The Global Burden of Disease
The Global Spine Care Initiative

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The Global Burden of Disease

Global, Regional, and National Burden of Neck Pain in the General Population, 1990-2017:
Systematic Analysis of the Global Burden of Disease Study 2017

British Medical Journal 2020 (Mar 26);   368:   m791 ~ FULL TEXT

Neck pain is a public health issue in general populations gobally, but varies considerably between countries. Improving health data on all musculoskeletal conditions such as neck pain in all countries and regions is strongly suggested for improving the Global Burden of Disease estimates. Although the age standardised point prevalence, annual incidence, and years lived with disability from neck pain did not change between 1990 and 2017, its burden remains high, with middle aged men and women particularly at risk. Increasing population awareness about neck pain and its risk factors as well as the importance of early detection and management is warranted to reduce the future burden of this condition.

Physical Rehabilitation Needs per Condition Type:
Results from the Global Burden of Disease study 2017

Archives of Physical Medicine and Rehabilitation 2020 (Feb 5) [Epub] ~ FULL TEXT

According to data from the GBD 2017, world’s physical rehabilitation needs per-capita are growing for all major groups of conditions germane to physical rehabilitation, with musculoskeletal & pain conditions currently accounting for over half of those needs. Countries of varying income level have different typologies and evolutionary trends in their rehabilitation needs. This paper shows that estimates from the GBD study can be used to identify the current typology of physical rehabilitation need and their changing trends over time. This type of estimates can be one indicator for an informed planning of the physical rehabilitation resources, services, and research to meet the expanding country-specific and global needs for rehabilitation.

The Global Burden of Musculoskeletal Pain - Where to From Here?
Am J Public Health. 2019 (Jan);   109 (1):   35–40 ~ FULL TEXT

To summarize the current understanding of the global burden of musculoskeletal pain-related conditions, consider the process of evidence generation and the steps to generate global pain estimates, identify key gaps in our understanding, and propose an agenda to address these gaps, we performed a narrative review. In the 2010 Global Burden of Disease Study (GBD), which broadened the scope of musculoskeletal conditions that were included over previous rounds, low back pain imposed the highest disability burden of all specific conditions assessed, and subsequent GBD reports further reinforce the size of this burden. Over the past decade, the GBD has produced compelling evidence of the leading contribution of musculoskeletal pain conditions to the global burden of disability, but this has not translated into global health policy initiatives. However, system- and service-level responses to the disease burden persist across high-, middle-, and low-income settings. There is a mismatch between the burden of musculoskeletal pain conditions and appropriate health policy response and planning internationally that can be addressed with an integrated research and policy agenda.

Global, Regional, and National Burden of Migraine and Tension-type Headache,
1990-2016: A Systematic Analysis for the Global Burden of Disease Study 2016

Lancet Neurol. 2018 (Nov);   17 (11):   954–976 ~ FULL TEXT

Almost three billion individuals were estimated to have a migraine or tension-type headache in 2016: 1·89 billion (95% uncertainty interval [UI] 1·71–2·10) with tension-type headache and 1·04 billion (95% UI 1·00–1·09) with migraine. However, because migraine had a much higher disability weight than tension-type headache, migraine caused 45·1 million (95% UI 29·0–62·8) and tension-type headache only 7·2 million (95% UI 4·6–10·5) years lived with disability (YLDs) globally in 2016. The headaches were most burdensome in women between ages 15 and 49 years, with migraine causing 20·3 million (95% UI 12·9–28·5) and tension-type headache 2·9 million (95% UI 1·8–4·2) YLDs in 2016, which was 11·2% of all YLDs in this age group and sex. Age-standardised DALYs for each headache type showed a small increase as SDI increased.

Global, Regional, and National Incidence, Prevalence, and Years Lived With
Disability for 328 Diseases and Injuries for 195 Countries, 1990-2016:
A Systematic Analysis for the Global Burden of Disease Study 2016

Lancet. 2017 (Sep 16);   390 (10100):   1211–1259 ~ FULL TEXT

The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised years lived with disability (YLD) rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.

Global, Regional, and National Disability-adjusted Life-years (DALYs) for 333 Diseases
and Injuries and Healthy Life Expectancy (HALE) for 195 Countries and Territories, 1990–2016:
A Systematic Analysis for the Global Burden of Disease Study 2016

Lancet. 2017 (Sep 16);   390 (10100):   1260–1344 ~ FULL TEXT

At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support.

The Contribution of Musculoskeletal Disorders in Multimorbidity:
Implications for Practice and Policy

Best Pract Res Clin Rheumatol. 2017 (Apr);   31 (2):   129–144 ~ FULL TEXT

People frequently live for many years with multiple chronic conditions (multimorbidity) that impair health outcomes and are expensive to manage. Multimorbidity has been shown to reduce quality of life and increase mortality. People with multimorbidity also rely more heavily on health and care services and have poorer work outcomes. Musculoskeletal disorders (MSDs) are ubiquitous in multimorbidity because of their high prevalence, shared risk factors, and shared pathogenic processes amongst other long-term conditions. Additionally, these conditions significantly contribute to the total impact of multimorbidity, having been shown to reduce quality of life, increase work disability, and increase treatment burden and healthcare costs. For people living with multimorbidity, MSDs could impair the ability to cope and maintain health and independence, leading to precipitous physical and social decline. Recognition, by health professionals, policymakers, non-profit organisations, and research funders, of the impact of musculoskeletal health in multimorbidity is essential when planning support for people living with multimorbidity.

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

Lancet. 2016 (Oct 8);   388 (10053):   1545–1602 ~ FULL TEXT

Ageing of the world's population is increasing the number of people living with sequelae of diseases and injuries. Shifts in the epidemiological profile driven by socioeconomic change also contribute to the continued increase in years lived with disability (YLDs) as well as the rate of increase in YLDs. Despite limitations imposed by gaps in data availability and the variable quality of the data available, the standardised and comprehensive approach of the GBD study provides opportunities to examine broad trends, compare those trends between countries or subnational geographies, benchmark against locations at similar stages of development, and gauge the strength or weakness of the estimates available.

Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability
for 301 Acute and Chronic Diseases and Injuries in 188 Countries, 1990-2013:
A Systematic Analysis for the Global Burden of Disease Study 2013

Lancet. 2015 (Aug 22);   386 (9995):   743–800 ~ FULL TEXT

Disease and injury were highly prevalent; only a small fraction of individuals had no sequelae. Comorbidity rose substantially with age and in absolute terms from 1990 to 2013. Incidence of acute sequelae were predominantly infectious diseases and short-term injuries, with over 2 billion cases of upper respiratory infections and diarrhoeal disease episodes in 2013, with the notable exception of tooth pain due to permanent caries with more than 200 million incident cases in 2013. Conversely, leading chronic sequelae were largely attributable to non-communicable diseases, with prevalence estimates for asymptomatic permanent caries and tension-type headache of 2·4 billion and 1·6 billion, respectively. The distribution of the number of sequelae in populations varied widely across regions, with an expected relation between age and disease prevalence. YLDs for both sexes increased from 537·6 million in 1990 to 764·8 million in 2013 due to population growth and ageing, whereas the age-standardised rate decreased little from 114·87 per 1000 people to 110·31 per 1000 people between 1990 and 2013. Leading causes of YLDs included low back pain and major depressive disorder among the top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the main drivers of increases were due to musculoskeletal, mental, and substance use disorders, neurological disorders, and chronic respiratory diseases; however HIV/AIDS was a notable driver of increasing YLDs in sub-Saharan Africa. Also, the proportion of disability-adjusted life years due to YLDs increased globally from 21·1% in 1990 to 31·2% in 2013.

The Burden of Disease in Older People and Implications for Health Policy and Practice
Lancet 2015 (Feb 7);   385 (9967):   549–562 ~ FULL TEXT

23% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (≥60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, and sensory, respiratory, and infectious disorders. The leading contributors to disease burden in older people are cardiovascular diseases (30·3% of the total burden in people aged 60 years and older), malignant neoplasms (15·1%), chronic respiratory diseases (9·5%), musculoskeletal diseases (7·5%), and neurological and mental disorders (6·6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. Primary prevention in adults aged younger than 60 years will improve health in successive cohorts of older people, but much of the potential to reduce disease burden will come from more effective primary, secondary, and tertiary prevention targeting older people. Obstacles include misplaced global health priorities, ageism, the poor preparedness of health systems to deliver age-appropriate care for chronic diseases, and the complexity of integrating care for complex multimorbidities. Although population ageing is driving the worldwide epidemic of chronic diseases, substantial untapped potential exists to modify the relation between chronological age and health. This objective is especially important for the most age-dependent disorders (ie, dementia, stroke, chronic obstructive pulmonary disease, and vision impairment), for which the burden of disease arises more from disability than from mortality, and for which long-term care costs outweigh health expenditure. The societal cost of these disorders is enormous.

The Global Burden of Other Musculoskeletal Disorders:
Estimates From the Global Burden of Disease 2010 Study

Ann Rheum Dis. 2014 (Aug);   73 (8):   1462–1469 ~ FULL TEXT

Global prevalence of other MSK was 8.4% (95% uncertainty interval (UI) 8.1% to 8.6%). DALYs increased from 20.6 million (95% UI 17.0 to 23.3 million) in 1990 to 30.9 million (95% UI 25.8 to 34.6 million) in 2010. The burden of other MSK increased with age. Globally, other MSK disability burden (YLD) ranked sixth.

The Global Burden of Neck Pain:
Estimates from the Global Burden of Disease 2010 study

Ann Rheum Dis. 2014 (Jul);   73 (7):   1309–1315 ~ FULL TEXT

The global point prevalence of neck pain was 4.9% (95% CI 4.6 to 5.3). Disability-adjusted life years (DALYs) increased from 23.9 million (95% CI 16.5 to 33.1) in 1990 to 33.6 million (95% CI 23.5 to 46.5) in 2010. Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, neck pain ranked 4th highest in terms of disability as measured by YLDs, and 21st in terms of overall burden.

The Global Burden of Low Back Pain:
Estimates from the Global Burden of Disease 2010 study

Ann Rheum Dis. 2014 (Jun);   73 (6):  968–974 ~ FULL TEXT

Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden disability-adjusted life years (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age.

A Time for Action: Opportunities for Preventing the Growing Burden and Disability
from Musculoskeletal Conditions in Low- and Middle-Income Countries

Best Pract Res Clin Rheumatol. 2014 (Jun);   28 (3):   377–393 ~ FULL TEXT

Musculoskeletal (MSK) conditions cause an enormous global burden, and this is dramatically increasing in developing countries, particularly due to rapidly ageing populations and increasing obesity. Many of the global non-communicable disease (NCD) initiatives need to expand beyond the traditional 'top four' NCD groups by incorporating MSK diseases. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. A better inclusion of MSK conditions will avoid doubling of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Other key opportunities for action include the following: ensuring the principles of 'development effectiveness' are met; strengthening leadership and commitment; building the research, information and evidence base; and reducing the incidence and disability of MSK conditions through better prevention. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.

The Global Burden of Occupationally Related Low Back Pain:
Estimates From the Global Burden of Disease 2010 Study

Ann Rheum Dis. 2014 (Jun);   73 (6):   975–981 ~ FULL TEXT

Worldwide, LBP arising from ergonomic exposures at work was estimated to cause 21.7 million disability-adjusted life years (DALYs) in 2010. The overall population attributable fraction was 26%, varying considerably with age, sex and region. 62% of LBP DALYs were in males-the largest numbers were in persons aged 35-55 years. The highest relative risk (3.7) was in the agricultural sector. The largest number of DALYs occurred in East Asia and South Asia, but on a per capita basis the biggest burden was in Oceania. There was a 22% increase in overall LBP DALYs arising from occupational exposures between 1990 and 2010 due to population growth; rates dropped by 14% over the same period.

Burden of Disability Due to Musculoskeletal (MSK) Disorders
Best Pract Res Clin Rheumatol. 2014 (Jun);   28 (3):   353–366 ~ FULL TEXT

This chapter summarises the global and regional prevalence, disability (Years Lived with Disability (YLDs)) and overall burden (Disability Adjusted Life Years (DALYs)) and costs for the common musculoskeletal disorders including low back and neck pain, hip and knee osteoarthritis, rheumatoid arthritis, gout, and a remaining combined group of other MSK conditions. The contribution of the role of pain in disability burden is introduced. Trends over time and predictions of increasing MSK disability with demographic changes are addressed and the particular challenges facing the developing world are highlighted.

The Global Burden of Musculoskeletal Conditions for 2010:
An Overview of Methods

Ann Rheum Dis. 2014 (Jun);   73 (6):   982–989 ~ FULL TEXT

The objective of this paper is to provide an overview of methods used for estimating the burden from musculoskeletal (MSK) conditions in the Global Burden of Diseases 2010 study. It should be read in conjunction with the disease-specific MSK papers published in Annals of Rheumatic Diseases. Burden estimates (disability-adjusted life years (DALYs)) were made for five specific MSK conditions: hip and/or knee osteoarthritis (OA), low back pain (LBP), rheumatoid arthritis (RA), gout and neck pain, and an 'other MSK conditions' category. For each condition, the main disabling sequelae were identified and disability weights (DW) were derived based on short lay descriptions. Mortality (years of life lost (YLLs)) was estimated for RA and the rest category of 'other MSK', which includes a wide range of conditions such as systemic lupus erythematosus, other autoimmune diseases and osteomyelitis.

Years Lived with Disability (YLDs) for 1160 Sequelae of 289 Diseases and
Injuries 1990-2010: A Systematic Analysis for the
Global Burden of Disease Study 2010

Lancet. 2012 (Dec 15);   380 (9859):   2163–2196 ~ FULL TEXT

Rates of years lived with disability (YLD) per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.

A Comparative Risk Assessment of Burden of Disease and Injury Attributable to
67 Risk Factors and Eisk Factor Clusters in 21 Regions, 1990-2010:
A Systematic Analysis for the Global Burden of Disease Study 2010

Lancet. 2012 (Dec 15);   380 (9859):   2224–20260 ~ FULL TEXT

In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure.

Disability-adjusted Life Years (DALYs) for 291 Diseases and Injuries in
21 Regions, 1990-2010: A Systematic Analysis for the
Global Burden of Disease Study 2010

Lancet. 2012 (Dec 15);   380 (9859):   2197–2223 ~ FULL TEXT

Global disability-adjusted life years (DALYs) remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.

Global Burden of Disease in Young People Aged 10-24 Years: A Systematic Analysis
Lancet. 2011 (Jun 18);   377 (9790):   2093–2102 ~ FULL TEXT

The health of young people has been largely neglected in global public health because this age group is perceived as healthy. However, opportunities for prevention of disease and injury in this age group are not fully exploited. The findings from this study suggest that adolescent health would benefit from increased public health attention.

The Global Burden of Selected Occupational Diseases and Injury Risks: Methodology and Summary
American J Industrial Medicine 2005 (Dec);   48 (6):   400-418 ~ FULL TEXT

Exposure to occupational hazards accounts for a substantial portion of the global burden of disease and injury. The impacts of these occupational deaths, diseases, and injuries extend far beyond the statistics reported here, to include reduced contributions by valuable employees in the workplace, economic loss to families, employers, and to nations, and untold human pain and suffering. The majority of these deaths, diseases, and injuries need not occur. The burden of occupational risk factors is largely preventable, as many examples from different countries have shown. Proven methods for reducing exposures are often quite simple: use of wet methods to reduce silica exposures, readjustment of work surfaces to reduce low back pain, substitution of safer chemicals or processes, and attention to electrical safety or machine guarding.We urge policy makers to use the evidence developed by this study to focus efforts to eliminate the preventable causes of occupational death, disease and injury.

Estimating the Global Burden of Low Back Pain Attributable to Combined Occupational Exposures
American J Industrial Medicine 2005 (Dec);   48 (6):   459–469 ~ FULL TEXT

Worldwide, 37% of LBP was attributed to occupation, with twofold variation across regions. The attributable proportion was higher for men than women, because of higher participation in the labor force and in occupations with heavy lifting or whole-body vibration. Work-related LBP was estimated to cause 818,000 disability-adjusted life years lost annually. Occupational exposures to ergonomic stressors represent a substantial source of preventable back pain. Specific research on children is needed to quantify the global burden of disease due to child labor.

The Burden of Musculoskeletal Conditions at the Start of the New Millenium
World Health Organization 2003 ~ FULL TEXT

A WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of the New Millennium met in Geneva from 13 to 15 January 2000. The meeting was opened by Dr G. Harlem Brundtland, Director-General of the World Health Organization. The meeting, organized by WHO in collaboration with the Bone and Joint Decade, marked the launch of the Bone and Joint Decade 2000–2010.


The Global Spine Care Initiative

The Global Spine Care Initiative:
A Summary of the Global Burden of Low Back and Neck Pain Studies

European Spine Journal 2018 (Sep);   27 (Suppl 6):   796–801 ~ FULL TEXT

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.

The Global Spine Care Initiative:
Care Pathway for People with Spine-related Concerns

European Spine Journal 2018 (Sep);   27 (Suppl 6):   901–914 ~ FULL TEXT

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 person-centered, 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.

The Global Spine Care Initiative:
Model of Care and Implementation

European Spine Journal 2018 (Sep);   27 (Suppl 6):   925–945 ~ FULL TEXT

A panel of international spine care experts developed the GSCI model of care based on eight core principles. The aim of this model is to help transform spine care globally, but especially in low- and middle-income regions and underserved communities. We consider this paper as a first step in a dialogue about this proposed model. It is our expectation that the GSCI model is dynamic and will evolve with new evidence and its application. We welcome others to join in our efforts, along with critiques, suggestions, and implementation of this model aimed at improving spine care globally.

The Global Spine Care Initiative:
Resources to Implement a Spine Care Program

European Spine Journal 2018 (Sep);   27 (Suppl 6):   915–924 ~ FULL TEXT

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 the entire spectrum of spine-related concerns. This resource list will need to be field tested in a variety of communities with different resource capacities to verify its utility.

The Global Spine Care Initiative:
Classification System for Spine-related Concerns

European Spine Journal 2018 (Sep);   27 (Suppl 6):   889–900 ~ FULL TEXT

This paper describes the first interprofessional and international attempt to provide a comprehensive classification for all potential presentations of people who may seek care or advice for spine-related symptoms or concerns. This classification system is sufficiently comprehensive to advise the development of a care pathway and sustainable model of care for spinal disorders. The classification system has been developed in a simplified manner so that it may be easily taught to clinicians and stakeholders. At present, the validity and reliability of the classification are not yet known. It will need to be field-tested to determine whether stakeholders, such as patients, policymakers, and clinicians in active practice, find it valuable.

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):   889–900 ~ FULL TEXT

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.

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 ~ FULL TEXT

Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. This information can be used to inform the GSCI care pathway and model of care in medically underserved areas and low- and middle-income countries.

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 ~ FULL TEXT

Evidence from high-quality clinical practice guidelines suggests that most surgical interventions lead to similar outcomes as non-invasive procedures for cervical and lumbar spine axial pain-related conditions. We have provided recommendations for surgical and interventional procedures based on evidence, these interventions should be reserved for patients with persistent and disabling spinal pain that fail to improve with non-invasive treatment. In low- and middleincome communities, prioritization of elective surgical procedures should be based on estimated benefits relative to harms and costs.

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 ~ FULL TEXT

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

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

European Spine Journal 2018 (Sep);   27 (Suppl 6):   816–827 ~ FULL TEXT

When assessing patients with spine-related complaints in medically underserved areas and low- and middle-income countries, we recommend that clinicians should: (1) take a clinical history to determine signs or symptoms suggesting serious pathology (red flags) and psychological factors (yellow flags); (2) perform a physical examination (musculoskeletal and neurological); (3) do not routinely obtain diagnostic imaging; (4) obtain diagnostic imaging and/or laboratory tests when serious pathologies are suspected, and/or presence of progressive neurologic deficits, and/or disabling persistent pain; (5) do not perform electromyography or nerve conduction studies for diagnosis of intervertebral disc disease with radiculopathy; and (6) do not perform discography for the assessment of spinal disorders. This information can be used to inform the GSCI care pathway and model of care. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: World Spine Care Executive Summary on Reducing
Spine-related Disability in Low- and Middle-income Communities

European Spine Journal 2018 (Sep);   27 (Suppl 6):   851–860 ~ FULL TEXT

The Global Spine Care Initiative GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The GSCI offers a framework to implement an evidence-based model of spine care. Each component of this model needs to be tested. Further research, especially in underserved communities and low- and middle-income countries, should be a priority if the global burden of spinal disorders is to be addressed. The GSCI model requires testing in clinical settings with different resources to determine feasibility and whether it has the desired impact on the burden of spinal disorders in these communities. If the GSCI model of care proves to be implementable and effective, it holds promise in addressing and reducing the tremendous global burden of spinal disorders.

The Global Spine Care Initiative: Methodology, Contributors, and Disclosures
European Spine Journal 2018 (Sep);   27 (Suppl 6):   786–795 ~ FULL TEXT

Reporting transparency in research is imperative, especially as this relates to a consensus process that makes recommendations for the management of important high impact health disorders in low- and middle-income countries. A group of experts may exert undue influence on policies and healthcare decisions; therefore, it is especially important to be transparent about the consensus process and to describe the qualifications, possible biases, and conflicts of interest of each participant. [1–5] Based on the assumption that no author is free from potential bias or conflicts of interest, reporting of conflicts and biases and providing transparency are important to any policy maker, government agency, or institutions attempting to interpret these recommendations. This is of particular importance when individuals and organizations are attempting to influence health care in impoverished communities or low- and middle-income countries. Of equal importance to policy makers and clinicians who are instituting these recommendations is a description of the methodology used to develop the recommendations. Therefore, the purpose of this paper is to report information about the GSCI team participants and their disclosures and to provide a general overview of the methodology used to develop the recommendations.


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