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

Effects of a Novel Web-Based Sensorimotor Exercise Program for Patients With Subacute Whiplash-Associated Disorders: Protocol for a Randomized Clinical Trial

INTRODUCTION

Whiplash-associated disorder (WAD) often becomes a persistent problem and is one of the leading causes of disability in the world. It is a costly condition for individuals, for insurance companies, and for society. Guidelines for the management of WAD have not been updated since 2014, and the use of computer-based sensorimotor exercise programs in treatment for this patient group has not been well documented. The purpose of this randomized clinical trial is to explore the degree of association between self-reported and clinical outcome measures in WAD.

METHODS

Individuals (n = 180) with subacute WAD grades I and II will be randomized into 3 groups using block randomization. The 2 primary intervention groups (A and B) will receive physical therapy involving manual therapy and either a remote, novel, computer-based cervical kinesthetic exercise (CKE) program starting at visit 2 (Group A) or neck exercises provided by the corresponding physical therapist (Group B). These groups will be compared to a "treatment as usual" Group C. Movement control, proprioception, and cervical range of motion will be measured. Neck disability and pain intensity, general health, self-perceived handicap, and physical, emotional, and functional difficulties due to dizziness will be measured using questionnaires. The short-term effects will be measured 10 to 12 weeks after the baseline measurements, and the long-term effects will be measured 6 to 12 months after the baseline measurements.

IMPACT

The successful completion of this trial will help guide clinicians in the selection of outcome measures for patients with subacute WAD in the assessment of the short- and long-term effectiveness of treatment combining manual therapy with computer-based CKE compared with manual therapy and non-computer-based exercises. This trial will also demonstrate the potential of using a computer-based intervention to increase the exercise dose for this patient group and how this influences outcomes such as levels of pain and disability in the short and long term.

Socioeconomic status, mental health, and nutrition are the principal traits for low back pain phenotyping: Data from the osteoarthritis initiative

Background

Low back pain (LBP) is a heterogeneous disease with biological, physical, and psychosocial etiologies. Models for predicting LBP severity and chronicity have not made a clinical impact, perhaps due to difficulty deciphering multidimensional phenotypes. In this study, our objective was to develop a computational framework to comprehensively screen metrics related to LBP severity and chronicity and identify the most influential.

Methods

We identified individuals from the observational, longitudinal Osteoarthritis Initiative cohort (N = 4796) who reported LBP at enrollment (N = 215). OAI descriptor variables (N = 1190) were used to cluster individuals via unsupervised learning and uncover latent LBP phenotypes. We also developed a dimensionality reduction algorithm to visualize clusters/phenotypes using Uniform Manifold Approximation and Projection (UMAP). Next, to predict chronicity, we identified those with acute LBP (N = 40) and persistent LBP over 8 years of follow-up (N = 66) and built logistic regression and supervised machine learning models.

Results

We identified three LBP phenotypes: a "high socioeconomic status, low pain severity group", a "low socioeconomic status, high pain severity group", and an intermediate group. Mental health and nutrition were also key clustering variables, while traditional biomedical factors (e.g., age, sex, BMI) were not. Those who developed chronic LBP were differentiated by higher pain interference and lower alcohol consumption (a correlate to poor physical fitness and lower soceioeconomic status). All models for predicting chronicity had satisfactory performance (accuracy 76%-78%).

Conclusions

We developed a computational pipeline capable of screening hundreds of variables and visualizing LBP cohorts. We found that socioeconomic status, mental health, nutrition, and pain interference were more influential in LBP than traditional biomedical descriptors like age, sex, and BMI.

Binary classification of non-specific low back pain condition based on the combination of B-mode ultrasound and shear wave elastography at multiple sites

Introduction: Low back pain (LBP) is a prevalent and complex condition that poses significant medical, social, and economic burdens worldwide. The accurate and timely assessment and diagnosis of LBP, particularly non-specific LBP (NSLBP), are crucial to developing effective interventions and treatments for LBP patients. In this study, we aimed to investigate the potential of combining B-mode ultrasound image features with shear wave elastography (SWE) features to improve the classification of NSLBP patients. Methods: We recruited 52 subjects with NSLBP from the University of Hong Kong-Shenzhen Hospital and collected B-mode ultrasound images and SWE data from multiple sites. The Visual Analogue Scale (VAS) was used as the ground truth to classify NSLBP patients. We extracted and selected features from the data and employed a support vector machine (SVM) model to classify NSLBP patients. The performance of the SVM model was evaluated using five-fold cross-validation and the accuracy, precision, and sensitivity were calculated. Results: We obtained an optimal feature set of 48 features, among which the SWE elasticity feature had the most significant contribution to the classification task. The SVM model achieved an accuracy, precision, and sensitivity of 0.85, 0.89, and 0.86, respectively, which were higher than the previously reported values of MRI. Discussion: In this study, we aimed to investigate the potential of combining B-mode ultrasound image features with shear wave elastography (SWE) features to improve the classification of non-specific low back pain (NSLBP) patients. Our results showed that combining B-mode ultrasound image features with SWE features and employing an SVM model can improve the automatic classification of NSLBP patients. Our findings also suggest that the SWE elasticity feature is a crucial factor in classifying NSLBP patients, and the proposed method can identify the important site and position of the muscle in the NSLBP classification task.

The John A. Sweaney Lecture: Virtual, September 2021, Given by Dr Michele Maiers. A Time to Lead: Reflections During a Pandemic

The following is The John A. Sweaney Lecture delivered by Dr Michele Maiers at the biannual Congress of the World Federation of Chiropractic that was held virtually on September 25, 2021.

The search for systemic biomarkers for monitoring degenerative lumbar spinal disorders

Objectives

In our previous study, we reported that low back pain (LBP) severity and disability significantly correlate with body composition and several blood biochemical factors. Herein, we tested the hypothesis that these covariates are associated with anatomical deformations of the lumbar spine, in particular, radiographic facet joint osteoarthritis (FJOA) and lumbar disc degeneration (LDD) features important contributors to LBP.

Methods

CT and MRI images of the lumbar spine were obtained from 200 individuals suffering from LBP-sciatica. We examined the FJOA and total LDD score - the sum of the scores of the three radiographic features (intervertebral disc herniation, osteophythosis and spondylolisthesis) at the L1 - S1 vertebral levels. By implementing a bioelectrical impedance analysis, we assessed the participants for body composition, specifically, extracellular water (ECW). Plasma levels of growth and differentiation factor 15 (GDF-15) and visceral adipose tissue-derived serine protease inhibitor (vaspin), were detected by ELISA.

Results

By conducting a series of multivariable regression analyses, we report that the circulating levels of GDF-15, vaspin, and ECW are significantly and independently associated with FJOA scores [β_GDF15 ​= ​0.38 ​± ​0.08, p ​= ​0.0001; β_VASPIN ​= ​0.36 ​± ​0.07, p ​= ​0.000004; β_ECW ​= ​0.24 ​± ​0.07, p ​= ​0.002]. The levels of GDF-15 (β ​= ​0.30 ​± ​0.10, p ​= ​0.007) and ECW (β ​= ​0.20 ​± ​0.09, p ​= ​0.03) were also found significantly associated with the LDD scores.

Conclusion

The obtained new data suggest that GDF-15, vaspin and ECW may serve as biomarkers for FJOA and LDD phenotypes.

Impact of meteorological factors on hospital admissions for spinal diseases in Shanghai during 2015-2019

PURPOSE

To assess the correlation between meteorological factors and spinal disease admissions.

METHODS

Data was obtained from the electronic medical records of a tertiary general hospital. Meteorological data was collected from China Meteorological Science Data Sharing Service. Distributed lag nonlinear models were used to evaluate the impact of meteorological variables on weekly spinal disease admissions.

RESULTS

A total of 2739 spinal cases were documented. Compared with estimates at the 50^th, the cumulative relative risk (RR) for extremely high temperatures at the 97.5^th over lag week 18 to lag week 20 increased by 75.7%. When the weekly maximum temperature reached 38°C during lag week 20, the maximum RR was 1.96 (95% CI:1.095-3.506). Moreover, the effects of extremely high temperatures on spinal disease admissions were more obvious in females and the age group ≥65 years old compared with males and the age group<65 years old.

CONCLUSIONS

Extremely high temperatures were significantly associated with higher risks of spinal disease admissions.

Modifiable lifestyle-related prognostic factors for the onset of chronic spinal pain: A systematic review of longitudinal studies

BACKGROUND

Stratified approaches to spinal pain that address psychosocial risk factors reduce long-term disability to a moderate extent. Identifying and managing other risk factors might help improve outcomes.

OBJECTIVE

This systematic review of longitudinal studies aimed to evaluate possible associations between the onset of chronic spinal pain (including low back, back and neck pain) and putative modifiable lifestyle-related risk or protective factors.

METHODS

This systematic review of longitudinal studies published during the last 2 decades followed PRISMA guidelines. Two reviewers screened Medline, Scopus, Pedro, Cochrane Library, Psycinfo, Science Direct, PTSDpubs and Google Scholar for relevant studies. The QUIPS tool was used to assess the risk of bias. A qualitative meta-synthesis of relevant factors was performed.

RESULTS

Of 3716 unique records, 14 studies met the inclusion criteria (10 with low risk of bias and 4 moderate risk of bias). The highest bias observed was attrition. For chronic low back pain, we found moderate evidence for the involvement of high body weight, waist circumference, and hip circumference and conflicting evidence for high body mass index (BMI), smoking, and physical activity. For chronic neck pain, we found strong evidence for high BMI in women, moderate evidence for sleep disorders in women and conflicting evidence for high BMI in men and physical activity. For chronic back pain, we found limited evidence for gardening/yard work in men and more than one adult at home. Effect sizes were small.

CONCLUSIONS

Several modifiable lifestyle-related factors were identified. Evidence is still sparse and there is a need for more studies. PROSPERO database registration: Ref 172,112 CRD42020172112.

Intra-rater and inter-rater reliability of neutral and target lumbar positioning tests in subjects with and without non-specific lower back pain

BACKGROUND

Proprioception, one's sense of movement and position, is a common term used in back rehabilitation. Kinesthetic rehabilitation may be useful in managing lower back pain; however, reliable measures are required to quantify lumbar proprioception sense.

OBJECTIVE

To investigate intrarater and interrater reliability of neutral lumbar positioning (NLP) and target lumbar positioning (TLP) tests and compare the position sense errors in subjects with non-specific low back pain and healthy controls.

METHODS

Intrarater (between-day) and interrater (within-day) reliability of NLP and TLP tests were assessed in 30 subjects with low back pain and 30 healthy subjects using a digital inclinometer. NLP is evaluated when the subject is repositioned to neutral from flexion, while TLP is evaluated in lumbar flexion, by bending laterally left and right.

RESULTS

Intrarater reliability for NLP tests had ICC values of 0.85 and 0.89 and TLP tests had 0.78 and 0.92. Likewise, interrater reliability for NLP had ICC values of 0.75 and 0.85, and for the TLP test, the interrater reliability had 0.78 and 0.93. Subjects with back pain had significantly larger neutral and target lumbar proprioceptive errors compared to healthy controls (p< 0.001).

CONCLUSIONS

Intrarater and interrater reliability showed good agreement for both NLP and TLP tests of lumbar proprioception. Subjects with nonspecific low back pain have impaired lumbar proprioceptive sense.

Extrapolating Beyond the Data in a Systematic Review of Spinal Manipulation for Nonmusculoskeletal Disorders: A Fall From the Summit

OBJECTIVE

The purpose of this article is to discuss a literature review-a recent systematic review of nonmusculoskeletal disorders-that demonstrates the potential for faulty conclusions and misguided policy implications, and to offer an alternate interpretation of the data using present models and criteria.

METHODS

We participated in a chiropractic meeting (Global Summit) that aimed to perform a systematic review of the literature on the efficacy and effectiveness of mobilization or spinal manipulative therapy (SMT) for the primary, secondary, and tertiary prevention and treatment of nonmusculoskeletal disorders. After considering an early draft of the resulting manuscript, we identified points of concern and therefore declined authorship. The present article was developed to describe those concerns about the review and its conclusions.

RESULTS

Three main concerns were identified: the inherent limitations of a systematic review of 6 articles on the topic of SMT for nonmusculoskeletal disorders, the lack of biological plausibility of collapsing 5 different disorders into a single category, and considerations for best practices when using evidence in policy-making. We propose that the following conclusion is more consistent with a review of the 6 articles. The small cadre of high- or moderate-quality randomized controlled trials reviewed in this study found either no or equivocal effects from SMT as a stand-alone treatment for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine, and found no or low-quality evidence available to support other nonmusculoskeletal conditions. Therefore, further research is needed to determine if SMT may have an effect in these and other nonmusculoskeletal conditions. Until the results of such research are available, the benefits of SMT for specific or general nonmusculoskeletal disorders should not be promoted as having strong supportive evidence. Further, a lack of evidence cannot be interpreted as counterevidence, nor used as evidence of falsification or verification.

CONCLUSION

Based on the available evidence, some statements generated from the Summit were extrapolated beyond the data, have the potential to misrepresent the literature, and should be used with caution. Given that none of the trials included in the literature review were definitively negative, the current evidence suggests that more research on nonmusculoskeletal conditions is warranted before any definitive conclusions can be made. Governments, insurers, payers, regulators, educators, and clinicians should avoid using systematic reviews in decisions where the research is insufficient to determine the clinical appropriateness of specific care.

Full-Coverage Chiropractic in Medicare: A Proposal to Eliminate Inequities, Improve Outcomes, and Reduce Health Disparities Without Increasing Overall Program Costs

OBJECTIVE

The purpose of this article is to discuss evidence that supports the resolution of inequities for Medicare beneficiaries who receive chiropractic care.

DISCUSSION

Medicare covers necessary examinations, imaging, exercise instruction, and treatments for beneficiaries with back pain when provided by medical doctors, osteopaths, and their associated support staff such as nurse practitioners, physician assistants, clinical nurse specialists, and physical therapists. However, if the same patient with back pain presents to a chiropractor, then the only service that is covered by Medicare is manipulation of the spine. Current evidence does not support this inequity in Medicare beneficiary service coverage. There is no evidence to show an increase in serious risks associated with chiropractic treatment of neck or back pain in Medicare beneficiaries. Chiropractors support national public health goals and endorse safe, evidence-based practices. Chiropractic care for Medicare beneficiaries has been associated with enhanced clinical outcomes such as faster recovery, fewer back surgeries a year later, reduced opioid-associated disability, fewer traumatic injuries and falls, and slower declines in activities of daily living and disability over time. Further evidence points to lower costs, fewer medical physician visits for low back pain, less opioid-related expense, and less back-surgery expense with chiropractic utilization. Use is lower among vulnerable populations: seniors, lower income women, and black and Hispanic beneficiaries who may be most affected by current inequities associated with the limited coverage. In this era of evidence-based and patient-centered care, beneficiaries who receive chiropractic care are very satisfied with the care they receive.

CONCLUSION

The current evidence suggests a need for change in US policy toward chiropractic in Medicare and support for HR 3654. Ending inequities by providing patients full coverage for chiropractic services has the potential to enhance care outcomes and reduce health disparities without increasing program costs.

Effectiveness of Hydrogalvanic Bath on Improving Pain, Disability, and Quality of Life in Individuals with Chronic Nonspecific Neck Pain: A Randomized Controlled Trial

Background

Neck pain is one of the world's leading factors in years lived with disability. Ambiguity in the effect of electrotherapy modalities for the treatment of chronic nonspecific neck pains (CNSNP) needs to be examined further. This study sought to elucidate the effectiveness of hydrogalvanic bath on improving pain, disability, and quality of life among individuals with CNSNP.

Methods

Thirty-four individuals with a diagnosis of CNSNP were selected through convenient sampling and randomly divided into two groups by block randomization. The control group treatment underwent low Transcutaneous Electrical Nerve Stimulation (TENS) and exercise, and the experimental group was subjected to hydrogalvanic bath therapy (HGBT) and exercise. Individuals were evaluated for pain using a visual analog scale (VAS), disability with the Neck Disability Index (NDI), and quality of life with Short Form-36 (SF-36). These measures were applied at baseline and after 12 weeks of treatment.

Results

The pretreatment and posttreatment results for VAS, NDI, and SF-36 were compared for both control and experimental groups. We found that all the three variables showed significant differences between the two time points with p < 0.05 in both the groups but the experimental group improvements were more significant than the control group with p < 0.05.

Conclusion

Twelve weeks of low TENS or HGBT along with exercises can decrease pain and neck disability and increase the quality of life in individuals with CNSNP. However, HGBT along with exercise has superior effects relative to low TENS along with exercise. This randomized controlled trial was registered in the International Standard Randomized Controlled Trials Number-ISRCTN29695190 and registered on 05/02/2020. This study is a retrospective registration.

The Role of Fear-Avoidance Beliefs on Low Back Pain-Related Disability in a Developing Socioeconomic and Conservative Culture: A Cross-Sectional Study of a Pakistani Population

Background

The relationship of low back pain, the world’s top disabling condition, with functional disability is often explained by the mediation effect of fear, catastrophizing, and psychological distress. These relationships have not been explored within chronic back pain patients from a low socio-economic, predominantly Muslim country. Thus, it was unclear whether previously established pathways would be consistent in Pakistani pain patients to help guide Pakistani clinicians caring for back pain patients. This cross-sectional study translated English versions of questionnaires within the fear-avoidance model into Urdu, tested the clinimetric properties of the Urdu versions for people with chronic low back pain (CLBP) in Pakistan, and performed mediation analysis to investigate pathways of the fear-avoidance model.

Methods

Translation of questionnaires was completed in 4 steps using the forward-backward technique, with subsequent analyses for internal consistency (Cronbach’s α), construct validity (Pearson’s r-value), and test–retest reliability (ICC r-value). Multiple mediation analysis with bootstrapping was performed to analyze pathways within the fear-avoidance model from the Urdu translated questionnaires.

Results

A total of 151 people from Pakistan with CLBP completed the questionnaires, with good results for internal consistency (r > 0.85), convergent validity (r > 0.59), and test–retest reliability (ICC r > 0.85). The association of pain with disability was significant (B=2.36, r² = 0.19, p<0.001), and the indirect effect of the mediators explained 81% of pain intensity’s total effect on disability. All mediators, apart from physical activity-related fear-avoidance beliefs, were significant mediators of the effect of pain intensity on disability.

Conclusion

The Urdu versions of the fear-avoidance questionnaires show good clinimetric properties for use in clinical settings and research in Pakistan. These analyses support existing data for the mediation effect of catastrophizing, psychological distress, and self-efficacy on pain-related disability, and extends these findings to suggest that fear about work may be more important in a relatively lower socioeconomic sample of pain patients.

Measuring disability-adjusted life years (DALYs) due to low back pain in Malta

Background

Low back pain (LBP) is a public health concern and a leading cause of ill health. A high prevalence of musculoskeletal complaints has been reported for Malta, a small European state. The aim was to estimate for the first time the burden of LBP at population level in Malta in terms of disability-adjusted life years (DALYs) and compare to estimates obtained by the Global Burden of Disease (GBD) study.

Method

The Maltese European Health Interview Survey dataset for 2015 provided the LBP prevalence data through representative self-reported history of chronic LBP within the past 12 months in combination with limitations to daily activities. Proportions of LBP severity (with and without leg pain – mild, moderate, severe and most severe) and their corresponding disability weights followed values reported in the GBD study. Years lived with disability (YLD) for LBP were estimated for the whole population by age and sex. Since LBP does not carry any mortality, YLD reflected DALYs. The estimated local DALYs per 100,000 were compared to the GBD 2017 study results for Malta for the same year.

Results

LBP with activity limitation gave a point prevalence of 6.4% (95% Uncertainty Interval [UI] 5.7–7.2%) (5.6% males [95% UI 4.6–6.6%]; 7.3% females [95% UI 6.2–8.4%]), contributing to a total of 23,649 (95% UI 20,974–26,463) Maltese suffering from LBP. The LBP DALYs were of 716 (95% UI 558–896) per 100,000. Females experienced higher LBP burden (739 [95% UI 575–927] DALYs per 100,000) than males (693 [95% UI 541–867] DALYs per 100,000). Our DALY estimates were lower than those reported by the GBD 2017 study (i.e., 1829 [95% UI 1300–2466] per 100,000).

Conclusions

LBP imposes a substantial burden on the Maltese population. Differences observed between national estimates and those of the GBD study suggest the integration of updated locally sourced data into the model and encouraging local contributors in order to improve the DALY estimates of each country.

Analysis of pain symptoms, flexibility and hydroxyproline concentration in individuals with low back pain submitted to Global Postural Re-education and stretching

Aim: To evaluate pain, flexibility and hydroxyproline (HP) urinary levels in patients with nonspecific low back pain submitted to Global Postural Re-education (GPR) and stretching. Materials & methods: 39 individuals who reported low back pain were randomly assigned to a group submitted to GPR (GPRG) or stretching exercises (SG) for 8 weeks. Pain and flexibility were assessed using the Borg CR10 scale and goniometry, respectively. Results: The GPR group showed a significant reduction in the HP levels and significant improvements in flexibility after the intervention when compared with SG. Both groups presented a significant reduction in HP and pain after the intervention. Conclusion: Both interventions were effective in the treatment of low back pain. However, the GPR method presented better responses than stretching.

Häufigkeiten muskuloskelettaler Symptome und Erkrankungen in der bevölkerungsbezogenen NAKO Gesundheitsstudie

Hintergrund

Muskuloskelettale Symptome und Erkrankungen sind in der Bevölkerung sehr weit verbreitet und verursachen hohe Kosten in Gesundheitswesen und Volkswirtschaft.

Ziel der Arbeit

Die Häufigkeit muskuloskelettaler Symptome und Erkrankungen aus den Bereichen Rückenschmerzen, Osteoporose, Arthrose und Arthritis wurde auf Basis von Daten der bevölkerungsbasierten NAKO Gesundheitsstudie beschrieben.

Material und Methoden

Die Daten wurden in der ersten Hälfte der NAKO-Basiserhebung von März 2014 bis März 2017 bei Erwachsenen im Alter von 20–75 Jahren erhoben. In die Analysen gingen Daten von 101.779 Interviewteilnehmenden sowie von 9370 Teilnehmenden aus zwei klinischen Untersuchungen ein. Mittels der klinischen Handuntersuchung wurden tastbar geschwollene Gelenke sowie auf Druck schmerzhafte Gelenke identifiziert. Die Winkelstuhluntersuchung lieferte Daten zu Ruheschmerzen am Knie- und Hüftgelenk. Häufigkeiten wurden auf die deutsche Standardbevölkerung 2011 gewichtet.

Ergebnisse

In den Selbstberichten der Teilnehmenden im Interview wurden am häufigsten jemals diagnostizierte andauernde Rückenschmerzen (22,5 %) und Arthrosen (20,6 %) angegeben, seltener Osteoporose (2,9 %) und rheumatoide Arthritis (1,9 %). In der Handuntersuchung wurden bei 6,0 % Schmerzen an mindestens einem Fingergelenk festgestellt. Laut Winkelstuhluntersuchung waren 8,2 % von einem Ruheschmerz in mindestens einem Knie betroffen sowie 5,1 % an der Hüfte. Frauen berichteten insgesamt häufiger muskuloskelettale Erkrankungen und Symptome als Männer, der Anteil Betroffener nahm mit dem Alter deutlich zu.

Diskussion

Die Ergebnisse belegen die große Verbreitung vieler muskuloskelettaler Erkrankungen. Die berichtete Beschwerdelast ist mit Ergebnissen aus früheren bevölkerungsbezogenen Erhebungen vergleichbar.

A case-series of patients with musculoskeletal conditions in an underserved community in Moca, Dominican Republic

Purpose

To describe characteristics and activity limitations of new patients with musculoskeletal conditions presenting to the World Spine Care (WSC) clinic located in the underserved community of Moca, Dominican Republic.

Methods

We conducted a prospective case series of consecutive adults between October 12 and December 5, 2015. A survey of valid and reliable measures including: Body pain diagram, Wong-Baker FACES® pain rating scale, Spine Functional Index (SFI), Lower Limb Functional Index (LLFI), Upper Limb Functional Index (ULFI) and the 12-item Short Form Health Survey (SF-12v2) was administered to collect socio-demographics, expectation of recovery, comorbidities, and self-reported health status data.

Results

Forty-two patients (23 females and 19 males) were included. The most common primary complaint was lower back pain (40.5%; 17/42) and 57% (24/42) of individuals reported pain that interfered with their ability to function and engage in daily activities. Half of the patients presented with two complaints. Complaints were similar between genders. Most patients (64%; 27/42) reported chronic pain (> 6 months) and 97% (41/42) reported believing that they would recover. Twenty-one percent (9/42) self-reported being diagnosed with depression and/or anxiety at some point in their life. In addition, most (57%; 24/42) individuals reported below average physical and mental health related quality of life.

Conclusions

This study is the first to describe characteristics of patients seeking care at the WSC clinic in Moca, Dominican Republic. Most patients attending the clinic suffer from persistent spine complaints that interfere with their ability to function and engage in daily activities. Nevertheless, the patients have positive expectations of recovery.

Chiropractic as Part of the Solution to the World Crisis in Spine-related Disability

The purpose of this article is to explore the concepts related to how chiropractic can contribute to addressing the issue of spine-related disability. This article is an edited transcription of the presentation made by Dr Richard Brown, Secretary General of the World Federation of Chiropractic, at the Florida Chiropractic Association National Conference on August 17, 2018, in Orlando, Florida.

The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities

PURPOSE

Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources.

METHODS

Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders.

RESULTS

Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care.

CONCLUSION

The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: resources to implement a spine care program

PURPOSE

The purpose of this report is to describe the development of a list of resources necessary to implement a model of care for the management of spine-related concerns anywhere in the world, but especially in underserved communities and low- and middle-income countries.

METHODS

Contents from the Global Spine Care Initiative (GSCI) Classification System and GSCI care pathway papers provided a foundation for the resources list. A seed document was developed that included resources for spine care that could be delivered in primary, secondary and tertiary settings, as well as resources needed for self-care and community-based settings for a wide variety of spine concerns (e.g., back and neck pain, deformity, spine injury, neurological conditions, pathology and spinal diseases). An iterative expert consensus process was used using electronic surveys.

RESULTS

Thirty-five experts completed the process. An iterative consensus process was used through an electronic survey. A consensus was reached after two rounds. The checklist of resources included the following categories: healthcare provider knowledge and skills, materials and equipment, human resources, facilities and infrastructure. The list identifies resources needed to implement a spine care program in any community, which are based upon spine care needs.

CONCLUSION

To our knowledge, this is the first international and interprofessional attempt to develop a list of resources needed to deliver care in an evidence-based care pathway for the management of people presenting with spine-related concerns. This resource list needs to be field tested in a variety of communities with different resource capacities to verify its utility. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: classification system for spine-related concerns

PURPOSE

The purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway.

METHODS

Existing classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate.

RESULTS

Thirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended.

CONCLUSIONS

An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: model of care and implementation

PURPOSE

Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions.

METHODS

The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps.

RESULTS

Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up.

CONCLUSION

The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: methodology, contributors, and disclosures

PURPOSE

The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations.

METHODS

World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care.

RESULTS

Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest.

CONCLUSION

The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: care pathway for people with spine-related concerns

PURPOSE

The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally.

METHODS

The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used.

RESULTS

After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records.

CONCLUSION

A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies

PURPOSE

This article summarizes relevant findings related to low back and neck pain from the Global Burden of Disease (GBD) reports for the purpose of informing the Global Spine Care Initiative.

METHODS

We reviewed and summarized back and neck pain burden data from two studies that were published in Lancet in 2016, namely: "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015" and "Global, regional, and national disability-adjusted life years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015."

RESULTS

In 2015, low back and neck pain were ranked the fourth leading cause of disability-adjusted life years (DALYs) globally just after ischemic heart disease, cerebrovascular disease, and lower respiratory infection {low back and neck pain DALYs [thousands]: 94 941.5 [95% uncertainty interval (UI) 67 745.5-128 118.6]}. In 2015, over half a billion people worldwide had low back pain and more than a third of a billion had neck pain of more than 3 months duration. Low back and neck pain are the leading causes of years lived with disability in most countries and age groups.

CONCLUSION

Low back and neck pain prevalence and disability have increased markedly over the past 25 years and will likely increase further with population aging. Spinal disorders should be prioritized for research funding given the huge and growing global burden. These slides can be retrieved under Electronic Supplementary Material.