From Local Action to Global Policy: A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development

Background

Musculoskeletal (MSK) health refers to the integrity and function of the locomotor system, comprising muscles, bones, joints, nerves and associated connective tissues. MSK health is required for mobility, physical function, and dexterity across the life course. Impairments of the MSK system are typically associated with pain, reduced physical function and mobility, often leading to reduced social engagement (eg, work, schooling) and quality of life. Encompassing a suite of more than 150 disorders MSK impairments comprise MSK conditions (eg, arthritis, osteoporosis) pain manifesting in MSK structures (eg, low back pain) and MSK injury and trauma (eg, fractures).¹ Despite MSK health conditions being the leading cause of disability worldwide representing 17% of the global years lived with disability in 2019, global strategy and policy guidance lags behind that for other non-communicable diseases (NCDs), particularly in low resource settings.^2-4 Global policy to guide action on MSK health is in a nascent phase. There is currently little global policy or strategic direction that serves as technical guidance to assist national governments in developing whole-of-system approaches to MSK health.^5,6

Global policy serves to inform best-practice targets and provide guidance on the technical implementation of policies at local, national and regional levels. The development of global policy, however, evolves through a long process of agenda-setting, policy development, debate, legitimation and dissemination, with each stage entailing political, procedural and technical aspects.^6,7 The goal is the facilitation of policy learning; where unique experiences and local knowledge are observed, combined and analysed to provide a basis for globally-relevant learnings. The challenge is creating global policy that is grounded in local experience but interpreted into principles that find relevance and applicability across contexts. In recent years these development processes have been helpful for rapidly progressing global policy with respect to mental health,⁸ NCDs,⁹ antimicrobial resistance,¹⁰ tobacco control and alcohol and other drugs.^9,11-13

Despite the attributed high health and economic burden, MSK health receives little attention on the global stage, and has not featured prominently in recent global goal setting and consequently national policies on NCDs.⁶ Despite overwhelming and increasing recognition of the burden of MSK disorders,¹⁴ recent research has identified gaps in the evidence base in terms of effective policy solutions.¹⁵ The purpose of this review is to extend this knowledge base and contribute to the feasibility and promise of global MSK policy. In acknowledging that the development of global policy is grounded in phases of policy comparison and learning from local experiences, we aimed to, (1) perform a comparative analysis of national MSK policies and develop a snapshot of current national MSK policy approaches and priorities; (2) collate themes covered from the combined content of existing national policies; and (3) draw key principles from the existing pool of local policies that can be used in policy learning.

This study was undertaken as part of a three-phase project that included key informant interviews with MSK policy experts and a global eDelphi to determine prioritised components for a global strategy for improving MSK health.^16-18 The goal of this paper is to provide the detailed findings from our policy analysis to assist policy-makers at both national and international levels. We also aim to outline a detailed method for undertaking comparative policy content analysis for this purpose, in the hope that it can be useful for facilitating global policy learning for other vital health challenges.

Methods

Design

We undertook a systematic comparative policy content analysis of MSK heath policy documents adapted from the framework proposed by Arksey and O’Malley,¹⁹ and used by Anderson et al,²⁰ for policy mapping.

Inclusion Criteria: Document Types

Documents were included where they described national, sub-national or multi-national level health policies for a MSK health condition(s) that were government-issued – or co-sponsored with government – labelled as ‘policy,’ ‘strategy,’ ‘framework,’ ‘action plan’ or similar, consistent with definitions used previously.³ Policies needed to focus on MSK health generally, MSK pain, or any specific MSK condition.

Document Collection

We conducted a broad search for national MSK policies via four search methods.

First, we performed a systematic online desktop search for national MSK policies and guidelines from the 30 most populous countries, informed by United Nations World Population Prospects 2019. A comprehensive search in English was performed for each country using Google as the search engine from July 1, 2020 to August 15, 2020. Authors JJY, SM, and SP used a combination of search terms (policy OR strategy OR action plan OR strategic framework OR health indicators) AND (musculoskeletal OR chronic pain OR rheumatology OR orthopedics OR pediatrics OR rehabilitation OR gerontology/geriatrics OR physiotherapy OR chiropractic) along with the country name, to locate potential national policy documents. See Supplementary file 1 for full search terms. When search terms led to the webpage of a national government agency relevant to MSK health or chronic pain, manual searching of the entire website for relevant documents was performed. In addition, manual searching of other linked government agencies webpages was also performed. Further, we made contact with experts in MSK health with language and contextual knowledge of included countries. Contacts from countries not included in the top 30 most populous nations were also asked to identify any potentially relevant documents.

Second, we identified policy documents via requests to the Global Alliance for Musculoskeletal Health International Coordinating Council members and policy researchers (expert round), including those with access to raw data from an earlier integrated NCD policy review of OECD (Organisation for Economic Co-operation and Development) member states.³ The request was deliberately broad to enable the collation of policies that could fit any of the potential criteria for inclusion.

Third, we extracted data from a related project that used an eDelphi method to collect information from the global MSK community on systems strengthening opportunities and priorities.¹⁷ As part of the eDelphi, panel members were asked to identify national policies for MSK health in their country of residence. The question was posed in an eDelphi survey administered between October 2 and November 8, 2020. Of the 674 respondents to the original eDelphi, which included stakeholders with a policy, clinical, health services or lived experience lens, 22 answered this purposive question, providing links to policy documents. This step represented a secondary data analysis of an existing dataset for which Human Research Ethics Committee approval had been granted by Curtin University, Australia, in 2020 (HRE2020-0183).

Fourth, we examined all documents for reference to additional MSK policy documents following snowballing methods. All documents that were not originally in English or German were translated using an online document translator (https://www.onlinedoctranslator.com/en/) as previously.³

Inclusion Criteria (Document Content) and Document Selection

An initial review of documents included in the pool showed a wide variety of document types, publishers, purposes and formats, with only three specifically designed as national-level policies for MSK health. Inclusion criteria outlined above were further refined to ensure the analysis was targeted at the study aims of comparing national MSK health policies, but also included documents that target MSK specific conditions. Our final inclusion criteria were: policy documents that are (1) government-issued; published by official government departments, or explicitly endorsed by government departments as representing the policy of a specified jurisdiction; (2) targeted at the population-level improvement in MSK health; or containing a substantial sections/chapters dedicated to MSK health (general) or any of the following clinically meaningful categories: non-cancer pain conditions (either regional or widespread); osteoarthritis; injury (including occupational), excluding trauma; and auto-immune inflammatory conditions with MSK manifestations; (3) was the current version (if regularly updated) with a publication/coverage date not older than 2010; and (4) contains jurisdiction-wide strategies, action plans or system-level models of care. We did not disaggregate classification categories for MSK conditions based on International Classification of Diseases 11th Revision (ICD-11), since many policies pre-dated this classification system and did not describe conditions at the granular level of ICD classification. Rather, we took a pragmatic approach to meaningfully group disease/condition classifications that aligned with classification approaches used across the policies. We defined a system-level model of care as a document including a care pathway that includes prevention, diagnosis, treatment, rehabilitation and recovery, and identified the roles played by different providers within the pathways, their responsibilities, and information on how the different providers connect within the system. Documents that were primarily targeting related aspects of health, such as NCDs, population health, occupational health and injuries were only included if they contained a substantial component addressing the above criteria.

Authors CHS and SP performed a review of documents for inclusion/exclusion, with verification of those meeting inclusion criteria undertaken by JJY and AMB. All excluded documents were reassessed independently, with discordance resolved through consensus meetings.

Data Analysis

Authors SP and CHS collated and prepared all documents for extraction. Two data extraction templates were developed in Excel, one for descriptive level information about the documents and a second for the comparative content analysis and abstraction of principles. Spreadsheets were used for a comparative policy content analysis, undertaken in three steps: (1) categorisation, (2) descriptive thematic analysis, and (3) interpretative analysis.

Categorisation

Authors CHS and SP read all policy documents independently and extracted high-level data about each document including, country of origin, jurisdiction, publisher, date, and target condition(s). We then identified and extracted the overarching targets, goals and objectives specified in each policy document and inductively open-coded these texts to identify themes. Open coding was undertaken manually by extracting excerpts for collation using Excel, with regularly review, consolidation and merging.

Analysis

Descriptive Thematic Analysis

We identified analysis categories a priori, initially based on World Health Organization (WHO) Building Block elements, given the universal acceptance and familiarity of this model with policy-makers addressing health systems strengthening. We assessed the construct validity and ‘fit’ of this model through a round of inductive coding of 6 policy documents from the yield that appeared in first order through the original search. Following this inductive coding, we added two further categories to the WHO Building Blocks, including “Citizens, Consumers and Communities” and “Research and Innovation.” These categories aligned intuitively with the themes identified in our earlier qualitative research which formed the framework for the ‘Empirically derived logic model for a global strategy for MSK health.’¹⁷ These categories were used to deductively code the remainder of the texts. CHS and SP were each allocated different analysis categories and extracted texts that were open-coded to determine the number and type of sub-themes included in the texts within each category. Definitional boundaries around each sub-theme were then agreed upon, in conference between SP and CHS, and reported for discussion to all authors. Sub-themes were refined, expanded or merged as necessary.

Interpretive Analysis

To extract key principles underlying the meaning of texts, we read, discussed and interpreted underlying meanings from across multiple texts within each category, reflecting on position, overarching goals, common linguistic patterns and purpose of texts.¹⁷ Principles were developed to represent the common underlying purpose of a policy action for achieving policy goals. Abstracted principles were presented at working group and project group meetings and discussed with all authors and refined for internal validity and consistency purposes.

Results

Overview of Included Policies

From an initial yield of 165 documents, 6 were excluded as duplicates. A further 7 documents were excluded as falling outside of the specified date range and 111 documents did not meet the criteria of being a policy document or did not have a substantial MSK component. It is notable that while our search was not designed to capture clinical and treatment guidelines, or reports on MSK burden and risk factors, we identified a far greater number of these than we did policy documents in our final yield. These peripheral documents also came from a greater range of high-, low- and middle-income countries (LMICs) (see Table 1) than policy documents. After exclusions, 41 (24.8%) policy documents remained for analysis, representing 22 countries including Australia,^21-23 Belgium,²⁴ Canada,^25-27 Chile,²⁸ Columbia,²⁹ Denmark,³⁰ Finland,³¹ France,^32,33 Hungary,³⁴ Italy,³⁵ Ireland,³⁶ New Zealand,^37-39 Norway,^40,41 Portugal,⁴² Republic of Korea,⁴³ Spain,⁴⁴ Switzerland,^45,46 Turkey,⁴⁷ the United Kingdom (England),^48-50 the United Kingdom (Scotland),^51,52 the United Kingdom (Wales),⁵³ the United States^54-58; and two multi-national regions (European Union^59,60; international⁶¹).We did not identify any eligible documents from LMICs, however, a number of MSK-relevant documents from LMICs were identified from the search (see Table 1). Of the 118 documents excluded after removal of duplicates, most were classified as clinical guidelines (n = 56), government reports on burden of disease (n = 14), non-governmental calls to action and reports (n = 17), and other non-policy literature (n = 14).

Policies collated via each method, are summarized in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-aligned flow chart (Figure). We included countries of origin of excluded documents in this figure to demonstrate the breadth of countries that are recognising and working towards action on MSK health, even where policies are not yet developed.

Close

Figure. Comparative Policy Content Analysis of National Polices to Address Musculoskeletal Health: PRIMA Diagram. Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Policy Characteristics

The documents we analysed varied greatly in form and purpose (see Table 2). Documents ranged from book-length reviews of the current health system, MSK services disease burden and future reform initiatives (for example, documents USA 1 and Belgium 1), to stand-alone tables of goals, target roles and responsibilities but without guiding text (for example, document Columbia 1).

Although the documents varied in form and even target condition, there was a commonality in purpose across most documents to improve understanding and awareness of the conditions they addressed and reduce disease burden.

Addressing Musculoskeletal Conditions

A range of MSK conditions were addressed in policies, while very few documents addressed MSK conditions in their full breadth (Table 3). Only 9 documents (European Union 1, International 1, New Zealand 3, Switzerland 2, Turkey 1, the United Kingdom [Scotland] 1, and the United Kingdom [England] 1, 2, and 3) aimed to address MSK health as its primary goal.^{39,46-50,52,60,61} Of those documents in the preceding list, only 3 were comprehensive national MSK policies addressing all parts of the health system (Switzerland 2, Turkey 1 and the United Kingdom (England) 3).^46,47,49

In our pool, six documents were broad national health plans or national NCD plan with substantial component on addressing MSK health (Italy 1, Finland 1, Hungary 1, Republic of Korea 1, Norway 2, and Switzerland 1).^{31,34,35,41,43,45} Other documents were either cross-jurisdictional, or only addressed parts of the health system (eg, residential care, or allied health workforce). Three countries (Australia, the United States, Canada) appeared to have a series of policies that each addressed different MSK conditions, which combined could be interpreted as entailing a comprehensive MSK policy response.

The most commonly addressed MSK conditions across all policies were pain (general, 19 policies), osteoarthritis (13 policies) occupational health (12 policies) and low back pain (12 policies) (Table 2). The MSK strategy of Turkey⁴⁷ contained a substantial focus on different conditions, compared with all other policy documents. While it did address low back pain, osteoarthritis and inflammatory rheumatic conditions, it also dedicated equal specific attention to familial Mediterranean fever and Behçet’s disease, indicating the country-specific burden of those conditions.

Policy Themes and Principles

Targets and Goals

Despite the variety in document formats and target conditions, there was a surprising consistency in the themes present in policy targets and goals. Almost all policies aimed to reduce the target burden of the diseases, frequently citing the relatively little attention given to MSK conditions in the health system compared to the known burden. Other key themes are listed in Box 1.

Policy Content

Across the 8 policy categories, we inductively derived 47 sub-themes. Table 3 summarises the strategies outlined across policies, presenting the derived sub-themes by analytic category with exemplar excerpts as evidence, along with the transferable derived principles.

The most comprehensively addressed major category across the policy documents was MSK health services. This included the range and types of services needed to promote MSK health, and how these services could be delivered. Many documents included texts that emphasized MSK health impairment as a collection of conditions that impact health and wellbeing over long periods of life and requires multi-disciplinary, coordinated services, individual-level assessment and tailored treatment. We drew a total of 9 sub-themes and transferable principles from the documents as they relate to service delivery.

The second most broadly addressed major category in the documents was centred around the health workforce. This is unsurprising considering the close connection between health services and human resources required for care delivery. Furthermore, with MSK being one of the most common reasons people seek primary care, and the recognized lack of primary care availability in many parts of the world by their own governments, particularly in underserved communities, this makes sense to be one of the more common themes. The need for formal and continuing education, as well as workforce planning and support tools were the most frequent sub-themes. In total, we found 8 distinct sub-themes and transferable principles with respect to the MSK health workforce.

The next two most broadly raised categories in the texts related to “financing” and “medicines and technologies.” The place of pharmacological and biological treatment in multidisciplinary care, medical education and knowledge for citizens; and the appropriate use, in particular concerning opioid medications, dominated texts around medicines. We determined 6 distinct sub-themes concerning medicines and technologies. Given the prevalence of texts around the appropriate use of opioid medication, we determined this warranted a separate distinct sub-theme.

There were very few documents that covered in-depth how MSK services, models of care or other activities addressing MSK health should be financed. We relied on smaller text excerpts from the breadth of documents to draw 6 distinct sub-themes and abstracted principles related to this category. Where financing was discussed, texts focused on ensuring that systems of risk pooling, public funding, safety nets, and reducing out-of-pocket costs should be in place for enabling affordable access to health services.

Almost all documents contained policy statements concerning data monitoring and information systems; with a considerable number of common themes and underlying principles. Ensuring that the quality of services and outcomes are measured, and building systems to collate data through standardized processes were key features in most policies. We determined 5 distinct sub-themes and transferable principles related to data and monitoring.

We also found 5 sub-themes in texts related to leadership and governance, although this was not commonly addressed specifically as an area for action. Rather we found a reference to the roles and responsibilities allocated to organisations and individuals within the system, as well as the decision-making structures that have been, or will be, established to govern MSK health. We also found a single reference to the roles that non-governmental organisations play in MSK health, particularly in agenda-setting and as issue-area champions.

Finally, we drew 4 distinct sub-themes in each of the inductively coded analysis categories. With respect to citizens, consumers and communities, most policies contained strategies or goals to educate and empower citizens with better knowledge of MSK health for both prevention and treatment. Policies also focused on reaching priority populations, either through screening, planning or by developing culturally sensitive models of care.

Policy documents that were comprehensive strategies targeting whole-of-systems approaches included calls for increased research and innovation for improving MSK health. This included strategies to ensure investment in research was commensurate with the burden and setting research priorities; for example, by means of establishing high-level research systems and funding mechanisms. Notably, only a minority of policies addressed a life course approach to MSK health or mentioned MSK health in children or younger people. Polices Canada, the United Kingdom, Australia, and France discussed childhood conditions including juvenile arthritis, bone health and pain care, while a life course approach was recommended in policies from Canada, Switzerland, and Australia.

Discussion

Our policy content analysis has found a paucity of policy documents that address the breadth of MSK conditions under one overarching strategy. Critically, very few documents brought together all major policy themes including the WHO Health System Building Blocks, as well as policy themes related to ‘research and innovation,’ and ‘citizens, consumers and communities.’ These findings underline the importance of creating tools and resources to facilitate MSK policy learning and sharing from the breadth of many policy examples, rather than the depth of a few.

In the few countries where a system-wide overarching policy and strategy to guide MSK health has been developed, such as England, Turkey, and Switzerland, this is likely to have been the product of particular policy entrepreneurship and a facilitating policy context. We propose further research into the history of the development of these policies to determine facilitating factors would be important to understand historical context and to inform prospective policy evolution and evaluation.^6,62 This approach has been used to better understand policy and global priority evolution related to NCDs generally.⁶³ However, even among these few national-level strategies, the variation in format and nature and depth of content, indicates that we are still firmly in a phase of sharing policy experiences and tools, with a focus on engaging in policy learning, rather than supporting widespread implementation and monitoring. Global technical advice to support the establishment of MSK policy has been lacking but could contribute to increased efficiency in the development of MSK policies at the national level, and indeed, an empirically-derived strategic framework has been developed recently for this purpose, as well as more nuanced and context-specific recommendations for low- and middle-income settings.^2,17,18

There are opportunities for policy entrepreneurs, from government, industry or civil society sectors to draw on the principles itemized in this review to drive MSK policy evolution locally. This is especially the case in countries that have already invested in monitoring and recording of MSK burden – and we found many examples of this as an incidental finding in our document collection – as well as countries where population health monitoring of MSK health is absent or emerging.⁶⁴ Indeed, as the burden attributed to MSK health impairment becomes more widely recognised and countries move towards arresting this burden, as recommended by Global Burden of Disease findings,^4,14,65 there will be an increasing need to identify extant and transferable policy solutions and foci. These data will be relevant not only to individual nations but also global health agencies such as the WHO, where programmatic activity related to MSK health is emerging. The combination of the evidence of burden, with examples of how strategies can be formulated and implemented can be used to pry open the policy window. This has become even more relevant due to both direct and indirect effects of the coronavirus disease 2019 (COVID-19) pandemic on MSK health – from the complex interlinkages between COVID-19, social circumstances and MSK pain; through the changing policy focus on local and global health authorities. With the COVID-19 pandemic drawing policy attention away from chronic conditions, including MSK health over the past 3 years, strong evidence and feasible policy solution are even more important tools in the tightened space of agenda setting.⁶⁶

Patterns and trends in the documents we analysed indicate that there may be several pathways that can be taken in the development of MSK policy at a country level.

For example, several countries (for example the United States and Australia) have built a series of policies targeting MSK specific conditions, rather than a single overarching MSK strategy. This may be a more feasible approach to developing MSK policy than a single strategy in some settings; while in others an integrated single strategy may be more resource efficient.⁶⁷

Another example is dispersing responsibility and authority for policy development. In some countries, notably Australia and, Canada, MSK policies were also authored by non-government organizations (including consumer advocacy and professional societies) and research institute with expertise in specific MSK conditions; with a mix of funding, endorsement or co-production with government. The relationship between peak bodies, national research institutes and governments differs from country to country but could also provide important resources and capacity in the development of new policy and system strategies.

As mentioned above, based on our operational definition, we identified a far greater number of clinical guidelines for MSK health, or reports on MSK disease burden, than we did policy documents. This is despite our search not targeting this type of document specifically. Clinical guidelines may be a useful foundation for the further development of MSK policy in more countries around the world, including LMICs, as it signals the challenges and size of evidence-practice gaps at service and clinical levels. Measuring and understanding the burden of disease and having sound best practice person-centred care are the foundations of understanding service and workforce needs and building the resources for system level strategies and MSK models of care.⁶⁸

This finding likely reflects an existing strong research network around disease surveillance and monitoring, including the MSK burden and the ensuing strong evidence base.⁴ Importantly, similar burden of disease documents were also identified from LMICs, potentially pointing to emergent activity for health systems strengthening in these countries, despite a recognised lack of local MSK population health surveillance.^64,69 Most documents were also dominated by goals, targets, service provision and strengthening the workforce, with considerably less focus on governance, technologies and workforce and only a few documents included aspects of monitoring, innovation and community engagement. Apart from a few, we also noted that most policies did not frame discussions around a life course approach or address MSK health in children. This is unusual for policies addressing an NCD where a life course approach is typically a guiding principle, the strong association between disease expression and life course behaviours, and that MSK impairments are common in children. Across all major themes, there is considerable potential for further policy learning and related system strengthening contextualised for country-specific purposes.

While we identified many national clinical guidelines and reports of national MSK disease burden, there were few system-level policies, strategies or action plans. This suggests that while there has been positive progress in recognizing burden of disease and articulating approaches for clinical management, system-level strengthening is rarely purposively and strategically developed in current policy. We found only 3 documents that could be considered system-wide strategy or policy for MSK health conditions at the national level^46,47,49 and two at the international level.^59,61

Collectively, the pool of documents contained a breadth of key issues, themes and principles. The content analysis of the policies triangulated closely with independently collected data from aligned mixed-methods research in our broader program of work on empirically deriving a co-designed health systems strengthening response for MSK health.^16,17 This close alignment between independently collected and analysed data validates the concurrent and construct validity of our findings. Importantly, the priorities and strategies articulated by key informants and the global MSK community sampled in our aligned work¹⁸ are also reflected closely in national policy documents, suggesting an evolution of policy that is reflective of community expectations.

Strengths and Limitations

This comparative policy analysis was the first to provide a comprehensive global search through multiple data collection steps, including networks facilitating the collection of documents in multiple languages combined with a global. Our refinement of categories enabled comparisons across a wide range of document types; enabling collation, analysis and extraction of principles in a policy field where complete, comprehensive national strategies were almost non-existent. The use of interpretive analysis methods enabled the extraction of principles that can be interpreted and applied across contexts, while maintaining the policy learning from original local country-level experience. This work was also strengthened by parallel work undertaken within a wider project that included eDelphi expert panel views on key themes and principles thereby enabling concurrent validation.¹⁷

We excluded documents addressing road traffic injury and injury through violent trauma and acknowledge these policy areas as critical for MSK health. We only included policy documents addressing NCDs if there was explicit and substantial inclusion of MSK policy, strategy, or targets, and acknowledge the close interplay between other NCDs and MSK health, and the common shared risk factors.

While our initial web-based search focused on the 30 most populous countries; and was then supplemented by an expert round and responses to an e-Delphi with participants from 72 countries, it is possible that our search failed to uncover all relevant documents, particularly those from less populated countries.

Conclusion

The development and use of national policies for MSK health is still in its infancy. Very few national policies covered multiple MSK conditions; nor did many documents in our analysis cover all health system building blocks or supplementary categories of MSK policy interest. However, the collective pool of documents contained a breadth of key issues, themes and principles and collated and grouped this content covered key principles and abstract key principles that can helpfully guide policy sharing and learning. Future global guidance to assist countries to develop their own MSK policies and strategies can draw on implemented principles across the health system building blocks, including service delivery, workforce, medicines and technologies, financing, data and information systems, and governance. Existing policy also embody underlying principles of action with respect to citizens, consumers and communities including public education and awareness and working in partnerships.

These collective key issues, themes and principles may be helpful in informing the development of a global policy and technical guidance on action to improve MSK health that is grounded in local experiences.

Ethical issues

This article reports on documentary analysis as well as secondary data analysis of an existing survey dataset for which Human Research Ethics Committee approval had been granted by Curtin University, Australia, in 2020 (HRE2020- 0183).

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

CHS and AMB conceptualised the study. AMB, DKG, JJY, SS, CHS, and SJ developed and performed search strategies. CHS and SP undertook data extraction and analysis and AMB and JJY performed verifications. AMB, DKG, HS, and LM contributed additional refinement of definitions and inclusions/exclusions. All authors reviewed the results and participated in analytical cycles. CHS lead the writing of the manuscript together with SP and AMB. All authors contributed to the manuscript including final review.

Funding

This project was funded by a grant awarded by the Bone and Joint Decade Foundation with additional funding provided by Curtin University, Australia, and guided by an international external steering group of experts in the field of musculoskeletal health.

Supplementary files

References

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