Introduction

Lower back pain is the leading cause of disability in most countries with an estimated global prevalence of 619 million.1 The bi-directional relationships between spine conditions and patient physical, mental, and social health status has been well documented. Understanding spine conditions and health status is complicated by the high prevalence of comorbid conditions which may independently impact health status or be risk factors for spinal conditions.2 Identifying comorbidities in patients with spine conditions may therefore provide a better understanding of how best to approach clinical care.

Fanuele and colleagues in 2000 found in a prospective study of over 17,000 patients that spine conditions were associated with five common comorbidities: congestive heart disease, chronic obstructive pulmonary disease, renal failure, rheumatoid arthritis and lupus.3 While the authors acknowledge that the role of comorbid conditions is not well understood, the physical status of the patient is further affected by them.

Kopec and others assessed a Canadian cohort using the National Population Health Survey in the mid-1990s and stated that predictors of chronic back pain (CBP) include both general health status and psychological/ social factors.4 Among the physical risk factors for men were: age, unusual pattern of activity such as heavy work, lack of gardening or yard work, and height. Women were more likely to report CPB if they self-reported arthritis or rheumatism and had a history of psychological trauma.

One study assessed cardiovascular risk factors among those with physician-diagnosed lumbar disc herniation and found increased risk for diabetes, hypertension, high cholesterol and myocardial infarction (CVD) before the age of 60 after controlling for age, body mass index, smoking status, exercise levels or employment status.5 For smokers, risk also increased with number of cigarettes per day and a higher BMI also increased risk for these conditions. In addition, Zhu and colleagues6 noted increased cardiovascular disease risks in those with CBP among elderly women that was significant even after controlling for known CVD risk factors and physical activity levels. The authors concluded that CBP when experienced daily was associated with lack of mobility, less longevity, and increased risk for CVD events than in the overall population.

A national health survey in Brazil with over 87,000 people assessed indicated 21.6% had CBP and the rates of all non-communicable conditions were higher in those with CBP.7 Sixty-two percent experienced comorbidities and the most common conditions were arthritis, depression and CVD compared to those without CBP. And in an Australian study that reviewed medical records for lower back pain, researchers found over 60% of adults with lower back pain specifically, had 1 of 17 comorbidities documented in the medical record.8 The more comorbidities, the poorer the overall health status and those patients were also less likely to receive appropriate care for lower back pain when applying specific indicators for care. Obesity in general, is also implicated as a risk factor for poor outcomes in the case of spinal fusion surgery,9 as is smoking.10

In a systematic review of patients with lower back pain, comorbidities ranged from 49-92% with 9 specific peer-reviewed studies included to assessment this.11 The 3 most prevalent conditions associated were hypertension, osteoarthritis, and chronic pain elsewhere in the body. Across all studies included in the review, diabetes, asthma and depression were also frequently reported.

When it comes to chronic pain in general, those who suffer from it have indications of changes in the brain.12 Gray matter changes are noted on imagining and those with chronic pain had a unique brain signature on imaging. Grachev and colleagues assessed brain chemistry changes in those with CBP and applied magnetic resonance imaging (MRI) spectroscopy.13 They found abnormalities in brain chemicals as well and the perception of measured pain and anxiety in those with CBP was likely due to long-term cortical reorganization.

Von Korff led a study on the physical and mental comorbidities of CBP in the United States (U.S.) and found 87% of people who had it also suffered at least one other comorbidity.14 Other chronic pain, chronic physical conditions, and mental conditions were the most common and included anxiety. They suggested that CBP was highly comorbid with other pain conditions, chronic diseases and mental disorders and that clinical management must take this into account. Assessment of the LifeLink Health Plan Claims Database including over 100,000 patients found CBP (lower back) patients had greater comorbidity than controls with other musculoskeletal conditions, neuropathic conditions, and depression/anxiety being the most common. Disordered sleep patterns were also noted.15

Using pain questionnaires and functional MRI data, Hashmi and others found large shifts in brain activity in those with CBP and especially the transition to chronic pain.16 They also noted that once chronic pain is ongoing beyond 6-12 months, the brain engages more emotional regions of the amygdala and medial prefrontal cortex. Specific brain signatures were noted for CBP within the first year and remained constant for over a decade. Depression was comorbid in males and females with CBP. These authors concluded that targeted interventions to prevent the development of CBP are warranted within 6-12 months of onset of spinal pain. Anxiety and depression are common with general discogenic back pain and can complicate clinical effectiveness if not addressed, including increasing hospital readmission after surgery.17 Other studies indicate that poor self-reported health, psychological symptoms, and pain-related disability reduce the probability of recovery from CBP.18 And postural alterations of the spine may also increase the need for support of general activities of daily living.19

Understanding the impact of comorbid conditions on health and prognosis is necessary to inform shared decision-making in chiropractic practice. Recognition of comorbid conditions and their implications may also provide opportunity for patient education and self-care recommendations. The purpose of this paper is to help spine focused providers identify opportunities to motivate patients towards healthy lifestyle changes that may positively impact CBP but also associated comorbid health conditions.

For this manuscript we did a focused search of PubMed and other literature using search terms, “comorbidity of chronic spine pain;” and “comorbidities and back pain.” We summarize the retrieved articles using a narrative approach to describe research summarizing the role of spine care practitioners in addressing overall health and wellbeing in a patient population with chronic illness. Other helpful citations to support practitioners in the field are also offered in the paper.

Discussion

Promoting Health and Wellbeing

Healthy People data reported by the U.S. show that prior to the SARS Co-V2 pandemic only 8.5% of adult patients received recommended preventive services screenings and advice and that after 2020 the percentage dropped to 5.3%.20 That means a minority of Americans are receiving recommended screenings and advice on preventive measures. However, previous reviews of the National Health Interview Survey in the U.S. found that when a medical physician or a Doctor of Chiropractic engaged their patient on preventive care, the patient tried to comply.21 That study indicated that the rate of attempted compliance was around 88% for patients of both provider groups. Patients in the study who stated they received advice on prevention and complied also self-reported 21% increased odds of improved health status.

A biopsychosocial model of care has been proposed for the chiropractic profession.22 The need to stress not only the biological and genetic aspects of care, but also the mental health status, expectations of care, health beliefs, and sociological interactions is suggested. Interpersonal issues, social support or lack of support and economic status should not be overlooked. In a triad, nutritional/chemical, structural/physical, and emotional/mental assessments are considered. For example, if a patient has an unreasonable fear of movement from CBP, it can lead to further physical withdrawal and social isolation which in turn has negative effects on overall metal health and wellbeing.22 One study on associations between social risk factors and CBP found 12% of people in a study population of 1,295 people had social risks.23 Social isolation, housing instability, and even food insecurity was noted in the population, as was financial strain. These risks held even when controlling for other known neighborhood-level social determinants of health, race, ethnicity, or type of health insurance. Clearly, there is a need to address preventable issues among those with CBP.

A Delphi panel on the role of chiropractors in the provision of health promotion and clinical preventive services has indicated that it is appropriate to screen and provide preventive services for overall health promotion in a CBP setting.24 This interprofessional panel found multiple components of health promotion to be valid areas of practice and they included general health promotion, diet physical activity, obesity management, tobacco cessation infectious disease prevention as measures with high degrees of support for implementation in a clinical setting managing CBP.

The 8 dimensions of wellness stresses not only the physical aspects of a patient but also social, emotional, spiritual, intellectual, environmental, financial, and occupational areas.25 Among these, many are modifiable. We propose this model of care when it comes to preventive messaging and health promotion. Though the practical, clinical application of all 8 dimensions may be challenging, the dimensions can be considered. Stoewen26 suggested helping people find self-awareness around these dimensions and addressing the ones that can be altered. For example, even if in pain, one may find purpose and activities that align with beliefs and values whether that is directly related to spiritual beliefs or other closely held ideologies. Maintaining healthy relationships and close ties to community may also be of benefit. Table 1 offers some additional areas to focus on with patients in the 8 dimensions.

Table 1.Applying the 8-Dimensions of Wellness in a Spine Care Setting
Dimension Action Resources Needed
Physical Promote general physical activity in line with Physical Activity Guidelines for Americans or 150 minutes of accumulated movement a week- more if already at that level; specific rehab exercises
Intellectual Promote life-long learning
  • Connect patients with resources in the community including libraries, or community events
Emotional Approach patients with non-judgmental efforts; have a trusted counselor for referral
  • Screen for suicidal ideation or emotion issues in those with CBP or disability
  • Use of Motivational Interviewing techniques in communication; referral list of mental health counselors in the area
Social Promote community involvement
  • Promote social events in the office including fairs, art crawls, or other local events to help patients stay connected, and mobile
Spiritual Promote mindfulness and support patients’ personal beliefs in this area
  • Offer resources on mindfulness, meditation, or other mind-body options Provide a list of local groups offering fitness classes
Occupational Ask specific intake questions on work environment
  • Offer ergonomic advice and ways to enhance work/life balance
Financial Be aware that patients vary in their financial status and offer ways to reduce costs of care where possible
  • Offer connections to financial planning resources, or community-based counseling in this area
Environmental Support local environmental causes, understand how the built environment enhances health in the community or detracts from it and support efforts to add to passive opportunities to enjoy the local environment
  • Advocate for walking paths, have a list of resources available in the area such as parks with walking paths or trails, national forests, or hiking trails
  • Recycle and support your local environment
  • Provide information on local food banks where healthy food options may be found in those with food insecurity

Specific Applications in a Clinical Setting

A few specifics may help the spine care provider to engage patients in a way they will be most receptive. Evans suggested that the Doctor of Chiropractic consider the ABC’S.27 That is, Assess the health status of the patient overall; extol the Benefits of needed behavior or lifestyle changes; Use Chiropractic care visits as the point of engagement for messages on health promotion and disease prevention; and Stay the Course messaging over time so they continue to work on needed behavior changes. This may begin with simply asking a patient if there are areas they are interested in trying to change.

Among the areas to specifically address, tobacco use status can be the most important preventable behavior that is associated with CBP. Not only is it comorbid with CBP, but surgical outcomes are much worse in smokers than non-smokers.28 Rechtine and colleagues stressed the importance of engagement in a spine care setting on the topic of smoking and suggested that the practitioner assigning this as a priority to better health and direct care outcomes could enhance the probability of cessation. And smoking cessation specifically, can improve spine care outcomes significantly.29,30

When assessing patients for tobacco use, the U.S. Surgeon General’s 5-As is a great acronym to employ.31 Ask the patient about tobacco use status; Advise they should make a cessation attempt; Assess their willingness to try; Assist in the process and Arrange for follow-up. A key feature here is that people in pain who also smoke, may not want to try to quit while in pain so staying the course with messaging is important. Also, the use of Motivational Interviewing (MI) techniques that ask open-ended questions, in a non-judgmental manner will make it more likely the patient will make a quit attempt.31,32 Table 2 outlines the basic use of MI in a clinical setting addressing various behavioral changes, including, but not limited to tobacco cessation. Specific to tobacco is a national quit line; 1-800-QUIT-NOW available free to anyone in the U.S. This site can also be reached at https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/quitline/index.html. Additionally, CPT codes for counseling on tobacco use are available for both 3–10-minute sessions or greater than 10 minutes.33

Table 2.Basic Motivational Interviewing Examples
Engagement Do’s Don’ts
Ask open-ended questions
  • “Would you be open to discussing a way to get more physical activity into your day?” (or, is there an area you are interested in working on?)
  • “Would be ok to discuss a healthier weight for you that might help your condition?”
  • “If I provide you with some smoking cessation information, would you consider it?”
  • “You need to exercise more.”
  • “You need to lose 30 pounds by your next visit.”
  • “You need to quit smoking.”
Roll with resistance
  • Upon encountering resistance, reiterate barriers but refocus patient on what is needed to help them heal- “I understand it’s getting dark earlier, and you find it hard to exercise. Can you think of anything you might be able to do at home that would work for you?”
  • Don’t cut patients off or state the obvious.
  • Don’t judge their circumstances.
  • Don’t assume they know of community resources to support behavior change and do offer resources.
Accentuate the positive
  • Stress how getting more movement or making a dietary change will help them. “If you move more, it will speed up the recovery process.”
  • “Quitting smoking is the single best thing you can do for your health (spinal health) right now.”
  • “If you don’t get more activity, you will get worse.”
  • “If you don’t stop smoking, you will die.”

Addressing the behavioral and lifestyle changes that help a spine patient will conveniently be helpful for most of the comorbid conditions noted in this manuscript. Increased physical activity by applying the Physical Activity Guidelines for Americans,34 addressing dietary changes for a healthy weight, and stressing the importance of mindfulness or other stress reduction methods and healthy sleep are all fair game when it comes to general health promotion.

This is a focused review on this topic and is by no means comprehensive. Therefore, the paper is limited in that manner. Specific methods related to health coaching or promoting overall health and wellbeing in a spine care practice are available and are not necessarily noted here. Practitioners wanting to do more health promotion or health screenings in practice should also do the needed preparation to be best equipped to offer those services.

Conclusion

Like primary care providers, Doctor of Chiropractic and other spine practitioners could encourage and facilitate health promotion behaviors. Evidence suggests patients want information on ways to improve their health and that they trust the advice given by those in specialty practice areas. Not engaging and empowering patients’ misses the opportunity to address overall health and holistic wellbeing. Health promotion strategies are likely needed to successfully address spinal conditions globally which are directly connected to health status and patient comorbidities.