entered the assessment process. A standardized risk stratification tool (STarT Back) was administered by community health workers, health care providers, and family physicians.
The findings showed that 77.55% of assessed individuals had no low back pain, while the prevalence of LBP was 22.45% (29,983 individuals). Risk stratification revealed that 18.4% were classified as low risk, 14.3% as medium risk, and only 0.88% as high risk. Among identified cases, 29,983 individuals were referred by community health workers to family physicians. Of all referrals, 63.8% were managed through horizontal referral within level-one specialized services, approximately 5% required referral to level two, and the majority of patients were effectively managed at the primary care level without the need for vertical referral. This pattern is consistent with findings from European, UK (NICE), and Australian guidelines, which emphasize non-invasive treatments and stepwise management.
Based on these results, and given the low prevalence of moderate and especially severe low back pain, active population-wide screening is not considered cost-effective. Instead, targeted risk assessment among individuals presenting with low back pain complaints represents a rational, evidence-based strategy. Education on lifestyle modification tailored to risk level, avoidance of occupational and behavioral risk factors, and reduction of unnecessary imaging are core components of care. All patients with acute or chronic low back pain should receive education, reassurance, and guidance on self-management options. Early return to activity, judicious use of medications such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), and selected use of physiotherapy are recommended. Management of chronic low back pain may include exercise therapy, paracetamol or NSAIDs, and multimodal rehabilitation combining physical and psychological interventions. In selected patients with lumbar disc herniation and radiculopathy, spinal manipulation may be beneficial, in line with international evidence.
Six policy options were evaluated to reduce the burden of low back pain: (1) primary prevention and public education; (2) secondary prevention through active screening and non-invasive treatment; (3) secondary prevention based on passive and voluntary screening; (4) systematic integration of low back pain management into the national electronic health record system (SIB) with continuous monitoring; (5) development of comprehensive rehabilitation services and psychosocial support; and (6) strengthening occupational ergonomics policies and improving workplace environments. Considering the available scientific evidence, existing resources, cost-effectiveness considerations, and the findings of the provincial pilot study, a combined policy option is recommended for Iran. This includes primary prevention with an emphasis on public education and health literacy, targeted and voluntary secondary prevention based on risk assessment for individuals with non-specific low back pain, and sustained integration and monitoring within the electronic health record system. This approach aligns with international clinical guidelines while enhancing public trust in the primary health care network, improving service efficiency, and supporting the long-term sustainability of health policies.
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| Keywords: Clinical practice guidelines, Low back pain, Neurologic Manifestations, Management, Recommendations, Treatment |
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Type of Study: Policy Brief |
Subject:
medicine, paraclinic
Received: 2025/12/6 | Revised: 2026/02/3 | Accepted: 2025/12/30
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Ethics code: IR.SKUMS.REC.1401.187
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