The Global Spine Care Initiative: A Narrative Review of
Psychological and Social Issues in Back Pain in
Low- and Middle-income Communities

This section is compiled by Frank M. Painter, D.C.
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FROM:   European Spine Journal 2018 (Sep); 27 (Suppl 6): 828–837 ~ FULL TEXT

Christine Cedraschi • Margareta Nordin • Scott Haldeman • Kristi Randhawa
Deborah Kopansky-Giles • Claire D Johnson • Roger Chou • Eric L Hurwitz • Pierre Côté

Division of General Medical Rehabilitation,
Geneva University and University Hospital,
Geneva, Switzerland.

PURPOSE:   The purpose of this review was to describe psychological and social factors associated with low back pain that could be applied in spine care programs in medically underserved areas and low- and middle-income countries.

METHODS:   We performed a narrative review of cohort, cross-sectional, qualitative and mixed methods studies investigating adults with low back pain using Medline and PubMed were searched from January 2000 to June 2015. Eligible studies had at least one of the following outcomes: psychological, social, psychosocial, or cultural/ethnicity factors. Studies met the following criteria: (1) English language, (2) published in peer-reviewed journal, (3) adults with spinal disorders, (4) included treatment, symptom management or prevention.

RESULTS:   Out of 58 studies, 29 were included in this review. There are few studies that have evaluated psychological and social factors associated with back pain in low- and middle-income communities, therefore, adapting recommendations from other regions may be needed until further studies can be achieved.

CONCLUSION:   Psychological and social factors are important components to addressing low back pain and health care providers play an important role in empowering patients to take control of their spinal health outcomes. Patients should be included in negotiating their spinal treatment and establishing treatment goals through careful listening, reassurance, and information providing by the health care provider. Instruments need to be developed for people with low literacy in medically underserved areas and low- and middle-income countries, especially where psychological and social factors may be difficult to detect and are poorly addressed. These slides can be retrieved under Electronic Supplementary Material.

KEYWORDS:   Communication barriers; Physician–patient relations; Psychology; Psychosomatic medicine; Somatosensory disorders; Spine

From the FULL TEXT Article:


For most of the twentieth century, spinal pain was assumed to be like other diseases in that symptoms were related to documentable spinal pathology. [1–3] This assumption implied that pain and disability were related directly to pathology severity [4, 5] and that interventions directed at the pathology would result in resolution of pain and disability. Toward the end of the century, research showed that changes noted on imaging and other diagnostic tests were not necessarily correlated with the degree of symptoms and disability. [6, 7] A growing body of research has shown that social and psychological factors contribute to spine pain and disability. [8]

The relationship among chronic pain, psychological, and social factors may be addressed using a biopsychosocial perspective of pain. [9, 10] This perspective requires a comprehensive conceptualization of pain, including sensory, afective, and cognitive dimensions, shifting the framework from biomedical pain relief to a biopsychosocial model. [11, 12] The somatic basis of pain is included in the biopsychosocial model, whether or not the cause is identifed. When pain becomes chronic, non-physical factors become increasingly important and the interaction between psychological, social, and physical traits must be considered in concert.

People who have musculoskeletal disorders may have psychological and social risk factors for developing persistent pain and long-term disability. [13–16] The concept of psychosocial “flags” were frst introduced in the 1990s and have evolved over time. [16, 17] “Yellow flags” are obvious psychological risk factors related to back pain that are considered normal but unhelpful (e.g., pain behaviors, emotional responses). Psychological risk factors include an individual’s emotional, cognitive and behavioral responses to pain and the ability to distinguish between pain and disability. [15]

Factors include:

(1)   depression, catastrophizing, anxiety, and stress,

(2)   beliefs and attitudes about back pain,

(3)   function, coping abilities, and

(4)   anticipation that passive treatments instead of active participation will help.

Psychological factors have been conceptualized as maladaptive psychological responses to pain [15] including maladaptive pain coping behaviors, anxiety, and depression as salient risk factors for the development of persistent back pain. [15, 18]

“Orange flags” are those psychological factors may be related to musculoskeletal symptoms but that are considered abnormal (e.g., posttraumatic stress disorder, major depression). “Blue flags” are social and environmental/workplace perceptions (e.g., stressful environment) and “black flags” are factors related to the nature of the work environment (e.g., heavy work without being allowed to modify, infuence from health care providers, family or legislative issues). Thus, social risk factors [19, 20] in general include the individual’s perception of the social environment, including: poor work satisfaction, unsupportive work environment, work stress, and compensation issues. [13–15]

Psychological and social factors can act as barriers to recovery and their risks are increased when more than one is present. [13, 15, 18, 21–25] Each of the “flags” infuences a patient’s response to care, and therefore, may need diferent assessment and interventions. Thus, it is essential that clinicians are able to diferentiate one fag from another. Identifying these factors may help clinicians identify which patients are more at risk of developing persistent pain and disability. These factors may inform decision-making and treatment outcomes [26] and are predictors of outcomes of clinical interventions. Addressing some factors through various cognitive/behavioral interventions has the potential to reduce disability associated with spine pain. [27–30] World Spine Care [31] developed an initiative, the Global Spine Care Initiative (GSCI), which includes biopsychosocial concepts in the model of care, thus incorporates psychological and social factors.

The goals of this narrative review were to:

(1)   provide an overview of psychological and social factors related to low back pain,

(2)   list the psychological and social factors that may infuence common interventions, and

(3)   describe assessments and interventions for psychological and social factors that could be considered in a care pathway for underserved communities.


Psychological and social factors are important for the development and prognosis of spinal pain and disability. These factors also infuence a person’s decision to seek health care, demand extensive investigation, consider themselves disabled, stop working, fle for disability, or fle a legal claim. [13–15, 51–55] However, such options are not available everywhere. These behaviors may amplify the efect of psychological risk factors by reinforcing pain symptoms. It is, therefore, crucial that clinicians assess patients with spine pain and disability for commonly associated psychological and social factors. [75] When psychosocial risk factors have been identifed, each issue should be addressed with an appropriate intervention. These may include: education, patient reassurance, advice to stay active, early return to activity, as well as cognitive behavioral therapy and multidisciplinary rehabilitation where available. [15, 18, 24, 25, 28, 29, 32–35, 53, 57, 71, 76]

      Instruments to investigate psychological and social factors

Psychological and social factors may be difcult to detect because of a lack of instruments or the instruments are not “culture-free”. Patients’ explanatory models and perceptions of illness and well-being vary widely across societies. [77] Defnitions of what is expected from the treatment, what care providers anticipate for coping with pain, and what can be labeled as (mal)adaptive coping will also difer across cultures. Primary care providers need to be educated in the socio-cultural background of their patients and should be able to provide the most effective therapist–patient communication, competent practice and clinical adherence. While many guidelines recommend that health care providers screen for psychological and social risk factors, no validated questions have been proposed. Open-ended questions aimed at screening for depression, catastrophizing, anxiety and stress, function, coping abilities, and patient expectations are recommended. [75]

In high-income communities, various questionnaires have been validated. Examples include: the Patient Health Questionnaire (PHQ) for depression [78, 79]; pain, enjoyment of life and general activity (PEG) for impact of pain on function [80], Fear Avoidance Beliefs Questionnaire (FABQ) for avoidance beliefs regarding work and general activity [81, 82], STarTBack to address fear avoidance, catastrophizing, and other risk factors for chronicity [83], and the Core Outcome Measures Index (COMI) including pain, back and leg, symptom-specifc function, generic well-being, social disability and work disability, along with satisfaction with treatment [84, 85] (see Table 1 in Supplemental File for links to examples of these instruments). While these tools are widely used, they have not been validated in underserved communities. Before implementation, they require ‘cross-cultural adaptation’ (i.e., adapt language and cultural issues to prepare a questionnaire for use in another setting). [86] This process aims at maximizing “semantic, idiomatic, experiential, and conceptual equivalence between the source and target questionnaires”. [87] Thus, there is then a need for further evaluation using the new cross-culturally adapted instrument. [88, 89]

Because of the lack of validated instruments for underserved communities, we must consider clinical practice within the framework of cultural competence. Napier proposes a list of questions to establish cultural and societal context: “‘What do you call this problem?’; ‘What do you believe is the cause of this problem?’’ What course do you expect this problem to take?’’ How serious is it?’; ‘What do you think this problem does inside your body?’; ‘How does this problem afect your body and your mind?’ What do you most fear about this problem?’; ‘What do you most fear about the treatment?”. [77] These aspects consider psychological and social factors [15, 75], patients’ explanatory models and beliefs, depression, catastrophizing, anxiety and stress, function and interference of spine problems with daily activities, coping and control over pain, and expectations about treatment [75] (see Online Resource Appendix for a clinical vignette). Introducing open-ended questions regarding psychological and social factors in the course of the consultation may not prove particularly demanding or conficting. However, assessing the patient’s responses may present some difculties for people with limited health care training or familiarity with psychosocial factors

      Psychological and social flag assessment

Assessment for psychological and social flags (see summary Table 2 in supplemental fle) should be done at the frst visit and screened again at 4 and 6 weeks if the patient has not recovered from back pain. [13, 14] Early identifcation and modifcation of ‘maladaptive’ thoughts and behaviors helps prevent the transition from acute to chronic pain and should be addressed as early as possible. [75] Factors pertaining to the work environment (e.g., blue and black flags) also need to be considered. [19, 20] The social and working environment (e.g., unemployment rate, quality of the welfare system) raise important concerns and need to be included in patient management. [90, 91] Psychological and social predictors of chronic disability should be assessed while taking a patient’s history [15, 92]). The European guidelines for acute and for chronic LBP recommend that psychosocial factors such as work-related factors, psychological distress, patient expectations, and extreme symptoms should be assessed at the frst primary care visit to identify patients at risk of developing chronic disability. [93, 94]

Reviews of clinical guidelines emphasize that clinicians should recognize psychological and social risk factors for chronicity and manage acute LBP patients with early and gradual activation and avoidance of bed rest. [27, 60] For chronic LBP, recommended psychosocial interventions include cognitive behavioral therapies. [57] However, clinician-guided cognitive-behavioral therapies, mindfulness therapy, or multidisciplinary treatments are not readily available in all areas. An approach to be considered in these situations is “psychologically informed practice”. This approach could be a ‘middle way’ between narrowly focused standard physical therapy practice based on biomedical principles and the more cognitive behavioral-oriented approaches originally developed for the treatment of mental illness. [95] The psychologically informed practice approach aims at preventing pain-related activity limitations. Emotional factors, such as anxiety, depression, or anger, that are possibly associated with patients’ beliefs, are addressed as potential obstacles to recovery as they may infuence behavioral responses. Such a practice method builds on the professional expertise of care providers, while integrating specifc and orderly attention to psychological and social factors.

      Health care provider role

Health care providers have an important role in recommending adequate work restrictions and participation. Considered in a wider context, primary care involves all providers delivering the frst-line interventions that most often include physicians, traditional healers and nurses, physical therapists, and other health care providers. Health care providers can contribute to prevent activity and work disability by reassuring patients that activities can be resumed safely, even if pain is still present. [53] Therefore, clinicians need to understand the work context in relation to the capacity and beliefs of the patients. [53] It is important that health care providers are trained and have a strong understanding of psychological and social issues and their impact on patient acceptance and response to care. For example, the Australian Musculoskeletal Education Collaboration training programs incorporate these competencies within their framework. [96, 97]

As noted above, a psychologically informed practice approach aiming at preventing painrelated activity limitations, and building on the professional expertise of care providers [95], may be of particular interest. Listening, reassurance, and information from the physician are important in patient satisfaction and help meet patients’ perceived needs. [98] These needs include the reduction of emotional uncertainty in a situation of stress and vulnerability. [99, 100] In such situations, the clinician should investigate further including patient’s perceptions, reaction pain and its consequences. Symptoms may infuence patients’ perceptions of what might be wrong and their reaction to pain. Therefore, symptom awareness and understanding infuence expectations and satisfaction and contribute to meaningful and acceptable outcomes. [32]


When a patient presents with acute LBP, health care providers should:

(1)   screen for psychosocial flags,

(2)   investigate and discuss irrational or maladaptive beliefs and

(3)   reassure and educate patients.

In the acute phase, one goal is to prevent chronicity, thus should include careful evaluation. [75]

Other treatment goals during the acute phase include:

(1)   improve function,

(2)   modify psychological and social barriers once maladaptive psychological responses to pain have been targeted, and

(3)   multidisciplinary rehabilitation including psychological therapy if available. [65]

Patients with chronic pain may benefit from multidisciplinary biopsychosocial rehabilitation that aims to improve backrelated physical dysfunction, address psychological issues, and targets social- and work-related behaviors. However, the prescription of multidisciplinary biopsychosocial rehabilitation should be informed by the availability of necessary resources. [76] The resources, however, to provide these services are not available in most settings. What is required is appropriate triage and evaluation of available tools and treatments in each setting.

      Strengths and limitations

To the best of our knowledge, this is the frst focused review on psychological and social issues in low back pain in the context of low- and middle-income communities. While these issues have received a great deal of attention in industrialized countries since the emergence of the biopsychosocial model of pain and illness, literature is scarce on these issues in low- and middle-income communities. Limitations include that this was not a systematic review of the literature. All languages and other search engines were not explored, thus some relevant studies may have been missed. Papers were not reviewed for bias or quality. The focus of the review was on low back pain, thus other spine-related issues including other spine regions, functional limitations and spine disorders were not included in this review.


Health care providers have the potential to empower patients to take control of their health outcomes by making them aware of biopsychosocial relationships with their spine pain and disability. Therefore, the patients need to be engaged in establishing treatment goals and negotiating their treatment. Developing psychosocial assessment instruments specifcally for groups with low literacy is of clear interest in the context of medically underserved areas and low- and middle-income countries where psychological and social factors may be difcult to detect. As a consequence, these psychological and social factors may also be poorly taken care of in these locations. If we are to use the instruments we know best, these instruments will require proper crosscultural validations, taking into account the diverse contexts considered by the GSCI. Such developments would contribute to the identifcation of psychological, social or environmental risk factors in these contexts. We know little about these risk factors and even less on how they may be organized into signifcant clusters in other cultures. This development may in turn help devising meaningful interventions allowing to prevent pain-related activity limitations and disability.


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