LAUSR

the Japanese population exceeding 80%1), LBP is a major health problem and the leading cause of disability worldwide2). It is one of the most common reasons people consult a physician, have activity limitations, or take time off work3). The number of individuals with LBP is projected to increase in the future and even more rapidly in low-income and middle-income countries4). Disability has the highest rate in working-age groups2) and is the most common cause of medically certified sick leave and early retirement. The onset can be work-related5), and many workers with prolonged absences from work attribute their back pain to their work6). Conversely, workers’ lost productivity includes absenteeism (productivity loss that stems from being absent from work) and presenteeism (productivity loss that stems from being at work while ill and performing at a lower level than usual). Among the costs related to workers’ health, lost productivity costs are significantly higher than medical and pharmacy costs and are, on average, 2.3 times higher7). Several studies have demonstrated that costs incurred from presenteeism are much higher than those incurred from absenteeism8–11) and account for the largest proportion of the total health-related costs8–10). LBP, along with neck and shoulder discomfort (Katakori), is also reportedly a primary cause of presenteeism in Japan12–14). Thus, the number of individuals with back pain and the loss of work continue to be significant, and looking at this situation from a bird’s eye view, it can be said that measures and interventions for LBP have been ineffective. Thus, can it be said that experts, including myself, are not producing successful results? I would like to consider the reasons for this. LBP is a complex condition with pain and disability in different manifestations, which are influenced by various biological, psychological, and social factors. Many consider it a category of nonspecific LBP for which no specific cause can be established4). We have reported in several prospective studies that not only ergonomic factors, but also psychosocial factors, including work-related factors such as job dissatisfaction and a lack of supervisor support, are the risk factors for both the occurrence and chronicity of nonspecific LBP that interferes with work, even among Japanese workers15–19). However, there is a lack of standardization and provision of appropriate approaches to assessments that include psychological (called yellow flags) and social factors (called blue flags, including perceptions about the relationship between work and health), which is the main reason. One global standard screening tool for understanding potential personal psychological factors4) called yellow flags, such as pain catastrophizing, fear-avoidance beliefs (kinesiophobia), depression, and anxiety, is the Keele STarT Back Screening Tool (SBST)20, 21). If prognostic factors are present or in case of a high-risk profile on the SBST, interventions should be considered to eliminate or reduce factors hindering work participation and to support beneficial factors22). The use of SBST is recommended in the world’s first multidisciplinary occupational health guideline focused on effective interventions for work participation23). If SBST has a high-risk profile, a mechanism needs to be established to share both the results and effective intervention methods with the clinicians and occupational health staff. From a health and safety perspective, bias toward the work environment and ergonomic approaches may be a reason. Many stakeholders in occupational health and workers and patients still believe that back pain is mostly caused by mechanical pain with tissue damage due to back strain. Conversely, in 2017, the International Association for the Study of Pain announced that, in addition to the long-standing pain mechanism classification of nociceptive pain, including intervertebral disc injuries and neuropathic pain (e.g., lumbosacral radicular syndrome), nociplastic pain was officially adopted and announced as the third mechanistic descriptor24). Nociplastic pain occurs even in the absence of tissue damage and is associated with various psychosocial factors. Thus, the pain created by the brain, which is distinct from the mind–body dualism, has finally become a civil right. Since it has already become clear that nociplastic pain with central sensitization is common in musculoskeletal disorders, such as LBP and osteoarthritis25), there is a need to recognize nociplastic pain and deEditorial