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



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.

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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.

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Correspondence to Claire D. Johnson.

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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.

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Green, B.N., Johnson, C.D., Haldeman, S. et al. The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities. Eur Spine J 27, 838–850 (2018).

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  • Health promotion
  • Spinal diseases
  • Risk factors
  • Epidemiology