Br J Pain. 2015 Nov; 9(4): 203–212.
PMCID: PMC4616980
1Musculoskeletal Research
Collaboration (Epidemiology Group), Institute of Applied Health
Sciences, The School of Medicine and Dentistry, University of Aberdeen,
Aberdeen, UK
2Division of Population Health Sciences, School of Medicine and Dentistry, University of Dundee, Dundee, UK
3Dental Hospital, The School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
Abstract
Introduction:
Biobank-type
studies are typically large but have very low participation rates. It
has been suggested that these studies may provide biased estimates of
prevalence but are likely to provide valid estimates of association. We
test these hypotheses using data collected on pain in a large Biobank
study in the United Kingdom.
Methods:
UK
Biobank recruited 503,325 persons aged 40–69 years (participation rate
5.5%). Participants completed questionnaires, including pain, lifestyle
and environment factors. As a comparison, we used both a large
population study of pain (MUSICIAN: n = 8847, aged:
40–69 years) conducted 2008–2009 and the National Child Development
study (NCDS) which recruited all persons in Great Britain born during
one week of 1958 and followed them up at age 44 years (n = 9377).
Results:
‘Any
pain’ (UK Biobank 61.0%; MUSICIAN 63.9%), chronic pain (42.9%, 52.2%)
and site-specific musculoskeletal pain (back 26.2%, 29.7%; shoulder/neck
23.3%, 25.3%) were generally similar in UK Biobank and MUSICIAN. The
prevalence of chronic pain and most regional musculoskeletal pains in UK
Biobank were all within 2% of that in NCDS.
Conclusion:
UK
Biobank has provided estimates of the prevalence of pain which are
similar to those from previous large-scale studies, although a formal
comparison of the estimates cannot be made. It has also confirmed known
associations with the reporting of pain. Despite its very low
participation rate, such a study provides the opportunity to investigate
novel exposure–pain relationships and investigate rarer exposures and
characteristics to further our knowledge of the epidemiology of pain.
Keywords: UK Biobank, pain, musculoskeletal, prevalence, associations
Introduction
In
the recent past, there has been an increase, internationally, in the
number of large-scale epidemiological studies undertaken to investigate
the genetic and environmental influences on disease. These studies which
typically include the collection of biological samples are generically
termed ‘Biobanks’ and the Public Population Project in Genomics and
Society (P3G) has been formed to provide the international
research community access to the expertise, resources and innovative
tools to exploit such collections of data. An example of such a study is
‘UK Biobank’. This study recruited half a million people aged between
40 and 69 years from across Great Britain (http://www.ukbiobank.ac.uk).
Participants completed questionnaires on aspects of health and
lifestyle. They also provided blood, urine and saliva samples and agreed
to have their health followed over time, including through routinely
collected health data.
In contrast to more traditional
epidemiological studies, Biobanks, although large in numbers, often have
very low participation rates. Epidemiologists have traditionally been
concerned about studies with low participation rates, because of
selection bias, and different prevalence of diseases and exposures has
been demonstrated among non-participants in epidemiological studies,
including for the reporting of pain.1
As non-participation increases, the potential for bias also increases.
Typically, large-scale Biobanks are concerned with examining genetic
influences on disease or the joint effect of genetic with environmental
factors and although there may be selection bias present and thus
participants are not representative of a sampling frame from which they
were drawn, it has been argued that the mechanisms of disease (observed
through associations) are unlikely to differ between participants and
non-participants.2 Although whether this universally applies has been challenged.3
Furthermore, with very large sample sizes, there may be sufficient
numbers within each socio-demographic and clinical subgroup (including
sub-groups which are proportionally under-represented) to allow
stratification-specific examination of associations.
We
wished to quantify the likely effect of selection bias on one of the
most common health conditions which has been collected by UK Biobank,
namely pain (with a focus on sites related to musculoskeletal pain).
Specifically, we wished to determine whether UK Biobank would confirm
findings from previous UK epidemiological studies: (a) the prevalence of
pain and (b) site-specific associations with age, and strong
associations with low socio-economic status and adverse psychosocial
factors. Finally, because of its size, UK Biobank is able to look at
potential associations with rare exposures or disease determinants which
other studies have been insufficiently powered to examine, and as an
example of this, we chose ethnic group.
Methods
A summary of the features of UK Biobank and the comparator studies used is given in Table 1.
Features of UK Biobank and comparator studies.
UK Biobank
Detailed methods used by UK Biobank4
have been published previously, and here, we provide only summary
details of relevance to the current analysis. The study aimed to recruit
persons aged 40–69 years who were registered with a general
practitioner (GP) within the National Health Service (NHS). As it is
estimated that over 95% of persons are so registered, this provides a
suitable population sampling frame in the United Kingdom5
Overall, around 9.2 million invitations were issued to people living
within about 25 miles of one of the 22 assessment centres in England,
Scotland and Wales. In total, the study recruited 503,325 people between
2006 and 2010, a participation rate of 5.5%.
At the
assessment centre, participants completed questionnaires including items
on lifestyle and environment. Information on pain was collected by
means of a touch screen questionnaire. Participants were asked ‘In the
last month have you experienced any of the following that interfered
with your usual activities?’ They were then provided with a list:
headache, facial pain, neck or shoulder pain, back pain, stomach or
abdominal pain, hip pain, knee pain, pain all over the body. For each
site for which they answered positively, they were asked whether this
pain had lasted at least 3 months, and persons reporting any individual
pain as chronic were defined as having ‘chronic pain’. Subjects who
reported ‘pain all over the body’ were not offered the option of
choosing any further regional sites. We have not considered the regional
pain sites abdominal pain, headache and facial pain further since the
first two are not primarily musculoskeletal, while an analysis of the
epidemiology of facial pain within UK Biobank has previously been
published.6
The determinants or exposures which we considered in relation to pain
in this analysis were self-reported sex, age and ethnic group. We have
classified the latter (based on the information collected by UK Biobank)
as white, mixed ethnic group, Asian or Asian British, Black or Black
British, Chinese or ‘other’ ethnic group. As an example of psychosocial
factors, we have used reporting consultations to a GP with mood
conditions (‘Have you ever seen a general practitioner (GP) for nerves,
anxiety, tension or depression?’), the number of self-reported such
episodes (‘How many periods have you had when you were feeling depressed
or down for at least a whole week?’), how happy they were (‘In general
how happy are you?’) and specifically with their job (‘In general how
satisfied are you with the work that you do?’). Participants were asked
about adverse life events (‘In the last 2 years have you experienced any
of the following?’); these related to death, serious illness or injury
to a partner or close relative, marital separation or financial
difficulties. Mood and adverse life events have been demonstrated to be
strongly related to the reporting of pain.7
Although there are considerable additional measures made on lifestyle
and environment, such as diet and physical activity and linkage to
routine datasets, and biological samples collected, these have not been
used for the current analysis.
Although we can make comparison with UK Biobank across several studies, as direct comparisons we used first the Managing Unexplained MuSculoskeletal Conditions UsIng traditional and Accessible New approaches (MUSICIAN) study and second The National Child Development Study (NCDS).
MUSICIAN study
The MUSICIAN study involved a randomised trial to test non-pharmacologic management of chronic widespread pain (CWP).8
Since identification of eligible patients with CWP is difficult from
primary care records, a large-scale recruitment survey of persons
25 years and over was undertaken in two areas of Great Britain. For the
purposes of the current analysis, we use only those within the age range
of UK Biobank. Pain was identified by asking participants, ‘Thinking
back over the past month, have you had any aches or pains that have
lasted for 1 day or longer?’ Respondents answering positively were
invited to shade the location(s) of their pain on 4-view body manikins.
In total, 8847 persons aged 40–69 years participated (crude
participation rate 35.9%). Participation generally increased with older
age, from 25.8% in those 40–44 years of age to 45.3% in those aged over
65–69 years and participation was higher in females (40.1% vs 31.8%).
NCDS
The
NCDS recruited all children born in Great Britain during a specific
week of March in 1958. Altogether the sample consisted of 18,558
individuals and comprehensive details have been presented previously.9
These children have thereafter been followed-up at seven points through
their childhood and adult life. Most recently, a biomedical survey was
conducted, commencing in 2002 (at 44 years) on the remaining
participants still in contact with the survey and not previously
requiring a proxy interview: 78.3% agreed to participate. The questions
asked about pain at this follow-up were identical to those used in the
MUSICIAN study.
Statistical analysis
UK Biobank versus MUSICIAN study
For
both studies, the crude prevalence of any pain, chronic pain and
regional musculoskeletal pains was calculated. The directly adjusted
prevalence (standardised prevalence (SP)) was thereafter calculated in
both studies by weighting according to the age, gender, or age and
gender structure reported in the 2011 UK census (denoted as SPage, SPgender and SPage/gender, respectively).10
UK Biobank versus NCDS
By
definition, most of the participants in the NCDS were of a similar age
when they responded in the follow-up which commenced in 2002: 95.5% were
aged 44 years, 4.1% were aged 45 years and 0.4% were aged 46 years.
Therefore, we directly adjusted the prevalence proportions obtained
within UK Biobank to this age distribution.
Furthermore,
for UK Biobank, the prevalence of any pain and chronic pain was
calculated for each of the socio-demographic and potential associated
factors used in this analysis and risk ratios (RRs) with 99% confidence
intervals (CIs) calculated by Poisson regression adjusted for age and
gender. In addition, the prevalence of each regional pain was calculated
by self-reported ethnic group and RRs with 99% CIs calculated using
‘white’ as the reference group and, using Poisson regression, adjusted
first for age and sex and second for other potential confounders:
income, employment status and number of adverse life events. All
analyses were conducted in STATA Statistical Software: Release 13.0.
Results
Prevalence of pain according to demographic factors in UK Biobank and MUSICIAN
In
total, 498,071 participants in UK Biobank between 40 and 69 years old
responded to the question about pain they had experienced in the last
month. Of these, 301,840 answered that they had any pain, providing a
crude prevalence of 60.6% and an age and gender SP (SPage/gender)
of 61.0%, 99% CI: 60.8%, 61.2%, while 217,608 reported pain which was
chronic, providing a crude prevalence of chronic pain of 43.7%, a SPage/gender of 42.9%, 99% CI: 42.7%, 43.1%. Pain was more common in females than males (SPage 62.4% vs 59.5%, RR: 1.05, 99% CI: 1.04, 1.06) as was chronic pain (SPage 45.7% vs 40.0% RR: 1.14, 99% CI: 1.13, 1.15). The most common regional musculoskeletal pain reported was back pain (SPage/gender
26.2%) followed by shoulder/neck (23.3%) and knee pain (20.7%) and hip
pain (10.2%). For all regional pains with the exception of back (female
25.1% vs male 27.4%) and knee pain (19.7% vs 21.6%), the prevalence was
higher in women (Table 2). Reporting of any pain only varied to a small extent across this age group: SPgender
was 61.9–62.6% between 40 and 49 years and thereafter decreased to
59.9% by age 65–69 years. The reporting of chronic pain increased
modestly across the age range from 39.6% at age 40–44 years to 45.7% at
age 65–69 years. For knee and hip pain, there was a clear pattern of
increasing prevalence with older age (knee pain 16.8% at age 40–44 years
to 24.7% at age 65–69 years; hip pain 6.8% to 14.4%). Back pain, and
shoulder/neck pain, did not vary much across this age range, with all
age-specific prevalence estimates around 26% and 23%, respectively.
Prevalence
of pain reporting in UK Biobank and the MUSICIAN study and by
musculoskeletal site, gender and age (standardised to UK 2011 population
structure).
In
total, 8847 participants in MUSICIAN between 40 and 69 years old
provided an answer for the question about pain they had experienced in
the last month. Of these, 5679 answered positively, providing a crude
prevalence of 64.2% (SPage/gender 63.9%, 99% CI: 62.5%, 65.2%), while 4684 reported pain which was chronic, providing a prevalence of chronic pain of 53.2% (SPage/gender 52.3%, 99% CI: 50.9%, 53.7%). Pain was more common in females than males (SPage 64.8% vs 63.0%, RR: 1.03, 99% CI: 0.99, 1.07). The most common regional pain reported was back pain (SPage/gender
29.7%) followed by shoulder/neck (25.3%), hip pain (24.7%) and knee
pain (24.3%). For all regional musculoskeletal pains, prevalence was
higher in women, but the excess prevalence was least for back pain
(female 29.7% vs male 29.6%) and knee pain (25.0% vs 23.6%), the two
sites which showed a small excess prevalence in males within UK Biobank.
Prevalence increased with older age from SPgender 61.8% in
40–44 years to 65.1% at age 60–64 years with a small decrease to 64.8%
at ages 65–69 years. The prevalence of chronic pain generally increased
across the eligible age range from 48.5% at age 40–44 to 56.8% at age
65–69 years (Table 2).
For knee and hip pain, there was a clear pattern of increasing
prevalence with older age (knee pain 19.0% at age 40–44 years to 29.4%
at age 65–69 years; hip pain 21.9% to 27.8%). Back pain and
shoulder/neck pain did not show any clear pattern in prevalence across
this age range.
Pain reporting in UK Biobank in comparison to NCDS
The
prevalence of chronic pain and the regional pain sites shoulder/neck
pain, back pain and knee pain reported in UK Biobank among subjects of
44–46 years were all within 2% of that reported within NCDS. Only the
reporting of any pain (62.8% UK Biobank vs 53.3% NCDS) and hip pain
(7.4% vs 15.4%) were out with this margin of agreement (Table 3).
Prevalence
of pain reporting by musculoskeletal site in UK Biobank and NCDS study
(standardised to age structure of respondents in NCDS follow-up
commencing in 2002).
Pain reporting in relation to socio-economic factors
In
UK Biobank, the prevalence of pain and particularly chronic pain in the
previous month was strongly related to various measures of social and
economic status. The SPage/gender of chronic pain decreased
monotonically as income group increased, from 52.5% among those with
annual incomes less than £18,000 to 33.5% among those with income
greater than £100,000 (RR: 0.64, 99% CI: 0.62, 0.66; Table 4):
Similarly those who left education prior to 16 years (53.2%) were more
likely to report chronic pain than those who remained in education to at
least 17 years (41.4%, RR: 0.77, 99% CI: 0.76, 0.78). In relation to
employment, chronic pain was least common among those in paid employment
(39.8%) and those doing unpaid or voluntary work (42.3%), while almost
all persons who were unable to work because of ill-health reported
chronic pain (78.9%; RR: 1.99, 99% CI: 1.96, 2.01).
Pain and chronic pain reporting in relation to socio-economic factors in UK Biobank.
Pain reporting in relation to psychosocial factors
The
reporting of pain was related to the measured psychosocial factors,
with stronger associations being observed with chronic pain. Those who
had consulted a GP for ‘nerves, anxiety, tension or depression’ had an
excess risk of reporting chronic pain (SPage/gender 52.2% vs
38.0%; RR: 1.36, 99% CI: 1.34, 1.37) and the likelihood of reporting
chronic pain increased strongly with the reported number of episodes of
depression (no episodes: 35.5%; 1 episode: 39.1%, 2/3 episodes 44.1%;
>3 episodes 52.4%; Table 5).
Similarly, there was a monotonic increase in the prevalence of chronic
pain reporting according to how unhappy respondents were (extremely
happy 35.7% to extremely unhappy 72.5% RR: 2.10, 99% CI: 1.91, 2.30).
The same relationship was found when respondents, who were employed,
were asked about how satisfied they were with their job (extremely happy
38.3% to extremely unhappy 59.4% RR: 1.56, 99% CI: 1.44, 1.69).
Finally, in relation to life events in the past 2 years, there was an
increase in chronic pain prevalence with number of adverse events (38.2%
with 0 events, up to 72.5% for 4 or more events RR: 1.94, 99% CI: 1.86,
2.02).
Pain and chronic pain reporting in relation to psychosocial factors in UK Biobank.
Pain reporting in relation to self-reported ethnicity
In comparison to persons who identified their ethnicity as ‘white’ (pain SPage/gender
60.3%), persons identifying themselves as Asian (71.8%; RR: 1.19, 99%
CI: 1.17, 1.21), Black (70.2%; RR: 1.15, 99% CI: 1.13, 1.18), mixed
ethnicity (66.3%, RR: 1.09, 99% CI: 1.05, 1.13), with the exception of
Chinese, (71.5%, RR: 1.18, 99% CI: 1.15, 1.21) were more likely to
report pain (Table 6).
After adjustment for potential confounders (income, employment status
and number of adverse life events), these differences between the groups
still remained but were considerably attenuated. The relationships were
similar for chronic pain, although slightly less strong, especially
after adjustment (RRadj: 1.04–1.12). Only persons identifying
themselves as of Chinese ethnicity were not more likely to report pain
(61.0%, RR: 1.00, 99% CI: 0.95, 1.06) and indeed were less likely to
report chronic pain (RR: 0.86, 99% CI: 0.79, 0.95). The excess pain
prevalence in non-Chinese (in comparison to those identifying themselves
as white) was observed for all musculoskeletal pain sites. For those of
Chinese origin, there were no differences, compared to whites in the
prevalence of back pain (27.3% vs 25.8%, RR: 1.06, 99% CI: 0.95, 1.19),
but they were significantly more likely to report neck or shoulder pain
(28.7% vs 23.0%, RR: 1.24, 99% CI: 1.11, 1.39) and significantly less
likely to report hip pain (6.7% vs 10.3%, RR: 0.72, 99% CI: 0.56, 0.92).
Pain, chronic pain and pain by musculoskeletal site according to self-reported ethnicity in UK Biobank.
Discussion
The
highly selected population recruited to UK Biobank has demonstrated
pain prevalence (overall and musculoskeletal site-specific) which is
only very slightly lower than a large population study conducted in two
centres in Scotland and England, and very similar prevalence for chronic
pain and musculoskeletal site-specific to a national UK birth cohort
study. Both the latter demonstrated considerably higher participation
rates (65% and 36%) than UK Biobank (5.5%). Reported pain in the UK
Biobank has demonstrated clear associations with measures of low
socio-economic status, adverse psychosocial factors and life events
which have previously been established in several UK epidemiological
studies. As an example of its ability to analyse prevalence in small
population sub-groups, it has provided the clearest evidence to date
that reporting of pain does vary by ethnic group but that this can
largely be explained by socio-economic factors, and adverse life events.
Methodological issues
There
are several methodological issues to consider. First, there has been no
major UK study, of which we are aware, which has used exactly the same
wording as the UK Biobank questions on pain, nor has any large-scale
population survey of pain used touch screen questionnaires. We have
previously shown that recording pain information by means of shading
body manikins on a paper questionnaire and indicating painful body
regions on computer can lead to differences in prevalence.11 Furthermore, small differences in the wording of questions on pain can lead to differences in estimated prevalence.12
Comparing UK Biobank with MUSICIAN study/NCDS definition of pain, the
former required that pain had caused some interference with activities
while the latter that it had lasted at least 1 day. There was also a
difference in the way information was collected on site of pain. UK
Biobank asked participants about pain in regional sites of the body and
‘pain all over’, while the MUSICIAN study and NCDS determined the site
of pain from shading on a blank body manikin which was then coded using a
template. It has been shown, for shoulder pain, that the former leads
to slightly lower prevalence estimates.13
This is probably because the former results in subjects making a
judgement from where the pain is arising, while the latter method of
recording, codes pain as being present in a region even if the subject
does not consider that pain is arising from that region. Thus,
radiating back pain illustrated on a body manikin might result in pain
being recorded in the lower back, hip and knee regions, while subjects
if questioned might report only back pain. Although the prevalence of
regional pains reported between UK Biobank and the two comparator
studies was similar overall, there was a sizeable difference for hip
pain. The coding area for hip pain in the body manikin includes the
buttocks and extends from the hip to just above the knee14 and when coded from the manikin, likely includes pain arising from elsewhere, such as the back and knee.
Both
comparator studies have advantages and disadvantages. While UK Biobank
was conducted within major population centres throughout the UK,
MUSICIAN was conducted in only two centres: in Aberdeen city, north-east
Scotland and Cheshire, north-west England. It includes both urban and
rural locations and the areas are geographically and culturally
distinct. We have previously assessed how pain reporting differs between
regions in the United Kingdom in NCDS and found that there were no
important or significant differences in pain reporting by area of
residence.9
Furthermore, although MUSICIAN has a participation rate over six times
as high as UK Biobank, it is still relatively modest. In contrast NCDS
is nationally representative with participation remaining high over its
five decades of follow-up. An analysis of those lost to follow-up
demonstrated that the sample remained broadly representative of the
surviving cohort, although there was some under-representation of
minority groups (non-white, children from families without a male head
of household, children who were in institutional care)15 However, by definition, it provides a comparison mainly at a single age.
Comparison with other studies
As
noted above, changes to the wording of questions on pain can
importantly affect the responses from study patients making it difficult
to compare prevalence directly between study. The Health Survey for
England (HSE)16
enquired about pain in its most recent data collection wave in 2011. It
samples households and reports its individual participation rate as
59%. It asked participants if they were ‘currently troubled by pain and
discomfort either all of the time or on and off’. If participants
reported that they were, they were asked whether they had had the pain
or discomfort for more than 3 months. Data reported in age groups
45–54 years and 55–64 years demonstrated chronic pain prevalence for
women of 42% and 51% and for men of 33% and 43%, respectively, which is
consistent with the overall chronic pain prevalence of 43.7% reported in
UK Biobank. As in the current study, HSE16
showed strong associations between reporting pain and low household
income, measures of anxiety and depression, and low scores for
‘happiness’.
The Global Burden of Disease study
recently published data on the global prevalence of low back pain. It
included 165 studies providing 966 separate estimates. The median
estimate of the 1-month period prevalence was 32.1% while considering
prevalence estimates from high income countries only, the median was
30.3%.12
Although age-specific prevalence rates were not given, it was noted
that prevalence peaked between 40 and 69 years in both men and women.
These data are consistent with the 27.8% 1-month period prevalence of
back pain which interferes with activities in UK Biobank.
This
study has provided clear evidence of differences in reporting of pain
according to self-reported ethnicity in a UK population. It also shows
that these differences are partly explained by socio-economic factors
and adverse life events. Most research into ethnic differences has been
conducted in the United States. Edwards et al.17 in a review, highlighted studies showing excess reporting in African Americans of post-operative pain,18 angina on exercise treadmill tests19
and in self-reported daily pain symptoms, which seemed to be partly
accounted for by differences in thermal pain tolerance thresholds.20 Rahim-Williams et al.21
undertook a quantitative review of pain response in experimental
studies. They concluded that there were important differences across
modalities comparing African Americans with non-Hispanic whites whereby
the former had lower pain tolerance, with important effect sizes, but
less clear differences between non-Hispanic whites and other ethnic
groups. The reasons for such differences could be biological,
psychological and/or cultural. In one experimental study included in the
previous review, it was reported that the more sensitive to
experimental pain the African Americans were likely to be, the more they
identified with their ethnic group.22
This is consistent with observations we have previously made in the
United Kingdom among South Asians whereby those with low levels of
acculturation (i.e. their culture remained predominantly South Asian)
reported higher levels of CWP compared to South Asians whose culture had
changed to predominantly reflect British culture.23
Conclusion
This
study has demonstrated that UK Biobank, despite very low participation
rates, has provided results regarding the descriptive epidemiology of
pain (overall) and for individual musculoskeletal pain sites, which are
similar to UK epidemiological studies of smaller scale but with higher
participation rates. It has also demonstrated similar prevalence
proportions to other national epidemiological studies which have
measured pain occurrence. Taken along with its very large sample size,
UK Biobank can therefore be usefully used for more detailed research
into the genetic and environmental factors associated with pain. Our
study has confirmed strong associations with socio-demographic factors
and adverse psychosocial factors which are also well established. At
least for one of the most common health conditions, selection effects
among participants do not appear to have biased prevalence estimates.
Finally, it has provided the strongest evidence for self-reported
ethnicity importantly influencing the reporting of pain. Some of these
differences may be explained by socio-economic and psychosocial factors
but warrant further investigation within this study.
Acknowledgments
This
research has been conducted using the UK Biobank resource. We are
grateful to other investigators in the MUSICIAN study: John McBeth,
Karina Lovell, Phil Keeley, Phil Hannaford, Deborah Symmons, Gordon
Prescott and Steve Woby. We are grateful to the following practices and
their patients for participating in the MUSICIAN study in Aberdeen:
Carden Medical Centre, Elmbank Medical Practice, Great Western Medical
Practice, Garthdee Medical Group, and Macclesfield: Readesmoor Medical
Group Practice, Lawton House Surgery, Bollington Medical Centre, Park
Lane Surgery. The Scottish Primary Care Research Network facilitated
access to patient information at the practices in Aberdeen city. Charlie
Stockton was the MUSICIAN study manager during the setting up and for
part of the conduct of the study and thereafter Chrysa Gkazinou. Dr John
Norrie, Alison MacDonald and Gladys McPherson of the Health Services
Research Unit (HSRU) at the University of Aberdeen provided input
regarding the conduct of the study. Dev Acharya, Jennifer Banister,
Flora Joyce and Michelle Rein from Aberdeen and Karen Kane and Rowan
Jasper at the Arthritis Research UK Epidemiology Unit, University of
Manchester, were the project assistants. Alison Littlewood, Arthritis
Research UK Epidemiology Unit, University of Manchester, performed the
MUSICIAN study management at the Manchester centre.
Footnotes
Declaration of Conflicting Interests:
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding:
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
analysis was supported by internal funds at the University of Aberdeen.
The MUSICIAN study was funded by Arthritis Research UK, Chesterfield
(Grant No. 17292).
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