European Spine Journal

, Volume 27, Supplement 6, pp 851–860 | Cite as

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

  • Roger ChouEmail author
  • Pierre Côté
  • Kristi Randhawa
  • Paola Torres
  • Hainan Yu
  • Margareta Nordin
  • Eric L. Hurwitz
  • Scott Haldeman
  • Christine Cedraschi
Review Article



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.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Spine 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, Book Royalties, McGraw Hill. Travel expense reimbursement—CMCC Board. CC declares no COI.

Supplementary material

586_2017_5433_MOESM1_ESM.pdf (15 kb)
Supplementary material 1 (PDF 15 kb)
586_2017_5433_MOESM2_ESM.pptx (165 kb)
Supplementary material 2 (PPTX 164 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Medical Informatics and Clinical EpidemiologyOregon Health and Science UniversityPortlandUSA
  2. 2.Department of MedicineOregon Health and Science UniversityPortlandUSA
  3. 3.Faculty of Health SciencesUniversity of Ontario Institute of TechnologyOshawaCanada
  4. 4.UOIT-CMCC Centre for Disability Prevention and RehabilitationTorontoCanada
  5. 5.Exercise Science Laboratory, School of Kinesiology, Faculty of MedicineUniversidad Finis TerraeSantiagoChile
  6. 6.Departments of Orthopedic Surgery and Environmental MedicineNew York UniversityNew YorkUSA
  7. 7.World Spine Care EuropeHolmfirthUK
  8. 8.Office of Public Health StudiesUniversity of HawaiiMānoaUSA
  9. 9.Department of Epidemiology, School of Public HealthUniversity of California Los AngelesLos AngelesUSA
  10. 10.Department of NeurologyUniversity of California, IrvineIrvineUSA
  11. 11.World Spine CareSanta AnaUSA
  12. 12.Division of General Medical RehabilitationUniversity of GenevaGenevaSwitzerland
  13. 13.Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain CentreGeneva University HospitalsGenevaSwitzerland

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