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
- 735 Downloads
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.
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.
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.
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.
KeywordsSpine Low back pain Neck pain Medically underserved area Therapeutics Conservative treatment
We thank Leslie Verville for her contributions to this paper.
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.
Compliance with ethical standards
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.
- 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 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 CrossRefPubMedGoogle 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, LondonGoogle Scholar
- 4.Gozna E (2001) Guidelines for the diagnosis and treatment of low back pain. Workplace Health, Safety and Compensation Commission of New Brunswick, New BrunswickGoogle 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, OsloGoogle Scholar
- 7.Bogduk N (2005) Clinical anatomy of the lumbar spine and sacrum. Elsevier Health Sciences, LondonGoogle 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 21:201–216Google Scholar
- 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):471–489CrossRefPubMedGoogle 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 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 CrossRefPubMedGoogle 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), RockvilleGoogle Scholar
- 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 CrossRefPubMedGoogle 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):1560–1571CrossRefPubMedPubMedCentralGoogle 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 CrossRefPubMedGoogle 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, SwitzerlandGoogle 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