The Spine Journal 8 (2008) 820

A systematic review of low back pain cost of illness studies

in the United States and internationally
Simon Dagenais, DC, PhDa,b,*, Jaime Caro, MDc,d, Scott Haldeman, DC, MD, PhDe,f,g
a

Division of Orthopaedic Surgery and Department of Epidemiology and Community Medicine,

Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
b
CAM Research Institute, Irvine, CA, USA
c
Division of General Internal Medicine and Department of Epidemiology, Biostatistics and Occupational Health,
Faculty of Medicine, McGill University, Montreal, QC, Canada
d
Caro Research Institute, Concord, MA, USA
e
Department of Neurology, University of California, Irvine, CA, USA
f
Department of Epidemiology, University of California, Los Angeles, CA, USA
g
Research Division, Southern California University of Health Sciences, Whittier, CA, USA
Received 25 September 2007; accepted 13 October 2007

Abstract

BACKGROUND CONTEXT: The economic burden of low back pain (LBP) is very large and
appears to be growing. It is not possible to impact this burden without understanding the strengths
and weaknesses of the research on which these costs are calculated.
PURPOSE: To conduct a systematic review of LBP cost of illness studies in the United States and
internationally.
STUDY DESIGN/SETTING: Systematic review of the literature.
METHODS: Medline was searched to uncover studies about the direct or indirect costs of LBP
published in English from 1997 to 2007. Data extracted for each eligible study included study design, population, definition of LBP, methods of estimating costs, year of data, and estimates of direct, indirect, or total costs. Results were synthesized descriptively.
RESULTS: The search yielded 147 studies, of which 21 were deemed relevant; 4 other studies and 2
additional abstracts were found by searching reference lists, bringing the total to 27 relevant studies. The
studies reported on data from Australia, Belgium, Japan, Korea, the Netherlands, Sweden, the UK, and
the United States. Nine studies estimated direct costs only, nine indirect costs only, and nine both direct
and indirect costs, from a societal (n518) or private insurer (n59) perspective. Methodology used to derive both direct and indirect cost estimates differed markedly among the studies. Among studies providing a breakdown on direct costs, the largest proportion of direct medical costs for LBP was spent on
physical therapy (17%) and inpatient services (17%), followed by pharmacy (13%) and primary care
(13%). Among studies providing estimates of total costs, indirect costs resulting from lost work productivity represented a majority of overall costs associated with LBP. Three studies reported that estimates
with the friction period approach were 56% lower than with the human capital approach.
CONCLUSIONS: Several studies have attempted to estimate the direct, indirect, or total costs associated with LBP in various countries using heterogeneous methodology. Estimates of the economic costs in different countries vary greatly depending on study methodology but by any
standards must be considered a substantial burden on society. This review did not identify any studies estimating the total costs of LBP in the United States from a societal perspective. Such studies
may be helpful in determining appropriate allocation of health-care resources devoted to this
condition. 2008 Elsevier Inc. All rights reserved.

Keywords:

Low back pain; Cost of illness; Economics

FDA device/drug status: not applicable.

Nothing of value received from a commercial entity related to this
manuscript.
1529-9430/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.spinee.2007.10.005

* Corresponding author. 25 Corona Ave., Rockcliffe, ON, K1M 1K8,

Canada. Tel.: (949) 466-8132; fax: (949) 266-8951.
E-mail address: simon@camresearch.com (S. Dagenais)

S. Dagenais et al. / The Spine Journal 8 (2008) 820

Introduction
The focus of this special focus issue of The Spine Journal is on the management of chronic low back pain
(CLBP). This topic was chosen partly because of its imposing socioeconomic burden, which appears to be increasing
rapidly despite technological advances in diagnosis and
the introduction of numerous interventions in recent years.
The general pessimism surrounding the prognosis of CLBP
is such that few clinicians, researchers, or third-party
payers would dispute any proposed cost estimate, no matter
how large it may appear. Such views are understandable
when faced with a prevalent, disabling, clinically challenging, and seemingly expensive condition such as CLBP.
However, it is essential to understand the precise magnitude
of the economic burden of CLBP before examining potential cost-saving solutions or comparing the cost effectiveness of competing interventions. This can be achieved by
reviewing cost of illness studies.
Cost of illness studies summarizing the economic burden of a particular disease must be considered by all
stakeholders, including patients, clinicians, and third-party
payers when deciding on the allocation of scarce healthcare resources [1]. It should be noted that cost of illness
studies serves a different purpose than health economic
evaluations (eg, cost-benefit analysis, cost-effectiveness
analysis, cost-utility analysis), which are focused on evaluating the costs of interventions rather than estimating the
cost of a particular disease [1]. The purpose of this study
was to conduct a systematic review of CLBP cost of illness
estimates in the United States and internationally. To help
readers understand some of the basic principles of health
economics pertinent to the studies summarized in this review, a brief overview of important concepts related to cost
of illness studies is presented below.

Cost of illness studies

The economic burden of a disease is the sum of all costs
associated with that condition which would not otherwise
be incurred if that disease did not exist. Given the many categories of costs that must be considered, it can be challenging to fully estimate the economic burden of an illness as
data are often unavailable. The term cost in health economics refers to the value of the consequences of using
a particular good or service rather than its price. That value
corresponds to the best alternative use of those resources,
which is termed the opportunity cost. The difference between cost and price can be demonstrated by comparing
what a clinician charges for his services versus the amount
actually reimbursed for those services; the latter may be
a better proxy of true cost than the former. Despite this example, it should be made clear that estimating the economic
burden of a disease is not simply a matter of tabulating the
amount reimbursed for all clinician services related to a particular diagnosis. The total cost of illnessdor economic

burdendhas three components: (1) direct (medical and

nonmedical) costs; (2) indirect costs; and (3) intangible
costs.
Direct costs
Direct costs refer to those that, at least in principle, involve a monetary exchange. Direct medical costs are most
familiar to readers and commonly include costs incurred for
physician services, medical devices, medications, hospital
services, diagnostic testing, etc [2]. The term direct healthcare costs may be more accurate because allied health,
complementary and alternative medicine (CAM), and other
nonphysician costs are included. Direct medical costs are
typically the easiest to estimate because records are kept
of such transactions by clinicians, third-party payers,
employers, or patients.
Direct nonmedical costs are those related to goods and
services consumed directly because of the illness but which
are not considered to be health care related. They include,
for example, transportation or other travel costs to attend
medical appointments, meals eaten outside the home when
receiving health care, renovations to make a house more accessible for those who may become physically disabled
secondary to a disease, and so on. These expenses are easy
to overlook when considering the economic burden of a disease but can constitute an important source of related costs.
Indirect costs
Indirect costs are those reflecting the economic value of
consequences for which there is no direct monetary transfer. They commonly include costs related to employment
and household productivity. Employment costs include
both work absences resulting in foregone productivity
(termed absenteeism) and decreased productivity for
those who continue to work despite being affected by their
condition (termed presenteeism) [3]. Indirect costs are
often more difficult to measure than direct costs. For example, it is nearly impossible to determine whether presenteeism is in fact occurring and which medical condition, if any,
is primarily responsible for its occurrence. Such productivity losses can be estimated by interviewing workers and
asking them to evaluate their own reduced productivity as
it relates to their health status, or by interviewing their
supervisors and asking for their opinions about whether
a particular workers productivity has changed secondary
to a disease. Rarely can such presenteeism costs be measured objectively or with certainty. Absenteeism costs are
generally easier to estimate because employer records and
workers compensation insurance systems will note
health-related work absences.
Human capital and friction cost approaches
There is debate among economists about the preferred
methods for estimating indirect costs, the majority of which
are often composed of lost productivity [3]. The most common method is the human capital approach, which assumes

10

S. Dagenais et al. / The Spine Journal 8 (2008) 820

that the economic value of an employees productivity is

equal to the cost of their salary and benefits [4]. Lost productivity is therefore estimated by calculating earnings lost
during work absences, regardless of the length of absence.
This method would therefore calculate lost productivity for
disability-related early retirement as the value of lost earnings from the date of disability until that worker would
have reached normal retirement age (eg, 65 y). Employers,
however, will eventually replace those employees that are
absent for extended periods and regain the value of the original employees lost productivity. Thus, productivity losses
are truly only incurred from the workers absence for health
reasons until a replacement worker is hired, trained, and has
reached the productivity of the disabled employee. The
length of time required for this transition to occur has been
termed the friction period and varies for different industries
and economic conditions based on factors that may influence the time required to replace an employee (eg, unemployment level, job skill and education requirements, and
location) [5]. Evaluating the cost of lost productivity with
this assumption has been termed the friction cost approach
[4]. Alternatively, the cost of hiring replacement workers
for employees on disability leave may also be used to estimate lost productivity [3]. A combination of methods may
be most appropriate to estimate indirect costs by, for example, using the human capital approach for temporary productivity losses from absences that are shorter than the
friction period, and using the friction cost approach for
longer-term productivity losses.
Household productivity
In addition to lost work productivity, individuals with an
illness may also incur productivity losses at home if they
are unable to complete routine household tasks (eg, cleaning, cooking, and maintenance). This is true whether they
must rely on paid outsiders to complete such tasks on their
behalf, or whether unpaid household members must do so.
These indirect costs can be estimated using the earnings of
a hired household worker or by using an estimate of the national or regional value of leisure time, which is typically
less than the mean hourly wage.
Intangible costs
The third type of cost that may be considered when estimating the total cost of illness for a particular disease is
termed intangible costs. These costs reflect the value of decreased enjoyment of life because of illness. However,
these costs are rarely included when estimating the economic burden of an illness because of general societal discomfort with placing a monetary value on these aspects of
a disease.

be estimated from a patient perspective (eg, out-of-pocket

costs), employer perspective (eg, cost of workers compensation insurance premiums and lost productivity), insurance
company perspective (eg, cost of claims paid), government
perspective (eg, cost of public health services), or societal
perspective, which would include all related costs. The latter is the most comprehensive and broadest perspective and
avoids underestimating costs when only considered from
a narrower perspective.
Sources of cost data
The perspective chosen will also impact the types and
sources of data used in the cost of illness study. Employer, insurer, or government perspective may derive acceptable cost estimates by apportioning claims in large
utilization databases to specific diagnoses, which has been
termed a top-down approach [4]. Alternatively, the patient
perspective may extrapolate costs from interviews or diaries about health-care utilization and costs, which has
been termed a bottom-up approach [4]. The societal perspective could combine both approaches to capture more
data.

Methods
A search of Medline was conducted on July 1, 2007, for
studies pertaining to the costs of low back pain (LBP) using
the following strategy:
1.
2.
3.
4.
5.
6.
7.
8.

*Back Pain/Economics
low back pain.mp. or exp Low Back Pain/
health care costs.mp. or exp Health Care Costs/
cost of illness.mp. or exp Cost of Illness/
health expenditures.mp. or exp health expenditures/
exp Health Resources/Economics, Utilization
exp Sick Leave/Economics
1 or (2 and (or/3-7))

The search was limited to studies published in English

from 1997 to 2007 to uncover relatively recent cost of illness studies. Search results were screened for relevance
according to the eligibility criteria outlined below.
Inclusion:
1. Back pain or LBP
2. Monetary estimate of direct or indirect costs
3. Societal or insurer perspective.
Exclusion:

Cost perspectives
The cost of an illness may be viewed from various perspectives and depends on who bears the costs. Costs could

1. Neck pain only

2. Economic evaluations of interventions (eg, cost-effectiveness analyses)

S. Dagenais et al. / The Spine Journal 8 (2008) 820

3. Details concerning only some specific direct costs

(eg, prescription costs)
4. Indirect costs expressed as lost work days without
monetary valuation
5. Elderly patients only (eg, O65 y)
6. Review articles without new data.
If information provided in search results was insufficient
to determine study eligibility, full-text articles were retrieved
for further screening. The following data were extracted for
all included studies:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Case definition of LBP

Cost perspective
Cost types
Country
Estimated direct costs
Estimated indirect costs
Estimated total costs
Prevalence of LBP according to case definition
Study design and data sources
Study population
Year of data.

For studies reporting detailed direct costs, portions attributable to each of the following (or similar) categories
were extracted:
1. Chiropractic (and osteopathy for studies outside the
United States)
2. CAM (eg, acupuncture, homeopathy, massage, and
naturopathy)
3. Emergency department (ED)
4. Imaging
5. Inpatient
6. Mental health
7. Other
8. Outpatient
9. Pharmacy
10. Physical therapy (PT)
11. Primary care
12. Specialists
13. Surgery.
For studies reporting detailed indirect costs, portions attributable to each of the following (or similar) categories
were extracted:
1.
2.
3.
4.
5.

Early retirement
Household
Inactivity
Presenteeism
Sick leave.

Because of considerable methodological heterogeneity,

results were synthesized descriptively.

11

Results
The search strategy yielded 147 studies, of which 12
(8%) were relevant, 114 (78%) were irrelevant because they
did not meet eligibility criteria, and 21 (14%) were of uncertain relevance based on information contained in the
search records (eg, title, abstract). When full-text articles
were retrieved for the latter group, an additional eight studies were deemed relevant; five additional studies were also
located by searching references of the studies obtained via
Medline. In addition, two relevant conference proceedings
were located, which were only available as abstracts.
The methodology for the 27 relevant studies included in
this review is summarized in Table 1.
Studies from Australia [6], Belgium [7], the Isle of Jersey [8], Japan [9], Korea [10], the Netherlands [2,11], Sweden [4,5,12,13], the United Kingdom [14], and the United
States [1,3,1527] were obtained. All non-US studies
(n512) [2,414] and 5 of the US studies [1,15,2022] examined costs from a societal perspective; the other 10 US
studies used an insurers perspective to estimate costs. Most
[1,3,4,69,11,1316,1927] took a top-down approach and
allocated portions of total costs from national public or private insurer databases according to related international
classification of diseases (ICD)-9 or ICD-10 diagnostic codes. Five top-down studies [4,6,7,13,14] also relied on data
provided in prior surveys or utilization studies to help allocate costs for specific interventions to LBP. Because only
three [2,12,21] had a temporal component (eg, O6 mo) to
their case definition of LBP, it was not possible to limit this
review to studies examining specifically CLBP.
The prevalence of LBP as defined in each study ranged
from 5% to 65%, with a mean of 18.7% and a standard
deviation (SD) of 4.6%. The mean time lag between the
year of data examined to derive cost estimates and the year
of study publication was 4.6 years (SD 0.5), with a range of
1 to 11 years. Four of the US top-down studies [1,17,26,27]
used the Medical Expenditures Panel Survey (MEPS) and
one [21] used its predecessor, the National Medical Expenditures Survey. There were three prospective cohort studies
[2,5,10] that examined costs incurred by a defined group of
patients over time based on health utilization or disability
benefit records. Only one study [2] used a bottom-up approach with self-reported patient diaries documenting the
use and cost of health services related to LBP to supplement information contained in utilization databases. One
cross-sectional study [12] interviewed physicians to inquire
about the perceived use of health services in some of their
patients with LBP, rather than interviewing patients directly. Two studies [17,18] compared the use of health services by those with LBP to a control group of people
without LBP.
National LBP cost of illness estimates uncovered in this
review are summarized in Table 2.
Eight studies from five countriesdAustralia, Belgium,
Japan, Sweden, and the UKdestimated the total national

12

Table 1
Methodology of included cost of LBP studies
Country

Year of
data

Cost types/cost
perspective

[6]

Australia

2001

[7]

Belgium

1999

[8]

1994

[9]

Isle of
Jersey
Japan

1994

[10]

Korea

1997

[11]

Netherlands

1991

[2]

Netherlands

2002

[13]

Sweden

1994

[5]

Sweden

[4]

Sweden

19941995
(2 y)
2001

[12]

Sweden

2002

[14]

UK

1998

[26]

United
States

1996

Direct only

National

Top-down based on MEPS

[27]

United
States

1996

Indirect only

National

Top-down based on MEPS

[21]

United
States
United
States
United
States
United
States
United
States

1987

Indirect only
Societal
Indirect only
Societal
Direct only
Societal
Direct only
Societal
Indirect only
Societal

National

National

Top-down based on National Medical

Expenditure Survey
Top-down based on National Health
Information Survey
Top-down based on MEPS

National
National

[15]
[1]
[17]
[22]

[19]

United
States

1995
1996
1998
2002

2004

Prevalence
(%)

Study population

Study design and data sources

Case definition of LBP

Direct and indirect

Societal
Direct and indirect
Societal
Indirect only
Societal
Direct and indirect
Societal
Direct only
Societal
Indirect only
Societal
Direct and indirect
Societal

National

Top-down based on survey, public,

and private insurance databases
Top-down based on national health
databases, prior studies
Top-down based on national databases

Pain in area between last ribs and gluteal folds

ICD-10 M4054, M96, M99
Nonoccupational LBP

Proprietary diagnostic coding

Accidental (occupational) organic or

nonspecific LBP
Lumbar spine, lumbar herniated nucleus
pulposus, lumbar fracture, and others
ICD-9 720724

NR

NR

Nonspecific LBP O6 mo

21

Direct and indirect

Societal
Direct and indirect
Societal
Direct and indirect
Societal
Direct only
Societal
Direct and indirect
Societal

National

ICD-10 81

NR

Low back or neck problems with minimum

28-d work incapacity
LBP

NR

LBP O50% d in last 3 mo

NR

Pain between the inferior angle of the

scapula and the gluteal folds; ICD-9 720
724, 846847
ICD-9 codes determined by an expert panel
of physicians and coders as indicative of
back pain
ICD-9 codes determined by an expert panel
of physicians and coders as indicative of
back pain
Repeated backache in past 3 mo

36

Indirect only
Societal

National
National
National
National
National
National

National
National
National
National

National

National (adults 4065 y)

Top-down based on national WC

database
Prospective cohort based on WC
databases
Top-down based on social security
register
Prospective cohort based on diaries,
national guidelines, national price
lists
Top-down based on national
databases, surveys
Prospective cohort based on social
insurance office
Top-down based on national
databases, surveys
Cross-sectional based on physician
surveys and official price lists
Top-down based on surveys,
utilization claims, prior studies

65

NR

16

NR

NR

22

Back pain every day for a week in the past

12 mo
Global burden of disease categories

18
NR

Comparative based on MEPS

ICD-9 720724, 805806, 839, 846, 847

NR

Top-down based on Caremark

American Productivity Audit
(national survey)
Top-down based on Caremark
American Productivity Audit
(national survey)

Back pain

Self-reported back pain on most days for at

least 1 mo in past year

15

S. Dagenais et al. / The Spine Journal 8 (2008) 820

Reference

NR

21

ICD-9 722, 724, 738, 739, 756, 846, 847

Related ICD-9 codes without hospitalization or

surgery and with at least one outpatient visit
Sixty-six related ICD-9 codes
[20]

[16]

[18]

Allocation of direct medical costs for LBP

NR5not reported; WC5workers compensation; LBP5low back pain; MEPS5Medical Expenditure Panel Survey.

2005

2002

2001

2001
[23]

13

economic burden of LBP [2,47,9,13,14]. An additional

four [1,10,17,26] reported only national estimates of direct
costs, whereas seven [8,11,15,19,21,22,27] reported only
national indirect costs. Most results are reported in the
studys local currency, though one study from the Netherlands [11] reported its estimates in US dollars. Country
populations according to the year of the study are provided
for comparisons. Three of the eight studies reporting combined direct and indirect costs of LBP originated in Sweden
[4,5,13]. The two Swedish studies reported in euros (V)
used different designs (prospective cohort [5] vs. top-down
database approach [4,12]), different definitions of LBP (low
back or neck problems with minimum 28-d work incapacity
[5] vs. not defined [4]), and reported different results
(V3.35 billion over 2 y [5] vs. V1.86 billion [4]). In the
eight studies that provided estimates of both direct and indirect costs, mean direct costs accounted for only 22% of
total costs, indicating that indirect costs are a much larger
contributor to the cost of LBP. There were no national estimates in the United States that combined direct and indirect
costs associated with LBP.

NR

7
Sixty-six related ICD-9 codes

Top-down based on health insurer

database

Top-down based on private databases

United
States
United
States
United
States
United
States
United
States

[25]

[3]

19971999

Indirect only
Insurer
Direct only
Insurer
Direct only
Insurer
Direct only
Insurer
Direct only
Insurer

WC insurer with 374,799 members

from 6 employers in 43 states
Health insurer with 255,958 members
in Pennsylvania
Health insurer with 240,000 members
in New Mexico
Two health insurers with 497,597
members in Washington State
Health insurer with 410,000 members
in Colorado

Top-down based on health insurer

database
Comparative based on health insurer
database
Top-down based on private databases

NR

Low back area, sacrum, coccyx, disc,

multiple trunk; sprain, strain,
inflammation, rupture, hernia, fracture,
contusion
Mechanical LBP
1996

NR

United
States
United
States
[24]

1992

Direct and indirect

Insurer
Indirect only
Insurer

WC insurer covering Oregon, Illinois,

Pennsylvania, Florida
Insurer with ~10% of WC market

Top-down based on Detailed Claim

Information database
Top-down based on WC databases

ICD-9 720724, 805806, 839, 846, 847

S. Dagenais et al. / The Spine Journal 8 (2008) 820

The allocation of direct medical costs for LBP is summarized in Table 3.

Fourteen studies reported on the allocation of direct
medical costs to various categories of health services
[2,47,1214,17,18,20,23,24,26] used for LBP. The categories differed slightly among studies and were combined
where appropriate to summarize results. For example, costs
for the categories general practitioner, primary care, and
nonspecialist office visits were combined under the rubric
of primary care, and costs for the categories X-rays
and computed tomography/magnetic resonance imaging
were combined into imaging. In one study reported in
an abstract [26], only three categories were mentioned (office based, inpatient, outpatient); the remainder of costs was
classified as other. The number of categories to which
medical costs were allocated ranged from 4 to 10 with
a mean of 6.7. The most commonly reported category of direct medical costs was pharmacy (n513), followed by inpatient (n511), PT (n510), primary care (n510), imaging
(n58), outpatient (n58), specialists (n57), other (n57),
chiropractic (n56), mental health (n55), ED (n54), surgery (n54), and CAM (n52). Only one study [7] specified
that its direct medical cost estimate did not include out-ofpocket expenses, over-the-counter medication, CAM, or
mental health. It was unclear in many instances how or
why only specific categories of direct medical costs were
included in estimates.
The largest mean cost components for care of LBP were
PT (17%) and inpatient services (17%), followed by pharmacy (13%) and primary care (13%), outpatient services
(8%), diagnostic imaging (7%), specialists (7%), surgery
(5%), chiropractic (including osteopathy) (5%), other

14

S. Dagenais et al. / The Spine Journal 8 (2008) 820

Table 2
National estimates of total, direct, or indirect costs for low back pain
Total costs
Reference Country

Year

Population

Currency National

[6]
[7]
[9]
[8]
[10]
[11]
[2]
[13]
[5]
[4]
[14]
[15]
[26]
[27]
[21]
[1]
[17]
[22]
[19]

2001
1999
1994
1994
1997
1991
2002
1994
19941995
2001
1998
1995
1996
1996
1996
1996
1998
2002
2004

19,357,954
10,182,034
124,712,000
82,000
45,948,811
15,022,393
16,067,754
8,730,290
8,778,461
8,909,128
58,970,119
260,713,585
263,814,032
263,814,032
263,814,032
263,814,032
270,311,756
280,562,489
293,027,571

AUD
V
Yen

Won
$
V
SEK
V
V

$
$
$
$
$
$
$
$

Australia
Belgium
Japan
Jersey
Korea
Netherlands
Netherlands
Sweden
Sweden
Sweden
UK
United States
United States
United States
United States
United States
United States
United States
United States

Direct costs
Per
capita National

Indirect costs
%

Per
capita National

9,174,931,649 474
1,025,840,000 11
53
1,179,605,000 116
187,005,000 16
18
6,022,403,378
48
2,713,454,390 45
22
d
d
d d
d
d 349,742,900,000 d 7612
d
d
d d
6,418,744,458 399
4,236,371,342 66 264
25,089,000,000 2874
832,000,000 3
95
3,346,300,485 381
234,241,034 7
27
1,860,000,000 209
297,600,000 16
33
12,332,000,000 209
1,632,000,000 13
28
d
d
d d
d
d 14,701,417,650 d
56
d
d
d d
d
d
d d
d
d 12,200,000,000 d
46
d
d 90,600,790,000 d 335
d
d
d d
d
d
d d

services (5%), CAM (2%), ED (1%), and mental health

(1%). Mean outpatient physician services (primary care,
specialists) in these studies accounted for only 20% of
costs, whereas nonphysician services (PT, chiropractic,
CAM, mental health, other) accounted for 30%. Hospital
costs (inpatient, outpatient, surgery, ED) were 30% of overall direct medical costs, whereas pharmacy costs were more
than twice those of diagnostic imaging. It should be noted
that these means assumed that there were no costs in categories for which no estimates were reported; these estimates were therefore influenced by the number of studies
that included a particular category of direct medical costs.
Allocation of indirect costs for LBP
Eighteen studies [28,1115,19,21,22,24,25,27] estimated indirect costs associated with LBP, and five categories of indirect costs were considered. The most
common was sick leave (n518), followed by early retirement (n56), lost household productivity (n53), presenteeism (n53), and inactivity (n51). Methodology differed
considerably, though the majority of studies used methods
consistent with the human capital approach by estimating
indirect costs according to lost wages as determined by disability payments. Only one study [2] used solely a friction
period approach, where work productivity losses were valued using a 22-week friction period and a national average
wage of V9-18 per hour depending on age and gender.
Three studies [6,11,14] used both methods and in all instances, the cost estimates derived were much lower with
the friction cost approach than the human capital approach.
The study by Hutubessy et al. [11] estimated work productivity losses at $4.6 billion with the human capital approach

8,149,091,649
992,600,000
3,308,948,988
1,287,204
d
4,613,000,000
2,182,373,116
24,257,000,000
3,112,059,451
1,562,400,000
10,700,000,000
13,925,940,000
d
18,533,583,620
28,170,000,000
d
d
19,800,000,000
7,400,000,000

Per
capita

89 421
84
97
55
27
d
16
d
d
d 307
34 136
97 2778
93 355
84 175
87 181
d
53
d
d
d
70
d 107
d
d
d
d
d
71
d
25

based on daily absenteeism and disability costs for the actual duration of work absences, but only $1.5 billion when
assuming a friction period of 3 months and labor elasticity
of 80% (ie, only 80% of productivity is lost during worker
absences because other employees can partially compensate for that loss). The study by Maniadakis and Gray
[14] estimated work productivity losses in the UK of 9.1
billion with the human capital approach based on 116 million lost work days and average earnings of 78, but only
3.4 billion based on a friction period of 90 days, much
shorter than the mean work absence duration of 232 days.
The study by Walker et al. [6] estimated work productivity
losses in Australia at AUD$8.1 billion with the human capital approach based on 62,441,052 lost work days and mean
daily earnings of AUD$130, but only AUD$5.1 billion assuming a friction period of 2.4 months for males and 1.4
months for female. The friction period method yielded estimates that were 56% (SD 9%) lower, on average, than the
human capital approach.
The allocation of indirect costs of LBP is summarized in
Table 4.
Incremental costs
A study analyzed data from the 1998 MEPS, a nationally
representative sample of the US population, to estimate the
cost of medical care provided to those with back pain (ICD9 codes 720724, 805806, 839, 846, 847) [17]. To overcome perceived weaknesses in prior estimates that included
only costs directly related to back pain, this study used multivariate regression to compare the overall costs of medical
care in those with back pain to a similar population without
back pain. Those with back pain had total medical care

S. Dagenais et al. / The Spine Journal 8 (2008) 820

15

Table 3
Allocation of direct medical costs for low back pain
CAM
Reference (%)

Chiropractica
(%)

ED Imaging
(%) (%)

Inpatient
(%)

Mental
health
(%)

Other
(%)

Outpatient
(%)

Pharmacy
(%)

PT Primary Surgery
(%) care (%) (%)

Specialists
(%)

Total
(%)

[2]
[12]
[4]
[5]
[13]
[17]
[14]
[18]
[26]
[20]
[7]
[23]
[6]
[24]
Mean

d
16
d
2
d
d
15
d
d
d
d
10
20
3
5

d
d
d
d
d
3
2
4
d
5
d
d
d
d
1

15
30
11
d
28
31
13
14
32
35
d
d
16
7
17

11
d
d
d
d
d
d
1
d
2
d
d
2
1
1

d
6
d
d
d
12
13
1
15
d
d
d
2
20
5

d
d
27
d
27
13
17
11
14
3
4
d
d
d
8

19
6
7
8
16
15
7
20
d
19
19
29
9
2
13

17
17
55
19
d
d
15
d
d
3
61
22
14
20
17

22
d
d
25
7
d
4
24
d
9
d
d
5
d
7

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

9
d
d
d
d
d
d
d
d
d
d
d
16
d
2

d
4
d
7
d
d
5
3
d
2
d
39
6
25
7

8
21
d
15
22
26
9
9
39
22
d
d
11
d
13

d
d
d
24
d
d
d
13
d
d
16
d
d
22
5

CAM5complementary and alternative medicine (includes acupuncture, massage, homeopathy, and similar services); ED5emergency department
(includes ambulance); PT5physical therapy (includes occupational therapy, rehabilitation).
a
Chiropractic includes osteopathy.

costs that were US$1,015 greater (US$3,498 vs. US$2,178)

than those without back pain. Incremental medical care
costs attributable to back pain totaled US$26 billion and included higher costs for office-based visits (US$11.1 billion), outpatient services (US$4.7 billion), inpatient care
(US$4.5 billion), prescription drugs (US$3.9 billion), and
ED visits (US$1.1 billion). Cost distribution was skewed,
with patients in the highest 10% of costs accounting for
99% of inpatient care costs, 90% of ED visits, 87% of outpatient services, 53% of prescription drugs, and 52% of
office-based visits.

Another study examined direct inpatient, outpatient, and

pharmacy costs for chronic back pain (ICD-9 codes 722,
724, 738, 739, 756, 846, 847) among members of a health
maintenance organization [18]. Data were obtained from
utilization records of the Lovelace Health Plan with
240,000 members in New Mexico. Costs were examined
from the health plans perspective using charges appearing
on claims in 2001. There were 3,864 patients with at least
two outpatient or one inpatient claim with chronic back
pain as the primary or secondary diagnosis during the 12month study period. Utilization records for that group were

Table 4
Allocation of indirect costs for low back pain
Reference

Method

[2]
[12]
[4]
[3]
[15]
[5]
[25]
[11]

Friction
Human capital
Not specified
Not specified
Not specified
Human capital
Not specified
Human capital
Friction
Human capital
Human capital
Friction
Human capital
Not specified
Not specified
Not specified
Not specified
Human capital
Friction
Not specified
Not specified

[13]
[14]
[27]
[19]
[21]
[22]
[7]
[6]
[8]
[24]

Early retirement (%)

16
52

Household (%)

Inactivity (%)

31
12

27

Presenteeism (%)
18

31
33
0
62
15
31
85
95
70

Sick leave (%)

Total (%)

42
54
48
100
100
69
100
67
100
38
85
69
100
15
5
30
100
100
100
100
100

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

16

S. Dagenais et al. / The Spine Journal 8 (2008) 820

compared with 11,557 controls without chronic back pain

or arthritis to estimate incremental use attributable to
chronic back pain. Patients with chronic back pain were
three times more likely (odds ratio 3.08; 95% confidence
interval 2.70 to 3.53) to be admitted to hospital than controls. Total incremental costs for the 3,864 patients with
chronic back pain were estimated at US$14.5 million.
A study was conducted to examine lost productivity related to exacerbations of back pain in US workers [19]
within the broader Caremark American Productivity Audit,
a telephone survey of lost productivity because of pain conditions in a nationally representative random sample of
adult US workers previously reported above [22]. The 2week prevalence of back pain in the survey was 15%, of
whom 17% reported lost productivity. There were 320 participants aged 40 to 65 years with self-reported clinically
meaningful LBP in the previous 2 weeks, and 91 ageand gender-matched controls without back pain or arthritis.
Lost productivity costs for any health reason in those with
back pain were estimated at $23.5 billion, and were $16.9
billion higher than controls without back pain or arthritis.
Length versus cost of claims for LBP
A study examined workers compensation claims for
LBP for the years 1988, 1990, 1992, 1994, and 1996 from
an insurer representing 10% of the private US workers
market [25]. The database included both direct costs for
medical claims and indirect costs for wage replacement
while on disability leave. Claims for LBP were compared
with non-LBP claims over 8 years to note general trends.
Although the proportion of LBP claims did not change
from 1988 (15%) to 1996 (15%), the proportion of costs
for LBP decreased from 38% in 1988 to 23% in 1996.
The length of disability (LOD) claims for 1996 were
heavily skewed, with an average of 61 days and a median
of 0 days. Costs were also skewed, with 60% of LBP claims
in 1996 costing less than $500 and 12% costing more than
$5,000. There was a clear association between LOD and
cost because 86% of all claims with LOD less than 1 month
in 1996 accounted for only 11% of all costs, and 5% of
claims with LOD for longer than 1 year accounted for
65% of total costs.
A study was conducted to examine the association between duration of treatment and costs of occupational
LBP in Korea using 9,277 claims from a workers compensation database [10]. Duration and costs of claims were
skewed, with the 51% of claims less than 6 months accounting for only 10% of costs and the 6% of claims longer
than 2 years accounting for 29% of costs. After 50 months,
418 (4.5%) claims were still open.
A study was undertaken to estimate the costs of disability pay resulting from back pain due on the isle of Jersey in
1994, a Crown possession of the UK, which operates under
its own system of health care and disability benefits [8].
Back pain was defined according to proprietary diagnostic

coding and subdivided into specific (sciatica, IVD disorders), nonspecific (backache, lumbago), and injuries. Data
were obtained from a health survey and public databases
for health utilization and disability benefits. Length of disability was longer in specific LBP (45.1 d) than nonspecific
back pain (35.8 d) and lowest in back injuries (23.1 d). Less
than 1% of new claims had not returned to work after 1
year. Disability benefit data were skewed, with 35% of
cases returning to work after 1 day and 3% of those disabled for more than 6 months accounting for 33% of benefit
costs.
A study examined the total costs of occupational LBP
(ICD-9 721724, 805, 806, 839.20, 846, 847) in four US
states (Oregon, Illinois, Pennsylvania, and Florida) [24].
Data were obtained from the detailed claim information database that includes claims in which there is compensable
lost work time because of a work-related injury. A random
sample of 520 closed claims was selected from the four
states for the years 1998 to 1992 to examine costs over
time. The distribution of work disability duration was as
follows: !30 days (50%), 30 to 90 days (25%), 91 to 180
days (12%), and O180 days (13%). Costs increased substantially with work disability duration, from $1,146 for !30
days, to $6,286 for 31 to 90 days, $16,284 for 91 to 180
days, and $32,555 for O180 days.
Prescription medication use for LBP
A study in Sweden asked 302 patients who presented to 16
physicians at 14 randomly selected outpatient clinics to complete questionnaires on health-care resource use in the past 6
months [12]. Direct costs were calculated based on unit costs
from hospital, pharmacy, and national health sources. Annual
direct costs per patient for pharmaceuticals were V183 and
patients took an average of two medications for CLBP. The
most common class of medication was analgesics (59%), followed by nonsteroidal anti-inflammatories (NSAIDs) (51%),
muscle relaxants/anxiolytics (11%), proton pump inhibitors
(8%), antidepressants (8%), cyclo-oxygenase 2 (COX-2) inhibitors (5%), antacids (2%), prostaglandins (1%), H2 antagonists (1%), and others (1%).
A study was conducted to examine health-care utilization
in patients with mechanical LBP as defined by one of 66 related ICD-9 codes [20]. Data were obtained from utilization
records of Kaiser Permanente Colorado, a health maintenance organization with 410,000 enrollees in the Denver
area. Costs were measured from the insurers perspective using actual costs in 1999, adjusted to 2005 with the consumer
price index. Pharmacy records indicated that 31% of patients
had a claim for NSAIDs and 29% for opioids.
A study was conducted to estimate the direct medical
costsdfocusing on analgesic medication usedfor mechanical LBP as defined by one of 66 ICD-9 codes [23]. Data
were obtained from utilization records of 255,958 commercial members enrolled in the University of Pittsburgh Medical Center Health System in 2001. Costs were examined

S. Dagenais et al. / The Spine Journal 8 (2008) 820

from the health plans perspective. Among the 9,417 patients (56%) with a pharmacy claim for analgesics related
to their LBP, the most frequent analgesic was opioids alone
(33%), followed by NSAIDs alone (27%), opioids and
NSAIDs (26%), opioid and other analgesics (9%), or
COX-2 inhibitors alone (3%). Most opioid use was short
term, with a duration of 1 to 30 days (71%), though a substantial portion had a duration of 31 to 90 days (14%).
Smaller proportions of patients used opioids for 90 to 179
days (6%), and more than 180 days (9%). Most costs for
analgesics were for opioids (61%), followed by COX-2 inhibitors (23%), NSAIDs (13%), and other (2%). Mechanical LBP represented 48% of total health system costs for
opioids, 24% of costs for NSAIDs, and 28% of costs for
COX-2 inhibitors.
Nonconventional health-care use
A study examined the costs of health care for individuals
with back pain (related ICD-9 codes) [16]. Utilization data
were obtained from two large insurers in the state of Washington for the year 2002. Of the 497,597 eligible insured,
104,358 (22%) made 652,593 visits related to LBP that represented 15% of all outpatient visits. Most visits were made
to chiropractors (49%), followed by medical doctors (20%),
massage (13%), PT (11%), other providers (11%), acupuncture (2%), naturopathy (1%), and nurse practitioner/
physicians assistant (1%). The largest group of insured
(45%) sought care from only conventional providers and
had mean costs of $506, whereas those who sought care
from only CAM providers (43%) had mean costs of
$342, and a third group of insured who saw both conventional and CAM providers (12%) had mean costs of
$1,079. The average cost allowed per visit was $128 for
conventional providers and $50 for CAM providers.
Health-care utilization assumptions for LBP
Several studies using top-down approaches made assumptions about health-care utilization for LBP to allocate
costs to that illness. These assumptions are summarized below to provide insight into study methodology and additional information about the proportion of specific health
resources consumed by patients with LBP. A study in Sweden [4] assumed that 2.5% of total outpatient visits were the
result of LBP, 42% of all public PT visits and 60% of private PT visits were the result of LBP, and 25.0% of pharmaceutical costs for musculoskeletal diseases were for LBP. A
study was undertaken to estimate the total costs of back
pain (ICD-9 codes 702724, 846847) in the UK in 1998
[14]. Data were obtained from various sources, including
prior surveys on the epidemiology of back pain, prior studies
on the use of care for back pain, and health utilization claims
from the national and private health-care databases. It was
estimated in this study that of those with back pain, 36%
use topical creams and sprays, 19% use over-the-counter

17

medication, 10% use outpatient clinics, 10% have X-rays,

9% use PT for an average of seven visits, 5% visit osteopaths for an average of five visits, 3% visit private consultants, 2% visit chiropractors for an average of five visits,
2% use the ED, 1% visit occupational therapists, 1% visit
acupuncturists, and 2% visit other specialists. A study
was conducted to estimate the direct medical costs for
LBP in Belgium in 1999 [7]. Data were gathered from
a variety of sources including national health utilization
databases and prior health utilization studies. Assumptions
made regarding the use of health services for LBP were that
29% of all sick days are the result of LBP, 56% of PT is for
LBP, 55% of transcutaneous electrical nerve stimulation
units are for LBP, 70% of epidural steroid injections are
for LBP, and 60% of intrathecal pumps are for LBP.
Costliest health conditions
A study was undertaken to estimate the 15 most costly
conditions in America using results from the 1996 MEPS
[1]. Back problems (no definition provided) were ranked
sixth in national costs at $12.2 billion, behind ischemic
heart disease, motor vehicle accidents, acute respiratory infections, arthropathies, and hypertension. Using a summary
disability score calculated from mean ranks in number of
bed days, missed work days, and rates of impairment in activities of daily living and instrumental activities of daily
living, back problems were ranked third in associated disability, behind arthropathies and mood disorders. This
study suggested that resources devoted to back problems
(#6) are proportionally smaller than its disability toll (#3).
A study was conducted to determine the 20 costliest health
conditions for employers in the United States using databases
from six large corporations with 374,799 employees in 43
states [3]. Costs were allocated to specific conditions based
on proprietary algorithms related to ICD-9 codes and temporal patterns of utilization. Mechanical LBP (no definition
provided) was the fourth most expensive health condition behind angina pectoris, essential hypertension, and diabetes
mellitus, with an estimated prevalence of 52.7 per 1,000 employees and costs of $90.24 per employee.
A study examined the indirect costs associated with
common pain conditionsdincluding back paindin the
US workforce [22]. Data were obtained from the Caremark
American Productivity Audit, a telephone survey of lost
productivity because of pain conditions in a nationally representative random sample of adult US workers. Using the
human capital approach, indirect costs for back pain were
estimated at $19.8 billion and were higher than those of
headache ($19.6 billion), arthritis ($10.3 billion), and other
pain conditions ($11.6 billion) considered in the survey.

Discussion
Numerous LBP cost of illness studies were identified in
this review and provided valuable information for readers

18

S. Dagenais et al. / The Spine Journal 8 (2008) 820

to understand the magnitude of its economic burden from

different perspectives in various countries. Despite differences in study methods producing a wide range of cost of
illness estimates, it was apparent that LBP represents an
important economic burden wherever it was studied. One
of the most notable findings in this review is that the methodology used to derive LBP cost of illness estimates varied
considerably among the 27 studies examined. More importantly, methodological differences that may not always be
readily apparent to LBP stakeholders appeared to exert
a substantial influence on the resulting cost of illness estimates. Some of these methodological differences that
should be considered when appraising cost of illness studies
related to LBP include the cost perspective adopted, delays
in publication, case definitions of LBP, sources of data for
estimating direct medical costs, direct medical cost categories considered, assumptions about health utilization to
apportion costs, total versus marginal medical costs, and
approaches used to estimate indirect costs from lost productivity. Each is briefly discussed below.
Comparisons of cost of illness estimates between countries were severely limited by differences observed in cost
perspectives adopted in different studies. Although the majority of economic burden studies originated from the US,
no studies attempted to accurately estimate the national total cost of illness of LBP from a societal perspective. None
of the studies conducted outside the United States examined costs solely from a private insurers perspective,
whereas several of the studies from the United States did
so. Although costs of illness estimates from a narrower perspective are no doubt informative for insurers who sponsor
such studies, they are of limited value when attempting to
understand the economic burden of a disease from a societal
perspective. Of particular concern is that any decreases observed over time because of cost containment efforts by insurers could simply indicate that costs are simply being
shifted to other payers. The importance of private health insurers in the United States should not preclude examining
costs from a societal perspective, as evidenced by a study
in the UK that included direct medical costs from both public and private health insurers. Differences in perspectives
adopted and health-care systems made it difficult to interpret the wide variations in the direct or indirect costs of
LBP among the countries studied.
Delays between data collection and study publication
should be examined closely to ensure that readers do not
draw conclusions on outdated data. For example, two studies published in the same year could be reporting estimates
based on data from as little as 2 years ago or much as 11
years ago. The year of publication is therefore not sufficient
to identify how current the cost estimate might be. Although some authors may attempt to compensate for these
delays by adjusting older cost data for inflation with a consumer price index, such methods are likely prone to error
and will fail to capture other changes that may have
occurred in the ensuing years.

The case definition of LBP differed considerably among

the studies. Some of the studies specified that algorithms
were used to estimate the probability of medical service utilization being related to LBP based on 66 ICD-9 codes,
whereas others did not provide any operational definition
of LBP. Comparisons across studies must therefore pay attention to whether the cost estimate was for all spinal pain
(eg, neck and back problems) or only subsets of LBP (eg,
trauma-related occupational LBP). Because much of the
difficulty surrounding the management of CLBP is related
to nonspecific pain of mechanical origin, estimates focusing on that category of disease appear warranted. It was
also not possible to examine the temporal component of
LBP because few studies included this aspect in their case
definition. Evidence that the costs of LBP are heavily
skewed by the most expensive claims with the longest duration suggests that most costs for LBP are for CLBP.
The sources of data on which estimates of direct medical
costs were based varied among the studies reviewed, most
of which used public or private health insurer claims databases (top-down approach). Although a few bottom-up
studies were conducted in Europe using patient diaries or
interviews, there were no such studies identified in the
United States to capture out of pocket medical or other expenses that contribute to the overall cost of LBP and may
be missed by top-down approaches.
Such studies could help validate some of the assumptions made regarding the use of specific interventions by
patients with LBP. For example, although it has been reported in the United States that 31% of patients with LBP
who seek care will consult a chiropractor [28], a study in
the UK based its LBP cost estimates on the assumption that
only 2% of those seeking care for LBP would use chiropractic. It would be important to understand the reasons
for such discrepancies in utilization estimates before making assumptions when estimating direct medical costs attributable to LBP. Bottom-up studies could also provide
data to support prior utilization surveys, which have reported that back pain was the leading reason for using interventions such as CAM, on which a total of $27 billion
was spent out of pocket in 1997 [29]; only two studies
included costs related to CAM in their estimates.
The number of categories of direct medical costs that
were considered by a study was likely to influence the magnitude and precision of their estimates. Whereas many studies reported costs related to PT, primary, outpatient, and
inpatient care, few reported costs for surgery, mental health,
ED, allied health, chiropractic, or CAM. Given that studies
which included these latter categories did in fact reported
associated costs, studies limited to the fewer categories
are likely to have underestimated the true direct medical
costs of LBP. Because care of LBP is often decentralized,
more comprehensive direct medical cost estimates should
include multiple categories of health providers and interventions, whether reimbursed by national or public insurers
or paid for by patients out of pocket.

S. Dagenais et al. / The Spine Journal 8 (2008) 820

Another challenge that was apparent in estimates based

on top-down approaches from utilization databases was determining whether costs for those with a history of LBP
were in fact receiving specific medical services for that
condition. Patients who develop LBP are likely to continue
receiving care for other medical conditions (eg, hypertension, diabetes, headache). It would therefore be incorrect
to attribute all medical costs for those with LBP solely to
that condition. A few studies attempted to address this issue
by comparing health utilization to age- and gender-matched
control groups without LBP. Estimates for incrementald
rather than totaldcosts attributed to LBP were substantially lower making this an important consideration for
future LBP cost of illness studies. This issue may also be
addressed by collecting data directly from patients about
the primary reason for seeking a particular medical service.
There were also notable differences in the assumptions
made to estimate the indirect costs of LBP attributable to
lost productivity, which was by far the largest component
of costs in studies reporting both direct and indirect costs.
The three studies that compared estimates of the human
capital and friction period approaches reported much lower
cost estimates with the latter. This difference should be explored in future studies because it is unclear whether assumptions made in this approach are valid with LBP,
where injured workers may have repeated work absences
of varying durations or be temporarily or permanently assigned to less physical job duties. Both scenarios may complicate or lengthen the process of hiring a replacement
worker and therefore potentially impact the length of the
friction period and cost of lost productivity.
Regardless of the differences in methods used to estimate costs related to LBP, studies reviewed suggest that
the greatest cost savings from a societal perspective may
be obtained from interventions that promote early return
to work and minimize lost productivity. However, a potential difficulty that may occur when attempting to implement
such strategies without a clearer understanding of all cost
components is that cost savings from reducing lost productivity would be primarily observed from an employer perspective, whereas costs related to interventions that
facilitate an early return to work (eg, exercise, fear avoidance training) would be primarily borne from a health insurer perspective. Cooperation among injured workers,
clinicians, employers, and third-party payers would be required to minimize such potential conflicts when evaluating
competing interventions that may be more favorable from
a narrower cost perspective but detrimental from a societal
perspective.
There were no studies identified in this review that provided a total LBP cost of illness estimate for the United
States. Those wishing to estimate the economic burden
for LBP in the United States may combine results of direct
($12.2$90.6 billion) and indirect ($7.4$28.2 billion)
costs to arrive at a combined total that ranges from $19.6
to $118.8 billion. However, estimates derived this way

19

are not materially different than those proposed in 1991

(eg, $50100 billion) and are therefore likely inaccurate
[30]. Alternatively, the total costs could be estimated by applying the median proportion of direct (14.5%) versus indirect (85.5%) costs obtained from eight international studies
to those obtained in the United States. Assuming that US
direct cost estimates of $12.2 to $90.6 billion represent only
14.5% of total costs, the total US costs attributable to LBP
could be estimated at $84.1 to $624.8 billion, which is substantially higher than previous estimates. However, the assumption that the median ratio of direct:indirect costs
obtained in other countries can be applied to the United
States has not been validated. Given the magnitude of the
problem, a more precise estimate of total costs of LBP in
the United States from a single study with robust methodology appears necessary and worthy of additional research.
Only then can comparisons between countries be explored
to determine the effects (if any) of social, cultural, economic, and health-care system differences on the relative
cost of illness of LBP.
The findings of this study are limited by having examined only one biomedical database (Medline) for studies
published in English in the last 10 years. It is possible that
a broader search with multiple databases and no language or
date restrictions may have uncovered additional LBP cost
of illness studies with different results than those included
in this review.

Conclusion
This review identified several studies that have previously attempted to estimate the direct, indirect, or total
costs associated with LBP, both in the United States and internationally. Study methodology differed considerably,
making direct cost comparisons across studies and between
countries difficult. The largest components of direct medical
costs were PT, inpatient services, pharmacy, and primary
care. From studies conducted outside the United States, it
appears that direct medical costs represent only a small portion of the total costs of LBP, suggesting that interventions
that are able to reduce LOD may present the opportunity
for cost savings from a societal perspective. Further studies
are required in the United States to estimate the total costs
of LBP and inform decision making for this complex and
challenging condition.
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