The Global Spine Care Initiative: a systematic review of individual and community-based burden of spinal disorders in rural populations in low- and middle-income communities



The purpose of this review was to synthesize literature on the burden of spinal disorders in rural communities to inform the Global Spine Care Initiative care pathway and model of care for their application in medically underserved areas and low- and middle-income countries.


A systematic review was conducted. Inclusion criteria included all age groups with nonspecific low back pain, neck pain, and associated disorders, nonspecific thoracic spinal pain, musculoskeletal chest pain, radiculopathy, or spinal stenosis. Study designs included observational study design (case-control, cross-sectional, cohort, ecologic, qualitative) or review or meta-analysis. After study selection, studies with low or moderate risk of bias were qualitatively synthesized.


Of 1150 potentially relevant articles, 43 were eligible and included in the review. All 10 low and 18 moderate risk of bias studies were cross-sectional, 14 of which included rural residents only. All studies included estimates of low back pain prevalence, one included neck pain and one reported estimates for spinal disorders other than back or neck pain. The prevalence of low back pain appears greater among females and in those with less education, psychological factors (stress, anxiety, depression), and alcohol consumers. The literature is inconsistent as to whether back pain is more common in rural or urban areas. High risk of bias in many studies, lack of data on disability and other burden measures and few studies on conditions other than back and neck pain preclude a more comprehensive assessment of the individual and community-based burden of spinal disorders in less-developed communities.


We identified few high-quality studies that may inform patients, providers, policymakers, and other stakeholders about spinal disorders and their burden on individuals and communities in most rural places of the developing world. These findings should be a call to action to devote resources for high-quality research to fill these knowledge gaps in medically underserved areas and low and middle-income countries.

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We thank Leslie Verville for her contributions to this paper.

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Corresponding author

Correspondence to Eric L. Hurwitz.

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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.

Conflict of interest

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. 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. LV declares funding to UOIT from Skoll Foundation and NCMIC Foundation through World Spine Care. JH declares his research group has extensive funding from Danish public funding agencies, the European Union, and Danish charities. 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. 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.

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Hurwitz, E.L., Randhawa, K., Torres, P. et al. The Global Spine Care Initiative: a systematic review of individual and community-based burden of spinal disorders in rural populations in low- and middle-income communities. Eur Spine J 27, 802–815 (2018).

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  • Spine
  • Neck pain
  • Back pain
  • Global burden of disease