European Spine Journal

, Volume 27, Supplement 6, pp 838–850 | Cite as

The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities

  • Bart N. Green
  • Claire D. JohnsonEmail author
  • Scott Haldeman
  • Edward J. Kane
  • Michael B. Clay
  • Erin A. Griffith
  • Juan M. Castellote
  • Matthew Smuck
  • Shanmuganathan Rajasekaran
  • Eric L. Hurwitz
  • Margareta Nordin
  • Kristi Randhawa
  • Hainan Yu
Original Article



The purpose of this study was to develop recommendations for prevention interventions for spinal disorders that could be delivered globally, but especially in underserved areas and in low- and middle-income countries.


We extracted risk factors, associations, and comorbidities of common spinal disorders (e.g., back and neck pain, spinal trauma, infection, developmental disorders) from a scoping review of meta-analyses and systematic reviews of clinical trials, cohort studies, case control studies, and cross-sectional studies. Categories were informed by the Global Spine Care Initiative (GSCI) classification system using the biopsychosocial model. Risk factors were clustered and mapped visually. Potential prevention interventions for individuals and communities were identified.


Forty-one risk factors, 51 associations, and 39 comorbidities were extracted; some were associated with more than one disorder. Interventions were at primary, secondary, tertiary, and quaternary prevention levels. Public health-related actions included screening for osteopenia, avoiding exposure to certain substances associated with spinal disorders, insuring adequate dietary intake for vitamins and minerals, smoking cessation, weight management, injury prevention, adequate physical activity, and avoiding harmful clinical practices (e.g., over-medicalization).


Prevention principles and health promotion strategies were identified that were incorporated in the GSCI care pathway. Interventions should encourage healthy behaviors of individuals and promote public health interventions that are most likely to optimize physical and psychosocial health targeting the unique characteristics of each community. Prevention interventions that are implemented in medically underserved areas should be based upon best evidence, resource availability, and selected through group decision-making processes by individuals and the community.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Health promotion Spinal diseases Risk factors Epidemiology 



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

BNG receives speaker fees and travel reimbursement from NCMIC Speakers' Bureau; he is secretary of Brighthall Inc; the views in this article are those of the authors and not those of Stanford University, Stanford Health Care, or Qualcomm. CDJ is president of Brighthall Inc; she is an NCMIC Board of Director, however neither she nor NCMIC board make funding decisions for the NCMIC Foundation; the views in this article are those of the authors and not those of Stanford University, Stanford Health Care, or Qualcomm. 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. EJK declares no COI. MBC declares no COI. EAG declares no COI. JMC declares funding from Spanish Government Grant ESPY 112/18. MS declares no COI. SR declares no COI. 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. 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. 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. HY declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care.

Supplementary material

586_2018_5635_MOESM1_ESM.pptx (619 kb)
Supplementary material 1 (PPTX 620 kb)
586_2018_5635_MOESM2_ESM.pdf (57 kb)
Supplementary material 2 (PDF 57 kb)


  1. 1.
    Connelly LB, Woolf A, Brooks P (2006) Cost-effectiveness of interventions for musculoskeletal conditions. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB et al (eds) Disease control priorities in developing countries, 2nd edn. World Bank, Washington, DCGoogle Scholar
  2. 2.
    March L, Smith EU, Hoy DG, Cross MJ, Sanchez-Riera L, Blyth F et al (2014) Burden of disability due to musculoskeletal (MSK) disorders. Best Pract Res Clin Rheumatol 28(3):353–366CrossRefGoogle Scholar
  3. 3.
    Global Burden of Disease Study Collaborators (2015) 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 386(9995):743–800CrossRefGoogle Scholar
  4. 4.
    Hoy D, Geere JA, Davatchi F, Meggitt B, Barrero LH (2014) A time for action: opportunities for preventing the growing burden and disability from musculoskeletal conditions in low- and middle-income countries. Best Pract Res Clin Rheumatol 28(3):377–393CrossRefGoogle Scholar
  5. 5.
    Jackson T, Thomas S, Stabile V, Han X, Shotwell M, McQueen K (2015) Prevalence of chronic pain in low-income and middle-income countries: a systematic review and meta-analysis. Lancet 385(Suppl 2):S10CrossRefGoogle Scholar
  6. 6.
    Vancampfort D, Koyanagi A, Ward PB, Rosenbaum S, Schuch FB, Mugisha J et al (2017) Chronic physical conditions, multimorbidity and physical activity across 46 low- and middle-income countries. Int J Behav Nutr Phys Act 14(1):6CrossRefGoogle Scholar
  7. 7.
    Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC et al (2008) Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain 9(10):883–891CrossRefGoogle Scholar
  8. 8.
    Burns AS, O’Connell C (2012) The challenge of spinal cord injury care in the developing world. J Spinal Cord Med 35(1):3–8CrossRefGoogle Scholar
  9. 9.
    Chamberlain JD, Meier S, Mader L, von Groote PM, Brinkhof MW (2015) Mortality and longevity after a spinal cord injury: systematic review and meta-analysis. Neuroepidemiology 44(3):182–198CrossRefGoogle Scholar
  10. 10.
    Rasanathan K, Sivasankara Kurup A, Jaramillo E, Lonnroth K (2011) The social determinants of health: key to global tuberculosis control. Int J Tuberc Lung Dis 15(Suppl 2):S30–S36CrossRefGoogle Scholar
  11. 11.
    Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W et al (2008) Expenditures and health status among adults with back and neck problems. JAMA 299(6):656–664CrossRefGoogle Scholar
  12. 12.
    Stewart Williams J, Ng N, Peltzer K, Yawson A, Biritwum R, Maximova T et al (2015) Risk Factors and disability associated with low back pain in older adults in low- and middle-income countries. Results from the WHO study on global AGEing and adult health (SAGE). PLoS ONE 10(6):e0127880CrossRefGoogle Scholar
  13. 13.
    Louw QA, Morris LD, Grimmer-Somers K (2007) The prevalence of low back pain in Africa: a systematic review. BMC Musculoskelet Disord. 8:105CrossRefGoogle Scholar
  14. 14.
    Rojas M, Gimeno D, Vargas-Prada S, Benavides FG (2015) Musculoskeletal pain in Central American workers: results of the first survey on working conditions and health in Central America. Rev Panam Salud Publica 38(2):120–128PubMedGoogle Scholar
  15. 15.
    Spiegel DA, Gosselin RA, Coughlin RR, Joshipura M, Browner BD, Dormans JP (2008) The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities. J Bone Joint Surg Am 90(4):915–923CrossRefGoogle Scholar
  16. 16.
    Stewart Williams J, Kowal P, Hestekin H, O’Driscoll T, Peltzer K, Yawson A et al (2015) Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecountries: results from the WHO Study on global AGEing and adult health (SAGE). BMC Med 13:147CrossRefGoogle Scholar
  17. 17.
    Wajed J, Ahmad Y, Durrington PN, Bruce IN (2004) Prevention of cardiovascular disease in systemic lupus erythematosus–proposed guidelines for risk factor management. Rheumatology (Oxford) 43(1):7–12CrossRefGoogle Scholar
  18. 18.
    Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F (2007) Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 36(2):190–196CrossRefGoogle Scholar
  19. 19.
    Haldeman S, Nordin M, Chou R, Côté P, Hurwitz EL, Johnson CD, Randhawa K et al (2018) The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities. Eur Spine J. CrossRefGoogle Scholar
  20. 20.
    Haldeman S, Johnson CD, Chou R, Nordin M, Côté P, Hurwitz EL et al (2018) The Global Spine Care Initiative: classification system for spine-related concerns. Eur Spine J. CrossRefGoogle Scholar
  21. 21.
    Haldeman S, Johnson CD, Chou R, Nordin M, Côté P, Hurwitz EL et al (2018) The Global Spine Care Initiative: care pathway for people with spine-related concerns. Eur Spine J. CrossRefGoogle Scholar
  22. 22.
    Johnson CD, Haldeman S, Chou R, Nordin M, Green BN, Côté P, Hurwitz EL et al (2018) The Global Spine Care Initiative: model of care and implementation. Eur Spine J. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Johnson CD, Haldeman S, Nordin M, Chou R, Côté P, Hurwitz EL et al (2018) The Global Spine Care Initiative: methodology, contributors, and disclosures. Eur Spine J. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Green BN, Johnson CD, Haldeman S, Griith E, Clay MB, Kane EJ et al (2018) A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PLOS ONE 13(6):e0197987. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Tricco AC, Lillie E, Zarin W, O’Brien K, Colquhoun H, Kastner M et al (2016) A scoping review on the conduct and reporting of scoping reviews. BMC Med Res Methodol 16:15CrossRefGoogle Scholar
  26. 26.
    International Association for the Study of Pain Taxonomy Working Group (2011) Classification of Chronic Pain. 2nd (revised) ed. International Association for the Study of Pain, Washington, DC. Accessed 16 Oct 2016
  27. 27.
    Deyo RA, Weinstein JN (2001) Low back pain. N Engl J Med 344(5):363–370CrossRefGoogle Scholar
  28. 28.
    Elfering A, Mannion AF (2008) Epidemiology and risk factors of spinal disorders. In: Boos N, Aebi M (eds) Spinal disorders: fundamentals of diagnosis and treatment. Springer, Berlin, pp 153–173CrossRefGoogle Scholar
  29. 29.
    Haldeman S, Kopansky-Giles D, Hurwitz EL, Hoy D, Mark Erwin W, Dagenais S et al (2012) Advancements in the management of spine disorders. Best Pract Res Clin Rheumatol 26(2):263–280CrossRefGoogle Scholar
  30. 30.
    Mathers C, Stevens G, Mascarenhas M (2009) Global health risks: mortality and burden of disease attributable to selected major risks. World Health Organization Press, GenevaGoogle Scholar
  31. 31.
    Friis RH, Sellers TA (2009) Epidemiology for public health practice, 4th edn. Jones and Bartlett Publishers, Sudbury, p 717Google Scholar
  32. 32.
    Rothstein WG (2003) Public health and the risk factor: a history of an uneven medical revolution. University of Rochester Press, Rochester, p 466Google Scholar
  33. 33.
    Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M (2009) Defining comorbidity: implications for understanding health and health services. Ann Fam Med 7(4):357–363CrossRefGoogle Scholar
  34. 34.
    Starfield B, Hyde J, Gervas J, Heath I (2008) The concept of prevention: a good idea gone astray? J Epidemiol Community Health 62(7):580–583CrossRefGoogle Scholar
  35. 35.
    Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE et al (2011) Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 378(9802):1560–1571CrossRefGoogle Scholar
  36. 36.
    Norris SL, Kansagara D, Bougatsos C, Fu R (2008) Force USPST. Screening adults for type 2 diabetes: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 148(11):855–868CrossRefGoogle Scholar
  37. 37.
    Vernon H (2008) The Neck Disability Index: state-of-the-art, 1991-2008. J Manip Physiol Ther 31(7):491–502CrossRefGoogle Scholar
  38. 38.
    MacAvoy S, Skinner T, Hines M (1996) Fall risk assessment tool. Appl Nurs Res 9(4):213–218CrossRefGoogle Scholar
  39. 39.
    Preventive US (2011) Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med 154(5):356–364CrossRefGoogle Scholar
  40. 40.
    Harden CL, Meador KJ, Pennell PB, Hauser WA, Gronseth GS, French JA et al (2009) Management issues for women with epilepsy-Focus on pregnancy (an evidence-based review): II. Teratogenesis and perinatal outcomes: Report of the Quality Standards Subcommittee and Therapeutics and Technology Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Epilepsia 50(5):1237–1246CrossRefGoogle Scholar
  41. 41.
    World Health Organization (2006) Guidelines for drinking-water quality. World Health Organization, Geneva. Accessed 2 Mar 2017
  42. 42.
    Scherer M, Hansen H, Gensichen J, Mergenthal K, Riedel-Heller S, Weyerer S et al (2016) Association between multimorbidity patterns and chronic pain in elderly primary care patients: a cross-sectional observational study. BMC Fam Pract 17:68CrossRefGoogle Scholar
  43. 43.
    Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE (2015) Diagnosis and management of osteoporosis. Am Fam Phys 92(4):261–268Google Scholar
  44. 44.
    McKenzie JF, Pinger RR, Kotecki KE (2008) Community organization/building and health promotion programming. In: McKenzie JF (ed) An introduction to community health. Jones and Bartlett Publishers, Sudbury, pp 120–144Google Scholar
  45. 45.
    Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S et al (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 25(10):2359–2381CrossRefGoogle Scholar
  46. 46.
    Bolland MJ, Leung W, Tai V, Bastin S, Gamble GD, Grey A et al (2015) Calcium intake and risk of fracture: systematic review. BMJ 351:h4580CrossRefGoogle Scholar
  47. 47.
    Reid IR, Bolland MJ, Grey A (2014) Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet 383(9912):146–155CrossRefGoogle Scholar
  48. 48.
    Winzenberg TM, Shaw K, Fryer J, Jones G (2006) Calcium supplementation for improving bone mineral density in children. Cochrane Database Syst Rev 2:CD005119Google Scholar
  49. 49.
    Nguyen VH (2017) Community osteoporosis screening services for the prevention of osteoporotic fractures in population health: a literature review. Int J Evid Based Healthc 15(2):43–52CrossRefGoogle Scholar
  50. 50.
    Dinh-Zarr TB, Sleet DA, Shults RA, Zaza S, Elder RW, Nichols JL et al (2001) Reviews of evidence regarding interventions to increase the use of safety belts. Am J Prev Med 21(4 Suppl):48–65CrossRefGoogle Scholar
  51. 51.
    Lee BB, Cripps RA, Fitzharris M, Wing PC (2014) The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord 52(2):110–116CrossRefGoogle Scholar
  52. 52.
    Jazayeri SB, Beygi S, Shokraneh F, Hagen EM, Rahimi-Movaghar V (2015) Incidence of traumatic spinal cord injury worldwide: a systematic review. Eur Spine J 24(5):905–918CrossRefGoogle Scholar
  53. 53.
    van den Berg ME, Castellote JM, de Pedro-Cuesta J, Mahillo-Fernandez I (2010) Survival after spinal cord injury: a systematic review. J Neurotrauma 27(8):1517–1528CrossRefGoogle Scholar
  54. 54.
    Kraft R, Dorstyn D (2015) Psychosocial correlates of depression following spinal injury: a systematic review. J Spinal Cord Med 38(5):571–583CrossRefGoogle Scholar
  55. 55.
    Craig A, Tran Y, Middleton J (2009) Psychological morbidity and spinal cord injury: a systematic review. Spinal Cord 47(2):108–114CrossRefGoogle Scholar
  56. 56.
    Dijkers M, Bryce T, Zanca J (2009) Prevalence of chronic pain after traumatic spinal cord injury: a systematic review. J Rehabil Res Dev 46(1):13–29CrossRefGoogle Scholar
  57. 57.
    Gilbert O, Croffoot JR, Taylor AJ, Nash M, Schomer K, Groah S (2014) Serum lipid concentrations among persons with spinal cord injury—a systematic review and meta-analysis of the literature. Atherosclerosis 232(2):305–312CrossRefGoogle Scholar
  58. 58.
    Xing D, Wang J, Song D, Xu W, Chen Y, Yang Y et al (2013) Predictors for mortality in elderly patients with cervical spine injury: a systematic methodological review. Spine (Phila Pa 1976) 38(9):770–777CrossRefGoogle Scholar
  59. 59.
    van Middendorp JJ, Albert TJ, Veth RP, Hosman AJ (2010) Methodological systematic review: mortality in elderly patients with cervical spine injury: a critical appraisal of the reporting of baseline characteristics, follow-up, cause of death, and analysis of risk factors. Spine (Phila Pa 1976) 35(10):1079–1087CrossRefGoogle Scholar
  60. 60.
    World Health Organization (2007) Preventing Injuries and violence: a guide for ministries of health. World Health Organization, GenevaGoogle Scholar
  61. 61.
    World Health Organization (2013) Global status report on road safety 2013. World Health Organization, GenevaGoogle Scholar
  62. 62.
    Krug EG, Sminkey LA (2007) The role of the ministry of health in preventing injuries and violence. Int J Inj Contr Saf Promot 14(3):199–201CrossRefGoogle Scholar
  63. 63.
    Cooper BS, Medley GF, Stone SP, Kibbler CC, Cookson BD, Roberts JA et al (2004) Methicillin-resistant Staphylococcus aureus in hospitals and the community: stealth dynamics and control catastrophes. Proc Natl Acad Sci USA 101(27):10223–10228CrossRefGoogle Scholar
  64. 64.
    Lonnroth K, Castro KG, Chakaya JM, Chauhan LS, Floyd K, Glaziou P et al (2010) Tuberculosis control and elimination 2010-50: cure, care, and social development. Lancet 375(9728):1814–1829CrossRefGoogle Scholar
  65. 65.
    Kamara E, Mehta S, Brust JC, Jain AK (2012) Effect of delayed diagnosis on severity of Pott’s disease. Int Orthop 36(2):245–254CrossRefGoogle Scholar
  66. 66.
    Rajasekaran S (2007) Buckling collapse of the spine in childhood spinal tuberculosis. Clin Orthop Relat Res 460:86–92PubMedGoogle Scholar
  67. 67.
    Rajasekaran S, Prasad Shetty A, Dheenadhayalan J, Shashidhar Reddy J, Naresh-Babu J, Kishen T (2006) Morphological changes during growth in healed childhood spinal tuberculosis: a 15-year prospective study of 61 children treated with ambulatory chemotherapy. J Pediatr Orthop 26(6):716–724CrossRefGoogle Scholar
  68. 68.
    Lonnroth K, Migliori GB, Abubakar I, D’Ambrosio L, de Vries G, Diel R et al (2015) Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J 45(4):928–952PubMedPubMedCentralGoogle Scholar
  69. 69.
    Rodrigues-De-Souza DP, Fernandez-De-Las-Penas C, Martin-Vallejo FJ, Blanco-Blanco JF, Moro-Gutierrez L, Alburquerque-Sendin F (2016) Differences in pain perception, health-related quality of life, disability, mood, and sleep between Brazilian and Spanish people with chronic non-specific low back pain. Braz J Phys Ther 20(5):412–421CrossRefGoogle Scholar
  70. 70.
    Susser M, Susser E (1996) Choosing a future for epidemiology: I. Eras and paradigms. Am J Public Health 86(5):668–673CrossRefGoogle Scholar
  71. 71.
    Krieger N, Zierler S (1996) What explains the public’s health?—A call for epidemiologic theory. Epidemiology 7(1):107–109CrossRefGoogle Scholar
  72. 72.
    Susser M, Susser E (1996) Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology. Am J Public Health 86(5):674–677CrossRefGoogle Scholar
  73. 73.
    Broadbent A (2009) Causation and models of disease in epidemiology. Stud Hist Philos Biol Biomed Sci 40(4):302–311CrossRefGoogle Scholar

Copyright information

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

Authors and Affiliations

  1. 1.Qualcomm Health Center, Stanford Health CareSan DiegoUSA
  2. 2.National University of Health SciencesLombardUSA
  3. 3.Department of Epidemiology, School of Public HealthUniversity of California Los AngelesLos AngelesUSA
  4. 4.Department of NeurologyUniversity of California, IrvineIrvineUSA
  5. 5.World Spine CareSanta AnaUSA
  6. 6.College of Rehabilitative Sciences, Doctor of Physical Therapy ProgramUniversity of St. Augustine for Health SciencesSan MarcosUSA
  7. 7.Rehabilitation Care Line, Physical Medicine and RehabilitationCincinnati Veterans Affairs Medical CenterCincinnatiUSA
  8. 8.Emergency MedicineCarlsbadUSA
  9. 9.National School of Occupational MedicineCarlos III Institute of HealthMadridSpain
  10. 10.Physical Medicine and Rehabilitation DepartmentUniversity ComplutenseMadridSpain
  11. 11.Physical Medicine and Rehabilitation Section, Department of Orthopaedic SurgeryStanford UniversityRedwood CityUSA
  12. 12.Department of Orthopaedics and Spine SurgeryGanga HospitalCoimbatoreIndia
  13. 13.Office of Public Health StudiesUniversity of Hawai’i, MānoaHonoluluUSA
  14. 14.Departments of Orthopedic Surgery and Environmental MedicineNew York UniversityNew YorkUSA
  15. 15.World Spine Care EuropeHolmfirthUK
  16. 16.Faculty of Health SciencesUniversity of Ontario Institute of TechnologyOshawaCanada
  17. 17.UOIT-CMCC Centre for Disability Prevention and RehabilitationTorontoCanada

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