Low Back Pain-related Beliefs
and Likely Practice Behaviours Among
Final-year Cross-discipline Health StudentsThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: European Journal of Pain 2013 (May); 17 (5): 766–775 ~ FULL TEXT
A.M. Briggs, H. Slater, A.J. Smith, G.F. Parkin-Smith, K. Watkins, J. Chua
Department of Health,
Government of Western Australia,
Perth, Australia.
andrew.briggs@health.wa.gov.au
BACKGROUND: Evidence points to clinicians' beliefs and practice behaviours related to low back pain (LBP), which are discordant with contemporary evidence. While interventions to align beliefs and behaviours with evidence among clinicians have demonstrated effectiveness, a more sustainable and cost-effective approach to positively developing workforce capacity in this area may be to target the emerging workforce. The aim of this study was to investigate beliefs and clinical recommendations for LBP, and their alignment to evidence, in Australian university allied health and medical students.
METHODS: Final-year students in chiropractic, medicine, occupational therapy, pharmacy and physiotherapy disciplines in three Western Australian universities responded to a survey. Demographic data, LBP-related beliefs data [modified Health Care Providers Pain and Impact Relationship Scale (HC-PAIRS) and the Back Pain Beliefs Questionnaire (BBQ)] and activity, rest and work clinical recommendations for an acute LBP clinical vignette were collected.
RESULTS: Six hundred two students completed the survey (response rate 74.6%). Cross-discipline differences in beliefs and clinical recommendations were observed (p > 0.001). Physiotherapy and chiropractic students reported significantly more helpful beliefs compared with the other disciplines, while pharmacy students reported the least helpful beliefs. A greater proportion of chiropractic and physiotherapy students reported guideline-consistent recommendations compared with other disciplines. HC-PAIRS and BBQ scores were strongly associated with clinical recommendations, independent to the discipline of study and prior experience of LBP.
CONCLUSIONS: Aligning cross-discipline university curricula with current evidence may provide an opportunity to facilitate translation of this evidence into practice with a focus on a consistent, cross-discipline approach to LBP management.
From the FULL TEXT Article:
What's already known about this topic?
Low back pain (LBP)-related beliefs among some practising clinicians are discordant with evidence. Clinicians’ beliefs influence patients’ beliefs and behaviours.
LBP-related beliefs and likely practice behaviours among cross-discipline students before entering the workforce have not been characterized previously.
What does this study add?
Beliefs of physiotherapy and chiropractic students are in closer alignment with evidence compared to students of other disciplines.
Students’ beliefs are associated with their clinical recommendations.
These results provide a direction for interprofessional curriculum development in musculoskeletal pain.
Background
Low back pain (LBP) represents a significant public health issue due to the associated personal and societal burden and the unsustainable drain on public health resources (Briggs and Buchbinder, 2009). Furthermore, the majority of people with persistent pain are not receiving best-practice care (Australian and New Zealand College of Anaesthetists, 2010), prompting calls for a paradigm shift in management approaches and pain education for health professionals, educators and the community (Henry, 2008; Australian and New Zealand College of Anaesthetists, 2010). While a myriad of barriers exist for the implementation of evidence into clinical practice, a potential strategy to facilitate the delivery of best-practice care is to educate and influence the emerging workforce during their professional training.
In the context of LBP, while consistent evidence points to the effectiveness of well-integrated and coordinated interdisciplinary management delivered within a biopsychosocial framework (Koes et al., 2010), clinicians’ practice behaviours and beliefs in the management of LBP can be discordant with such a service delivery framework and with current evidence (Linton et al., 2002; Buchbinder et al., 2009). Moreover, these non-evidence-based behaviours and beliefs result in poorer patient outcomes and management approaches that are less cost-effective (Lin et al., 2011a,b; Darlow et al., 2012). There are a range of educational and practice culture factors that might interact and drive discordance with best-practice care for both the emerging and current workforce (Foster and Delitto, 2011). While several studies have explored the beliefs related to pain and/or LBP held by various emerging health workforce cohorts, including physiotherapy (Ferreira et al., 2004; Latimer et al., 2004; Ali and Thomson, 2009; Burnett et al., 2009; Ryan et al., 2010; Domenech et al., 2011), nursing (Burnett et al., 2009) and medicine (Ali and Thomson, 2009), gaps remain in the knowledge base informing this important bridge between evidence and practice. Given that beliefs are likely to underpin practice behaviours of an emerging workforce, such as clinical recommendations, understanding the relationship between LBPrelated beliefs and likely practice behaviours is important. Additionally, most studies have focussed on single professional disciplines, despite evidence for the effectiveness of interdisciplinary management for chronic LBP and acknowledgement of the differences reported between professional disciplines on the relationship between LBP and disability (Rainville et al., 1995).
Despite the recognition of the need to upskill the health workforce, recent reports highlight that painrelated curriculum for health students remains inadequate (Watt-Watson et al., 2009; Briggs et al., 2011; Jones and Hush, 2011). This raises the question as to whether the emerging workforce has the appropriate skills and knowledge to provide integrated co-care for consumers with LBP; a condition that represents the largest proportion pain presentations of musculoskeletal origin in Australia. The aim of this study was to measure beliefs and likely practice behaviours related specifically to LBP among Australian final-year health students in disciplines (including chiropractic, medicine, occupational therapy, pharmacy and physiotherapy) where the management of LBP lies within their scope of clinical practice in a primary care context.
Methods
Participants and setting
This cross-sectional study was conducted during 2011, across three publicly funded and one privately funded university inWestern Australia (WA). Students in their final year of study in physiotherapy (two universities; 4-year programme or 2.5 years if graduate entry with a previous degree), chiropractic (one university: 5-year programme), medicine (two universities: 6-year programme or 4-year programme if graduate entry with a previous degree), occupational therapy (one university: 4-year programme or 2 years if graduate entry with a previous degree) and pharmacy (two universities: one with a 4-year programme and one with a 2-year programme if graduate entry with a previous degree) were invited to participate. Approval to conduct the study was granted by local university’s Human Research Ethics Committees and adhered to the Declaration of Helsinki. The Department of Health, Government of Western Australia, remained the coordinating institution for the project and custodian of the pooled data set, while each institution was granted access to data provided by their students.
Procedure
Each discipline was approached at each facility and asked to nominate a time at which their student cohort was close to completion of their training (i.e., last semester). At these nominated times, students were invited to participate in the study by one of the authors (J.C.). This author also liaised with all course coordinators, to ensure that convenient times were negotiated with each university department. Across all the student cohorts, data were collected between 0 and 108 days prior to completion of their university training. A research officer was present during each nominated data collection time for each cohort to briefly describe the study and to answer questions. Each student was given a survey, constructed as a four-page Teleform booklet, and a study information sheet. Passive consent was assumed upon completion and return of survey at the end of the lecture or tutorial. Students were advised by their tutor/lecturer and the research officer that completion of the survey was voluntary. This information was also reflected in the study information sheet. Those students who elected not to complete the survey exited the tutorial or lecture theatre.
Outcome measuresDemographic and LBP history data Demographic data included age, gender, degree course, total years of education and international student enrolment status. History about LBP and chronicity (an LBP episode lasting 3 months) were collected, based on the Nordic Musculoskeletal Pain Questionnaire (Kuorinka et al., 1987). Respondents were also asked to indicate whether they had accessed or utilized any of the following options for a previous episode of LBP: medication, physiotherapy, occupational therapy, chiropractic, self-management and imaging.
Instruments to measure beliefs The modified Health Care Providers Pain and Impact Relationship Scale (HC-PAIRS) measures practitioner beliefs regarding the relationship between LBP and physical function. The modified HC-PAIRS consists of 13 items each rated on a 7-point Likert scale, scored from 1 (completely disagree) to 7 (completely agree) (Evans et al., 2005). Scores range from 13 to 91, with higher scores representing less helpful beliefs about the relationship between LBP and impairment. Validity of the original HC-PAIRS and internal consistency (a = 0.78–0.84) have been established previously (Rainville et al., 1995; Houben et al., 2004), based on cohorts of health professionals in disciplines comparable with those student disciplines included in this study. The instrument has also been used previously in studies using health professional student cohorts (Ferreira et al., 2004; Latimer et al., 2004; Burnett et al., 2009; Ryan et al., 2010; Domenech et al., 2011).
Beliefs about inevitable consequences of future life with low back problems were measured using the Back Pain Beliefs Questionnaire (BBQ) (Symonds et al., 1995). The BBQ consists of 14 items each rated on a 5-point Likert scale, scored from 1 (completely disagree) to 5 (completely agree). Scores range between 9 and 45 with higher scores representing more helpful beliefs about the consequences of LBP. The internal consistency (a = 0.70) and test–retest reliability (intraclass correlation coefficient = 0.87) of the BBQ have been established previously (Symonds et al., 1996). The BBQ has been used among students and adolescents previously (Burnett et al., 2009; Smith et al., 2012).
Instruments to measure likely practice behaviours (clinical recommendations) Likely practice behaviour was measured using a patient vignette and associated questionnaire described by Evans et al. (2005), and adapted from an original vignette (Bombardier et al., 1995). Justification for the use of a vignette as a blueprint for practice behaviour has been discussed extensively by Evans et al. (2005). The vignette describes a 28-year-old woman with nonspecific acute LBP and no ‘red flags’. The questionnaire related to the vignette, based on the original format developed by Rainville et al. (2000), consists of three items each rated on a 5-point Likert scale, exploring health professional’s recommendations for patient behaviour in relation to work, activity and bed rest. Lower scores represent more restrictive recommendations. Responses to the vignette are considered either ‘guideline-consistent’ or ‘guideline-inconsistent’ and thresholds for dichotomization have been determined previously through expert opinion and evidence-based guidelines (Evans et al., 2005). Although a similar vignette has been used among students previously (Domenech et al., 2011), the reliability of selecting recommendations has not been explored previously among students. For the purposes of examining test– retest reliability for this instrument, a subgroup of 26 physiotherapy students from one institution responded to the vignette questionnaire twice, 5 weeks apart.
Delivery of spinal pain-related education among disciplines Following completion of the study, educators at all participating institutions were asked the following questions:
Please indicate the approximate number of hours in your curriculum dedicated to knowledge and skills related to the management of spinal pain conditions over the duration of the training. Please indicate as ‘x’ hours.
Have your students had specific clinical experience in the management of patients with LBP/spinal pain (e.g. during clinical placements)? Please indicate by circling one response: yes/no/do not know.
Have your students had any exposure to interprofessional education or interprofessional practice in their training in the context of management of spinal pain conditions? Please indicate your answer on a scale of 1–5, where 1 = nil; 2 = minimal; 3 = moderate; 4 = considerable; and 5 = a lot.
Data analysis
Standard descriptive statistics were used to summarize demographic and baseline characteristics of across the cohort. Odds ratios (ORs) and 95% confidence interval (CI) were calculated to determine the odds of chiropractic, physiotherapy and occupational therapy students who reported LBP in the last 12 months having sought chiropractic, physiotherapy and occupational therapy care, respectively, compared with not selecting those interventions. Scores for each instrument were derived according to the developer’s method (Symonds et al., 1996; Evans et al., 2005) and compared between the clinical disciplines using a oneway analysis of variance. To account for multiple comparisons, a Bonferroni correction was applied to post hoc tests. Categorical (recommendations) data were examined using a chi-square as an omnibus test, followed by comparisons between independent proportions. To assess the association between guidelineconsistent recommendations and beliefs, multivariable logistic regression was used, with the guideline recommendation as the dichotomous outcome variable and either HC-PAIRS and BBQ scales as predictor, adjusted for pain in the last months and discipline of study. Interaction effects for both pain in the last month and discipline with beliefs scales were tested. Test–retest reliability of responses to the vignette was expressed as overall percentage agreement for guideline consistency and inconsistency, while the probability of disagreement was determined using McNemar’s exact test. Differences between disciplines in responses to questions related to pain curricula were not statistically analysed due to small cell numbers. Data were examined using IBM Statistical Package for the Social Sciences version 19 (SPSS Inc., Chicago, IL, USA).
Results
Demographic and pain history characteristics
Table 1 A total of 602 students participated in this study, representing an overall response rate of 74.6%. Table 1 summarizes the demographic and pain history characteristics and the questionnaire scores across each discipline. There was strong evidence of differences between disciplines for age, gender, years of tertiary education, proportion of international students, LBP prevalence and chronicity and interventions sought for LBP (p < 0.0001). On average, medicine students were slightly older and had undertaken a greater number of years of tertiary education than students in the other disciplines. Chiropractic students reported a significantly higher lifetime, 12- and 1-month prevalence of LBP compared with the other disciplines, while occupational therapy students had the second highest prevalence of LBP; significantly higher than medicine and pharmacy students.
Care-seeking choices for LBP
Of the 42 (91.3%) chiropractic students who had experienced LBP in the last year, 100% reported previously seeking chiropractic care. Physiotherapy students who experienced LBP in the last year were likely to select physiotherapy as a treatment option (OR 4.26; 95% CI: 2.01–9.01), compared with not selecting physiotherapy as a treatment option. No association was observed between occupational therapy students reporting LBP in the last year and their selection of occupational therapy as a treatment option (OR 1.08; 95% CI: 0.18–6.38). Across all students, selfmanagement was the most commonly reported intervention used (54.7%; range: 49.8–90.7%) (Table 1).
LBP-related beliefs across student disciplines
There was strong evidence for differences between the discipline groups in the HC-PAIRS and BBQ scores (p < 0.001) (Table 1). Compared with all other students, physiotherapy students reported significantly more helpful beliefs (lower score) on the HC-PAIRS, while pharmacy students reported the least helpful beliefs on the HC-PAIRS, with a significantly higher score compared with chiropractic and medicine students. Both physiotherapy and chiropractic students reported significantly more helpful beliefs on the BBQ (higher scores) compared with all other disciplines. Pharmacy students reported the least helpful beliefs on the BBQ, with a significantly lower score compared with chiropractic, medicine and physiotherapy students.
Recommendations for physical activity, work and bed rest across student disciplines
The proportions of students in each discipline who reported guideline-consistent responses for physical activity, work and bed rest recommendations differed significantly (p < 0.0001). A significantly greater proportion of chiropractic and physiotherapy students reported recommendations that were guidelineconsistent compared with other disciplines, while a significantly lower proportion of occupational therapy and pharmacy students reported recommendations that were guideline-consistent compared with other disciplines (Table 1). The percentage agreement in guideline responses to the patient vignette over time was moderate to high (physical activity: 84.6%; work: 80.8%; bed rest: 65.4%), supported by the absence of significant disagreement as tested with the McNemar’s statistic (p = 0.38–1.00).
Associations between clinical recommendations and beliefs
HC-PAIRS scores were strongly associated with clinical recommendations. Results of multivariable logistic regression indicated that a 1-point increase in HC-PAIRS (i.e., less helpful beliefs) was associated with a decrease in the odds of guideline-consistent responses of 4% for physical activity (OR: 0.96; 95% CI: 0.94, 0.98; p < 0.001), 6% for work (OR: 0.94; 95% CI: 0.92, 0.96; p < 0.001) and 7% for bed rest recommendations (OR: 0.93; 95% CI: 0.91, 0.95; p < 0.001). These estimates are adjusted for the experience of pain in the last month and discipline. There was no statistical evidence for differences in these associations according to either experience of pain in the last month or discipline (i.e., no interaction effect).
BBQ scores were also associated with clinical recommendations. Results of multivariable logistic regression indicated that a 1-point increase in BBQ (i.e., more helpful beliefs) was associated with an increase in the odds of guideline-consistent responses of 5% for physical activity (OR: 1.05; 95% CI: 1.01, 1.09; p < 0.001) and 12% for bed rest recommendations (OR: 1.12; 95% CI: 1.08, 1.16; p < 0.001). These estimates are adjusted for the experience of pain in the last month and discipline. There was no statistical evidence for an association of BBQ with guideline recommendations for work after adjustment for pain and discipline (OR: 1.03; 95% CI: 0.99, 1.06; p = 0.114), or for differences in any associations according to either experience of pain in the last month or discipline (i.e., no interaction effect).
Spinal pain curricula characteristics across student disciplines
Table 2 Table 2 summarizes responses collected from institutions regarding the volume and nature of spinal pain-related curriculum delivered to students. The approximate number of hours in the curricula dedicated to knowledge and skills related to the management of spinal pain conditions over the duration of the training varied considerably across the disciplines (range 2–310 h) with chiropractic students having the highest volume of training hours.
Discussion and conclusions
This is the first study to examine beliefs and clinical practice recommendations related specifically to LBP among multidisciplinary Australian health professional students. We observed strong evidence for differences in self-reported LBP-related beliefs and clinical recommendations. Physiotherapy and chiropractic students demonstrated more helpful beliefs about LBP, and a greater proportion of these students made guideline-consistent recommendations in response to a patient vignette, compared with medicine, pharmacy or occupational therapy students. While domain-specific knowledge and skills necessarily vary between disciplines, more consistent alignment of LBP-related beliefs, attitudes and clinical behaviours across disciplines may have bilateral benefits for the health workforce and consumers.
While the pooled prevalence and chronicity of LBP aligned with Australian adult population norms (Walker et al., 2004) and student-derived data (Smith and Leggat, 2007; Burnett et al., 2009; Falavigna et al., 2011; Moroder et al., 2011), chiropractic students reported a significantly higher prevalence of LBP. Given the response rate, it is unlikely this finding is related to responder bias. Consistent with earlier research, physiotherapy students reported a significantly higher prevalence of LBP compared with medical students (Falavigna et al., 2011), yet comparative data for chiropractic students are unavailable. Although the use of management strategies by students in each discipline was closely related to their discipline, suggesting a domain-specific orientation to the choice of intervention, a large proportion of students from all disciplines adopted self-management as an intervention for their LBP. While this finding indicates a guideline-consistent approach to LBP management, we cannot speculate on the nature of the self-management strategies used.
Although students’ beliefs varied significantly across disciplines, our pooled data, representing a preemergent workforce, overall indicate more helpful LBP-related beliefs compared with the Australian general population (Buchbinder et al., 2001; Urquhart et al., 2008; Briggs et al., 2010), with BBQ data derived from practising Australian health care professionals (HCPs) (Buchbinder and Jolley, 2004), and with other final-year health student cohorts (Burnett et al., 2009). Similarly, our data point to more helpful beliefs overall, evident from lower HC-PAIRS scores, compared with data reported for physiotherapy students from Australia (Latimer et al., 2004; Burnett et al., 2009), Spain (Domenech et al., 2011) and Brazil (Ferreira et al., 2004). Both the pooled BBQ and HC-PAIRS scores from our study were similar to scores [BBQ mean (standard deviation): 34.3 (6.8); HC-PAIRS: 43.2 (9.3) ] reported recently for crossdiscipline clinically active HCPs from regional WA (Slater et al., 2011), collected over the same period as data were collected for this current study. Collectively, these data suggest that the pre-emergent and current clinical workforce inWA generally have helpful beliefs related to LBP, possibly reflecting both contemporary health policy (Department of Health Western Australia, 2009) and contemporary LBP-related education models that increasingly adopt a biopsychosocial orientation.
Across the disciplines, chiropractic and physiotherapy students demonstrated significantly more helpful beliefs regarding LBP compared with medicine, occupational therapy and pharmacy students, and these differences were clinically and statistically significant. Physiotherapy students’ beliefs regarding the relationship between LBP and physical function were the most helpful. These data likely reflect the substantially greater volume of spinal pain-oriented curricula and clinical placements in physiotherapy and chiropractic courses. The HC-PAIRS score reported by physiotherapy students may reflect the greater emphasis of functional restoration in physiotherapy curriculum, compared with chiropractic. Notably, Ryan et al. (2010) observed HC-PAIRS scores in physiotherapy students to reflect more helpful beliefs compared with non-health students, and also showed that HC-PAIRS scores improved among physiotherapy students over the course of their university training. Despite pharmacy students reporting the least helpful beliefs, their BBQ scores were still higher than scores reported from community-based Australian cohorts (Buchbinder et al., 2001; Urquhart et al., 2008; Briggs et al., 2010); a finding that aligns with BBQ data collected from community pharmacists in England (Silcock et al., 2007). These data suggest that while emerging pharmacists’ beliefs relating to LBP could be improved relative to other disciplines, their beliefs remain more helpful than those held by the general community. This highlights the importance of involving pharmacy students (and pharmacists) in interprofessional learning activities related to spinal pain conditions, particularly given the central role of community pharmacists in providing evidence-informed information to consumers with spinal pain.
While we do not have access to each specific discipline’s curricula content, it is likely that differences in beliefs scores and clinical recommendations may partly reflect domain-specific orientation of university curricula, for which there is a significant focus in chiropractic and physiotherapy disciplines related to the management of spinal pain. Nonetheless, given that even a short (6.5 h), targeted, spinal pain education intervention can encourage health professionals to adopt more evidence-based beliefs and attitudes and self-reported clinical behaviours related to LBP, and these changes are sustained at 2 months postintervention (Slater et al., 2012), a targeted session within the current curricula could also be effective for students across disciplines.
In the context of spinal pain, HCPs beliefs are recognized as key factors influencing treatment approaches to LBP and the beliefs of their patients. For example, there is evidence that HCPs demonstrating a biomedical orientation or elevated fear avoidance beliefs are more likely to offer people with LBP guideline-inconsistent advice regarding work and physical activities (Darlow et al., 2012). Paradoxically, doctors who profess a special interest in back pain may offer advice that is discordant with evidence (Buchbinder et al., 2009). Houben et al. (2004) found that back pain beliefs were significantly correlated with work and activity recommendations. Our data support this literature, where multivariable logistic regression models confirm that more positive beliefs are associated with greater odds of respondents generally selecting clinical recommendations that are guideline-consistent, independent of their clinical discipline and prior experience of LBP. Therefore, optimizing LBP-related beliefs and attitudes across disciplines may be effective in encouraging young clinicians to select recommendations in clinical practice that are consistent with clinical guidelines. This approach may be particularly important for occupational therapy and pharmacy students, of whom 55–83% did not recommend guideline-consistent approaches for physical activity, work and rest.
Given that epidemiologic data predict a substantial increase in the burden of musculoskeletal pain over the next three decades (Woolf et al., 2010), and in LBP specifically (Hoy et al., 2010), this area of health care need requires cooperation between health policy, health services, professional bodies and health discipline training facilities such as universities. Effective and sustainable management of pain requires systemwide changes, particularly at the primary care level. In Australia, state (e.g. Models of Care; http://www. healthnetworks.health.wa.gov.au/modelsofcare/) and national (e.g. National Pain Strategy; http:// www.painaustralia.org.au/the-national-pain-strategy/ national-pain-strategy.html) policies emphasize the importance of addressing pain using a multidimensional approach, involving development of workforce capacity, upskilling consumers, disseminating appropriate public health messages and improving information exchange between consumers and health systems and providers. While strategies to improve beliefs and likely practice behaviours among practising clinicians have been shown to be effective (Buchbinder and Jolley, 2004; Evans et al., 2010; Domenech et al., 2011), a more sustainable approach and one that can be undertaken in parallel, could be to educate the emerging workforce in evidence-based practice for managing people with LBP. Indeed, this approach has been advocated strongly in the fields of musculoskeletal and pain medicine (Chehade et al., 2011; Jones and Hush, 2011; Briggs et al., 2012). Given the evidence for the effectiveness of interprofessional management for LBP (Turk, 2002; Lamb et al., 2010; Davies et al., 2011), this approach would adopt an interprofessional framework (Ali and Thomson, 2009) as a means to lever an interdisciplinary health professional culture shift regarding best-practice management. Despite recognition of the benefits of an interprofessional approach, a recent study identified limited opportunities for pain-related interprofessional learning opportunities across university health courses in the United Kingdom (Briggs et al., 2011). Delivering interprofessional education in a single location may be most effective, since at least some, if not a majority of students, would be likely to interact in a clinical network or community of practice, a model that has been shown to be effective for improving health outcomes and building effective professional relationships, and ultimately delivering better quality care (Cunningham et al., 2012).
The strengths of this study are reflected in the crossdiscipline and primary care-oriented approach and, consequently, the large sample size, a very good response rate and the assessment of likely clinical recommendations through the use of a patient vignette. To our knowledge, the use of a clinical vignette in this context has only been used by Domenech et al. (2011), and represents an approach that is considered to provide information more representative of practice behaviour and quality of care (Peabody et al., 2004). The study was cross-sectional in design, relied on selfreport and was based only on Australian students. Therefore we cannot speculate on the temporal stability of the results we reported, the accuracy of the outcome measures in predicting actual practice behaviours and beliefs of the students upon commencing clinical practice, or the generalizability of the findings to students studying in other nations. An important area of future research would be reassessing international cohorts following their engagement in the workforce in order to determine any shifts in clinical behaviours and beliefs.
Author contributions
All authors discussed the results and commented on the manuscript. A.M.B. and H.S. were responsible for the conception, design and management of the study. H.S., G.F.P., K.W. and J.C. were responsible for data collection. A.M.B., H.S. and A.J.S. were responsible for data analysis. All authors were responsible for interpretation of the data, drafting of the manuscript and approving the final version.
Acknowledgements
The authors acknowledge in kind support provided by Curtin University (Ingrid Van Zyl), Murdoch University, Notre Dame University (Ajanthy Arulpragasam) and the University of Western Australia (Eva Schluchter, Liza Seubert and Neil Boudville). Dr. Andrew Briggs and Dr. Anne Smith are supported by Fellowships from the Australian National Health and Medical Research Council and Curtin University, respectively. The authors acknowledge the support of the WA Spinal Pain Model of Care Group within the WA Musculoskeletal Health Network.
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