Skip to main content

Advertisement

SpringerLink
Log in

The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities

  • Review Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

The purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain.

Methods

We synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries.

Results

Clinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction.

Conclusion

Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Global Burden of Disease 2013 Collaborators (2013) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (London, England) 386(9995):743–800. https://doi.org/10.1016/s0140-6736(15)60692-4

    Article  Google Scholar 

  2. Hogg-Johnson S, van der Velde G, Carroll LJ, Holm LW, Cassidy JD, Guzman J, Côté P, Haldeman S, Ammendolia C, Carragee E, Hurwitz E, Nordin M, Peloso P (2008) The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 33(4 Suppl):S39–S51. https://doi.org/10.1097/BRS.0b013e31816454c8

    Article  PubMed  Google Scholar 

  3. Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G, Cotterell M, Hill D, Browne N, Buchanan E, Coffey P, Dixon P (2009) Low back pain: early management of persistent non-specific low back pain. National Collaborating Centre for Primary Care and Royal College of General Practitioners, London

  4. Gozna E (2001) Guidelines for the diagnosis and treatment of low back pain. Workplace Health, Safety and Compensation Commission of New Brunswick, New Brunswick

    Google Scholar 

  5. Lærum E, Dullerud R, Kirkesola G, Mengshoel A, Nygaard Ø, Kouen J (2002) Acute low back pain: Interdisciplinary clinical guidelines. The Norwegian Back Pain Network, Oslo

    Google Scholar 

  6. Deyo RA, Tsui-Wu YJ (1987) Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine 12(3):264–268

    Article  CAS  Google Scholar 

  7. Bogduk N (2005) Clinical anatomy of the lumbar spine and sacrum. Elsevier Health Sciences, London

    Google Scholar 

  8. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 19(12):2075–2094. https://doi.org/10.1007/s00586-010-1502-y

    Article  PubMed  PubMed Central  Google Scholar 

  9. Wong JJ, Côté P, Sutton D, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer H, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, varatharajan T, Taylor-Vaisey A (2017) Clinical practice guidelines for the noninvasive management of low back pain: a systematic review by the Ontario protocol for traffic injury management collaboration (EURJPAIN-D-16-00096R1). Eur J Pain 21:201–216

  10. Wong JJ, Côté P, Shearer HM, Carroll LJ, Yu H, Varatharajan S, Southerst D, van der Velde G, Jacobs C, Taylor-Vaisey A (2015) Clinical practice guidelines for the management of conditions related to traffic collisions: a systematic review by the OPTIMa Collaboration. Disabil Rehabil 37(6):471–489

    Article  Google Scholar 

  11. Chou R, Huffman LH (2007) Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 147(7):505–514

    Article  Google Scholar 

  12. Chou R, Huffman LH (2007) Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 147(7):492–504

    Article  Google Scholar 

  13. Côté P, Wong JJ, Sutton D, Shearer HM, Mior S, Randhawa K, Ameis A, Carroll LJ, Nordin M, Yu H, Lindsay GM, Southerst D, Varatharajan S, Jacobs C, Stupar M, Taylor-Vaisey A, van der Velde G, Gross DP, Brison RJ, Paulden M, Ammendolia C, David Cassidy J, Loisel P, Marshall S, Bohay RN, Stapleton J, Lacerte M, Krahn M, Salhany R (2016) Management of neck pain and associated disorders: a clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. https://doi.org/10.1007/s00586-016-4467-7

    Article  PubMed  Google Scholar 

  14. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S (2008) Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 33(4 Suppl):S123–S152. https://doi.org/10.1097/BRS.0b013e3181644b1d

    Article  PubMed  Google Scholar 

  15. Mousavi SJ, Akbari ME, Mehdian H, Mobini B, Montazeri A, Akbarnia B, Parnianpour M (2011) Low back pain in Iran: a growing need to adapt and implement evidence-based practice in developing countries. Spine 36(10):E638–E646. https://doi.org/10.1097/BRS.0b013e3181fa1da2

    Article  PubMed  Google Scholar 

  16. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147(7):478–491

    Article  Google Scholar 

  17. Bouwmeester W, van Enst A, van Tulder M (2009) Quality of low back pain guidelines improved. Spine 34(23):2562–2567. https://doi.org/10.1097/BRS.0b013e3181b4d50d

    Article  PubMed  Google Scholar 

  18. AGREE (Appraisal of Guidelines R, and Evaluation in Europe) Collaborative Group (2000) Guideline development in Europe. An international comparison. Int J Technol Assess Health Care 16(4):1039–1049

    Article  Google Scholar 

  19. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E (2016) AHRQ comparative effectiveness reviews. In: Noninvasive treatments for low back pain. Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I. AHRQ Publication No. 16-EHC004-EF. Agency for Healthcare Research and Quality (US), Rockville

  20. Guzman J, Hurwitz EL, Carroll LJ, Haldeman S, Côté P, Carragee EJ, Peloso PM, van der Velde G, Holm LW, Hogg-Johnson S, Nordin M, Cassidy JD (2008) A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 33(4 Suppl):S14–S23. https://doi.org/10.1097/BRS.0b013e3181643efb

    Article  PubMed  Google Scholar 

  21. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E (1995) Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining “whiplash” and its management. Spine 20(8 Suppl):1S–73S

    CAS  PubMed  Google Scholar 

  22. National Institute for Health and Care Excellence (NICE) (2012) The guidelines manual. https://www.nice.org.uk/article/pmg6/chapter/1%20introduction#ftn.footnote_1. Accessed 16 May 2016

  23. Hill JC, Whitehurts DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM (2011) Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 378(9802):1560–1571

    Article  Google Scholar 

  24. Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin CW (2014) Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet (London, England) 384(9954):1586–1596. https://doi.org/10.1016/s0140-6736(14)60805-9

    Article  CAS  Google Scholar 

  25. The Centers for Disease Control and Prevention (2011) Policy impact: prescription painkiller overdoses. https://www.cdc.gov/drugoverdose/pubs/index.html#tabs-760094-4. Accessed 28 Sept 2016

  26. Qaseem A, Wilt TJ, McLean RM, Forciea M, For the Clinical Guidelines Committee of the American College of P (2017) Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the american college of physicians. Ann Intern Med 166(7):514–530. https://doi.org/10.7326/m16-2367

    Article  PubMed  Google Scholar 

  27. World Health Organization (2007) WHO normative guidelines on pain management. Report of a Delphi Study to determine the need for guidelines and to identify the number and topics of guidelines that should be developed by WHO. Geneva, Switzerland

  28. Size M, Soyannwo OA, Justins DM (2007) Pain management in developing countries. Anaesthesia 62(Suppl 1):38–43. https://doi.org/10.1111/j.1365-2044.2007.05296.x

    Article  PubMed  Google Scholar 

  29. ADAPTE Collaboration (2009) Guideline adaptation: a resource toolkit. http://www.g-i-n.net/document-store/working-groups-documents/adaptation/adapte-resource-toolkit-guideline-adaptation-2-0.pdf. Accessed 2 June 2016

Download references

Acknowledgements

We thank Leslie Verville for her contributions to this paper.

Funding

The Global Spine Care Initiative and this study were funded by grants from the Skoll Foundation and NCMIC Foundation. World Spine Care provided financial management for this project. The funders had no role in study design, analysis, or preparation of this paper.

Author information

Authors and Affiliations

  1. Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA

    Roger Chou

  2. Department of Medicine, Oregon Health and Science University, Portland, OR, USA

    Roger Chou

  3. Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada

    Pierre Côté, Kristi Randhawa & Hainan Yu

  4. UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Toronto, Canada

    Pierre Côté, Kristi Randhawa & Hainan Yu

  5. Exercise Science Laboratory, School of Kinesiology, Faculty of Medicine, Universidad Finis Terrae, Santiago, Chile

    Paola Torres

  6. Departments of Orthopedic Surgery and Environmental Medicine, New York University, New York, NY, USA

    Margareta Nordin

  7. World Spine Care Europe, Holmfirth, UK

    Margareta Nordin

  8. Office of Public Health Studies, University of Hawaii, Mānoa, HI, USA

    Eric L. Hurwitz

  9. Department of Epidemiology, School of Public Health, University of California Los Angeles, Los Angeles, CA, USA

    Scott Haldeman

  10. Department of Neurology, University of California, Irvine, Irvine, CA, USA

    Scott Haldeman

  11. World Spine Care, Santa Ana, CA, USA

    Scott Haldeman

  12. Division of General Medical Rehabilitation, University of Geneva, Geneva, Switzerland

    Christine Cedraschi

  13. Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Centre, Geneva University Hospitals, Geneva, Switzerland

    Christine Cedraschi

Authors
  1. Roger Chou
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pierre Côté
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kristi Randhawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Paola Torres
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hainan Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Margareta Nordin
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Eric L. Hurwitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Scott Haldeman
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Christine Cedraschi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roger Chou.

Ethics declarations

Conflict of interest

RC declares funding from AHRQ to conduct systematic reviews on treatments for low back pain within last 2 years. Honoraria for speaking at numerous meetings of professional societies and non-profit groups on topics related to low back pain (no industry sponsored talks). PC is funded by a Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology, and declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. Canadian Institutes of Health Research Canada. Research Chair Ontario Ministry of Finance. Financial Services Commission of Ontario. Ontario Trillium Foundation, ELIB Mitac. Fond de Recherche and Sante du Quebec. KR declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. PT declares no COI. HY declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. MN declares funding from Skoll Foundation and NCMIC Foundation through World Spine Care;. Co-Chair, World Spine Care Research Committee. Palladian Health, Clinical Policy Advisory Board member. Book Royalties Wolters Kluwer and Springer. Honoraria for speaking at research method courses. EH declares he is a consultant for: RAND Corporation; EBSCO Information Services; Southern California University of Health Sciences; Western University of Health Sciences. Data and Safety Monitoring Committee Chair, Palmer Center for Chiropractic Research. Research Committee Co-chair, World Spine Care. SH declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. Clinical Policy Advisory Board and stock holder, Palladian Health. Advisory Board, SpineHealth.com. Book Royalties, McGraw Hill. Travel expense reimbursement—CMCC Board. CC declares no COI.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 15 kb)

Supplementary material 2 (PPTX 164 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chou, R., Côté, P., Randhawa, K. et al. The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. Eur Spine J 27 (Suppl 6), 851–860 (2018). https://doi.org/10.1007/s00586-017-5433-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-017-5433-8

Keywords

Search

Navigation