Prognostic Factors in Low Back Pain: From Identification to Stratified Care

Background: Low back pain (LBP) is a leading cause of disability worldwide and a major burden on individuals, healthcare systems, and economies. Its prognosis is determined by a multifactorial interplay of psychosocial, demographic, occupational, lifestyle, clinical, and genetic factors, extending beyond biomedical explanations. Previous reviews are now partially outdated, as they did not fully integrate recent findings on systemic comorbidities, genetic predispositions, sleep disturbances, and stress-related disorders. This review addresses this gap by synthesizing evidence up to early 2025, with a particular focus on implications for physical activity and sport participation, an aspect rarely emphasized in earlier literature. Methods: This narrative review was conducted in accordance with SANRA guidelines. A comprehensive search of PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar identified publications between 1987 and early 2025. Eligible studies included systematic reviews, meta-analyses, randomized controlled trials, large prospective cohorts, and landmark conceptual papers. A total of 121 publications were included and synthesized thematically across psychosocial, demographic, occupational, lifestyle, clinical, genetic, and systemic domains. Results: The analysis confirmed psychosocial determinants as the strongest predictors of chronicity and disability. Occupational exposures, lifestyle behaviors, and comorbid conditions such as hypertension, diabetes, and multisite pain also contributed substantially to prognosis. Emerging evidence highlighted novel domains, including genetic predispositions, biological markers, sleep disturbances, and stress-related disorders such as PTSD. Importantly, this review identified the underexplored relationship between prognostic factors and sport participation: moderate leisure-time activity appears protective, whereas excessive or high-load training may increase risk, underscoring the need for sport-specific prognostic insights. Conclusion: LBP prognosis is complex and requires a holistic biopsychosocial approach. The novelty of this review lies in its integration of evidence up to 2025 and its unique emphasis on systemic health indicators, genetic predispositions, and the implications of physical activity and sport participation. These findings expand the scope of prognostic research and highlight domains not adequately addressed in previous reviews. Early risk identification, tailored interventions, and multidisciplinary models of care are essential to improve outcomes and prevent chronicity. Future research should refine prognostic models, incorporate systemic and genetic markers, and develop sport- and activity-specific recommendations to advance prevention, optimize treatment, and support sustained engagement in healthy, active lifestyles.