Risk factors of neck and low back pain

Numerous clinical trials have provided evidence that define what characteristics of a person, events, habits and living conditions are risk factors or moderators to develop neck or low back pain:

Female gender and advanced age are demographic factors that are associated to higher prevalence of neck and low back pain.

General health and life habits also increase or moderate the risk of neck and low back pain. Obesity or smoking are associated with higher risk; on the other hand physical activity reduces the risk and is associated to faster improvement trajectories.

The previous clinical history is another important risk factor: people who suffered neck or low back disorders in the past are more likely to develop new nonspecific pain episodes in either body part, and those episodes are more likely to develop into chronic pain if there are other negative circumstances, like initial high pain intensity, accompanying pain in multiple body parts, significant disability, or comorbidities (other diseases).

The best known risk factors are psychological problems, known as “yellow flags”: psychological distress, fear of pain or pain avoidance, catastrophizing behaviours and beliefs, or depression, among others, are issues that often derive in unhelpful pain comping strategies and a growing sensation of sickness, such that the problem may eventually become chronic.

Occupational factors or “blue flags” (physical and psychosocial) have a very substantial impact. Physical risk factors are heavy labour in jobs that require carrying loads, awkward postures, repetitive movements, or sedentary work. But as important or more than those physical factors are occupational psychosocial factors like level of job satisfaction, relation and communication with colleagues or superiors, level of stress or job stability.

“Black flags” are socioeconomic factors that affect sick workers, related to insurance and legislation. For instance, policies for economic compensation, sick leave, or legal claims. Those conditions may affect the attitudes and behaviours of the patients during sickness and in the return to work, and perpetuate or aggravate symptoms and pain coping strategies.

All these factors do not operate in isolation. On the contrary, they influence to each other, such that for instance disadvantageous sickness policies (black flag) can be an indirect cause of catastrophizing behaviour (yellow flag).


  • Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., … Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet. https://doi.org/10.1016/S0140-6736(18)30480-X
  • Kim, R., Wiest, C., Clark, K., Cook, C., & Horn, M. (2018). Identifying risk factors for first-episode neck pain: A systematic review. Musculoskeletal Science and Practice, 33, 77-83. https://doi.org/10.1016/j.msksp.2017.11.007
  • Lardon, A., Dubois, J.-D., Cantin, V., Piché, M., & Descarreaux, M. (2018). Predictors of disability and absenteeism in workers with non-specific low back pain: A longitudinal 15-month study. Applied Ergonomics, 68, 176-185. https://doi.org/10.1016/j.apergo.2017.11.011