European Spine Journal 2018 (Sep); 27 (Suppl 6): 901–914 ~ FULL TEXT
Scott Haldeman, Claire D. Johnson, Roger Chou, Margareta Nordin, Pierre Côté, Eric L. Hurwitz, Bart N. Green, Christine Cedraschi et. al.
Department of Epidemiology,
School of Public Health,
University of California Los Angeles,
Los Angeles, CA, USA.
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.
KEYWORDS: Delivery of health care; Evidence-based practice; Quality of health care; Triage
From the FULL TEXT Article:
In the last two decades, there has been a significant
increase in the burden and costs of spinal disorders
throughout the world. This impact has been seen not only
in high-income countries but also in low- and middleincome
countries. [1, 2] Non-communicable diseases such
as spinal disorders are contributing a higher proportion
of the total burden of disease than previously considered.
At the same time in low- and middle-income countries,
minimal health care resources are being expended internally
and through international health care priorities to
reduce the disability associated with spinal disorders. In
high-income countries, such as the USA, there has been
a marked and progressive increase in the cost of health
care for people with spinal disorders with a concomitant
increase in spine-related disability. [3, 4]
Disability and costs attributed to spinal pain are projected
to increase, which is a concern particularly for lowand
middle-income countries where the infrastructure may
be fragile and not equipped to cope with a growing burden.  There is an increasing call to action by leaders
in the spine care community who stress it is essential to
prevent the use of practices that are ineffective, harmful
or wasteful of limited resources.  The concern is that
fragmented and outdated models of care fail to address
widespread misconceptions in the population and among
health professionals about the causes, prognosis, and effectiveness
of different treatments for spinal pain. 
Controlled clinical trials have been the primary tool to
assess the benefits and harms of common interventions for
the management of spinal pain with the assumption that
this will improve outcomes and reduce the costs and disability
associated with spinal disorders. These trials have
been performed in high-income countries, so little is known
about low- and middle-income countries. At the same time,
task forces, government, and professional committees have
reviewed and synthesized the results of this research to
develop clinical practice guidelines. These guidelines have
focused primarily on non-specific or axial low back and
neck pain although guidelines have also been developed to
address specific pathological spinal disorders, such as spinal
stenosis, spondyloarthropathies, scoliosis, and radiculopathy.
Implementation of these guidelines, however, has
proved difficult. [7–9] The difficulty in implementation and
failure of clinicians to follow guidelines in high-income
countries has been attributed to complex issues including
provider and patient behavior, health literacy, legal, and systems/
There are challenges to implementing evidence-based
guidelines in any health care community. In many communities,
health care providers are scarce  or the primary care
clinician or team of providers may not have the experience,
relevant professional training, or resources to implement
evidence-based management for the wide spectrum of spinal
disorders. For low- and middle-income countries, resources
are scarce [11, 12], thus providers may be less likely to have
the skills and resources to manage spine-related concerns.
Patients in these settings present with a full spectrum of
spine-related disorders such as low back, middle back and
neck pain, which might be acute, chronic, and/or episodic
or recurrent and associated with varying degrees of impairment
of function or activities of daily living. The incidence
of chronic diseases in low- and middle-income countries
is higher than in high-income countries. [13, 14] As well,
primary health care could perform better within the care
delivery system in underserved areas. [12, 15] There may
be no imaging or laboratory testing facilities readily available
at the primary care level and advanced imaging and
testing may not be available even at secondary care centers
or district hospitals. 
Some communities have no or few
clinicians that commonly manage spinal disorders, such as
chiropractors, psychologists or physical therapists. There
may be limited access to medical specialists in the fields of
psychiatry, rheumatology, neurology, psychiatry, or spine
surgery at secondary care and even at the tertiary centers
where patients with the most serious spinal pathology are
likely to be referred. There may not be resources available
to manage the complications of the interventions recommended
in guidelines such as gastric bleeding from nonsteroidal
anti-inflammatory drugs (NSAIDs), constipation,
and addiction from opioids, follow-up care and rehabilitation
following surgery and psychiatric and psychological
care that often is associated with chronic pain. Thus, there
is a need to develop a care pathway that could address these
concerns and that could be adapted to the community and
Care pathways are “a complex intervention for mutual
(between patient and clinician) decision-making and organization
of care processes for a well-defined group of patients
during a well-defined period”.  Care pathways have been
proposed as a means of implementing guidelines into specific
clinical settings. A care pathway provides a mechanism
whereby multiple guidelines can be integrated and modified
to adapt to the available professional and physical resources.
They are a means of coordinating health care and to provide
a mechanism for integrating evidence-based health care with
real-world clinical practice. Chawla et al.  describe this
process as having the “goal of using high-quality evidence
for pathway development and affording physician flexibility
in implementation”. Care pathways “are used to reduce variation
(in care), improve the quality of care, and maximize
the outcomes for specific groups of patients”. 
et al.  describe care pathways as being organized by
the stages of care and including the full range of interventions
that may be offered at each stage. They note that pathways
should include all treatments, ranging from primary
prevention to rehabilitative services, that may be offered to
patients and that care pathways should describe steps that
are considered at each stage of care. Whereas most current
spine-related guidelines tend to address specific subgroups
of patients such as non-specific back or neck pain or pathologies
such as stenosis or radiculopathy, a comprehensive care
pathway has the capacity to integrate guidelines for multiple
spinal disorders into a single clinical decision tree and is,
therefore, more applicable in clinical settings with limited
There is an increased interest in developing and evaluating
care pathways for musculoskeletal conditions including
low back pain. [21, 22] However, we are not aware of a
care pathway to guide the management of the full spectrum
of potential presentations of spinal symptoms, concerns or
pathology. This variety includes the most benign questions
requiring a public health message through the most severe
systemic and life-threatening destructive spinal pathologies
while focusing on the most common variations of spinal pain
irrespective of location (i.e., neck, middle back, low back,
arm, or leg symptoms). However, other care pathways may
focus on a particular symptom, such as back pain, or a specific
disorder or disease, resulting in a more narrow approach
to a patient care pathway. The purpose of this study was
to develop a care pathway supported by current evidencebased
guidelines that could apply to any person presenting
with a spine-related concern, especially those who live in
low- and middle-income communities or in underserved
communities in high-income countries. At the same time,
it was felt to be essential to prevent the use of practices that
are ineffective, harmful or wasteful of limited resources and
to satisfy reported concerns that fragmented and outdated
models of care fail to address widespread misconceptions
in the population and among health professionals about the
causes, prognosis, and effectiveness of different treatments
for spinal pain. 
Criteria for care pathway development
Figure 1 continued
The Global Spine Care Initiative (GSCI) steering committee,
primary authors for the GSCI component articles and
guest participants held several meetings to determine the
essential characteristics that were required while building
the pathway.  Criteria used to build the spinal disorders
care pathway were selected from the current literature,
WHO principles, and from a consensus of panelist expertise.
(see Online Resource Figure 1 for guiding principles for
the GSCI Pathway). This project was approved by National
University of Health Sciences Institutional Review Board
(#H-1503). All authors were informed about the nature of
the study and the modified Delphi process and gave written
consent by completing an electronic questionnaire.
The following 4 steps were completed to create a care
Step 1 Determine the broad categories of interventions for spinal disorders
During five face-to-face meetings, the GSCI members used a
consensus process to identify six major intervention categories
recommended by current guidelines for the management
of different categories of spinal disorders:
(2) non-invasive treatment;
(3) invasive treatment;
(4) psychological and social;
(5) prevention and public health; and
(6) specialty care and interdisciplinary/multidisciplinary management. [24–29]
A review of the literature on compression
fractures was included as a case study for spinal
symptoms related to systemic pathology, in part because
many patients with compression fractures can be managed
in a primary spine care setting. The literature on the management
of other serious or systemic disease with spine-related
symptoms (including the inflammatory spondyloarthropathies,
infections and neoplastic disorders) was not reviewed
due to lack of resources. The description of interventions for
these disorders was defined by referral to a specific medical
specialist or tertiary spine center.
Step 2 Grouping of interventions into subcategories for the care pathway
Interventions recommended in the reviewed evidence-based
guidelines were used to develop the care pathway. An extraction
table was created to include the interventions from the
GSCI foundational papers. These were consolidated into subcategories
(1) had similar broad definitions (e.g., reassurance, imaging, non-opioid analgesics, exercise, decompression surgery);
(2) could easily be differentiated based on skills or resources (e.g., manual therapy, complex fusion, cognitive behavioral therapy);
(3) and had similar evidence of effectiveness and harms (e.g., exercise, non-opioid analgesics,
The extraction table was reviewed by the primary
authors for each of the six review articles, the principal investigators,
GSCI scientific secretariat, and other GSCI co-authors
to ensure that the reported content was compatible with the
evidence and met reasonable health care principles. Where
there was disagreement between authors, the final decision to
include an intervention was determined by the primary authors
of the six articles in which the evidence had been reviewed.
Step 3 Link interventions to the GSCI Spinal Disorders Classification system
Content from the intervention categories was linked with
the different presentations as defined by the GSCI Classification
system.  The resulting tables were reviewed by
the GSCI executive team and intervention paper authors for
agreement. Once an agreement was achieved, the tables were
circulated among other members of the GSCI for comment
Step 4 Develop a care pathway for people or patients with symptoms or concerns about spinal disorders
The primary authors of the care pathway (SH, CJ) developed
a seed draft of a care pathway utilizing the tables developed
in Step 3. The care pathway was based on the principles
outlined (see Online Resource Figure 1). Three rounds of
review and revision of the care pathway and the article were
developed after receiving input from other members of the
GSCI executive team and intervention chapter authors.
Finally, input was requested from 70 spine care clinicians
and researchers that included co-authors of the GSCI articles
and individuals selected to ensure that there was both interprofessional
and international representation. Responses
were obtained from 53, six had no comments and felt that
they had not contributed to process, four appeared to have
concerns which precluded them serving as co-authors.
Therefore, 46 participants from 16 countries (Australia,
Botswana, Cameroon, Canada, Chile, France, Ghana, India,
Iran, Kenya, Malaysia, South Africa, Spain, Switzerland,
Turkey, and USA) provided input and agreed to serve as
co-authors of the Care Pathway.
Figure 1 lists the major assessment; non-invasive treatment;
invasive treatment; psychological and social; prevention and
public health; specialty care and interprofessional management
interventions that were extracted from the reviews of
the literature and divided into the six broad intervention categories
described in the methodology. [24–29, 31, 32] Under
each broad category of intervention, the individual interventions
were divided into subsections where the mechanisms
of action, outcomes, costs, and skills necessary to provide
the service are similar. Interventions from the GSCI review
articles are included in this table.
The GSCI care pathway includes five steps that are common
to most clinical decision trees.  The GSCI care pathway
guides the person who has spine-related symptoms or concerns
and the clinician who is consulted through five steps
and four decisions that make up the care pathway in Figure 2.
The following is a description of each step.
Step 1 Awareness
The first step is when an individual with a spine-related
symptom or concern becomes aware (i.e., the person has a
worry that something is or will be wrong with the spine)
and seeks information. The person may request information
from friends, family, or health care personnel, or perform
a search of the media (e.g., internet, magazines, or professional
health care information sources). At this stage of
the care pathway, educational materials and public health
messages about spine-related concerns should include
evidence-based information about risks and prognostic
factors, prevention, self-assessment, and self-management.
Educational messages and programs should provide
adequate information so that the person is informed about
when to consider self-care and when to seek care from
health care personnel.
Step 2 Initial Triage
After considering information in Step 1, the individual
decides whether or not to seek care. Initial triage may be
done by those who have adequate education to read and
understand the triage questions, thus may include the individual
him/herself, friends, family members, health care
workers, or health care providers. Information in the care
pathway screening questions help to determine which major
class of spinal disorder fits the spine-related concern. This
information should differentiate between people with nonspecific
spinal pain and those who are likely to have more
serious pathology requiring more advanced care.
Triage Screening Questions: (1) Are there any
risk factors? (2) Are there any symptoms? (3) If there
are symptoms, do they interfere with function or activities?
If there are minimal or no spine-related symptoms
and the person is looking for information on prevention,
prognosis or self-care, he or she may look for information
or seek advice from a general health care setting.
Examination, further assessment, or interventions beyond
advice, education, and prevention recommendations are
unlikely to be indicated. The majority of concerns in
Class 0 would benefit from information consistent with
current guidelines and do not need active care.
Triage Screening Questions: (1) Is pain acute/
subacute (less than 3 months) or recurrent or chronic
(> 3 months)? (2) Does pain interfere with function or
activities? (3) Are there any neurological deficits? (4)
Are there any signs of serious or systemic pathology (red
Class 1 includes non-specific pain in one or more
spinal regions that is not interfering with activities and
has no neurological symptoms or red flags. Most people
in Class I can self-manage their symptoms. If the person
is not able to self-manage, the person should seek care for
further assistance at a primary care setting ideally from a
provider with knowledge and skills in primary spine care.
Triage Screening Questions: (1) Is pain acute/
subacute (less than 3 months) or recurrent or chronic (>
3 months)? (2) Does pain interfere with function or activities?
(3) Are there any neurological deficits? (4) Are there
any signs of serious or systemic pathology (red flags)?
Class II has non-specific pain in one or more spinal
regions that is interfering with function or activities but
without neurological symptoms or red flags. The person
in this class should seek care in a primary care setting. If
more advanced care is needed, the health care provider
will refer to the appropriate specialty provider.
Triage Screening Questions: (1) Are neurological
symptoms acute (recent) or chronic (longstanding)?
(2) Have the neurological symptoms been getting worse?
(3) Are there any signs of serious or systemic pathology
Class III is when the person has symptoms
or signs consistent with neurological compromise (numbness,
weakness, loss of balance, gait disturbance or any
other symptom or sign that is consistent with a neurological
lesion). The person in this class should seek care
in a primary care setting as soon as possible especially
if the symptoms are progressive or pathologic. If more
advanced care is needed, the health care provider will
refer to secondary or tertiary care.
Triage Screening Questions: (1) Is the deformity
stable? (2) Is the deformity acute (recent) or chronic
(longstanding)? (3) Are there any symptoms related to the
deformity? (4) Are there any signs of serious or systemic
pathology (red flags)?
Class IV has serious bony structural
deformity (e.g., severe scoliosis or congenital bone
changes), fracture, dislocation, or instability. The person
in this class should seek care in a primary care setting.
If symptoms relate to pathology such as acute trauma
with the possibility of fracture, severe and progressive
scoliosis or instability, the person may require secondary
or tertiary care on either emergency or elective basis.
Triage Screening Questions: (1) Is the condition
acute? (2) Is it progressive? (3) Are there any signs of
serious or systemic pathology (red flags)?
Class V has red
flags and spinal symptoms may be associated with potentially
serious or systemic pathology. Depending upon the
situation, the person may be referred to primary care or
may be referred directly to a secondary or tertiary care
setting on either emergency or elective basis.
Step 3 Provider assessment
If the individual triage determines that self-management is
insufficient, a health care provider with knowledge and skills
in spine care should be sought based upon the answers to
the triage questions (e.g., for class I concerns, primary care
is appropriate, for Class V the condition may require emergency
care.) Spine assessment should include:
(1) a detailed
clinical history (e.g., onset, chronicity, severity and impact
of the symptoms on function or activities of daily living);
(2) the use of assessment tools to measure pain severity, disability,
impairment, or other relevant outcomes:
the presence of psychological and social flags;
the presence of red flags (serious pathology);
spinal, neurological and general physical examination; and
(6) appropriate diagnostic imaging or laboratory testing. [25, 27–29, 31, 32]
The history, clinical examination, and other
assessments provide the information for additional triage
and to assign the spine-related concern to a specific class
Step 4 Intervention
Interventions are based upon the previous steps in addition
to the assessment findings, available resources, and patient
preferences. The clinician engages in a conversation to
discuss the benefits, harms, costs, treatment alternatives,
availability of the interventions within the clinical setting
or community and addresses any concerns or questions the
patient may have. Clinicians and patients should consider
recent recommendations from the American College of Physicians
that recommends non-pharmacological treatments be
implemented first.  A shared decision is made regarding
the most appropriate treatment plan and is agreed upon by
the patient/family and the clinician/interdisciplinary team
as recommended under WHO principles [35–37] and care
pathway principles.  The intervention is then initiated
with emphasis that the patient must play an active role in his/
her own health decisions.
Step 5 Outcomes
After the recommended interventions have been administered,
completed, or discontinued, the clinician conducts a
reassessment to determine the outcome of the intervention.
Each patient presentation is unique and may range from
benign to life-threatening. Therefore, the frequency and timing
of assessments are based on the patient’s condition and
response to care. Assessments should be decided on using
a joint-decision-making process between the patient and
health care provider. The follow-up may or may not include
additional relevant assessment (e.g., history, examination,
or additional testing). In most cases, there are three possible
If the person has responded favorably, their questions
have been answered, and they no longer have a need for
further information or other interventions, the person is
If the person has responded somewhat favorably but
requests further treatment or information, then a further
assessment may be needed to determine whether he or
she now falls into the same or less severe class of the
GSCI classification system. If another class is assigned,
the clinician will follow the steps as outlined above for
If the person has not responded favorably in a reasonable
timeframe or has noted increased symptoms or disability,
then further assessment may be needed to determine
whether he or she now falls into the same or more severe
class. If in the same class, it is reasonable to consider
different interventions for the same class and subclass
from the table of recommended evidence-based interventions.
If the patient has increased symptoms he or
she may fall within a different spinal disorders class and
require a different set of intervention options or referral
to a higher level of spine care. If the patient has tried
all available evidence-based interventions for the class
and subclass that best describes his or her presentation,
then consideration should be given to reassessment of
the patient needs to identify other possible underlying
reasons for poor response to care that may be outside
of the purview of the health care system. Possible additional
follow-up actions could include discharging the
patient for home-care or referring to a tertiary spine care
setting for multidisciplinary care, if these have not been
Several caveats must be considered when implementing the
Interventions are dependent upon presentation, clinical
signs and symptoms, assessment of the evidence,
patient preferences, affordability of the interventions,
availability and clinician knowledge/skill. Therefore,
each individual presentation of a person with a spinerelated
concern and the clinical and cultural setting
of the presentation should be considered unique. Recommendations
should be consistent with the patient
presentation and available resources.
The evidence and indications for specific interventions
are determined from the six GSCI intervention
articles and subsequently published evidence-based
guidelines. Evidence, however, is not static and, as
evidence evolves, the care pathway recommendations
should evolve with new knowledge.
The evidence for a particular intervention may be
stronger for one region of the spine than for other
regions. For example, the evidence for interventions
of any kind for thoracic pain is very limited. Therefore,
the development of treatment options may need
extrapolation of the evidence from one spinal region
to other spinal regions. This should be consistent with
evidence which would suggest that the extrapolation is
or is not appropriate.
In the absence of red flags that may indicate the presence
of a progressive disability or life-threatening
diseases, interventions for each class should be
viewed as treatment options. This is especially true
when benefits, harms, available resources, and costs
are similar. Selection of specific interventions should
be determined by available resources, clinical knowledge,
GSCI class of spinal disorder, the training and
skill of the clinician providing care and patient preference.
Education of the public and individuals should include
information on benefits, risk, and costs of all interventions
irrespective of the class of spinal disorders.
A person may have more than one spinal disorder and
therefore may be classified in more than one class
(e.g., one class for neck pain and a different class for
low back pain). From the provider point of view, the
selection of interventions should match the evidencebased
recommendations for the class of spinal disorders
which may be different for different regions of the
Management should be prioritized to the area of the
spine that is the greatest of the individual’s concern
or which requires the most immediate intervention to
prevent progression of the condition or further harm
to the patient.
With some exceptions, spinal disorders are dynamic
health conditions. Therefore, their classification and
management are also dynamic. An individual can move
within and between classes as the condition evolves.
Therefore, clinicians should monitor patients and if
needed, adjust the classification during the evolution
of each patient’s symptoms, impairment, or disability.
The selected interventions should be consistent with
the most current classification of spinal disorders and
not necessarily with the initial classification.
In the majority of cases of non-specific spinal pain,
management can be accomplished by a clinician with
the skills and knowledge found within a primary spine
care setting and it may not be necessary to consider
referral to multiple clinicians or to secondary or tertiary
spine care settings.  However, if multiple
clinicians are involved in the care, at all stages of the
care pathway, there should be communication among
the team members and with the individual seeking care
and his or her family.
In the case where there are multiple clinicians involved
in care, there must be close coordination of the roles, a
common goal for the interventions and sequencing of
activities of each member of the multidisciplinary care
team to avoid duplication, conflicting or unnecessary
delays in services.
Spine care should not be considered a vertical or standalone
service as this would risk disruption or fragmentation
of already under-resourced health systems,
especially in low- and middle-income countries. As
noted by Green et al.  and Cedrashi et al. , spinal
symptoms are commonly associated with a wide variety
of co-morbid diseases and psychological and social
factors that often have to be managed at the same time
as the spinal symptoms. The current thinking is that
initiatives should be integrated into health systems in
low- and middle-income countries. 
This is the first attempt by an interprofessional and international
task force to create a care pathway that may accommodate
all individuals presenting with spine-related symptoms,
concerns, or risk factors. The proposed care pathway
is based on evidence-based practices and patient’s expectations
and allows the clinician a level of flexibility based
on available resources. [17, 18] We hope that this pathway
provides a consistent approach to the provision of health care
services while at the same time considering available health
care resources in underserved communities.
The GSCI Care Pathway is consistent with a proposed
approach to low back pain.  This approach uses current
evidence to guide practice and focuses on the importance of
public health policy, self-care and education of the general
population, patients and clinicians concerning prevention
strategies and expectation from interventions. [5, 6] It is
insufficient to focus only on low back pain. Instead, we must
also include neck concerns and other spine-related symptoms
and the higher incidence of untreated serious spinal
pathology that may present in underserved communities.
We recommend a care pathway with five sequential
steps irrespective of the clinical setting. Our hope is that
its simplicity may facilitate communication between clinicians,
patients, and their communities. The pathway aims to
reduce confusion by clarifying the most appropriate manner
in which a person with spinal symptoms should be managed.
Improved communication allows for interventions
that emphasize appropriate self-care and avoids reliance
on unnecessary treatments. Our assumption is that common
understanding and application of an evidence-based
approach to spinal disorders will lead to improved outcomes
and less costly care.
The care pathway, however, requires that clinicians who
manage people with spine-related symptoms have the knowledge,
skills, and resources to apply evidence-based care. The
pathway provides a guide to what care should be considered
in primary, secondary and tertiary spine care settings.  The pathway does not require high cost, high technology
interventions for the majority of people who present
with spinal concerns. In this way, the care pathway may be
implemented in most clinical settings, but especially in communities
with limited resources such as in low- and middleincome
countries. For primary, secondary and tertiary settings
that do not have providers with the knowledge, skills,
and resources to apply evidence-based spine care, it may be
necessary to establish a training program.
The care pathway may be used by clinicians from different
clinical disciplines and different specialties or if a clinician
has limited training in managing of spinal disorders.
The care pathway was developed so it could be displayed in
a chart or easily adapted into an electronic medical record
or educational tool. A clinician should be able to review the
pathway and quickly determine the class or subclass, the
assessments, and the relevant evidence-based interventions.
The clinician can then select which recommended interventions
are available in the current clinical setting and then
review the options with the patient and/or family members to
describe the benefits, harms, and costs of the different intervention
options and incorporate the patient’s preferences.
This approach is consistent with the WHO principles of
interprofessional “collaborative practice-ready” health care
. The care pathway also follows the WHO principles of
incorporating integrated, people-centered health services,
which is considered an essential element of continuity of
care, defragmenting of health systems and improving health
care outcomes by the WHO. [35–37]
This care pathway was developed to be implemented in
communities with varying resource capacities, available
health care providers, and public health personnel. The triage
process helps to differentiate people who may not require
professional spine care from those who can be managed with
available resources in a health care setting, and those who
require referral to a health care setting with higher levels of
resources. Low-income communities may consider prioritizing
interventions within the options recommended for each
class to conform to the available resources including the
relative costs of, and availability of the treatment options.
Strengths and limitations
The GSCI care pathway was developed by an international,
interprofessional team of clinicians, scientists, and stakeholders
from high-, middle- and low-income countries and
based on a model recommended by the WHO which includes
person-centered health services. [35–37] The pathway considers
available resources, clinician skills, and patient preferences
and focusses on evidence-based interventions. It is
consistent with, and incorporates currently used guidelines
and has the capacity to evolve as new guidelines are published.
The pathway was developed to accommodate all
people who may present with spine-related symptoms or
concerns, is not limited to a specific symptom (i.e., pain) or
spinal region (low back or neck) or chronicity and does not
require a pathological diagnosis for axial spinal pain. This
pathway incorporates psychological and social factors, takes
into consideration public health interventions and addresses
people who present with neurological symptoms, structural
pathology, serious and life-threatening systemic pathology.
These features should facilitate the implementation of this
pathway in a wide variety of health care settings.
Limitations include that not all of the 68 GSCI experts
participated in the development of the care pathway and
therefore is subject to bias. Like any care pathway, its
value will depend on field testing to determine whether it
can be implemented in communities with different cultures
and resources. The care pathway described here has not yet
been tested for validity and reliability. It is also necessary
to determine whether it can be easily administered and utilized
by all stakeholders including patients and clinicians.
Resources and the implementation of the model of care
are described elsewhere. [38, 41] The final determination
of the value of this care pathway will be its acceptance
by patients and clinicians with different expectations or
training, the ability to implement the care pathway and
the determination as to whether, when implemented, it
has the desired outcomes of reduced costs and disability
associated with spinal disorders.
This is the first international and interprofessional attempt
to develop a care pathway for the management of any person
presenting with spine-related symptoms or concerns
that incorporate the recommendations from multiple evidence-
based guidelines. The decision steps are personcentered,
community-based and consistent with recommendations
established by the WHO, evidence-based and
limited to five steps. This care pathway will need to be
field tested in different cultural and resource communities
to determine its utility.
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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
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,
SpineHealth.com. Book Royalties, McGraw Hill. Travel expense reimbursement—
CMCC Board. CDJ is president of Brighthall Inc; she
is an NCMIC Board of Director; however, neither she nor NCMIC
board makes 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. RC declares funding from
AHRQ to conduct systematic reviews on treatments for low back pain
within last 2 years. Honoraria for speaking at numerous meetings of
professional societies and non-profit groups on topics related to low
back pain (no industry sponsored talks). 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. 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 Cochair,
World Spine Care. 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. EAc
declares grants: Depuy Synthes Spine, Medtronic; Speaker’s Bureau:
AOSpine, Zimmer Biomet. DKG declares travel expenses: CMCC to
present at the WSC Spine Conference in Botswana. OB declares he is
a consultant for: Pacira Pharmaceuticals, Inc. Palladian Health. Travel
expenses: World Spine Care. Stipend: World Spine Care. PB declares
contribution to salary for Global Musculoskeletal Alliance (G-MUSC),
The Bone and Joint Decade work. JMC declares Government Grant
ESPY 1281/15. CG declares travel expenses: Palmer College to GSCI
meetings. Consultant: American Chiropractic Association, Spine IQ,
Healthwise, Quality Insights of Pennsylvania, RAND Co.; Prezacor,
Inc. (Stock Options). PCORI (Board Member). Grants: Collaborative
Care for Veterans with Spine pain and Mental Health Issues. NIH/
Kiernan Chiropractic Care in Rehabilitation at Crotched Mountain:
Crotched Mountain Private Sector Integrated Chiropractic Study N/A.
NCMIC Foundation Chiropractic services, Assessment of Chiropractic
Treatment for Low Back Pain; RAND Subcontract, Department of
Defense Prime Award #W81XWH-11-2-017 Sub #9920110071. MH
declares travel support from World Spine Care. JM declares general
research resources from USF Research Center. Research grants from
funding agencies: FEMA, US Department of Homeland Security
(EMW-2013-FP-00723). Palladian Health Advisory board: Clinical
Policy and Advisory Board,. Intellectual property rights: Inventor of
Web-based system to deliver exercise (Employer - USF: copyright
holder). TM declares Fellowship grant-Medtronics. JM declares WSC
Board Member. EM declares AO Spine Africa Faculty courses - honorarium.
GO declares he is a consultant and receives travel support as
Clinic Director, World Spine Care. KR declares funding to UOIT from
Skoll Foundation, NCMIC Foundation through World Spine Care. HR
declares funding to UOIT from Skoll Foundation, NCMIC Foundation
through World Spine Care. ES declares funding from Ba?kent
University Research Fund. LV declares funding to UOIT from Skoll
Foundation and NCMIC Foundation through World Spine Care. WW
declares Palladian Health, Clinical Policy Advisory Board member.
HY declares funding to UOIT from Skoll Foundation, NCMIC Foundation
through World Spine Care, the remaining authors declare that
they have no conflict of interest.
Hurwitz EL, Randhawa K, Yu H, Cote P, Haldeman S (2018)
The Global Spine Care Initiative: a summary of the global burden of low back and
neck pain studies.
Eur Spine J. https ://doi.org/10.1007/s0058 6-017-5432-9
Hurwitz EL, Randhawa K, Torres P, Yu H, Verville L, Hartvigsen
J, et al (2017)
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. https ://doi.org/10.1007/s0058 6-017-5393-z
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 2008 (Feb 13); 299 (6): 656–664
Dieleman JL, Baral R, Birger M, et al.
US Spending on Personal Health Care and Public Health, 1996-2013
JAMA 2016 (Dec 27); 316 (24): 2627-2646
Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J et al.
What Low Back Pain Is and Why We Need to Pay Attention
Lancet. 2018 (Jun 9); 391 (10137): 2356–2367
Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P.
Low Back Pain: A Call For Action
Lancet. 2018 (Jun 9); 391 (10137): 2384–2388
Bishop PB, Wing PC.
Compliance with Clinical Practice Guidelines in Family
Managing Worker's Compensation Board Patients with Acute Lower Back Pain
Spine J 2003 (Nov); 3 (6): 442–450
Bishop PB, Wing PC (2006)
Knowledge transfer in family physicians managing patients with acute low back pain:
a prospective randomized control trial.
Spine J 6(3):282–288
Briggs AM, Towler SC, Speerin R, March LM (2014)
Models of care for musculoskeletal health in Australia: now more than ever to drive
evidence into health policy and practice.
Aust Health Rev 38(4):401–405
Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D et al
Task shifting for non-communicable disease management in low and middle income
countries—a systematic review.
PLoS ONE 9(8):e103754
Mills A (2014)
Health care systems in low-and middle-income countries.
N Engl J Med 370(6):552–557
Veillard J, Cowling K, Bitton A, Ratcliffe H, Kimball M, Barkley
S et al (2017)
Better measurement for performance improvement in low-and middle-income countries:
the Primary Health Care Performance Initiative (PHCPI) experience of conceptual
framework development and indicator selection.
Milbank Q 95(4):836–883
Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K
The burden and costs of chronic diseases in low-income and middle-income countries.
The Lancet 370(9603):1929–1938
Beveridge M, Howard A (2004)
The burden of orthopaedic disease in developing countries.
J Bone Joint Surg Am 86-A(8):1819–1822
Bitton A, Ratcliffe HL, Veillard JH, Kress DH, Barkley S, Kimball
M et al (2017)
Primary health care as a foundation for strengthening health systems in
low-and middle-income countries.
J Gen Intern Med 32(5):566–571
Cherkin DC, Deyo RA, Wheeler K, Ciol MA (1994)
Physician variation in diagnostic testing for low back pain. Who you see is what you get.
Arthritis Rheumatol 37(1):15–22
Schrijvers GHA, Huiskes N (2012)
The care pathway: concepts and theories: an introduction.
Int J Integr Care 12:e192
Chawla A, Westrich K, Matter S, Kaltenboeck A, Dubois R (2016)
Care pathways in US healthcare settings: current successes and limitations, and future challenges.
Am J Manag Care 22(1):53–62
Lawal AK, Rotter T, Kinsman L, Machotta A, Ronellenfitsch U,
Scott SD et al (2016)
What is a clinical pathway? Refinement of an operational definition to identify clinical
pathway studies for a Cochrane systematic review.
BMC Med 14(1):35
Cavlan O, Dash P, Drouin J, Fountaine T, Riahi F (2011)
Using care pathways to improve health systems.
Health Int 11:6–17
Fourney DR, Dettori JR, Hall H, Härtl R, McGirt MJ, Daubs MD
A systematic review of clinical pathways for lower back pain and introduction of the
Saskatchewan Spine Pathway.
Murray CJ, Richards MA, Newton JN, Fenton KA, Anderson
HR, Atkinson C et al (2013)
UK health performance: findings of the Global Burden of Disease Study 2010.
The Lancet 381(9871):997–1020
Johnson CD, Haldeman S, Nordin M, Chou R, Côté P, Hurwitz EL et al (2018)
The Global Spine Care Initiative: Methodology, Contributors, and Disclosures
European Spine Journal 2018 (Sep); 27 (Suppl 6): 786–795
Acaroglu E, Mmopelwa T, Yuksel S, Ayhan S, Nordin M, Randhawa
K, et al (2017)
The Global Spine Care Initiative: a consensus process to develop and validate a stratification
scheme for surgical care of spinal disorders as a guide for improved resource utilization
in low- and middle-income communities.
Eur Spine J. https ://doi.org/10.1007/s0058 6-017-5332-z
Acaroglu E, Nordin M, Randhawa K, Chou R, Cote P, Mmopelwa T et al (2018)
The Global Spine Care Initiative: A Summary of Guidelines on Invasive Interventions for the Management
of Persistent and Disabling Spinal Pain in Low- and Middle-income Communities
European Spine Journal 2018 (Sep); 27 (Suppl 6): 870–878
Ameis A, Randhawa K, Yu H, Cote P, Haldeman S, Chou R,
et al (2017)
The Global Spine Care Initiative: a review of reviews and recommendations for
the non-invasive management of acute osteoporotic vertebral compression fracture
pain in low- and middle-income communities.
Eur Spine J. https ://doi.org/10.1007/s0058 6-017-5273-6
Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD (2009)
The Global Spine Care Initiative: A Narrative Review of Psychological and Social Issues in Back Pain
in Low- and Middle-income Communities
European Spine Journal 2018 (Sep); 27 (Suppl 6): 823–837
Chou R, Cote P, Randhawa K, Torres P, Yu H, Nordin M et al (2017)
The Global Spine Care Initiative: Applying Evidence-based Guidelines on the Non-invasive
Management of Back and Neck Pain to Low- and Middle-income Communities
European Spine Journal 2018 (Sep); 27 (Suppl 6): 851–860
Green BN, Johnson CD, Haldeman S, Kane EJ, Clay MB, Griffith E et al (2018)
The Global Spine Care Initiative: Public Health and Prevention Interventions for Common
Spine Disorders in Low- and Middle-income Communities
European Spine Journal 2018 (Sep); 27 (Suppl 6): 838–850
Haldeman S., Johnson C.D., Chou R. et al.
The Global Spine Care Initiative: Classification System for Spine-related Concerns
European Spine Journal 2018 (Sep); 27 (Suppl 6): 889–900
Nordin M, Randhawa K, Torres P, Yu H, Haldeman S, Brady O, et al (2018)
The Global Spine Care Initiative: A Systematic Review for the Assessment of Spine-related
Complaints in Populations with Limited Resources and in Low- and Middle-income Communities
Eur Spine J. https ://doi.org/10.1007/s0058 6-017-5446-3
Green BN, Johnson CD, Haldeman S, Griffith E, Clay MB, Kane
EJ et al (2018)
A Scoping Review of Biopsychosocial Risk Factors and Co-morbidities for Common Spinal Disorders
PLoS One. 2018 (Jun 1); 13 (6) :e0197987
Kamper SJ, Apeldoorn A, Chiarotto A, Smeets R, Ostelo R, Guzman
J et al. (2015)
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain:
Cochrane systematic review and
Qaseem A, Wilt TJ, McLean RM, Forciea MA;
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530
World Health Organization (2010)
Framework for action on interprofessional education and collaborative practice.
World Health Organization, Geneva.
http://www.who.int/hrh/resou rces/framework_actio n/en/
Organization WH (2016)
Framework on integrated, peoplecentred health services.
Report by the Secretariat, p 18. WHO, Geneva.
Organization WH (2013)
Transforming and scaling up health professionals’ education and training:
World Health Organization guidelines 2013.
World Health Organization
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
European Spine Journal 2018 (Sep); 27 (Suppl 6): 925–945
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 lowand middle-income countries.
Best Pract Res Clin Rheumatol 28(3):377–393
Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM.
Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions
Lancet. 2018 (Jun 9); 391 (10137): 2368–2383
Kopansky-Giles D, Johnson CD, Haldeman S, Chou R, Côté P, Green BN, Nordin M et al (2018)
The Global Spine Care Initiative: Resources to Implement a Spine Care Program
European Spine Journal 2018 (Sep); 27 (Suppl 6): 915–924
Return to GLOBAL BURDEN OF DISEASE
Return to CHIROPRACTIC CARE FOR VETERANS