Welcome back to SpineIQ’s Back Blog! Last week, we discussed a thought-provoking research article by Louw et al. “Evaluation is treatment for low back pain.”1 This week, we will continue with our September theme of reviewing research articles that we believe could potentially influence spine care outcomes.  Whether you are able to evaluate and address the social determinants of health on a regular basis within your practice or not,  the study “Low back pain and the social determinants of health: a systematic review and narrative synthesis” by Karran et al.2  provides you with important information regarding the “biopsychosocial model”3. Some of you have employed aspects of the biopsychosocial model in your practice for many years while many others it is a new concept. Regardless, one aspect of this model that is often forgotten or underappreciated is the “social domain”.4 Wondering what in the heck a social domain is and why it matters to your patients? Keep reading to get a great summary of what is it and how it relates to low back pain.

What are the social determinants of health?

The World Health Organization defines the social determinants of health as “conditions in which people are born, grow, work, live, and age.”5 Examples of social determinants of health include socioeconomic status, education, access to healthcare, neighborhood, built environment, social connectedness, food/housing insecurity, and employment.6 Each of these determinants influences the daily lives of every single one of you patients in a unique way. The PROGRESS framework helps us think about the social determinants of health and how they impact patients by creating the following domains:7

  • Place of residence (
  • Race, ethnicity, culture, and language
  • Occupation
  • Gender and sex
  • Religion
  • Education
  • Socioeconomic status
  • Social capital

Which social determinants of health effect low back pain?

When you consider the impact that living on the streets or not having enough to eat might have on your low back pain, it is not so surprising that the social determinants of health have stronger independent relationships with “outcomes” than any treatment provided.2,6,8 For example, a recent study by Stevans et al.9 found that receiving two treatments that are not supported by guidelines increased the odds of developing chronic low back pain by 1.88 times. However, being on Medicaid (proxy for low socioeconomic status) increased the odds of developing chronic low back pain even more. Consistent with this, Karren et al. identified 13 independent relationships between low socioeconomic status, unemployment with worse low back pain outcomes.2 Rural living, low educational attainment, poor workplace support, and being single are also associated with a higher prevalence of chronic low back pain and poorer low back pain outcomes. While none of the findings are surprising when you think about it, the busy clinician does not often reflect on these relationships and how they might influence patient.

So what can clinicians do about social determinants of health?

The social determinants of health that you might encounter in your community will be different based upon where you practice. Are there populations that need your services but have trouble accessing you? What could help make your community healthier? How could you hape your practice to be inclusive and accessible to all?8,10 By reading this blog and considering the answers to these questions, you are already taking important steps in the right direction. In addition to the ideas provided below, please share your ideas with us. Understanding more about the social determinants of health and their impact on your patients allow us to begin addressing issues of health equity at a meaningful level.

The Social Interventions Research and Evaluation Network offers free social screening tools that can be added to your intake form based on what social domains you think are important to screen for. In addition,

  • Consider having your intake forms in different languages and at a middle school reading level
  • Stay connected with local community workers/groups that you can refer to if you find that someone has food/housing insecurity
  • Create or join social groups that foster a sense of community and belonging for patients that might be high risk for loneliness
  • Be conscious of your recommendations and aware that some people might live in dangerous neighborhoods and won’t have the ability to do things like “go on walks/bike rides”
  • Be conscious of what your patients have access to at home before giving home exercise programs built around weights/equipment they do not have


It is important that we are vigilant in considering the many different things that can affect a person’s LBP prevalence, prognosis, and outcomes, including factors that we might not always think about on a daily basis. While it is not always possible to change the social determinants of health that influence your patient, as clinicians we should be aware, conscious, and prepared to help as much as possible when we can. Thinking beyond the manual treatment provided to also consider ways to help connect the patient with employment opportunities, housing, food, or a sense of belonging has the potential to have a profound impact their lives, and yours.


  1. Louw A, Goldrick S, Bernstetter A, et al. Evaluation is treatment for low back pain. J Man Manip Ther. 29(1):4-13. doi:10.1080/10669817.2020.1730056
  2. Karran EL, Grant AR, Moseley GL. Low back pain and the social determinants of health: a systematic review and narrative synthesis. Pain. 2020;161(11):2476-2493. doi:10.1097/j.pain.0000000000001944
  3. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136. doi:10.1126/science.847460
  4. Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Rep. 2014;129(Suppl 2):19-31.
  5. Social determinants of health. Accessed February 13, 2021. https://www.who.int/westernpacific/health-topics/social-determinants-of-health
  6. Marmot M, Bell R. Social determinants and non-communicable diseases: time for integrated action. BMJ. 2019;364:l251. doi:10.1136/bmj.l251
  7. O’Neill J, Tabish H, Welch V, et al. Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. J Clin Epidemiol. 2014;67(1):56-64. doi:10.1016/j.jclinepi.2013.08.005
  8. Rethorn ZD, Cook C, Reneker JC. Social Determinants of Health: If You Aren’t Measuring Them, You Aren’t Seeing the Big Picture. J Orthop Sports Phys Ther. 2019;49(12):872-874. doi:10.2519/jospt.2019.0613
  9. Stevans JM, Delitto A, Khoja SS, et al. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open. 2021;4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371
  10. Quantifying the collective influence of social determinants of health using conditional and cluster modeling. Accessed December 15, 2020. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241868