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The Burden of Musculoskeletal Diseases in the United States Second Editi on

Prevalence, Societal, and Economic Cost The Burden of Musculoskeletal Diseases in the United Project Coordinator States, Second Edition, is a joint project of the Sylvia I. Watkins-Castillo, PhD American Academy of Orthopaedic Surgeons, American Academy of Physical Medicine Staff and Rehabilitation, American College of Robert H. Haralson, III, MD, MBA, Medical Director, Rheumatology, American Society for Bone and AAOS Mineral Research, Arthritis Foundation, National Toby R.W. King, CAE, Executive Director, USBJD University of Health Sciences, Orthopaedic Amy Miller, Senior Director, Research, Training and Research Society, Scoliosis Research Society, and Quality, ACR the United States Bone and Joint Decade. Thomas E. Stautzenbach, MA, MBA, CAE, Executive Director, AAPM&R Management Oversight Team and Charles M. Turkelson, PhD, Director, Research and Major Contributing Organizations Scientifi c Aff airs, AAOS Marilyn Fox, PhD, Director, Publications, AAOS Joshua J. Jacobs, MD Mary Steermann Bishop, Senior Manager, Production Chair, Management Oversight Team, The Burden of & Archives, AAOS Musculoskeletal Diseases in the United States Courtney Astle, Assistant Production Manager, AAOS

Gunnar B. J. Andersson, MD, PhD Cover Design John-Erik Bell, MD Rick Cosaro, Cosaro & Associates, Ltd. Stuart L. Weinstein, MD American Academy of Orthopaedic Surgeons (AAOS) The material presented in The Burden of Musculoskeletal Diseases in the United States is made available for informational purposes John P. Dormans, MD only. This material is not intended to suggest procedures or course of Scoliosis Research Society (SRS) treatment, only to provide an interpretation of available data on the incidence and prevalence of most major musculoskeletal conditions. Steve M. Gnatz, MD, MHA American Academy of Physical Medicine and All rights reserved. No part of this publication may be reproduced, Rehabilitation (AAPM&R) stored in retrieval system, or transmitt ed, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, Nancy Lane, MD without prior writt en permission from the publisher. United States Bone and Joint Decade (USBJD) Copyright © 2008 by the American Academy of Orthopaedic J. Edward Puzas, PhD Surgeons. Orthopaedic Research Society (ORS) ISBN 978-0-89203-533-5 President, United States Bone and Joint Decade (USBJD) The Burden of Musculoskeletal Diseases in the United States 6300 N. River Road E. William St. Clair, MD Rosemont, IL 60018 Edward H. Yelin, PhD United States of America American College of Rheumatology (ACR) 1-800-626-6726

Additional Contributing Organizations Suggested citation: United States Bone and Joint Decade: The Burden American Society for Bone and Mineral Research of Musculoskeletal Diseases in the United States, Second Edition. (ASBMR) Rosemont, IL: American Academy of Orthopaedic Surgeons;2010. Arthritis Foundation National University of Health Sciences

ii The Burden of Musculoskeletal Diseases in the United States - Copyright © 2010 Authors and Reviewers Steven M. Kurtz, PhD Gunnar B. J. Andersson, MD, PhD Nancy Lane, MD Jeannett e Bouchard Assia Miller, MD, MPH Kevin J. Bozic, MD, MBA Reba L. Novich, MSW Robert M. Campbell, Jr., MD Richard Olney, MD, MPH Miriam G. Cisternas, MS Peter Panopalis, MD Adolfo Correa, MD. MPH, PhD David J. Pasta, MS Felicia Cosman, MD Andrew N. Pollak, MD Janet D. Cragan, MD, MPH J. Edward Puzas, PhD Kristen D’Andrea, BA B. Steven Richards, III, MD Nancy Doernberg John P. Sestito, JD, MS John P. Dormans, MD, FACS Csaba Siﬀ el, MD, PhD Ann L. Elderkin, PA Paul D. Sponseller, MD Zarina Fershteyn, MPH E. William St. Clair, MD Aimee J. Foreman, MA Andrew Stuart, MA Steven Gitelis, MD Kimberly J. Templeton, MD Steve M. Gnatz, MD, MHA George Thompson, MD Robert H. Haralson, III, MD, MBA Laura Tosi, MD Charles G. (Chad) Helmick, MD William G. Ward, Sr., MD Serena Hu, MD Sylvia I. Watkins-Castillo, PhD Jeﬀ rey N. Katz, MD Stuart L. Weinstein, MD Toby King, CAE James G. Wright, MD, MPH, FRCSC Ron Kirk, MA, DC Edward H. Yelin, PhD

Bone and Joint Decade

The Bone and Joint Decade is an international collaborative movement sanctioned by the United Nations/ World Health Organization and working to improve the quality of life for people with musculoskeletal conditions and to advance the understanding, prevention and treatment of these conditions.

Oﬃ cially proclaimed by the U.S. President, the United States Bone and Joint Decade (USBJD) 2002-2011 has been endorsed by all 50 States and more than one hundred national health care professional, patient and public organizations, all 125 U.S. medical schools and many colleges of medicine.

The goal of the United States Bone and Joint Decade is to improve bone and joint health by enhancing collaborative eﬀ orts among individuals and organizations in order to raise awareness of the growing burden of musculoskeletal disorders on society, to promote wellness and prevent musculoskeletal disease, and to advance research that will lead to improvements in prevention, diagnosis and treatment.

www.usbjd.org [email protected] Phone: 847-384-4010

vii Preface

ix Foreword

1 Chapter 1: Burden of Musculoskeletal Disease Overview

21 Chapter 2: Spine: Low Back and Neck Pain

57 Chapter 3: Spinal Deformity and Related Conditions

75 Chapter 4: Arthritis and Related Conditions

103 Chapter 5: Osteoporosis and Bone Health

129 Chapter 6: Musculoskeletal Injuries

181 Chapter 7: Congenital and Infantile Developmental Conditions of the Musculoskeletal System

195 Chapter 8: Neoplasms of Bone and Connective Tissue

219 Chapter 9: Health Care Utilization and Economic Cost of Musculoskeletal Diseases

253 Appendices

269 Index

It is with pleasure that I introduce you to this high expectations of the health system. With publication of the Burden of Musculoskeletal the National Center for Health Statistics’ 2008 Diseases in the United States, the timely result of National Health Interview Survey as a solid base, a partnership between the American Academy this publication examines such issues as spinal of Orthopaedic Surgeons and a number of other problems, arthritis and joint pain, osteoporosis, organizations supporting the U.S. Bone and injuries, congenital conditions, neoplasms, and Joint Decade (2002-2011). The level of disease health care utilization and costs. The biomedically recognition that the Decade has provided has done inclined reader will fi nd within these pages both much to push the state of the science forward, and food for thought and a call to action. this new publication presents a snapshot of how far we have come since its predecessor, the 1999 The plight of millions of Americans whose Musculoskeletal Conditions in the United States, was lives are aff ected by the physical, fi nancial, and released. emotional demands of musculoskeletal conditions make the fi ndings of Burden diffi cult to ignore. I Although many advances have been made, encourage you to read and digest its contents, and musculoskeletal conditions remain common, to appropriate for yourself those parts within your chronic, and costly—and potentially disabling— specifi c areas of interest or expertise. to an increasingly graying population with

Stephen I. Katz, MD, PhD Director National Institute of Arthritis and Musculoskeletal and Skin Diseases National Institutes of Health Bethesda, Maryland January 10, 2008

Musculoskeletal disorders and diseases are the two previous editions entitled Musculoskeletal leading cause of disability in the United States Conditions in the United States, published in and account for more that one-half of all chronic 1992 and 1999 by the American Academy of conditions in people over 50 years of age in Orthopaedic Surgeons, and the second edition developed countries. The economic impact of these of the most recent edition, renamed The Burden conditions is also staggering: in 2004 the sum of of Musculoskeletal Diseases in the United States the direct expenditures in health care costs and when published in 2070. The book represents a the indirect expenditures in lost wages has been true collaboration of a coalition of professional estimated to be $950 billion dollars, or 7.4% of the organizations committ ed to the mission of the US 2006 GDP (national gross domestic product.) Bone and Joint Decade.

Beyond these statistics, the human toll in terms These data should stimulate increased investment of the diminished quality of life is immeasurable. in basic, translational, clinical and health policy This situation is unlikely to improve in the research to delineate the underlying mechanisms foreseeable future and will likely be intensiﬁ ed by of these diseases and their response to treatment. current demographic trends, including the graying Through such research, novel preventive of the baby boomer population, the epidemic of and therapeutic approaches with potential to morbid obesity, and the higher recreational activity mitigate the societal and personal impact of levels of our elderly population. musculoskeletal disease will emerge.

Despite these compelling facts, the investment Joshua J. Jacobs, M.D. in musculoskeletal research in the United States President, U.S. Bone and Joint Decade lags behind other chronic conditions. While Chair, Management Oversight Team, Burden of musculoskeletal diseases are common, disabling Musculoskeletal Diseases in the United States and costly, they remain under-appreciated, under- American Academy of Orthopaedic Surgeons recognized and under-resourced by our national policy makers. John P. Dormans, M.D. Scoliosis Research Society In March 2002, President George W. Bush declared the years 2002–2011 the National Bone and Joint Steve M. Gnatz, M.D., M.H.A. Decade. The mission of the U.S. Bone and Joint American Academy of Physical Medicine and Decade is to “promote and facilitate collaboration Rehabilitation among organizations committ ed to improving bone and joint health through education and Nancy Lane, M.D. research.” United States Bone and Joint Decade

This volume serves the mission of the decade in J Edward Puzas, Ph.D. that several professional organizations concerned Orthopaedic Research Society with musculoskeletal health have collaborated President, United States Bone and Joint Decade to tabulate up-to-date data on the burden of musculoskeletal diseases to educate health care E. William St. Clair, M.D. professionals, policy makers and the public. American College of Rheumatology The information presented here is an update of

Chapter 1 Burden of Musculoskeletal Disease Overview

Musculoskeletal conditions are among the most The impact of musculoskeletal diseases includes disabling and costly conditions suff ered by loss of productivity for persons who live with Americans. In March 2002, President George a musculoskeletal condition that reduces their W. Bush proclaimed the years 2002–2011 as ability to work and perform activities of daily the United States Bone and Joint Decade, living, and those persons who die prematurely providing national recognition to the fact that from a musculoskeletal condition. It also takes into musculoskeletal disorders and diseases are consideration the quality of life, pain, discomfort, the leading cause of physical disability in this and disability for disabled persons and their country.1,2 relatives and friends. Direct costs of the burden of musculoskeletal disease include hospital inpatient, As the U.S. population rapidly ages in the next 25 hospital emergency and outpatient services, years, musculoskeletal impairments will increase physician outpatient services, other practitioner because they are most prevalent in the older services, home health care, prescription segments of the population. By the year 2030, drugs, nursing home cost, prepayment and the number of individuals in the United States administration and non-health sector costs. older than the age of 65 is projected to double, Indirect cost relates to morbidity and mortality, with persons aged 85 and over the most rapidly including the value of productivity losses due to expanding segment of society. In Europe, by 2010, premature death due to a disease and the value of for the fi rst time there will be more people older lifetime earnings. than 60 years of age than people younger than 20 years of age.3 Health care services worldwide will Musculoskeletal conditions are not among the top be facing severe fi nancial pressures in the next 10 ten health conditions funded by research.5 In spite to 20 years due to the escalation in the numbers of of the widespread prevalence of musculoskeletal people aff ected by musculoskeletal diseases. Bone conditions; this is primarily due to the low and joint disorders account for more than one-half mortality from musculoskeletal conditions of all chronic conditions in people older than 50 in comparison with other health conditions. years of age in developed countries, and are the However, the morbidity cost of musculoskeletal most common cause of severe, long-term pain and conditions is tremendous, as musculoskeletal disability.4 conditions oft en restrict activities of daily living, cause lost work days, and are the source of The goal of the United States Bone and Joint lifelong pain. Decade is to improve the quality of life for people with musculoskeletal conditions and to advance In 1998, the Institute of Medicine wrote “in understanding and treatment of these conditions sett ing national priorities NIH should strengthen through research, prevention, and education. its analysis in the use of health data, such as The cornerstone of the Bone and Joint Decade burdens of disease, and of data on the impact of movement is the burden of musculoskeletal research and the health of the public.”6 National disease, defi ned as the incidence and prevalence health data in several countries show that of musculoskeletal conditions; the resources musculoskeletal conditions rank among the top used to prevent, care, and cure for them; and health concerns for citizens in the United States the impact on individuals, families, and society. and worldwide. By current estimates, over 40%

of the disabling conditions of persons aged 18 (Table 1.2 and Graph 1.1.1) The NHIS annual years and over are musculoskeletal related, yet survey of self-reported health conditions is used research funding to alleviate this major health throughout this chapter to highlight chronic health condition remains substantially below that of conditions of the U.S. population. other major health conditions, such as cancer, Graph 1.1.1: Prevalence of Self-Reported Primary Medical respiratory, and circulatory (e.g., heart) diseases. Conditions for Persons Aged 18 and Over, United States Funding for the National Institute of Arthritis and Musculoskeletal [1] Musculoskeletal and Skin Diseases (NIAMS) began Emotional Disorder [2] in 1987. In subsequent years, research funding Circulatory [3] Respiratory [4] for these conditions has declined and since 2000, Migraines/Severe Headaches routinely less than 2% of the annual National Blind/Trouble Seeing w/Glasses Institutes of Health (NIH) budget is appropriated Diabetes Cancer [5] to musculoskeletal disease research. In fact, the Hearing Trouble [6] annual average rate of funding continues to Kidney Disease Liver Disease decline. (Table 1.1) 0 1020304050 Age-Adjusted Rate [7] per 100 Population Clearly, musculoskeletal conditions are common, [1] Includes arthritis, chronic joint symptoms (more than 3 months in duration), pain in lower back or neck (more than 3 months duration) disabling, and costly. Yet they remain under- [2] Includes feelings that interfere with life and activities in past 30 days: sad, nervous, restless, hoplessness, worthlesness, depression, general recognized, under-appreciated, and under- an¡iety, panic disorder, and living is an eěort resourced. This book provides a strong case for the [3] Includes coronary heart disease, angina pectoris, heart aĴack, stroke, chronic hypertension, heart disease immediate and ongoing need to understand and [4] Includes emphysema, chronic asthma, hay fever, sinusitis, chronic bronchitis support musculoskeletal conditions and reduce the [5] Includes all types of cancer burden it brings to our people. [6] Includes respondents reporting "moderate trouble," "a lot of trouble” or "deaf" without a hearing aid/hearing device, or currently uses a hearing aid. [7] Age-adjusted by direct method to US Census population estimate for July 1, 2008. Accessed June 22, 2009. Section 1.1: Prevalence of Select Source: National Center for Health Statistics, National Health Interview Medical Conditions in the U.S. Survey, Adult Sample, 2008 Population Musculoskeletal conditions are found among all age groups, with the proportion of persons Musculoskeletal medical conditions were reported reporting these conditions increasing with age. by 110.34 million adults in the U.S. in 2008 in Musculoskeletal conditions are reported by nearly the National Health Interview Survey (NHIS), three of four (69%) persons aged 75 years and over, representing nearly one in two persons aged 18 slightly less than the 74% reporting circulatory and over of the estimated 2008 population. The conditions, the majority of whom report chronic rate of chronic musculoskeletal conditions found hypertension. (Table 1.2) in the adult population is 60% greater than that of chronic circulatory conditions, which include Females, in general, on an age-adjusted basis, coronary and heart conditions, and more than report a higher rate of occurrence than males for twice that of all chronic respiratory conditions. most major medical conditions. Among females, On an age adjusted basis, which accounts for 53 women in every 100 females in the population diﬀ erences in the age distribution of the health report musculoskeletal conditions; among males care database sample and the actual population, the rate is 45 per 100, a slight increase in recent musculoskeletal conditions are reported by 48% years. (Table 1.3) of the population, or 48 persons per every 100 in the population. This compares to a rate of 30 and Musculoskeletal conditions were reported at a 24 persons per every 100 in the population for higher rate among whites and persons of mixed circulatory and respiratory conditions, respectively. or other race, with 51 and 53 persons, respectively,

in every 100 person in the population reporting increasing. In 2008, nearly one in ﬁ ve persons aged a musculoskeletal condition. Among persons 18 to 44 reported they suﬀ er from chronic joint of the black/African American race, 43 in 100 pain, while more than one-third (35%) aged 45 to reported a musculoskeletal condition. Persons 64 reported chronic joint pain. Active lifestyles will of Asian descent reported the lowest level of continue to be a major cause of joint pain in the musculoskeletal conditions, at a rate of 30 persons coming years. in every 100 persons in the population. (Table 1.4)

Graph 1.1.2: Prevalence of Self-Reported Select Medical Conditions [1] for Persons Aged 18 and Over, Section 1.1.1: Musculoskeletal, Circulatory, and United States 2008 Respiratory Conditions Chronic [2] Joint Pain Arthritis Neck Pain On an age-adjusted basis, musculoskeletal Lower Back Pain Lower Back Pain Below Knee

conditions are reported equal to or more Musculoskeletal frequently than other common chronic or serious Chronic Hypertension Coronary or Heart Condition [3] medical conditions related to the circulatory or Stroke Circulatory respiratory systems by persons aged 18 and older. Sinusitis Hay Fever Three of the four most common medical conditions Chronic [2] Asthma reported in 2008 were musculoskeletal conditions: Chronic [2] Bronchitis Respiratory Emphysema low back pain, chronic joint pain, and arthritis. The 0 5 10 15 20 25 30 other most commonly reported medical condition Ae Adusted [Ś] ate per 100 Population [1] Specięc conditions are not mutually e¡clusive in overall condition cateory is chronic hypertension. (Table 1.5 and Graph 1.1.2) [2] Symptoms lastin 3 months or loner [3] ncludes heart aĴackǰ anina pectorisǰ and other heart disease [Ś] AeȬadusted y direct method to S Census population estimate or July 1ǰ 200ŝǯ Accessed June 22ǰ 200şǯ Nearly 62.0 million adults reported low back pain, SourceǱ National Center or Health Statisticsǰ National Health nterview the most frequently reported musculoskeletal Surveyǰ Adult Sampleǰ 200Ş condition, an age-adjusted rate of 27 in 100 persons aged 18 or older reporting this condition. Among Chronic hypertension, defi ned as hypertension persons reporting low back pain, more than 20.1 diagnosed at two or more physician visits, is the million, or one-third, also reported pain radiating only other medical condition that approaches down the leg below the knee. Cervical/neck pain is the rate of chronic musculoskeletal conditions. also a commonly reported musculoskeletal disease, Among adults aged 18 and older, 56.1 million reported by 31.4 million adults in 2008. persons reported chronic hypertension in 2008, an age-adjusted rate of 24 in 100 persons. Coronary In recent years, chronic joint pain, defi ned as or heart conditions, which increase with age, joint pain lasting three months or longer, has were reported by 26.6 million, a rate of 12 in 100 approached the level of low back pain as a persons. Chronic respiratory ailments, while common musculoskeletal condition. Chronic common, are reported in signifi cantly lower joint pain, reported by 61.6 million adults aged 18 numbers, with sinusitis, reported by 30.6 million and older (27 of 100 persons), while 51.2 million (13 in 100) persons, the most common condition. (22 in 100) reported having been diagnosed with arthritis. Chronic joint pain and arthritis are Gender is a greater predictor of chronic not mutually exclusive and may be reported by musculoskeletal and respiratory conditions the same individual. Although age is a general than of chronic circulatory conditions. Among predictor of chronic joint pain and arthritis, with 7 all musculoskeletal and respiratory conditions, out of 10 persons aged 65 and over reporting one females are more likely to report a specifi c or both of these conditions, the rate of reported condition than are males. Similar proportions of chronic joint pain in younger persons is rapidly males and females reported chronic circulatory conditions in 2008. (Table 1.6)

Chronic circulatory and respiratory conditions aged 65 and older reporting knee pain. Shoulder do not show the racial variation seen in pain, reported by 18.9 million persons aged 18 musculoskeletal conditions, with the exception and older, is the second most common joint for of the Asian population reporting all conditions chronic pain, with rates fairly equal aged 45 and at lower rates than other races. (Table 1.7) over. Fingers account for chronic joint pain in Musculoskeletal conditions, overall, are reported 15.5 million persons, closely followed by hip pain in higher proportions by persons of the white race reported by 14.8 million. than by persons of the black/African American or Asia races. Persons of other or mixed race report While multiple joints can be the source of chronic slightly higher rates of musculoskeletal conditions joint pain, overall, one in four persons over the age that those of the white race. of 18 reports suff ering from chronic joint pain. The ratio jumps to more than 2 in 5 persons aft er the Section 1.1.2: Chronic Joint Pain age of 65. However, even among younger adults aged 18 to 44, nearly one in fi ve reports they suff er Chronic joint pain increases with age, but peaks from chronic joint pain. (Table 1.8 and Graph 1.1.3) in the 65 to 74 year age group. Among the 61.6 million persons reporting chronic joint pain in Section 1.2: Activity Limitation Due to 2008, knee pain is the most frequently cited, with Select Medical Conditions more than 39 million persons reporting knee pain. Chronic knee pain is reported by all ages in the age 18 and over population, with one in four persons Participants in the 2008 NHIS survey were asked about limitations they experience in activities of daily living due to medical conditions. Nearly Graph 1.1.3: Proportion of Population [1] 32.6 million adults aged 18 years and over, or Aged 18 and Older Reporting Joint Pain [2], 14% of the population, report they have diffi culty United States 2008 performing routine daily activities of life without assistance due to medical conditions. An additional

Shoulder=8.4% 5.5 million children between the ages of 1 and 17 years are reported by their parents as needing

Elbow=4.6% more assistance in daily activities than would be expected for their age due to a medical condition. Wrist=5.1% (Table 1.9)

Graph 1.2.1: Self-Reported Impairment in Activities of Daily Living for Persons Due to Select Medical Conditions for Persons Aged 18 Hip=6.6% Fingers=6.9% and Older, United States 2008

Musculoskeletal [1] Circulatory [2] Knee=17.3% Toes=2.7% Emotional Problem [3] Diabetes Ankle=6.0% Respiratory Nervous System Vision Problem Hearing Problem Other Joint=1.4% Cancer All Chronic Joint Pain=27.4% Birth Defect/Developmental Other Condition/Disorder % of Population Reporting Joint Pain 0 5,000 10,000 15,000 20,000 Prevalence (in 000s) [1] Age-adjusted to July 1, 2008 U.S. Census population [1] Includes arthritis/rheumatism condition, back or neck problem, fracture/bone/joint injury, estimates, 26.4% of all persons. ȦȱȱǰȱȱȱȱȦęȦǯ ǽŘǾȱ ȱȱȱ¢ǰȱǰȱȱȱȱǯ [2] Symptoms lasting 3 months or longer ǽřǾȱ ȱȦ¡¢Ȧȱǯ Source: National Center for Health Statistics, National Source: National Center for Health Statistics, National Health Interview Survey, Health Interview Survey, Adult Sample, 2008 Person Sample, 2008

The most frequently cited medical condition for other or mixed race are slightly more likely to which persons report limitations in the activities of report a limitation than found in other races. (Table daily life is musculoskeletal. More than 17 million 1.11) adults aged 18 and over are limited by one or more musculoskeletal conditions, including arthritis or Section 1.3: Lost Work Days and Bed rheumatism, back or neck problems, fracture or Days bone/joint injury, a missing or amputated limb, or a musculoskeletal connective tissue condition. (Graph 1.2.1) Overall, 14% of adults aged 18 and Musculoskeletal conditions are also the greatest over have reduced quality of life due to medical cause of total lost work days and medical bed days conditions, and more than one-half of these are in the U.S. One in six persons (17%) employed in due to musculoskeletal conditions. (Graph 1.2.2) the previous 12 months in the U.S. at the time of the survey reported lost work days totaling more Reﬂ ecting the overall prevalence of medical than 509 million days as a result of musculoskeletal conditions in females, females are also more conditions. Musculoskeletal conditions accounted likely to report impairment in activities of daily for more than one-half of all persons reporting living than are males. This is particularly true for lost work days due to a medical condition. Chronic circulatory conditions accounted for 239

Graph 1.2.2: Self-Reported Impairment in Activities of Daily million lost work days, and were reported by just Living for Persons Due to Select Medical Conditions by Age, under 8% of the working population. Chronic United States 2008 respiratory conditions accounted for 228 million, Musculoskeletal Conditions [1] All Medical Conditions and were reported by slightly more than 9% of the 50 42.6% population. On average, workers lost nearly 13½ 40 days in a 12-month period due to musculoskeletal conditions. Workers lost an average of only 0.3 30 26.4% 22.3% days longer due to circulatory conditions than was 20 17.0% 14.3% 14.5% lost for musculoskeletal conditions. (Table 1.12) 9.6% 10 6.2% 7.4% 2.4% More than one in ﬁ ve persons (21%) reported at 0 % of Total Estimated U.S.Population % of Total 18-44 45-64 65-74 75 years Total years years years & over population least one bed day in the previous 12 months due to [1] Includes arthritis/rheumatism condition, back or neck problem, fracture/bone/ a musculoskeletal condition, nearly twice the rate joint injury, musculoskeletal/connective tissue condition, missing or amputated limb/ęnger/digit. reported for circulatory and respiratory conditions. Source: National Center for Health Statistics, National Health Interview Survey, Person Sample, 2008 Total bed days due to musculoskeletal conditions were reported at more than one billion days. An average of nearly 18 bed days per person was musculoskeletal conditions. Females account for reported. (Table 1.13) 56% of all adults aged 18 and over reporting they are limited in activities of daily living; they account Musculoskeletal conditions accounted for for 61% of those reporting a musculoskeletal approximately one-half of both lost work days and condition impairment. (Table 1.10) bed days due to major medical conditions in 2008. (Graphs 1.3.1 and 1.3.2) Compared to circulatory Members of the white and black/African American and respiratory conditions, musculoskeletal populations report limitations due to medical conditions accounted for more than twice the conditions in approximately the same proportions. number of lost work days; they accounted for Members of the Asian race are signiﬁ cantly less 29% and 53% more bed days than circulatory and likely to report limitations in activities of daily respiratory conditions, respectively. (Graph 1.3.3) living due to a medical condition. Members of

Graph 1.3.1: Proportion of Total Lost Work Days [1] for Table 1.3.4: Total Productivity Loss Due to Select Medical Conditions [1,2] for Persons Aged 18 and Over, Persons Age 18 and Over by Major Medical Condition, United States, 2008 United States 2008 1200 Total Work Total 3.4% Days Lost Bed Days 1,035 Cancer 1000 843 8.9% 800 Migraines/ 698 26.4% severe headache 596 600 509 Respiratory 450 18.3% condition 400 239 Hypertension/ Days (in millions) Total 228 Conditions Musculoskeletal 200 heart condition [2] 17.1% 25.8% 0 Back/neck pain Respira- Circula- Musculo- All tory tory [3] skeletal Conditions Chronic [3] joint [1] Reported 'yes' to at least one of the 23 medical conditions (70% of the weighted pain/arthritis population). Multiple conditions resulting in lost work or bed days possible. [2] Symptoms lasting 3 months or longer OR 2 or more physician visits ǽřǾȱ ȱȱĴǰȱȱǰȱȱȱȱȱ ȱ ȱ [1] Lost work days due to multiple conditions possible. Source: National Center for Health Statistics, National Health Interview [2] ncludes heart aĴackǰ angina pectorisǰ and other heart disease Survey, Adult Sample, 2008 [3] Symptoms lasting 3 months or longer OR 2 or more physician visits SourceǱ ational Center or Health Statisticsǰ ational Health nterview Surveyǰ dult Sample Level ileǰ 2ŖŖŞ Table 1.3.3: Total Productivity Loss Due to Select Musculoskeletal Conditions [1,2] for Persons Aged 18 and Over, United States, 2008

800 Total Work Total Graph 1.3.2: Proportion of Total Bed Days [1] for Days Lost Bed Days 700 Persons Age 18 and Over by Major Medical Condition, 609 600 555 United States 2008 504 3.6% 500

Cancer 400 366 359 302 313 8.1% 300 Migraines/ 226 203 200 162 24.1% severe headache Days (in millions) Total Respiratory 100 19.0% condition 0 Chronic Arthritis Cervical Lumbar Leg Pain Hypertension/ Conditions Musculoskeletal Joint Pain Back Pain Back Pain 22.2% heart condition 23.0% [1] Reported 'yes' to at least one of the 23 medical conditions (70% of the weighted Back/neck pain population). Multiple conditions resulting in lost work or bed days possible. [2] Symptoms lasting 3 months or longer OR 2 or more physician visits ǽřǾȱ ȱȱĴǰȱȱǰȱȱȱȱȱ ȱ ȱ Chronic joint Source: National Center for Health Statistics, National Health Interview pain/arthritis Survey, Adult Sample, 2008

[1] Bed days due to multiple conditions possible. ǽŘǾȱ ȱȱĴǰȱȱǰȱȱȱȱ burden on the economy that is twice that reported [3] Symptoms lasting 3 months or longer OR 2 or more physician visits Ǳȱȱȱȱ ȱǰȱȱ ȱ ȱ for chronic circulatory or chronic respiratory ¢ǰȱȱȱȱȱǰȱŘŖŖŞ conditions.

Major musculoskeletal causes of lost work Section 1.4: Summary Health Care days and medical bed days are chronic joint Utilization and Economic Cost of pain, arthritis, cervical/neck pain, and low back Musculoskeletal Diseases pain. (Graph 1.3.4) Persons reporting low back pain that radiates below the knee reported the highest average number of lost work days (25.8) The annual average proportion of the U.S. and medical bed days (34.1) among all medical population with a musculoskeletal condition conditions. (Tables 1.12 and 1.13) requiring medical care has increased by more than two percentage points over the past decade and Overall, the high proportion of workers reporting now constitutes more than 30% of the population. lost work days or bed days as a result of a The increasing prevalence of musculoskeletal musculo-skeletal condition results in an economic conditions, along with a growing and aging

population, has resulted in a more than 47% 1. Weinstein S: 2000-2010: The Bone and Joint Decade. J Bone increase in total aggregate direct cost to treat Joint Surg Am 2000;82:1-3. persons with a musculoskeletal condition. 2. A Proclamation by the President of the United States of For the years 2004-2006, the annual average direct America: National Bone and Joint Decade Proclamation: cost, in 2006 dollars, for musculoskeletal health National Bone and Joint Decade, 2002-2011. Oﬃ ce of the care, both as a direct result of a musculoskeletal Press Secretary, 2002. disease and for patients with a musculoskeletal disease in addition to other health issues, is 3. Murray CJL, Lopez AD: The Global Burden of Disease: A estimated to be $576 billion, the equivalent of 4.5% Comprehensive Assessment of Mortality and Disability from of the national gross domestic product (GDP). Diseases, Injuries, and Risk Factors in 1990 and Projected to Incremental medical cost, that proportion of total 2020. Cambridge, MA: Harvard University Press, 1996. direct cost associated with treatment incurred beyond that of persons of similar demographic 4. Conference proceedings: The bone and joint decade and health characteristics but who do not have 2000-2010 for prevention and treatment of musculoskeletal one or more musculoskeletal diseases (i.e., most disorders. Lund, Sweden. Acta Orthop. Scand. Suppl.; likely att ributable to a musculoskeletal disease), is 1998:218. estimated to be $160.5 billion. 5. Michaud CM, Murray CJL, Bloom BR: Burden of disease: Indirect cost, expressed primarily as wage losses implications for future research. JAMA 2001;285:535-539. for persons aged 18 to 64 with a work history, add another $373.1 billion, or 2.9% of the GDP 6. Committ ee on the NIH Research Priority-Sett ing Process, in 2004-2006, to the cost for all persons with Institute of Medicine: Scientiﬁ c opportunities and public a musculoskeletal disease, either treated as a needs: Improving sett ing and public input. Institute of primary condition or in addition to another Medicine of the National Academies, 1998. condition. Annual indirect costs att ributable to musculoskeletal disease alone (incremental cost) are estimated to account for $127 billion of these indirect costs.

The annual estimated direct and indirect cost att ributable to persons with a musculoskeletal disease is $287 billion. Taking into account all costs for persons with a musculoskeletal disease, including other comorbid conditions, the cost of treating these individuals in addition to the cost to society in the form of decreased wages, is estimated to be nearly $950 billion per year.

Treatments that mitigate the long-term impacts of musculoskeletal conditions and return persons to full and active lives are needed.

Section 1.5: Burden of Musculoskeletal Diseases Overview Data Tables

Tableȱ1.1:ȱNationalȱInstitutesȱofȱHealthȱ(NIH)ȱFunding,ȱ2000Ȭ2008

Meanȱ%ȱFundingȱ Meanȱ%ȱofȱ Meanȱ%ȱofȱ Varianceȱ TotalȱNIHȱFundingȱ TotalȱNIHȱFundingȱ 2006ȱAverageȱtoȱ NationalȱInstitutesȱofȱHealthȱ(NIH)ȱOrganizations 2000Ȭ2006 2000Ȭ2008 2008ȱAverage NCI NationalȱCancerȱInstitute 17.5% 17.3% Ȭ0.2% NIAID NationalȱInstituteȱofȱAllergyȱandȱInfectiousȱDiseases 12.6% 13.1% 0.5% NHLBI NationalȱHeart,ȱLung,ȱandȱBloodȱInstitute 10.7% 10.6% Ȭ0.1% NIGMS NationalȱInstituteȱofȱGeneralȱMedicalȱSciences 7.1% 7.0% Ȭ0.1% NIDDK NationalȱInstituteȱofȱDiabetesȱandȱDigestiveȱandȱKidneyȱDiseases 6.5% 6.5% 0.0% NINDS NationalȱInstituteȱofȱNeurologicalȱDisordersȱandȱStroke 5.5% 5.5% 0.0% NIMH NationalȱInstituteȱofȱMentalȱHealth 5.1% 5.1% 0.0% NICHD NationalȱInstituteȱofȱChildȱHealthȱandȱHumanȱDevelopment 4.6% 4.5% Ȭ0.1% NCRR NationalȱCenterȱforȱResearchȱResources 4.0% 4.0% 0.0% NIA NationalȱInstituteȱonȱAging 3.7% 3.7% 0.0% NIDA NationalȱInstituteȱonȱDrugȱAbuse 3.7% 3.6% Ȭ0.1% NIEHS NationalȱInstituteȱofȱEnvironmentalȱHealthȱSciences 2.6% 2.6% 0.0% NEI NationalȱEyeȱInstitute 2.4% 2.4% 0.0% NIAMS NationalȱInstituteȱofȱArthritisȱandȱMusculoskeletalȱandȱSkinȱ 1.9% 1.8% Ȭ0.1% NHGRI NationalȱHumanȱGenomeȱResearchȱInstitute 1.8% 1.8% 0.0% NIAAA NationalȱInstituteȱonȱAlcoholȱAbuseȱandȱAlcoholism 1.6% 1.6% 0.0% NIDCR NationalȱInstituteȱofȱDentalȱandȱCraniofacialȱResearch 1.4% 1.4% 0.0% NIDCD NationalȱInstituteȱonȱDeafnessȱandȱOtherȱCommunicationȱDisorders 1.4% 1.4% 0.0% NLM NationalȱLibraryȱofȱMedicine 1.1% 1.1% 0.0% NIBIB NationalȱInstituteȱofȱBiomedicalȱImagingȱandȱBioengineering 0.7% 0.7% 0.0% NCMHD NationalȱCenterȱonȱMinorityȱHealthȱandȱHealthȱDisparities 0.6% 1.6% 1.0% NINR NationalȱInstituteȱofȱNursingȱResearch 0.5% 0.5% 0.0% NCCAM NationalȱCenterȱforȱComplementaryȱandȱAlternativeȱMedicine 0.4% 0.4% 0.0% FIC JohnȱE.ȱFogartyȱInternationalȱCenterȱforȱAdvancedȱStudyȱinȱtheȱHealthȱ 0.2% 0.2% 0.0% Sciences OD OfficeȱofȱtheȱDirectorȱ(includesȱOfficeȱofȱAIDSȱResearchȱandȱOfficeȱofȱ 1.2% 1.8% 0.6% ResearchȱonȱWomenȇsȱHealth)

TotalȱAverageȱAnnualȱFundingȱ(inȱ000s) $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ24,783,710 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25,758,698 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ974,988

Source:ȱNIHȱAlmanacȬAppropriations.ȱAvailableȱat:ȱhttp://www.nih.gov/about/almanac/appropriations/index.htm.ȱLastȱupdatedȱMayȱ26,ȱ2009.ȱ AccessedȱJuneȱ22,ȱ2009.

Tableȱ1.2:ȱPrevalenceȱandȱAgeȬAdjustedȱRateȱofȱSelfȬReportedȱSelectȱMedicalȱ ConditionsȱbyȱAge,ȱUnitedȱStatesȱ2008

AgeȬAdjustedȱ PrevalenceȱAgedȱ18ȱ&ȱOverȱȱ(inȱmillions) Rateȱ[7]ȱPerȱ100ȱ MedicalȱCondition 18Ȭ44 45Ȭ64 65Ȭ74 75+ Total TotalȱPopulation Musculoskeletalȱ[1] 41.946 43.340 13.048 ȱȱȱȱȱȱȱȱȱȱȱȱȱ12.002 110.336 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47.95ȱ EmotionalȱDisorderȱ[2] 38.071 30.796 6.629 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.641 81.137 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ35.26ȱ Circulatoryȱ[3] 13.771 29.617 12.544 ȱȱȱȱȱȱȱȱȱȱȱȱȱ12.932 68.864 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29.93ȱ Respiratoryȱ[4] 23.437 21.176 5.846 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.401 54.861 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ23.84ȱ MigrainesȱorȱSevereȱHeadaches 18.364 10.258 1.120 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.529 30.271 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.15ȱ BlindȱorȱTroubleȱSeeingȱw/Glasses 7.999 10.672 2.825 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.660 25.156 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.93ȱ Diabetes 2.555 9.247 3.931 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.929 18.662 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.11ȱ Cancerȱ[5] 2.523 6.838 3.814 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.687 17.862 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.76ȱ HearingȱTroubleȱ[6] 2.413 4.833 2.678 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.484 14.408 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.26ȱ KidneyȱDisease 0.797 1.372 0.596 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.955 3.720 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.62ȱ LiverȱDisease 1.058 1.682 0.326 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.182 3.248 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.41ȱ

ProportionȱofȱPopulationȱinȱAgeȱGroupȱReportingȱCondition MedicalȱCondition 18Ȭ44 45Ȭ64 65Ȭ74 75+ Total Musculoskeletalȱ[1] 37.9% 56.0% 65.8% 69.1% 49.0% EmotionalȱDisorderȱ[2] 34.4% 39.8% 33.4% 32.5% 36.0% Circulatoryȱ[3] 12.4% 38.3% 63.3% 74.5% 30.6% Respiratoryȱ[4] 21.2% 27.3% 29.5% 25.4% 24.4% MigrainesȱorȱSevereȱHeadaches 16.6% 13.2% 5.7% 3.0% 13.4% BlindȱorȱTroubleȱSeeingȱw/Glasses 7.2% 13.8% 14.3% 21.1% 11.2% Diabetes 2.3% 11.9% 19.8% 16.9% 8.3% Cancerȱ[5] 2.3% 8.8% 19.2% 27.0% 7.9% HearingȱTroubleȱ[6] 2.2% 6.2% 13.5% 25.8% 6.4% KidneyȱDisease 0.7% 1.8% 3.0% 5.5% 1.7% LiverȱDisease 1.0% 2.2% 1.6% 1.0% 1.4%

[6]ȱIncludesȱrespondentsȱreportingȱȈmoderateȱtrouble,ȈȱȈaȱlotȱofȱtroubleȇȈȱorȱȈdeafȈȱwithoutȱaȱhearingȱaidȱorȱhearingȱdevice,ȱorȱcurrentlyȱusesȱaȱhearingȱaid.ȱ

[7]ȱAgeȬadjustedȱbyȱdirectȱmethodȱtoȱUSȱCensusȱpopulationȱestimateȱforȱJulyȱ1,ȱ2008.ȱAccessedȱJuneȱ22,ȱ2009. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.3:ȱPrevalenceȱofȱSelfȬReportedȱSelectȱMedicalȱConditionsȱbyȱ Gender,ȱUnitedȱStatesȱ2008

PrevalenceȱAgedȱ18ȱ&ȱOverȱȱ(inȱmillions) MedicalȱCondition Male Female Totalȱ Musculoskeletalȱ[1] 49.104 61.232 110.336 EmotionalȱDisorderȱ[2] 32.607 48.530 81.137 Circulatoryȱ[3] 32.127 36.707 68.864 Respiratoryȱ[4] 20.968 33.893 54.861 MigrainesȱorȱSevereȱHeadaches 8.897 21.375 30.271 BlindȱorȱTroubleȱSeeingȱw/Glasses 10.073 15.083 25.156 Diabetes 8.946 9.715 18.662 Cancerȱ[5] 6.896 10.966 17.862 HearingȱTroubleȱ[6] 8.551 5.857 14.408 KidneyȱDisease 1.757 1.963 3.720 LiverȱDisease 1.578 1.670 3.248

ProportionȱofȱPopulationȱAgedȱ18ȱ&ȱOverȱbyȱSexȱ ReportingȱCondition MedicalȱCondition Male Female Totalȱ Musculoskeletalȱ[1] 45.2% 52.6% 49.0% EmotionalȱDisorderȱ[2] 30.0% 41.7% 36.0% Circulatoryȱ[3] 29.6% 31.5% 30.6% Respiratoryȱ[4] 19.3% 29.1% 24.4% MigrainesȱorȱSevereȱHeadaches 8.2% 18.4% 13.4% BlindȱorȱTroubleȱSeeingȱw/Glasses 9.3% 12.9% 11.2% Diabetes 8.2% 8.3% 8.3% Cancerȱ[5] 6.3% 9.4% 7.9% HearingȱTroubleȱ[6] 7.9% 5.0% 6.4% KidneyȱDisease 1.6% 1.7% 1.7% LiverȱDisease 1.5% 1.4% 1.4%

[1]ȱIncludesȱarthritis,ȱchronicȱjointȱsymptomsȱ(moreȱthanȱ3ȱmonthsȱinȱduration),ȱpainȱinȱlowerȱbackȱorȱneckȱ(moreȱthanȱ3ȱ monthsȱduration) [2]ȱIncludesȱfeelingsȱthatȱinterfereȱwithȱlifeȱandȱactivitiesȱinȱpastȱ30ȱdays:ȱsad,ȱnervous,ȱrestless,ȱhoplessness,ȱworthlesness,ȱ depression,ȱgeneralȱanxiety,ȱpanicȱdisorder,ȱandȱlivingȱisȱanȱeffort [3]ȱIncludesȱcoronaryȱheartȱdisease,ȱanginaȱpectoris,ȱheartȱattack,ȱstroke,ȱchronicȱhypertension,ȱheartȱdisease [4]ȱIncludesȱemphysema,ȱchronicȱasthma,ȱhayȱfever,ȱsinusitis,ȱchronicȱbronchitis [5]ȱIncludesȱallȱtypesȱofȱcancer [6]ȱIncludesȱrespondentsȱreportingȱȈmoderateȱtrouble,ȈȱȈaȱlotȱofȱtroubleȇȈȱorȱȈdeafȈȱwithoutȱaȱhearingȱaidȱorȱorȱhearingȱ device,ȱorȱcurrentlyȱusesȱaȱhearingȱaid.ȱ Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.4:ȱPrevalenceȱofȱSelfȬReportȱSelectedȱMedicalȱConditionsȱbyȱRace,ȱ UnitedȱStates,ȱ2008

PrevalenceȱAgedȱ18ȱ&ȱOverȱ(inȱmillions) Black/ȱAfricanȱ Otherȱorȱ MedicalȱCondition White American Asian MixedȱRace Total Musculoskeletalȱ[1] 92.822 11.502 3.188ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2.825 110.336 EmotionalȱDisorderȱ[2] 68.236 8.571 2.037ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2.293 81.137 Circulatoryȱ[3] 56.438 8.728 2.156ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.542 68.864 Respiratoryȱ[4] 45.541 6.254 1.715ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.351 54.861 MigrainesȱorȱSevereȱHeadaches 24.927 3.525 0.845ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.974 30.271 BlindȱorȱTroubleȱSeeingȱw/Glasses 20.533 3.020 0.876ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.727 25.156 Diabetes 14.537 2.759 0.749ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.617 18.662 Cancerȱ[5] 16.170 1.013 0.323ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.356 17.862 HearingȱTroubleȱ[6] 12.963 0.843 0.310ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.292 14.408 KidneyȱDisease 3.004 0.502 0.141ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.074 3.720 LiverȱDisease 2.751 0.251 0.143ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.104 3.248

ProportionȱofȱPopulationȱAgedȱ18ȱ&ȱOverȱbyȱRaceȱReportingȱCondition Black/ȱAfricanȱ Otherȱorȱ MedicalȱCondition White American Asian MixedȱRace Total Musculoskeletalȱ[1] 50.8% 43.0% 30.4% 53.1% 49.0% EmotionalȱDisorderȱ[2] 37.4% 32.0% 19.4% 43.1% 36.0% Circulatoryȱ[3] 30.9% 32.6% 20.5% 29.0% 30.6% Respiratoryȱ[4] 24.9% 23.4% 16.3% 25.4% 24.4% MigrainesȱorȱSevereȱHeadaches 13.6% 13.2% 8.1% 18.3% 13.4% BlindȱorȱTroubleȱSeeingȱw/Glasses 11.2% 11.3% 8.3% 13.7% 11.2% Diabetes 8.0% 10.3% 7.1% 11.6% 8.3% Cancerȱ[5] 8.9% 3.8% 3.1% 6.7% 7.9% HearingȱTroubleȱ[6] 7.1% 3.1% 3.0% 5.5% 6.4% KidneyȱDisease 1.6% 1.9% 1.3% 1.4% 1.7% LiverȱDisease 1.5% 0.9% 1.4% 1.9% 1.4%

[1]ȱIncludesȱarthritis,ȱchronicȱjointȱsymptomsȱ(moreȱthanȱ3ȱmonthsȱinȱduration),ȱpainȱinȱlowerȱbackȱorȱneckȱ(moreȱthanȱ3ȱmonthsȱduration) [2]ȱIncludesȱfeelingsȱthatȱinterfereȱwithȱlifeȱandȱactivitiesȱinȱpastȱ30ȱdays:ȱsad,ȱnervous,ȱrestless,ȱhoplessness,ȱworthlesness,ȱdepression,ȱgeneralȱ anxiety,ȱpanicȱdisorder,ȱandȱlivingȱisȱanȱeffort [3]ȱIncludesȱcoronaryȱheartȱdisease,ȱanginaȱpectoris,ȱheartȱattack,ȱstroke,ȱchronicȱhypertension,ȱheartȱdisease [4]ȱIncludesȱemphysema,ȱchronicȱasthma,ȱhayȱfever,ȱsinusitis,ȱchronicȱbronchitis [5]ȱIncludesȱallȱtypesȱofȱcancer [6]ȱIncludesȱrespondentsȱreportingȱȈmoderateȱtrouble,ȈȱȈaȱlotȱofȱtroubleȇȈȱorȱȈdeafȈȱwithoutȱaȱhearingȱaidȱorȱorȱhearingȱdevice,ȱorȱcurrentlyȱusesȱaȱ hearingȱaid.ȱ Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.5:ȱPrevalenceȱofȱMostȱFrequentlyȱReportedȱMedicalȱConditionsȱbyȱAge,ȱUnitedȱ Statesȱ2008

AgeȬAdjustedȱRateȱ PrevalenceȱAgedȱ18ȱ&ȱOverȱȱ(inȱmillions) [4]ȱPerȱ100ȱTotalȱ MedicalȱCondition 18Ȭ44 45Ȭ64 65Ȭ74 75+ Total Population Musculoskeletalȱ[1,ȱ2] 41.946 43.340 13.048 ȱȱȱȱȱȱȱȱȱȱȱȱ12.002 110.336 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ48.0ȱ ȱȱȱChronicȱ[2]ȱJointȱPainȱ 18.485 27.063 8.520 7.567 61.635 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26.8ȱ ȱȱȱArthritis 8.299 23.902 9.568 9.445 51.241 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22.3ȱ ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) 14.009 12.738 2.614 2.069 31.430 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.7ȱ ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) 27.136 22.788 6.345 5.446 61.715 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26.8ȱ ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee 6.571 9.159 2.608 1.766 20.104 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7ȱ

Circulatoryȱ 13.771 29.617 12.544 ȱȱȱȱȱȱȱȱȱȱȱȱ12.932 68.864 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29.9ȱ ȱȱȱChronicȱHypertension 9.642 25.157 10.738 10.583 56.121 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ24.4ȱ ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] 5.071 9.470 5.292 6.795 26.628 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.6ȱ ȱȱȱStroke 0.714 2.258 1.231 2.239 6.442 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.8ȱ

Respiratoryȱ 23.437 21.176 5.846 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.401 54.861 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ23.8ȱ ȱȱȱSinusitis 12.848 12.074 3.353 2.337 30.611 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.3ȱ ȱȱȱHayȱFever 7.379 7.825 1.531 1.272 18.007 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.8ȱ ȱȱȱChronicȱ[2]ȱAsthma 7.945 5.765 1.546 1.109 16.365 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.1ȱ ȱȱȱChronicȱ[2]ȱBronchitis 3.492 4.251 1.168 0.917 9.828 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.3ȱ ȱȱȱEmphysema 0.222 1.575 1.118 0.873 3.788 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.7ȱ

ProportionȱofȱPopulationȱinȱAgeȱGroupȱReportingȱCondition MedicalȱCondition 18Ȭ44 45Ȭ64 65Ȭ74 75+ Total Musculoskeletalȱ[1,ȱ2] 37.9% 56.0% 65.8% 69.1% 49.0% ȱȱȱChronicȱ[2]ȱJointȱPainȱ 16.7% 35.0% 43.0% 43.6% 27.4% ȱȱȱArthritis 7.5% 30.9% 48.3% 54.4% 22.7% ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) 12.7% 16.5% 13.2% 11.9% 14.0% ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) 24.5% 29.4% 32.0% 31.4% 27.4% ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee 5.9% 11.8% 13.2% 10.2% 8.9%

Circulatoryȱ 12.4% 38.3% 63.3% 74.5% 30.6% ȱȱChronicȱHypertension 8.7% 32.5% 54.2% 61.0% 24.9% ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] 4.6% 12.2% 26.7% 39.1% 11.8% ȱȱȱStroke 0.6% 2.9% 6.2% 12.9% 2.9%

Respiratoryȱ 21.2% 27.3% 29.5% 25.4% 24.4% ȱȱȱSinusitis 11.6% 15.6% 16.9% 13.5% 13.6% ȱȱȱHayȱFever 6.7% 10.1% 7.7% 7.3% 8.0% ȱȱȱChronicȱ[2]ȱAsthma 7.2% 7.4% 7.8% 6.4% 7.3% ȱȱȱChronicȱ[2]ȱBronchitis 3.2% 5.5% 5.9% 5.3% 4.4% ȱȱȱEmphysema 0.2% 2.0% 5.6% 5.0% 1.7%

[1]ȱSpecificȱconditionsȱareȱnotȱmutuallyȱexclusiveȱinȱoverallȱconditionȱcategory [2]ȱSymptomsȱlastingȱ3ȱmonthsȱorȱlonger [3]ȱIncludesȱheartȱattack,ȱanginaȱpectoris,ȱandȱotherȱheartȱdisease [5]ȱAgeȬadjustedȱbyȱdirectȱmethodȱtoȱUSȱCensusȱpopulationȱestimateȱforȱJulyȱ1,ȱ2007.ȱAccessedȱJuneȱ22,ȱ2009. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.6:ȱPrevalenceȱofȱMostȱFrequentlyȱReportedȱMedicalȱConditionsȱ byȱGender,ȱUnitedȱStatesȱ2008

PrevalenceȱAgeȱ18ȱ&ȱOverȱȱ(inȱmillions) MedicalȱCondition Males Females Totalȱ Musculoskeletalȱ[1,ȱ2] 49.104 61.232 110.336 ȱȱȱChronicȱ[2]ȱJointȱPainȱ 22.710 33.925 61.635 ȱȱȱArthritis 31.536 38.878 70.414 ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) 12.368 19.062 31.430 ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) 27.334 34.381 61.715 ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee 8.498 11.606 20.104

Circulatoryȱ 32.157 36.707 68.864 ȱȱȱChronicȱHypertension 25.997 30.124 56.121 ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] 13.171 13.457 26.628 ȱȱȱStroke 2.948 3.493 6.441

Respiratoryȱ 20.968 33.892 54.861 ȱȱȱSinusitis 10.072 20.540 30.611 ȱȱȱHayȱFever 7.444 10.563 18.007 ȱȱȱChronicȱ[2]ȱAsthma 6.118 10.247 16.365 ȱȱȱChronicȱ[2]ȱBronchitis 3.115 6.712 9.828 ȱȱȱEmphysema 1.768 2.020 3.788

ProportionȱofȱPopulationȱbyȱSexȱReportingȱCondition MedicalȱCondition Males Females Totalȱ Musculoskeletalȱ[1,ȱ2] 45.2% 52.6% 49.0% ȱȱȱChronicȱ[2]ȱJointȱPainȱ 20.9% 29.1% 27.4% ȱȱȱArthritis 18.5% 26.7% 22.7% ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) 11.4% 16.4% 14.0% ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) 25.1% 29.5% 27.4% ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee 7.8% 10.0% 8.9%

Circulatoryȱ 29.6% 31.5% 30.6% ȱȱChronicȱHypertension 23.9% 25.9% 24.9% ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] 12.1% 11.6% 11.8% ȱȱȱStroke 2.7% 3.0% 2.9%

Respiratoryȱ 19.3% 29.1% 24.4% ȱȱȱSinusitis 9.3% 17.6% 13.6% ȱȱȱHayȱFever 6.8% 9.1% 8.0% ȱȱȱChronicȱ[2]ȱAsthma 5.6% 8.8% 7.2% ȱȱȱChronicȱ[2]ȱBronchitis 2.9% 5.8% 4.4% ȱȱȱEmphysema 1.0% 1.7% 1.7%

[1]ȱSpecificȱconditionsȱareȱnotȱmutuallyȱexclusiveȱinȱoverallȱconditionȱcategory [2]ȱSymptomsȱlastingȱ3ȱmonthsȱorȱlonger [3]ȱIncludesȱheartȱattack,ȱanginaȱpectoris,ȱandȱotherȱheartȱdisease Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.7:ȱPrevalenceȱofȱMostȱFrequentlyȱReportedȱMedicalȱConditionsȱbyȱRace,ȱUnitedȱ Statesȱ2008

PrevalenceȱAgedȱ18ȱ&ȱOverȱȱ(inȱmillions) MedicalȱCondition White American Asian Race Total Musculoskeletalȱ[1,ȱ2] 92.822 11.502 3.188ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2.825 110.336 ȱȱȱChronicȱ[2]ȱJointȱPainȱ 52.415 6.372 1.338ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.511 61.635 ȱȱȱArthritis 43.618 5.367 1.118ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.112 51.214 ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) 26.702 2.785 0.923ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.021 31.430 ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) 51.800 6.264 1.817ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.833 61.715 ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee 17.021 1.942 0.460ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0.681 20.104

Circulatoryȱ 56.438 8.728 2.156ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.542 68.864 ȱȱChronicȱHypertension 45.056 7.902 1.942 1.221 56.121 ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] 23.087 2.443 0.463 0.635 26.628 ȱȱȱStroke 5.286 0.831 0.136 0.189 6.442

Respiratoryȱ 45.541 6.254 1.715ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1.351 54.861 ȱȱȱSinusitis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25.597ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.644ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.728ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.642 30.611 ȱȱȱHayȱFever ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ15.131ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.697ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.709ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.470 18.007 ȱȱȱChronicȱ[2]ȱAsthma ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.033ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.165ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.488ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.679 16.365 ȱȱȱChronicȱ[2]ȱBronchitisȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8.443 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.020 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.118 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.246 9.828 ȱȱȱEmphysema ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.446ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.217ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.030ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.095 3.788

ProportionȱofȱPopulationȱAgedȱ18ȱ&ȱOverȱbyȱRaceȱReportingȱCondition Musculoskeletalȱ[1,ȱ2] 50.8% 43.0% 30.4% 53.1% 49.0% ȱȱȱChronicȱ[2]ȱJointȱPainȱ 28.7% 23.8% 12.7% 28.4% 27.4% ȱȱȱArthritis 23.9% 20.1% 10.6% 20.9% 22.7% ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) 14.6% 10.4% 8.8% 19.2% 14.0% ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) 28.4% 23.4% 17.3% 34.5% 27.4% ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee 9.3% 7.3% 4.4% 12.8% 8.9%

Circulatoryȱ 30.9% 32.6% 20.5% 29.0% 30.6% ȱȱChronicȱHypertension 24.7% 29.5% 18.5% 23.0% 24.9% ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] 12.6% 9.1% 4.4% 11.9% 11.8% ȱȱȱStroke 2.9% 3.1% 1.3% 3.6% 2.9%

Respiratoryȱ 24.9% 23.4% 16.3% 25.4% 24.4% ȱȱȱSinusitis 14.9% 13.6% 6.9% 12.1% 13.6% ȱȱȱHayȱFever 8.3% 6.3% 6.8% 8.8% 8.0% ȱȱȱChronicȱ[2]ȱAsthma 7.1% 8.1% 4.6% 12.8% 7.3% ȱȱȱChronicȱ[2]ȱBronchitis 4.6% 3.8% 1.1% 4.6% 4.4% ȱȱȱEmphysema 1.9% 0.8% 0.3% 1.8% 1.7%

[1]ȱSpecificȱconditionsȱareȱnotȱmutuallyȱexclusiveȱinȱoverallȱconditionȱcategory [2]ȱSymptomsȱlastingȱ3ȱmonthsȱorȱlonger [3]ȱIncludesȱheartȱattack,ȱanginaȱpectoris,ȱandȱotherȱheartȱdisease Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.8:ȱPrevalenceȱofȱChronicȱJointȱPainȱ[1]ȱbyȱJointȱbyȱAge,ȱUnitedȱStatesȱ2008

PersonsȱwithȱSelfȬReportedȱChronicȱJointȱConditionȱ(inȱ000s) %ȱJointȱ AgeȬAdjustedȱ Representsȱofȱ Rateȱ[2]ȱperȱ AllȱChronicȱ 100ȱTotalȱ JointȱPainȱ 18Ȭ44 45Ȭ64 65Ȭ74 75+ AllȱAges Population Reportedȱ[3] Kneeȱȱȱȱȱȱȱȱȱȱȱȱ 11,565 ȱȱȱȱȱȱȱȱȱȱȱȱ17,717 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,308 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,475 ȱȱȱȱȱȱȱȱȱȱȱȱ39,065 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17.0 63.4% Shoulderȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,864 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,630 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,868 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,517 ȱȱȱȱȱȱȱȱȱȱȱȱ18,879 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.2 30.6% Fingersȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,146 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,154 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,790 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,449 ȱȱȱȱȱȱȱȱȱȱȱȱ15,539 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.8 25.2% Hipȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,474 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,672 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,656 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,071 ȱȱȱȱȱȱȱȱȱȱȱȱ14,873 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.5 24.1% Ankleȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,301 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,185 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,619 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,389 ȱȱȱȱȱȱȱȱȱȱȱȱ13,494 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.9 21.9% Wristȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,739 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,003 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,527 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,187 ȱȱȱȱȱȱȱȱȱȱȱȱ11,456 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.0 18.6% Elbowȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,985 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,133 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,283 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ854 ȱȱȱȱȱȱȱȱȱȱȱȱ11,456 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.5 16.6% Toesȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,143 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,204 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,108 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ723 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,078 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6 9.9% OtherȱJointȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 910 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,404 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ382 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ388 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,084 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.3 5.0% AllȱChronicȱJointȱȱȱȱȱȱȱȱȱȱȱȱ 18,485 ȱȱȱȱȱȱȱȱȱȱȱȱ27,063 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,520 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,567 ȱȱȱȱȱȱȱȱȱȱȱȱ61,635 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26.8

%ȱAgeȱGroupȱw/JointȱPain Knee 10.5% 22.9% 26.8% 25.8% 17.3% Shoulder 4.4% 11.1% 14.5% 14.5% 8.4% Fingers 2.8% 9.2% 14.1% 14.1% 6.9% Hip 3.1% 8.6% 13.4% 11.9% 6.6% Ankle 3.9% 8.0% 8.2% 8.0% 6.0% Wrist 3.4% 6.5% 7.7% 6.8% 5.1% Elbow 2.7% 6.6% 6.5% 4.9% 4.6% Toes 1.0% 4.1% 5.6% 4.2% 2.7% OtherȱJoint 0.8% 1.8% 1.9% 2.2% 1.4% AllȱChronicȱJoint 16.7% 35.0% 43.0% 43.6% 27.4%

[1]ȱSymptomsȱlastingȱ3ȱmonthsȱorȱlonger [2]ȱAgeȬadjustedȱtoȱJulyȱ1,ȱ2008ȱU.S.ȱCensusȱpopulationȱestimates [3]ȱChronicȱpainȱinȱmultipleȱjointsȱmayȱbeȱreported Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSample,ȱ2008

Tableȱ1.9:ȱSelfȬReportedȱImpairmentȱinȱActivitiesȱofȱDailyȱLivingȱforȱPersonsȱDueȱtoȱ SelectȱMedicalȱConditionsȱbyȱAge,ȱUnitedȱStatesȱ2008

Prevalenceȱ(N)ȱofȱReportedȱImpairmentȱ(inȱ000s)

Totalȱ Total Allȱ Agedȱ18 Condition ȱ0Ȭ17 18Ȭ44 45Ȭ64 65Ȭ74 75+ Ages &ȱOver Musculoskeletalȱ[1] ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ283 ȱȱȱȱȱȱȱȱȱȱȱȱȱ2,664ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ7,416ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ2,838ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ3,852 ȱȱȱȱ17,053ȱ 16,770 Circulatoryȱ[2] *ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ663ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ3,447ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,842ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ2,503 ȱȱȱȱȱȱ8,455ȱ 8,455 Depression/Anxiety/EmotionalȱProblemȱ[3] ȱȱȱȱȱȱȱȱȱȱȱȱ1,037 ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,494ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,952ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ265ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ183 ȱȱȱȱȱȱ4,931ȱ 3,894 Diabetes *ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ263ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,680ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ974ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ619 ȱȱȱȱȱȱ3,536ȱ 3,536 Respiratoryȱ(LungȱBreathingȱProblem)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 489 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ397ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,466ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ728ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ605 ȱȱȱȱȱȱ3,685ȱ 3,196 NervousȱSystemȱ[4]/SensoryȱOrganȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ127 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ816ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,388ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ336ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ452 ȱȱȱȱȱȱ3,119ȱ 2,992 VisionȱProblemȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 202 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ269ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ715ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ388ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ718 ȱȱȱȱȱȱ2,292ȱ 2,090 HearingȱProblemȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 186 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ191ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ432ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ197ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ589 ȱȱȱȱȱȱ1,595ȱ 1,409 Cancer *ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ151ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ573ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ266ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ360 ȱȱȱȱȱȱ1,350ȱ 1,350 BirthȱDefect/MentalȱRetardation/ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ432 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ932 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ350 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ24 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 ȱȱȱȱȱȱ1,771ȱ 1,339 ȱȱȱDevelopmentalȱProblem OtherȱCondition/Disorderȱȱȱȱȱȱȱȱȱȱȱȱ 3,526 ȱȱȱȱȱȱȱȱȱȱȱȱ1,354 ȱȱȱȱȱȱȱȱȱȱȱȱ2,346 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ939 ȱȱȱȱȱȱȱȱȱȱȱȱ1,969 ȱȱȱȱ10,134ȱ 6,608 TotalȱAllȱConditionsȱȱȱȱȱȱȱȱȱȱȱȱ 5,478 ȱȱȱȱȱȱȱȱȱȱȱȱ6,824 ȱȱȱȱȱȱȱȱȱȱ13,176 ȱȱȱȱȱȱȱȱȱȱȱȱ5,243 ȱȱȱȱȱȱȱȱȱȱȱȱ7,351 ȱȱȱȱ38,072ȱ ȱȱȱȱȱȱ32,594ȱ

ProportionȱofȱPersonsȱwithȱReportedȱImpairmentȱwithinȱAgeȱGroup Musculoskeletalȱ[1] 0.4% 2.4% 9.6% 14.3% 22.3% 5.7% 7.4% Circulatoryȱ[2] *ȱ 0.6% 4.4% 9.3% 14.5% 2.8% 3.8% Depression/Anxiety/EmotionalȱProblemȱ[3] 1.4% 1.4% 2.5% 1.3% 1.1% 1.6% 1.7% Diabetes *ȱ 0.2% 2.2% 4.9% 3.6% 1.2% 1.6% Respiratoryȱ(LungȱBreathingȱProblem) 0.7% 0.4% 1.9% 3.7% 3.5% 1.2% 1.4% NervousȱSystemȱ[4]/SensoryȱOrganȱ 0.2% 0.7% 1.8% 1.7% 2.6% 1.0% 1.3% VisionȱProblem 0.3% 0.2% 0.9% 2.0% 4.2% 0.8% 0.9% HearingȱProblem 0.3% 0.2% 0.6% 1.0% 3.4% 0.5% 0.6% Cancer *ȱ 0.1% 0.7% 1.3% 2.1% 0.5% 0.6% BirthȱDefect/MentalȱRetardation/ 0.6% 0.8% 0.5% 1.0% 0.2% 0.6% 0.6% ȱȱȱDevelopmentalȱProblem OtherȱCondition/Disorder 4.8% 1.2% 3.0% 4.7% 11.4% 3.4% 2.9% TotalȱAllȱConditions 7.4% 6.2% 17.0% 26.4% 42.6% 12.7% 14.5%

[1]ȱIncludesȱarthritis/rheumatismȱcondition,ȱbackȱorȱneckȱproblem,ȱfracture/bone/jointȱinjury,ȱmusculoskeletal/connectiveȱtissueȱ condition,ȱmissingȱorȱamputatedȱlimb/finger/digit;ȱinȱ0Ȭ17ȱpopulationȱdefinedȱasȱinjuryȱorȱbone/joint/muscleȱproblem. [2]ȱIncludesȱheartȱorȱhypertension,ȱstroke,ȱcirculationȱorȱbloodȱproblem. [3]ȱIncludesȱdepression/anxiety/emotionalȱproblem;ȱinȱ0Ȭ17ȱpopulation,ȱdefinedȱasȱemotional/behavioralȱproblem. [4]ȱInȱ0Ȭ17ȱpopulation,ȱdefinedȱasȱepilepsy/seizures *ȱReportedȱnumberȱdoesȱnotȱmeetȱsampleȱsizeȱreliability Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱPersonȱSample,ȱ2008

Tableȱ1.10:ȱSelfȬReportedȱImpairmentȱinȱActivitiesȱofȱDailyȱLivingȱforȱPersonsȱ Agedȱ18ȱandȱOverȱDueȱtoȱSelectȱMedicalȱConditionsȱbyȱGender,ȱUnitedȱStatesȱ2008

PrevalenceȱofȱReportedȱImpairmentȱforȱPersonsȱAgeȱ18ȱandȱOver ȱ(inȱ000s)ȱ Males Females

%ȱTotalȱ %ȱTotalȱ Totalȱ Prevalenceȱ Maleȱ %ȱofȱTotalȱ Prevalenceȱ Femaleȱ Prevalenceȱ Condition (N) Population N (N) Population %ȱofȱTotal (N) Musculoskeletalȱ[1] ȱȱȱȱȱȱȱȱȱȱ6,531ȱ 6.0% 38.9% ȱȱȱȱȱȱȱȱ10,238ȱ 8.8% 61.1% ȱȱȱȱȱȱȱȱ16,770ȱ Circulatoryȱ[2] ȱȱȱȱȱȱȱȱȱȱ3,889ȱ 3.6% 46.0% ȱȱȱȱȱȱȱȱȱȱ4,565ȱ 3.9% 54.0% ȱȱȱȱȱȱȱȱȱȱ8,454ȱ Depression/Anxiety/EmotionalȱProblemȱȱȱȱȱȱȱȱȱȱ1,488ȱ 1.4% 38.2% ȱȱȱȱȱȱȱȱȱȱ2,406ȱ 2.1% 61.8% ȱȱȱȱȱȱȱȱȱȱ3,894ȱ Diabetes ȱȱȱȱȱȱȱȱȱȱ1,530ȱ 1.4% 43.3% ȱȱȱȱȱȱȱȱȱȱ2,006ȱ 1.7% 56.7% ȱȱȱȱȱȱȱȱȱȱ3,536ȱ Respiratory ȱȱȱȱȱȱȱȱȱȱ1,281ȱ 1.2% 40.1% ȱȱȱȱȱȱȱȱȱȱ1,915ȱ 1.6% 59.9% ȱȱȱȱȱȱȱȱȱȱ3,196ȱ NervousȱSystem/SensoryȱOrganȱ ȱȱȱȱȱȱȱȱȱȱ1,247ȱ 1.1% 41.7% ȱȱȱȱȱȱȱȱȱȱ1,745ȱ 1.5% 58.3% ȱȱȱȱȱȱȱȱȱȱ2,992ȱ VisionȱProblem ȱȱȱȱȱȱȱȱȱȱȱȱȱ777ȱ 0.7% 37.2% ȱȱȱȱȱȱȱȱȱȱ1,313ȱ 1.1% 62.8% ȱȱȱȱȱȱȱȱȱȱ2,090ȱ HearingȱProblem ȱȱȱȱȱȱȱȱȱȱȱȱȱ588ȱ 0.5% 41.7% ȱȱȱȱȱȱȱȱȱȱȱȱȱ820ȱ 0.7% 58.3% ȱȱȱȱȱȱȱȱȱȱ1,408ȱ BirthȱDefect/MentalȱRetardation/ ȱȱȱȱȱȱȱȱȱȱȱȱȱ741ȱ 0.7% 55.4% ȱȱȱȱȱȱȱȱȱȱȱȱȱ598ȱ 0.5% 44.6% ȱȱȱȱȱȱȱȱȱȱ1,339ȱ ȱȱȱDevelopmentalȱProblem Cancer ȱȱȱȱȱȱȱȱȱȱȱȱȱ629ȱ 0.6% 46.6% ȱȱȱȱȱȱȱȱȱȱȱȱȱ721ȱ 0.6% 53.4% ȱȱȱȱȱȱȱȱȱȱ1,350ȱ OtherȱCondition/Disorder ȱȱȱȱȱȱȱȱȱȱ2,684ȱ 12.5% 40.6% ȱȱȱȱȱȱȱȱȱȱ3,923ȱ 13.4% 59.4% ȱȱȱȱȱȱȱȱȱȱ6,607ȱ TotalȱAllȱConditions ȱȱȱȱȱȱȱȱ14,196ȱ 13.1% 43.6% ȱȱȱȱȱȱȱȱ18,397ȱ 15.8% 56.4% ȱȱȱȱȱȱȱȱ32,594ȱ

[1]ȱIncludesȱarthritis/rheumatismȱcondition,ȱbackȱorȱneckȱproblem,ȱfracture/bone/jointȱinjury,ȱmusculoskeletal/connectiveȱtissueȱ condition,ȱmissingȱorȱamputatedȱlimb/finger/digit [2]ȱIncludesȱheartȱorȱhypertension,ȱstroke,ȱcirculationȱorȱbloodȱproblem. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱPersonȱSample,ȱ2008

Tableȱ1.11:ȱSelfȬReportedȱImpairmentȱinȱActivitiesȱofȱDailyȱLivingȱforȱPersonsȱAgedȱ18ȱandȱ OverȱDueȱtoȱSelectȱMedicalȱConditionsȱbyȱRace,ȱUnitedȱStatesȱ2008

PrevalenceȱofȱReportedȱImpairmentȱforȱPersonsȱAgeȱ18ȱandȱOver ȱ(inȱ000s)ȱ Black/ȱAfricanȱ OtherȱorȱMixedȱ White American Asian Race %ȱofȱ %ȱofȱ %ȱofȱ %ȱofȱ Totalȱ Prevalenc Totalȱ Prevalenc Totalȱ Prevalenc Totalȱ Prevalenc Totalȱ Prevalenc Condition eȱ(N) Race eȱ(N) Race eȱ(N) Race eȱ(N) Race eȱ(N) Musculoskeletalȱ[1] ȱȱȱȱȱȱȱ13,953ȱ 7.6% ȱȱȱȱȱȱȱȱȱ2,025ȱ 7.5% ȱȱȱȱȱȱȱȱȱȱȱȱ302ȱ 2.9%ȱȱȱȱȱȱȱȱȱȱȱ 489 9.8% ȱȱȱȱȱȱȱ16,770ȱ Circulatoryȱ[2] ȱȱȱȱȱȱȱȱȱ6,685ȱ 3.7% ȱȱȱȱȱȱȱȱȱ1,437ȱ 5.4% ȱȱȱȱȱȱȱȱȱȱȱȱ155ȱ 1.5%ȱȱȱȱȱȱȱȱȱȱȱ 176 3.6% ȱȱȱȱȱȱȱȱȱ8,454ȱ Depression/Anxiety/EmotionalȱProblemȱȱȱȱȱȱȱȱȱ3,176ȱ 1.7% ȱȱȱȱȱȱȱȱȱȱȱȱ500ȱ 1.9% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ46ȱ 0.4%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 70 3.4% ȱȱȱȱȱȱȱȱȱ3,894ȱ Diabetes ȱȱȱȱȱȱȱȱȱ2,627ȱ 1.4% ȱȱȱȱȱȱȱȱȱȱȱȱ723ȱ 2.7% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73ȱ 0.7%ȱȱȱȱȱȱȱȱȱȱȱ 113 2.3% ȱȱȱȱȱȱȱȱȱ3,536ȱ Respiratory ȱȱȱȱȱȱȱȱȱ2,653ȱ 1.5% ȱȱȱȱȱȱȱȱȱȱȱȱ407ȱ 1.5% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ41ȱ 0.4%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 96 1.9% ȱȱȱȱȱȱȱȱȱ3,196ȱ NervousȱSystem/SensoryȱOrganȱ ȱȱȱȱȱȱȱȱȱ2,449ȱ 1.3% ȱȱȱȱȱȱȱȱȱȱȱȱ344ȱ 1.3% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44ȱ 0.4%ȱȱȱȱȱȱȱȱȱȱȱ 155 3.1% ȱȱȱȱȱȱȱȱȱ2,992ȱ VisionȱProblem ȱȱȱȱȱȱȱȱȱ1,714ȱ 0.9% ȱȱȱȱȱȱȱȱȱȱȱȱ260ȱ 1.0% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ50ȱ 0.5%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 66 1.3% ȱȱȱȱȱȱȱȱȱ2,090ȱ HearingȱProblem ȱȱȱȱȱȱȱȱȱ1,217ȱ 0.7% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ93ȱ 0.3% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ28ȱ 2.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 70 1.4% ȱȱȱȱȱȱȱȱȱ1,408ȱ BirthȱDefect/MentalȱRetardation/ ȱȱȱȱȱȱȱȱȱ1,019ȱ 0.6% ȱȱȱȱȱȱȱȱȱȱȱȱ224ȱ 0.8% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ36ȱ 0.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 60 1.2% ȱȱȱȱȱȱȱȱȱ1,339ȱ ȱȱȱDevelopmentalȱProblem Cancer ȱȱȱȱȱȱȱȱȱ1,140ȱ 0.6% ȱȱȱȱȱȱȱȱȱȱȱȱ116ȱ 0.4% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ37ȱ 0.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 58 1.2% ȱȱȱȱȱȱȱȱȱ1,350ȱ OtherȱCondition/Disorder ȱȱȱȱȱȱȱȱȱ5,432ȱ 3.0% ȱȱȱȱȱȱȱȱȱȱȱȱ854ȱ 3.2% ȱȱȱȱȱȱȱȱȱȱȱȱ155ȱ 1.5%ȱȱȱȱȱȱȱȱȱȱȱ 166 3.3% ȱȱȱȱȱȱȱȱȱ6,607ȱ TotalȱAllȱConditions ȱȱȱȱȱȱȱ26,703ȱ 14.6% ȱȱȱȱȱȱȱȱȱ4,274ȱ 15.9% ȱȱȱȱȱȱȱȱȱȱȱȱ638ȱ 6.0%ȱȱȱȱȱȱȱȱȱȱȱ 979 19.7% ȱȱȱȱȱȱȱ32,594ȱ

[1]ȱIncludesȱarthritis/rheumatismȱcondition,ȱbackȱorȱneckȱproblem,ȱfracture/bone/jointȱinjury,ȱmusculoskeletal/connectiveȱtissueȱcondition,ȱ missingȱorȱamputatedȱlimb/finger/digit [2]ȱIncludesȱheartȱorȱhypertension,ȱstroke,ȱcirculationȱorȱbloodȱproblem. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱPersonȱSample,ȱ2008

Tableȱ1.12:ȱLostȱWorkȱDaysȱfromȱSelfȬReportedȱSelectȱMedicalȱConditionsȱforȱPersonsȱAgedȱ18ȱ andȱOver,ȱUnitedȱStatesȱ2008

%ȱU.S.ȱPopulation ReportingȱLostȱ ȱTotalȱ#ȱw/ȱ WorkȱDaysȱasȱaȱ Totalȱ#ȱ ȱTotalȱ ȱAverageȱWorkȱ Conditionȱ ResultȱofȱMedicalȱ ReportingȱLostȱ WorkȱDaysȱLostȱ DaysȱLostȱ Condition (ȱinȱ000s)ȱ Condition WorkȱDaysȱ (inȱ000s)ȱ perȱConditionȱ

AllȱConditionsȱ[1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 175,653 32.1%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 72,360 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ697,540 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.6 Musculoskeletalȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 110,336 16.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 37,920 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ509,392 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.4 Circulatoryȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 68,864 7.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 17,430 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ239,101 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.7 Respiratoryȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 54,861 9.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 20,961 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ227,913 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.9

MusculoskeletalȱConditions ȱȱȱChronicȱ[2]ȱJointȱPainȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ61,635 8.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 19,872 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ302,141 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ15.2 ȱȱȱArthritis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ51,214 6.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 13,574 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ226,472 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16.7 ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ31,430 5.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 12,019 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ203,285 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16.9 ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ40,284 9.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 22,093 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ313,487 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14.2 ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20,104 2.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6,283 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ162,319 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25.8

Circulatory ȱȱȱChronicȱ[2]ȱHypertension ȱȱȱȱȱȱȱȱȱȱȱȱȱ66,278 7.6% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17,028ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ238,786ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14.0 ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26,628 2.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,944 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ81,471 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.7 ȱȱȱStroke ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,473 0.4%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 813 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ21,504 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26.5

Respiratory ȱȱȱSinusitis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30,611 5.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 12,641 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ150,005 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.9 ȱȱȱHayȱFever ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18,007 3.2%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7,215 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ79,164 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱChronicȱ[2]ȱAsthmaȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16,365 2.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6,022 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ69,681 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.6 ȱȱȱChronicȱ[2]ȱBronchitis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,828 1.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,774 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ57,177 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ15.2 ȱȱȱEmphysema ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,788 0.2%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 549 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10,037 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.3

Migraines/SevereȱHeadaches ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30,271 6.1%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 13,686 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ179,086 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.1 Cancer ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17,862 1.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,795 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ68,867 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.1

[1]ȱReportedȱȇyesȇȱtoȱatȱleastȱoneȱofȱtheȱ36ȱmedicalȱconditionsȱ(78%ȱofȱtheȱweightedȱpopulation). [2]ȱSymptomsȱlastingȱ3ȱmonthsȱorȱlongerȱORȱ2ȱorȱmoreȱphysicianȱvisits [3]ȱIncludesȱheartȱattack,ȱanginaȱpectoris,ȱandȱotherȱheartȱdisease Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSampleȱLevelȱFile,ȱ2008

Tableȱ1.13:ȱBedȱDaysȱfromȱSelfȬReportedȱSelectȱMedicalȱConditionsȱforȱpersonsȱAgedȱ18ȱ andȱOver,ȱUnitedȱStatesȱ2008

%ȱU.S.ȱ Populationȱ ReportingȱBedȱ DaysȱasȱaȱResultȱ Totalȱ#ȱ ȱTotalȱ Averageȱ Totalȱ#ȱw/ȱ ofȱMedicalȱ Reporting BedȱDaysȱ BedȱDaysȱ Condition Conditionȱ Condition BedȱDaysȱ (inȱ000s)ȱ perȱConditionȱ AllȱConditionsȱ[1]ȱȱȱȱȱȱȱȱ 175,653 35.9%ȱȱȱȱȱȱȱȱȱ 80,757 ȱȱȱȱȱ1,035,005 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12.8 Musculoskeletalȱȱȱȱȱȱȱȱ 110,336 21.2%ȱȱȱȱȱȱȱȱȱ 47,655 ȱȱȱȱȱȱȱȱ842,867 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17.7 Circulatoryȱȱȱȱȱȱȱȱȱȱ 68,864 12.1%ȱȱȱȱȱȱȱȱȱ 27,255 ȱȱȱȱȱȱȱȱ595,933 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ21.9 Respiratoryȱȱȱȱȱȱȱȱȱȱ 54,861 11.4%ȱȱȱȱȱȱȱȱȱ 25,766 ȱȱȱȱȱȱȱȱ450,378 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17.5

MusculoskeletalȱConditions ȱȱȱChronicȱ[2]ȱJointȱPainȱ ȱȱȱȱȱȱȱȱȱȱ61,635 12.2%ȱȱȱȱȱȱȱȱȱ 27,381 ȱȱȱȱȱȱȱȱ555,033 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20.3 ȱȱȱArthritis ȱȱȱȱȱȱȱȱȱȱ51,214 9.9%ȱȱȱȱȱȱȱȱȱ 22,326 ȱȱȱȱȱȱȱȱ504,164 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22.6 ȱȱȱNeckȱPainȱ(CervicalȱBackȱPain) ȱȱȱȱȱȱȱȱȱȱ31,430 7.1%ȱȱȱȱȱȱȱȱȱ 15,960 ȱȱȱȱȱȱȱȱ365,654 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22.9 ȱȱȱLowerȱBackȱPainȱ(LumbarȱBackȱPain) ȱȱȱȱȱȱȱȱȱȱ40,284 12.9%ȱȱȱȱȱȱȱȱȱ 29,097 ȱȱȱȱȱȱȱȱ608,822 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20.9 ȱȱȱLowerȱBackȱPainȱSpreadingȱBelowȱKnee ȱȱȱȱȱȱȱȱȱȱ20,104 4.7%ȱȱȱȱȱȱȱȱȱ 10,525 ȱȱȱȱȱȱȱȱ359,190 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ34.1

Circulatory ȱȱȱChronicȱ[2]ȱHypertension ȱȱȱȱȱȱȱȱȱȱ66,278 11.1% ȱȱȱȱȱȱȱȱȱȱ25,101ȱ ȱȱȱȱȱȱȱȱ515,782 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20.5 ȱȱȱCoronaryȱorȱHeartȱConditionȱ[3] ȱȱȱȱȱȱȱȱȱȱ26,628 5.2%ȱȱȱȱȱȱȱȱȱ 11,661 ȱȱȱȱȱȱȱȱ332,655 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ28.5 ȱȱȱStroke ȱȱȱȱȱȱȱȱȱȱȱȱ1,473 1.3%ȱȱȱȱȱȱȱȱȱȱȱ 2,917 ȱȱȱȱȱȱȱȱ163,869 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ56.2

Respiratory ȱȱȱSinusitis ȱȱȱȱȱȱȱȱȱȱ30,611 6.8%ȱȱȱȱȱȱȱȱȱ 15,335 ȱȱȱȱȱȱȱȱ269,590 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17.6 ȱȱȱHayȱFever ȱȱȱȱȱȱȱȱȱȱ18,007 3.7%ȱȱȱȱȱȱȱȱȱȱȱ 8,366 ȱȱȱȱȱȱȱȱ124,238 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14.9 ȱȱȱChronicȱ[2]ȱAsthmaȱ ȱȱȱȱȱȱȱȱȱȱ16,365 3.6%ȱȱȱȱȱȱȱȱȱȱȱ 8,152 ȱȱȱȱȱȱȱȱ185,232 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22.7 ȱȱȱChronicȱ[2]ȱBronchitis ȱȱȱȱȱȱȱȱȱȱȱȱ9,828 2.5%ȱȱȱȱȱȱȱȱȱȱȱ 5,680 ȱȱȱȱȱȱȱȱ168,225 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29.6 ȱȱȱEmphysema ȱȱȱȱȱȱȱȱȱȱȱȱ3,788 0.8%ȱȱȱȱȱȱȱȱȱȱȱ 1,836 ȱȱȱȱȱȱȱȱȱȱ88,706 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ48.3

Migraines/SevereȱHeadaches ȱȱȱȱȱȱȱȱȱȱ30,271 7.6%ȱȱȱȱȱȱȱȱȱ 17,178 ȱȱȱȱȱȱȱȱ355,273 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20.7 Cancer ȱȱȱȱȱȱȱȱȱȱ17,862 3.2%ȱȱȱȱȱȱȱȱȱȱȱ 7,147 ȱȱȱȱȱȱȱȱ156,848 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ21.9

Chapter 2 Spine: Low Back and Neck Pain

Lumbar/low back pain and cervical/neck Eleven percent (11%) of the population aged pain are among the most common physical 18 or older report they have a physical, mental, conditions requiring medical care and aff ecting or emotional problem or illness that precludes an individual’s ability to work and manage the work; 20% of persons with either low back or daily activities of life. Back pain is also the most neck pain report they cannot work, while 33% of common physical condition for which patients persons with multiple back pain sites are unable to visit their doctor. In a given year, between 12% and work.2 Back pain also greatly limits the type and 15% of the United States population will visit their duration of work a person can do. Three of four physician with a complaint of back pain. Over the persons with multiple back pain sites report work past decade, this rate has shown a slow, but steady, limitations. increase. In 2006, more than 44.4 million patients visited a physician with a complaint of back pain. Estimated annual direct medical costs for all spine related conditions for the years 2002-2004 were Joint pain, also called musculoskeletal pain, $193.9 billion, with $30.3 billion estimated as the from mild strains to severe disabling conditions, incremental cost directly related to spine pain. aff ects many. In the United States, two major (Chapter 9: Health Care Utilization and Economic annual health care surveys are conducted by the Cost of Musculoskeletal Diseases.) In addition, National Center for Health Statistics to identify annual indirect costs of $14.0 billion in lost wages the incidence and prevalence of select health were incurred as a result of spine disorders. conditions. One of the conditions included is referred to as “joint pain.” In reality it is not pain Back pain oft en results from complex conditions arising from a joint, but rather a musculoskeletal that are not easily understood. Many are probably pain in a defi ned body area. Joint pain is among related to degeneration, but the actual underlying the most frequently reported conditions in both cause of a back pain episode is oft en uncertain. surveys. Thus, in reviewing administrative data sets for prevalence of conditions, it is important to realize Back pain, including cervical/neck pain and that diagnostic categories may be inaccurate, lumbar/low back pain, is more common than refl ecting the probable diagnosis rather than the severe headaches or allergies resulting from hay defi nitive diagnosis. fever or sinus conditions. In recent years, between 48%1 and 60%2 of adult persons in the United Section 2.1: Low Back and Joint Pain States reported experiencing neck or low back pain in the previous 3 months, while severe headache or migraine was reported by 13% in the most recent Between 2004 and 2008, 28% to 40% of people survey. Hay fever or sinusitis was reported by in the United States report they experienced 8% and 14%, respectively, in a previous 12-month low back pain in a previous 3 month period in period. Back pain is also reported more frequently the two self-reported health condition national than other musculoskeletal pain, including pain health surveys. (Tables 2.1 and 2.2 and Graph in the arm, shoulder, hip, or knee. Low back pain 2.1.1) Among those persons reporting low back prevalence increases with age, while neck pain pain, one-fourth to one-third (26% to 33%) tends to peak in the 45 to 64 age range. also experienced pain radiating into the leg. An additional 14% to 21% of persons reported

Graph 2.1.1: Prevalence of Self-Reported Joint Pain by Site for Graph 2.1.3: Distribution of Joint Pain Other than Persons Aged 18 and Over in Two National Health Surveys, Back Pain by Site for Persons Aged 18 and Over, United States 1999-2007 United States 1999-2004 40 Multiple pain sites (49%) 35 NHIS [1] NHANES [2] 30 Upper limb pain only (15%) 25 Shoulder pain only (6%) 20 Lower limb pain only (7%) 15 10 Knee pain only (19%) 5

Prevalence of Pain by Site of Pain Prevalence (rate per 100 population) Hip pain only (4%) 0 Lower Neck Back w/ Upper Shoulder Lower Knee Hip Source: National Center for Health Statistics. National Health and back pain radiating limb pain limb pain pain Nutrition Examination Survey, 1999-2004. pain leg pain pain pain [1] Source: National Center for Health Statistics, National Health Interview Survey, Adult Sample Level File, 2007 backgrounds in the United States. On average, 4% [2] Source: National Center for Health Statistics. National Health and Nutrition Examination Survey Data, 1999-2004 to 5% of all annual health care visits to physicians, experiencing neck pain. Overall, about one in two emergency departments, outpatient clinics, ad persons report experiencing back pain at least once hospitals are for treatment of back pain. a year. This is a greater rate of pain than is reported for hips, knees, legs, shoulders, and the upper limb The epidemiology of low back pain is not well (arm, elbow, wrist, and hands). Approximately understood and the overall prevalence, as one-half of all persons reporting joint pain supported by health care assessment databases, experience it in more than one site. This is true remains unclear. In 2006, 45.1 million patient visits for persons reporting back pain and for persons to hospitals and physician offi ces had low back reporting joint pain other than back pain. The most pain as the fi rst diagnosis. More than 3 out of 4 frequently reported single site of joint pain is in the visits were to a physician’s offi ce, but 4% entailed lower back. (Graphs 2.1.2 and 2.1.3) hospitalization. (Tables 2.5 and 2.5a and Graph 2.1.4) The two major diagnostic categories in Graph 2.1.2: Distribution of Back Pain by Site for patients with low back pain are disc degeneration Persons Aged 18 and Over, United States 1999-2004 and “back injury.”

Neck and spinespip ne onlyonly (19%)(19%) The most common diagnosis in patients with low back pain is disc degeneration. Graph 2.1.4: Distribution of Health UppUpperpper backback ppainain onlyonly (5%)(5%) Care Visits for Low Back Pain, Until recently, Lower back painp onlyy (26%) United States 2006/2007 degenerative back 4.2% 11.5% 6.9% 77.4%

Source: National Center for Health Statistics. National Health and pain was thought Hospital Hospital Nutrition Examination Survey, 1999-2004. tpatint to be primarily the ischas patnts [1] Hospital result of use or wear ncy [3] Physician and tear. Recent patnts Ĝc Back pain is reported by slightly higher rates [2] Visits studies, however, [4] among females than among males. Back pain is ȱȱ[1]ȱocǱȱncyȱoȱHalthcaȱsachȱan have shown a ȱȱalityǰȱHalthcaȱostȱanȱtili£ationȱPoctǰ reported in the highest rate by persons over the age ȱȱation iȱ npatintȱaplǰȱ2ŖŖ7 of 65 and lowest by those aged 18 to 44. Among strong genetic ȱȱ[2ȱ]ocǱȱationalȱntȱoȱHalthȱtatisticsǰ 3 ȱȱationalȱHospitalȱlatoyȱicalȱaȱ racial groups, back pain is reported at the highest link. Intervertebral ȱȱyǰȱHospitalȱncyǰȱ2ŖŖ6 disc degeneration ȱȱ[3]ȱocǱȱationalȱntȱoȱHalthȱtatisticsǰ rate by those reporting an Other race, and lowest ȱȱationalȱHospitalȱlatoyȱicalȱaȱ is a common and ȱȱyǰȱtpatintǰȱ2ŖŖ6 by those of the Asian race. (Tables 2.1, 2.2, 2.3 ȱȱ[4]ȱocǱȱationalȱntȱoȱHalthȱtatisticsǰ natural process of ȱȱationalȱlatoyȱicalȱaȱyǰȱ and 2.4) Back pain is not selective, but is a major ȱȱ2ŖŖ6 health concern for persons of all ages and ethnic the human spine.

Degeneration occurs gradually with aging and can alter the biomechanics and function of the spine. Graph 2.1.5: Distribution of Health Care Resource Use for Low Back Pain by Type of Diagnosis, United States, Although these changes go unnoticed in many 2006/2007 persons, in others they manifest in back pain and Hospitalizations [1] 80 sometimes even neurological compromise. ER Visits [2] 70 Outpatient Visits [3] 60 In this discussion we are dividing the diagnostic 50 Physicisn Visits [4] codes into three groups: back disorders, disc 40 All Low Back Pain Visits disorders, and back injuries. This approach was 30 chosen to allow comparison to earlier editions of 20 10 % Total Low Back Pain Visits Low Back Pain % Total this text. Back disorders include infl ammatory 0 Lumbar Back Lumbar Disc Low Back spine conditions, spondylosis, spinal stenosis, Disorders Disorders Injury lumbago, sciatica, backache, and disorders of the [1] Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 sacrum (ICD-9-CM codes 720, 721, and 724). Disc [2] Source: National Center for Health Statistics, National Hospital disorders include herniations, disc degeneration, Ambulatory Medical Care Survey, Hospital Emergency, 2006 [3] Source: National Center for Health Statistics, National Hospital and post laminectomy syndromes (ICD-9-CM code Ambulatory Medical Care Survey, Outpatient, 2006 [4] Source: National Center for Health Statistics, National Ambulatory 722). Back injuries include fractures, dislocation, Medical Care Survey, 2006 and sprains (ICD-9-CM codes 805, 806, 839, 846, and 847). This division, while useful in analyzing the databases, may not always accurately refl ect the primary diagnosis. Further there is some Back injury, which includes fractures, sprains, and overlap. For example, a patient with back pain strains, oft en reported as caused by over-exertion of unknown origin could be given a diagnosis of or overuse, accounted for 20% of 2006 low back lumbago, placing him or her in the back disorder pain resource visits. Note that diagnoses equate to category; a diagnosis of disc degeneration, falling more than 100%, indicating multiple diagnoses for into the disc disorder category; or a diagnosis of some patients. Back injuries accounted for 32% of back strain, falling into the back injury category. emergency room visits in 2006, but only 10% of Unfortunately, databases do not permit diagnostic hospitalizations. (Table 2.5a and Graph 2.1.5) verifi cation, and sometimes a diagnosis is provided The incidence Graph 2.1.6: Distribution of Low Back Pain primarily for reimbursement purposes. of low back Health Care Resource Visits by Age, United States 2006/2007 pain is greatest Back disorders accounted for 70% of 2006 low 2% back pain health care resource visits. Hospital in persons of 13% young adult 34% <18 emergency room and outpatient hospital visits 10% for back disorders accounted for more than three- and middle 18-44 age. In 2006, quarters of back pain visits in 2006, and 69% of 45-64 74% of all hospitalizations were for back disorders. 65-74 health care visits for low 75 & Over Disc disorders, which include disc displacement 40% back pain (herniation) and degeneration, were diagnosed in Sources: Agency for Healthcare Research and Quality, were made Healthcare Cost and Utilization Project, Nationwide about one-half (18%) of the remaining low back Inpatient Sample, 2007; National Center for Health pain resource visits. Disc disorders comprised by persons Statistics, National Hospital Ambulatory Medical between Care Survey, Hospital Emergency, 2006; National 27% of the hospitalizations in 2006, but only 3% of Center for Health Statistics, National Hospital the ages of Ambulatory Medical Care Survey, Outpatient, 2006; emergency room visits. National Center for Health Statistics, National 18 and 64. Ambulatory Medical Care Survey, 2006 (Table 2.5 and Graph 2.1.6) Low back pain in this group is

oft en accompanied by reduced ability to work or Persons hospitalized for low back pain in 2007 inability to work at all. The socioeconomic impact spent an average of nearly 5 days in the hospital. of low back pain, including both direct and indirect (Table 2.8 and Graph 2.1.8) Persons hospitalized costs of health care and disability att endant to the for lumbar back injuries were hospitalized for the disorder, has been estimated to exceed $100 billion longest period of time, an average of more than each year.4 seven days.

Back disorders are found more frequently among Graph 2.1.8: Average Length of Hospital Stay for Lumbar Spine Diagnosis, United States 2006/2007 persons aged 75 and over than in any other age 8 NIS [1] group, accounting for 83% of health care visits 7 NHDS [2] in this age group in 2006. (Table 2.5a and Graph 6 2.1.7) This is probably a reﬂ ection of the prevalence 5 of spinal stenosis in elderly patients. Among 4 the small percentage of persons with low back 3 2 pain who are younger than 18, back disorders Hospital Average

Length of Stay (in days) 1 represented 67% of their visits; the balance of 0 Lumbar Lumbar Lumbar All Lumbar visits for low back pain among the young were Back Disc Injury Back Pain due to back injuries. Disc herniations and disc Disorders Disorders [1] Source: Agency for Healthcare Research and Quality, Healthcare Cost degeneration are rare in this age group. Lumbar and Utilization Project, Nationwide Inpatient Sample, 2007 back injuries accounted for 31% of the health care [2] Source: National Center for Health Statistics, National Hospital Discharge Survey, 2006 visits among persons aged 18 to 44, the highest proportion of all age groups. Disc disorders were seen in 22% of persons over the age of 45 in 2006. Low back pain is found more frequently among females than males, with females representing Graph 2.1.7: Distribution of Health Care Resource Use for Low 56% of the 2006 health care visits. Males were Back Pain by Type and Age, United States 2006/2007 seen more oft en for low back injuries (24% of Lumbar Back <18 Years Disorders visits) while 18% of both males and females were Lumbar Disc diagnosed with disc disorders; 74% of the female 18-44 years Disorders Low Back visits for low back pain were diagnosed as back Injury 45-64 Years

65-74 Years Graph 2.1.9: Distribution of Health Care Resource Use for 75 & Over Low Back Pain by Type and Gender, United States, 2006/2007 All Low Back Pain Visits 0 20406080100 Lumbar Back % Total Health Care Visits Disorders Sources: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007; National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, Hospital Emergency, Lumbar Disc Visits by Females 2006; National Center for Health Statistics, National Hospital Ambulatory Medical Disorders Care Survey, Outpatient, 2006; National Center for Health Statistics, National Visits by Males Ambulatory Medical Care Survey, 2006 All Low Back Lumbar Pain Visits The average age of persons hospitalized in 2007 Injuries for low back pain was 60.5 years. This compares to 0 1020304050607080 an average age of 42.1 years for persons visiting an % Total Health Care Visits Sources: Agency for Healthcare Research and Quality, Healthcare Cost emergency department, 48.8 years for visits to an and Utilization Project, Nationwide Inpatient Sample, 2007; National Center for Health Statistics, National Hospital Ambulatory Medical Care outpatient department, and 51.4 years for visits to Survey, Hospital Emergency, 2006; National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, Outpatient, 2006; a physician. (Table 2.5) National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006

disorders. Again, this is probably a refl ection of the Cervical disorders accounted for 58% of health prevalence of spinal stenosis. (Table 2.5 and Graph care visits for upper back pain in 2006. (Table 2.1.9) 2.6a) Patients with cervical disorders are treated primarily in outpatient sett ings, accounting for Overall, lumbar/low back pain accounted for 1 in 67% of cervical pain patient visits in hospital 25 health care resource visits in 2006, a proportion outpatient sett ings and 65% of physicians offi ce that has been steady for the past several years. The visits. staggering impact of low back pain on both the health care resources in the United States and the Cervical disc disorders accounted for only 14% of disability infl icted on the individual is diffi cult to all neck pain health care visits in 2006, and were fully quantify. seen primarily in physicians offi ces and hospital outpatient clinics. (Table 2.6a and Graph 2.2.2) Section 2.2: Cervical/Neck Pain Neck injuries accounted for 28% of all neck pain. This is a higher percentage than found in low back pain injuries. The majority of patients with cervical Cervical/neck pain is a very common reason for injuries were treated in an outpatient sett ing, and visiting a doctor. In 2006, 13.2 million patient accounted for 69% of all emergency department visits, or more than 1% of all health care visits visits for cervical/ neck pain. to hospitals and physician offi ces, were for neck pain. Three out of four (75%) of the visits were to Inpatient care for cervical/neck pain is, on average, physician offi ces, while only 4% of patients with utilized primarily by older persons. The average cervical/neck pain were hospitalized. (Table 2.6a age for persons hospitalized for cervical/neck pain and Graph in 2007 was 57.0 years, with persons having a neck Graph 2.2.1: Distribution of Health Care 2.2.1) Visits for Cervical/Neck Pain, injury being somewhat younger at 52.0 years. United States 2006/2007 (Table 2.6) The average age of persons treated in 4.0% 14.5% 6.1% 75.4% In presenting an emergency department for neck injury was health care 37.0 years. The overall average age of emergency Hospital Hospital resource [1] Hospital [3] Physician utilization for Graph 2.2.2: Distribution of Health Care Resource Use ¢ Ĝ cervical pain, for Cervical/Neck Pain by Type of Diagnosis, Visits [2] [4] three categories United States, 2006/2007 ȱȱǽŗǾȱǱȱ¢ȱȱ ȱȱ Hospitalizations [1] ER Visits [2] ȱȱ¢ǰȱ ȱȱȱ£ȱǰ of cervical pain ȱȱ ȱ ȱǰȱŘŖŖŝ are addressed. Outpatient Visits [3] Physicisn Visits [4] ȱȱǽŘȱǾǱȱȱȱȱ ȱǰ 80 All Low Back Pain Visits ȱȱȱ ȱ¢ȱȱȱ One is labeled 70 ȱȱ¢ǰȱ ȱ¢ǰȱŘŖŖŜ cervical disc ȱȱǽřǾȱǱȱȱȱȱ ȱǰ 60 ȱȱȱ ȱ¢ȱȱȱ disorders, and 50 ȱȱ¢ǰȱǰȱŘŖŖŜ ȱȱǽŚǾȱǱȱȱȱȱ ȱǰ includes disc 40 ȱȱȱ¢ȱȱȱ¢ǰȱ 30 2006 displacements, herniations, 20 and disc degeneration (ICD-9-CM code 722). A 10 % Total Cervical/Neck Pain Visits Cervical/Neck Pain % Total 0 second group is cervical injuries, and includes Cervical Back Cervical Disc Cervical/Neck Disorders Disorders Injury sprains, strains, and fractures (ICD-9-CM codes [1] Source: Agency for Healthcare Research and Quality, Healthcare Cost 805, 806, 839, and 847). A third group, referred to and Utilization Project, Nationwide Inpatient Sample, 2007 [2] Source: National Center for Health Statistics, National Hospital as cervical disorders, includes pain caused by other Ambulatory Medical Care Survey, Hospital Emergency, 2006 disease entities, including cervical spondylosis and [3] Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, Outpatient, 2006 stenosis (ICD-9-CM codes 721 and 723). [4] Source: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006

room patients with a neck pain diagnosis was 38.0 Persons hospitalized for neck pain in 2007 spent an years. Hospital outpatient and physician oﬃ ce average of just under 5 days in the hospital. (Table patients were, on average, 47.3 and 49.5 years old, 2.8 and Graph 2.2.5) Persons hospitalized for neck respectively. injuries were hospitalized for the longest period of time, an average of 8 days. Four out of ﬁ ve neck pain diagnoses (80%) in 2006 were for persons between the ages of 18 and 64. Graph 2.2.5: Average Length of Hospital Stay for Cervical (Table 2.6a Spine Diagnosis, United States 2006/2007 Graph 2.2.3: Distribution of Cervical/Neck Pain and Graph 8 NIS [1] Health Care Resource Visits by Age, 7 United States 2006/2007 NHDS [2] 2.2.3) Only 6 5% 5% 5% of patients 5 11% 34% <18 were over 4 3 18-44 the age of 75, 2 Average Hospital Average 45-64 with 5% also

Length of Stay (in days) 1 65-74 younger than 0 Cervical Cervical Neck All Cervical/ 18 years of Disorders Disc Injury Neck Pain 46% 75 & Over age. Among Disorders [1] Source: Agency for Healthcare Research and Quality, Healthcare Cost Sources: Agency for Healthcare Research and Quality, persons and Utilization Project, Nationwide Inpatient Sample, 2007 Healthcare Cost and Utilization Project, Nationwide [2] Source: National Center for Health Statistics, National Hospital Inpatient Sample, 2007; National Center for Health aged 18 to 44 Discharge Survey, 2006 Statistics, National Hospital Ambulatory Medical Care Survey, Hospital Emergency, 2006; National years, cervical Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, Outpatient, 2006; injuries (42%) Females accounted for 58% of the health care visits National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 and cervical for neck pain in 2006, a slightly higher proportion disorders than was found with low back pain. (Table 2.6a (49%) accounted for nearly all health care visits and Graph 2.2.6) Cervical disorders accounted for for upper back pain. (Table 2.6a and Graph 2.2.4) 60% of visits by females, with injuries accounting Health care visits for neck injuries by persons for 25%. Among males, 32% of health care visits for under the age of 18 accounted for a larger share of cervical/neck pain were the result of neck injuries, total visits than was found in any other age group with cervical neck disorders accounting for 56% of (51%). Cervical disc disorders, as the ﬁ rst diagnosis the visits. for neck pain, was found most frequently in persons aged 45 to 64 years. Graph 2.2.6: Distribution of Health Care Resource Use for Cervical/Neck Pain by Type and Gender, United States, 2006/2007 Graph 2.2.4: Distribution of Health Care Resource Use for Cervical/Neck Pain by Type and Age, United States 2006/2007 Cervical Back Cervical Back Disorders <18 Years Disorders Cervical Disc Disorders Visits by Females 18-44 years Cervical/Neck Cervical Disc Injury Visits by Males Disorders 45-64 Years All Cervical/Neck Pain Visits 65-74 Years Cervical/Neck

75 & Over Injuries 0 102030405060 All Low Back % Total Health Care Visits Pain Visits 0 1020304050607080 Sources: Agency for Healthcare Research and Quality, Healthcare Cost % Total Health Care Visits and Utilization Project, Nationwide Inpatient Sample, 2007; National Sources: Agency for Healthcare Research and Quality, Healthcare Cost and Center for Health Statistics, National Hospital Ambulatory Medical Care Utilization Project, Nationwide Inpatient Sample, 2007; National Center for Health Survey, Hospital Emergency, 2006; National Center for Health Statistics, Statistics, National Hospital Ambulatory Medical Care Survey, Hospital Emergency, National Hospital Ambulatory Medical Care Survey, Outpatient, 2006; 2006; National Center for Health Statistics, National Hospital Ambulatory Medical National Center for Health Statistics, National Ambulatory Medical Care Care Survey, Outpatient, 2006; National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 Survey, 2006

Section 2.3: Burden of Back Pain The fi nancial cost associated with back pain is obviously enormous and, unfortunately, rising. Greater understanding of the causes of back pain While lumbar/low back pain is more common than and its resultant disability is needed to thwart cervical/neck pain, together they accounted for and reduce this rising trend. Understanding why 5%, or 1 in 20, health care visits in 2006. (Tables 2.7 disc degeneration causes pain in some, yet not in and 2.7a and Graph 2.3.1) The majority of visits others, is needed to address the burden of pain (77%) were physician offi ce visits. Over the past and disability and the signifi cant economic impact 9 years, physician offi ce visits for back pain have low back pain treatment creates on health care increased steadily. In 1998, 12% of the population resources each year. aged 18 and over visited a physician for back pain, accounting for 32 million visits. In 2006, Section 2.3.1: Limitations Resulting from Back the proportion of the population visiting their Pain physician for back pain had increased to 15%, and the total number of visits increased to nearly 45 More than one in ten persons (11%) over the million. (Table 2.9 and Graph 2.3.2) age of 18 in the United States report health care Graph 2.3.1: Spine Diagnosis Visits as a Proportion of All problems limit their ability to work, and one in Health Care Visits, United States 2006/2007 three (32%) report their health limits the amount 8 Lumbar/Low Back Pain Cervical/Neck Pain or type of work they can perform. An additional 7 Total Back Pain 8% of the population report that their ability to 6 walk is impacted by their health. Pain is a major 5 4 cause of these limitations. Back pain is cited more 3 frequently than any other pain entity (e.g., head, 2 shoulder, leg, foot) by persons reporting work or 1 % Total Health Care Visits % Total walking limitations. (Table 2.10 and Graph 2.3.3) 0 Hospital Hospital Hospital Physician Total Health Discharges Emergency Outpatient Ĝȱȱ Care Visits Graph 2.3.3: Proportion of Persons Aged 18 and Over Reporting [1] [2] [3] [4] Pain Limits Ability to Walk or Work by Pain Site, [1] Source: Agency for Healthcare Research and Quality, Healthcare Cost United States 1999-2004 and Utilization Project, Nationwide Inpatient Sample, 2007 [2 ]Source: National Center for Health Statistics, National Hospital 80 Ambulatory Medical Care Survey, Hospital Emergency, 2006 [3] Source: National Center for Health Statistics, National Hospital 70 Ambulatory Medical Care Survey, Outpatient, 2006 60 [4] Source: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 50 40 Graph 2.3.2: Trend in Number and Proportion of Population with Physician Visit for Back Pain, United States 1998-2006 30 20 50 20 Visiting Physician for Back Pain 10 % Population with Limitations % Population Total Number of Persons 0 15 Low Neck Head- Lower Upper Head Torso

(in millions) Back aches Limb Limb

10 40 Pain Limits Pain Limits Pain Limits Ability to Walk Amount of Work All Work (8% of population) (32% of population) (11% of population) 5 Source: National Center for Health Statistics, National Health and % Population Visiting % Population

Physician for Back Pain Nutrition Examination Survey Data, 1999-2004

0 30 1998 2000 2002 2004 2006 Between 1999 and 2004, an average of 62% of Total Physician Visits Source: National Center for Health the population who reported work or walking Statistics, National Ambulatory % of Population with Medical Care Survey,1998- 2006 Back Pain Visit limitations also reported they had low back pain.

During this same time period, 38% to 41% Graph 2.3.4a: Proportion of Persons Aged 18 with Work History reported they had neck pain. Low back pain for Whom Pain Limits Their Ability to Work by Age, was reported nearly twice as oft en as headaches United States 1999-2004 18 to 44 44 to 65 or lower limb joint pain (hip, leg, foot) as the 50 65 to 74 75 & Over cause of work or walking limitations. 40 All Ages with Limitations Work limitations due to back pain are reported 30 in similar proportion by males and females. 20

The presence of back pain in more than one site 10

(e.g., low back, upper back, butt ocks, neck, and Limitations % with Work 0 spine) is more likely to be the cause of work Back Pain Back Pain No Back All Pain 1 Site Multiple Sites Pain Sites limitations than back pain that is localized. Source: National Center for Health Statistics, National Health and Nutrition Examination Survey Data, 1999-2004 Back pain severe enough to keep people from working at any occupation is most likely to Graph 2.3.4b: Proportion of Persons Aged 18 with Work History for Whom Pain Limits The Amount of Work They Can Perform be reported by individuals aged 65 to 74, by Age, United States 1999-2004 and may be the cause of involuntary early 18 to 44 44 to 65 100 retirement. However, individuals in the 65 to 74 75 & Over prime working ages of 45 to 64 frequently 80 All Ages with Limitations report back pain as the cause of their 60 inability to work at all; they also report that the pain places limitations on the amount 40

or type of work they can do in nearly the % with Limitations 20

same proportion as those aged 65 and older. 0 Back Pain Back Pain No Back All Pain Overall, 14% of the population aged 45 to 64 1 Site Multiple Sites Pain Sites reports they cannot work at all due to health Source: National Center for Health Statistics, National Health and Nutrition Examination Survey Data, 1999-2004 limitations; among this group, 24% to 43% report back pain as the cause. This compares back pain also reported losing an average of 14.2 to only 10% of persons in this age group with total work days. (Table 2.12 and Graphs 2.3.5a-b) Hence, work restrictions who report they have no back in 2008, an estimated 385.0 million work days were pain. Among the 32% of the population reporting lost due to back pain. limitations in the amount or type of work they can perform, the diﬀ erences are even greater. Between The most severe pain, resulting in the highest 55% and 84% report back pain, while only 29% of average number of bed and lost work days, was those with no back pain report work restrictions. reported by persons with low back pain and (Table 2.11 and Graphs 2.3.4a-b) radiating leg pain. This group of 10.5 million persons spent an average of 34.1 days in bed and In another national study in 2006, bed days lost an average of 25.8 work days. They probably and lost work days were reported for persons include most patients with disc herniation and self-reporting back pain in the previous 3 months. symptomatic spinal stenosis. Of the total 74.3 million persons reporting back pain, approximately one in two (35.0 million) Females reported higher levels of back pain and reported they spent one or more days in bed due slightly more bed than did males, but in 2008 to back pain. With an average of 19.2 bed days males reported the highest number of lost work reported, persons in the United States spent a total days (14.9 vs. 13.6, respectively). of 671.1 million days in bed due to back pain in 2008. In addition, 27.1 million persons reporting

Graph 2.3.5a: Average Lost Work Days for Persons Aged 18 and spine procedures performed in 2007. Both were Over with Work History Reporting Back Pain by Pain Site, performed on more than one-half (57% and 50%, United States 2007 respectively) of spine pain patients hospitalized. 30 The remaining two top procedures performed in 25 2007 were spinal decompression and the insertion 20 of a spinal device. Decompression, which may or 15 may not be performed in conjunction with a spinal 10 fusion, accounted for 14% of all spine procedures Work Days Reported Work Averge Number of Lost Averge 5 and was performed on one-fourth (25%) of all 0 Back/ Neck pain Low back Radiating All back/ hospitalized spine patients. The insertion of neck (12.0M) pain leg pain spine pain problem (22.1M) (6.3M) (27.1M) a spinal device, which includes replacement (6.3M) spinal disc procedures, accounted for 19% of all Type of Back Pain and Total Persons Reporting Lost Work Days procedures and was performed on one-third (34%) Males Females Total of all hospitalized spine patients. (Table 2.13 and Source: National Center for Health Statistics, National Health Interview Survey, 2007 Graph 2.4.1). Graph 2.3.5b: Average Bed Days for Persons Aged 18 and Over Reporting Back Pain by Pain Site, United States 2007 Section 2.4.1: Spinal Fusion 35

30 The rate of spinal fusion procedures has risen

25 rapidly over the past several decades. Spinal

20 fusion is performed either alone or in conjunction

15 with decompression and/or reduction of a spine Reported 10 deformity. Fusion is performed on the cervical,

5 thoracic and lumbar regions of the spine. Averge Number of Bed Days Averge 0 The increase in spinal fusion rates has been Back/ Neck pain Low back Radiating All back/ neck (16.0M) pain leg pain spine pain documented by several authors, with increased problem (29.1M) (10.5M) (35.0M) rates of 55% between 1979 and 19905; 220% (10.0M) 6 Type of Back Pain and Total Persons Reporting Bed Days between 1990 and 2001 ; and 250% between 1990 and 20037 cited. Revision fusion rates have been Males Females Total reported at increased rates of 180% between 1990 Source: National Center for Health Statistics, National Health Interview Survey, 2007 and 2003.7

Graph 2.4.1: Spine Procedures as Proportion of Total Spine Procedures Section 2.4: Spine Procedures and of Spine Patients, United States 2007 Spine Procedures [1] Spine Patients [2]

While nonsurgical treatment for back pain is the 50

treatment of choice, when back pain becomes so 40 disabling that patients can no longer function in 30 the activities of daily living, spine surgery may be 20 performed. 10 % Total Procedures/Patients % Total 0 Four procedures accounted for 93% of spine Spinal Spinal Spinal Spinal Kypho- Vertebro- Insertion fusion refusion decom- diskectomy plasty plasty spinal procedures reported in 2007. The most (cervical/ pression device frequently performed spine procedure in 2007 lumbar) [1] Total number of procedures in 2007=1.19 million. was a spinal fusion, accounting for 32% of spine [2] Total number of spine procedure patients in 2007=0.66 million; multiple procedures for some patients possible. procedures performed in an inpatient sett ing. Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Spinal diskectomy accounted for 28% of all Project, Nationwide Inpatient Sample, 2007

Increased rates of spinal fusion have been noted by 73%. (Table 2.14 and Graph 2.4.2) This growth since the 1980s. Likely explanations for these refl ects a primary fusion procedure rate per increases are advances in technology, including 100,000 persons aged 18 and over of 115.5 in the development of new diagnostic techniques and 1998 and 178.5 in 2006. Although data from 2004 new implant devices that allow for bett er surgical showed a slight decline from 2002 in this growth management; increased training in spinal surgery; curve, the rate spiked again in 2006. Whether the and the aging of the population with inherent decline was is an indication of a slowing of the medical problems. spinal fusion procedures rate or an anomaly in the 2004 data is unknown. Lumbar spinal fusion rates have increased more rapidly than the rates for cervical or thoracic Between 1998 and 2006, the rate of revision fusion fusion and are increasingly being performed on procedures increased by 69%. The revision rate an older population. Rates of lumbar fusion vary over this 9 year period had a fl uctuating rate, but dramatically among geographic regions, hospitals, overall continued growth. In 1998, revision spinal and even between surgeons in the same hospital, fusions were performed at a rate of 5.9 per 100,000 indicating that the outcomes and indications for persons aged 18 and over. By 2006, the rate had lumbar fusion vary.8 The primary diagnosis for increased to 9.5 per 100,000 persons. several conditions have shown increased rates of fusion, with disc degeneration outpacing those During this 1998 to 2006 period, the cost of of spondylolysis/ spondylolisthesis and spinal performing spinal fusion procedures increased stenosis.6 by 191% for a primary spinal fusion and 272% for a revision spinal fusion procedure. In 2006, the Since the mid-1980s, cervical spinal fusion rates mean hospital cost, as reported in the National have been reported at 25% of the rates of lumbar Inpatient Sample for a primary spinal fusion was fusion. Wide geographic variation is found in the $77,000 and a revision spinal fusion was $96,000. rates of both cervical and lumbar fusion.9 However, Signifi cant cost increases were seen between 2004 cervical rates may have been aff ected by reporting and 2006, an indication of the rising cost of medical procedures, as it was not until 1995 that multilevel care. spinal procedures were reported with more than one procedural code. Between 1985 and 1996, Combining the increased rate of procedures cervical spinal fusion procedures were reported at with the increasing cost of performing them, the an increased rate of 310%, while the same author estimated cost of primary spinal fusion procedures reports increased rates of 286% in lumbar and increased by 408% between 1998 and 2006, totaling 358% in thoracic fusion rates.9 $27.2 billion in 2006. An additional $1.9 billion was spent on revision spinal procedures, an increase Graph 2.4.2: Nine-Year Trend in Spinal Fusion Procedures per In more of 535% between 1998 and 2006. (Table 2.14 and 100,000 Population Aged 18 & Over, United States 1998-2006 200 recent years, Graph 2.4.3) 1998 to 2006, 150 primary spinal Mean charges for lumbar spinal fusion procedures fusion rates in 2006 were $87,100, based on an average hospital 100 based on the stay of 4.4 days. The average cost of a cervical Primary Spinal Fusion Aged 18 & Over All Spinal Fusions Nationwide spinal fusion procedure was nearly 40% less, 50 Revised Spinal Fusion Inpatient $54,500, based on an average hospital stay of 3.2

Fusion Procedures per 100,000 Population Fusion Procedures per 100,000 Population Sample (NIS) days. (Table 2.16)

0 1998 2000 2002 2004 2006 have shown Sources: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1998-2006, and a continued U.S. Census population estimates published July 1st of each year. rise, increasing

Graph 2.4.3: Nine-Year Trend in Total Hospitalization Charges of cervical disc pain, accounting for 19% of fi rst for Spinal Fusion Procedures, United States 1998-2006 diagnosis of spinal fusion patients in 2004. (Table 30 30 2.0 2.17) Lumbar disc degeneration and lumbar disc displacement were the second and third most 25 25 frequent fi rst diagnosis, accounting for 13% and 1.5 11% of fi rst diagnoses, respectively. 20 20

15 15 1.0 The introduction of motion preservation options in the past few years will most certainly have an (in billions) 10 10 impact on spinal fusion as the preferred treatment 0.5 option.

Total Hospitalization Charges Total 5 5

0 0 0.0 Section 2.4.2: Ruptured Spine Diagnosis and 1998 2002 2006 1998 2002 2006 1998 2002 2006 2000 2004 2000 2004 2000 2004 Diskectomy Procedures All Spinal Fusions Primary Spinal Fusion A diskectomy was the second most frequent Revised Spinal Fusion inpatient spine procedure performed in 2006, Sources: Agency for Healthcare Research and Quality, Healthcare Cost and accounting for nearly 331,200 procedures. Nine Utilization Project, Nationwide Inpatient Sample, 1998-2006. out of ten (90%) of diskectomy procedures were performed on patients with a ruptured disc In 2006, 380,000 spinal fusion procedures were diagnosis, primarily for a lumbar disc. (Tables 2.18 performed on patients with lumbar/low back pain and 2.19) The average age at which a diskectomy or cervical/neck pain. The number of primary was performed in 2006 was 51.7 years. Patients lumbar fusion procedures was slightly higher with a diskectomy than cervical procedures (197,000 versus 152,000, performed spent a Graph 2.4.5: Health Care Visits for respectively), accounting for 49% versus 38% of mean of 2.8 days Ruptured Spine by Location, all fusion procedures. (Table 2.15 and Graph 2.4.4) in the hospital, United States 2006/2007 Because many more patients are operated on for 2% 8% at a mean cost 6% low back pain problems requiring decompression of $50,890 per only (e.g., disc herniations, some spinal stenosis), patient. Total the percentage of patients who were fused in the health care cost low back group was lower (10.4%) than in the for inpatient 84% neck group (30.2%). Spinal fusion procedures were diskectomy performed about equally on males and females; procedures in Hospital discharges [1] Graph 2.4.4 : Distribution of Spine Fusion however, patients 2006 was $16.8 Procedures by Spine Section, United States between the ages 2007 billion. Hospital Emergency Departments [2] of 18 and 64 were Hospital Outpatient Departments [3] signiﬁ cantly more Although the (49%(49%)) likely to have the majority of hysician OĜce isits [Ś] procedure than those persons with [1] Source: Agency for Healthcare Research and under age 18 and a ruptured Quality, Healthcare Cost and Utilization Project, those 65 years and Nationwide Inpatient Sample, 2007 disc diagnosis [2] Source: National Center for Health Statistics, CervicalCervicarvicalc older. (Table 2.16) undergoing National Hospital Ambulatory Medical Care ThorThoracic/horacici / Survey, Hospital Emergency, 2006 DDorsalorsarss l surgery were [3] Source: National Center for Health Statistics, Fusiono National Hospital Ambulatory Medical Care (7%(7%)) Spinal fusion is most hospitalized in Survey, Outpatient, 2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide frequently performed 2006, the health [Ś] Source: National Center for Health Statistics, Inpatient Sample, 2007 following a diagnosis National Ambulatory Medical Care Survey, 2006

care impact and cost of a ruptured, or herniated, Section 2.5: Neuromusculoskeletal disc is much more severe due to only 8% of Conditions patients with this diagnosis being hospitalized. The majority (84%) of the total 4.8 million persons diagnosed with a ruptured disc in 2006 were seen The spinal column is an extremely complex in a physician’s offi ce. (Table 2.18 and Graph 2.4.5) biomechanical structure with intimate A ruptured disk occurs primarily between the neurological, muscular, and ligamentous ages of 18 and 64 (81% of diagnoses); rarely does interfaces. Functional and structural disorders of it occur in persons under the age of 18 or over the the spine oft en produce symptomatology aff ecting age of 65. (Graph 2.4.6) contiguous structures and regions. The resultant types of disorders aff ecting multiple domains have been referred to as neuromusculoskeletal or spine- Graph 2.4.6: Health Care Visits for Ruptured The mean Spine by Age, United States 2006 number of related disorders. Included in this group are spinal diskectomy subluxations, spinal sprains and strains, cervical, 100 procedures thoracic, lumbar and pelvic symptoms and 18% 65 & Over reported ill-defi ned conditions; and spine-related (cervico- 80 45 to 64 by the genic) headaches. These types of conditions are prevalent, disturbing, and compromising 18 to 44 National 48% 60 Hospital to patients’ functional abilities. In 2007, over Discharge 152.7 million patient visits had a diagnosis of 40 Survey a neuromusculoskeletal condition, either as a over the primary diagnosis or secondary diagnosis. In part, 20 33% past 11 the reason for the ill-defi ned nature of some of

% of Ruptured Spine Health Care Visits years is these conditions may lie in the intrinsic complexity 0 297,000 per of the spinal column and the multiple structures Sources: Agency for Healthcare Research and Quality, year, with and systems with which it interfaces. For example, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007; National Center for Health a range individuals with chronic lumbar or pelvic pain Statistics, National Hospital Ambulatory Medical Care may also complain of depression, digestive Survey, Hospital Emergency, 2006: National Center for of 279,000 Health Statistics, National Hospital Ambulatory Medical to 324,000 problems, and sexual dysfunction. Many patients Care Survey, Outpatient, 2006; National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 ﬂ uctuating with chronic cervical symptoms suﬀ er from around this headaches as well. mean. (Table 2.20 and Graph 2.4.7) Since 1999, neuromusculoskeletal complaints Graph 2.4.7: Ten Year Trend in Spinal Diskectomy Procedures, have shown a steady increase in incidence. This United States 1996-2006 increase may be associated with the increasingly 350 sedentary lifestyle of Americans and the marked

11-Year increase in occupational and recreational use of Mean: 300 297,000 computers with att endant ergonomic risks. The procedures (in 000s) proportionate rise in cervical and thoracic and per year lumbar spine symptoms and ill-deﬁ ned conditions

Diskectomy Procedures 250 1996 1998 2000 2002 2004 2006 has been similar in distribution since 1999. In Source: National Center for Health Statistics, National 2007, the number of patient visits with a diagnosis Hospital Discharge Survey, 1996-2006 related to cervical spine symptoms and ill-deﬁ ned conditions (64.3 million) were approximately equal in number to visits with a diagnosis for similar lumbar spine disorders (64.1 million). In 2007, thoracic symptoms and ill-deﬁ ned disorders

diagnoses numbered 49.0 million, while pelvic complaint of back pain in 2006, while 74.3 persons disorders diagnoses numbered 26.6 million. self-reported low back or neck pain in 2008 in Neuromusculoskeletal diagnoses related to the the NHIS. Economic projections are based on head and headaches numbered 22.1 million. the MEPS self-reported spine conditions, or 32.7 Females are more prone than males to these spine- million incidences. related disorders across a range of categories. The estimated annual cost for medical care of Section 2.6: Economic Cost of Spine spine conditions, discussed in Chapter 9, both as Conditions a primary condition and secondary to another condition, in 2004 was $193.9 billion or an average of $5,923 for each of the 32.7 million persons Chapter 9 summarizes the cost of musculoskeletal who reported having a spine condition. Of this conditions based on analysis of the Medical total, $30.3 billion is estimated as the incremental Expenditures Panel Survey (MEPS) from 1996 to cost directly related to spine conditions. A 2004. The MEPS, which began in 1996, is a set of breakdown of the $193.9 billion cost due to spine large-scale surveys of families and individuals, conditions shows 34% for ambulatory care, 32% their medical providers (doctors, hospitals, for emergency room or inpatient care, 20% for pharmacies, etc.) and their employers. MEPS prescription drugs, and 14% for other expenses. collects data on the speciﬁ c health services The cost of spine conditions, in 2004 dollars, that Americans use, how frequently they use rose from $130.2 billion in 1996 to $193.9 billion them, the cost of these services, and how they in 2004, an increase of 49%. The increasing cost are paid for, as well as data on the cost, scope, of prescription drugs accounts for the largest and breadth of health insurance held by and percentage of this total cost increase, rising from available to U.S. workers. Currently MEPS collects 13% of total cost to 20% over the 9-year period. data from two major components: households Earnings loss, or indirect costs, due to spine and insurance companies. The Household conditions for persons between the ages of 18 to 64 Component (MEPS-HC) provides data from years with a work history was estimated at $22.4 individual households and their members, which billion per year between 2000 and 2004. is supplemented by data from their medical providers. The Insurance Component (MEPS-IC) is 1. National Center for Health Statistics: National Health a separate survey of employers that provides data Interview Survey, Adult Sample Level File, 2007. on employer-based health insurance. MEPS also includes a Medical Provider Component (MEPS- 2. National Center for Health Statistics: National Health and MPC), that covers hospitals, physicians, home Nutrition Examination Survey Data, 1998-2006. health care providers, and pharmacies identiﬁ ed by MEPS-HC respondents. Its purpose is to 3. Batt ie MC, Videman T: Lumbar disc degeneration: supplement and/or replace information received Epidemiology and genetics. J Bone Joint Surg Am 2006;88:3- from the MEPS-HC respondents.10 9.

As with the National Health Interview Survey 4. Katz J: Lumbar disc disorders and low-back pain: (NHIS), data in the household component is socioeconomic factors and consequences. J Bone Joint Surg self-reported. Self-reported data from available Am 2006;88:21-24. databases indicates a range in the prevalence of all speciﬁ c conditions. As noted earlier in this 5. Katz J: Lumbar spinal fusion: Surgical rates, costs, and chapter, more than 58.4 million persons visited complications. Spine 1995;20:78S-83S. their physician, an emergency room, hospital outpatient center, or were hospitalized with a

6. Deyo R: Epidemiology of spinal surgery: Rates and trends. 9. Abraham DJ, Herkowitz HN, Katz JN: Indications and Center for Cost and Outcomes Research, University of trends in use in cervical spinal fusions. Orthop Clin North Washington; available at: htt p://depts.washington.edu/ Am 1998;29:731-744. ccor/studies/SpineSurgEpi.shtml. Accessed May 2, 2007. 10. Agency for Health Care Research and Quality: Medical 7. Ong KL, Lau E, Kurtz SM, et al: Cervical, thoracic, and Expenditure Panel Survey Background. 2007. Available at: lumbar fusion rates in the U.S.: Perspective from two htt p://www.meps.ahrq.gov/mepsweb/about_meps/survey_ health databases. Paper presented at: 53rd Annual Meeting, back.jsp. Accessed May 7, 2007. Orthopaedic Research Society; 2007;San Diego, CA.

8. Abraham DJ, Herkowitz HN, Katz JN: Indications for thoracic and lumbar spine fusion and trends in use. Orthop Clin North Am 1998;29:803-811.

Section 2.7: Spine: Low Back + Neck Pain Data Tables

Tableȱ2.1:ȱȱSelfȬReportedȱPrevalenceȱofȱJointȱPainȱbyȱSiteȱofȱJointȱandȱSelectedȱ DemographicȱCharacteristicsȱforȱPersonsȱAgedȱ18ȱandȱOver,ȱNationalȱHealthȱInterviewȱ Survey,ȱUnitedȱStatesȱ2008

PrevalenceȱofȱPainȱbyȱSiteȱ(rateȱperȱ100ȱpersons)

Backȱw/ȱ ȱLowerȱ Radiatingȱ Upperȱ LowerȱLimbȱ Backȱ[1]ȱ Neckȱ[2] LegȱPainȱ[3]ȱ Limbȱ[4]ȱShoulderȱ[5]ȱ [6]ȱ Kneeȱ[7]ȱ Hipȱ[8]ȱ

Gender Maleȱȱȱȱȱȱȱȱȱȱȱȱ 25.1 ȱȱȱȱȱȱȱȱȱȱȱȱ11.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.8 ȱȱȱȱȱȱȱȱȱȱȱȱ10.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.4 ȱȱȱȱȱȱȱȱȱȱȱȱ17.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.1 Femaleȱȱȱȱȱȱȱȱȱȱȱȱ 29.5 ȱȱȱȱȱȱȱȱȱȱȱȱ16.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.0 ȱȱȱȱȱȱȱȱȱȱȱȱ14.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7 ȱȱȱȱȱȱȱȱȱȱȱȱ20.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.0

Age 18Ȭ44ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 24.5 ȱȱȱȱȱȱȱȱȱȱȱȱ12.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.8 ȱȱȱȱȱȱȱȱȱȱȱȱ12.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.5 45Ȭ64ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 29.4 ȱȱȱȱȱȱȱȱȱȱȱȱ16.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱȱȱȱ16.7 ȱȱȱȱȱȱȱȱȱȱȱȱ12.2 ȱȱȱȱȱȱȱȱȱȱȱȱ10.1 ȱȱȱȱȱȱȱȱȱȱȱȱ24.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.2 65Ȭ74ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 32.0 ȱȱȱȱȱȱȱȱȱȱȱȱ13.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.2 ȱȱȱȱȱȱȱȱȱȱȱȱ21.0 ȱȱȱȱȱȱȱȱȱȱȱȱ15.4 ȱȱȱȱȱȱȱȱȱȱȱȱ10.7 ȱȱȱȱȱȱȱȱȱȱȱȱ28.1 ȱȱȱȱȱȱȱȱȱȱȱȱ13.8 75ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱ 31.4 ȱȱȱȱȱȱȱȱȱȱȱȱ11.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱȱȱȱȱȱȱ19.7 ȱȱȱȱȱȱȱȱȱȱȱȱ15.5 ȱȱȱȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱȱȱȱȱȱȱ27.7 ȱȱȱȱȱȱȱȱȱȱȱȱ13.2

Race Whiteȱȱȱȱȱȱȱȱȱȱȱȱ 28.4 ȱȱȱȱȱȱȱȱȱȱȱȱ14.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.3 ȱȱȱȱȱȱȱȱȱȱȱȱ13.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱȱȱȱ19.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.8 Blackȱȱȱȱȱȱȱȱȱȱȱȱ 23.4 ȱȱȱȱȱȱȱȱȱȱȱȱ10.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.2 ȱȱȱȱȱȱȱȱȱȱȱȱ18.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.6 Asianȱȱȱȱȱȱȱȱȱȱȱȱ 17.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.6 Otherȱȱȱȱȱȱȱȱȱȱȱȱ 34.5 ȱȱȱȱȱȱȱȱȱȱȱȱ19.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12.8 ȱȱȱȱȱȱȱȱȱȱȱȱ20.1 ȱȱȱȱȱȱȱȱȱȱȱȱ12.2 ȱȱȱȱȱȱȱȱȱȱȱȱ10.0 ȱȱȱȱȱȱȱȱȱȱȱȱ20.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.5

Total ȱȱȱȱȱȱȱȱȱȱȱȱ27.4 ȱȱȱȱȱȱȱȱȱȱȱȱ14.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.9 ȱȱȱȱȱȱȱȱȱȱȱȱ12.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.6 ȱȱȱȱȱȱȱȱȱȱȱȱ19.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.1

[1]ȱȈDuringȱtheȱPASTȱTHREEȱMONTHS,ȱdidȱyouȱhaveȱ…Lowȱbackȱpain?Ȉ [2]ȱȈDuringȱtheȱPASTȱTHREEȱMONTHS,ȱdidȱyouȱhaveȱ...Neckȱpain?Ȉ [3]ȱIfȱlowȱbackȱpain,ȱȈDidȱthisȱpainȱspreadȱdownȱeitherȱlegȱtoȱareasȱbelowȱtheȱknees?Ȉ ȈDURINGȱTHEȱPASTȱ30ȱDAYS,ȱhaveȱyouȱhadȱanyȱsymptomsȱofȱpain,ȱaching,ȱorȱstiffnessȱinȱorȱaroundȱaȱjoint?Ȉȱ [4]ȱHand,ȱwrist,ȱfingers [5]ȱShoulder [6]ȱAnkle,ȱfoot [7]ȱKnee,ȱright/left [8]ȱHip,ȱright/left Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱAdultȱSampleȱLevelȱFile,ȱ2008

Tableȱ2.2:ȱSelfȬReportedȱPrevalenceȱofȱJointȱorȱBackȱPainȱbyȱSiteȱandȱSelectedȱDemographicȱ CharacteristicsȱforȱPersonsȱAgedȱ18ȱandȱOver,ȱȱUnitedȱStatesȱ1999Ȭ2004

PrevalenceȱofȱPainȱbyȱSiteȱ(rateȱperȱ100ȱpersons)

Backȱw/ȱ ȱLowerȱ RadiatingȱUpperȱLimbȱ LowerȱLimbȱ Backȱ[1]ȱ Neckȱ[2] LegȱPainȱ[3]ȱ [4]ȱShoulderȱ[5]ȱ [6]ȱ Kneeȱ[7]ȱ Hipȱ[8]ȱ

Gender Maleȱȱȱȱȱȱȱȱȱȱȱȱ 36.7 ȱȱȱȱȱȱȱȱȱȱȱȱ18.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.0 ȱȱȱȱȱȱȱȱȱȱȱȱ19.4 ȱȱȱȱȱȱȱȱȱȱȱȱ14.4 ȱȱȱȱȱȱȱȱȱȱȱȱ10.4 ȱȱȱȱȱȱȱȱȱȱȱȱ14.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.1 Femaleȱȱȱȱȱȱȱȱȱȱȱȱ 41.4 ȱȱȱȱȱȱȱȱȱȱȱȱ23.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.7 ȱȱȱȱȱȱȱȱȱȱȱȱ23.3 ȱȱȱȱȱȱȱȱȱȱȱȱ14.0 ȱȱȱȱȱȱȱȱȱȱȱȱ14.5 ȱȱȱȱȱȱȱȱȱȱȱȱ14.0 ȱȱȱȱȱȱȱȱȱȱȱȱ10.2

Age 18Ȭ44ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 38.0 ȱȱȱȱȱȱȱȱȱȱȱȱ19.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱȱȱȱ15.6 ȱȱȱȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.1 ȱȱȱȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.8 45Ȭ64ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 41.5 ȱȱȱȱȱȱȱȱȱȱȱȱ24.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.8 ȱȱȱȱȱȱȱȱȱȱȱȱ28.5 ȱȱȱȱȱȱȱȱȱȱȱȱ19.4 ȱȱȱȱȱȱȱȱȱȱȱȱ16.3 ȱȱȱȱȱȱȱȱȱȱȱȱ19.4 ȱȱȱȱȱȱȱȱȱȱȱȱ11.5 65Ȭ74ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 37.0 ȱȱȱȱȱȱȱȱȱȱȱȱ19.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12.1 ȱȱȱȱȱȱȱȱȱȱȱȱ26.6 ȱȱȱȱȱȱȱȱȱȱȱȱ16.7 ȱȱȱȱȱȱȱȱȱȱȱȱ16.5 ȱȱȱȱȱȱȱȱȱȱȱȱ16.7 ȱȱȱȱȱȱȱȱȱȱȱȱ12.2 75ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱ 39.7 ȱȱȱȱȱȱȱȱȱȱȱȱ17.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.3 ȱȱȱȱȱȱȱȱȱȱȱȱ26.8 ȱȱȱȱȱȱȱȱȱȱȱȱ17.9 ȱȱȱȱȱȱȱȱȱȱȱȱ16.4 ȱȱȱȱȱȱȱȱȱȱȱȱ17.9 ȱȱȱȱȱȱȱȱȱȱȱȱ14.6

Race Whiteȱȱȱȱȱȱȱȱȱȱȱȱ 40.2 ȱȱȱȱȱȱȱȱȱȱȱȱ21.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.3 ȱȱȱȱȱȱȱȱȱȱȱȱ23.2 ȱȱȱȱȱȱȱȱȱȱȱȱ15.1 ȱȱȱȱȱȱȱȱȱȱȱȱ13.3 ȱȱȱȱȱȱȱȱȱȱȱȱ15.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.4 Black/ArcianȱAmericanȱȱȱȱȱȱȱȱȱȱȱȱ 36.6 ȱȱȱȱȱȱȱȱȱȱȱȱ16.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.3 ȱȱȱȱȱȱȱȱȱȱȱȱ14.3 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱȱȱȱ11.9 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.4 MexicanȱAmericanȱȱȱȱȱȱȱȱȱȱȱȱ 33.3 ȱȱȱȱȱȱȱȱȱȱȱȱ18.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.1 ȱȱȱȱȱȱȱȱȱȱȱȱ17.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.2 OtherȱHispanicȱȱȱȱȱȱȱȱȱȱȱȱ 31.6 ȱȱȱȱȱȱȱȱȱȱȱȱ16.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.2 ȱȱȱȱȱȱȱȱȱȱȱȱ18.6 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.5 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.2 Otherȱȱȱȱȱȱȱȱȱȱȱȱ 43.8 ȱȱȱȱȱȱȱȱȱȱȱȱ25.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12.5 ȱȱȱȱȱȱȱȱȱȱȱȱ20.3 ȱȱȱȱȱȱȱȱȱȱȱȱ15.0 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱȱȱȱ15.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.9

Total ȱȱȱȱȱȱȱȱȱȱȱȱ39.2 ȱȱȱȱȱȱȱȱȱȱȱȱ21.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.4 ȱȱȱȱȱȱȱȱȱȱȱȱ21.4 ȱȱȱȱȱȱȱȱȱȱȱȱ14.2 ȱȱȱȱȱȱȱȱȱȱȱȱ12.5 ȱȱȱȱȱȱȱȱȱȱȱȱ14.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.2

Tableȱ2.3:ȱDistributionȱofȱBackȱPainȱbyȱSiteȱandȱSelectedȱDemographicȱ CharacteristicsȱforȱPersonsȱAgedȱ18ȱandȱOver,ȱUnitedȱStatesȱ1999Ȭ2004

ProportionȱofȱPersonsȱReportingȱBackȱPain

LowerȱBackȱ UpperȱBackȱ NeckȱandȱSpineȱ MultipleȱBackȱ PainȱOnlyȱ[1] PainȱOnlyȱ[2] Buttocksȱ[3] Onlyȱ[4] PainȱSitesȱ[5]ȱ Gender Male 28% 5% 6% 22% 40% Female 25% 5% 9% 17% 44%

Age 18Ȭ44ȱyears 28% 6% 4% 20% 42% 45Ȭ64ȱyears 23% 5% 10% 18% 44% 65Ȭ74ȱyears 26% 4% 12% 21% 38% 75ȱ&ȱover 33% 6% 11% 14% 36%

Race White 25% 5% 7% 20% 43% Black/AfricanȱAmerican 39% 3% 7% 15% 36% MexicanȱAmerican 27% 3% 8% 23% 40% OtherȱHispanic 25% 8% 8% 17% 43% Other 28% 3% 4% 23% 42%

Total 26% 5% 7% 19% 42%

[1]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…lowȱbackȱpain?Ȉ [2]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…upperȱbackȱpain?Ȉ [3]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…buttocks?Ȉ [4]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…neckȱandȱspine?Ȉ [5]ȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…multipleȱsitesȱofȱbackȈ Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurveyȱData,ȱ1999Ȭ2004.

Tableȱ2.4:ȱDistributionȱJointȱPainȱbyȱSiteȱandȱSelectedȱDemographicȱCharacteristicsȱforȱ PersonsȱAgedȱ18ȱandȱOver,ȱUnitedȱStatesȱ1999Ȭ2004

ProportionȱofȱPersonsȱReportingȱJointȱPainȱ(excludingȱbackȱpain) HipȱPainȱ KneeȱPainȱ LowerȱLimbȱ ShoulderȱPainȱ UpperȱLimbȱ MultipleȱPainȱ Onlyȱ[1] Onlyȱ[2] PainȱOnlyȱ[3] Onlyȱ[4] PainȱOnlyȱ[5]ȱ Sitesȱ[6]ȱ Gender Male 3% 21% 7% 8% 16% 45% Female 5% 18% 7% 5% 14% 52%

Age 18Ȭ44ȱyears 3% 22% 8% 8% 17% 42% 45Ȭ64ȱyears 4% 18% 6% 5% 13% 53% 65Ȭ74ȱyears 5% 16% 8% 5% 13% 54% 75ȱ&ȱover 6% 15% 6% 5% 13% 54%

Race White 4% 18% 7% 6% 15% 49% Black/AfricanȱAmerican 5% 26% 10% 7% 10% 43% MexicanȱAmerican 3% 17% 5% 5% 19% 50% OtherȱHispanic 5% 21% 4% 9% 20% 41% Other 4% 15% 5% 10% 13% 52%

Total 4% 19% 7% 6% 15% 49%

[1]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…hipȱpain?Ȉ [2]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…kneeȱpain?Ȉ [3]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…leg,ȱfootȱpain?Ȉ [4]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…shoulderȱpain?Ȉ [5]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…elbow,ȱwristȱorȱfingerȱpainȈ [6]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…multipleȱjointȱpainȱsitesȈ Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurveyȱData,ȱ1999Ȭ2004.

Tableȱ2.5:ȱPrevalenceȱofȱLumbar/LowȱȱBackȱDisordersȱbyȱGenderȱandȱAge,ȱUnitedȱStatesȱ2006/2007

Gender AgeȱinȱYears AveȱAge ȱTotalȱ Maleȱ Femaleȱ <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover forȱDx

HospitalȱDischargesȱ[1] TotalȱNumberȱofȱHospitalȱDischargesȱforȱLowȱBackȱDisordersȱ(inȱ000s) BackȱDisordersȱȱȱȱȱȱȱȱȱȱ 1,312 ȱȱȱȱȱȱȱȱȱȱȱȱȱ535 ȱȱȱȱȱȱȱȱȱȱȱȱȱ777 *ȱȱȱȱȱȱȱȱȱȱȱȱȱ 224 ȱȱȱȱȱȱȱȱȱȱȱȱȱ446 ȱȱȱȱȱȱȱȱȱȱȱȱȱ236 ȱȱȱȱȱȱȱȱȱȱȱȱȱ276 ȱȱȱȱȱȱȱȱȱȱȱȱ62.0 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱ 521 ȱȱȱȱȱȱȱȱȱȱȱȱȱ236 ȱȱȱȱȱȱȱȱȱȱȱȱȱ283 *ȱȱȱȱȱȱȱȱȱȱȱȱȱ 127 ȱȱȱȱȱȱȱȱȱȱȱȱȱ207 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ85 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ77 ȱȱȱȱȱȱȱȱȱȱȱȱ57.5 BackȱInjuryȱȱȱȱȱȱȱȱȱȱȱȱȱ 191 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ87 ȱȱȱȱȱȱȱȱȱȱȱȱȱ104 *47ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ41 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ23 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ46 ȱȱȱȱȱȱȱȱȱȱȱȱ60.6 AllȱLumbar/LowȱBackȱPainȱ(N)ȱȱȱȱȱȱȱȱȱȱ 1,898 ȱȱȱȱȱȱȱȱȱȱȱȱȱ805 ȱȱȱȱȱȱȱȱȱȱ1,091 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱȱȱȱ379 ȱȱȱȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱȱȱȱ321 ȱȱȱȱȱȱȱȱȱȱȱȱȱ370 ȱȱȱȱȱȱȱȱȱȱȱȱ60.5

HospitalȱEmergencyȱRoomȱVisitsȱ[2] TotalȱNumberȱofȱEmergencyȱRoomȱVisitsȱforȱLowȱBackȱDisordersȱ(inȱ000s) BackȱDisordersȱȱȱȱȱȱȱȱȱȱ 3,830 ȱȱȱȱȱȱȱȱȱȱ1,724 ȱȱȱȱȱȱȱȱȱȱ2,106 ȱȱȱȱȱȱȱȱȱȱȱȱȱ124 ȱȱȱȱȱȱȱȱȱȱ2,029 ȱȱȱȱȱȱȱȱȱȱ1,195 ȱȱȱȱȱȱȱȱȱȱȱȱȱ197 ȱȱȱȱȱȱȱȱȱȱȱȱȱ285 ȱȱȱȱȱȱȱȱȱȱȱȱ43.5 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱ 164 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ69 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ95 ȱȱ*53ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ55 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29 ȱȱȱȱȱȱȱȱȱȱȱȱ52.6 BackȱInjuryȱȱȱȱȱȱȱȱȱȱ 1,641 ȱȱȱȱȱȱȱȱȱȱȱȱȱ738 ȱȱȱȱȱȱȱȱȱȱȱȱȱ903 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ97 ȱȱȱȱȱȱȱȱȱȱ1,011 ȱȱȱȱȱȱȱȱȱȱȱȱȱ426 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ52 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ55 ȱȱȱȱȱȱȱȱȱȱȱȱ38.6 AllȱLumbar/LowȱBackȱPainȱ(N)ȱȱȱȱȱȱȱȱȱȱ 5,199 ȱȱȱȱȱȱȱȱȱȱ2,355 ȱȱȱȱȱȱȱȱȱȱ2,844 ȱȱȱȱȱȱȱȱȱȱȱȱȱ221 ȱȱȱȱȱȱȱȱȱȱ2,867 ȱȱȱȱȱȱȱȱȱȱ1,515 ȱȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱȱ335 ȱȱȱȱȱȱȱȱȱȱȱȱ42.1

HospitalȱOutpatientȱVisitsȱ[3] TotalȱNumberȱofȱOutpatientȱDepartmentȱVisitsȱforȱLowȱBackȱDisordersȱ(inȱ000s) BackȱDisordersȱȱȱȱȱȱȱȱȱȱ 2,380 ȱȱȱȱȱȱȱȱȱȱȱȱȱ958 ȱȱȱȱȱȱȱȱȱȱ1,421 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ71 ȱȱȱȱȱȱȱȱȱȱȱȱȱ860 ȱȱȱȱȱȱȱȱȱȱȱȱȱ968 ȱȱȱȱȱȱȱȱȱȱȱȱȱ219 ȱȱȱȱȱȱȱȱȱȱȱȱȱ263 ȱȱȱȱȱȱȱȱȱȱȱȱ50.2 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱ 556 ȱȱȱȱȱȱȱȱȱȱȱȱȱ242 ȱȱȱȱȱȱȱȱȱȱȱȱȱ314 *ȱȱȱȱȱȱȱȱȱȱȱȱȱ 165 ȱȱȱȱȱȱȱȱȱȱȱȱȱ286 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ42 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ63 ȱȱȱȱȱȱȱȱȱȱȱȱ52.7 BackȱInjuryȱȱȱȱȱȱȱȱȱȱȱȱȱ 384 ȱȱȱȱȱȱȱȱȱȱȱȱȱ189 ȱȱȱȱȱȱȱȱȱȱȱȱȱ196 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 ȱȱȱȱȱȱȱȱȱȱȱȱȱ219 ȱȱȱȱȱȱȱȱȱȱȱȱȱ102 * *ȱȱȱȱȱȱȱȱȱȱȱȱ 37.6 AllȱLumbar/LowȱBackȱPainȱ(N)ȱȱȱȱȱȱȱȱȱȱ 3,107 ȱȱȱȱȱȱȱȱȱȱ1,295 ȱȱȱȱȱȱȱȱȱȱ1,812 ȱȱȱȱȱȱȱȱȱȱȱȱȱ103 ȱȱȱȱȱȱȱȱȱȱ1,165 ȱȱȱȱȱȱȱȱȱȱ1,278 ȱȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱȱ300 ȱȱȱȱȱȱȱȱȱȱȱȱ48.8

PhysicianȱOfficeȱVisitsȱ[4] TotalȱNumberȱofȱPhysicianȱVisitsȱforȱLowȱBackȱDisordersȱ(inȱ000s)ȱ BackȱDisordersȱȱȱȱȱȱȱȱ 24,067 ȱȱȱȱȱȱȱȱȱȱ9,820 ȱȱȱȱȱȱȱȱ14,258 ȱȱȱȱȱȱȱȱȱȱȱȱȱ501 ȱȱȱȱȱȱȱȱȱȱ6,551 ȱȱȱȱȱȱȱȱ10,175 ȱȱȱȱȱȱȱȱȱȱ2,807 ȱȱȱȱȱȱȱȱȱȱ4,034 ȱȱȱȱȱȱȱȱȱȱȱȱ53.2 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱ 6,978 ȱȱȱȱȱȱȱȱȱȱ3,084 ȱȱȱȱȱȱȱȱȱȱ3,894 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ23 ȱȱȱȱȱȱȱȱȱȱ1,599 ȱȱȱȱȱȱȱȱȱȱ3,383 ȱȱȱȱȱȱȱȱȱȱȱȱȱ842 ȱȱȱȱȱȱȱȱȱȱ1,130 ȱȱȱȱȱȱȱȱȱȱȱȱ54.7 BackȱInjuryȱȱȱȱȱȱȱȱȱȱ 6,889 ȱȱȱȱȱȱȱȱȱȱ3,769 ȱȱȱȱȱȱȱȱȱȱ3,120 ȱȱȱȱȱȱȱȱȱȱȱȱȱ182 ȱȱȱȱȱȱȱȱȱȱ3,452 ȱȱȱȱȱȱȱȱȱȱ2,674 ȱȱȱȱȱȱȱȱȱȱȱȱȱ272 ȱȱȱȱȱȱȱȱȱȱȱȱȱ309 ȱȱȱȱȱȱȱȱȱȱȱȱ43.4 AllȱLumbar/LowȱBackȱPainȱ(N)ȱȱȱȱȱȱȱȱ 34,945 ȱȱȱȱȱȱȱȱ15,529 ȱȱȱȱȱȱȱȱ19,416 ȱȱȱȱȱȱȱȱȱȱȱȱȱ705 ȱȱȱȱȱȱȱȱ10,970 ȱȱȱȱȱȱȱȱ14,768 ȱȱȱȱȱȱȱȱȱȱ3,676 ȱȱȱȱȱȱȱȱȱȱ4,825 ȱȱȱȱȱȱȱȱȱȱȱȱ51.4

TotalȱHealthȱCareȱVisitsȱforȱLumbar/LowȱȱBackȱPain,ȱ2004 TotalȱNumberȱofȱȱHealthȱCareȱVisitsȱforȱLowȱBackȱDisordersȱ(inȱ000s)ȱ BackȱDisordersȱȱȱȱȱȱȱȱ 31,589 ȱȱȱȱȱȱȱȱ13,037 ȱȱȱȱȱȱȱȱ18,562 ȱȱȱȱȱȱȱȱȱȱȱȱȱ703 ȱȱȱȱȱȱȱȱȱȱ9,664 ȱȱȱȱȱȱȱȱ12,784 ȱȱȱȱȱȱȱȱȱȱ3,459 ȱȱȱȱȱȱȱȱȱȱ4,858 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱ 8,219 ȱȱȱȱȱȱȱȱȱȱ3,631 ȱȱȱȱȱȱȱȱȱȱ4,586 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 ȱȱȱȱȱȱȱȱȱȱ1,944 ȱȱȱȱȱȱȱȱȱȱ3,931 ȱȱȱȱȱȱȱȱȱȱȱȱȱ987 ȱȱȱȱȱȱȱȱȱȱ1,299 BackȱInjuryȱȱȱȱȱȱȱȱȱȱ 9,105 ȱȱȱȱȱȱȱȱȱȱ4,783 ȱȱȱȱȱȱȱȱȱȱ4,323 ȱȱȱȱȱȱȱȱȱȱȱȱȱ318 ȱȱȱȱȱȱȱȱȱȱ4,729 ȱȱȱȱȱȱȱȱȱȱ3,243 ȱȱȱȱȱȱȱȱȱȱȱȱȱ364 ȱȱȱȱȱȱȱȱȱȱȱȱȱ423 AllȱLumbar/LowȱBackȱPainȱ(N)ȱȱȱȱȱȱȱȱ 45,149 ȱȱȱȱȱȱȱȱ19,984 ȱȱȱȱȱȱȱȱ25,163 ȱȱȱȱȱȱȱȱȱȱ1,043 ȱȱȱȱȱȱȱȱ15,381 ȱȱȱȱȱȱȱȱ18,221 ȱȱȱȱȱȱȱȱȱȱ4,519 ȱȱȱȱȱȱȱȱȱȱ5,830 PercentȱofȱTotal 44% 56% 2% 34% 40% 10% 13%

HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱȱ 1,898 ȱȱȱȱȱȱȱȱȱȱȱȱȱ805 ȱȱȱȱȱȱȱȱȱȱ1,091 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱȱȱȱ379 ȱȱȱȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱȱȱȱ321 ȱȱȱȱȱȱȱȱȱȱȱȱȱ370 ȱȱȱȱȱȱȱȱȱȱȱȱ60.5 HospitalȱEmergencyȱRoomȱVisitsȱ[2]ȱȱȱȱȱȱȱȱȱȱ 5,199 ȱȱȱȱȱȱȱȱȱȱ2,355 ȱȱȱȱȱȱȱȱȱȱ2,844 ȱȱȱȱȱȱȱȱȱȱȱȱȱ221 ȱȱȱȱȱȱȱȱȱȱ2,867 ȱȱȱȱȱȱȱȱȱȱ1,515 ȱȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱȱ335 ȱȱȱȱȱȱȱȱȱȱȱȱ42.1 HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱȱ 3,107 ȱȱȱȱȱȱȱȱȱȱ1,295 ȱȱȱȱȱȱȱȱȱȱ1,812 ȱȱȱȱȱȱȱȱȱȱȱȱȱ103 ȱȱȱȱȱȱȱȱȱȱ1,165 ȱȱȱȱȱȱȱȱȱȱ1,278 ȱȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱȱ300 ȱȱȱȱȱȱȱȱȱȱȱȱ48.8 PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱȱ 34,945 ȱȱȱȱȱȱȱȱ15,529 ȱȱȱȱȱȱȱȱ19,416 ȱȱȱȱȱȱȱȱȱȱȱȱȱ705 ȱȱȱȱȱȱȱȱ10,970 ȱȱȱȱȱȱȱȱ14,768 ȱȱȱȱȱȱȱȱȱȱ3,676 ȱȱȱȱȱȱȱȱȱȱ4,825 ȱȱȱȱȱȱȱȱȱȱȱȱ51.4 AllȱLumbar/LowȱBackȱPainȱ(N)ȱȱȱȱȱȱȱȱ 45,149 ȱȱȱȱȱȱȱȱ19,984 ȱȱȱȱȱȱȱȱ25,163 ȱȱȱȱȱȱȱȱȱȱ1,043 ȱȱȱȱȱȱȱȱ15,381 ȱȱȱȱȱȱȱȱ18,221 ȱȱȱȱȱȱȱȱȱȱ4,519 ȱȱȱȱȱȱȱȱȱȱ5,830 PercentȱofȱTotal 44% 56% 2% 34% 40% 10% 13%

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability [1]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2006 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱOutpatient,ȱ2006 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006

Tableȱ2.5a:ȱPrevalenceȱRateȱofȱLumbarȱandȱLowȱBackȱDisordersȱbyȱGenderȱandȱAge,ȱUnitedȱStatesȱ2006/2007

Gender AgeȱinȱYears ȱTotalȱ Maleȱ Femaleȱ <18ȱ 18Ȭ44ȱ ȱ45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover

HospitalȱDischargesȱ[1] ProportionȱofȱHospitalȱDischargesȱforȱLowȱBackȱDisorders BackȱDisorders 69% 66% 71% * 59% 68% 74% 75% DiscȱDisorders 27% 29% 26% * 34% 31% 26% 21% BackȱInjury 10% 11% 10% * 12% 6% 7% 12% AllȱLumbarȱandȱLowȱBackȱPainȱȱ(inȱ000s) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,898 ȱȱȱȱȱȱȱȱȱȱȱȱȱ805 ȱȱȱȱȱȱȱȱȱȱ1,091 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ379 ȱȱȱȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱȱȱȱ321 ȱȱȱȱȱȱȱȱȱȱȱȱȱ370

HospitalȱEmergencyȱRoomȱVisitsȱ[2] ProportionȱofȱEmergencyȱRoomȱVisitsȱforȱLowȱBackȱDisorders BackȱDisorders 74% 73% 74% 56% 71% 79% 75% 85% DiscȱDisorders 3% 3% 3% ȱȱ*2%4%0ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0 BackȱInjury 32% 31% 32% 44% 35% 28% 20% 16% AllȱLumbarȱandȱLowȱBackȱPainȱȱ(inȱ000s) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,199 ȱȱȱȱȱȱȱȱȱȱ2,355 ȱȱȱȱȱȱȱȱȱȱ2,844 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ221 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,867 ȱȱȱȱȱȱȱȱȱȱ1,515 ȱȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱȱ335

HospitalȱOutpatientȱVisitsȱ[3] ProportionȱofȱHospitalȱOutpatientȱDepartmentȱVisitsȱforȱLowȱBackȱDisorders BackȱDisorders 77% 74% 78% 69% 74% 76% 84% 88% DiscȱDisorders 18% 19% 17% * 14% 22% 16%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0 BackȱInjury 12% 15% 11%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0 19% 8% * * AllȱLumbarȱandȱLowȱBackȱPainȱȱ(inȱ000s) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,107 ȱȱȱȱȱȱȱȱȱȱ1,295 ȱȱȱȱȱȱȱȱȱȱ1,812 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ103 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,165 ȱȱȱȱȱȱȱȱȱȱ1,278 ȱȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱȱ300

PhysicianȱOfficeȱVisitsȱ[4] ProportionȱofȱPhysicianȱOfficeȱVisitsȱforȱLowȱBackȱDisorders BackȱDisorders 69% 63% 73% 71% 60% 69% 76% 84% DiscȱDisorders 20% 20% 20%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0 15% 23% 23% 23% BackȱInjury 20% 24% 16% 26% 31% 18% 7% 6% AllȱLumbarȱandȱLowȱBackȱPainȱȱ(inȱ000s) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ34,945 ȱȱȱȱȱȱȱȱ15,529 ȱȱȱȱȱȱȱȱ19,416 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ705 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10,970 ȱȱȱȱȱȱȱȱ14,768 ȱȱȱȱȱȱȱȱȱȱ3,676 ȱȱȱȱȱȱȱȱȱȱ4,825

TotalȱHealthȱCareȱVisitsȱforȱLumbarȱandȱLowȱBackȱPain,ȱ2004 ProportionȱofȱHealthȱCareȱVisitsȱforȱLowȱBackȱDisordersȱ BackȱDisorders 70% 65% 74% 67% 63% 70% 77% 83% DiscȱDisorders 18% 18% 18%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0 13% 22% 22% 22% BackȱInjury 20% 24% 17% 30% 31% 18% 8% 7% AllȱLumbarȱandȱLowȱBackȱPainȱȱ(inȱ000s) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ45,149 ȱȱȱȱȱȱȱȱ19,984 ȱȱȱȱȱȱȱȱ25,163 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,043 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ15,381 ȱȱȱȱȱȱȱȱ18,221 ȱȱȱȱȱȱȱȱȱȱ4,519 ȱȱȱȱȱȱȱȱȱȱ5,830

%ȱȱbyȱResource ȱTotalȱ AllȱMedicalȱConditionsȱ LowȱBackȱDisordersȱasȱ Diagnoses LowȱBackȱDisordersȱ Distributionȱbyȱ %ȱofȱTotalȱDiagnoses ȱ(inȱ000s)ȱ DistributionȱbyȱResource Resource HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 39,434 4.8% 4.2% 3.4% HospitalȱEmergencyȱRoomȱVisitsȱ[2] ȱȱȱȱȱȱȱȱȱȱȱȱ119,192 5.1% 11.5% 10.3% HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱȱȱȱ 102,208 3.0% 6.9% 8.8% PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱȱȱȱȱȱ 901,954 3.9% 77.4% 77.6% AllȱLumbar/LowȱBackȱPainȱDiagnosesȱ ȱȱȱȱȱȱȱȱȱ1,162,788 3.9% 45,149 1,162,788 (inȱ000s)

Tableȱ2.6:ȱPrevalenceȱofȱNeckȱandȱCervicalȱSpineȱDisordersȱbyȱGenderȱandȱAge,ȱUnitedȱStatesȱ2006/2007

Gender AgeȱinȱYears AveȱAge ȱTotalȱ Maleȱ Femaleȱ <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover forȱDx

HospitalȱDischargessȱ[1] TotalȱNumberȱofȱHospitalȱDischargesȱforȱCervicalȱPainȱDisordersȱ(inȱ000s) CervicalȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 301 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ137 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ164 *51ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ128 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ51 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ50 ȱȱȱȱȱȱȱȱȱȱȱȱȱ59.4 CervicalȱDiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 177 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ81 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ96 *44ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ90 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22 *ȱȱȱȱȱȱȱȱȱȱȱȱȱ 54.8 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 71 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ41 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30 *26ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18 *11ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ52.0 AllȱCervical/NeckȱPainȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 503 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ237 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ266 *ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 111 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ212 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ72 ȱȱȱȱȱȱȱȱȱȱȱȱȱ57.0

HospitalȱEmergencyȱRoomȱVisitsȱ[2] TotalȱNumberȱofȱEmergencyȱRoomȱVisitsȱforȱCervicalȱPainȱDisordersȱsȱ(inȱ000s) CervicalȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 645 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ274 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ372 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ59 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ366 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ164 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ34 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ23 ȱȱȱȱȱȱȱȱȱȱȱȱȱ38.9 CervicalȱDiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 36 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ19 ȱȱ*24ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱ* ȱȱ* ȱȱ*ȱȱȱȱȱȱȱȱȱȱȱȱȱ 42.8 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱ 1,222 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ488 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ734 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ154 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ698 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ223 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ94 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ53 ȱȱȱȱȱȱȱȱȱȱȱȱȱ37.0 AllȱCervical/NeckȱPainȱȱȱȱȱȱȱȱȱȱȱ 1,831 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ754 ȱȱȱȱȱȱȱȱȱȱȱ1,076 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ196 ȱȱȱȱȱȱȱȱȱȱȱ1,048 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ380 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ133 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74 ȱȱȱȱȱȱȱȱȱȱȱȱȱ38.0

HospitalȱOutpatientȱVisitsȱ[3] TotalȱNumberȱofȱOutpatientȱDepartmentȱVisitsȱforȱCervicalȱPainȱDisordersȱȱ(inȱ000s) CervicalȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 517 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ165 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ351 *ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 166 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ218 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ86 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 ȱȱȱȱȱȱȱȱȱȱȱȱȱ50.4 CervicalȱDiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 117 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74 *27ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74 * *ȱȱȱȱȱȱȱȱȱȱȱȱȱ 51.4 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 186 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ42 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ144 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ34 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ95 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43 * *ȱȱȱȱȱȱȱȱȱȱȱȱȱ 36.2 AllȱCervical/NeckȱPainȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 774 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ240 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ534 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ263 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ317 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ97 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ50 ȱȱȱȱȱȱȱȱȱȱȱȱȱ47.3

PhysicianȱOfficeȱVisitsȱ[4] TotalȱNumberȱofȱPhysicianȱVisitsȱforȱCervicalȱPainȱDisordersȱȱ(inȱ000s)ȱ CervicalȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 6,222 ȱȱȱȱȱȱȱȱȱȱȱ2,565 ȱȱȱȱȱȱȱȱȱȱȱ3,657 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ166 ȱȱȱȱȱȱȱȱȱȱȱ1,613 ȱȱȱȱȱȱȱȱȱȱȱ3,277 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ826 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ285 ȱȱȱȱȱȱȱȱȱȱȱȱȱ50.8 CervicalȱDiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 1,529 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ537 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ991 *ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 319 ȱȱȱȱȱȱȱȱȱȱȱ1,000 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ139 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ71 ȱȱȱȱȱȱȱȱȱȱȱȱȱ52.0 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱ 2,211 ȱȱȱȱȱȱȱȱȱȱȱ1,219 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ992 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ116 ȱȱȱȱȱȱȱȱȱȱȱ1,078 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ794 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ138 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ86 ȱȱȱȱȱȱȱȱȱȱȱȱȱ43.3 AllȱCervical/NeckȱPainȱȱȱȱȱȱȱȱȱȱȱ 9,513 ȱȱȱȱȱȱȱȱȱȱȱ4,105 ȱȱȱȱȱȱȱȱȱȱȱ5,408 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ282 ȱȱȱȱȱȱȱȱȱȱȱ2,903 ȱȱȱȱȱȱȱȱȱȱȱ4,817 ȱȱȱȱȱȱȱȱȱȱȱ1,070 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ442 ȱȱȱȱȱȱȱȱȱȱȱȱȱ49.5

TotalȱHealthȱCareȱVisitsȱforȱLumbarȱandȱLowȱBackȱPain,ȱ2004 TotalȱNumberȱofȱȱHealthȱCareȱVisitsȱforȱCervicalȱPainȱDisordersȱȱ(inȱ000s)ȱ CervicalȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 7,685 ȱȱȱȱȱȱȱȱȱȱȱ3,141 ȱȱȱȱȱȱȱȱȱȱȱ4,544 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ242 ȱȱȱȱȱȱȱȱȱȱȱ2,196 ȱȱȱȱȱȱȱȱȱȱȱ3,787 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ997 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ391 CervicalȱDiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 1,859 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ678 ȱȱȱȱȱȱȱȱȱȱȱ1,180 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ414 ȱȱȱȱȱȱȱȱȱȱȱ1,169 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ180 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ91 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱ 3,690 ȱȱȱȱȱȱȱȱȱȱȱ1,790 ȱȱȱȱȱȱȱȱȱȱȱ1,900 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ308 ȱȱȱȱȱȱȱȱȱȱȱ1,897 ȱȱȱȱȱȱȱȱȱȱȱ1,078 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ293 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ164 AllȱCervical/NeckȱPainȱȱȱȱȱȱȱȱ 13,234 ȱȱȱȱȱȱȱȱȱȱȱ5,609 ȱȱȱȱȱȱȱȱȱȱȱ7,624 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ550 ȱȱȱȱȱȱȱȱȱȱȱ4,507 ȱȱȱȱȱȱȱȱȱȱȱ6,034 ȱȱȱȱȱȱȱȱȱȱȱ1,470 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ646 PercentȱofȱTotal 42% 58% 4% 34% 46% 11% 5%

HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 503 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ237 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ266 *ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 111 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ212 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ72 ȱȱȱȱȱȱȱȱȱȱȱȱȱ55.2 HospitalȱEmergencyȱRoomȱVisitsȱ[2]ȱȱȱȱȱȱȱȱȱȱȱ 1,831 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ754 ȱȱȱȱȱȱȱȱȱȱȱ1,076 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ196 ȱȱȱȱȱȱȱȱȱȱȱ1,048 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ380 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ133 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74 ȱȱȱȱȱȱȱȱȱȱȱȱȱ35.0 HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 774 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ240 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ534 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ263 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ317 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ97 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ50 ȱȱȱȱȱȱȱȱȱȱȱȱȱ46.0 PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱȱȱȱȱ 9,513 ȱȱȱȱȱȱȱȱȱȱȱ4,105 ȱȱȱȱȱȱȱȱȱȱȱ5,408 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ282 ȱȱȱȱȱȱȱȱȱȱȱ2,903 ȱȱȱȱȱȱȱȱȱȱȱ4,817 ȱȱȱȱȱȱȱȱȱȱȱ1,070 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ442 ȱȱȱȱȱȱȱȱȱȱȱȱȱ48.4 AllȱCervicalȱ/NeckȱPainȱDiagnosesȱȱȱȱȱȱȱȱ 13,234 ȱȱȱȱȱȱȱȱȱȱȱ5,609 ȱȱȱȱȱȱȱȱȱȱȱ7,624 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ550 ȱȱȱȱȱȱȱȱȱȱȱ4,507 ȱȱȱȱȱȱȱȱȱȱȱ6,034 ȱȱȱȱȱȱȱȱȱȱȱ1,470 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ646 PercentȱofȱTotal 42% 58% 4% 34% 46% 11% 5%

Tableȱ2.6a:ȱPrevalenceȱRateȱofȱNeckȱandȱCervicalȱSpineȱDisordersȱbyȱGenderȱandȱAge,ȱ UnitedȱStatesȱ2006/2007

Gender AgeȱinȱYears ȱTotalȱ Maleȱ Femaleȱ <18ȱ 18Ȭ44ȱ ȱ45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover

HospitalȱDischargesȱ[1] ProportionȱofȱHospitalȱDischargesȱforȱCervicalȱPainȱDisorders CervicalȱDisorders 35% 36% 35%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0 35% 43% 26% 31% CervicalȱDiscȱDisorders 2% 2% 2% ȱȱ*2%* * * NeckȱInjury 67% 65% 68% 79% 67% 59% 71% 72% AllȱCervical/NeckȱPainȱ(N)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 504 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ237 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ266 *ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 111 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ212 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ72

HospitalȱEmergencyȱRoomȱVisitsȱ[2] ProportionȱofȱEmergencyȱRoomȱVisitsȱforȱCervicalȱPainȱDisorders CervicalȱDisorders 31% 30% 31% 26% 28% 39% * * CervicalȱDiscȱDisorders ȱȱ* ȱȱ* ȱȱ* ȱȱ***ȱȱ* ȱȱ* NeckȱInjury 69% 70% 69% 74% 72% 61% 100% 100% AllȱCervical/NeckȱPainȱ(N)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,831 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ754 ȱȱȱȱȱȱȱȱȱȱȱ1,076 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ196 ȱȱȱȱȱȱȱȱȱȱȱ1,048 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ380 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ133 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74

HospitalȱOutpatientȱVisitsȱ[3] ProportionȱofȱOutpatientȱDepartmentȱVisitsȱforȱCervicalȱPainȱDisorders CervicalȱDisorders 67% 69% 66% * 63% 69% 89%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 CervicalȱDiscȱDisorders 15% 18% 14% * 10% 23% * * NeckȱInjury 24% 18% 27%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 36% 14% * * AllȱCervical/NeckȱPainȱ(N)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 774 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ240 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ534 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ263 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ317 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ97 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ50

PhysicianȱOfficeȱVisitsȱ[4] ProportionȱofȱPhysicianȱVisitsȱforȱCervicalȱPainȱDisorders CervicalȱDisorders 65% 62% 68% 59% 56% 68% 77% 64% CervicalȱDiscȱDisorders 16% 13% 18% * 11% 21% 13% 16% NeckȱInjury 23% 30% 18% 41% 37% 16% 13% 19% AllȱCervical/NeckȱPainȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 9,513 ȱȱȱȱȱȱȱȱȱȱȱ4,105 ȱȱȱȱȱȱȱȱȱȱȱ5,408 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ282 ȱȱȱȱȱȱȱȱȱȱȱ2,903 ȱȱȱȱȱȱȱȱȱȱȱ4,817 ȱȱȱȱȱȱȱȱȱȱȱ1,070 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ442

TotalȱHealthȱCareȱVisitsȱforȱLumbarȱandȱLowȱBackȱPain,ȱ2004 ProportionȱofȱȱHealthȱCareȱVisitsȱforȱCervicalȱPainȱDisorders CervicalȱDisorders 58% 56% 60% 49% 49% 63% 68% 61% CervicalȱDiscȱDisorders 14% 12% 15%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 0 9% 19% 12% 14% NeckȱInjury 28% 32% 25% 51% 42% 18% 20% 25% AllȱCervical/NeckȱPainȱ(N) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13,234 ȱȱȱȱȱȱȱȱȱȱȱ5,609 ȱȱȱȱȱȱȱȱȱȱȱ7,624 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ605 ȱȱȱȱȱȱȱȱȱȱȱ4,507 ȱȱȱȱȱȱȱȱȱȱȱ6,034 ȱȱȱȱȱȱȱȱȱȱȱ1,470 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ646

%ȱȱbyȱResource

ȱTotalȱDiagnoses CervicalȱDisordersȱ CervicalȱDisordersȱ AllȱMedicalȱConditionsȱ ȱ(inȱ000s)ȱ asȱ%ȱofȱTotalȱDiagnoses DistributionȱbyȱResource DistributionȱbyȱResource HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 39,434 1.3% 4.0% 3.4% HospitalȱEmergencyȱRoomȱVisitsȱ[2]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 119,192 1.5% 14.5% 10.3% HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 102,208 0.8% 6.1% 8.8% PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 901,954 1.1% 75.4% 77.6%

AllȱCervical/NeckȱPainȱ(inȱ000s) ȱȱȱȱȱȱȱȱȱȱȱȱ1,162,788 1.1% 13,234 1,162,788

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability

[1]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2006 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱOutpatient,ȱ2006 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006

Tableȱ2.7:ȱSummaryȱofȱResourceȱAllocationȱofȱTotalȱHealthȱCareȱOccurrencesȱforȱBackȱPainȱandȱRelatedȱConditionsȱbyȱGenderȱ andȱAge,ȱUnitedȱStatesȱ2006/2007

Gender AgeȱinȱYears

ȱTotalȱ ȱMaleȱ ȱFemaleȱ ȱ<18ȱ ȱ18Ȭ44ȱ ȱ45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover

Lumbar/Lowȱ ȱDiagnosesȱ ȱAveȱAgeȱ BackȱPainȱasȱ Lumbar/LowȱBackȱPain TotalȱNumberȱofȱSpinalȱDiagnosesȱ(inȱ000s) AllȱConditionsȱ atȱDxȱ %ȱofȱTotalȱ (inȱ000s)ȱ Diagnoses HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱ 1,898 ȱȱȱȱȱȱȱȱȱȱȱȱ805 ȱȱȱȱȱȱȱȱȱ1,091 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱȱȱ379 ȱȱȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱȱȱ321 ȱȱȱȱȱȱȱȱȱȱȱȱ370 ȱȱȱȱȱȱȱȱȱȱȱ60.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39,434 4.8% HospitalȱEmergencyȱRoomȱVisitsȱ[2]ȱȱȱȱȱȱȱȱȱ 5,199 ȱȱȱȱȱȱȱȱȱ2,355 ȱȱȱȱȱȱȱȱȱ2,844 ȱȱȱȱȱȱȱȱȱȱȱȱ221 ȱȱȱȱȱȱȱȱȱ2,867 ȱȱȱȱȱȱȱȱȱ1,515 ȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱ335 ȱȱȱȱȱȱȱȱȱȱȱ42.1 ȱȱȱȱȱȱȱȱȱȱȱȱ119,192 5.1% HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱ 3,107 ȱȱȱȱȱȱȱȱȱ1,295 ȱȱȱȱȱȱȱȱȱ1,812 ȱȱȱȱȱȱȱȱȱȱȱȱ103 ȱȱȱȱȱȱȱȱȱ1,165 ȱȱȱȱȱȱȱȱȱ1,278 ȱȱȱȱȱȱȱȱȱȱȱȱ261 ȱȱȱȱȱȱȱȱȱȱȱȱ300 ȱȱȱȱȱȱȱȱȱȱȱ48.8 ȱȱȱȱȱȱȱȱȱȱȱȱ102,208 3.0% PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱ 34,945 ȱȱȱȱȱȱȱ15,529 ȱȱȱȱȱȱȱ19,416 ȱȱȱȱȱȱȱȱȱȱȱȱ705 ȱȱȱȱȱȱȱ10,970 ȱȱȱȱȱȱȱ14,768 ȱȱȱȱȱȱȱȱȱ3,676 ȱȱȱȱȱȱȱȱȱ4,825 ȱȱȱȱȱȱȱȱȱȱȱ51.4 ȱȱȱȱȱȱȱȱȱȱȱȱ901,954 3.9% AllȱLumbar/LowȱBackȱPainȱDiagnosesȱȱȱȱȱȱȱ 45,149 ȱȱȱȱȱȱȱ19,984 ȱȱȱȱȱȱȱ25,163 ȱȱȱȱȱȱȱȱȱ1,043 ȱȱȱȱȱȱȱ15,381 ȱȱȱȱȱȱȱ18,221 ȱȱȱȱȱȱȱȱȱ4,519 ȱȱȱȱȱȱȱȱȱ5,830 ȱȱȱȱȱȱȱȱȱ1,162,788 3.9% PercentȱofȱTotal 44% 56% 2% 34% 40% 10% 13%

Cervical/ȱ ȱDiagnosesȱ ȱAveȱAgeȱ NeckȱPainȱasȱ Cervical/NeckȱPain TotalȱNumberȱofȱSpinalȱDiagnosesȱ(inȱ000s) AllȱConditionsȱ atȱDxȱ %ȱofȱTotalȱ (inȱ000s)ȱ Diagnoses HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱȱȱȱ 503 ȱȱȱȱȱȱȱȱȱȱȱȱ237 ȱȱȱȱȱȱȱȱȱȱȱȱ266 *ȱȱȱȱȱȱȱȱȱȱȱȱ 111 ȱȱȱȱȱȱȱȱȱȱȱȱ212 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ72 ȱȱȱȱȱȱȱȱȱȱȱ55.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39,434 1.3% HospitalȱEmergencyȱRoomȱVisitsȱ[2]ȱȱȱȱȱȱȱȱȱ 1,831 ȱȱȱȱȱȱȱȱȱȱȱȱ754 ȱȱȱȱȱȱȱȱȱ1,076 ȱȱȱȱȱȱȱȱȱȱȱȱ196 ȱȱȱȱȱȱȱȱȱ1,048 ȱȱȱȱȱȱȱȱȱȱȱȱ380 ȱȱȱȱȱȱȱȱȱȱȱȱ133 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74 ȱȱȱȱȱȱȱȱȱȱȱ35.0 ȱȱȱȱȱȱȱȱȱȱȱȱ119,192 1.5% HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱȱȱȱ 774 ȱȱȱȱȱȱȱȱȱȱȱȱ240 ȱȱȱȱȱȱȱȱȱȱȱȱ534 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱȱȱȱȱ263 ȱȱȱȱȱȱȱȱȱȱȱȱ317 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ97 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ50 ȱȱȱȱȱȱȱȱȱȱȱ46.0 ȱȱȱȱȱȱȱȱȱȱȱȱ102,208 0.8% PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱȱȱ 9,513 ȱȱȱȱȱȱȱȱȱ4,105 ȱȱȱȱȱȱȱȱȱ5,408 ȱȱȱȱȱȱȱȱȱȱȱȱ282 ȱȱȱȱȱȱȱȱȱ2,903 ȱȱȱȱȱȱȱȱȱ4,817 ȱȱȱȱȱȱȱȱȱ1,070 ȱȱȱȱȱȱȱȱȱȱȱȱ442 ȱȱȱȱȱȱȱȱȱȱȱ48.4 ȱȱȱȱȱȱȱȱȱȱȱȱ901,954 1.1% AllȱCervical/NeckȱPainȱDiagnosesȱȱȱȱȱȱȱ 13,234 ȱȱȱȱȱȱȱȱȱ5,609 ȱȱȱȱȱȱȱȱȱ7,624 ȱȱȱȱȱȱȱȱȱȱȱȱ605 ȱȱȱȱȱȱȱȱȱ4,507 ȱȱȱȱȱȱȱȱȱ6,034 ȱȱȱȱȱȱȱȱȱ1,470 ȱȱȱȱȱȱȱȱȱȱȱȱ646 ȱȱȱȱȱȱȱȱȱ1,162,788 1.1% PercentȱofȱTotal 42% 58% 5% 34% 46% 11% 5%

Spine/Backȱ ȱDiagnosesȱ TotalȱBackȱPainȱ(Lumbarȱandȱ ȱAveȱAgeȱ Painȱasȱ%ȱofȱ TotalȱNumberȱofȱSpinalȱDiagnosesȱ(inȱ000s) AllȱConditionsȱ atȱDxȱ Totalȱ Cervical)ȱDiagnoses (inȱ000s)ȱ Diagnoses

ȱTotalȱ ȱMaleȱ Femaleȱ <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ 65Ȭ74ȱ 75ȱ&ȱover HospitalȱDischargesȱ[1]ȱȱȱȱȱȱȱȱȱ 2,401 ȱȱȱȱȱȱȱȱȱ1,042 ȱȱȱȱȱȱȱȱȱ1,357 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱȱȱ490 ȱȱȱȱȱȱȱȱȱȱȱȱ872 ȱȱȱȱȱȱȱȱȱȱȱȱ394 ȱȱȱȱȱȱȱȱȱȱȱȱ442 ȱȱȱȱȱȱȱȱȱȱȱ59.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39,434 6.1% HospitalȱEmergencyȱRoomȱVisitsȱ[2]ȱȱȱȱȱȱȱȱȱ 7,030 ȱȱȱȱȱȱȱȱȱ3,109 ȱȱȱȱȱȱȱȱȱ3,920 ȱȱȱȱȱȱȱȱȱȱȱȱ417 ȱȱȱȱȱȱȱȱȱ3,915 ȱȱȱȱȱȱȱȱȱ1,895 ȱȱȱȱȱȱȱȱȱȱȱȱ394 ȱȱȱȱȱȱȱȱȱȱȱȱ409 ȱȱȱȱȱȱȱȱȱȱȱ41.5 ȱȱȱȱȱȱȱȱȱȱȱȱ119,192 5.9% HospitalȱOutpatientȱVisitsȱ[3]ȱȱȱȱȱȱȱȱȱ 3,881 ȱȱȱȱȱȱȱȱȱ1,535 ȱȱȱȱȱȱȱȱȱ2,346 ȱȱȱȱȱȱȱȱȱȱȱȱ150 ȱȱȱȱȱȱȱȱȱ1,428 ȱȱȱȱȱȱȱȱȱ1,595 ȱȱȱȱȱȱȱȱȱȱȱȱ358 ȱȱȱȱȱȱȱȱȱȱȱȱ350 ȱȱȱȱȱȱȱȱȱȱȱ48.8 ȱȱȱȱȱȱȱȱȱȱȱȱ102,208 3.8% PhysicianȱOfficeȱVisitsȱ[4]ȱȱȱȱȱȱȱ 44,458 ȱȱȱȱȱȱȱ19,634 ȱȱȱȱȱȱȱ24,824 ȱȱȱȱȱȱȱȱȱȱȱȱ987 ȱȱȱȱȱȱȱ13,873 ȱȱȱȱȱȱȱ19,585 ȱȱȱȱȱȱȱȱȱ4,746 ȱȱȱȱȱȱȱȱȱ5,267 ȱȱȱȱȱȱȱȱȱȱȱ51.9 ȱȱȱȱȱȱȱȱȱȱȱȱ901,954 4.9% AllȱBackȱPainȱDiagnosesȱȱȱȱȱȱȱ 58,383 ȱȱȱȱȱȱȱ25,593 ȱȱȱȱȱȱȱ32,787 ȱȱȱȱȱȱȱȱȱ1,648 ȱȱȱȱȱȱȱ19,888 ȱȱȱȱȱȱȱ24,255 ȱȱȱȱȱȱȱȱȱ5,989 ȱȱȱȱȱȱȱȱȱ6,476 ȱȱȱȱȱȱȱȱȱ1,162,788 5.0% PercentȱofȱTotal 44% 56% 3% 34% 42% 10% 11%

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability

Tableȱ2.7a:ȱSummaryȱofȱResourceȱAllocationȱasȱaȱProportionȱofȱTotalȱHealthȱCareȱOccurrencesȱforȱBackȱPainȱandȱRelatedȱ ConditionsȱbyȱGenderȱandȱAge,ȱUnitedȱStatesȱ2006/2007

Lumbar/Lowȱ ȱDiagnosesȱ ȱAveȱAgeȱ BackȱPainȱasȱ Lumbar/LowȱBackȱPain ProportionȱofȱTotalȱLumbar/LowȱBackȱPainȱDiagnosesȱbyȱResource AllȱConditionsȱ atȱDxȱ %ȱofȱTotalȱ (inȱ000s)ȱ Diagnoses Gender AgeȱinȱYears ȱTotalȱ ȱMaleȱ ȱFemaleȱ <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ 65Ȭ74ȱ 75ȱ&ȱover HospitalȱDischargesȱ[1] 4.2% 4.0% 4.3% * 2.5% 3.6% 7.1% 6.3% 60.5ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 39,434 4.8% HospitalȱEmergencyȱRoomȱVisitsȱ[2] 11.5% 11.8% 11.3% 21.2% 18.6% 8.3% 5.8% 5.7% 42.1ȱȱȱȱȱȱȱȱȱȱȱȱ 119,192 5.1% HospitalȱOutpatientȱVisitsȱ[3] 6.9% 6.5% 7.2% 9.9% 7.6% 7.0% 5.8% 5.1% 48.8ȱȱȱȱȱȱȱȱȱȱȱȱ 102,208 3.0% PhysicianȱOfficeȱVisitsȱ[4] 77.4% 77.7% 77.2% 67.6% 71.3% 81.0% 81.3% 82.8% 51.4ȱȱȱȱȱȱȱȱȱȱȱȱ 901,954 3.9% AllȱLumbarȱandȱLowȱBackȱPainȱDiagnosesȱ ȱȱȱȱȱȱȱ45,149 ȱȱȱȱȱȱȱ19,984 ȱȱȱȱȱȱȱ25,163 ȱȱȱȱȱȱȱȱȱ1,029 ȱȱȱȱȱȱȱ15,381 ȱȱȱȱȱȱȱ18,221 ȱȱȱȱȱȱȱȱȱ4,519 ȱȱȱȱȱȱȱȱȱ5,830 ȱȱȱȱȱȱȱȱȱ1,162,788 3.9% PercentȱofȱTotal 44% 56% 2% 34% 40% 10% 13%

Cervical/ȱ ȱDiagnosesȱ ȱAveȱAgeȱ NeckȱPainȱasȱ Cervical/NeckȱPain ProportionȱofȱTotalȱCervical/NeckȱPainȱDiagnosesȱbyȱResource AllȱConditionsȱ atȱDxȱ %ȱofȱTotalȱ (inȱ000s)ȱ Diagnoses

Gender AgeȱinȱYears ȱTotalȱ ȱMaleȱ ȱFemaleȱ <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ 65Ȭ74ȱ 75ȱ&ȱover HospitalȱDischargesȱ[1] 3.8% 4.2% 3.5% * 2.5% 3.5% 5.0% 11.1%ȱȱȱȱȱȱȱȱȱȱȱ 55.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39,434 1.3% HospitalȱEmergencyȱRoomȱVisitsȱ[2] 13.8% 13.4% 14.1% 32.4% 23.3% 6.3% 9.0% 11.5%ȱȱȱȱȱȱȱȱȱȱȱ 35.0 ȱȱȱȱȱȱȱȱȱȱȱȱ119,192 1.5% HospitalȱOutpatientȱVisitsȱ[3] 5.8% 4.3% 7.0% 7.8% 5.8% 5.3% 6.6% 7.7%ȱȱȱȱȱȱȱȱȱȱȱ 46.0 ȱȱȱȱȱȱȱȱȱȱȱȱ102,208 0.8% PhysicianȱOfficeȱVisitsȱ[4] 71.9% 73.2% 70.9% 46.6% 64.4% 79.8% 72.8% 68.4%ȱȱȱȱȱȱȱȱȱȱȱ 48.4 ȱȱȱȱȱȱȱȱȱȱȱȱ901,954 1.1% AllȱCervicalȱ(Neck)ȱBackȱPainȱDiagnosesȱ(in ȱȱȱȱȱȱȱ13,234 ȱȱȱȱȱȱȱȱȱ5,609 ȱȱȱȱȱȱȱȱȱ7,624 ȱȱȱȱȱȱȱȱȱȱȱȱ605 ȱȱȱȱȱȱȱȱȱ4,507 ȱȱȱȱȱȱȱȱȱ6,034 ȱȱȱȱȱȱȱȱȱ1,470 ȱȱȱȱȱȱȱȱȱȱȱȱ646 ȱȱȱȱȱȱȱȱȱ1,162,788 1.1% PercentȱofȱTotal 42% 58% 5% 34% 46% 11% 5%

Spine/Backȱ ȱDiagnosesȱ TotalȱBackȱPainȱ(Lumbarȱandȱ ȱAveȱAgeȱ Painȱasȱ%ȱofȱ ProportionȱofȱTotalȱBackȱPainȱDiagnosesȱbyȱRespource AllȱConditionsȱ atȱDxȱ Totalȱ Cervical)ȱDiagnoses (inȱ000s)ȱ Diagnoses Gender AgeȱinȱYears ȱTotalȱ ȱMaleȱ ȱFemaleȱ <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ 65Ȭ74ȱ 75ȱ&ȱover HospitalȱDischargesȱ[1] 4.2% 4.1% 4.1% 0.8% 2.5% 3.6% 6.6% 6.8%ȱȱȱȱȱȱȱȱȱȱȱ 59.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39,434 6.1% HospitalȱEmergencyȱRoomȱVisitsȱ[2] 12.2% 12.1% 12.0% 25.3% 19.7% 7.8% 6.6% 6.3%ȱȱȱȱȱȱȱȱȱȱȱ 41.5 ȱȱȱȱȱȱȱȱȱȱȱȱ119,192 5.7% HospitalȱOutpatientȱVisitsȱ[3] 6.7% 6.0% 7.2% 9.1% 7.2% 6.6% 6.0% 5.4%ȱȱȱȱȱȱȱȱȱȱȱ 48.8 ȱȱȱȱȱȱȱȱȱȱȱȱ102,208 3.8% PhysicianȱOfficeȱVisitsȱ[4] 77.0% 76.7% 75.7% 59.9% 69.8% 80.7% 79.2% 81.3%ȱȱȱȱȱȱȱȱȱȱȱ 51.9 ȱȱȱȱȱȱȱȱȱȱȱȱ901,954 4.8% AllȱBackȱPainȱDiagnosesȱ(inȱ000s)ȱȱȱȱȱȱȱ 57,770 ȱȱȱȱȱȱȱ25,593 ȱȱȱȱȱȱȱ32,787 ȱȱȱȱȱȱȱȱȱ1,648 ȱȱȱȱȱȱȱ19,888 ȱȱȱȱȱȱȱ24,255 ȱȱȱȱȱȱȱȱȱ5,989 ȱȱȱȱȱȱȱȱȱ6,476 ȱȱȱȱȱȱȱȱȱ1,162,788 4.8% PercentȱofȱTotal 44% 57% 3% 34% 42% 10% 11%

Tableȱ2.8:ȱAverageȱLengthȱofȱHospitalȱStayȱforȱSpineȱ Diagnoses,ȱUnitedȱStatesȱ2004ȱ&ȱ2006/2007

ȱAverageȱLOSȱ AverageȱLOSȱ (inȱdays),ȱ2004ȱ (inȱdays),ȱ2006/2007ȱ NISȱ[1] NHDSȱ[2] NISȱ[3] NHDSȱ[4] SpinalȱDeformityȱ&ȱRelatedȱConditionsȱȱȱȱȱȱȱȱȱȱȱ 5.5 ȱȱȱȱȱȱȱȱȱȱȱ5.1 5.3 5.3

Lumbar/LowȱBackȱPain BackȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 4.7 ȱȱȱȱȱȱȱȱȱȱȱ4.3 4.5 4.6 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 4.1 ȱȱȱȱȱȱȱȱȱȱȱ3.6 4.1 4.0 BackȱInjuryȱȱȱȱȱȱȱȱȱȱȱ 7.3 ȱȱȱȱȱȱȱȱȱȱȱ7.9 7.1 7.8 AllȱLumbarȱandȱLowȱBackȱPainȱȱȱȱȱȱȱȱȱȱȱ 4.8 ȱȱȱȱȱȱȱȱȱȱȱ4.5 4.7 4.8

Cervical/NeckȱPain NeckȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 4.3 ȱȱȱȱȱȱȱȱȱȱȱ3.6 4.2 3.9 CervicalȱDiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱ 3.1 ȱȱȱȱȱȱȱȱȱȱȱ2.8 3.1 2.7 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱ 8.2 ȱȱȱȱȱȱȱȱȱ10.2 7.7 6.4 AllȱCervicalȱBackȱPainȱȱȱȱȱȱȱȱȱȱȱ 4.7 ȱȱȱȱȱȱȱȱȱȱȱ4.6 4.4 4.0

Totalȱȱȱȱȱȱȱȱȱȱȱ 4.8 ȱȱȱȱȱȱȱȱȱȱȱ4.6 4.6 4.7

[1]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱ Project,ȱNationwideȱInpatientȱSample,ȱ2004

[2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ2004

[1]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱ Project,ȱNationwideȱInpatientȱSample,ȱ2007

[2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ2006

Tableȱ2.9:ȱTrendsȱinȱPhysicianȱVisitsȱforȱBackȱPain,ȱUnitedȱStatesȱ1998Ȭ2006

PhysicianȱVisitsȱforȱBackȱPain ȱTotalȱNumberȱofȱPatientsȱ(inȱ000s)ȱ 1998 2000 2002 2004 2006 PhysicianȱVisitsȱforȱLumbar/LowȱBackȱPain BackȱDisordersȱȱȱȱȱȱȱȱȱȱ 15,885,027 ȱȱȱȱȱȱȱȱȱ16,151,063 ȱȱȱȱȱȱȱȱ20,040,222 ȱȱȱȱȱȱȱȱ21,813,342 ȱȱȱȱȱȱȱȱȱ24,067,360 DiscȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱ 3,004,051 ȱȱȱȱȱȱȱȱȱȱȱ3,727,512 ȱȱȱȱȱȱȱȱȱȱ4,997,489 ȱȱȱȱȱȱȱȱȱȱ6,497,275 ȱȱȱȱȱȱȱȱȱȱȱ6,977,543 BackȱInjuryȱȱȱȱȱȱȱȱȱȱȱȱ 5,252,323 ȱȱȱȱȱȱȱȱȱȱȱ6,835,017 ȱȱȱȱȱȱȱȱȱȱ7,351,373 ȱȱȱȱȱȱȱȱȱȱ5,454,239 ȱȱȱȱȱȱȱȱȱȱȱ6,888,624 Total,ȱBackȱPainȱ ȱȱȱȱȱȱȱȱȱȱ23,037,014 ȱȱȱȱȱȱȱȱȱ25,018,925 ȱȱȱȱȱȱȱȱ29,145,552 ȱȱȱȱȱȱȱȱ31,539,908 ȱȱȱȱȱȱȱȱȱ34,944,733

PhysicianȱVisitsȱforȱCervical/NeckȱPain NeckȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱ 4,337,258 ȱȱȱȱȱȱȱȱȱȱȱ4,806,514 ȱȱȱȱȱȱȱȱȱȱ6,691,617 ȱȱȱȱȱȱȱȱȱȱ8,637,699 ȱȱȱȱȱȱȱȱȱȱȱ6,221,797 DiskȱDisordersȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 567,516 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ867,893 ȱȱȱȱȱȱȱȱȱȱ1,266,028 ȱȱȱȱȱȱȱȱȱȱ1,689,635 ȱȱȱȱȱȱȱȱȱȱȱ1,528,678 NeckȱInjuryȱȱȱȱȱȱȱȱȱȱȱȱ 4,324,183 ȱȱȱȱȱȱȱȱȱȱȱ2,936,164 ȱȱȱȱȱȱȱȱȱȱ4,776,856 ȱȱȱȱȱȱȱȱȱȱ3,444,789 ȱȱȱȱȱȱȱȱȱȱȱ2,211,089 Total,ȱCervicalȱBackȱPainȱ ȱȱȱȱȱȱȱȱȱȱȱȱ8,922,199 ȱȱȱȱȱȱȱȱȱȱȱ8,266,345 ȱȱȱȱȱȱȱȱ11,726,898 ȱȱȱȱȱȱȱȱ13,104,000 ȱȱȱȱȱȱȱȱȱȱȱ9,513,081

PhysicianȱVisitsȱforȱBackȱPainȱ(LumbarȱandȱCervical) TotalȱVisitsȱȱȱȱȱȱȱȱȱ 31,959,213 ȱȱȱȱȱȱȱȱȱ33,285,270 ȱȱȱȱȱȱȱȱ40,872,450 ȱȱȱȱȱȱȱȱ44,643,908 ȱȱȱȱȱȱȱȱȱ44,457,814

PhysicianȱVisitsȱforȱBackȱPainȱasȱProportionȱofȱTotalȱPopulation ProportionȱofȱTotalȱU.S.ȱPopulationȱ[1] 1998 2000 2002 2004 2006 PhysicianȱVisitsȱforȱLumbar/LowȱBackȱPain BackȱDisorders 5.9% 5.7% 6.9% 7.4% 8.1% DiscȱDisorders 1.1% 1.3% 1.7% 2.2% 2.3% BackȱInjury 1.9% 2.4% 2.5% 1.8% 2.3% Total,ȱBackȱPainȱ 8.5% 8.8% 10.0% 10.6% 11.7%

PhysicianȱVisitsȱforȱCervical/NeckȱPain CervicalȱDisorders 1.6% 1.7% 2.3% 2.9% 2.1% DiskȱDisorders 0.2% 0.3% 0.4% 0.6% 0.5% NeckȱInjury 1.6% 1.0% 1.6% 1.2% 0.7% Total,ȱCervicalȱBackȱPainȱ 3.3% 2.9% 4.0% 4.4% 3.2%

PhysicianȱVisitsȱforȱBackȱPainȱ(LumbarȱandȱCervical) TotalȱVisits 11.8% 11.7% 14.0% 15.1% 14.9%

[1]ȱProportionȱofȱtotalȱpopulationȱbasedȱonȱU.S.ȱCensusȱPopulationȱEstimatesȱasȱofȱJulyȱ1ȱforȱeachȱyear.

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,1998Ȭȱ2006

Tableȱ2.10:ȱWorkȱLimitationsȱwithȱReportedȱJointȱorȱBackȱPainȱforȱ PersonsȱAgedȱ18ȱandȱOver,ȱUnitedȱStatesȱ1999Ȭ2004

%ȱReportingȱSiteȱPain

PainȱLimitsȱ PainȱLimitsȱ PainȱLimitsȱ AllȱWorkȱ AmountȱofȱWork AbilityȱtoȱWalkȱ PainȱinȱSiteȱReported (11%ȱofȱ (32%ȱofȱ (8%ȱofȱ population) population) population) LowȱBackȱPain 63% 62% 62% NeckȱPain 41% 40% 38% Headaches 37% 35% 28% LowerȱLimbȱ(Leg,ȱFoot) 28% 28% 37% Upperȱlimbȱ(Shoulder,ȱGirdle,ȱArm,ȱHand) 26% 26% 26% Head 16% 15% 12% Torsoȱ(Sternum,ȱChest,ȱAbdomen) 9% 8% 7%

Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurveyȱData,ȱ 1999Ȭ2004.

Tableȱ2.11:ȱLimitationȱinȱWorkȱDueȱtoȱBackȱPainȱbyȱGenderȱandȱAgeȱforȱPersonsȱAgeȱ18ȱ andȱOver,ȱUnitedȱStatesȱ1999Ȭ2004

ProportionȱofȱPersonsȱReportingȱWorkȱLimitations PainȱKeepsȱfromȱWorkingȱ[1] BackȱPainȱLimitsȱAmountȱofȱWorkȱCanȱDoȱ[2]

WithȱBackȱ WithȱBackȱ WithȱBackȱ Painȱinȱ NoȱBackȱ WithȱBackȱ Painȱinȱ NoȱBackȱ PainȱinȱOneȱ Multipleȱ Painȱ AllȱPainȱ PainȱinȱOneȱ Multipleȱ Painȱ AllȱPainȱ StatusȱofȱBackȱPain Siteȱ[3] Sitesȱ[4] Reported Sites Siteȱ[3] Sitesȱ[4] Reported Sites Gender Male 18% 33% 8% 10% 51% 69% 25% 31% Female 21% 33% 8% 11% 51% 75% 31% 34%

Age 18Ȭ44ȱyears 13% 23% 4% 6% 39% 57% 14% 20% 45Ȭ64ȱyears 24% 43% 10% 14% 55% 84% 29% 40% 65Ȭ74ȱyears 30% 41% 11% 15% 74% 87% 39% 46% 75ȱ&ȱover 29% 31% 16% 18% 70% 82% 53% 56%

Totalȱ 20% 33% 8% 11% 51% 72% 25% 32%

[1]ȱ11%ȱofȱtheȱpopulationȱreportsȱaȱlongȬtermȱphysical,ȱmentalȱorȱemotionalȱproblemȱkeepsȱthemȱfromȱworking. [2]ȱ32%ȱofȱtheȱpopulationȱreportsȱaȱlongȬtermȱphysical,ȱmentalȱorȱemotionalȱproblemȱlimitsȱtheȱkindȱorȱamountȱofȱworkȱtheyȱcanȱdo. [3]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…Lowȱbackȱpain,ȱupperȱbackȱpain,ȱbuttocks,ȱneckȱandȱspine?Ȉ [4]ȱȈWithȱrespectȱtoȱpainȱproblem,ȱlocatedȱinȱ…multipleȱsitesȱofȱbackȈ Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurveyȱData,ȱ1999Ȭ2004.

Tableȱ2.12:ȱBedȱandȱLostȱWorkȱDaysȱAssociatedȱwithȱBackȱPainȱforȱPersonsȱAgedȱ18ȱandȱOver,ȱ UnitedȱStatesȱ2008

ȱIncidenceȱofȱ Averageȱ Incidenceȱofȱ ȱAverageȱ Reportedȱ ȱ%ȱofȱ ȱIncidenceȱofȱ %ȱofȱ Numberȱ ȱTotalȱBedȱ LostȱWorkȱ ȱ%ȱofȱ Numberȱ TotalȱLostȱ Conditionȱ Totalȱ BedȱDaysȱ Totalȱ ofȱ Daysȱ Daysȱ Totalȱ ofȱWorkȱ WorkȱDaysȱ (Nȱinȱ000s)ȱ Populationȱȱ (Nȱinȱ000s)ȱ Populationȱ BedȱDaysȱ (inȱ000s)ȱ (Nȱinȱ000s)ȱ Populationȱ DaysȱLostȱ (inȱ000s)ȱ Back/NeckȱProblemȱCausesȱDifficultyȱwithȱActivity Maleȱȱȱȱȱȱȱȱȱȱ 8,408 7.7%ȱȱȱȱȱȱȱȱȱȱ 4,156 3.8%ȱȱȱȱȱȱȱȱ 33.1 ȱȱȱȱȱȱ 137,564 ȱȱȱȱȱȱȱȱȱȱ 2,826 2.6%ȱȱȱȱȱȱȱȱȱȱ 23.2 ȱȱȱȱȱȱȱȱ 65,563 Femaleȱȱȱȱȱȱȱȱ 10,640 9.1%ȱȱȱȱȱȱȱȱȱȱ 5,865 5.0%ȱȱȱȱȱȱȱȱ 25.5 ȱȱȱȱȱȱ 149,558 ȱȱȱȱȱȱȱȱȱȱ 3,511 3.0%ȱȱȱȱȱȱȱȱȱȱ 23.9 ȱȱȱȱȱȱȱȱ 83,913 Totalȱȱȱȱȱȱȱȱ 19,048 8.5%ȱȱȱȱȱȱȱȱ 10,021 4.4%ȱȱȱȱȱȱȱȱ 28.7 ȱȱȱȱȱȱ 287,603 ȱȱȱȱȱȱȱȱȱȱ 6,338 2.8%ȱȱȱȱȱȱȱȱȱȱ 23.6 ȱȱȱȱȱȱ 149,577

NeckȱPainȱinȱPastȱ3ȱMonths Maleȱȱȱȱȱȱȱȱ 12,368 11.4%ȱȱȱȱȱȱȱȱȱȱ 5,610 5.2%ȱȱȱȱȱȱȱȱ 21.9 ȱȱȱȱȱȱ 122,859 ȱȱȱȱȱȱȱȱȱȱ 4,543 4.2%ȱȱȱȱȱȱȱȱȱȱ 18.2 ȱȱȱȱȱȱȱȱ 82,683 Femaleȱȱȱȱȱȱȱȱ 19,062 16.4%ȱȱȱȱȱȱȱȱ 10,350 8.9%ȱȱȱȱȱȱȱȱ 23.4 ȱȱȱȱȱȱ 242,190 ȱȱȱȱȱȱȱȱȱȱ 7,475 6.4%ȱȱȱȱȱȱȱȱȱȱ 16.1 ȱȱȱȱȱȱ 120,348 Totalȱȱȱȱȱȱȱȱ 31,430 14.0%ȱȱȱȱȱȱȱȱ 15,960 7.1%ȱȱȱȱȱȱȱȱ 22.9 ȱȱȱȱȱȱ 365,484 ȱȱȱȱȱȱȱȱ 12,019 5.3%ȱȱȱȱȱȱȱȱȱȱ 16.9 ȱȱȱȱȱȱ 203,121

LowȱBackȱPainȱinȱPastȱ3ȱMonths Maleȱȱȱȱȱȱȱȱ 27,334 25.1%ȱȱȱȱȱȱȱȱ 11,858 10.9%ȱȱȱȱȱȱȱȱ 19.8 ȱȱȱȱȱȱ 234,788 ȱȱȱȱȱȱȱȱ 10,004 9.2%ȱȱȱȱȱȱȱȱȱȱ 14.1 ȱȱȱȱȱȱ 141,056 Femaleȱȱȱȱȱȱȱȱ 34,381 29.5%ȱȱȱȱȱȱȱȱ 17,239 14.8%ȱȱȱȱȱȱȱȱ 21.7 ȱȱȱȱȱȱ 374,086 ȱȱȱȱȱȱȱȱ 12,090 10.4%ȱȱȱȱȱȱȱȱȱȱ 14.3 ȱȱȱȱȱȱ 172,887 Totalȱȱȱȱȱȱȱȱ 61,715 27.4%ȱȱȱȱȱȱȱȱ 29,097 12.9%ȱȱȱȱȱȱȱȱ 20.9 ȱȱȱȱȱȱ 608,127 ȱȱȱȱȱȱȱȱ 22,093 9.8%ȱȱȱȱȱȱȱȱȱȱ 14.2 ȱȱȱȱȱȱ 313,721

RadiatingȱLegȱPainȱ(withȱLowȱBackȱPain) Maleȱȱȱȱȱȱȱȱȱȱ 8,498 7.8%ȱȱȱȱȱȱȱȱȱȱ 3,963 3.6%ȱȱȱȱȱȱȱȱ 33.1 ȱȱȱȱȱȱ 131,175 ȱȱȱȱȱȱȱȱȱȱ 2,670 2.5%ȱȱȱȱȱȱȱȱȱȱ 28.9 ȱȱȱȱȱȱȱȱ 77,163 Femaleȱȱȱȱȱȱȱȱ 11,606 10.0%ȱȱȱȱȱȱȱȱȱȱ 6,561 5.6%ȱȱȱȱȱȱȱȱ 34.8 ȱȱȱȱȱȱ 228,323 ȱȱȱȱȱȱȱȱȱȱ 3,613 3.1%ȱȱȱȱȱȱȱȱȱȱ 23.6 ȱȱȱȱȱȱȱȱ 85,267 Totalȱȱȱȱȱȱȱȱ 20,104 8.9%ȱȱȱȱȱȱȱȱ 10,525 4.7%ȱȱȱȱȱȱȱȱ 34.1 ȱȱȱȱȱȱ 358,903 ȱȱȱȱȱȱȱȱȱȱ 6,283 2.8%ȱȱȱȱȱȱȱȱȱȱ 25.8 ȱȱȱȱȱȱ 162,101

AllȱSpineȱPainȱorȱProblems Maleȱȱȱȱȱȱȱȱ 32,135 29.5%ȱȱȱȱȱȱȱȱ 13,776 12.7%ȱȱȱȱȱȱȱȱ 18.7 ȱȱȱȱȱȱ 257,611 ȱȱȱȱȱȱȱȱ 11,761 10.8%ȱȱȱȱȱȱȱȱȱȱ 14.9 ȱȱȱȱȱȱ 175,239 Femaleȱȱȱȱȱȱȱȱ 42,182 36.2%ȱȱȱȱȱȱȱȱ 21,188 18.2%ȱȱȱȱȱȱȱȱ 19.5 ȱȱȱȱȱȱ 413,166 ȱȱȱȱȱȱȱȱ 15,353 13.2%ȱȱȱȱȱȱȱȱȱȱ 13.6 ȱȱȱȱȱȱ 208,801 Totalȱȱȱȱȱȱȱȱ 74,317 33.0%ȱȱȱȱȱȱȱȱ 34,954 15.5%ȱȱȱȱȱȱȱȱ 19.2 ȱȱȱȱȱȱ 671,117 ȱȱȱȱȱȱȱȱ 27,113 12.0%ȱȱȱȱȱȱȱȱȱȱ 14.2 ȱȱȱȱȱȱ 385,005

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱ2008

Tableȱ2.13:ȱSelectȱSpineȱProceduresȱasȱaȱProportionȱofȱAllȱ SpineȱProceduresȱandȱSpineȱPatients,ȱUnitedȱStatesȱ2007

AllȱSpineȱProcedures,ȱ2007ȱ[1]

Numberȱofȱ %ȱofȱTotalȱ %ȱofȱTotalȱ Patientsȱ Spineȱ Spineȱ Procedure w/Procedure Procedures Patientsȱ[2] Spinalȱfusionȱ(cervical,ȱlumbar,ȱdorsal,ȱother)ȱȱȱȱȱȱȱȱȱȱ 379,912 32.0% 57.3% Spinalȱdiskectomyȱȱȱȱȱȱȱȱȱȱ 332,525 28.0% 50.2% Insertionȱofȱspinalȱdeviceȱȱȱȱȱȱȱȱȱȱ 224,522 18.9% 33.9% Spinalȱdecompressionȱȱȱȱȱȱȱȱȱȱ 163,385 13.8% 24.7% Kyphoplastyȱȱȱȱȱȱȱȱȱȱȱȱ 45,878 3.9% 6.9% Spinalȱrefusionȱȱȱȱȱȱȱȱȱȱȱȱ 21,279 1.8% 3.2% Vertebroplastyȱ ȱȱȱȱȱȱȱȱȱȱȱȱ13,646 1.1% 2.1% Replacementȱspinalȱdiscȱprocedureȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,557 0.5% 0.8% Allȱselectȱspineȱproceduresȱ ȱȱȱȱȱȱȱ1,186,704 100.0% 179.1% Totalȱspineȱprocedureȱpatientsȱȱȱȱȱȱȱȱȱȱ 662,446

[1]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱ Project,ȱNationwideȱInpatientȱSample,ȱ2007 [2]ȱMultipleȱproceduresȱperformedȱonȱsomeȱpatients

Tableȱ2.14:ȱTrendsȱinȱSpinalȱFusionȱProcedures,ȱUnitedȱStatesȱ1998Ȭ2006

RateȱofȱTwoȱ RateȱofȱTwoȱ RateȱofȱTwoȱ RateȱPerȱ RateȱofȱTwoȱ YearȬtoȬYearȱ YearȬtoȬYearȱ YearȬtoȬYearȱ 100,000ȱ YearȬtoȬYearȱ Totalȱ CycleȱIncreaseȱ Cycleȱ Numberȱofȱ Cycleȱ Populationȱ Meanȱ Meanȱ Meanȱ Cycleȱ Hospitalizationȱ inȱTotalȱ Numberȱofȱ Increaseȱinȱ Proceduresȱ Increaseȱinȱ Agedȱ18ȱ&ȱ Ageȱofȱ Lengthȱ Hospitalizationȱ Increaseȱinȱ Chargesȱ(inȱ Hospitalȱ ICDȬ9ȬCM Description Year Patients Patients [1] Procedures Overȱ[2] Patient ofȱStay Chargeȱ[3] MeanȱCharge Billions) Charges

1998 204,000 220,000ȱȱȱȱȱȱȱȱȱ 109.57 49.0 4.7 $26ȱ,000 $5.35 2000 242,000 18% 263,000 20%ȱȱȱȱȱȱȱȱȱ 125.93 49.4 4.3 $32ȱ,000 21% $7.18 34% Spinalȱ 81.00Ȭ81.08 2002 289,000 20% 323,000 23%ȱȱȱȱȱȱȱȱȱ 150.07 50.2 4.4 $42ȱ,000 29% $11.87 65% Fusionȱ 2004 307,000 6% 307,000 Ȭ5%ȱȱȱȱȱȱȱȱȱ 139.29 51.8 4.5 $56ȱ,000 34% $16.87 42% 2006 354,000 15% 380,000 24%ȱȱȱȱȱȱȱȱȱ 169.02 53.2 4.2 $77ȱ,000 38% $27.17 61%

9ȬYearȱChange 73% 73% 191% 408%

1998 12,000 12,000ȱȱȱȱȱȱȱȱȱȱȱȱȱ 5.90 47.1 4.6 $26ȱ,000 $0.30 Spinalȱ 2000 13,000 12% 13,000 12%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 6.36 49.0 5.4 $39ȱ,000 49% $0.47 57% 81.30Ȭ Refusionȱ 2002 19,000 43% 20,000 53%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 9.47 50.0 4.4 $46ȱ,000 20% $0.86 83% 81.393 [4] 2004 19,000 1% 19,000 Ȭ7%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 8.62 52.7 4.8 $63ȱ,000 37% $1.18 37% 2006 20,000 4% 21,000 12%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 9.47 53.8 5.0 $96ȱ,000 52% $1.90 62%

9ȬYearȱChange 69% 80% 272% 535%

1998 214,000 231,000ȱȱȱȱȱȱȱȱȱ 115.48 48.9 4.7 $26ȱ,000 $5.59 81.00Ȭ81.08 2000 253,000 18% 277,000 20%ȱȱȱȱȱȱȱȱȱ 132.28 49.4 4.3 $32ȱ,000 22% $7.53 35% + Total 2002 304,000 20% 343,000 24%ȱȱȱȱȱȱȱȱȱ 159.54 50.2 4.3 $42ȱ,000 29% $12.50 66% 81.30Ȭ 2004 321,000 5% 327,000 Ȭ5%ȱȱȱȱȱȱȱȱȱ 148.37 51.8 4.5 $56ȱ,000 34% $17.87 43% 81.393 2006 373,000 16% 401,000 23%ȱȱȱȱȱȱȱȱȱ 178.49 53.2 4.2 $77ȱ,000 38% $28.72 61%

9ȬYearȱChange 74% 73% 193% 414%

[1]ȱUpȱtoȱ15ȱdiagnosisȱperȱpatientȱwereȱincluded;ȱmultipleȱspineȱproceduresȱperȱpatientȱcanȱbeȱcoded [2]ȱComputedȱfromȱU.S.ȱCensusȱpopulationȱestimatesȱreleasedȱJulyȱ1stȱofȱeachȱyearȱ( www.census.govȱ). [3]ȱȈChargeȈȱrefersȱtoȱhospitalizationȱchargesȱandȱdoesȱnotȱincludeȱprofessionalȱ(i.e.,ȱphysicianȱfees),ȱdrugsȱorȱnonȬcoveredȱcharges [4]ȱPriorȱtoȱ2002,ȱspinalȱrefusionȱproceduresȱwereȱcodedȱtoȱtheȱsingleȱcode,ȱ81.09.ȱInȱ2002,ȱthisȱcodeȱwasȱdroppedȱandȱmultipleȱcodesȱimplemented. Source:ȱȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ1998Ȭ2006

Tableȱ2.15:ȱDistributionȱofȱSpineȱFusionȱProceduresȱbyȱSpineȱSection,ȱUnitedȱStatesȱ2004ȱ&ȱ2007

2007ȱSpineȱFusionȱProceduresȱ[1] 2004ȱSpineȱFusionȱProceduresȱ[2]

%ȱofȱTotalȱ %ȱofȱTotalȱ %ȱofȱTotalȱ %ȱofȱTotalȱ Spineȱ Spineȱ %ȱofȱTotalȱ Spineȱ Spineȱ %ȱofȱTotalȱ Fusionȱ Fusionȱ Spineȱ Fusionȱ Fusionȱ Spineȱ Number Procedures Patientsȱ[3] Patients Number Procedures Patientsȱ[3] Patients CervicalȱFusionȱȱȱȱȱȱȱȱ 152,360 38.0% 43.1% 6.3%ȱȱȱȱȱ 134,761 41.2% 44.3% 6.6% ThoracicȱorȱDorsalȱFusionȱȱȱȱȱȱȱȱȱȱ 26,735 6.7% 7.6% 1.1%ȱȱȱȱȱȱȱ 23,601 7.2% 7.8% 1.2% LumbarȱFusionȱȱȱȱȱȱȱȱ 196,867 49.1% 55.7% 8.1%ȱȱȱȱȱ 149,516 45.7% 49.2% 7.3% OtherȱorȱUnspecifiedȱFusionȱȱȱȱȱȱȱȱȱȱȱȱ 3,950 1.0% 1.1% 0.2% SpineȱRefusionȱProceduresȱȱȱȱȱȱȱȱȱȱ 21,279 5.3% 6.0% 0.9%ȱȱȱȱȱȱȱ 18,935 5.8% 6.2% 0.9% TotalȱSpinalȱFusionȱorȱRefusionȱProceduresȱȱȱȱȱȱȱȱ 401,191 100.0% 113.4%ȱȱȱȱȱ 326,813 100.0% 107.5% TotalȱSpineȱFusionȱPatientsȱȱȱȱȱȱȱȱ 353,694 14.6%ȱȱȱȱȱ 303,904 14.9% AllȱSpineȱDiagnosedȱPatientsȱȱȱȱȱ 2,428,956 ȱȱ2,036,165

[1]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [2]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2004 [3]ȱMultipleȱproceduresȱperformedȱonȱsomeȱpatients

Tableȱ2.16:ȱProportionȱofȱBackȱPainȱDiagnosesȱwithȱSpinalȱFusionȱProcedureȱbyȱGenderȱandȱAge,ȱUnitedȱSta

TotalȱNumberȱofȱSpinalȱDiagnosisȱ(inȱ000s) Meanȱ Gender AgeȱinȱYears Lengthȱofȱ 75ȱ& ȱAveȱAge Stayȱ ȱMeanȱ Total ȱMaleȱ ȱFemaleȱ ȱ<18ȱ ȱ18Ȭ44ȱ ȱ45Ȭ64ȱ ȱ65Ȭ74ȱ ȱover forȱFusionȱ (inȱdays) Chargesȱ Lumbar/LowȱBackȱPain AllȱLumbar/LowȱBackȱPainȱ ȱȱȱȱȱȱȱ1,898 ȱȱȱȱȱȱȱȱȱȱ805 ȱȱȱȱȱȱȱ1,091 ȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱ379 ȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱ321 ȱȱȱȱȱȱȱȱȱȱ370 ȱȱȱȱȱȱȱȱȱȱȱ60.5 4.7$ȱȱȱ 32,775 Diagnoses

TotalȱLumbarȱSpineȱFusionȱ ȱȱȱȱȱȱȱȱȱȱ197 ȱȱȱȱȱȱȱȱȱȱȱȱ79 ȱȱȱȱȱȱȱȱȱȱ101 ȱ*43ȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱ81 ȱȱȱȱȱȱȱȱȱȱȱȱ34 ȱȱȱȱȱȱȱȱȱȱȱȱ19 ȱȱȱȱȱȱȱȱȱȱȱ55.2 4.4$ȱȱȱ 87,073 Proceduresȱ(ICDȬ9ȬCM=8106)

%ȱDiagnosesȱwithȱSpinalȱFusionȱ 10.4% 9.8% 9.3% ȱ* 11.3% 12.3% 10.6% 5.1% Procedure

Cervical/NeckȱPainȱ(Neck)

AllȱCervical/NeckȱPainȱDiagnosesȱȱȱȱȱȱȱȱȱȱ 503 ȱȱȱȱȱȱȱȱȱȱ237 ȱȱȱȱȱȱȱȱȱȱ266 ȱ*ȱȱȱȱȱȱȱȱȱȱ 111 ȱȱȱȱȱȱȱȱȱȱ212 ȱȱȱȱȱȱȱȱȱȱȱȱ73 ȱȱȱȱȱȱȱȱȱȱȱȱ72 ȱȱȱȱȱȱȱȱȱȱȱ55.2 4.4$ȱȱȱ 37,623

TotalȱCervicalȱSpineȱFusionȱ ȱȱȱȱȱȱȱȱȱȱ152 ȱȱȱȱȱȱȱȱȱȱȱȱ75 ȱȱȱȱȱȱȱȱȱȱȱȱ76 ȱ*39ȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱ83 ȱȱȱȱȱȱȱȱȱȱȱȱ19 ȱȱȱȱȱȱȱȱȱȱȱȱ81 ȱȱȱȱȱȱȱȱȱȱȱ52.6 3.2$ȱȱȱ 54,510 Proceduresȱ(ICDȬ9ȬCM=8102)

%ȱDiagnosesȱwithȱSpinalȱFusionȱ 30.2% 31.6% 28.6% ȱ* 35.1% 39.2% 26.0% 112.5% Procedure

AllȱBackȱPainȱ

AllȱBackȱPainȱDiagnosesȱȱȱȱȱȱȱ 2,401 ȱȱȱȱȱȱȱ1,042 ȱȱȱȱȱȱȱ1,357 ȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱ490 ȱȱȱȱȱȱȱȱȱȱ872 ȱȱȱȱȱȱȱȱȱȱ394 ȱȱȱȱȱȱȱȱȱȱ442 ȱȱȱȱȱȱȱȱȱȱȱ56.2 4.6$ȱȱȱ 33,714

TotalȱSpineȱFusionȱProceduresȱ ȱȱȱȱȱȱȱȱȱȱ380 ȱȱȱȱȱȱȱȱȱȱ169 ȱȱȱȱȱȱȱȱȱȱ196 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9 ȱȱȱȱȱȱȱȱȱȱȱȱ92 ȱȱȱȱȱȱȱȱȱȱ177 ȱȱȱȱȱȱȱȱȱȱȱȱ57 ȱȱȱȱȱȱȱȱȱȱȱȱ30 ȱȱȱȱȱȱȱȱȱȱȱ53.2 4.2$ȱȱȱ 76,924 (ICDȬ9ȬCM=ȱ810,813)

%ȱDiagnosesȱwithȱSpinalȱFusionȱ 15.8% 16.2% 14.4% 64.3% 18.8% 20.3% 14.5% 6.8% Procedure

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ2.17:ȱPrimaryȱ(1st)ȱDiagnosisȱforȱSpinalȱFusionȱProcedures,ȱ UnitedȱStatesȱ2007

%ȱofȱTotal Spineȱ1stȱDiagnosisȱ Diagnosis Number w/FusionȱProcedure 722.00 CervicalȱDiscȱDisplacementȱȱȱȱȱȱȱȱȱȱ 50,038 14.3% 722.52 LumbarȱDiscȱDegenerationȱȱȱȱȱȱȱȱȱȱ 42,246 12.0% 722.10 LumbarȱDiscȱDisplacementȱȱȱȱȱȱȱȱȱȱ 35,001 10.0% 724.02 LumbarȱSpinalȱStenosisȱȱȱȱȱȱȱȱȱȱ 31,384 8.9% 738.40 AcquiredȱSpondylolisthesisȱȱȱȱȱȱȱȱȱȱ 22,698 6.5% 721.00 CervicalȱSpondylosisȱȱȱȱȱȱȱȱȱȱ 21,024 6.0% 721.10 CervicalȱSpondylosisȱwithȱMyelopathyȱȱȱȱȱȱȱȱȱȱ 19,767 5.6% 722.71 CervicalȱDiskȱDisorderȱȱȱȱȱȱȱȱȱȱ 17,522 5.0% 721.30 LumbosacralȱSpondylosisȱȱȱȱȱȱȱȱȱȱ 16,688 4.8% 722.40 CervicalȱDiscȱDegenerationȱȱȱȱȱȱȱȱȱȱ 11,307 3.2% 723.00 CervicalȱSpinalȱStenosisȱȱȱȱȱȱȱȱȱȱ 10,274 2.9% 756.12 Spondylolisthesisȱȱȱȱȱȱȱȱȱȱȱȱ 8,358 2.4% 737.30 IdiopathicȱScoliosisȱȱȱȱȱȱȱȱȱȱȱȱ 7,378 2.1% 996.49 ComplicationȱofȱInternalȱOrthopaedicȱDeviceȱȱȱȱȱȱȱȱȱȱȱȱ 3,897 1.1% 805.40 FXȱLumbarȱVertebraȬClosedȱȱȱȱȱȱȱȱȱȱȱȱ 3,513 1.0% AllȱOtherȱDiagnosesȱȱȱȱȱȱȱȱȱȱ 49,710 14.2% st AllȱPrimary(1 )ȱDiagnosisȱforȱFusionȱProcedure ȱȱȱȱȱȱȱȱ350,806 100.0%

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱ Project,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ2.18:ȱHealthȱCareȱVisitsȱforȱRupturedȱSpineȱandȱSpinalȱDiskectomyȱProcedures,ȱUnitedȱStatesȱ2006/2007

TotalȱNumberȱofȱSpinalȱDiagnosisȱ(inȱ000s) Meanȱ HealthȱCareȱVisitsȱforȱRupturedȱ Gender Ageȱ(inȱyears) %ȱofȱTotalȱ Lengthȱofȱ ȱMeanȱ (Herniated)ȱSpineȱDiagnosisȱ[1] Averageȱ Visits Stayȱ Chargesȱ ȱTotalȱ ȱMaleȱ ȱFemaleȱ ȱ<18ȱ ȱ18Ȭ44ȱ ȱ45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover Age (inȱdays) HospitalȱDischargesȱ[2]ȱȱȱȱȱȱȱȱ 366.4 ȱȱȱȱȱ 180.3 ȱȱȱȱȱ 184.0 0.8ȱȱȱȱȱ 122.8 ȱȱȱȱȱ 163.4 ȱȱȱȱȱȱȱ 45.3 ȱȱȱȱȱȱȱ 28.5 ȱȱȱȱȱȱȱ 52.0 7.6% 3.1$ȱȱȱȱȱȱȱȱ 37,373 HospitalȱEmergencyȱDepartmentȱVisitsȱ[3]ȱȱȱȱȱȱȱȱ 115.2 ȱȱȱȱȱȱȱ 33.5 ȱȱȱȱȱȱȱ 81.6 0.0ȱȱȱȱȱȱȱ 64.5 ȱȱȱȱȱȱȱ 30.5 ȱȱȱȱȱȱȱ 10.5 ȱȱȱȱȱȱȱȱȱ 9.6 ȱȱȱȱȱȱȱ 46.7 2.4% NA NA HospitalȱOutpatientȱVisitsȱ[4]ȱȱȱȱȱȱȱȱ 311.7 ȱȱȱȱȱ 129.4 ȱȱȱȱȱ 182.3 0.0ȱȱȱȱȱ 125.7 ȱȱȱȱȱ 173.1 ȱȱȱȱȱȱȱ 10.6 ȱȱȱȱȱȱȱȱȱ 2.3 ȱȱȱȱȱȱȱ 47.8 6.4% NA NA PhysicianȱOfficeȱVisitsȱ[5]ȱȱȱȱȱ 4,044.6 ȱȱ 2,112.2 ȱȱ 1,932.3 22.6ȱȱ 1,277.8 ȱȱ 1,970.3 ȱȱȱȱȱ 327.8 ȱȱȱȱȱ 446.0 ȱȱȱȱȱȱȱ 50.5 83.6% NA NA AllȱRupturedȱSpineȱDiagnosesȱȱȱȱȱ 4,837.9 ȱȱ 2,455.4 ȱȱ 2,380.2 ȱȱȱȱȱȱȱ 23.4 ȱȱ 1,590.8 ȱȱ 2,337.3 ȱȱȱȱȱ 394.2 ȱȱȱȱȱ 486.4 100.0% PercentȱofȱTotal 50.8% 49.2% 0.5% 32.9% 48.4% 8.2% 10.1%

Meanȱ Lengthȱofȱ ȱMeanȱ SpinalȱDiskectomyȱProcedureȱ[6] Stayȱ Chargesȱ (inȱdays)

HospitalȱDischargesȱ[2]ȱȱȱȱȱȱȱȱȱȱȱȱ 330.7 ȱȱȱȱȱȱȱȱȱ166.6 ȱȱȱȱȱȱȱȱȱ164.0 ȱȱȱȱȱȱȱȱȱȱȱ1.40 ȱȱȱȱȱȱȱȱȱ105.4 ȱȱȱȱȱȱȱȱȱ159.7 ȱȱȱȱȱȱȱȱȱȱȱ43.4 ȱȱȱȱȱȱȱȱȱȱȱ20.4 ȱȱȱȱȱȱȱȱȱȱȱ51.7 2.8$ȱȱȱȱȱȱȱȱ 50,884 PercentȱofȱTotal 50.4% 49.6% 0.4% 31.9% 48.3% 13.1% 6.2% ȱTotalȱ ProportionȱofȱInpatientȱ[1]ȱDiskectomyȱ 90% 92% 89% 175% 86% 98% 96% 72% Proceduresȱ ProceduresȱwithȱRupturedȱSpineȱDiagnosis Costȱ TotalȱHospitalȱChargesȱforȱDiskectomyȱ $ȱȱȱȱȱȱȱȱȱȱȱȱ16.8 Proceduresȱ(inȱbillions)

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability

[1]ȱICDȬ9ȬCMȱdiagnosisȱcodes:ȱ722.00,ȱ722.10,ȱ722.11,ȱ722.20,ȱ722.70,ȱ722.71,ȱ722.72,ȱ722.73 [2]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2006 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱOutpatient,ȱ2006 [5]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006 [6]ȱICDȬ9ȬCMȱprocedureȱcodes:ȱ805.00,ȱ805.10

Tableȱ2.19:ȱPrimaryȱ(1st)ȱDiagnosisȱforȱSpineȱDiskectomyȱProcedures,ȱ UnitedȱStatesȱ2007

%ȱofȱTotal ȱSpineȱ1stȱ Diagnosisȱ w/Diskectomyȱ Diagnosis Number Procedure 722.10 LumbarȱDiscȱDisplacementȱȱȱȱȱȱȱȱ 124,576 37.5% 722.00 CervicalȱDiskȱDisplacementȱȱȱȱȱȱȱȱȱȱ 48,862 14.7% 722.52 LumbarȱDiscȱDegenerationȱȱȱȱȱȱȱȱȱȱ 26,149 7.9% 721.00 CervicalȱSpondylosisȱȱȱȱȱȱȱȱȱȱ 18,015 5.4% 722.71 CervicalȱDiskȱDisorderȱȱȱȱȱȱȱȱȱȱ 15,229 4.6% 724.02 LumbarȱSpinalȱStenosisȱȱȱȱȱȱȱȱȱȱ 15,065 4.5% 721.10 CervicalȱSpondylosisȱwithȱMyelopathyȱȱȱȱȱȱȱȱȱȱ 12,938 3.9% 722.40 CervicalȱDiscȱDegenerationȱȱȱȱȱȱȱȱȱȱ 10,071 3.0% 738.40 AcquiredȱSpondylolisthesisȱȱȱȱȱȱȱȱȱȱȱȱ 9,292 2.8% 721.30 LumbosacralȱSpondylosisȱȱȱȱȱȱȱȱȱȱȱȱ 8,560 2.6% 723.00 CervicalȱSpinalȱStenosisȱȱȱȱȱȱȱȱȱȱȱȱ 7,093 2.1% 722.73 ThoracicȱDiscȱDisorderȱwithȱMyelopathyȱȱȱȱȱȱȱȱȱȱȱȱ 5,234 1.6% 756.12 Spondylolisthesisȱȱȱȱȱȱȱȱȱȱȱȱ 3,201 1.0% AllȱOtherȱdiagnosesȱȱȱȱȱȱȱȱȱȱ 26,997 8.1% st AllȱPrimaryȱ(1 )ȱDiagnosisȱforȱDiskectomyȱProcedure ȱȱȱȱȱȱȱȱ331,282 100.0%

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱ InpatientȱSample,ȱ2007

Tableȱ2.20:ȱDiskectomyȱProcedureȱTrends,ȱUnitedȱStatesȱ1996ȱtoȱ2006

11ȱYearȱ Year 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Mean Proceduresȱ[1] (toȱnearestȱ000) 285,000 281,000 303,000 303,000 279,000 289,000 319,000 317,000 324,000 292,000 276,000 297,000

[1]ȱICDȬ9ȬCMȱProcedureȱCode:ȱ805.00ȱorȱ805.10 Source:ȱNationalȱCenterȱforȱHealthȱStatistics;ȱCentersȱforȱDiseaseȱControlȱandȱPrevention,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ1996Ȭ2006

Chapter 3 Spinal Deformity and Related Conditions

The term spinal deformity includes several In spite of the severity of these conditions and conditions in which the spine is abnormally the impact they have on the lives of children curved or aligned. One of the more frequent and adults, the prevalence of spinal deformities spinal deformities is scoliosis, or a side to side in children under the age of 18 is diﬃ cult to abnormal curvature of the spine. Spinal deformity determine due to relatively low numbers and the and scoliosis can be found at birth due to genetic degree to which the condition manifests initially in causes, develop during childhood, or develop late pain or disability. Estimated prevalence of spinal in life due to degenerative disc and joint disease. deformity conditions has been cited in numerous studies. (Table 3.1) Common signs of scoliosis are a prominent shoulder, shoulder blade, or chest wall asymmetry. Section 3.1: Scoliosis and Spinal Another sign is uneven hips with one hip Deformity in Children seemingly higher than the other. (Figure 3.0.1) It is important not to confuse scoliosis with poor posture and to realize that scoliosis will usually There are several diﬀ erent types of scoliosis. not disappear with age. Other deformities include The most common type of scoliosis is idiopathic, kyphosis, an exaggerated rounding of the back meaning the cause of the curve is unknown. that may occur by itself or in conjunction with Approximately 80 to 85% of scoliosis cases are osteoporosis, and spondylolisthesis, a slippage idiopathic.1 Idiopathic scoliosis can initially occur

Figure 3.0.1: Scoliosis

of one vertebra onto its neighboring vertebra. A as early as the ﬁ rst three years of life (infantile variety of other spinal deformity conditions will be idiopathic scoliosis), from 4 to 10 years of age discussed in this chapter including spondylolysis (juvenile idiopathic scoliosis), or from 10 years and Scheuermann kyphosis. of age to skeletal maturity (adolescent idiopathic scoliosis). Adolescent idiopathic scoliosis is the most common type.

Figure 3.1.1: Cobb Angle Scoliosis, if severe enough (>25°), is Graph 3.1.1: Prevalence of Adolescent Idiopathic Scoliosis usually treated

with bracing if the ** > 40 B B 0.0% - 0.1% child is growing * 86° > 30 B B 0.1% - 0.3% or with surgery if > 20 B B 0.3% - 0.5% 2.0% - 3.0% the curvature is Cobb Angle > 10 B B * more severe (>45°- (degrees of curvature) of (degrees 50°). The standard 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% radiographic/x- Prevalence (%) Data reprinted with permission from Weinstein SL. Adolescent ray measurement idiopathic scoliosis: Prevalence and natural history. Instr Course Lect technique for all 1988;38:115–126. forms of scoliosis is the Cobb angle Several studies have investigated the natural measurement history and natural course of curve progression *Both lines are drawn along the end of in adolescent idiopathic scoliosis. All report the the vertebrae that are most tilted from technique the horizontal. strongest predictive factors in the development ** The Cobb angle is the angle formed by (Figure 3.1.1), the intersection of these two lines. measured from of idiopathic scoliosis are age, magnitude of 5-9 the end-plates of curve, and gender. Girls are more likely to have the maximally tilted end vertebral bodies in a adolescent idiopathic scoliosis than boys, and some standing radiograph.2 Whether the curve is >25° or >40°-45°, the treatment is preventative in nature, ȱřǯŗǯŘǱȱȱę helping to avoid progression of the curve and Curve Type (1-6) more signifi cant future problems if left untreated. Lumbar Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 (Main (Triple (TL/L) (TL/ While this preventative aspect is hugely valuable Spinal (Double (Double ięr Thoracic) Thoracic) Major) Major) L.MT) and intuitively important, its benefi t is diffi cult A to measure from a public health standpoint, (No Curve to especially for rare conditions of childhood, such as Minimal Curve) juvenile and adolescent pediatric scoliosis. 1Ș 2Ș 3Ș 4Ș B (Moderate Section 3.1.1: Adolescent Idiopathic Scoliosis Curve)

According to the Scoliosis Research Society (SRS), 1B* 2B* 3B* 4B* C idiopathic scoliosis is diagnosed when a patient (Large has asymmetry on forward bending combined Curve) with a curve of at least 10°.3 By this deﬁ nition, the prevalence of adolescent idiopathic scoliosis 1C* 2C* 3C* 4C* 5C* 6C* oible agiĴal in children from 10 to 16 years of age is 2%-3%. ǃ2Ŗǚ structural criteria ǃ2Ŗǚ (Table 3.2 and Graph 3.1.1) Though the male-to- (to determine) ǃ2Ŗǚ ǃ2Ŗǚ female ratio for smaller curves is about equal, specięc curve type) larger curves seem to be more common in females. Normal PT TL PT Ƹ TL Kyphosis Kyphosis Kyphosis Similar results were found in a study conducted - Ǳ ǀ1Ŗǚ in 1985, where 29,195 children were screened for Ș T5-12 sagiĴal alignment modięerǱ ǛǛǰ Nǰ or Ƹ NǱ 1Ŗǚ - 4Ŗǚ idiopathic scoliosis.4 Ƹ Ǳ ǁ4Ŗǚ ourceǱ Lene L ǰ Bet£ ǰ arms ǰ et alǱ dolescent idiopathic scoliosisǱ ne classięcation to determine e¡tent o spinal arthrodesis. J Bone Joint Surg Am 2ŖŖ1ǲŞ3(Ş)Ǳ116ş-Ş1.

studies report the onset is earlier in girls than boys. who have curves ≤25°. Bracing, which is used to A factor highly correlated with curve progression stop curve progression (rather than for lasting is age at diagnosis; patients diagnosed at a younger correction of the curve), is usually used for patients age have a greater risk of curve progression. It who have curves ≥25° and who are still growing. should be noted, however, that those diagnosed Surgery is generally used for patients with curves at a younger age seem to have a more favorable ≥45°. (Figure 3.1.3) response to milder forms of treatment, supporting school screening to detect and lead to earlier While technical outcomes of surgery are well diagnosis for those children with a smaller degree known and show obvious benefi ts for those with of curvature. signifi cant deformity, long-term health related outcomes have yet to be precisely documented. Within the past several years, a two-dimensional The paucity of quality, long-term studies of classifi cation system, the Lenke classifi cation suffi cient size hampers our understanding of the system, was developed to assess the type of a curve mortality and morbidity rates for patients with for adolescent idiopathic scoliosis. (Figure 3.1.2) congenital and idiopathic scoliosis, both with and without treatment. Fift y years of follow-up The three components included in this system studies of children and adolescents with untreated include curve type, lumbar spine modifi er, and scoliosis have shown confl icting results, with some sagitt al thoracic modifi er.10 A study conducted in studies indicating a higher risk of mortality and 2001 evaluated the prevalence of six curve types in respiratory compromise.11,12 Another study shows 606 adolescent patients diagnosed with idiopathic compromise only in patients with early reduced scoliosis. Approximately one-half (51%) of the lung function and a large curvature.13 Yet another patients were found to have a Type 1, or main study has shown no diff erences in untreated thoracic, curve. childhood scoliosis and a control group.14 Several articles from the 1960s and one recent article report Treatment decisions for individuals with that low back pain does not occur more frequently adolescent idiopathic scoliosis are made based in untreated scoliosis patients than in the general on location, shape, patt ern, and cause of the population,14-16 unless the curvature is greater than curve. The treatment choice is also a function of 40°.17,18 It has also been shown that persons treated the patient’s future growth potential. Treatment with surgery, rather than bracing, for adolescent choices include observation, bracing, and surgery. idiopathic scoliosis have less pain at 10 to 20 year Observation is usually reserved for patients follow-up, although function remains similar.19,20 The Figure 3.1.3: Idiopathic Scoliosis cosmetic/ self-image aspect of scoliosis is obvious and important, and oft en a major factor aff ecting the lives of individuals with this condition.

Section 3.1.2: Juvenile Idiopathic Scoliosis exhibit curve progression and require some form of treatment. In a study conducted in 1981, 55 of In 12% to 21% of idiopathic scoliosis cases, the 98 patients (56%) with juvenile idiopathic scoliosis diagnosis is made between 4 and 10 years of age. required spinal surgery.21 The most common and When diagnosed at this age the condition is called traditional surgery is posterior instrumentation juvenile idiopathic scoliosis.21 Between the ages and fusion.21 of 4 and 6, the female-to-male ratio of juvenile idiopathic scoliosis is 1:1; however, the ratio of Section 3.1.3: Infantile Idiopathic Scoliosis female to male cases rises to between 2:1 and 4:1 in children between the ages of 4 and 10, and to 8:1 Infantile scoliosis currently accounts for less than 21 in children who are 10 years of age. Both right 1% of all cases of idiopathic scoliosis in the United and left curves are found with equal frequency for States. Boys are aff ected by infantile idiopathic patients younger than 6 years, but rise to a 3:1 ratio scoliosis at a higher rate than girls (3:2 ratio).23 of right versus left thoracic curves aft er the age of Infantile scoliosis curves tend to be left -sided 22 6. (75%-90%). Past studies have indicated this rare type of scoliosis occurs more frequently in Europe Observation is the main treatment for patients than in North America.24 with a small curve less than 20° to 25°. Follow-up visits are recommended every 4, 6, 9, or 12 months Treatment for patients with infantile idiopathic depending on the patient’s age, the degree of scoliosis is determined by anticipated or actual the curve, and the characteristics of the clinical curve progression.23 In addition to measuring 21 deformity. the Cobb angle, the RVAD is used as a common predictor of curve progression.25 Patients with a Curves between 25° and 50° are usually treated Cobb angle of ≤25° and a RVAD of ≤20° are at a low with bracing in this age group. Bracing can be done risk for progression and should be re-evaluated either on a part-time or full-time basis, depending every 4 to 6 months.23 on the size of the curve as well as the age of the 21 child. A study completed in 1982 evaluating the Nonoperative treatment, such as bracing or casting, success of bracing reported an excellent prognosis will be initiated if a curve progression of ≥ 10° when part-time bracing was utilized for patients occurs. Surgical treatment should be considered with a curve of ≤35° and rib-vertebra angle when nonoperative measures, including both i diff erence (RVAD) of ≤20°; however, curves ≥45° bracing and casting, are not successful.23 Surgical and RVAD of ≥20° had a less favorable prognosis treatment is utilized when a curve is ≥ 45° and 21 for successful treatment with bracing. progressive in an immature child.23 Overall, surgical methods are continually evolving with the Overall, the curve patt erns in patients with juvenile goal of obtaining and maintaining curve correction idiopathic scoliosis are similar to those with while simultaneously preserving or encouraging adolescent idiopathic scoliosis. Approximately spinal and trunk growth. 70% of patients with juvenile idiopathic scoliosis Surgical options currently utilized include various i RVAD - Rib Vertebral Angle Degree: The angle formed on each side between types of spinal fusion or hemiepiphysiodesis, the apical thoracic vertebra and its corresponding rib. The rib-vertebra angle diff erence is the diff erence between the rib-vertebral angle on the convexity of a minimally invasive implant procedure to the curve subtracted from that on the concavity and may be either a positive slow progression of curve growth. Additional or negative value. In a normal spine the rib-vertebra angle diff erence at any vertebra is zero. Resolving curves are nearly always thoracic and when fi rst seen techniques include growing-rod instrumentation the rib-vertebral angle diff erence is less than 20° in 80% of patients. The usual (rods that expand and support the deformed spine) patt ern is for the rib-vertebral angle diff erence to decrease as the curve resolves. (Bradford Book, 1986) Available at: htt p://www.infantilescoliosis.org/terms.htm. and vertical expandable (telescoping) prosthetic Accessed October 3, 2007.

Figure 3.1.4: Infantile Idiopathic Scoliosis idiopathic scoliosis. Bracing is not as eﬀ ective for congenital scoliosis as it is for idiopathic scoliosis.

Major abnormal spinal deformity presenting during infancy or early childhood poses a clinical problem because of the anticipated long growth period (at least 10 years); variable presentation and treatment methods; and the length of time that must pass before meaningful outcome results can be assessed in the small number of Growing Rod VEPTR: Back view VEPTR: Side view patients for deﬁ nitive studies. Curves that result from congenital scoliosis titanium rib (VEPTR) instrumentation.ii (Figure are oft en not treated as easily as idiopathic curves 3.1.4) The goal of using surgical methods is to halt because the deformity is in the bones rather than the progression of the curve and gain correction

of the deformity, allowing Figure 3.1.5: Congenital Anomalies maximum growth of the spine, Defects of Segmentation lungs, and thoracic cage.23 Block Vertebra Block Vertebra Unilateral Bar & Hemivertebra

Section 3.1.4: Congenital Bilateral Unilateral Scoliosis failure of failure of Congenital scoliosis is believed to aﬀ ect approximately 1 child for every 1000 live births.26 The cause is unknown in most cases, Defects of Formation but in some cases it is associated Hemivertebra Wedge Vertebra with various syndromes. (Figure 3.1.5) Diagnosis is Unilateral Unilateral ȱ partial occasionally made during failure of failure of prenatal ultrasound. In cases of congenital scoliosis, additional

congenital conditions, such ¢ȱȬ Incarcerated as chest wall malformation or Source: McMaster MJ: Congenital scoliosis, in: Weinstein SL (ed): The Pediatric Spine: Principles and Practice, ed 2. kidney or heart abnormalities, ǰȱǱȱĴȱȱǭȱǲȱŘŖŖŗǲȱȱŗŜřǯ are oft en present. Treatment options for congenital scoliosis are bracing and/ the soft tissue, causing the curve to be rigid.27 or surgery, and are similar to those discussed for

ii Section 3.1.5: Neuromuscular Scoliosis Titanium Rib or VEPTR (Vertical Expandable Prosthetic Titanium Rib): An expandable titanium metal rod placed in a vertical position alongside the spine and att ached to the ribs and pelvis or the spine. The VEPTR expands and Scoliosis also occurs in conjunction with several supports a deformed chest wall cavity giving the lungs room to operate and grow. Used to treat many chest wall deforming and/or spine defect diagnoses congenital conditions that occur in infancy or which result in Thoracic Insuﬃ ciency Syndrome. Available at: htt p://www. childhood. These include muscular dystrophy, infantilescoliosis.org/terms.htm. Accessed October 3, 2007.

cerebral palsy, spina bifi da, and spinal muscular protein that helps muscle cells function. The most atrophy. Scoliosis associated with these conditions common type is Duchenne muscular dystrophy, is referred to as neuromuscular scoliosis. Both and it primarily aff ects males who inherit a the likelihood and the severity of the scoliosis defective gene through their mother.30 Duchenne generally increases with the severity of the muscular dystrophy occurs in approximately underlying condition. For example, a child with 1 in 3500 live male births.30 Many patients with severe cerebral palsy who is unable to walk Duchenne muscular dystrophy develop scoliosis is more likely to have severe scoliosis than a by the age of 12.31 Because muscular dystrophy is child with mild cerebral palsy who can walk. usually progressive, patients are typically treated These conditions are also discussed in Chapter surgically, usually with spinal fusion.32 Potential 6, Congenital and Infantile Developmental advantages of surgery include comfort and sitt ing Conditions of the Musculoskeletal System. tolerance, cosmetic improvement, elimination of the need for orthopaedic braces, ease of nursing Cerebral palsy (CP) is defi ned as a non-progressive care for parents, and pain relief. disturbance in the developing brain of the fetus or infant. Musculoskeletal problems are frequently Spinal muscular atrophy (SMA) aff ects eight seen as a result of the motor disorder. The more children out of every 100,000 live births. The common musculoskeletal problem is scoliosis. prevalence of scoliosis for patients with SMA is Besides bracing, which is usually an ineff ective directly related to the severity of the disease and form of treatment for more severe muscular the specifi c type of SMA that the patient has.33 scoliosis, surgical procedures are frequently SMA equally aff ects both females and males.34 indicated in pediatric patients with CP. In 2005, There is no specifi c treatment for SMA, but bracing more than 100,000 children under the age of 18 can slow the inevitable progression of a scoliotic were disabled with CP, and its prevalence has curve and postpone surgical treatment in some increased by 18% in the past two decades.28 In cases. Surgical treatment is generally spinal fusion 1997, 37,000 pediatric patients were discharged or a segmental spinal instrumentation, and is from hospitals with a diagnosis of CP. Among performed when the curve progresses to greater these patients, spinal fusion with instrumentation than 50° to 60°. The goal of surgical treatment is was among the top fi ve most commonly performed to improve balance and sitt ing capability of the surgical procedures, and was performed on 765 patient.33 patients that year in the United States. Treatment for CP with spinal fusion accounted for more Section 3.2: Other Childhood Spinal than 4,000 hospital days and charges of nearly $40 Conditions million.28

The prevalence of spina bifi da (a failure of the Additional spinal conditions seen in children spine—usually, the lower spine—to close and form include spondylolysis, a stress fracture of the lower normally during fetal development) has decreased end of the spine; spondylolisthesis, a condition dramatically since the 1970s with the introduction where one of the spinal vertebrae (usually in of folic acid into the diet of pregnant women. Since the lower/lumbar spine) slips forward on the 1990, the annual incidence of spina bifi da has been one below it; Scheuermann kyphosis, an oft en reported at 3.2 cases per 10,000 live births, with no painful condition manifested in exaggerated variation in ethnic groups observed.29 roundness of the upper part of the spine; and others. Occasionally, children have herniated discs There are several diff erent types of muscular that require surgical intervention. Children also dystrophy (i.e., abnormal function of muscle), can have diff erent types of spinal infections and but all are genetic in cause and due to a lack of tumors. While most of these conditions are quite

rare, they can cause signifi cant disability if not Many children with spondylolysis do not recognized early and treated appropriately. Again, experience back pain and, therefore, may the preventative nature of treatment is intuitively not require treatment. If the child remains obvious, but diffi cult to measure for these rare asymptomatic, he or she is examined every 3 to 6 conditions. months; if the child begins to experience pain, a bone scan and proper radiographs are oft en used to reassess the situation and confi rm the diagnosis. Conservative management, such as bracing, may help. Spondylolysis Figure 3.2.1: Spondylolysis and Spondylolisthesis that progresses or remains painful in spite of conservative measures, and which interferes with daily activities, is treated with a localized spinal fusion. A similar observation/ treatment patt ern is used for children with spondylolisthesis. Preoperative radiograph CT Scan Postoperative radiograph Surgery is recommended if the slip Section 3.2.1: Spondylolysis and Spondylolisthesis of one vertebra over another is greater than 50%. Overall, the goal of surgery for either condition Spondylolysis is disintegration or dissolution is to stabilize the spondylolytic segment, prevent of a vertebra. It is usually accompanied by further slippage, relieve pain and/or nerve root spondylolisthesis, a forward displacement of a irritation, and prevent neurological defi cit. When lumbar vertebra on the one below it, especially the indicated, surgery can help correct hamstring fi ft h lumbar vertebra on the sacrum, producing tautness, poor posture, and abnormality of gait.34 pain by compression of nerve roots. (Figure 3.2.1) Although spondylolysis is virtually nonexistent in newborns, by the age of 6 the incidence Section 3.2.2: Scheuermann Kyphosis has reached approximately 6% for the general pediatric population. Both spondylolysis and Scheuermann kyphosis aff ects 0.4% to 8% of spondylolisthesis are found at higher levels in healthy children. Kyphosis is an exaggerated certain populations. Examination of Eskimo outward curvature of the thoracic region of the skeletons indicates the incidence of spondylolysis is 13% in pediatric patients. A study conducted Figure 3.2.2: Scheuermann Kyphosis in 1953 found an overall incidence of 4.2% in the Note the increased general pediatric population, with incidence of curvature of the upper back associated with 6.4% in white males, 2.8% in black males, 2.3% wedging and end plate irregularity of individual in white females, and 1.1% in black females. vertebrae at the apex. Most reports have found a higher incidence of spondylolysis in males than in females (2:1 ratio, respectively), although females have a higher risk of progression.35

spinal column resulting in a rounded upper of the vertebral column. Degenerative scoliosis, back. (Figure 3.2.2) There is no defi nitive answer particularly in the very elderly, is oft en associated to whether it aff ects males or females at higher with other conditions, such as osteoporosis. rates, with prevalence leaning to both sexes found Treatment outcomes for both nonsurgical and in studies.36 Patients who are skeletally mature surgical procedures are not well documented; with acceptable kyphosis (curvature) and no hence, recognition and earlier intervention are observable symptoms do not require treatment. important to ward off the more complex problems If the individual is still growing and the kyphosis of adult scoliosis. The role played by undiagnosed, is severe, treatment is required, and bracing mild idiopathic adolescent scoliosis on the or casting is usually used, with surgery rarely development of degenerative scoliosis in later life indicated and only for skeletally mature patients is unknown. with chronic back pain and a curve of more than 60°.34 Section 3.4: Health Care Resource Use for Spinal Deformity in 2004 Section 3.3: Adult Spinal Deformity and Degenerative Scoliosis While the incidence of spinal deformity among patients seeking care in any given year can be Deformity of the adult spine includes patients estimated, the relatively low proportion of the with curvature of the spine (scoliosis) of varying population seeking care for spinal deformity magnitudes caused or impacted by degenerative conditions precludes statistically reliable numbers. disc and joint disease. Adult scoliosis may be the In addition, many persons do not seek care, or seek result of persistent or progressive deformity since care for severe or disabling back or leg pain that adolescence or a new, de novo, onset of deformity is oft en caused by spinal deformity. Hence, the as a result of degeneration or “aging” of the spine. overall prevalence of spinal deformity in the total Degenerative scoliosis accounts for the majority population is projected to be much higher than of scoliosis cases in older populations aged 65 current data implies. Furthermore, degenerative years and older, as refl ected in the low proportion scoliosis is rarely a primary, or 1st, diagnosis and of older patients with a diagnosis of primary may not be included as a diagnosis at all. idiopathic scoliosis. Idiopathic and degenerative scoliosis are both The prevalence of adult spinal deformity and found in a higher Graph 3.4.1: Distribution of Health scoliosis is not well established, with estimates proportion of Care Visits for Spinal Deformity 16, and Related Conditions Diagnoses, ranging from 2.5% to 25% of the population. females than United States 2006/2007 37-41 3 A recent study reported mild to severe adult males. As the 10% 13% 73% scoliosis prevalence as high as 68% in a healthy (no ratio of the 5% known scoliosis or spine surgery) population aged curve increases, Hospital Hospital 42 60 and over. Many cases of degenerative scoliosis indicating more [1] Hospital Physician ¢ [3] Ĝ are undiagnosed, but elderly patients oft en seek severe scoliosis, Visits [2] care because of back and leg pain that may be the female to male [4] ȱȱǽŗǾȱǱȱ¢ȱȱ ȱȱ caused by scoliosis and associated spinal stenosis. ratio is reported as ȱȱ¢ǰȱ ȱȱȱ£ȱǰ ȱȱ ȱ ȱǰȱŘŖŖŝ high as 10:1 among ȱȱǽŘȱǾǱȱȱȱȱ ȱǰ Degenerative scoliosis is one of the most persons with a ȱȱȱ ȱ¢ȱȱȱ ȱȱ¢ǰȱ ȱ¢ǰȱŘŖŖŜ challenging spine conditions to treat due to curve of greater ȱȱǽřǾȱǱȱȱȱȱ ȱǰ ȱȱȱ ȱ¢ȱȱȱ 13,43 the variability of the condition. It is generally than 30°. ȱȱ¢ǰȱǰȱŘŖŖŜ ȱȱǽŚǾȱǱȱȱȱȱ ȱǰ thought to originate with the degeneration of the ȱȱȱ¢ȱȱȱ¢ǰȱ intervertebral discs, which leads to misalignment ȱȱŘŖŖŜ

In 2007, an estimated 1.24 million Graph 3.4.3: Relationship of Spinal Deformity and Primary Idiopathic Scoliosis patients utilized health care Diagnoses by Age, United States 2007

resources for care of problems 100 associated with a spinal deformity. 75 & Over

(Table 3.3) The majority (73%) 80 65 to 74 of these care episodes were 45 to 64 with a physician (Graph 3.4.1), 60 and involved non-surgical and 18 to 44 pre-surgical management of this 40 complex patient population. Under 18 In addition, more than 200,000 20 Unknown Age

persons visited hospital outpatient Hospitalizations Proportion of Total or emergency centers for care, 0 while approximately 120,000 All Spinal Idiopathic Primary Deformity and Scoliosis Idiopathic persons were hospitalized with Scoliosis (any Dx of 737.30) Scoliosis a diagnosis of spinal deformity. Diagnoses (Dx) (Dx1 of 737.30) Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, although not the only diagnosis, Nationwide Inpatient Sample, 2007 virtually all hospitalized patients had a diagnosis of scoliosis. In 2007, 89% (107,200) of patients released Other diagnoses were kyphosis, a curvature of from a hospital with a scoliosis diagnosis had a the thoracic region of the spinal column resulting diagnosis of idiopathic scoliosis (ICD-9-CM code in a rounded upper back, or excessive lordosis of 737.30). Eight percent (8%, or 8,300) of these (swayback), an increased amount of curvature 107,200 patients had a primary, or 1st, diagnosis of of the lumbar or cervical regions of the spinal idiopathic scoliosis; 92% had an idiopathic scoliosis column. diagnosis that was in addition to their primary Graph 3.4.2: Hospitalization and diagnosis. Physician Visits for Spinal Deformity and Related Conditions The overwhelming Diagnosis by Age, United States majority of spinal Of these 107,200 patients with idiopathic scoliosis 2006/2007 deformity and diagnoses, 12% were under the age of 18 years, 100 while 20% were aged 75 and over. (Tables 3.4, 75 & over scoliosis patients in 2007 were female 3.4c, and Graph 3.4.3) However, a primary (1st) 80 diagnosis of idiopathic scoliosis was far more 65 to 74 (69%), and close to one-half (44%) common in young persons, with 54% under 60 45 to 64 were under the the age of 18, supporting the assumption that age of 18. While degenerative scoliosis or spinal deformity is 40 frequently not the primary (1st) diagnosis of 18 to 44 hospitalizations for elderly patients.

Proportion of Total Visits Proportion of Total spinal deformity 20 are represented Under 18 More than one-half of the young patient group 0 nearly equally by Hospital Physician all age groups in (55%) were between the ages of 14 and 17 years. Discharges [1] Visits [2] (n=120,000) (n=901,000) 2007, physician Another 37% were between the ages of 11 and 13, [1] Source: Agency for Healthcare Research visits are primarily with the remainder aged 10 years or younger. and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 the young (under [2] Source: National Center for Health Statistics, National Ambulatory Medical age 18) and the old Care Survey, 2006 (aged 75 and over). NOTE: Data by age groups does not (Graph 3.4.2) meet standards of reliability.

Three of four patient visits to a physician’s oﬃ ce in additional $511.2 million, for a total estimated 2007 with a primary (1st) diagnosis of idiopathic hospitalization cost to treat primary idiopathic scoliosis (72%) were for patients under the age of scoliosis in 2007 of $1.04 billion. (Table 3.4) 18 years. More than 90% of these visits were for children aged 11 and older. (Table 3.5) Additional hospital costs of nearly $3.2 billion were incurred by patients with a diagnosis of Graph 3.4.4: Relationship of Scoliosis Diagnosis and Spine Surgical Procedures by Age, United States 2007 idiopathic scoliosis in addition to their primary (1st) diagnosis. It is unknown what proportion of Scoliosis Diagnosis [2] Scoliosis Procedure [1] these costs resulted directly from treatment given 35 as a result of scoliosis; however, it can be assumed 30 some proportion of these additional costs would 25 not have occurred in the absence of the sc≥oliosis

20 condition.

15 Proportion of Total In addition to health care costs associated with 10 surgery for spinal deformity and scoliosis, 5 signifi cant nonsurgical resources are utilized by 0 adults with scoliosis, increasing the burden of Under 18 18-44 45-64 65-74 75 & Over Unknown Age Group [3] this condition on the health care system. A study [1] Scoliosis procedures includes ICD-9-CM procedure codes 81.04, 81.05, of nonsurgical resource use, including exercise, 81.06, 81.08, 81.62, 61.63, 81.64, 84.51. [2] Scoliosis conditions includes ICD-9-CM diagnostic codes 737.30, 737.31, bracing, medications, steroid injections, and 737.32, 737.33, 737.34, 737.39. formal pain management, by adults with a spinal [3] Data by age group does not meet criteria for reliability. curvature of ≥30° showed 90% of patients utilized Source: Agency for Healthcare Research and Quality, Healthcare Cost and non-surgical resources, with those patients with a Utilization Project, Nationwide Inpatient Sample, 2007 high level of symptoms using more resources than those with a low level of symptoms.44 Although only 12% of scoliosis diagnosed patients in 2007 were for children under the age of 18, the Overall, the cost related to spinal deformity is young patients accounted for 31% of spine surgical signifi cant, with more than one million patient procedures for scoliosis. Overall, one in six persons visits each year for treatment of pain due to this (17%) hospitalized with a scoliosis diagnosis condition. A majority of spinal deformity cases underwent a surgical procedure for scoliosis, but each year are the result of degenerative scoliosis. 2 in 5 persons under the of 18 underwent scoliosis With the aging of the U.S. population, increased surgical procedures. (Table 3.6 and Graph 3.4.4) awareness, identifi cation, and treatment of spinal deformity in its earliest stages is necessary to Section 3.4.1: Estimated 2007 Cost for Treatment of reduce the current and future burden of this Scoliosis and Spinal Deformity condition.

A conservative estimate of the hospitalization 1. National Institute of Arthritis and Musculoskeletal and cost for adult scoliosis in 2007 was $520.9 million. Skin Diseases (NIAMS): Questions and answers about This estimate, which generally does not include scoliosis in children and adolescents. National Institutes of professional fees, is based on the average cost Health, U.S. Department of Health and Human Services, per hospital stay for four age groups of patients 2007. Available at: htt p://www.niams.nih.gov/Health_Info/ aged 18 and over with a primary (1st) diagnosis of Scoliosis/default.asp. Accessed August 30, 2007. idiopathic scoliosis. Child and adolescent primary idiopathic scoliosis hospitalization fees added an

2. Herzenberg JE, Waanders NA, Closkey RF, et al: Cobb 14. Weinstein SL, Dolan LA, Spratt KF, et al: Health and angle versus spinous process angle in adolescent idiopathic function of patients with untreated idiopathic scoliosis: a scoliosis: The relationship of the anterior and posterior 50-year natural history study. JAMA 2003;289:559-567. deformities. Spine 1990;15:874-879. 15. Nachemson A: A long term follow-up study of non-treated 3. Lonstein J: Scoliosis: surgical versus nonsurgical treatment. scoliosis. Acta Orthop Scand 1968;39:466-476. Clin Ortho Relat Res 2006;443:248-259. 16. Nilsonne U, Lundgren KD: Long term prognosis in 4. Morais T, Bernier M, Turcott e F: Age- and sex-speciﬁ c idiopathic scoliosis. Acta Orthop Scand 1968;39:456-465. prevalence of scoliosis and the value of school screening programs. Am J Public Health Nations Health 1985;75:1377- 17. Kostuik JP, Bentivoglio J: The incidence of low-back pain in 1380. adult scoliosis. Spine 1981;6:268-273.

5. Bunnell W: Spinal deformity. Pediatr Clin North Am 18. Haefeli M, Elfering A, Kilian R, et al: Nonoperative 1986;33:1475-1487. treatment for adolescent idiopathic scoliosis: a 10- to 60-year follow-up with special reference to health related 6. Weinstein S: Idiopathic scoliosis: Natural history. Spine quality of life. Spine 2006;31:355-366. 1986;11:780-783. 19. Andersen MO, Christensen SB, Thomsen K: Outcome at 10 7. Karol LA, Johnston CE 2nd, Browne RH, Madison M: years treatment for adolescent idiopathic scoliosis. Spine Progression of the curve in boys who have idiopathic 2006;31:350-354. scoliosis. J Bone Joint Surg Am 1993;75:1804-1810. 20. Danielsson AJ, Romberg K, Nachemson AL: Spinal 8. Porter SB, Blount BW: Pseudotumor of infancy and range of motion, muscle endurance, and back pain and congenital mascular torticollis. Am Fam Physician function at least 20 years aft er fusion or brace treatment for 1995;52:1731-1736. adolescent idiopathic scoliosis: A case-control study. Spine 2006;31:275-283. 9. Willner S: Continuous screening and treatment of teenage scoliosis is recommended. Lakartidningen 1994;91:22. 21. Lenke LG, Dobbs MB: Management of juvenile idiopathic scoliosis. J Bone Joint Surg Am 2007;89:55-63. 10. Lenke LG, Betz RR, Clements D, et al: Curve prevalence of a new classiﬁ cation of operative adolescent idiopathic 22. Warner WC Jr.: Juvenile idiopathic scoliosis, in Weinstein scoliosis: Does classiﬁ cation correlate with treatment? Spine S (ed): The Pediatric Spine: Principles and Practice, ed 2. 2002;27:604-611. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, p 330. 11. Goldberg CJ, Gillic I, Connaughton O, et al: Respiratory function and cosmesis at maturity in infantile-onset 23. Akbarnia B: Management themes in early onset scoliosis. J scoliosis. Spine 2003;28:2397-2406. Bone Joint Surg Am 2007;89:42-54.

12. Pehrsson K, Larsson S, Oden A, Nachemson A: Long-term 24. Fernandes P, Weinstein SL: Natural history of early onset follow-up of patients with untreated scoliosis: A study scoliosis. J Bone Joint Surg Am 2007;89:21-33. of mortality, causes of death, and symptoms. Spine 1992;17:1091-1096. 25. Mehta M: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J 13. Pehrsson K, Bake B, Larsson S, Nachemson A: Lung Bone Joint Surg Br 1972;54:230-243. function in adult idiopathic scoliosis: a 20 year follow up. Thorax 1991;46:474-478.

26. Hedequist D, Emans J: Congenital scoliosis: A review and 37. Batt ie MC, Videman T: Lumbar disc degeneration: update. J Pediatr Orthop 2007;27:106-116. Epidemiology and genetics. J Bone Joint Surg Am 2006;88:3- 9. 27. Lonstein J: Scoliosis, in Lovell WW, Winter RB, Morrissy RT, Weinstein SL (ed): Lovell and Winter’s Pediatric 38. Gupta M: Degenerative scoliosis: Options for surgical Orthopaedics, ed 4. Philadelphia, PA: Lippincott Williams management. Ortho Clin North Am 2003;34:269-279. Wilkins, 1996, vol II. 39. Carter OD, Haynes SG: Prevalence rates for scoliosis in 28. Murphy NA, Hoﬀ C, Jorgensen T, et al: A national U.S. adults: Results from the ﬁ rst National Health and perspective of surgery in children with cerebral palsy. Nutrition Examination Survey. Int J Epidemiol 1987;16:537- Pediatr Rehabil 2006;9:293-300. 544.

29. Kaufmann B: Congenital intraspinal anomalies: spinal 40. Perennou D, Marcelli C, Herisson C, Simon L: Adult dysraphism-embrology, pathology, and treatment, in lumbar scoliosis: Epidemiologic aspects in a low-back pain Bridwell KH, DeWald RL (ed): The Textbook of Spinal population. Spine 1994;19:123-128. Surgery, ed 2. Philadelphia, PA: Lippincott -Raven, 1997, vol 1, p 366. 41. Robin GC, Span Y, Steinberg R, et al: Scoliosis in the elderly: A follow-up study. Spine 1982;7:355-359. 30. Thompson G: Neuromuscular disorders, in Lovell WW, Winter RB, Morrissy RT, Weinstein SL (ed): Lovell and 42. Schwab F, Dubey A, Galez L, et al: Adult scoliosis: Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA: Prevalence, SF-36, and nutritional parameters in an elderly Lippincott Williams & Wilkins, 1996, vol I. volunteer population. Spine 2005;30:1082-1085.

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32. Cheuk DKL, Wong V, Wraige E, et al: Surgery for scoliosis 44. Glassman SD, Berven S, Kostuik J, et al: Nonsurgical in Duchenne muscular dystrophy. Available at: htt p:// resource utilization in adult spinal deformity. Spine www.mrw.interscience.wiley.com/cochrane/clsysrev/ 2006;31:941-947. articles/CD005375/frame.html. Accessed August 28, 2007.

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Section 3.5: Spinal Deformity and Related Conditions Data Tables

Tableȱ3.1:ȱEstimatedȱandȱNormalizedȱPrevalenceȱofȱSpinalȱDeformityȱandȱRelatedȱ Conditions

Normalizedȱ CitedȱPrevalenceȱRateȱ PrevalenceȱRateȱ PrevalenceȱRateȱ (midpointȱofȱrangeȱcited) (perȱ100ȱpersons) (perȱ100,000ȱpersons) Congenitalȱscoliosisȱ[1] 1 inȱȱȱȱ 1,000 0.100ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 100 Infantileȱidiopathicȱscoliosisȱ[2] 0.04 inȱȱȱȱȱȱȱȱȱ 100 0.040ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 40 Juvenileȱidiopathicȱscoliosisȱ[3] 0.06 inȱȱȱȱȱȱȱȱȱ 100 0.060ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 60 Adolescentȱidiopathicȱscoliosisȱ[4] 2.5 inȱȱȱȱȱȱȱȱȱ 100 2.500ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,500 Spinaȱbifidaȱ[5] 4.6 inȱȱȱȱ 10,000 0.046ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46 Cerebralȱpalsyȱ[6] 0.001 inȱȱȱȱȱȱȱȱȱ 100 0.001ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 MuscularȱDystrophyȱ[7] 1 inȱȱȱȱȱȱ 3,500 0.029ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 29 Spondylolysis,ȱageȱ6ȱ[8] 6 inȱȱȱȱȱȱȱȱȱ 100 6.000ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6,000 Spinalȱmuscularȱatrophyȱ[9] 8 inȱȱ 100,000 0.008ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8 Scheuermannȱkyphosisȱ[9,10] 4 inȱȱȱȱȱȱȱ 100 4.000ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,000 Adultȱspinalȱdeformityȱorȱscoliosisȱ(ageȱ>18ȱyrs)ȱ[11,12,13] 11.3 inȱȱȱȱȱȱȱ 100 11.300ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 11,300 Adultȱspinalȱdeformityȱorȱscoliosisȱ(ageȱ>60ȱyrs)ȱ[14] 68 inȱȱȱȱȱȱȱ 100 68.000ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 68,000

[1]ȱHedequistȱD,ȱEmansȱJ:ȱCongenitalȱscoliosis:ȱaȱreviewȱandȱupdate.ȱJȱPediatrȱOrtho ȱ2007:27:106Ȭ116. [2]ȱAkbarniaȱB:ȱManagementȱthemesȱinȱearlyȱonsetȱscoliosis.ȱJȱBoneȱJointȱSurgȱAm ȱ2007:89:42Ȭ54.ȱ(Prevalenceȱrateȱcomputedȱbasedȱonȱcitedȱ rateȱforȱadolescentȱidiopathicȱscoliosisȱandȱproportionȱofȱtotalȱidiopathicȱcasesȱthatȱareȱinfantileȱinȱcitation.)

[3]ȱLenkeȱLG,ȱDobbsȱMB:ȱManagementȱofȱjuvenileȱidiopathicȱscoliosis.ȱJȱBoneȱJointȱSurgȱAm ȱ2007:89:55Ȭ63.ȱȱ(Prevalenceȱrateȱcomputedȱ basedȱonȱcitedȱrateȱforȱadolescentȱidiopathicȱscoliosisȱandȱproportionȱofȱtotalȱidiopathicȱcasesȱthatȱareȱjuvenileȱinȱcitation.) [4]ȱMoraisȱT,ȱBernierȱM,ȱTurcotteȱF:ȱAgeȬȱandȱsexȬspecificȱprevalenceȱofȱscoliosisȱandȱtheȱvalueȱofȱschoolȱscreeningȱprograms.ȱAmȱJȱPublicȱ HealthȱNationsȱHealth ȱ1985:75:1377Ȭ1380. [5]ȱKaufmannȱB:ȱCongenitalȱintraspinalȱanomalies:ȱspinalȱdysraphismȬembrology,ȱpathology,ȱandȱtreatment,ȱinȱBridwellȱKH,ȱDeWaldȱRLȱ (ed):ȱTheȱtextbookȱofȱspinalȱsurgery,ȱ edȱ2.ȱPhiladelphia,ȱPA:ȱLippincottȬRavenȱPublishers,ȱ1997,ȱvolȱ1,ȱpȱ366. [6]ȱMurphyȱNA,ȱHoffȱC,ȱJorgensenȱT,ȱet.ȱal.:ȱAȱnationalȱperspectiveȱofȱsurgeryȱinȱchildrenȱwithȱcerebralȱpalsy.ȱPediatrȱRehabil ȱ2006:9:293Ȭ 300.ȱ(Note:ȱrateȱwasȱcomputedȱbasedȱonȱcensusȱpopulationȱandȱcitedȱnumberȱofȱcases.) [7]ȱThompsonȱG:ȱNeuromuscularȱdisorders,ȱinȱLovellȱWW,ȱWinterȱRB,ȱMorrissyȱRT,ȱWeinsteinȱSLȱ(ed):ȱLovellȱandȱWinterȇsȱpediatricȱ orthopaedics, ȱedȱ4.ȱPhiladelphia,ȱPA:ȱLippincottȱWilliamsȱandȱWilkins,ȱ1996,ȱvolȱI. [8]ȱHuȱSS,ȱBradfordȱDS:ȱSpondylolysisȱandȱspondylolisthesis,ȱinȱWeinsteinȱSȱ(ed):ȱTheȱpediatricȱspine:ȱprinciplesȱandȱpractice,ȱ edȱ2.ȱ Philadelphia,ȱPA:ȱLippincottȱWilliamsȱ&ȱWilkins,ȱ2001,ȱppȱ433Ȭ434. [9]ȱSucatoȱD:ȱSpineȱdeformityȱinȱspinalȱmuscularȱatrophy.ȱJȱBoneȱJointȱSurgȱAm ȱ2007:89:148Ȭ154. [10]ȱAscaniȱE,ȱLaȱRosaȱG,ȱAscaniȱC:ȱScheuermannȱkyphosis,ȱinȱWeinsteinȱSȱ(ed):ȱTheȱpediatricȱspine:ȱprinciplesȱandȱpractice,ȱ edȱ2.ȱPhiladelphia,ȱ PA:ȱLippincottȱWilliamsȱ&ȱWilkins,ȱ2001,ȱpȱ415. [11]ȱBattieȱMC,ȱVidemanȱT:ȱLumbarȱdiscȱdegeneration:ȱepidemiologyȱandȱgenetics.ȱJȱBoneȱJointȱSurgȱAm ȱ2006:88:3Ȭ9.ȱ [12]ȱCarterȱOD,ȱHaynesȱSG:ȱPrevalenceȱratesȱforȱscoliosisȱinȱU.S.ȱadults:ȱresultsȱfromȱtheȱfirstȱNationalȱHealthȱandȱNutritionȱExaminationȱ Survey.ȱIntȱJȱEpidemiol ȱ1987:16:537Ȭ544. [13]ȱGuptaȱM:ȱDegenerativeȱscoliosis:ȱoptionsȱforȱsurgicalȱmanagement.ȱOrthoȱClinȱNorthȱAm ȱ2003;34:269Ȭ279. [14]ȱSchwabȱF,ȱDubeyȱA,ȱGalezȱL,ȱetȱal:ȱAdultȱscoliosis:ȱprevalence,ȱSFȬ36,ȱandȱnutritionalȱparametersȱinȱanȱelderlyȱvolunteerȱpopulation.ȱ Spineȱ 2005:30:1082Ȭ1085.

Tableȱ3.2:ȱPrevalenceȱofȱAdolescentȱIdiopathicȱScoliosis

CobbȱAngle FemaleȬtoȬMaleȱRatio Prevalenceȱ(%) >10 1.4Ȭ2.0ȱ:ȱ1 2.0%Ȭ3.0% >20 5.4ȱ:ȱ1 0.3%Ȭ0.5% >30 10ȱ:ȱ1 0.1%Ȭ0.3% >40 Notȱapplicable <0.1%

Source:ȱReprintedȱwithȱpermissionȱfromȱWeinsteinȱSL.ȱAdolescentȱidiopathicȱscoliosis:ȱ Prevalenceȱandȱnaturalȱhistory.ȱInstrȱCourseȱLect ȱ1988;38:115–126.

Tableȱ3.3:ȱHealthȱCareȱResourceȱUsageȱwithȱSpinalȱDeformityȱandȱRelatedȱConditionsȱDiagnosisȱbyȱGenderȱandȱ Age,ȱUnitedȱStatesȱ2004

TotalȱOccurrencesȱ(inȱ000s)[2] Gender Ageȱ(inȱyears) Averageȱ Ageȱatȱ ȱTotalȱ ȱMaleȱ ȱFemaleȱ ȱ<18ȱ ȱ18Ȭ44ȱ ȱ45Ȭ64ȱ ȱ65Ȭ74ȱ 75ȱ&ȱover Diagnosis SpinalȱDeformityȱ&ȱRelatedȱConditionsȱ[1] HospitalȱDischargesȱ[3]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 120 ȱȱȱȱȱȱȱȱȱȱȱ 30 ȱȱȱȱȱȱȱȱȱȱȱ 90 ȱȱȱȱȱȱȱȱȱȱȱ 15 ȱȱȱȱȱȱȱȱȱȱȱ 26 ȱȱȱȱȱȱȱȱȱȱȱ 25 ȱȱȱȱȱȱȱȱȱȱȱ 16 ȱȱȱȱȱȱȱȱȱȱȱ 24 58.8 HospitalȱEmergencyȱDepartmentsȱ[4]*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 59 ȱȱȱȱȱȱȱȱȱȱȱ 30 ȱȱȱȱȱȱȱȱȱȱȱ 29 ȱȱ*22ȱȱȱȱȱȱȱȱȱȱȱ ȱȱ*12ȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱ 23 55.4 HospitalȱOutpatientȱDepartmentsȱ[5]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 156 ȱȱȱȱȱȱȱȱȱȱȱ 55 ȱȱȱȱȱȱȱȱȱ 101 ȱȱȱȱȱȱȱȱȱ 106 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 8 ȱȱ* ȱȱ* ȱȱȱȱȱȱȱȱȱȱȱ 40 31.8 PhysicianȱOfficeȱVisitsȱ[6]*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 901 ȱȱȱȱȱȱȱȱȱ 272 ȱȱȱȱȱȱȱȱȱ 628 ȱȱȱȱȱȱȱȱȱ 428 ȱȱȱȱȱȱȱȱȱȱȱ 44 ȱȱȱȱȱȱȱȱȱ 157 ȱȱȱȱȱȱȱȱȱȱȱ 56 ȱȱȱȱȱȱȱȱȱ 217 39.0 AllȱSpinalȱDeformityȱ&ȱRelatedȱConditionsȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,236 ȱȱȱȱȱȱȱȱȱ 387 ȱȱȱȱȱȱȱȱȱ 848 ȱȱȱȱȱȱȱȱȱ 549 ȱȱȱȱȱȱȱȱȱ 100 ȱȱȱȱȱȱȱȱȱ 182 ȱȱȱȱȱȱȱȱȱȱȱ 84 ȱȱȱȱȱȱȱȱȱ 304 Diagnoses

ProportionȱofȱSpinalȱDeformityȱ&ȱRelatedȱConditionsȱ SpinalȱDeformityȱ&ȱRelatedȱConditions %ȱbyȱResource TreatedȱatȱResourceȱbyȱDemographicȱGroup HospitalȱDischargesȱ[3] 10% 25% 75% 14% 25% 24% 15% 23% HospitalȱEmergencyȱDepartmentsȱ[4]* 5% 51% 49% ȱȱ* ȱȱ* ȱȱ* ȱȱ* ȱȱ* HospitalȱOutpatientȱDepartmentsȱ[5] 13% 35% 65% 68% 5% ȱȱ* ȱȱ* 26% PhysicianȱOfficeȱVisitsȱ[6]* 73% 30% 70% 48% 5% 17% 6% 24% AllȱSpinalȱDeformityȱ&ȱRelatedȱConditionsȱ 100% 31% 69% 44% 8% 15% 7% 25% Diagnoses

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability [1]ȱSpinalȱdeformityȱ&ȱrelatedȱconditionsȱincludesȱICDȬ9ȬCMȱcodesȱ737.00ȱtoȱ737.19,ȱ737.20ȱtoȱ737.22,ȱ73729,ȱ737.30ȱtoȱ737.34,ȱ737.39,ȱȱ737.40ȱtoȱ737.43,ȱ737.80,ȱ737.90 [2]ȱMultipleȱoccurrencesȱperȱpatientȱpossible [3]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2006 [5]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱOutpatient,ȱ2006 [6]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006

Tableȱ3.4:ȱHospitalizationȱandȱMeanȱHospitalȱCostȱ[1]ȱforȱScoliosisȱandȱIdiopathicȱ ScoliosisȱbyȱGenderȱandȱAge,ȱUnitedȱStatesȱ2007

Proportion Proportion AllȱSpinalȱ Meanȱ Proportion byȱAgeȱandȱ Deformityȱ Lengthȱ Estimatedȱ Estimatedȱ Allȱ Genderȱ Diagnosesȱofȱ Meanȱ ofȱStay TotalȱCostȱ Costȱbyȱ Diagnosesȱ Group TotalȱGroup Chargeȱ (LOS) (inȱmillions) AgeȱGroup HospitalȱDischargesȱwithȱScoliosisȱDiagnosisȱ[2] (n=117,766) (nȬ119.953) ȱTOTALȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ119,957 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44,099 5.3$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,290.0

ȱMaleȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29,550 24.6% ȱFemaleȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ90,348 75.3%

ȱ<18ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14,982 12.5%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 72,203 5.8$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,081.7 20.4% ȱ18Ȭ44ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26,024 21.7%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 30,804 4.8$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 801.6 15.2% ȱ45Ȭ64ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ24,428 20.4%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 53,039 5.4$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,295.6 24.5% ȱ65Ȭ74ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16,208 13.5%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 53,076 5.1$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 860.3 16.3% 75ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 24,356 20.3%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 37,182 5.3$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 905.6 17.1% Unknown ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13,959 11.6% 18ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 91,016 75.9%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 42,460 5.2$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,864.5 73.1%

HospitalȱDischargesȱwithȱIdiopathicȱScoliosisȱDiagnosisȱ [3] (n=105,169) (n=107,205) ȱTOTALȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ107,209 89.4%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 40,220 5.2$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,311.9

ȱMaleȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25,729 24.0% 87.1% ȱFemaleȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ81,426 76.0% 90.1%

ȱ<18ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12,284 11.5% 82.0%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 66,354 5.6$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 815.1 18.9% ȱ18Ȭ44ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ24,350 22.7% 93.6%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 28,990 4.8$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 705.9 16.4% ȱ45Ȭ64ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ21,583 20.1% 88.4%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 48,161 5.3$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,039.5 24.1% ȱ65Ȭ74ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14,163 13.2% 87.4%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 47,930 5.1$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 678.8 15.7% 75ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 21,917 20.4% 90.0%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 34,815 5.3$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 763.0 17.7% Unknown ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12,913 12.0% 92.5% 18ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 82,013 76.5% 90.1%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 38,875 5.1$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,188.3 73.9%

[1]ȱGenerally,ȱtotalȱchargesȱdoȱnotȱincludeȱprofessionalȱfeesȱandȱnonȬcoveredȱcharges.ȱInȱtheȱrareȱcasesȱwhereȱprofessionalȱfeesȱcannotȱbeȱ removed,ȱtheyȱareȱincludedȱinȱtheȱdatabase.ȱEmergencyȱdepartmentȱchargesȱincurredȱpriorȱtoȱadmissionȱtoȱtheȱhospitalȱmayȱbeȱincludedȱinȱ totalȱcharges.

[2]ȱScoliosisȱconditionsȱincludesȱICDȬ9ȬCMȱcodesȱ737.30,ȱ737.31,ȱ737.32,ȱ737.33,ȱ737.34,ȱ737.39. [3]ȱIdiopathicȱscoliosisȱincludesȱICDȬ9ȬCMȱcodeȱ737.30. Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ3.4:ȱHospitalizationȱandȱMeanȱHospitalȱCostȱ[1]ȱforȱIdiopathicȱScoliosisȱbyȱGenderȱ andȱAge,ȱUnitedȱStatesȱ2007ȱ(continued)

Proportionȱ Allȱ Proportionȱ Allȱ Meanȱ Proportionȱ Idiopathicȱ byȱAgeȱ Idiopathicȱ Hospitalȱ EstimatedȱTotalȱ EstimatedȱCostȱ Scoliosisȱ andȱGenderȱ Scoliosisȱ Mean Lengthȱofȱ Costȱ byȱ Diagnosesȱ Group Diagnosesȱ Chargeȱ Stay (inȱmillions) AgeȱGroup HospitalȱDischargesȱwithȱPrimaryȱ(Dx1)ȱDiagnosisȱofȱIdiopathicȱScoliosisȱ[2] (n=8,265) (n=8,283) ȱTOTALȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,283 7.7%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 125,213 5.7 $1,037.1

ȱMaleȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,133 25.8% 8.3% ȱFemaleȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,128 74.0% 7.5%

ȱ<18ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,452 53.7% 36.2%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 114,815 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.2 $511.2 49.3% ȱ18Ȭ44ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ877 10.6% 3.6%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 130,776 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.2 $114.7 11.1% ȱ45Ȭ64ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,361 16.4% 6.3%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 161,940 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.1 $220.4 21.3% ȱ65Ȭ74ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ870 10.5% 6.1%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 141,024 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.6 $122.7 11.8% 75ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 625 7.5% 2.6%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 100,634 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.6 $62.9 6.1% Unknown ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ98ȱ 1.2% 0.7% 18ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,733 45.1% 4.1%$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 139,544 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.3 $520.9 50.2%

HospitalȱDischargesȱwithȱPediatricȱIdiopathicȱScoliosisȱDiagnosisȱ(Ageȱ<18ȱYears)*

Proportionȱ Proportionȱ <18ȱYearsȱ IdiopathicȱinȱAllȱ PrimaryȱinȱAllȱ Idiopathicȱ SpinalȱDeformityȱ Idiopathicȱ Scoliosisȱ Diagnosesȱbyȱ Primaryȱ Diagnosesȱbyȱ (AllȱDiagnoses) AgeȱGroup Diagnosisȱ(Dx1) AgeȱGroup ȱTOTALȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12,284 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,452 36.2%

ȱ0Ȭ3ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 653 5.3% * 0.0% ȱ4Ȭ7 1035 8.4%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 96 2.2% ȱ8Ȭ10ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,138 9.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 255 5.7% ȱ11Ȭ13ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,411 27.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,648 37.0% ȱ14Ȭ17ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,047 49.2%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,449 55.0%

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability

[2]ȱIdiopathicȱscoliosisȱincludesȱICDȬ9ȬCMȱcodeȱ737.30. Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ3.5:ȱPhysicianȱOfficeȱVisitsȱforȱIdiopathicȱScoliosis*ȱbyȱGenderȱandȱAge,ȱUnitedȱStatesȱ2006

PhysicianȱOfficeȱVisitsȱforȱSpinalȱDeformityȱ[1]* PrimaryȱDiagnosisȱȱofȱIdiopathicȱScoliosisȱ(DX1ȱ=ȱ737.30)ȱ[2]*

Proportion ȱȱȱȱProportionȱAll PrimaryȱIdiopathicȱ ȱȱȱȱȱProportion SpinalȱDeformityȱ Primaryȱ Diagnosisȱ PrimaryȱIdiopathicȱ AllȱDiagnosesȱof byȱAgeȱ Idiopathicȱ byȱAgeȱ toȱAllȱIdiopathicȱ SpinalȱDeformity andȱGender Scoliosisȱ andȱGender Diagnoses TOTAL ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ900,833 TOTAL ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ408,426 74.3%

Male 272,405 30% Male ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ65,571 16.1% 55.9% Female 628,428 70% Female ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ342,855 83.9% 79.2%

<18 427,718 47.5% <18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ292,877 71.7% 83.0% 18Ȭ44 43,952 4.9% 18Ȭ44 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 32,135 7.9% 83.3% 45Ȭ64 156,777 17.4% 45Ȭ64 * 0.0% 0.0% 65Ȭ74 55,625 6.2% 65Ȭ74 * 0.0% 0.0% 75ȱ&ȱover ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ216,761ȱ 24.1% 75ȱ&ȱover ȱȱȱȱȱȱȱȱȱȱȱ83,414 20.4% 98.3% 18ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 473,115 52.6% 18ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 115,549 28.3% 58.6%

IdiopathicȱScoliosisȱ[2]* Pediatricȱ(<18ȱYears)ȱIdiopathicȱScoliosisȱDiagnosisȱ[2]*

Proportion Proportion Prevalenceȱ Proportion Idiopathicȱ Idiopathicȱ Idiopathicȱ Proportion Primaryȱ Diagnosisȱ toȱAllȱSpinal ScoliosisȱinȱUnderȱ Idiopathic Primaryȱ Idiopathicȱ IdiopathicȱScoliosisȱ byȱAgeȱ Deformityȱ 18ȱPopulation Diagnosesȱ (Dx1)ȱ Diagnosesȱ Diagnosis andȱGender Diagnoses (AllȱDiagnoses) byȱAge Diagnosis byȱAgeȱ TOTAL ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ549,965 61.1% TOTAL ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ352,718 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ292,877 83.0%

Male ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ117,315 21.3% 43.1% Female ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ432,650 78.7% 68.8%

<18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ352,718 64.1% 82.5% ȱ0Ȭ3 * 0.0% * 0.0% 18Ȭ44 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ38,567 7.0% 87.7% ȱ4Ȭ7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30,792 8.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 30,792 10.5% 45Ȭ64 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ59,276 10.8% 37.8% ȱ8Ȭ10 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,636 0.7% * 0.0% 65Ȭ74 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14,568 2.6% 26.2% ȱ11Ȭ13 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ198,510 56.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 167,627 57.2% 75ȱ&ȱover ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ84,836ȱ 15.4% 39.1% ȱ14Ȭ17ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ120,780ȱ 34.2% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ94,458ȱ 32.3% 18ȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 197,247 35.8% 41.7% Totalȱ0Ȭ17ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 352,718 100.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 292,877 100.0%

*ȱEstimatesȱdoȱnotȱmeetȱstandardsȱforȱreliability.ȱDataȱisȱincludedȱbecauseȱitȱconstitutesȱtheȱmajorityȱofȱpatientȱvisitsȱforȱspinalȱdeformityȱandȱscoliosisȱinȱ2006. [1]ȱSpinalȱdeformityȱ&ȱrelatedȱconditionsȱincludesȱICDȬ9ȬCMȱcodesȱ737.00ȱtoȱ737.19,ȱ737.20ȱtoȱ737.22,ȱ73729,ȱ737.30ȱtoȱ737.34,ȱ737.39,ȱȱ737.40ȱtoȱ737.43,ȱ737.80,ȱ737.90 [2]ȱIdiopathicȱscoliosisȱincludesȱICDȬ9ȬCMȱcodeȱ737.30. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006

Tableȱ3.6:ȱSpineȱProceduresȱ[1]ȱwithȱScoliosisȱDiagnosisȱ[2]ȱbyȱAge,ȱUnitedȱStatesȱ2007

Ageȱ[3] Underȱ18 18Ȭ44 45Ȭ64 65Ȭ74 75ȱ&ȱOver Unknown Total ScoliosisȱDiagnosisȱ(N)ȱȱȱȱȱȱȱȱȱ 14,982 ȱȱȱȱȱȱȱȱȱ26,024 ȱȱȱȱȱȱȱȱȱ24,428 ȱȱȱȱȱȱȱȱȱ16,208 ȱȱȱȱȱȱȱȱȱ24,356 ȱȱȱȱȱȱȱȱȱ13,959 ȱȱȱȱȱȱ119,957 ȱȱProportionȱofȱTotalȱbyȱAgeȱGroup 12.5% 21.7% 20.4% 13.5% 20.3% 11.6% 100.0%

ScoliosisȱProcedureȱ(N)ȱȱȱȱȱȱȱȱȱȱȱ 6,118 ȱȱȱȱȱȱȱȱȱȱȱ1,844 ȱȱȱȱȱȱȱȱȱȱȱ5,319 ȱȱȱȱȱȱȱȱȱȱȱ3,817 ȱȱȱȱȱȱȱȱȱȱȱ2,637 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ227 ȱȱȱȱȱȱȱȱ19,961 ȱȱProportionȱofȱTotalȱbyȱAgeȱGroup 30.6% 9.2% 26.6% 19.1% 13.2% 1.1% 100.0%

ȱȱProportionȱofȱAgeȱGroupȱwith ȱȱȱȱȱSciolosisȱDiagnosisȱandȱ 40.8% 7.1% 21.8% 23.6% 10.8% 1.6% 16.6% ȱȱȱȱȱScoliosisȱProcedure

[1]ȱScoliosisȱproceduresȱincludesȱICDȬ9ȬCMȱprocedureȱcodesȱ81.04,ȱ81.05,ȱ81.06,ȱ81.08,ȱ81.62,ȱ61.63,ȱ81.64,ȱ84.51. [2]ȱScoliosisȱconditionsȱincludesȱICDȬ9ȬCMȱdiagnosticȱcodesȱ737.30,ȱ737.31,ȱ737.32,ȱ737.33,ȱ737.34,ȱ737.39. [3]ȱDataȱbyȱageȱgroupȱdoesȱnotȱmeetȱcriteriaȱforȱreliability.

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Chapter 4 Arthritis and Related Conditions

In adults, arthritis is the most common cause of Section 4.1: Prevalence of Arthritis and disability1 and is among the leading conditions Other Rheumatic Conditions causing work limitations.2 Over the next 25 years the number of people aff ected with doctor- diagnosed arthritis and the corresponding The NADW focuses on AORC, as distinct from arthritis-att ributable activity limitations are other highly prevalent musculoskeletal conditions projected to increase by 40% in the United States.3 such as back problems and osteoporosis. Initially, Estimating the prevalence and burden of the AORC was defi ned in terms of ICD-9-CM codes, various conditions that comprise arthritis and a defi nition still in use for analyses of health care other rheumatic conditions (AORC) is important system data. (Table 4.1) However, due to changes to understanding the current and potential impact in national surveys previously used to estimate of these conditions on health care and the public prevalence of AORC, prevalence is now estimated health systems. Equally important is identifying using self-reported, doctor-diagnosed arthritis, the gaps in our understanding of these measures. defi ned as a “yes” response to the question, “Have you EVER been told by a doctor or other Prevalence estimates presented in this chapter health professional that you have some form of are based on studies4,5 recently published by the arthritis, rheumatoid arthritis, gout, lupus, or National Arthritis Data Workgroup (NADW), a fi bromyalgia?” consortium of experts in epidemiology organized to provide a single source of national data on the Section 4.1.1: Prevalence of Arthritis and Other prevalence and impact of AORC. The NADW Rheumatic Conditions found that for estimates of specifi c conditions they oft en had to rely on a few, small-sized studies of Using doctor-diagnosed arthritis as the basis for uncertain generalizability to the U.S. population. analysis, the prevalence of AORC among U.S. Until there are bett er data, the results of NADW adults aged 18 or older was 21.6%, or 46.4 million, reviews are the best prevalence estimates available in 2003-20056. (Table 4.2 and Graph 4.1.1) Although and their application to the 2005 population arthritis prevalence is higher in older age groups, provides the best estimate of the number of with half of adults aged 65 and over now aff ected, people aff ected by AORC overall and by selected nearly two-thirds of the adults reporting doctor- rheumatic conditions. diagnosed arthritis are younger than 65 years. More than 60% are women. This update also includes data from most recently available datasets analyzed specifi cally for this Adjusting prevalence by age, the prevalence of book. The reader should be aware that both all types of arthritis is higher among women than self-reported data and annual data may include men (24% versus 18%). Among race/ethnic groups, both data errors and response errors that produce AORC is similar for non-Hispanic whites and variations from a norm found when analyzing African Americans (~22%), while lower among data across multiple years. Hispanics (16.5%).

ȱȱ ȱŚǯŗǯŗǱȱȱȱȬȱȬȱȱȱȬĴ The prevalence of ȱȱ¢ȱȱȱȱȱŗŞȱǭȱȱ¢ȱǰȱ¡ǰȱȱȦ¢ǰȱ activity limitations ȱȱȱǰȱŘŖŖřȬŘŖŖśȱȱŘŖŖŞ increases as people ŘŖŖřȬŘŖŖś ŘŖŖŞ age. Among adults Female Female aged 65 years and Male Male older, 22% reported arthritis-att ributable 18-44 Years 18-44 Years activity limitations 45-64 Years 45-64 Years in the 2003-2005 time 65 & Over 65 & Over period, while nearly 28% did so in 2008.

White, White Activity limitations non-Hispanic Black/African Black American are also higher among

Hispanic Asian women, but lower

Other, Other or among Hispanics and non-Hispanic Mixed Asians.

Total Total Among all adults 0 102030405060 0 102030405060with doctor- Prevalence (in millions) Prevalence (in millions) diagnosed arthritis, Doctor-Diagnosed ȬĴ Arthritis [1] Activity Limitation [2] arthritis or joint [1] Responded "yes" when asked: Have you EVER been told by a doctor or other health professional that you have some form of symptoms limited ǰȱȱǰȱǰȱǰȱȱę¢ǵȱ [2] Responded "yes" when asked: Are you now limited in any way in any of your usual activities because of arthritis or joint activities in over ¢ǵȱȱ 40% in 2003-2005, Source: National Center for Health Statistics National Health Interview Survey 2003 2005 and 2008 jumping to 57% in By 2030, the number of persons with doctor- 2008. Arthritis-att ributable activity limitations are diagnosed arthritis is projected to increase by 40% projected to aff ect 9.3% of the adult population, over current levels to nearly 67 million, or 25% of or 25 million persons, by the year 2030,3 a number the adult population.3 that was already surpassed in the 2008 data. Future analysis may fi nd the 2008 numbers higher than Section 4.1.2: Impact and Health Care Utilization the norm across multiple years. for All Arthritis and Other Rheumatic Conditions The high prevalence of arthritis and of arthritis- In 2003-2005, an estimated 8.8% of all adults in the related activity limitations results in signifi cant United States, or nearly 19 million persons over the personal and societal burdens; this burden oft en age of 18, had self-reported arthritis-att ributable diff ers by race or ethnicity.7 For example, “arthritis activity limitations. In 2008, these numbers had and rheumatism” is the most common cause of jumped to 13.0% of adults aged 18 and over, or disability in the U.S.,1 and aff ected persons have more than 29 million persons. (Table 4.2 and Graph a substantially lower health-related quality of 4.1.1). This rapid increase in arthritis-att ributable life.8 In 1997, AORC was the underlying cause of activity limitations is not clearly understood. death for 9,340 persons,9 while 19% of nursing However, a similar increase in the response to home residents were diagnosed with AORC.10 arthritis-att ributable activity limitations was found The estimated incremental cost of medical care in the 2006 and 2007 NHIS surveys. Future analysis expenditures and earnings losses for persons with by NADW may be able to explain the increase. an AORC condition was $128 billion in 2003.11

AORC, as a primary, or 1st, diagnosis for persons of AORC patients seeing an orthopaedic surgeon aged 18 and older accounted for 50.3 million has increased, although there was a slight decline non-injury ambulatory care visits in 2006, or in this proportion between 2004 and 2006. Health 5.0% of all health care visits, and aff ected broad care providers included physicians (98%), nurses components of the health care system. (Tables (22%), and midlevel practitioners (9%), with many 4.3 and 4.3a) Health care visits for AORC patients seeing multiple providers. (Table 4.4 and occurred in physicians offi ces (88%), outpatient Graph 4.1.2) departments (5%), and emergency departments (7%), a proportion that has changed litt le AORC, as the primary diagnosis, accounted for since 1997. (Table 4.4) By physician specialty, 1.17 million nonfederal, short stay hospitalizations physician offi ce visits in 2006 were to primary in 2007, or 3.1% of all such disease-related care physicians (39%), orthopaedic surgeons (nondelivery) hospitalizations in 2007. Two-thirds (31%), rheumatologists, neurologists or physical (67%) of the primary diagnosis AORC cases medicine and rehabilitation specialists (14%), and involved joint arthroplasty procedures of the hip other providers (16%). Since 1997, the proportion or knee, an increasingly common treatment to restore function in arthritis diseased joints. Graph 4.1.2: Health Care Resource Use for Non-Injury Arthritis and AORC, as either a principal or secondary Other Rheumatic Conditions (AORC) for Persons Aged 18 and Older, United States, 1997, 2004 & 2006 diagnosis, accounted for 5.24 million hospitalizations, or over 14% of all disease- Physician related hospitalizations, in 2007. In addition Nurse [3] to the above numbers, persons hospitalized

Midlevel with a principal diagnosis of an orthopaedic Provider [2] ȱ Provider [4] procedure, rather than an arthritis condition, or those related to arthritis treatment

Primary Care [5] 1997 [1] complications (e.g., gastrointestinal bleeding

Orthopaedic related to NSAID use) add to the overall Surgeon 2004 burden of arthritis in this country.

Physician Rheumatologist [6] Specialty [2] 2006 Other Provider Section 4.2: Osteoarthritis

Physician Osteoarthritis (OA), also known as ĜȱǽŘǾ degenerative joint disease, is the most Outpatient [7] common type of arthritis. It is characterized by

Resource progressive damage to the cartilage and other Emergency [8] Ambulatory Care joint tissues, and frequently aﬀ ects the hand, 0 20406080100 Ɩȱȱȱȱ¢ȱĜȱ ȱȱ knees, and hips. ǽŗǾȱǱȱ ȱ ǰȱ ȱ ǰȱȱǯȱȱȱȱȱ ȱȱȱȱȱȱ¢ȱȱȱǰȱȱ ǰȱŗşşŝǯȱArthritis RheumȱŘŖŖŘǲŚŝǱśŝŗȮśŞŗǯ Section 4.2.1: Prevalence and Incidence of ǽŘǾȱǱȱȱȱȱ ȱǰȱȱ¢ȱȱȱ ¢ǰȱŘŖŖŚȱǭȱŘŖŖŜ Osteoarthritis ǽřǾȱ ȱȱǰȱȱȱǰȱȱȦȱǯ ǽŚǾȱ ȱ¢ȱȱȱȱȦ ǽśǾȱ ȱ¢ȱǰȱ¢ȱȱǻȱǼǰȱȱȱ Estimating the prevalence of OA is diﬃ cult as ǻ¢ȱǼǰȱȱǰȱȱ¢ǰȱȱǰȱȱ ȱǻȱǼǯ radiographic changes related to the presence ǽŜǾȱ ȱ¢ǰȱ¢ǰȱ¢ȱȱȱǰȱȱȱ ǯ of osteoarthritis can be seen in most persons as ǽŝǾȱǱȱȱȱȱ ȱǰȱȱ ȱ¢ȱȱ they age. However, these changes may not be ¢ǰȱȱǰȱŘŖŖŚȱǭȱŘŖŖŜ ǽŞǾȱǱȱȱȱȱ ȱǰȱȱ ȱ¢ȱȱ accompanied by symptoms. Symptomatic OA, ¢ǰȱ ȱ¢ǰȱŘŖŖŚȱǭȱŘŖŖŜ

experienced as frequent pain and radiographic adults and females were more aff ected, and an changes indicating osteoarthritis in the joint, estimated 9.3 million adults had symptomatic knee is considered a bett er measure of important OA in 2005. (Table 4.5 and Graph 4.2.1) or consequential OA and is used to identify prevalence. The prevalence of symptomatic hip OA was 10% among adults aged 45 years and older in the Longitudinal studies conducted in several Johnston County study. No prevalence estimates communities, some as long as 40 years or more, for symptomatic OA at multiple joints exists, but have focused on identifying the prevalence of the NADW estimated that clinical OA in at least osteoarthritis, as well as other factors related to one joint, based on a physician’s examination in its causes. The longest study has been of adults a national survey, aff ected 26.9 million adults in aged 26 years and older living in Framingham, 2005. MA. The prevalence of symptomatic hand OA in the Framingham study is 6.8% of adults aged Section 4.2.2: Impact and Health Care Utilization 26 and over; however, in older adults it is found for Osteoarthritis much more frequently. Among persons aged 71 and older, OA is found in 26.2% of females and in Osteoarthritis as a primary diagnosis accounted 13.4% of males. The NADW estimated that 13.1 for 11.25 million ambulatory care visits in 2006, million adults in the United States experienced or 22.3% of the 50.3 million non-injury visits symptomatic hand OA in 2005. with a primary diagnosis of AORC. (Table 4.3) Osteoarthritis as the primary diagnosis accounted The prevalence of symptomatic knee OA is about for 70% of the 1.17 million nonfederal, short stay 5% of adults aged 26 years and older in the hospitalizations in 2007. This estimate does not Framingham study. In another study conducted capture arthritis hospitalizations with orthopaedic in Johnston County, NC, 17% of adults aged 45 procedures as the principal diagnosis or those and over were found to have symptomatic knee related to arthritis treatment complications, such as OA, while the 1988-1994 NHANES III survey gastrointestinal bleeding related to NSAID use. found 12.1% of adults aged 60 years and older suff ered from symptomatic knee OA. Again, older Section 4.3: Rheumatoid Arthritis Graph 4.2.1: Prevalence of Symptomatic Osteoarthritis in the Hands, Knees and Hips, United States

Hand, 6.8 Rheumatoid arthritis (RA) is a chronic age 26 & over [1] autoimmune disease that causes pain, stiff ness, swelling, and limitation in the motion and function Knee, 26 & over [1] 4.9 of multiple joints. Though joints are the principal Knee, 45 & over [1] 6.7 body parts aff ected by RA, infl ammation can 16.7 Knee, 45 & over [2] develop in other organs as well.

Knee, 60 & over [3] 12.1 Section 4.3.1: Prevalence of Rheumatoid Arthritis

Hip, 45 & over [2] 9.2 0 5 10 15 20 The only current source of data from which to Prevalence per 100 Persons estimate the prevalence of rheumatoid arthritis is *Age-standardized to the projected 2000 census population; a study from Rochester, MN. This study reported exception is the NHANES III estimates are standardized to the 1980 U.S. population a prevalence of RA in 1985 of 1.07% among adults Sources: ǽŗǾȱȱǻĴǼȱȱ¢ aged 35 years and older, but by 1995 this estimate ǽŘǾȱ ȱ¢ȱǻȱǼȱȱ¢ [3] NHANES III, 1988-1994 had fallen to 0.85%.

Twice as many women as men are aff ected by AORC. (Table 4.3) As the primary diagnosis, RA rheumatoid arthritis (1.06% vs. 0.61%).4 Trends in accounted for about 15,400, or 1.3%, of the 1.17 prevalence in Rochester, MN, by age and calendar million nonfederal, short stay hospitalizations year, show increasing prevalence with older age for AORC in 2007. This estimate does not capture but refl ect the decreasing overall prevalence in arthritis hospitalizations with orthopaedic most age groups in more recent time periods. procedures as the principal diagnosis or those (Table 4.6 and Graphs 4.3.1) This observation, related to arthritis treatment complications, such as along with the expected rapid growth in the gastrointestinal bleeding related to NSAID use. population of Americans aged 60 years and older, suggests that RA associated morbidity, mortality, Section 4.4: Other Forms of Arthritis and disability are likely to increase among older adults. The NADW studies found that older adults and females are more aff ected, and estimated that AORC, as a group of conditions, includes more 1.3 million adults over the age of 17 years, 0.6% of than 100 kinds of arthritis and rheumatic diseases, all adults, had RA in 2005. most of which last a lifetime. Although prevalence numbers for these individual conditions do Section 4.3.2: Impact and Health Care Utilization not begin to approach those of osteoarthritis for Rheumatoid Arthritis and rheumatoid arthritis, these conditions are as disabling, and oft en more so, than medical Rheumatoid arthritis as a primary diagnosis conditions found in higher numbers. Because accounted for 2.9 million ambulatory care visits these conditions are less common and aff ect fewer in 2006, representing 4.4% of the 50.3 million numbers of patients, research to treat or prevent non-injury visits with a primary diagnosis of them has fallen behind that of other conditions.

Graph 4.3.1: Trends in Prevalence of Rheumatoid Arthritis by Age [1], Rochester, MN 1965-1995

Females 1965 1975 1985 1995 3000000 2500 2000 1500 1000

Prevalence per 100,000 Prevalence 500 0 35 to 44 45 to 54 55 to 64 65 to 74 75 & older All females Males

30300000 22500500 22000000 15150000 10100000

Prevalence per 100,000 Prevalence 500500 0 355 tot 4444 4545 to 5454 55 to 6464 65 to 74 7575 & oldeolderlder AllAll malesmalesl [1] AAge-adjustedge-adjusted to U.S.U.S. WhiteWhite ppopulation,opulation, 20002000 Source: Helmick CGCG,, Felson DT,DT, Lawrence RCRC,, eet.t. al. National ArthritisArthritis Data Workgroup:Workgroup: EstimatesEstimates of ththee pprevalencerevalence of arthritis and other rheumatic conditions in the United States: Part I. Arthritis Rheum;2008(58:1):15-25.

Only a few of these conditions are described below, higher in African Americans than whites aged 45 but many more need to be brought to awareness years and older. Lifetime self-reported prevalence and supported with research funding. was 2.6% of adults aged 20 and older between the years 1988-1994, with 8% in adults aged 70 to 79 Section 4.4.1: Juvenile Arthritis years reporting they have suff ered from gout at some point in their lives. The NADW estimates 3.0 Juvenile arthritis appears in a variety of types, with million adults aged 18 years and older had gout in the most common form being juvenile rheumatoid the previous 12 months in 2005, while 6.1 million arthritis. All types cause joint infl ammation, begin adults had experienced gout during their lifetime. before the age of 16, and are oft en associated with Prevalence numbers may be overestimated as they symptoms and complications that are diff erent are based on self-reported data rather than clinical from those in adults. Although some types of examination. juvenile arthritis resolve over time and with maturity, damage to young joints can remain Gout and other crystal arthropathies as a primary throughout a lifetime. diagnosis accounted for 1.57 million ambulatory care visits in 2006, or 3.1% of the 50.3 million The prevalence of juvenile arthritis in children is non-injury visits with a primary diagnosis of very diffi cult to estimate because of the variety AORC. (Tables 4.3a and 4.3b) Gout and other of the diseases and their subtypes.12 The NADW crystal arthropathies as the principal diagnosis reported a novel approach using pediatric accounted for 1.5% of the 1.17 million nonfederal, ambulatory care visits4,13 to estimate that 294,000 short stay hospitalizations in 2007. (95% CIi 188,000-400,000) children aged 0 to 17 were aff ected by the broadly defi ned “arthritis Section 4.4.3: Connective Tissue Diseases or other rheumatic conditions” annually for the years 2001 to 2004. The same study estimates these Section 4.4.3a: Systemic Lupus Erythematosus children made 827,000 ambulatory care visits per year during the same time period. Systemic lupus erythematosus, also called SLE or lupus, is an autoimmune disorder that can aff ect Section 4.4.2: Gout and Other Crystal the skin, joints, kidneys, lungs, nervous system, Arthropathies and other organs of the body. The most common symptoms include skin rashes and arthritis, oft en Gout is a painful, episodic, recurrent, and accompanied by fatigue and fever. The clinical sometimes chronic and disabling form of arthritis course of SLE varies from mild to severe, and that has been recognized since ancient times. typically involves alternating periods of remission Symptoms typically consist of intense episodes of and relapse. painful swelling in single joints, most oft en in the feet and especially in the big toe. The underlying Estimates of the prevalence of SLE vary metabolic cause is an excess of serum uric acid that considerably because it is diffi cult to diagnose results in the deposition of crystal in joints and and because few good surveys have been done. elsewhere. The NADW used data from the San Francisco study4,14 and estimates that defi nite and suspected The self-reported prevalence of gout in a 12- month SLE together aff ects 322,000 persons, with period prior to the interview has increased over women aff ected far more than men, and African time, reaching 0.94% of all adults aged 18 years Americans far more than whites. Diff use diseases and older in 1996.5 Prevalence increases with age, of connective tissue, mainly SLE, as a primary is higher in men than women at all ages, and is diagnosis accounted for 762,100 ambulatory care

visits in 2006, or 1.5% of the 50.3 million non-injury Section 4.4.4a: Fibromyalgia visits with a primary diagnosis of AORC. (Tables 4.3a and 4.3b) Diff use diseases of connective tissue, Fibromyalgia is a clinical syndrome defi ned mainly SLE, as the principal diagnosis accounted by chronic widespread muscular pain, fatigue for 1.4% of the 1.17 million nonfederal, short stay and tenderness of unknown cause. Primary hospitalizations in 2007. fi bromyalgia occurs in people with no other rheumatologic disease. Secondary fi bromyalgia Section 4.4.3b: Systemic Sclerosis (SSc, occurs in people who are diagnosed with another scleroderma) rheumatologic disease, most oft en SLE and rheumatoid arthritis. Diff use systemic sclerosis (SSc) is an autoimmune disease that causes thickening and hardening of The NADW used a 1993 Wichita, Kansas, study the skin. It can also aff ect the lungs, the heart, and estimates about 5.0 million adults aged 18 gastrointestinal tract, and other internal organs. years and older had primary fi bromyalgia in A population-based study in southeast Michigan 2005. Prevalence is much higher among women 5 estimates the prevalence of SSc to be 27.6 cases than among men (3.4% vs. 0.5%). A primary per 100,000 population, translating to 49,000 diagnosis of “myalgia and myositis, unspecifi ed”, adults nationally, with women aff ected far more a very crude surrogate for primary fi bromyalgia, frequently than men and African Americans accounted for 1.8 million ambulatory care visits in slightly more than whites in 2005.4 2006, or 3.5% of the 50.3 million non-injury visits with a primary diagnosis of AORC. (Tables 4.3a and 4.3b) “Myalgia and myositis, unspecifi ed” Section 4.4.3c: Primary Sjögren’s Syndrome as the principal diagnosis accounted for less than 1% of the 1.17 million nonfederal, short stay Sjögren’s syndrome is an autoimmune, hospitalizations in 2007. Ambulatory and hospital infl ammatory disease that most oft en aff ects the visits declined by approximately one-half from tear and saliva glands, leading to dry eyes and those reported in 2004. mouth. “Primary” Sjögren’s syndrome occurs in people with no other rheumatologic disease. Section 4.4.4b: Polymyalgia Rheumatica and Giant “Secondary” Sjögren’s syndrome occurs in people Cell (temporal) Arteritis also diagnosed with another rheumatologic disease, most oft en SLE and rheumatoid arthritis. Polymyalgia rheumatica (PMR) typically causes The NADW reports the prevalence of primary a symmetrical and rapidly developing aching Sjögren’s syndrome to range from 0.19% to 1.39% and stiff ness around the upper arms, neck, lower of the adult population, aff ecting from 0.4 to 3.1 back and thighs among persons aged 50 and million adults in 2005.4 older. It is closely related to giant cell arteritis (GCA), an infl ammation of blood vessels. The Sjögren’s syndrome, as a primary diagnosis most commonly involved blood vessels are the accounted for 197,500 ambulatory care visits in arteries of the scalp and head. The NADW used 2006, or 0.4% of the 50.3 million non-injury visits the only population-based study of PMR and with a primary diagnosis of AORC. (Tables 4.3a GCA, conducted in Olmsted County, Minnesota, and 4.3b) Diff use diseases of connective tissue, to estimate that among persons 50 years of age or mainly SLE, as the principal diagnosis accounted older in the U.S., PMR aff ected 711,000 (0.74%) and for less than 500 of the 1.17 million nonfederal, GCA aff ected 228,000 (0.28%) in 2005.5 In both of short stay hospitalizations in 2007. these conditions, prevalence is higher in women than men, and increases dramatically with age. Section 4.4.4: Other Rheumatic Conditions

PMR and GCA, as a primary diagnoses accounted ambulatory care visits, or 28.1% of the 50.3 million for 576,300 ambulatory care visits in 2006, or 1.1% non-injury visits with a primary diagnosis of of the 50.3 million non-injury visits with a primary AORC were for joint pain. (Tables 4.3a and 4.3b) diagnosis of AORC. (Tables 4.3a and 4.3b) As the Joint pain as the principal diagnosis accounted principal diagnosis, they accounted for 6,000 , for 4.1% of the 1.17 million nonfederal, short stay approximately ½ of a percent, of the 1.17 million hospitalizations in 2007. nonfederal, short stay hospitalizations in 2007. Section 4.5: Treatments and Prevention Section 4.4.4c: Spondylarthropathies of Arthritis

Spondylarthropathies are a family of diseases that include ankylosing spondylitis (AS), reactive In recent years, a greater variety of medications arthritis (formerly known as Reiter’s syndrome), have been used to address pain and disability psoriatic arthritis, enteropathic arthritis (associated associated with arthritis and other rheumatic with ulcerative colitis or Crohn’s disease), juvenile conditions. For pain, acetaminophen has remained spondylarthropathy, and undiff erentiated a primary treatment. For conditions thought spondylarthropathy, which encompasses disorders to involve infl ammation, generic non-steroidal expressing elements of, but failing to fulfi ll, criteria anti-infl ammatory drugs (NSAIDs) remain in for the above diseases. widespread use. More specifi c NSAIDs, the Cox-2 inhibitors, have also been developed, The NADW estimates the prevalence of although concerns about heart disease as a side spondylarthropathies to range roughly from 0.35% eff ect have limited their use. For specifi c types to 1.31% of the population aged 25 and older, of infl ammatory arthritis, disease modifying aff ecting between 639,000 and 2,417,000 adults. anti-rheumatic drugs (DMARDs) are being used Spondylosis/spondylitis and allied disorders as earlier in the course of disease and more widely to a primary diagnosis accounted for 3.8 million try to prevent joint damage and disability. A major ambulatory care visits in 2006, or 7.5% of the 50.3 improvement in the treatment of rheumatoid million non-injury visits with a primary diagnosis arthritis and other types of infl ammatory arthritis of AORC. (Tables 4.3a and 4.3b) Spondylosis/ has been the introduction of expensive, but spondylitis and allied disorders as the primary eff ective, biological agents, such as tumor necrosis diagnosis accounted for 9% of the 1.17 million factor-alpha (TNF-α) inhibitors, which oft en work nonfederal, short stay hospitalizations in 2007. well where other DMARDs have failed.

Primary prevention, the preventing of an Section 4.4.5: Joint Symptoms and Joint Pain occurrence of AORC, remains a sought-aft er but elusive goal. Risk factors are not well understood Longitudinal prevalence numbers for joint pain for most of the conditions, and studies are needed are not available; however, as noted in Chapter to identify these before preventive measures 1, Burden of Musculoskeletal Diseases Overview, can be developed. Secondary prevention, chronic joint pain, pain experienced for at least 3 which is early diagnosis and treatment to help months, was self-reported by 61.6 million persons prevent joint damage, is a goal for those with 15 aged 18 and older in 2008. Chronic joint pain is rheumatoid arthritis and other inﬂ ammatory experienced by persons of all ages, with one in types of arthritis. Tertiary prevention, or the ﬁ ve (20%) of adults under the age of 44 reporting prevention of complications for those with AORC, chronic joint pain in 2008, and with more than is being pursued through the use of medications one-third (35%) between the ages of 45 and 64 and other recommended interventions, such reporting it. In 2006, an estimated 14.1 million as self-management of the disease, education,

physical activity, and weight loss. Cures at Section 4.6.2: Underlying Diagnoses specifi c joint sites may come about through joint replacement surgery. Total hip and primary knee replacements are done almost exclusively due to an underlying diagnosis Section 4.6: Arthroplasty and Total of osteoarthritis (86% and 97%, respectively). Joint Procedures (Table 4.8) A small proportion of patients having primary knee replacement have an underlying diagnosis of rheumatoid arthritis or other Total joint arthroplasty remains the defi nitive disorders. Among patients having primary total treatment for advanced, symptomatic joint hip replacement, 3% were due to fracture and 7% destruction regardless of the underlying cause. to other disorders, such as avascular necrosis, a Arthroplasty procedures have been developed disease resulting from the temporary or permanent for a multitude of joints, including hips, knees, loss of the blood supply to the bone. Partial hip shoulders, spine, ankles, elbows, wrists and replacement, generally a hemiarthoplasty, in which smaller joints of the hand and foot. The most the prosthesis is placed in the femur but not in frequently replaced joints are the knee and hip, the acetabulum, is performed principally for hip followed by the shoulder. The frequency of fracture (76% of cases). arthroplasty procedures involving the hand and foot, such as carpal metacarpal arthroplasty, is Section 4.6.3: Age and Gender Distribution of diffi cult to estimate because these procedures are Arthroplasty Procedures oft en performed on an outpatient basis. Outpatient surgical data are not captured as reliably as Females undergo twice as many hip, knee and inpatient procedure; however, the 2006 National shoulder joint replacement procedures as males, Survey of Ambulatory Surgery reported 32,300 accounting for 63% to 64% of these procedures. hand arthroplasty procedures and 58,100 fi nger Males and females are more equally divided on arthroplasty procedures were performed. other types of joint replacement, which includes wrist, ankle, spine, and upper/lower extremity Section 4.6.1: Anatomic Distribution of Joint joint replacements. Hip and knee revision rates Arthroplasty are also more evenly done on males and females. (Table 4.7) In 2006, hip and knee replacements, including revision replacement procedures, accounted The most striking diff erence in procedure rates for 96% of the nearly one million inpatient between males and females occurs in partial hip arthroplasty procedures performed. (Table 4.7 replacement, 73% of which were performed on and Graph 4.6.1) Shoulder procedures accounted females in 2006. This diff erence refl ects the much for another 3%, with all other joint replacement greater incidence of osteoporotic hip fracture in procedures representing only 1% of the total females than occurs in males. The diff erence in inpatient arthroplasty procedures performed. total hip and knee replacements likely refl ects the As previously noted, hand and foot arthroplasties are oft en performed on an Graph 4.6.1: Arthroplasty Procedures By Type, United States 2006 outpatient basis, and are not included in these numbers.

Total Hip Partial Hip Revision Hip Total Knee Revision Knee Shoulder, All Other (81.51) (81.52) (81.53) (81.54) (81.55) Primary Joints 23% 14% 15% 52% 4% & Revision 1% 3% Source: National Center for Health Statistics, National Hospital Discharge Survey, 2006

greater prevalence of osteoarthritis in females than complexity of revision than of primary elective in males, which in turn refl ects disproportionate procedures, the most recent data shows similar distributions of risk factors. In particular, females hospitalization time for both primary and revision have higher prevalence of obesity, which has been hip and knee procedures. identifi ed as a risk factor in osteoarthritis of the knee. Length of stay provides only part of the story of inpatient utilization following total joint Age distributions of joint arthroplasty procedures arthroplasty. Rates of discharge to home (routine), are predictable on the basis of the underlying short-term/skilled nursing/intermediate care, diagnosis. The mean age of patients at the time or other discharge sites varies with the national various arthroplasty procedures are performed database analyzed and the age of the population. has declined only a few years since 1992, varying Overall, rates of routine discharge to home are between 66 to 68 years of age in 2006. The lower in the Nationwide Inpatient Survey (NIS) exception is partial hip replacements, which are than are shown in the National Hospital Discharge performed on patients approximately a decade Survey (NHDS). Using the most optimum picture older due to the incidence of hip fracture in the (NHDS), nearly one-half of joint arthroplasty elderly population. (Table 4.9) Two-thirds (66%) recipients (44%) who are aged 65 and over are of partial hip replacements were performed in discharged to rehabilitation and nursing facilities patients older than 74 years in 2006, with 25% for an additional period of inpatient recovery and performed on patients older than 85. Primary rehabilitation. (Table 4.11 and Graph 4.6.3) This and revision total hip and knee arthroplasty rate compares to 27% of all hospital inpatient procedures are distributed across the adult age discharges of patients aged 65 and older to another strata, but about 50% of each of these procedures care facility. Even more striking is the 68% of are performed on patients aged 65 and older. partial hip replacement recipients discharged to long or short-term care facilities for further care in Section 4.6.4: Hospitalization for Arthroplasty 2006, refl ecting the frailty of this population. Procedures

The length of the average hospital stay following Graph 4.6.2: Average In Patient Length of Stay for Selected Arthroplasty Procedures, United States 1992-2006 total joint procedures has declined by 50% since 12 1992. Although the reductions appear to have reached a plateau between 2000 and 2004, the 10 most recent data again shows a decline in the length of hospital stay for arthroplasty procedures. (Table 4.10 and Graph 4.6.2) The length of stay 8 for partial hip replacement remains considerably higher than those for elective total hip and knee 6

replacement, reﬂ ecting the older age and more Mean Hospitalization Days frail medical status of the hip fracture population. 4 Additionally, surgery is not always done on the day of admission for hip fracture patients, as it 2 1992 1994 1996 1998 2000 2002 2004 2006 generally is for the elective total joint arthroplasty population. While in the past patients generally Total Hip (81.51) Total Knee (81.54) Partial Hip (81.52) Revision Knee (81.55) remained as inpatients for up to a day longer for Revision Hip (81.53)

revision procedures than did those with primary Source: National Center for Health Statistics, National Hospital procedures, consistent with the greater level of Discharge Survey, 1992-2006

Graph 4.6.3: Discharge Status for Patients Aged 18 & Over and Aged 65 and (NHDS)was signifi cantly higher than Over Undergoing Selected Major Joint Procedures, United States 2006 was found in the Nationwide Inpatient Aged 18 & Over Sample. To adjust for these diff erences, 100 14% partial hip procedures with a primary 80 30% 34% 31% 30% 32% (fi rst) diagnosis of spine disorders or 60 59% spinal fracture were removed from the 40 NHDS numbers. In 2006, the number of

20 partial hip replacement procedures was % Discharge Total Cases % Discharge Total estimated to be about 138,000. 0 Total Partial Revision Total Revision All Hip All [81.51] [81.52] [81.53] [81.54] [81.55] and Knee Inpatient Discharges Hip Knee Revision joint arthroplasty procedures Aged 65 & Over for total knee replacement between 1991 100 and 2006 have remained consistent at

80 8% to 9% of the primary procedures in 46% 27% 39% 39% both the national databases. Hip revision 60 46% 44% 68% procedures are substantially higher, 40 with the rate of revision to primary 20 hip procedures averaging 19% to 20% % Discharge Total Cases % Discharge Total 0 between 1991 and 2004. In 2006, data in Total Partial Revision Total Revision All Hip All [81.51] [81.52] [81.53] [81.54] [81.55] and Knee Inpatient both national health care databases saw Discharges Hip Knee a signiﬁ cant increase in the hip revision

Routine Discharged/Transferred Unknown/ procedure rate, jumping to 63% to 65% Discharge to Short-Term/ Other Discharge Home Skilled Nursing/ Status of the primary total hip replacement Intermediate Care procedures. The reason for this increase is Source: National Center for Health Statistics, National Hospital Discharge Survey, 2006 unknown, and may be an anomaly in the Thus, hospital length of stay, by itself, substantially data for that year. Future rates of revision underestimates the totality of health system care, hip arthroplasty will be watched to see if this rate especially for the hip fracture population. is increasing, or if the 2006 data were in error.

The increases in joint arthroplasty utilization are Section 4.6.5: Trends in Recent Utilization of Joint far more dramatic than would be expected from Arthroplasty Procedures overall population growth and from the increase in the proportion of the population that is elderly.16 From 1991 to 2004, the annual number of primary knee replacements increased by Graph 4.6.4: Total Hip and Knee Joint Replacement Procedures, almost 3-fold, while the annual number of United States, 1992 to 2006 600 primary total hip replacements doubled. In the last two years, the number of primary knee 500 replacement procedures continued to increase, 400 while total hip procedures reﬂ ected a leveling 300 (in 000s) oﬀ (Table 4.12 and Graph 4.6.4) 200

100 Partial hip joint replacements have seen the Joint Replacement Procedures 0 slowest rate of increase over the past couple 1992 1994 1996 1998 2000 2002 2004 2006 Total Partial Hip Total Knee of decades. However, in the past few years the Hip Hip Revision Knee Revision number of partial hip replacement procedures (81.51) (81.52) (81.53) (81.54) (81.55) in the National Hospital Discharge Survey Source: National Center for Health Statistics, National Hospital Discharge Survey, 1992-2006

As joint replacement procedures become safer and Graph 4.6.5: Mean Hospitalization Charges [1] for Hip and Knee more durable, the range of symptoms for which Joint Replacement Procedures, United States, 1998 to 2007 $60000 joint replacement is successful is broadening. Total hip and knee replacement are now suggested to younger and more active patients on the one hand, $50000 and older and more frail patients on the other. The more modest increase in partial hip replacements, $40000 a procedure reﬂ ective of the epidemiology of age-related hip fracture rather than of Mean Cost per Procedure physiological changes, supports this hypothesis of $30000 total replacement in younger, active patients.

$20000 The slower increase in the rate of revisions than 1998 1999 2000 2001 2002 2003 2004 2007 [1] Generally, total charges do not include Total Hip in primary procedures likely reﬂ ects the temporal professional fees and non-covered charges. In the (81.51) lag between primary and revision procedures, rare cases where professional fees cannot be Partial Hip removed, they are included in the database. (81.52) Emergency department charges incurred prior to which generally occurs with a wearing out of the admission to the hospital may be included in total Hip Revision charges. (81.53) original replacement device. One would expect Total Knee Source: Agency for Healthcare Research and (81.54) that the rate of increase in revisions will reﬂ ect Quality, Healthcare Cost and Utilization Project, Knee Revision the increased rate in primaries aft er 10 to 15 years. Nationwide Inpatient Sample, 1998-2007 (81.55) This assumption may be what is happening to the increase of 327%. (Table 4.13 and Graph 4.6.6) hip revision rate in the most recent data. The total hospitalization cost of hip and knee joint replacements in 2007 was approximately $50 Section 4.6.6: Cost of Arthroplasty Procedures billion.

The mean hospitalization cost of hip and knee joint Joint replacement procedures are proven to be replacement procedures, excluding charges not one of the most successful procedures available routinely billed by the hospital such as physician today. In the vast majority of cases, the procedure and prescription costs, increased in the last Graph 4.6.6: Total Hospitalization Charges [1] for Hip and Knee decade (1998 to 2007) by an average 109%. Nearly Joint Replacement Procedures, United States, 1998 to 2007 one-fourth of the increase was seen in the past $25 three years (2004 to 2007), in spite of the reported shorter hospital length of stay for the procedures. $20

Partial hip replacements (125%) and knee revision $15 procedures (133%) have shown the highest levels of increase. (Table 4.13 and Graph 4.6.5) Total knee $10

replacements and revision hip replacements, with Cost (in billion $s) Total mean increases of 93% and 86%, respectively, in $5 hospitalization cost, showed the lowest level of per $0 procedure cost increase. 1998 1999 2000 2001 2002 2003 2004 2007

[1] Generally, total charges do not include Total Hip In spite of this, due to the rapid increase in the professional fees and non-covered charges. In the (81.51) rare cases where professional fees cannot be Partial Hip number of total knee procedures performed, removed, they are included in the database. (81.52) Emergency department charges incurred prior to the total estimated cost of performing total admission to the hospital may be included in total Hip Revision charges. (81.53) knee replacement procedures jumped from Total Knee Source: Agency for Healthcare Research and (81.54) Quality, Healthcare Cost and Utilization Project, $5.36 billion in 1998 to $22.88 billion in 2007, an Knee Revision Nationwide Inpatient Sample, 1998-2007 (81.55)

signiﬁ cantly improves quality of life and the 2007 dollars, this volume of total joint replacement patient’s ability to continue work, activities of would generate costs exceeding $100 billion, or 1% daily living, and recreational activities. Continued of the gross domestic product (GDP). It is critical research to improve the longevity of implants that the orthopaedic profession anticipate these with younger, more active patients will reduce the profound needs for total knee and hip replacement overall burden of arthritis and damaged joints on services over the next generation. future generations. Section 4.7: Economic Cost of Arthritis Section 4.6.7: Forecasting Future Utilization of and Related Conditions Joint Arthroplasty Procedures

Kurtz and colleagues have performed The estimated annual cost for medical care of sophisticated modeling of projected growth in arthritis and joint pain for patients with any hip and knee replacement procedures.17 These diagnosis in 2004 was $281.5 billion, an average investigators included in their estimates the of $7,500 for each of the 37.6 million persons who growth in the overall population and in the reported having arthritis or joint pain. (Chapter proportion of elderly, as well as recent age and sex 9: Health Care Utilization and Economic Cost speciﬁ c increases in arthroplasty rates. The results of Musculoskeletal Diseases) Of this total, $37.3 are striking. The investigators estimate that by billion is estimated to be incremental cost that 2030 there will be over 570,000 primary total hip can be directly att ributed to arthritis and joint replacements performed annually in the U.S. and pain, and not a combination of arthritis and other nearly 3.5 million primary total knee replacements. medical conditions. A breakdown of the $281.5 (Table 4.14 and Graph 4.6.7) Although the rate of billion cost due to arthritis and joint pain shows revision procedures is expected to slowly decline, 32% for ambulatory care, 32% for emergency room revisions are projected to remain at a rate of 17% or inpatient care, 23% for prescription drugs, and to 18% of primary hip replacements and around 13% for other expenses. The cost of arthritis and 8% of primary knee replacements. (Table 4.14 and joint pain, in 2004 dollars, rose from $184.3 billion Graph 4.6.8) Such staggering growth will have in 1996 to the $281.5 billion in 2004, an increase profound consequences for manpower needs, of 53%. The increasing cost of prescription drugs operating room capacity, and health care costs. In accounts for the largest percentage of this total cost increase, Graph 4.6.7: Projected Number of Primary Total Hip Graph 4.6.8: Projected Number of Revision Total Hip rising from and Knee Arthroplasties, United States 2005-2030 and Knee Arthroplasties, United States 2005-2030 15% of total 300 3500 cost to 23% 3000 250 over the 9 2500 200 year period. 2000 150 1500 The indirect 100 cost of

1000 Procedures (in 000s) Procedures (in 000s) 50 earnings 500 Annual Number of Projected Annual Number of Projected 0 losses for 0 2005 2010 2020 2030 2005 2010 2020 2030 Source: Kurtz S, Ong K, Lau E, Mowat F, Revision total persons Primary total Source: Kurtz S, Ong K, Lau E, Mowat F, et al. The future burden of hip and knee hip arthroplasty aged 18 to 64 et al. The future burden of hip and knee hip arthroplasty arthroplasties: U.S. projections from 2005 arthroplasties: U.S. projections from 2005 to 2030. Paper presented at: 73rd Annual Revision total years with a to 2030. Paper presented at: 73rd Annual Primary total Meeting of the American Academy of knee arthroplasty Meeting of the American Academy of knee arthroplasty Orthopaedic Surgeons: Chicago, IL; 2006. work history Orthopaedic Surgeons: Chicago, IL; 2006. Used with permission of the primary Used with permission of the primary author. due to author. three major

AORC conditions totals $54.3 billion per year. 9. Sacks JJ, Helmick CG, Langmaid G: Deaths from arthritis This includes an estimated $15.2 billion due to and other rheumatic conditions, United States, 1979-1998. J gout, $22 billion as a result of osteoarthritis and Rheumatol 2004;31:1823-1828. allied disorders, and $17.1 billion resulting from rheumatoid arthritis. 10. Abell JE, Hootman JM, Helmick CG: Prevalence and impact of arthritis among nursing home residents. Ann 1. Centers for Disease Control (CDC): Prevalence of Rheum Dis 2004;63:591-594. disabilities and associated health conditions among adults-United States, 1999. MMWR Morb Mortal Wkly Rep 11. Yelin E, Murphy L, Cisternas MG, et al: Medical care 2001;50:120-125. expenditures and earnings losses among persons with arthritis and other rheumatic conditions in 2003 and 2. Stoddard S, Jans L, Ripple J, Kraus L: Chartbook on comparisons with 1997. Arthritis Rheum 2007;56:1397-1407. work and disability in the United States, 1998, in An InfoUse Report. Washington DC: U.S. National Institute on 12. Manners PJ, Bower C: Worldwide prevalence of juvenile Disability and Rehabilitation Research, 1998. arthritis - Why does it vary so much? J Rheumatol 2002;29:1520-1530. 3. Hootman JM, Helmick CG: Projections of U.S. prevalence of arthritis and associated activity limitations. Arthritis 13. Sacks JJ, Helmick CG, Luo Y-H, et al: Prevalence of and Rheum 2006;54:226-229. annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions, United States, 4. Helmick CG, Felson DT, Lawrence, RC, et al: Estimates of 2001-2004. Arthritis Rheum 2007;57(8):1439-1445. the prevalence of arthritis and other rheumatic conditions in the United States: part I. Arthritis Rheum 2008;58(1):15- 14. Fessel W: Systemic lupus erythematosus in the 25. community: incidence, prevalence, outcome and ﬁ rst symptoms: The high prevalence in black women. Arch 5. Lawrence, RC, Felson DT, Helmick CG, et al: Estimates of Intern Med 1974;134:1027-1035. the prevalence of arthritis and other rheumatic conditions in the United States: part II. Arthritis Rheum 2008;58(1):26- 15. National Center for Health Statistics: National Health 35. Interview Survey, Adult Sample Level File, 2005.

6. Hootman J, Bolen J, Helmick C, Langmaid G: Prevalence 16. Praemer A, Furner S, Rice DP: Musculoskeletal Conditions of doctor-diagnosed arthritis and arthritis-att ributable in the United States, ed 2. Rosemont, IL: American activity limitation-United States, 2003-2005. MMWR Morb Academy of Orthopaedic Surgeons, 1999, p 182. Mortal Wkly Rep 2006;55:1089-1092. 17. Source: Kurtz S, Lau E, Mowat F, et al: The future burden 7. Bolen J, Sniezek J, Theis K, et al: Racial and ethnic of hip and knee revisions: U.S. projections from 2005 to diﬀ erences in the prevalence and impact of doctor- 2030. Paper presented at: 73rd Annual Meeting of the diagnosed arthritis-United States, 2002. MMWR Morb American Academy of Orthopaedic Surgeons: Chicago, Mortal Wkly Rep 2005;54:119-123. IL;2006.

8. Mili F, Helmick CG, Moriarty DG: Health related quality of life among adults reporting arthritis: Analysis of data from the Behavioral Risk Factor Surveillance System,US, 1996-99. J Rheumatol 2003;30:160-166.

Section 4.8: Arthritis and Related Conditions Data Tables

Tableȱ4.1:ȱDiagnosticȱCategoriesȱICDȬ9ȬCMȱCodesȱforȱArthritisȱandȱOtherȱ RheumaticȱConditionsȱ(AORC)

Osteoarthritisȱandȱalliedȱdisorders Otherȱspecifiedȱrheumaticȱconditionsȱ(continued) 715ȬOsteoarthritisȱandȱalliedȱdisorders OtherȱAORC Rheumatoidȱarthritis 711ȬArthritisȱassociatedȱwithȱinfections 714ȬRheumatoidȱarthritisȱandȱotherȱinflammatoryȱ 713ȬArthropathyȱassociatedȱw/disordersȱ ȱȱȱȱpolyarthropathies ȱȱȱȱclassifiedȱelsewhere Goutȱandȱotherȱcrystalȱarthropathies 716.0,ȱ.2,ȱ.8ȬSpecifiedȱarthropathies 274ȬGout 719.2,ȱ.3ȬSpecifiedȱjointȱdisorders 712ȬCrystalȱarthropathies 95.6ȬSyphilisȱofȱmuscle Jointȱpain,ȱeffusionȱandȱotherȱunspecifiedȱjointȱdisorders 95.7ȬSyphilisȱofȱsynovium/tendon/bursa 716.1,ȱ.3Ȭ.6Ȭ.9ȱȬȱOtherȱunspecifiedȱarthropathies 98.5ȬGonococcalȱinfectionȱofȱjoint ȱ 719.0,ȱ.4Ȭ.9ȬOtherȱandȱunspecifiedȱjointȱdisorders 136.1ȬBehcet’sȱsyndrome Spondylarthropathies 277.2ȬOtherȱdisordersȱpurine/pyrimidineȱmetabolism 720ȬAS/inflammatoryȱspondylopathies 287.0ȬAllergicȱpurpura 721ȬSpondylosisȱandȱalliedȱdisorders 344.6ȬCaudaȱequinaȱsyndrome 99.3ȬReiter’sȱDisease 353.0ȬBrachialȱplexus/thoracicȱoutletȱlesions 696.0ȬPsoriaticȱarthopathy 355.5ȬTarsalȱtunnelȱsyndrome SystemicȱLupusȱErythematosusȱ(SLE) 357.1ȬPolyneuropathyȱinȱcollagenȱvascularȱdisease 710.0ȬSystemicȱlupusȱerythematosus 390ȬRheumaticȱfeverȱw/oȱheartȱdisease SystemicȱSclerosisȱ(SSC,ȱscleroderma) 391ȬRheumaticȱfeverȱw/heartȱdisease 710.1ȬSystemicȱsclerosis 437.4ȬCerebralȱarteritis Fibromyalgia 443.0ȬRaynaud’sȱsyndrome 729.1ȬMyalgiaȱandȱmyositisȱunspecified 446ȬPolyarteritisȱnodosaȱandȱalliedȱconditionsȱ Sjögrenȇsȱsyndrome ȱȱ ȱȱȱȱ[exclȱ446.5] 710.2ȬSiccaȱsyndromeȱ(alsoȱcalledȱSjögrenȇsȱsyndrome) ȱȱ 447.6ȬArteritis,ȱunspecified Polymyalgiaȱrheumaticaȱ(PMR)ȱandȱGiantȱcellȱ Softȱtissueȱdisordersȱ(excludingȱback) ȱȱ(temporal)ȱarteritisȱ(GCA) 726ȬPeripheralȱenthesopathiesȱandȱalliedȱdisorders 725ȬPolymyalgiaȱrheumatica 727ȬOtherȱdisordersȱofȱsynovium/tendon/bursa 446.5ȬPolyarteritisȱnodosaȱandȱalliedȱconditions 728.0Ȭ.3,ȱ.6–.9ȬDisordersȱofȱmuscle/ligament/fascia Otherȱspecifiedȱrheumaticȱconditions 729.0ȬRheumatism,ȱunspecifiedȱandȱfibrositisȱ 710ȬDiffuseȱconnectiveȱtissueȱdiseaseȱ[exclȱ710.0Ȭ.2] ȱȱȱȱ[exclȱ729.1] Carpalȱtunnelȱsyndromeȱ 729.4ȬFascitis,ȱunspecified 354.0ȬCarpalȱtunnelȱsyndromeȱ

Source:ȱCentersȱforȱDiseaseȱControlȱandȱPrevention,ȱArthritisȱProgram,ȱNationalȱArthritisȱDataȱWorkgroup.ȱAvailableȱat:ȱ http://www.cdc.gov/arthritis/data_statistics/arthritis_codes_2004.pdf.ȱAccessed:ȱAugustȱ16,ȱ2007

Tableȱ4.2:ȱPrevalenceȱofȱSelfȬReportedȱDoctorȬDiagnosedȱArthritisȱandȱArthritisȬAttributableȱActivityȱ LimitationsȱAmongȱAdultsȱAgedȱ18ȱ&ȱOlderȱbyȱAge,ȱSex,ȱandȱRace/Ethnicity,ȱUnitedȱStates,ȱ2003Ȭ2005ȱ andȱ2008

2003Ȭ2005ȱDataȱAnalyzedȱbyȱNationalȱArthritisȱDataȱWorkgroup ArthritisȱandȱArthritisȬAttributableȱActivityȱLimitationȱPrevalenceȱ ProportionȱwithȱArthritisȬ AttributableȱActivityȱLimitationȱ DoctorȬDiagnosedȱArthritisȱ[1] ArthritisȬAttributableȱActivityȱLimitationȱ[2] AmongȱThoseȱwithȱDoctorȬ DiagnosedȱArthritis

Unadjustedȱ Unadjustedȱ Prevalenceȱ %ȱAgeȱ %ȱAgeȬ Prevalenceȱ %ȱAgeȱ %ȱAgeȬ %ȱAgeȱ %ȱAgeȬ (inȱmillions) Unadjustedȱ Adjustedȱ[3]ȱ (inȱmillions) Unadjustedȱ Adjustedȱ[3]ȱ Unadjustedȱ Adjustedȱ[3]ȱ Gender Male 18.2 17.6% 18.1% 7.0 6.8% 7.0% 38.8% 36.6% Female 28.3 25.4% 24.4% 11.9 10.7% 10.3% 42.3% 39.0%

Age 18Ȭ44ȱyears 8.7 7.9% na 3.0 2.7% na 34.6% na 45Ȭ64ȱyears 20.5 29.3% na 8.2 11.8% na 40.3% na 65ȱ&ȱover 17.2 50.0% na 7.7 22.4% na 44.9% na

Race/Ethnicity White,ȱnonȬHispanic 37.2 24.3% 22.6% 14.7 9.6% 8.9% 39.5% 36.4% Black,ȱnonȬHispanic 4.6 19.2% 21.4% 2.2 9.2% 10.3% 47.8% 44.3% Hispanic 3.1 11.4% 16.5% 1.5 5.4% 8.2% 47.6% 45.2% OtherȱnonȬHispanic 1.6 14.7% 17.3% 0.7 6.0% 7.2% 41.1% 40.5%

Total 46.4 21.6% 21.5% 18.9 8.8% 8.8% 40.9% 38.1%

[1]ȱRespondedȱȈyesȈȱwhenȱasked:ȱHaveȱyouȱEVERȱbeenȱtoldȱbyȱaȱdoctorȱorȱotherȱhealthȱprofessionalȱthatȱyouȱhaveȱsomeȱformȱofȱarthritis,ȱrheumatoidȱarthritis,ȱgout,ȱ lupus,ȱorȱfibromyalgia? [2]ȱRespondedȱȈyesȈȱwhenȱasked:ȱAreȱyouȱnowȱlimitedȱinȱanyȱwayȱinȱanyȱofȱyourȱusualȱactivitiesȱbecauseȱofȱarthritisȱorȱjointȱsymptoms? [3]ȱAgeȱadjustedȱtoȱtheȱprojectedȱ2000ȱpopulationȱageȱ18ȱyearsȱorȱolderȱbyȱthreeȱageȱgroups:ȱ18Ȭ44,ȱ45Ȭ64ȱandȱ65ȱ&ȱover Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱ2003Ȭ2005

2008ȱDataȱAnalyzedȱbyȱAAOSȱProjectȱAnalyst

ArthritisȱandȱArthritisȬAttributableȱActivityȱLimitationȱPrevalenceȱ ProportionȱwithȱArthritisȬ AttributableȱActivityȱLimitationȱȱ DoctorȬDiagnosedȱArthritisȱ[1] ArthritisȬAttributableȱActivityȱLimitationȱ[2] AmongȱThoseȱwithȱDoctorȬ DiagnosedȱArthritis

Unadjustedȱ Unadjustedȱ Prevalenceȱ %ȱAgeȱ %ȱAgeȬ Prevalenceȱ %ȱAgeȱ %ȱAgeȬ %ȱAgeȱ (inȱmillions) Unadjustedȱ Adjustedȱ[3]ȱ (inȱmillions) Unadjustedȱ Adjustedȱ[3]ȱ Unadjustedȱ Gender Male 20.1 18.5% na 11.7 10.8% na 58.2% Female 31.1 26.7% na 17.5 15.0% na 56.3%

Age 18Ȭ44ȱyears 8.3 7.5% 7.3% 5.7 5.2% 5.0% 68.7% 45Ȭ64ȱyears 23.9 30.9% 30.6% 13.1 16.9% 16.8% 54.8% 65ȱ&ȱover 19.0 51.1% 48.9% 10.3 27.7% 26.5% 54.2%

Race/Ethnicity White,ȱnonȬHispanic 43.6 23.9% na 24.5 13.4% na 56.2% Black,ȱnonȬHispanic 5.4 20.1% na 3.2 12.0% na 59.3% Asian 1.1 10.6% na 0.7 6.7% na 63.6% OtherȱorȱMixed 1.1 20.9% na 0.9 17.0% na 81.8%

Total 51.2 22.7% na 29.2 13.0% na 57.0%

[1]ȱRespondedȱȈyesȈȱwhenȱasked:ȱHaveȱyouȱEVERȱbeenȱtoldȱbyȱaȱdoctorȱorȱotherȱhealthȱprofessionalȱthatȱyouȱhaveȱsomeȱformȱofȱarthritis,ȱrheumatoidȱarthritis,ȱgout,ȱ lupus,ȱorȱfibromyalgia? [2]ȱRespondedȱȈyesȈȱwhenȱasked:ȱAreȱyouȱnowȱlimitedȱinȱanyȱwayȱinȱanyȱofȱyourȱusualȱactivitiesȱbecauseȱofȱarthritisȱorȱjointȱsymptoms? [3]ȱAgeȬadjustedȱbyȱdirectȱmethodȱtoȱUSȱCensusȱpopulationȱestimateȱforȱJulyȱ1,ȱ2008.ȱAccessedȱJuneȱ22,ȱ2009. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱInterviewȱSurvey,ȱ2008

Tableȱ4.3a:ȱImpactȱandȱHealthȱCareȱUtilizationȱforȱSelectȱArthritisȱandȱOtherȱRheumaticȱ ConditionsȱforȱAdultsȱAgedȱ18ȱ&ȱOlder,ȱUnitedȱStates,ȱ2006/2007

AllȱDiagnoses Visitsȱ(inȱ000s) AmbulatoryȱCareȱServices Inpatientȱ Totalȱ Hospitalizatio Physicianȱ Outpatientȱ Ambulatoryȱ AORCȱConditionȱ[1] nȱ[2] Visitsȱ[3] ERȱVisitsȱ[4] Visitsȱ[5] Careȱ Osteoarthritis ȱȱȱȱȱȱȱȱȱȱȱȱȱ2,544.9ȱ ȱȱȱȱȱȱȱ18,431.6ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ186.2ȱ ȱȱȱȱȱȱȱȱȱ1,322.4ȱ ȱȱȱȱȱȱȱȱȱ19,940.2ȱ RheumatoidȱArthritis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ399.2ȱ ȱȱȱȱȱȱȱȱȱ3,196.6ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ40.0ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ344.6ȱ ȱȱȱȱȱȱȱȱȱȱȱ3,581.2ȱ GoutȱandȱOtherȱCrystalȱArthropathies ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ552.1ȱ ȱȱȱȱȱȱȱȱȱ2,306.8ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ277.8ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ265.0ȱ ȱȱȱȱȱȱȱȱȱȱȱ2,849.6ȱ SystemicȱLupusȱErythematosusȱ(SLE) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ166.5ȱ ȱȱȱȱȱȱȱȱȱ1,061.5ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44.0ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ85.6ȱ ȱȱȱȱȱȱȱȱȱȱȱ1,191.1ȱ SystemicȱSclerosisȱ(SSc,ȱscleroderma) 0.0ȱ 0.0ȱ 0.0ȱ 0.0ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȬȱȱȱ PrimaryȱSjögren’sȱSyndrome ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27.2ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ462.2ȱȱ*ȱ 0.0ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.9ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ473.1ȱ Fibromyalgia ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ262.2ȱ ȱȱȱȱȱȱȱȱȱ3,182.5ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ412.7ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ369.1ȱ ȱȱȱȱȱȱȱȱȱȱȱ3,964.3ȱ PolymyalgiaȱRheumaticaȱandȱGiantȱCellȱȱArteritisȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ96.1ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ707.2ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.2ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.7ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ722.1ȱ Spondylarthropathies ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ418.6ȱ ȱȱȱȱȱȱȱȱȱ6,378.4ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ38.2ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ361.5ȱ ȱȱȱȱȱȱȱȱȱȱȱ6,778.1ȱ JointȱPainȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ816.6ȱ ȱȱȱȱȱȱȱ18,961.1ȱ ȱȱȱȱȱȱȱȱȱ1,957.6ȱ ȱȱȱȱȱȱȱȱȱ2,051.9ȱ ȱȱȱȱȱȱȱȱȱ22,970.6ȱ AllȱOtherȱArthritisȱandȱOtherȱRheumaticȱCondition ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ707.3ȱ ȱȱȱȱȱȱȱ18,586.2ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ892.6ȱ ȱȱȱȱȱȱȱȱȱ1,728.1ȱ ȱȱȱȱȱȱȱȱȱ21,206.9ȱ TotalȱAORCȱDiagnoses ȱȱȱȱȱȱȱȱȱȱȱȱȱ5,240.5ȱ ȱȱȱȱȱȱȱ66,590.9ȱ ȱȱȱȱȱȱȱȱȱ3,632.6ȱ ȱȱȱȱȱȱȱȱȱ5,965.7ȱ ȱȱȱȱȱȱȱȱȱ76,189.2ȱ AllȱVisits ȱȱȱȱȱȱȱȱȱȱȱ39,542.0ȱ ȱȱȱȱȱ720,394.6ȱ ȱȱȱȱȱȱȱ92,881.8ȱ ȱȱȱȱȱȱȱ78,529.0ȱ ȱȱȱȱȱȱȱ885,464.2ȱ

PrimaryȱDiagnosisȱ(Dx1) Visitsȱ(inȱ000s) AmbulatoryȱCareȱServices

Inpatientȱ Totalȱ Hospitalizatio Physicianȱ Outpatientȱ Ambulatoryȱ AORCȱConditionȱ[1] nȱ[2] Visitsȱ[3] ERȱVisitsȱ[4] Visitsȱ[5] Careȱ Osteoarthritis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ814.9ȱ ȱȱȱȱȱȱȱ10,505.7ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ76.9ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ663.8ȱ ȱȱȱȱȱȱȱȱȱ11,246.4ȱ RheumatoidȱArthritis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ15.4ȱ ȱȱȱȱȱȱȱȱȱ1,948.4ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.3ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ236.9ȱ ȱȱȱȱȱȱȱȱȱȱȱ2,193.6ȱ GoutȱandȱOtherȱCrystalȱArthropathies ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.0ȱ ȱȱȱȱȱȱȱȱȱ1,307.3ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ185.6ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ79.0ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱ1,571.9ȱ SystemicȱLupusȱErythematosusȱ(SLE) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16.0ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ693.5ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16.3ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ52.3ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ762.1ȱ SystemicȱSclerosisȱ(SSc,ȱscleroderma) 0.0ȱ 0.0ȱ 0.0ȱ 0.0ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȬȱȱȱ PrimaryȱSjögren’sȱSyndrome ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.5ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ192.7ȱȱ*ȱ 0.0ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.8ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ197.5ȱ Fibromyalgia ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.7ȱ ȱȱȱȱȱȱȱȱȱ1,323.9ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ270.8ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ175.5ȱ ȱȱȱȱȱȱȱȱȱȱȱ1,770.2ȱ PolymyalgiaȱRheumaticaȱandȱGiantȱCellȱȱArteritisȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.0ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ562.9ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.2ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.2ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ576.3ȱ Spondylarthropathies ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ103.4ȱ ȱȱȱȱȱȱȱȱȱ3,570.3ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14.7ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ209.0ȱ ȱȱȱȱȱȱȱȱȱȱȱ3,794.0ȱ JointȱPainȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47.6ȱ ȱȱȱȱȱȱȱ11,489.4ȱ ȱȱȱȱȱȱȱȱȱ1,448.3ȱ ȱȱȱȱȱȱȱȱȱ1,182.3ȱ ȱȱȱȱȱȱȱȱȱ14,120.0ȱ AllȱOtherȱArthritisȱandȱOtherȱRheumaticȱCondition ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ138.7ȱ ȱȱȱȱȱȱȱ12,498.8ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ506.5ȱ ȱȱȱȱȱȱȱȱȱ1,134.9ȱ ȱȱȱȱȱȱȱȱȱ14,140.2ȱ TotalȱPrimaryȱAORCȱDiagnoses ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,166.3ȱ ȱȱȱȱȱȱȱ44,046.2ȱ ȱȱȱȱȱȱȱȱȱ2,531.5ȱ ȱȱȱȱȱȱȱȱȱ3,747.1ȱ ȱȱȱȱȱȱȱȱȱ50,324.8ȱ

%ȱPrimaryȱAORCȱofȱAllȱAORCȱDiagnoses 22.3% 66.1% 69.7% 62.8% 66.1%

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability [1]ȱICDȬ9ȬCMȱdiagnosisȱcodesȱȱforȱAORCȱlistedȱinȱTableȱ4.1. [2]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2006 [5]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱOutpatientȱCenters,ȱ2006ȱ

NOTE:ȱThisȱtableȱandȱallȱrelatedȱgraphsȱcreatedȱbyȱtheȱBurdenȱofȱMusculoskeletalȱDiseasesȱprojectȱanalyst.ȱ

Tableȱ4.3b:ȱProportionȱofȱTotalȱAORCȱVisitsȱforȱSelectȱArthritisȱandȱOtherȱRheumaticȱ ConditionsȱforȱAdultsȱAgedȱ18ȱ&ȱOlder,ȱUnitedȱStates,ȱ2006/2007

AllȱDiagnoses ProportionȱofȱTotalȱAORCȱVisits AmbulatoryȱCareȱServices

Inpatientȱ Totalȱ Hospitalizationȱ Physicianȱ Outpatientȱ Ambulatoryȱ AORCȱConditionȱ[1] [2] Visitsȱ[3] ERȱVisitsȱ[4] Visitsȱ[5] Careȱ Osteoarthritis 48.6% 27.7% 5.1% 22.2% 26.2% RheumatoidȱArthritis 7.6% 4.8% 1.1% ȱ*ȱ 5.8% 4.7% GoutȱandȱOtherȱCrystalȱArthropathies 10.5% 3.5% 7.6% 4.4% 3.7% SystemicȱLupusȱErythematosusȱ(SLE) 3.2% 1.6% ȱ*ȱ 1.2% ȱ*ȱ 1.4% 1.6% SystemicȱSclerosisȱ(SSc,ȱscleroderma) 0.0% 0.0% 0.0% 0.0% 0.0% PrimaryȱSjögren’sȱSyndrome 0.5% 0.7% ȱ*ȱ 0.0% 0.2% ȱ*ȱ 0.6% Fibromyalgia 5.0% 4.8% 11.4% 6.2% 5.2% PolymyalgiaȱRheumaticaȱandȱGiantȱCellȱȱArteritisȱ 1.8% 1.1% ȱ*ȱ 0.1% ȱ*ȱ 0.2% ȱ*ȱ 0.9% Spondylarthropathies 8.0% 9.6% 1.1% ȱ*ȱ 6.1% 8.9% JointȱPainȱ 15.6% 28.5% 53.9% 34.4% 30.1% AllȱOtherȱArthritisȱandȱOtherȱRheumaticȱConditionsȱ 13.5% 27.9% 24.6% 29.0% 27.8% %ȱTotalȱAORCȱDiagnosesȱtoȱAllȱDiagnoses 14.3% 8.4% 4.0% 7.3% 7.5% %ȱofȱAmbulatoryȱVisitsȱbyȱResource 87.4% 4.8% 7.8%

PrimaryȱDiagnosisȱ(Dx1) ProportionȱofȱTotalȱAORCȱVisits AmbulatoryȱCareȱServices

Inpatientȱ Totalȱ Hospitalizationȱ Physicianȱ Outpatientȱ Ambulatoryȱ AORCȱConditionȱ[1] [2] Visitsȱ[3] ERȱVisitsȱ[4] Visitsȱ[5] Careȱ Osteoarthritis 69.9% 23.9% 3.0% ȱ*ȱ 17.7% 22.3% RheumatoidȱArthritis 1.3% 4.4% 0.3% ȱ*ȱ 6.3% 4.4% GoutȱandȱOtherȱCrystalȱArthropathies 1.5% 3.0% 7.3% 2.1% ȱ*ȱ 3.1% SystemicȱLupusȱErythematosusȱ(SLE) 1.4% 1.6% ȱ*ȱ 0.6% ȱ*ȱ 1.4% ȱ*ȱ 1.5% SystemicȱSclerosisȱ(SSc,ȱscleroderma) 0.0% 0.0% 0.0% 0.0% 0.0% PrimaryȱSjögren’sȱSyndrome 0.0% 0.4% ȱ*ȱ 0.0% 0.1% ȱ*ȱ 0.4% Fibromyalgia 0.6% 3.0% 10.7% 4.7% 3.5% PolymyalgiaȱRheumaticaȱandȱGiantȱCellȱȱArteritisȱ 0.5% 1.3% ȱ*ȱ 0.2% ȱ*ȱ 0.2% ȱ*ȱ 1.1% Spondylarthropathies 8.9% 8.1% 0.6% ȱ*ȱ 5.6% 7.5% JointȱPainȱ 4.1% 26.1% 57.2% 31.6% 28.1% AllȱOtherȱArthritisȱandȱOtherȱRheumaticȱConditionsȱ 11.9% 28.4% 20.0% 30.3% 28.1% %ȱTotalȱAORCȱPrimaryȱDiagnosesȱtoȱAllȱDiagnoses 3.1% 5.6% 2.8% 4.7% 5.0% %ȱofȱAmbulatoryȱVisitsȱbyȱResource 87.5% 5.0% 7.4%

NOTE:ȱThisȱtableȱandȱallȱrelatedȱgraphsȱcreatedȱbyȱtheȱBurdenȱofȱMusculoskeletalȱDiseasesȱprojectȱanalyst.ȱ

Tableȱ4.4:ȱAmbulatoryȱCareȱResourceȱUseȱforȱNonȬInjuryȱArthritisȱandȱOtherȱ RheumaticȱConditionsȱ(AORC)ȱforȱPersonsȱAgedȱ18ȱandȱOlder,ȱUnitedȱStates,ȱ 1997,ȱ2004,ȱandȱ2006

ProportionȱofȱAllȱPrimaryȱ(1st)ȱDiagnosisȱofȱAORC,ȱUnitedȱStatesȱ1997 PhysicianȱOfficeȱVisits AmbulatoryȱCareȱResource PhysicianȱSpecialty HealthȱCareȱProvider PhysicianȱOffice 89% PrimaryȱCareȱPhysician 53% Physician 97% OutpatientȱDepartment 7% OrthopaedicȱSurgeon 20% Nurse 51% EmergencyȱDepartment 4% Rheumatologist 17% MidlevelȱProvider 24% OtherȱProvider 10%

TotalȱVisitsȱforȱPrimaryȱAORC 36.5ȱmillion AORCȱasȱ%ȱAllȱHealthȱCareȱVisits 3.8%

Source:ȱHootmanȱJM,ȱHelmickȱCG,ȱSchappertȱSM.ȱMagnitudeȱandȱcharacteristicsȱofȱarthritisȱandȱotherȱrheumaticȱ conditionsȱonȱambulatoryȱmedicalȱcareȱvisits,ȱUnitedȱStates,ȱ1997.ȱArthritisȱRheum ȱ2002;47:571–581.

ProportionȱofȱAllȱPrimaryȱDiagnosisȱ(Dx1)ȱofȱAORC,ȱUnitedȱStatesȱ2004ȱ PhysicianȱOfficeȱVisitsȱ[1] AmbulatoryȱCareȱResource PhysicianȱSpecialtyȱ HealthȱCareȱProviderȱVisits PhysicianȱOfficeȱ[1] 89% PrimaryȱCareȱPhysicianȱ[4] 45% Physician 98% OutpatientȱDepartmentȱ[2] 6% OrthopaedicȱSurgeon 36% Nurseȱ[6] 41% EmergencyȱDepartmentȱ[3] 5% Rheumatologist,ȱPM&Rȱ[5] 5% MidlevelȱProviderȱ[7] 3% OtherȱProvider 14% OtherȱProvider 8%

TotalȱVisitsȱforȱPrimaryȱAORC 41.2ȱmillion AORCȱasȱ%ȱAllȱHealthȱCareȱVisits 5.6%

ProportionȱofȱAllȱPrimaryȱDiagnosisȱ(Dx1)ȱofȱAORC,ȱUnitedȱStatesȱ2006ȱ PhysicianȱOfficeȱVisitsȱ[1] AmbulatoryȱCareȱResource PhysicianȱSpecialtyȱ HealthȱCareȱProviderȱVisits PhysicianȱOfficeȱ[1] 88% PrimaryȱCareȱPhysicianȱ[4] 39% Physician 98% OutpatientȱDepartmentȱ[2] 5% OrthopaedicȱSurgeon 31% Nurseȱ[6] 22% EmergencyȱDepartmentȱ[3] 7% Rheumatologist,ȱPM&Rȱ[5] 14% MidlevelȱProviderȱ[7] 9% OtherȱProvider 16% OtherȱProvider 12%

TotalȱVisitsȱforȱPrimaryȱAORC 50.3ȱmillion PrimaryȱAORCȱasȱ%ȱAllȱHealthȱCareȱVisits 5.0%

[1]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2004ȱ&ȱ2006 [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱCareȱSurvey,ȱOutpatientȱCenters,ȱ2004ȱ&ȱ 2006 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2004ȱ &ȱ2006

[4]ȱIncludesȱfamilyȱpractice,ȱfamilyȱpracticeȱ(geriatricȱmedicine),ȱsportsȱmedicineȱ(familyȱpractice),ȱgeneralȱpractice,ȱ generalȱsurgery,ȱinternalȱmedicine,ȱgeriatricȱmedicineȱ(internalȱmedicine). [5]ȱIncludesȱrheumatology,ȱneurology,ȱphysicalȱmedicineȱandȱrehabilitation,ȱandȱpainȱspecialists. [6]ȱIncludesȱregisteredȱnurse,ȱlicensedȱpracticalȱnurse,ȱandȱmedical/nursingȱassistant. [7]ȱIncludesȱphysicianȱassistantȱandȱnurseȱpractitioner/midwife.

Tableȱ4.5:ȱPrevalenceȱofȱSymptomaticȱOsteoarthritisȱinȱtheȱ Hands,ȱKneesȱandȱHips,ȱUnitedȱStates,ȱVariousȱStudiesȱ

SymptomaticȱOsteoarthritisȱ Prevalenceȱperȱ100ȱPersons* Age Source Male Female Total Hands 26ȱ&ȱover [1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.8

Knees 26ȱ&ȱover [1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.9 45ȱ&ȱover [1]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.7 45ȱ&ȱover [2]ȱȱȱȱȱȱȱȱȱȱȱȱȱ 13.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ16.7 60ȱ&ȱover [3]ȱȱȱȱȱȱȱȱȱȱȱȱȱ 10.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ13.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12.1

Hips 45ȱ&ȱover [2]ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.2

*AgeȬstandardizedȱtoȱtheȱprojectedȱ2000ȱcensusȱpopulation;ȱexceptionȱisȱtheȱNHANESȱIIIȱ estimatesȱareȱstandardizedȱtoȱtheȱ1980ȱU.S.ȱpopulation [1]ȱFraminghamȱ(Massachusetts)ȱOsteoarthritisȱStudy [2]ȱJohnstonȱCountyȱ(NorthȱCarolina)ȱOsteoarthritisȱStudy [3]ȱNHANESȱIII,ȱ1988Ȭ1994

Tableȱ4.6:ȱTrendsȱinȱPrevalenceȱofȱ RheumatoidȱArthritisȱbyȱSexȱandȱAgeȱ[1],ȱ Rochester,ȱMN,ȱ1965Ȭ1995

Females Prevalenceȱ(inȱ100,000s) AgeȬgroup 1965 1975 1985 1995 35Ȭ44ȱȱȱȱȱȱȱȱȱȱȱȱȱ 310 ȱȱȱȱȱȱȱȱȱȱȱȱȱ451 ȱȱȱȱȱȱȱȱȱȱȱȱȱ300 ȱȱȱȱȱȱȱȱȱȱȱȱȱ379 45Ȭ54ȱȱȱȱȱȱȱȱȱȱ 1,020 ȱȱȱȱȱȱȱȱȱȱȱȱȱ977 ȱȱȱȱȱȱȱȱȱȱ1,110 ȱȱȱȱȱȱȱȱȱȱȱȱȱ494 55Ȭ64ȱȱȱȱȱȱȱȱȱȱ 1,572 ȱȱȱȱȱȱȱȱȱȱ1,901 ȱȱȱȱȱȱȱȱȱȱ1,888 ȱȱȱȱȱȱȱȱȱȱ1,382 65Ȭ74ȱȱȱȱȱȱȱȱȱȱ 2,081 ȱȱȱȱȱȱȱȱȱȱ2,312 ȱȱȱȱȱȱȱȱȱȱ2,438 ȱȱȱȱȱȱȱȱȱȱ2,421 75+ȱȱȱȱȱȱȱȱȱȱ 1,969 ȱȱȱȱȱȱȱȱȱȱ2,568 ȱȱȱȱȱȱȱȱȱȱ2,352 ȱȱȱȱȱȱȱȱȱȱ1,943 AllȱFemalesȱȱȱȱȱȱȱȱȱȱ 1,171 ȱȱȱȱȱȱȱȱȱȱ1,368 ȱȱȱȱȱȱȱȱȱȱ1,345 ȱȱȱȱȱȱȱȱȱȱ1,064

Males Prevalenceȱ(inȱ100,000s) AgeȬgroup 1965 1975 1985 1995 35Ȭ44ȱȱȱȱȱȱȱȱȱȱȱȱȱ 161 ȱȱȱȱȱȱȱȱȱȱȱȱȱ133 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ97 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 45Ȭ54ȱȱȱȱȱȱȱȱȱȱȱȱȱ 452 ȱȱȱȱȱȱȱȱȱȱȱȱȱ473 ȱȱȱȱȱȱȱȱȱȱȱȱȱ286 ȱȱȱȱȱȱȱȱȱȱȱȱȱ219 55Ȭ64ȱȱȱȱȱȱȱȱȱȱȱȱȱ 946 ȱȱȱȱȱȱȱȱȱȱȱȱȱ885 ȱȱȱȱȱȱȱȱȱȱȱȱȱ848 ȱȱȱȱȱȱȱȱȱȱȱȱȱ753 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱȱȱ 606 ȱȱȱȱȱȱȱȱȱȱ1,540 ȱȱȱȱȱȱȱȱȱȱ1,792 ȱȱȱȱȱȱȱȱȱȱ1,574 75+ȱȱȱȱȱȱȱȱȱȱ 1,394 ȱȱȱȱȱȱȱȱȱȱ1,592 ȱȱȱȱȱȱȱȱȱȱ1,589 ȱȱȱȱȱȱȱȱȱȱ1,498 AllȱMalesȱȱȱȱȱȱȱȱȱȱȱȱȱ 593 ȱȱȱȱȱȱȱȱȱȱȱȱȱ733 ȱȱȱȱȱȱȱȱȱȱȱȱȱ701 ȱȱȱȱȱȱȱȱȱȱȱȱȱ606

[1]ȱAgeȬadjustedȱtoȱU.S.ȱWhiteȱpopulation,ȱ2000 Source:ȱHelmickȱCG,ȱFelsonȱDT,ȱLawrenceȱRC,ȱet.ȱal .ȱNationalȱ ArthritisȱDataȱWorkgroup:ȱEstimatesȱofȱtheȱprevalenceȱof arthritisȱandȱotherȱrheumaticȱconditionsȱinȱtheȱUnitedȱStates:ȱȱ PartȱI.ȱArthritisȱ&ȱRheumatism ;ȱ2008;58(1):15Ȭ25.

Tableȱ4.7ȱInpatientȱArthroplastyȱProceduresȱbyȱTypeȱbyȱGender,ȱUnitedȱStates,ȱ2006

Male Female AllȱPersons

%ȱofȱTotalȱ %ȱofȱTotalȱ %ȱofȱTotalȱJonitȱ %ȱofȱTotalȱ Numberȱofȱ Proceduresȱbyȱ Numberȱofȱ Proceduresȱbyȱ Numberȱofȱ Replacementȱ Proceduresȱ Procedures Gender Procedures Gender Procedures Proceduresȱ[8] Performed AllȱHipȱReplacementȱProceduresȱ[1] ȱȱȱȱȱȱȱȱȱȱ151,658ȱ 37.6% ȱȱȱȱȱȱȱ251,890ȱ 62.4% 403,548 40.6% 1.0% TotalȱHipȱReplacementȱ(81.51) ȱȱȱȱȱȱȱȱȱȱ101,598ȱ 44.1% ȱȱȱȱȱȱȱ128,546ȱ 55.9% 230,144 23.1% 0.6% PartialȱHipȱReplacementȱ(81.52)ȱ[7] ȱȱȱȱȱȱȱȱȱȱȱȱ34,436ȱ 24.9% ȱȱȱȱȱȱȱ104,111ȱ 75.1% 138,547 13.9% 0.4% RevisionȱHipȱReplacementȱ(81.53) ȱȱȱȱȱȱȱȱȱȱȱȱ62,763ȱ 436.0% ȱȱȱȱȱȱȱȱȱ81,236ȱ 56.4% 143,999 14.5% 0.4%

AllȱKneeȱReplacementȱProceduresȱ[2]ȱ ȱȱȱȱȱȱȱȱȱȱ200,542ȱ 36.4% ȱȱȱȱȱȱȱ350,803ȱ 63.6% 551,345 55.4% 1.4% TotalȱKneeȱReplacementȱ(81.54) ȱȱȱȱȱȱȱȱȱȱ185,998ȱ 36.0% ȱȱȱȱȱȱȱ330,437ȱ 64.0% 516,435 51.9% 1.3% RevisionȱKneeȱReplacementȱ(81.55) ȱȱȱȱȱȱȱȱȱȱȱȱ14,544ȱ 41.2% ȱȱȱȱȱȱȱȱȱ20,758ȱ 58.8% 35,302 3.5% 0.1%

AllȱShoulderȱReplacementȱProceduresȱ[3] ȱȱȱȱȱȱȱȱȱȱȱȱ11,047ȱ 36.4% ȱȱȱȱȱȱȱȱȱ19,331ȱ 63.6% 30,378 3.1% 0.1% AllȱOtherȱJointȱReplacementȱProceduresȱ[4] ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,597ȱ 51.5% ȱȱȱȱȱȱȱȱȱȱȱ5,261ȱ 48.5% 10,858 1.1% <0.1%

AllȱJointȱReplacementȱProceduresȱ[5,ȱ6] ȱȱȱȱȱȱȱȱȱȱ368,209ȱ 37.0% ȱȱȱȱȱȱȱ626,882ȱ 63.0% 995,091 100% 2.6%

[1]ȱIncludesȱICDȬ9ȬCMȱprocedureȱcodesȱforȱtotal,ȱpartial,ȱrevision,ȱandȱhipȱrepairȱprocedures [2]ȱIncludesȱICDȬ9ȬCMȱprocedureȱcodesȱforȱtotal,ȱrevision,ȱandȱkneeȱrepairȱprocedures [3]ȱIncludesȱICDȬ9ȬCMȱprocedureȱcodesȱforȱprimaryȱandȱrevisionȱshoulderȱarthroplasty [4]ȱIncludesȱICDȬ9ȬCMȱprocedureȱcodesȱfinger,ȱwrist,ȱhand,ȱelbow,ȱtoe,ȱfoot,ȱankle,ȱandȱlowerȱextremity [5]ȱIncludesȱICDȬ9ȬCMȱprocedureȱcodesȱforȱallȱaboveȱprocedures.ȱ [6]ȱTotalȱproceduresȱmayȱincludeȱcasesȱwithȱmultipleȱprocedures. [7]ȱAnȱunknownȱerrorȱinȱtheȱpartialȱhipȱreplacementȱdataȱoccurredȱinȱtheȱNHDSȱ2006ȱdataȱfile.ȱAȱcorrectionȱforȱtotalȱpartialȱhipȱcasesȱwasȱmadeȱbyȱ excludingȱcasesȱwithȱdiagnosisȱofȱspineȱ(720.xxȬ724.xx,ȱ737.xx,ȱ756.xx,ȱ805.xx,ȱ806.xx)ȱ [8]ȱMultipleȱproceduresȱperȱpatientȱmayȱhaveȱoccurred.

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ2006

Tableȱ4.8:ȱPrincipalȱDiagnosesȱAssociatedȱwithȱHipȱandȱKneeȱJointȱ Replacement,ȱUnitedȱStatesȱ2006

ProportionȱofȱTotalȱReplacementȱProcedures

TotalȱHipȱ PartialȱHipȱ PrimaryȱKneeȱ Replacement Replacement Replacement ȱ[1] [2,ȱ4] ȱ[3] Osteoarthritis,ȱPrimaryȱandȱSecondary 85.5% 0.5% 96.9% RheumatoidȱArthritisȱ 0.3% 0.9% OtherȱorȱUnspecifiedȱArthropathy 2.0% 1.1%

FractureȱofȱNeckȱofȱFemur,ȱFemurȱorȱLowerȱLeg,ȱ 3.2% 75.7% ȱȱȱȱIncludingȱPathologicalȱFracture

OtherȱDiseasesȱofȱBoneȱandȱCartilage 7.0% 4.4% Congenitalȱorȱacquiredȱdeformities 0.6% 9.9% Complicationsȱofȱspecificȱprocedures 0.3% 4.8% AllȱOther 1.1% 4.7% 1.1%

TotalȱProcedures ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 230,144 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 138,547 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 516,435

[1]ȱICDȬ9ȬCMȱprocedureȱcodeȱ8151.ȱȱȱȱȱ[2]ȱICDȬ9ȬCMȱprocedureȱcodeȱ8152.ȱȱȱȱȱ[3]ȱICDȬ9ȬCMȱprocedureȱcodeȱ8154. [4]ȱAnȱunknownȱerrorȱinȱtheȱpartialȱhipȱreplacementȱdataȱoccurredȱinȱtheȱNHDSȱ2006ȱdataȱfile.ȱAȱcorrectionȱforȱ totalȱpartialȱhipȱcasesȱwasȱmadeȱbyȱexcludingȱcasesȱwithȱdiagnosisȱofȱspineȱ(720.xxȬ724.xx,ȱ737.xx,ȱ756.xx,ȱ805.xx,ȱ 806.xx)ȱ

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ2006

Tableȱ4.9:ȱArthroplastyȱProceduresȱByȱTypeȱbyȱMeanȱAge,ȱ UnitedȱStates,ȱ1992Ȭ2006

MeanȱAgeȱofȱJointȱReplacementȱPatients

TotalȱHipȱ PartialȱHipȱ RevisionȱHipȱ TotalȱKneeȱRevisionȱKneeȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ [1] [2,6] [3] [4] [5]

1992ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 76.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 69.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.7 1994ȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 79.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 63.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 69.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.5 1996ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 78.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 69.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.8 1998ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 79.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 70.3 2000ȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 78.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.7 2002ȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 79.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 69.7 2004ȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 74.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.0 2006ȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 75.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 64.2

15ȬYearȱ Average ȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 78.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.0

[1]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.51. [2]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.52. [3]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.53 [4]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.54. [5]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.55 [6]ȱAnȱunknownȱerrorȱinȱtheȱpartialȱhipȱreplacementȱdataȱoccurredȱinȱtheȱNHDSȱ2004ȱ dataȱfile.ȱAȱcorrectionȱforȱtotalȱpartialȱhipȱcasesȱwasȱmadeȱbyȱexcludingȱcasesȱwithȱ diagnosisȱofȱspineȱ(720.xxȬ724.xx,ȱ737.xx,ȱ756.xx,ȱ805.xx,ȱ806.xx).ȱTheȱresultingȱageȱdropȱ mayȱbeȱdueȱtoȱthisȱerror.ȱ

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ1992Ȭ 2006

Tableȱ4.10:ȱAverageȱInpatientȱLengthȱofȱStayȱforȱSelectȱ ArthroplastyȱProcedures,ȱUnitedȱStatesȱ1992Ȭ2006

MeanȱDaysȱofȱHospitalizationȱforȱProcedure Revisionȱofȱ Revisionȱofȱ TotalȱHipȱ PartialȱHipȱ Hipȱ TotalȱKneeȱ Kneeȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ [1] [2,ȱ6] [3] [4] [5]ȱ

1992 8.9 10.6 9.7 8.9 8.4 1994 7.2 9.4 7.9 6.8 6.2 1996 5.3 7.0 6.0 5.1 4.4 1998 4.8 6.7 5.5 4.5 4.7 2000 4.9 7.5 6.2 4.5 4.7 2002 4.5 7.1 5.4 4.2 4.4 2004 4.3 7.3 5.4 3.9 4.7 2006 3.9 6.3 4.2 3.8 4.0

[6]ȱAnȱunknownȱerrorȱinȱtheȱpartialȱhipȱreplacementȱdataȱoccurredȱinȱtheȱNHDSȱ2004ȱ dataȱfile.ȱAȱcorrectionȱforȱtotalȱpartialȱhipȱcasesȱwasȱmadeȱbyȱexcludingȱcasesȱwithȱ diagnosisȱofȱspineȱ(720.xxȬ724.xx,ȱ737.xx,ȱ756.xx,ȱ805.xx,ȱ806.xx)ȱ

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ1992Ȭ 2006

Tableȱ4.11:ȱDischargeȱStatusȱforȱPatientsȱAgedȱ18ȱ&ȱOverȱandȱ65ȱ&ȱOverȱUndergoingȱHipȱorȱKneeȱ JointȱReplacementȱProcedures,ȱComparisonȱofȱTwoȱNationalȱHealthȱCareȱHospitalȱDischargeȱ Surveys,ȱUnitedȱStatesȱ2006/2007 Agedȱ18ȱYearsȱandȱOlder NHDSȱSurveyȱ[1] ProportionȱofȱTotalȱReplacementȱPatients

RoutineȱDischargeȱHome 55.3% 22.3% 50.3% 54.2% 59.6% 53.8% 75.8% Discharged/ȱTransferredȱtoȱShortȬ 28.9% 59.2% 33.6% 31.3% 29.8% 31.8% 14.4% Term/SkilledȱNursing/IntermediateȱCare

Unknown/ȱOtherȱDischargeȱStatus 15.8% 18.5% 16.1% 14.5% 10.6% 14.4% 9.8% TotalȱCases ȱȱȱȱȱȱ 230,103 ȱȱȱȱȱȱ 136,409 ȱȱȱȱȱȱ 143,706 ȱȱȱȱȱȱ 516,382 ȱȱȱȱȱȱȱȱȱȱ 35,302 ȱȱȱ 1,060,142 ȱȱȱȱȱȱȱ31,949,366

NISȱSurveyȱ[2] ProportionȱofȱTotalȱReplacementȱPatients TotalȱHipȱ PartialȱHipȱ RevisionȱHip TotalȱKneeȱ RevisionȱKnee AllȱHipȱandȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Kneeȱ AllȱInpatientȱ [3] [4] [5] [6] [7] Replacements Discharges RoutineȱDischargeȱHome 23.3% 6.5% 23.6% 24.8% 24.8% 23.0% 72.4% Term/SkilledȱNursing/IntermediateȱCare 38.6% 82.7% 38.8% 36.8% 33.8% 40.4% 14.5% HomeȱHealthȱCare 38.0% 8.9% 37.1% 38.3% 41.2% 36.2% 9.9% Unknown/ȱOtherȱDischargeȱStatus 0.1% 1.9% 0.5% 0.1% 0.2% 0.4% 3.2% TotalȱCasesȱȱȱȱȱȱȱȱȱȱ 243,009 ȱȱȱȱȱȱȱȱȱȱȱȱ68,492 ȱȱȱȱȱȱȱȱȱȱ153,838 ȱȱȱȱȱȱȱȱȱȱ539,621 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43,565 ȱȱȱȱȱȱȱȱȱȱ938,433 ȱȱȱȱȱȱȱ30,194,233

Agedȱ65ȱYearsȱandȱOlder NHDSȱSurveyȱ[1] ProportionȱofȱTotalȱReplacementȱPatients TotalȱHipȱ PartialȱHipȱ RevisionȱHip TotalȱKneeȱ RevisionȱKnee AllȱHipȱandȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Kneeȱ AllȱInpatientȱ [3] [4,8] [5] [6] [7] Replacements Discharges RoutineȱDischargeȱHome 43.5% 12.4% 37.6% 45.3% 44.5% 39.0% 59.9% Discharged/ȱTransferredȱtoȱShortȬ 38.6% 67.9% 46.0% 38.9% 46.2% 44.1% 26.9% Term/SkilledȱNursing/IntermediateȱCare Unknown/ȱOtherȱDischargeȱStatus 17.9% 19.7% 16.4% 15.8% 9.3% 16.9% 13.2% TotalȱCases ȱȱȱȱȱȱ 125,841 ȱȱȱȱȱȱ 114,922 ȱȱȱȱȱȱȱȱȱ 87,789 ȱȱȱȱȱȱ 313,527 ȱȱȱȱȱȱȱȱȱȱ 18,554 ȱȱȱȱȱȱ 614,916 ȱȱȱ 13,070,499

NISȱSurveyȱ[2] ProportionȱofȱTotalȱReplacementȱPatients

TotalȱHipȱ PartialȱHipȱ RevisionȱHip TotalȱKneeȱ RevisionȱKnee AllȱHipȱandȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Replacementȱ Kneeȱ AllȱInpatientȱ [3] [4] [5] [6] [7] Replacements Discharges RoutineȱDischargeȱHome 16.1% 4.3% 15.2% 19.9% 18.7% 18.7% 52.9% Discharged/ȱTransferredȱtoȱShortȬ 53.5% 87.0% 56.3% 47.1% 45.2% 53.3% 27.2% Term/SkilledȱNursing/IntermediateȱCare HomeȱHealthȱCare 30.1% 6.7% 27.9% 32.9% 35.8% 29.3% 15.9% Unknown/ȱOtherȱDischargeȱStatus 0.3% 2.0% 0.6% 0.1% 0.3% Ȭ1.3% 4.0% TotalȱCases ȱȱȱȱȱȱ 129,288 ȱȱȱȱȱȱȱȱȱ 59,790 ȱȱȱȱȱȱȱȱȱ 79,109 ȱȱȱȱȱȱ 308,363 ȱȱȱȱȱȱȱȱȱȱ 23,991 ȱȱȱȱȱȱ 542,380 ȱȱȱ 10,705,554

[1]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ2006 [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationwideȱInpatientȱSample,ȱ2007 [3]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.51 [4]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.52 [5]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.53 [6]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.54ȱ [7]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.55 [8]ȱAnȱunknownȱerrorȱinȱtheȱpartialȱhipȱreplacementȱdataȱoccurredȱinȱtheȱNHDSȱ2006ȱdataȱ file.ȱAȱcorrectionȱforȱtotalȱpartialȱhipȱcasesȱwasȱmadeȱbyȱexcludingȱcasesȱwithȱdiagnosisȱofȱ spineȱ(720.xxȬ724.xx,ȱ737.xx,ȱ756.xx,ȱ805.xx,ȱ806.xx)

Tableȱ4.12:ȱJointȱReplacementȱProcedures,ȱAllȱAges,ȱinȱtheȱUnitedȱStates,ȱ1991Ȭ2006/2007

NationalȱHospitalȱDischargeȱSurvey JointȱReplacementȱProceduresȱ(inȱ000s) ICDȬ9ȱ CMȱ Descriptionȱ Codeȱ 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2006

TotalȱHipȱReplacement 81.51 117.0 127.0 125.0 124.0 134.0 138.0 144.0 160.0 168.0 152.0 165.5 193.0 220.1 234.0 230.1

PartialȱHipȱReplacementȱ[1] 81.52 90.0 88.0 84.0 93.0 97.0 103.0 103.0 112.0 106.0 106.0 118.5 108.8 108.0 119.7 138.5

RevisionȱofȱHipȱReplacementȱ[2] 81.53 25.0 23.0 26.0 28.0 29.0 30.0 37.0 33.0 30.0 31.0 36.1 42.7 35.6 46.0 144.0

ȱȱRatioȱHipȱRevisionȱtoȱPrimary 21.4% 18.1% 20.8% 22.6% 21.6% 21.7% 25.7% 20.6% 17.9% 20.4% 21.8% 22.1% 16.2% 19.7% 62.6%

TotalȱKneeȱReplacementȱ 81.54 160.0 167.0 179.0 209.0 216.0 245.0 259.0 266.0 267.0 299.0 325.6 381.3 418.3 478.0 516.4

RevisionȱofȱKneeȱReplacement 81.55 17.0 13.0 15.0 19.0 18.0 20.0 25.0 23.0 25.0 28.0 29.4 35.1 33.1 40.0 35.3

ȱȱRatioȱKneeȱRevisionȱtoȱPrimary 10.6% 7.8% 8.4% 9.1% 8.3% 8.2% 9.7% 8.6% 9.4% 9.4% 9.0% 9.2% 7.9% 8.4% 6.8%

TOTALȱHipȱandȱKneeȱ 409.0 418.0 429.0 473.0 494.0 536.0 568.0 594.0 596.0 616.0 675.1 760.8 815.1 917.7ȱȱȱȱȱ 954.1 Replacement/RevisionȱProcedures

[1]ȱAnȱunknownȱerrorȱinȱtheȱpartialȱhipȱreplacementȱdataȱoccurredȱinȱtheȱNHDSȱ2004ȱandȱ2006ȱdataȱfiles.ȱAȱcorrectionȱforȱtotalȱpartialȱhipȱcasesȱwasȱmadeȱbyȱexcludingȱ casesȱwithȱdiagnosisȱofȱspineȱ(720.xxȬ724.xx,ȱ737.xx,ȱ756.xx,ȱ805.xx,ȱ806.xx)ȱ [2]ȱAȱsignificantȱjumpȱinȱtheȱnumberȱofȱhipȱrevisionȱproceduresȱwasȱfoundȱbetweenȱtheȱ2004ȱandȱtheȱ2006/2007ȱdata.ȱHowever,ȱtheȱincreaseȱwasȱsimilarȱinȱbothȱtheȱNHDSȱ andȱNISȱdataȱsets,ȱindicatingȱtheȱincreaseȱoccurred.

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ1991Ȭ2006

NationwideȱInpatientȱSample JointȱReplacementȱProceduresȱ(inȱ000s) ICDȬ9ȱ CMȱ Descriptionȱ Codeȱ 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2007

TotalȱHipȱReplacement 81.51 135.7 139.9 144.1 148.2 152.6 157.0 161.6 166.7 171.7 176.1 181.5 187.7 194.3 227.5 252.7

PartialȱHipȱReplacementȱ 81.52 96.3 97.9 99.5 100.8 102.2 103.5 104.7 105.8 106.8 107.4 108.7 109.9 111.2 105.1 103.7

RevisionȱofȱHipȱReplacementȱ[2] 81.53 27.5 28.3 29.1 29.9 30.8 31.7 32.5 33.5 34.4 35.2 36.2 37.2 38.3 37.9 164.0

ȱȱRatioȱHipȱRevisionȱtoȱPrimary 20.3% 20.2% 20.2% 20.2% 20.2% 20.2% 20.1% 20.1% 20.0% 20.0% 19.9% 19.8% 19.7% 16.7% 64.9%

TotalȱKneeȱReplacementȱ 81.54 192.2 203.6 215.5 227.9 241.1 255.1 270.0 286.6 304.0 321.8 342.0 365.3 391.1 435.5 551.3

RevisionȱofȱKneeȱReplacement 81.55 16.5 17.5 18.5 19.5 20.7 21.9 23.2 24.6 26.1 27.6 29.3 31.2 33.4 36.2 45.0

ȱȱRatioȱKneeȱRevisionȱtoȱPrimary 8.6% 8.6% 8.6% 8.6% 8.6% 8.6% 8.6% 8.6% 8.6% 8.6% 8.6% 8.5% 8.5% 8.3% 8.2%

TOTALȱHipȱandȱKneeȱ 468.2 487.2 506.7 526.3 547.4 569.2 592.0 617.2 643.0 668.1 697.7 731.3 768.3 842.2 999.5 Replacement/RevisionȱProcedures

[2]ȱAȱsignificantȱjumpȱinȱtheȱnumberȱofȱhipȱrevisionȱproceduresȱwasȱfoundȱbetweenȱtheȱ2004ȱandȱtheȱ2006/2007ȱdata.ȱHowever,ȱtheȱincreaseȱwasȱsimilarȱinȱbothȱtheȱNHDSȱ andȱNISȱdataȱsets,ȱindicatingȱtheȱincreaseȱoccurred.

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ1991Ȭ2007

Tableȱ4.13:ȱMeanȱandȱTotalȱHospitalizationȱChargesȱ[1]ȱforȱHipȱandȱKneeȱJointȱReplacementȱ Procedures,ȱUnitedȱStates,ȱ1998Ȭ2007

Averageȱ(Mean)ȱChargesȱPerȱHospitalizationȱ(roundedȱtoȱnearestȱ000) (roundedȱtoȱnearestȱ000 (inȱ00s) 1998 1999 2000 2001 2002 2003 2004 2007 TotalȱHipȱReplacementȱ[2] $22,000 $23,000 $26,000 $27,000 $31,000 $35,000 $37,000 $45,500 PartialȱHipȱReplacementȱ[3] $22,000 $23,000 $26,000 $28,000 $32,000 $35,000 $39,000 $49,300 RevisionȱHipȱReplacementȱ[4] $27,000 $31,000 $32,000 $34,000 $39,000 $45,000 $46,000 $50,200 TotalȱKneeȱReplacementȱ[5] $21,000 $22,000 $24,000 $26,000 $29,000 $31,000 $33,000 $41,500 RevisionȱKneeȱReplacementȱ[6] $24,000 $25,000 $30,000 $30,000 $35,000 $42,000 $42,000 $55,100

TotalȱȱHospitalizationȱChargesȱforȱJointȱReplacementsȱ(inȱbillions) 1998 1999 2000 2001 2002 2003 2004 2007 TotalȱHipȱReplacementȱ[2] $3.37 $3.64 $4.00 $5.07 $5.91 $6.77 $8.34 $11.50 PartialȱHipȱReplacementȱ[3] $2.27 $2.39 $2.63 $2.98 $3.35 $3.58 $3.97 $5.11 RevisionȱHipȱReplacementȱ[4] $0.83 $0.99 $1.04 $1.32 $1.47 $1.66 $1.69 $8.23 TotalȱKneeȱReplacementȱ[5] $5.36 $5.67 $6.22 $8.06 $9.82 $11.38 $14.26 $22.88 RevisionȱKneeȱReplacementȱ[6] $0.54 $0.63 $0.70 $0.85 $1.01 $1.47 $1.48 $2.48 TotalȱHipȱandȱKneeȱReplacementȱCost $12.37 $13.32 $14.59 $18.29 $21.57 $24.86 $29.74 $50.20

[1]ȱGenerally,ȱtotalȱchargesȱdoȱnotȱincludeȱprofessionalȱfeesȱandȱnonȬcoveredȱcharges.ȱInȱtheȱrareȱcasesȱwhereȱprofessionalȱfeesȱcannotȱbeȱremoved,ȱtheyȱ areȱincludedȱinȱtheȱdatabase.ȱEmergencyȱdepartmentȱchargesȱincurredȱpriorȱtoȱadmissionȱtoȱtheȱhospitalȱmayȱbeȱincludedȱinȱtotalȱcharges.

[2]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.51ȱȱȱȱȱ[3]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.52ȱȱȱȱȱ[4]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.53ȱȱȱȱȱȱȱȱȱ [5]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.54ȱȱȱȱȱ[6]ȱICDȬ9ȬCMȱprocedureȱcodeȱ81.55ȱȱȱȱȱ

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ1998Ȭ2004

Tableȱ4.14:ȱProjectedȱNumberȱofȱHipȱandȱKneeȱArthroplasties,ȱUnitedȱStatesȱ2005Ȭ2030

AnnualȱNumberȱofȱProceduresȱ(inȱ000s) 2005 2010 2020 2030 Variableȱ Constantȱ Variableȱ Constantȱ Variableȱ Constantȱ Variableȱ Constantȱ Rateȱ[1] Rateȱ[2] Rateȱ[1] Rateȱ[2] Rateȱ[1] Rateȱ[2] Rateȱ[1] Rateȱ[2] PrimaryȱTotalȱHipȱArthroplastyȱȱȱȱȱȱȱȱȱȱȱȱȱ 209 ȱȱȱȱȱȱȱȱȱȱȱȱȱ179 ȱȱȱȱȱȱȱȱȱȱȱȱȱ253 ȱȱȱȱȱȱȱȱȱȱȱȱȱ194 ȱȱȱȱȱȱȱȱȱȱȱȱȱ384 ȱȱȱȱȱȱȱȱȱȱȱȱȱ236 ȱȱȱȱȱȱȱȱȱȱȱȱȱ572 ȱȱȱȱȱȱȱȱȱȱȱȱȱ277 PrimaryȱTotalȱKneeȱArthroplastyȱȱȱȱȱȱȱȱȱȱȱȱȱ 450 ȱȱȱȱȱȱȱȱȱȱȱȱȱ301 ȱȱȱȱȱȱȱȱȱȱȱȱȱ663 ȱȱȱȱȱȱȱȱȱȱȱȱȱ329 ȱȱȱȱȱȱȱȱȱȱ1,520 ȱȱȱȱȱȱȱȱȱȱȱȱȱ415 ȱȱȱȱȱȱȱȱȱȱ3,481 ȱȱȱȱȱȱȱȱȱȱȱȱȱ488

RevisionȱTotalȱHipȱArthroplastyȱȱȱȱȱȱȱȱȱȱȱȱ 40.8 ȱȱȱȱȱȱȱȱȱȱȱȱ36.0 ȱȱȱȱȱȱȱȱȱȱȱȱ47.8 ȱȱȱȱȱȱȱȱȱȱȱȱ38.9 ȱȱȱȱȱȱȱȱȱȱȱȱ67.6 ȱȱȱȱȱȱȱȱȱȱȱȱ47.2 ȱȱȱȱȱȱȱȱȱȱȱȱ96.7 ȱȱȱȱȱȱȱȱȱȱȱȱ56.6 RevisionȱTotalȱKneeȱArthroplastyȱȱȱȱȱȱȱȱȱȱȱȱ 38.3 ȱȱȱȱȱȱȱȱȱȱȱȱ25.9 ȱȱȱȱȱȱȱȱȱȱȱȱ55.3 ȱȱȱȱȱȱȱȱȱȱȱȱ28.1 ȱȱȱȱȱȱȱȱȱȱ121.0 ȱȱȱȱȱȱȱȱȱȱȱȱ35.1 ȱȱȱȱȱȱȱȱȱȱ268.0 ȱȱȱȱȱȱȱȱȱȱȱȱ41.7

[1]ȱProjectionȱbasedȱonȱarthroplastyȱrateȱincreaseȱdueȱtoȱagingȱofȱpopulationȱandȱchangesȱinȱtheȱrateȱofȱjointȱreplacementȱsurgery. [2]ȱProjectionȱbasedȱonȱtheȱhistoricalȱrateȱofȱproceduresȱfoundȱinȱtheȱNationwideȱInpatientȱSample,ȱ1990ȱtoȱ2003.

Source:ȱKurtzȱS,ȱLauȱE,ȱMowatȱF,ȱetȱal:ȱTheȱfutureȱburdenȱofȱhipȱandȱkneeȱrevisions:ȱU.S.ȱprojectionsȱfromȱ2005ȱtoȱ2030.ȱPaperȱpresentedȱat:ȱ73rdȱ AnnualȱMeetingȱofȱtheȱAmericanȱAcademyȱofȱOrthopaedicȱSurgeons:Chicago,ȱIL;2006.ȱUsedȱwithȱpermissionȱofȱtheȱprimaryȱauthor.

Chapter 5 Osteoporosis and Bone Health

Osteoporosis has been called the “silent disease” Although oft en considered a disease primarily because it typically progresses without symptoms of females, within the past decade it has become until a fracture occurs.1 Osteoporosis is age-related apparent that osteoporosis is not solely a women’s and characterized by low bone mass due to the disease. It aff ects an estimated 2 million men loss of bone in the aging process. Bones are easier in the United States, particularly older men. In to break even from falls at low heights, such as men, as in women, the low bone mineral density standing, or during the course of simple daily characteristic of osteoporosis is associated with activities. In 2002, the National Osteoporosis an increased risk of bone fracture. Fracture most Foundation estimated 44 million persons over commonly aff ects the hip and lumbar vertebrae, the age of 50 in the United States were at risk but the radius, tibia, and ribs also may be aff ected. for fracture due to osteoporosis or low bone Rates of fracture-related morbidity and mortality mass. By 2020, if current trends continue and are signifi cant in all older persons, but are eff ective treatments are not found and widely substantially higher in men than in women. implemented, it is estimated that over 61 million persons will be at risk.1 The presentation and cause of osteoporosis diff er between men and women in several important The economic burden of inpatient, outpatient and ways. For example, the condition manifests later long-term care of incident osteoporotic fractures in life in men, probably because men initially have in the U.S. was estimated at nearly $17 billion in a greater bone mass. Moreover, unlike among 2005; cumulative cost over the next 2 decades are women, for nearly half of men with osteoporosis estimated to be $474 billion.2 In addition to dollar an underlying cause can be identifi ed. Among the cost, osteoporosis-related fractures bring a burden causes of osteoporosis in men are corticosteroid of pain and disability, resulting in time lost from therapy for arthritis or asthma, hypogonadism in work or the inability to perform activities of daily patients being treated for cancer of the prostate living. with androgen-withdrawal therapy, consumption of large amounts of alcohol, hyperthyroidism, and Section 5.1: Osteoporosis and Low vitamin D defi ciency. Bone Mass Currently, the diagnosis of osteoporosis is defi ned by the World Health Organization (WHO), and Osteoporosis is a disease characterized by low is based on the results of dual energy x-ray bone mass and deterioration of bone structure absorptiometry (DXA) testing, which evaluates that causes bone fragility and increases the risk the bone mineral density (BMD) present at several of fracture. Gradual loss of bone with aging is sites. WHO defi nes osteoporosis as a BMD value normal; however, that loss may be accelerated more than 2.5 standard deviations (SD) below by factors such as menopause, serious health the average value for a young, healthy woman conditions or their treatment, and lifestyle factors (a T-score of <-2.5 SD).3 Osteopenia, or low bone such as inadequate diet, lack of exercise, smoking, mass, is defi ned as -1.0 to -2.5 SD, or 10% to 30%, or excessive alcohol consumption. below the normal bone mass.4

Section 5.1.1: Osteoporosis Disease Classifi cations Clinical trials have shown that suppression of Defi ned bone turnover markers, an indication of a slowing of bone loss, can be achieved in as litt le as three For purposes of this chapter, osteoporosis-related months of using prescription therapies, reducing conditions will be presented using three broad the risk for low energy fractures.6 However, it is categories, based on ICD-9-CM diagnosis codes. also known that many patients diagnosed with (Table 5.1) Primary osteoporosis includes only osteoporosis do not follow the treatment regime, persons who have a diagnosis of osteoporosis. It oft en due to medication side eff ects, and that not is found primarily among elderly persons, with all patients respond to current therapies. Perhaps postmenopausal women aff ected at the highest most important, current data demonstrate that rates. The reasons why some persons develop the majority of patients who suff er a low energy osteoporosis while others do not is unclear; fracture and are subsequently among those at however, estrogen defi ciency has been identifi ed highest risk for repeat fracture typically are not by the U.S. Department of Health and Human evaluated for osteoporosis, much less treated. Services, Offi ce of the Surgeon General, as a primary cause in both men and women.4 Section 5.1.2: Prevalence of Osteoporosis

Low energy fractures, formerly referred to as Estimates of the prevalence of osteoporosis and fragility fractures, occur from an event such as a low bone mass are based on the best available fall from a standing height or less (versus a high scientifi c information from leading researchers. energy cause such as a vehicular accident). In There are no defi nitive sources of information general, the lower the BMD, the higher risk of a on the numbers of persons with osteoporosis or low energy fracture. However, the reasons why at risk for low energy fractures, as this is truly some women and men with low BMD do not a “silent disorder.” Estimates of prevalence experience low energy fractures in circumstances among white females are generally believed to similar to those who do are not well understood. be more reliable because this group has been studied the most due to their high fracture rate. Secondary osteoporosis occurs when another The incidence or prevalence among males and condition or treatment causes erosion of bone racial groups is even more diffi cult to estimate health. Causes of secondary osteoporosis include as there are no defi nitions of what constitutes certain diseases, such as hyperthyroidism or osteoporosis and low bone mass in these groups celiac disease, and certain medications, especially as there are with white women. However, the glucocorticoids. In addition, some lifestyle habits, incidence of osteoporosis and low bone mass such as low activity levels, diets with low calcium among these groups is believed to be higher than intake, and smoking are believed to contribute previously estimated. The leading national study to the development of osteoporosis. In 2006, 5.4 that provides data upon which to make these million persons aged 45 and over in the United estimates is the National Health and Nutrition States were treated for a condition that can Examination Study (NHANES), a self-reported contribute to the development of osteoporosis. This study that includes questions related to diagnosis number does not take into account persons with a and treatment of osteoporosis, fractures, and cause previous condition diagnosis who were not treated of fracture. Data from the NHANES surveys for in 2006. the years 2001-2002, 2003-2004, and 2005-2006 were merged and analyzed for this report to provide In recent years, knowledge about osteoporosis estimated prevalence. risk factors, diagnostic criteria, and treatment options has advanced rapidly.1,5 Research into treatments and preventive measures is fl ourishing.

The National Osteoporosis Foundation (NOF) Graph 5.1.2: Self-Reported Rate of Hip Fracture [1] for Persons estimated there were 29.5 million women and Aged 65 and Over in the United States, 1988-1994 and 2001-2006 11.7 million men in the United States with 12 12 12 osteoporosis or low bone mass in 2002. Asian 1988-1994 [2] and non-Hispanic white women are aﬀ ected 10 about equally, and at higher proportions than 2001- 2006 [3] Hispanic and non-Hispanic black women. The 8 7 7 prevalence of osteoporosis and low bone mass 6 6 among males was substantially lower, but 5 4 1 4 followed the same general racial patt erns. 4 3 3 Rate per 100 Persons 3 3 2 2 2 Based on data in the NHANES self-reported 2 2 study, the prevalence of osteoporosis in 0 both females and males aged 65 and over in 65 to 75 to 85 & All 65 to 75 to 85 & All 74 84 Over 65 & 74 84 Over 65 & 2001-2006 was 260% that reported in 1988-1994. Over Over (Table 5.2 and Graph 5.1.1) The rapid increase Females Males in the prevalence of osteoporosis diagnosis [1] Has a doctor ever told you that you had broken or fractured your hip? [2] Source: Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United is likely due to the extensive educational and States, ed 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999. awareness eﬀ orts aimed at both the general [3] Source: National Center for Health Statistics. National Health and Nutrition Examination Survey Data, 2001-2006. public and health care professionals, as well as 4 increased testing of bone mass in older women. of Medicare databases. Although reasons for During that same time frame, females of this age this shift are unknown, greater awareness of group reported a slight decline in the rate of hip osteoporosis and fracture potential, increased fractures, while males aged 65 and over reported testing, and the impact of recent treatments in an increased rate of hip fracture. (Graph 5.1.2) A females may be contributing factors. Awareness of similar decline in hip fracture rates was found by osteoporosis among men is less prevalent. They are a team of Dartmouth researchers in examination less likely to be evaluated early for osteoporosis, even in the face of serious, contributing medical Graph 5.1.1: Self-Reported Rate of Osteoporosis [1] for Persons conditions. Aged 65 and Over in the United States, 1988-1994 and 2001-2006 35 33 On average, for each year between 2001 and 30 30 28 2006, 22.3 million people over the age of 45 1988-1994 [2] 25 reported they were told by their doctor they had 25 2001-2006 [3] osteoporosis or had sustained a fracture of the 20 hip, spine, or wrist, the most common locations

15 of fractures associated with osteoporosis. (Table 12 11 11 10 5.3 and Graph 5.1.3) These self-reports were Rate per 100 Persons 10 7 primarily among women in all age groups; 5 4 5 3 the sole exception was persons aged 45 to 64, 112 1 among whom the self-reports were nearly evenly 0 65 to 75 to 85 & All 65 to 75 to 85 & All divided between the females and males (51% 74 84 Over 65 & 74 84 Over 65 & Over Over to 49%, respectively.) Among those 85 years of Females Males age or older, 83% self-reporting a diagnosis of [1] Has a doctor ever told you that you had osteoporosis, sometimes called thin or osteoporosis or fracture were female, most likely Ĵȱǵ [2] Source: Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United reﬂ ecting the longevity of females and their States, ed 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999. [3] Source: National Center for Health Statistics. National Health and Nutrition preponderance in this age group. Examination Survey Data, 2001-2006.

data suggest that if patients recognize Graph 5.1.3: Self-Reported Prevalence of Osteoporosis or Fracture of Hip, Spine or Wrist for Persons Aged 45 and Over, United States, 2001-2006 they have osteoporosis, the likelihood they will receive treatment rises, 14,000 50 45 an indication that education about

12,000 % Total Population by Age 40 screening or testing for osteoporosis is 10,000 35 an important factor in ensuring bett er 30 8,000 long term outcomes. 25 6,000 20 Section 5.2: Health Care Prevalence (in 000s) Prevalence 4,000 15 10 Resource Utilization for 2,000 5 Osteoporosis and Low Energy 0 0 Fractures 45 to 65 to 75 to 85 & 64 74 84 Over Females Females Section 5.2.1: Patient Visits, 2006 Males Males

Total Population Total Population In 2006, 5.4 million persons aged 45

Prevalence Rate and over with a diagnosis of primary

Source: National Center for Health Statistics. National Health and Nutrition Examination Survey Data, osteoporosis utilized health care 2001-2006 resources;, while 7.1 million persons of this age with low energy fractures The higher proportions of women in older age also utilized health care resources. (Table 5.4) groups reporting a diagnosis of osteoporosis and/ An additional 5.4 million persons aged 45 and or low energy fractures may also be due to the fact over were diagnosed with a condition that can that, as the population ages, the incidence of both contribute to the development of osteoporosis, and of these conditions rises steadily among women, were therefore at risk for secondary osteoporosis. while that of males remains relatively steady. Nearly 56,000 persons sustained a vertebral Between the ages of 45 and 64, approximately 18% fracture with spinal cord injury as a result of a low of both females and males report they have been

told by a doctor they have osteoporosis or have Graph 5.1.4: Self-Reported Treatment for Osteoporosis [1] by had a fracture of the hip, spine, or wrist. By the age Gender for Persons Aged 45 and Over, United States, of 85 or older, 47% of females report osteoporosis 2001-2006 100% and/or a fracture, while only 20% of males in this age group do so. 80%

Thirty-six percent (36%) of females, compared to 60% 48% of males, reporting an osteoporosis condition

were under the age of 65 years. (Table 5.3) The 40% reason for this variation is not known.

% of Total with Osteoporosis % of Total 20% Rates of treatment for osteoporosis reported between 2001 and 2006 were slightly higher 0% 45 to 65 to 75 to 85 & All Ages for females than for males under the age of 75; 64 74 84 Over 45 & Over however, the diﬀ erences narrowed in individuals Females (8.6 M) Males (1.4 M) between the ages of 65 and 84. Treatment rates for [1] Replied "yes" when asked if ever been told by a doctor that you had females aged 85 and over are nearly twice that for osteoporosis and had been treated for osteoporosis. similar aged males. (Table 5.3 and Graph 5.1.4) The Source: National Center for Health Statistics. National Health and Nutrition Examination Survey Data, 2001-2006

Graph 5.2.1: Health Care Visits for Osteoporosis [1] and Low Eighty-nine percent (89%) of individuals aged 45 Energy Fractures [2] for Persons Aged 45 and Over by Site, and over diagnosed with primary osteoporosis in United States, 2006/2007 5000 an inpatient sett ing in 2006 were females. (Table 5.5) Among individuals age 45 and over, low 4000 energy fractures occurred in females at a fairly 3000 constant 2:1 ratio to males. This is a change from 2000 two years earlier, when the ratio was closer to 3:1, Visits (in 0000s) Visits 1000 females to males. (Tables 5.5 and 5.6 and Graph

0 * * 5.2.2) Inpatient [4] Physician Emergency Outpatient ĜȱǽśǾ room [6] department [7]

* Estimate does not meet standards for reliability. Primary Graph 5.2.2: Low Energy Fracture [1] Treatment for Persons [1] Osteoporosis and related condition ICD-9-CM osteopoeosis Aged 45 and Over by Sex and Site, United States, 2006/2007 codes shown in the Table 5.1. [1] [2] Treatment for fractures, excluding those with high 100% Low energy causes (i.e., vehicular [auto, air, water] energy accidents, war injuries, violence/abuse). fracture 80% [3] Diagnosis of another medical condition that may [2] lead to or contribute to the development of osteoporo- 60% sis. Secondary [4] Source: Agency for Healthcare Research and osteoporosis Quality, Healthcare Cost and Utilization Project, [3] 40% Nationwide Inpatient Sample, 2007 [5] Source: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 20% % of Total Persons Treated Persons % of Total [6] Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, Hospital Emergency, 2006 0% [7] Source: National Center for Health Statistics, National Hospital Ambulatory Hip Wrist Pelvic All Hip Wrist Pelvic All Medical Care Survey, Outpatient Centers, 2006 Low Low Energy Energy energy fall, unlike in 2004 when the 1.4 million Fractures Fractures Inpatient Treatments [2] Emergency Room Treatments [3] spinal cord injuries were all the result of a high [1] Treatment for fractures, excluding those with Females energy impact (i.e., motor vehicle accident). (Table high energy causes (i.e., vehicular [auto, air, water] accidents, war injuries, violence/abuse). Males 5.4) [2] Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 [3] Source: National Center for Health Statistics, National Hospital Health care utilization by persons aged 45 and Ambulatory Medical Care Survey, Hospital Emergency Room, 2006 over with a diagnosis of primary osteoporosis and low energy fractures involves primarily physician offi ce visits. In 2006, 81% of patients aged 45 and Compared to data analyzed two years earlier, the over with primary osteoporosis were diagnosed in proportion of low energy fractures occurring in a physician’s offi ce, while 68% of patients over the males increased substantially, comprising about age of 45 with a low energy fracture were treated one-third of all fractures treated in inpatient in a physician’s offi ce. (Table 5.4 and Graph 5.2.1) sett ings and close to one-half of emergency room treatments. A slight increase in the proportion of Persons aged 45 and over hospitalized with males diagnosed with osteoporosis in an inpatient a diagnosis of primary osteoporosis or a low sett ing was also found. (Tables 5.5 and 5.6) energy fracture accounted for 4% of all inpatient admissions in 2006, representing 1.5 million Section 5.2.2: Age at Time of Osteoporosis incidents. In addition, 1.2 million low energy Diagnosis or Low Energy Fracture Incident, 2004 fractures of persons aged 45 and over were treated in emergency rooms, 17% of all low energy Although osteoporosis may occur in younger fractures utilizing health care resources in 2006. patients, it is primarily a condition of older adults. (Table 5.4) Among patients 45 years of age or older, the mean age at time of diagnosis of osteoporosis in a physician’s offi ce in 2006 was 70.8 years, more than six years older than the average patient. One-third

Graph 5.2.3: Age Distribution for of these diagnoses between the ages of 45 and 64 (48%). Among Osteoporosis Diagnosis in Physician's (30%) were for females aged 45 to 64, 24% of all low energy ȱȱĜȱȱȱȱŚśȱȱǰ ȱȱȱǰȱŘŖŖŜ females between fractures treated in an inpatient sett ing were this the ages of 45 and age, while 35% seen in an emergency department 64, an increase of were females of this age. (Graph 5.2.4) 4% over two years earlier, indicating With the exception of hip fractures, males aged that diagnosis of 45 and over are more likely to have a low energy osteoporosis may fracture at a younger age than are women. This

% of Patients by Age Group by % of Patients be being made could be due to exposure to more physical activity at younger ages. or sett ings in which low energy impacts more (Graph 5.2.3) Due frequently occur. Overall, 39% of low energy to the very small fractures treated in an inpatient sett ing and 53% number of males treated in emergency departments were males Source: National Center for Health Statistics, diagnosed with aged 45 to 64 in 2006. (Graph 5.2.4) National Ambulatory Medical Care Survey, 2006 osteoporosis, this age is primarily Graph 5.2.4: Low Energy Fracture [1] Treatment for Persons Aged 45 and Over by Age, Gender, and Site, United States, representative of females. 2006/2007 Females The mean age of females aged 45 or over receiving 100%

a diagnosis of primary osteoporosis in an inpatient 80% sett ing was 73.4 years, with 55% of the diagnosed patients aged 75 or over. The age of patients with 60%

an osteoporosis diagnosis dropped from 2004 by 40% more than four years; the proportion of patients 20% aged 75 and older dropped by 11%. The proportion Treated Persons % of Total of women aged 18 to 44 with an osteoporosis 0% Hip Wrist Pelvic All Hip Wrist Pelvic All diagnosis rose from 13% in 2004 to 18% in 2006, Low Low Energy Energy while the proportion between the ages of 65 and Fractures Fractures 74 changed from 21% to 27%. This shift may be Inpatient Treatments [2] Emergency Room Treatments [3] a preliminary indication that the age at which Males osteoporosis is recognized in females is lowering. 100%

80% Males aged 45 or over received a diagnosis of 60% primary osteoporosis at a slightly younger mean age of 71.7 years. A higher proportion of males 40% (24%) than females (18%) between the ages of 45 20% and 64 had a diagnosis of osteoporosis. (Table 5.5) Treated Persons % of Total 0% Hip Wrist Pelvic All Hip Wrist Pelvic All Low energy fractures also occur more frequently Low Low Energy Energy in the elderly, particularly among females. Fractures Fractures Among female patients 45 years of age and older Inpatient Treatments [2] Emergency Room Treatments [3] and treated for a hip fracture, 67% treated in an [1] Treatment for fractures, excluding those with 45 to 64 high energy causes (i.e., vehicular [auto, air, water] inpatient sett ing and 85% treated in an emergency accidents, war injuries, violence/abuse). 64 to 74 [2] Source: Agency for Healthcare Research and department were aged 75 years or older. However, Quality, Healthcare Cost and Utilization Project, 75 & Over Nationwide Inpatient Sample, 2007 wrist fractures treated in emergency departments [3] Source: National Center for Health Statistics, National Hospital were more commonly seen in younger women Ambulatory Medical Care Survey, Hospital Emergency Room, 2006

Graph 5.2.5: Proportion of Low Energy Fracture ǽ1Ǿ Section 5.2.3: Short/Long-Term Care for Low Patients Aged 45 and Over with a Diagnosis of Energy Fracture Patients Osteoporosis by Health Care Resource and Gender, United States 2006/2007

eales ǽ2Ǿ 2Ŝǯş% Regardless of the age at which a low energy ales ǽ2Ǿ 8.0% fracture occurs, both females and males are more likely to be transferred to a short, intermediate, atet ǽ2Ǿ 20.8% or long-term skilled nursing care sett ing upon erec¢ Roo ǽ3Ǿ 1.0% their release from inpatient care than are persons utatet ǽŚǾ 2.5% without a fracture. The older the patient, the h¢scaȇs Ĝce ǽ5Ǿ 1.Ś% greater the likelihood that such a transfer will be Total Health 3.3% Care Resources0% 5% 10% 15% 20% 25% 30% necessary. Among non-fracture female patients % o atets aged 45 and over, approximately 23% were ǽ1Ǿ Treatet or racturesǰ e¡clu those th hh eer¢ causes ǻǯeǯǰ ehcular ǽautoǰ arǰ aterǾ accetsǰ ar uresǰ released to additional care sett ings in 2006, oleceȦauseǼǯ while 36% of non-fracture patients aged 75 and ǽ2Ǿ ourceǱ ec¢ or Healthcare Research a ualt¢ǰ Healthcare Cost a tl£ato roectǰ ato e atet over were released to another care sett ing. By aleǰ 200ŝ ǽ3Ǿ ourceǱ atoal Ceter or Health tatstcsǰ atoal contrast, among all female hip fracture patients, Hostal ulator¢ ecal Care ure¢ǰ Hostal erec¢ǰ 200Ŝ the proportions are 83% for all patients and 86% ǽŚǾ ourceǱ atoal Ceter or Health tatstcsǰ atoal Hostal ulator¢ ecal Care ure¢ǰ utatet those aged 75 and over. Even female patients with Cetersǰ 200Ŝ a wrist fracture are more likely to be released to ǽ5Ǿ ourceǱ atoal Ceter or Health tatstcsǰ atoal ulator¢ ecal Care ure¢ǰ 200Ŝ additional care, with 45% of all patients aged 45 and over with this type of fracture going to another In 2006, the proportion of low energy fractures in care sett ing, and 60% of those aged 75 and over persons aged 45 and over who also are diagnosed doing so. The rates for males with a low energy with osteoporosis as a potential contributing cause was very low. Among all patients aged Graph 5.2.6: Hospital Discharge to Short/Intermediate/Skilled Nursing Care for 45 and older with a low energy fracture Persons Aged 45 and Over by Age and Sex for Persons with Osteoporosis, Low seen in a physician’s oﬃ ce, an emergency Energy Fractures [1], and without a Fracture, United States, 2007 room, or an outpatient sett ing in 2004, 100% fewer than 2% were also diagnosed

with osteoporosis. Even in an inpatient 80% sett ing, only 20.8% of low energy

fracture patients also had an osteoporosis 60% diagnosis, an indication that osteoporosis is under-diagnosed even when patients 40% are admitt ed to a hospital. Females with a low energy fracture were three % Patients with Diagnoses times as likely as males with a fracture 20% to be diagnosed with osteoporosis. 0% The failure to recognize osteoporosis 45 & 45 & 45 to 65 to 75 & 45 & 45 & 45 to 65 to 75 & as a possible contributing cause of the Over Over 64 74 Over Over Over 64 74 Over without without fracture increases the possibility of Fracture With Fracture Fracture With Fracture future fractures in this already at risk Females Males population. (Tables 5.4 and 5.5 and Graph [1] Treatment for fractures, excluding those with high Osteoporosis 5.2.5) energy causes (i.e., vehicular [auto, air, water] accidents, war injuries, violence/abuse). Hip fracture

Source: Agency for Healthcare Research and Quality, Pelvic fracture Healthcare Cost and Utilization Project, Nationwide Leg fracture Inpatient Sample, 2007

fracture released to an additional care sett ing are As the number of U.S. persons over the age of slightly lower, but still substantially higher than 75 increases in the next few decades, the burden for patients with no fracture. (Table 5.7 and Graph placed on nursing home care due to fragile bones 5.2.6) The cost of additional care for patients with will increase. Reducing the incidence and severity low energy fractures has not been quantifi ed due of osteoporosis will be critical to maintaining the to lack of available data. health of the aging population, as well as reducing health care costs. Section 5.2.4: Nursing Home Population and Risks of the Fragile Elderly Section 5.3: Falls and Low Energy Fractures Aft er an elderly person has sustained a fall resulting in fracture, his or her ability to live independently is reduced due to pain and Falls are the leading cause of injury, including limitations in activity. These patients are also at mortality and non-fatal injuries, for persons risk of additional falls and consequent fractures. aged 65 and older in the United States and a These patients require additional care and leading cause of hospitalization among persons resources. Among persons in the nursing home of all ages. In 2000, falls accounted for 46% of all population in 2004, 7,640 (< 1% of total admissions) hospitalizations from injuries; 309 out of every were diagnosed with osteoporosis at the time of 100,000 persons suff ering a fall were hospitalized.7 their admission; the majority were aged 75 and In 2002, 12% of unintentional injury deaths older. (Table 5.8) A substantially larger number, resulted from falls and 1.6 million nonfatal injuries more than 118,000 (8% of admissions), had from falls were treated at hospital emergency sustained a low energy fracture at the time of departments throughout the United States.8 admission, most likely due to osteoporosis and fragile bones. Females accounted for more than Fractures are the primary cause of hospitalization 82% of the nursing home admitt ances due to or death following a fall, particularly among fracture; 92% of the nursing home admitt ances individuals aged 65 and over. Osteoporosis is a were aged 75 years of age or older at the time of leading underlying cause of low energy fractures the fracture. Hip fractures are the most common aft er a fall, especially among the elderly. One in type of fracture that places older persons in a two women and one in four men over aged 50 will nursing home, accounting for 44% of admitt ances have an osteoporosis-related fracture in her or his due to fracture. However, pelvic, upper and lower remaining lifetime.9 limb, ankle or foot, and stress fractures are also a common cause of placement in a nursing home for Self-reported fracture rates for hip, wrist, and persons aged 75 and older. spine, from 2001 to 2006, indicate an increasing rate of fracture among females as the population At the time of interview in 2004, nearly 40,200 ages, particularly among individuals aged 85 nursing home residents aged 65 and older had and older. Among males, relatively stable rates of sustained a new fracture since being admitt ed. spine fracture occurred between the ages of 45 and The majority of these were females (74%); more older, while wrist fracture rates decreased with than one-half (58%) were 85 years of age or older. age and hip fracture rates increased. (Table 5.9 and Nearly 522,000 nursing home residents aged 65 Graph 5.3.1) Overall, 12% of fractures reported for and older, or two in fi ve, reported a fall within persons aged 45 and over were hip fractures; 19% the past 6 months. Of those falling, 2%, or 27,600, were spine fractures; and 69% were wrist fractures. sustained a hip fracture within the past 6 months, and 33,900 (3%) another type of fracture.

Graph 5.3.1: Self-Reported Fracture Rate [1] for Select Fractures by Sex and Age, a 20% loss of height from United States 2001-2006 early adulthood, hence 20 compressing the vertebral column. Since many of these 15 fractures occur without acute

10 symptoms and patients are rarely admitt ed to the

5 hospital, it is easier to obtain prevalence than incidence. Fracture Rate (per 100 persons) 0 Oft en they are diagnosed 45-64 65-74 75-84 85 & Older 45-64 65-74 75-84 85 & Older when the patient complains Females Males of chronic back pain as [1] Replied "yes" when asked if ever been told by a doctor that Broken or Fractured Hip you had broken or fractured your (hip)(spine)(wrist). the result of compression Source: National Center for Health Statistics. National Health Broken or Fractured Wrist or stress on the weakened and Nutrition Examination Survey Data, 2001-2006. Broken or Fractured Spine spine.4 Even without acute symptoms, vertebral Hip fractures signifi cantly impact quality of life, compression fractures can and are invariably associated with chronic pain, impact signifi cantly on quality of life, aff ecting reduced mobility, disability, and an increasing the ability to walk, balance, and sometimes cause degree of dependence.10 The mortality rate in upper back, neck or abdominal pain. The presence the fi rst 12 months aft er hip fracture is 20%, and of existing vertebral fractures are generally is higher in males than females.9 Some studies considered a predictor for future fracture risk of suggest that mortality may be higher, with a the spine, wrist and hip. 30% rate following hip fracture surgery noted.11 Current estimates are that one in four hip fractures Among all females aged 45 and over, falls were occur in males, and recent research indicates that responsible for nearly all wrist fractures, as men will have a diff erent course of recovery than well as for the majority of hip fractures, treated women, with higher rates of disability as well as between 2001 and 2006. Males follow a similar mortality.12,13 Fift y percent of persons experiencing patt ern, although falls account for a slightly lower a hip fracture will be unable to walk without proportion of fractures among men. In 2001 to assistance, and 25% will require long term care.14 Graph 5.3.2: Proportion of Self-Reported First Fractures Resulting from a Fall [1] for Select Fractures by Sex and Age, United States 2001-2006 There is no generally 100%

accepted deﬁ nition of 80% a spine fracture, also referred to as compression 60%

fractures, resulting in a 40%

wide variation of overall % of First Fractures Resulting from a Fall prevalence estimates.15 20%

Only about one in four 0% spinal fractures are 45-64 65-74 75-84 85 & Older 45-64 65-74 75-84 85 & Older diagnosed as a result of Females Males falls. The most widely [1] Replied "yes" when asked if ever been told by a doctor that Broken or Fractured Hip you had broken or fractured your (hip)(spine)(wrist) with accepted deﬁ nition self-reported cause as a “fall/tripped/slipped/fell out of bed” or Broken or Fractured Wrist ȃȱȱěȱȦȦ ǯȄǯ of suspected spine Ǳȱȱȱȱ ȱǯȱȱ ȱ Broken or Fractured Spine fractures in use today is ȱȱ¡ȱ¢ȱǰȱŘŖŖŗȬŘŖŖŜǯ

2006, three-fourths of spine fractures were caused previous study when a diff erence of nearly 5 years by falls; other causes, including automobile was observed. Spine fractures due to a fall also accidents, accounted for the remainder. The older occur at a younger age, 63.6 years, among males. the patient, the more likely that a fall is the cause As the population ages, the age at which they of a fracture. (Table 5.9 and Graph 5.3.2) report their fi rst fracture also rises. (Table 5.9 and Graph 5.3.3) In 2001-2006, the mean age at time of fi rst fracture of the wrist caused by a fall for all females aged The mean number of lifetime fractures of all sites 45 and over reporting a wrist fracture was 63.3 reported by all persons in the NHANES for the years. The mean age at fi rst fracture of the spine years 2001 to 2006 was slightly over one; however, was 71.2 years; for fi rst hip fracture it was 73.4 some persons reported multiple fractures of two years. Wrist fractures are more common among lifetime hip fractures, up to six lifetime wrist younger females, but the rate for all types of fractures, and up to ten lifetime spine fractures.16 fracture increase signifi cantly among females aged 85 and older. Among males aged 45 and Section 5.3.1: Inpatient Treatment for Low Energy older, the mean age of fi rst wrist fracture was 60.0 Fractures, 2004 years, refl ecting a slightly increasing rate of wrist fracture as males age. The mean age of fi rst hip In 2007, slightly more than 677,000 persons over fracture among males, at 72.9 years, was only a age 45 were discharged from the hospital aft er few months younger than females, unlike in the sustaining a low energy fracture. More than one-third of the inpatient fractures were hip Graph 5.3.3: Mean Age of Self-Reported First Fractures fractures, evenly distributed between females When Cause is a Fall [1] for Select fractures by Sex and and males. Vertebrae/ pelvic fractures comprised Age, United States 2001-2006 about one-fi ft h (20% and 24% for females and Females males, respectively). The remaining fracture sites 100 years accounted for 13% or less of all fractures treated 80 years in inpatient facilities. In 2006, nearly 1.2 million 60 years fractures to persons aged 45 and older were treated

40 years in emergency rooms. Low energy fractures among females were spread among all sites, with fractures 20 years

Mean Age of First Fracture Mean of the foot/ankle accounting for the largest share 0 years 45-64 65-74 75-84 85 & All 45 & (26%). Among males, fracture sites were even more Older Over evenly distributed. The wrist/hand accounted Males 100 years for the lowest share of low energy fractures in males (13%).This was followed by fractures of the 80 years foot and ankle and upper limb (arm/shoulder) 60 years fractures. (Table 5.10 and Graph 5.3.4)

40 years

20 years Section 5.4: Cost and Burden of

Mean Age of First Fracture Mean Osteoporosis and Low Energy 0 years 45-64 65-74 75-84 85 & All 45 & Older Over Fractures, 2004 [1] Sel-reported ae at tie o ęrst Broken or fracture and reported cause of fracture Fractured Hip was “fall/tripped/slipped/fell out of edȄ or “ard fall oě The mean length of inpatient stay for persons Broken or ladder/stool/downstairs.”. Fractured Wrist Source: National Center for Health aged 45 and older with a diagnosis of osteoporosis Statistics. National Health and Broken or Nutrition Examination Survey Data, (but not a fracture) in 2007 was 5.0 days, about Fractured Spine 2001-2006. one-half day shorter than the mean stay of 5.3 days

Graph 5.3.4: Proportion of Fracture Treatment [1] for Persons Aged 45 and energy fractures in patients aged 45 and Over by Anatomic Site and Treatment Location, United States, 2006/2007 older who were hospitalized as a result of 100% Foot/Ankle the fracture was $25.8 billion. (Table 5.11)

Lower Limb 80% (Leg) The burden of osteoporosis is already high, and it is growing. The costs associated Upper Limb (Arm/Shoulder) 60% with this disease are also increasing in both

Vertebrae/Pelvic men and women and in all ethnic groups. These data provide strong support for 40% Wrist/Hand the initiation of society-wide prevention

% of Total Fractures Treated % of Total measures, including early and regular 20% Hip screening for bone health, as well as for greater emphasis on the diagnosis of 0% Females Males Females Males individuals at risk for osteoporosis and

Inpatient Treatment Emergency Room identifi cation of new strategies to improve [2] Treatment [3] treatment and treatment adherence in high [1] Osteoporosis and related condition ICD-9-CM codes shown in the Section 5.4 risk groups. [2] Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 [3] Source: National Center for Health Statistics, National Hospital Ambulatory Medical 1. National Osteoporosis Foundation (NOF): Care Survey, Hospital Emergency Room, 2006 America’s Bone Health: The State of Osteoporosis and for patients without an osteoporosis diagnosis. Low Bone Mass in Our Nation. Washington DC: Osteoporosis patients with a low energy fracture National Osteoporosis Foundation, 2002. were hospitalized only 0.1 day longer than those 2. Burge RT, Dawson-Hughes B, Solomon DH, et al: with no fracture or osteoporosis diagnosis. Incidence and economic burden of osteoporosis-related The mean cost per inpatient stay for persons aged fractures in the United States, 2005-2025. J Bone Miner Res 45 and older with an osteoporosis diagnosis in 2007;22:465-475. 2007 was $28,549, which was 13% less than that of 3. World Health Organization (WHO): WHO Scientifi c Group patients with similar demographics but without an on the Assessment of Osteoporosis at Primary Health Care Level. osteoporosis diagnosis. The estimated cost in 2007 Brussels, Belgium: WHO Press, Geneva, Switzerland, 2004. of treating patients aged 45 and older who were hospitalized and had a diagnosis of osteoporosis 4. US Department of Health and Human Services (USDHHS): was $22.9 billion. (Table 5.11) It is unlikely the Bone Health and Osteoporosis: A Report of the Surgeon General. osteoporosis diagnosis was the primary diagnosis Rockville, MD: U.S. Government Printing Offi ce, Offi ce of for which the patients were hospitalized. the Surgeon General, 2004, p 107. The mean length of inpatient stay for persons aged 5. Baim S, Biegel R, Binkley NC: Medicare and private 45 and older with a low energy fracture in 2007 reimbursement of osteoporosis diagnosis and treatment, was 6.1 days, or 17% longer than the mean stay of in Osteoporosis Clinical Updates. Washington DC: National 5.2 days for patients without a fracture injury. The Osteoporosis Foundation, 2006, vol 7, pp 1-8. mean cost per inpatient stay for persons aged 45 and older with a low energy fracture in 2007 was 6. Bonnick SL, Shulman L: Monitoring osteoporosis therapy: $37,982, a cost that was 13% greater than that of bone mineral density, bone turnover markers, or both? Am patients with similar demographics but without a J Med 2006;119:25S-31S. fracture. The estimated cost in 2007 of treating low

7. Finkelstein EA, Corso PS, Miller TR: The Incidence and 12. Orwig DL, Chan J, Magaziner J: Hip fracture and its Economic Burden of Injuries in the United States. New York, consequences: diﬀ erences between men and women. NY: Oxford University Press, Inc., 2006, p 187. Orthop Clin North Am 2006;37:611-622.

8. National Safety Council (NSC): Injury Facts, 2005-2006 13. Hawkes WG, Wehren L, Orwig D, et al: Gender diﬀ erences Edition. Itasca, IL: National Safety Council, 2006. in functioning aft er hip fracture. J Gerontol A Biol Sci Med Sci 2006;61:495-499. 9. National Osteoporosis Foundation (NOF): National Osteoporosis Foundation Fast Facts. Available at: htt p:// 14. Riggs BL, Melton LJ: The worldwide problem of www.nof.org/osteoporosis/diseasefacts.htm. Accessed osteoporosis: insights aﬀ orded by epidemiology. Bone September 19, 2007 and November 2, 2009. 1995;17:505S-511S.

10. International Osteoporosis Foundation (IOF): Facts and 15. Genant HK, Jergas M: Assessment of prevalent and statistics about osteoporosis and its impact, in, 2007. incident vertebral fractures in osteoporosis research. Available at: htt p://www.iofb onehealth.org/facts-and- Osteoporos Int 2003;14:S43-S55. statistics.html. Accessed September 19, 2007 and November 2, 2009. 16. National Center for Health Statistics (NCHS): National Health and Nutrition Examination Survey 2003-2004: 11. Moran CG, Wenn RT, Sikand M, Taylor AM: Early Documentation, Codebook, and Frequencies. Hyatt sville, MD: mortality aft er hip fracture: is delay before surgery Centers for Disease Control, 2006, p 34. important? J Bone Joint Surg Am 2005;87:483-489.

Section 5.5: Osteoporosis and Bone Health Data Tables

For purposes of this study, osteoporosis has been categorized into the three classiﬁ cations. Primary osteoporosis is a diagnosis of osteoporosis. Low energy fracture is one caused by an event such as a fall from a standing height. (A high energy fracture, by contrast, is caused by involvement in a motor vehicle accident.) Secondary osteoporosis is the presence of another condition or treatment that may cause eroding of bone health and osteoporosis. Codes included in these three osteoporosis categories are as shown in Table 5.1.

Tableȱ5.1:ȱOsteoporosisȱandȱBoneȱHealth:ȱȱAnalysisȱCodes

CODE ICDȬ9ȬCMȱCODEȱDESCRIPTION CODE ICDȬ9ȬCMȱCODEȱDESCRIPTION OSTEOPOROSIS 73300 OsteoporosisȱNOS 73303 DisuseȱOsteoporosis 73301 SenileȱOsteoporosis 73309 OsteoporosisȱNEC 73302 IdiopathicȱOsteoporosis

LOWȱENERGYȱFRACTURES VertebralȱandȱPelvicȱFracturesȱ WristȱandȱHandȱFracture 80500 VertebralȱFractureȱ(Closed) 81300 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80501 VertebralȱFractureȱ(Closed) 81301 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80502 VertebralȱFractureȱ(Closed) 81302 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80503 VertebralȱFractureȱ(Closed) 81303 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80504 VertebralȱFractureȱ(Closed) 81304 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80505 VertebralȱFractureȱ(Closed) 81305 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80506 VertebralȱFractureȱ(Closed) 81306 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80507 VertebralȱFractureȱ(Closed) 81307 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80508 VertebralȱFractureȱ(Closed) 81308 WristȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUpperȱEnd 80520 VertebralȱFractureȱ(Closed)ȬThoracic 81320 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱShaft 80540 VertebralȱFractureȱ(Closed)ȬLumbar 81321 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱShaft 80560 PelvicȱFractureȱ(Closed)ȬSacrumȱandȱCoccyxȱ 81322 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱShaft 80580 VertebralȱFractureȱ(Closed)ȬUnspecified 81323 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱShaft 80800 PelvicȱFractureȱ(Closed)ȬAcetabulum 81340 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱLowerȱEnd 80820 PelvicȱFractureȱ(Closed)ȬPubis 81341 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱLowerȱEnd 80841 PelvicȱFractureȱ(Closed)ȬIlium 81342 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱLowerȱEnd 80842 PelvicȱFractureȱ(Closed)ȬIschium 81343 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱLowerȱEnd 80843 PelvicȱFractureȱ(Closed)ȬMultiple 81344 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱLowerȱEnd 80849 PelvicȱFractureȱ(Closed)ȬOther 81345 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱLowerȱEnd 80880 PelvicȱFractureȱ(Closed)ȬUunspecified 81380 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUnspecified 81381 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUnspecified UpperȱLimbȱFractureȱ(ShoulderȱandȱArm) 81382 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUnspecified 81000 UpperȱlimbȱFractureȱ(Closed)ȬClavicleȱ(Shoulder) 81383 Wrist/forearmȱFractureȱ(Closed)ȬRadiusȱandȱUlnaȱUnspecified 81001 UpperȱlimbȱFractureȱ(Closed)ȬClavicleȱ(Shoulder) 81400 WristȱFractureȱ(Closed)ȬCarpalȱBones 81002 UpperȱlimbȱFractureȱ(Closed)ȬClavicleȱ(Shoulder) 81401 WristȱFractureȱ(Closed)ȬCarpalȱBones 81003 UpperȱlimbȱFractureȱ(Closed)ȬClavicleȱ(Shoulder) 81402 WristȱFractureȱ(Closed)ȬCarpalȱBones 81100 UpperȱlimbȱFractureȱ(Closed)ȬScapulaȱ(Shoulder) 81403 WristȱFractureȱ(Closed)ȬCarpalȱBones 81101 UpperȱlimbȱFractureȱ(Closed)ȬScapulaȱ(Shoulder) 81404 WristȱFractureȱ(Closed)ȬCarpalȱBones 81102 UpperȱlimbȱFractureȱ(Closed)ȬScapulaȱ(Shoulder) 81405 WristȱFractureȱ(Closed)ȬCarpalȱBones 81103 UpperȱlimbȱFractureȱ(Closed)ȬScapulaȱ(Shoulder) 81406 WristȱFractureȱ(Closed)ȬCarpalȱBones 81109 UpperȱlimbȱFractureȱ(Closed)ȬScapulaȱ(Shoulder) 81407 WristȱFractureȱ(Closed)ȬCarpalȱBones 81200 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81408 WristȱFractureȱ(Closed)ȬCarpalȱBones 81201 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81409 WristȱFractureȱ(Closed)ȬCarpalȱBones 81202 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81500 HandȱFractureȱ(Closed)ȬMetacarpalȱBones 81203 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81501 HandȱFractureȱ(Closed)ȬMetacarpalȱBones 81209 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81502 HandȱFractureȱ(Closed)ȬMetacarpalȱBones 81220 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81503 HandȱFractureȱ(Closed)ȬMetacarpalȱBones 81221 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81504 HandȱFractureȱ(Closed)ȬMetacarpalȱBones 81240 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81509 HandȱFractureȱ(Closed)ȬMetacarpalȱBones 81241 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81242 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81243 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd 81244 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd Tableȱ5.1ȱcontinuedȱnextȱpage. 81249 UpperȱlimbȱFractureȱ(Closed)ȬHumerusȱUpperȱEnd

Tableȱ5.1:ȱOsteoporosisȱandȱBoneȱHealth:ȱAnalysisȱCodes ȱ(continued)

CODE ICDȬ9ȬCMȱCODEȱDESCRIPTION CODE ICDȬ9ȬCMȱCODEȱDESCRIPTION AnkleȱandȱFootȱFracture HipȱFracture 82400 AnkleȱFractureȱ(Closed)ȬMedialȱMalleolus 82000 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82420 AnkleȱFractureȱ(Closed)ȬLateralȱMalleolus 82001 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82440 AnkleȱFractureȱ(Closed)ȬBimalleolar 82002 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82460 AnkleȱFractureȱ(Closed)ȬTrimalleolar 82003 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82480 AnkleȱFractureȱ(Closed)ȬUnspecified 82009 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82500 FootȱFractureȱ(Closed)ȬȱCalcaneus 82020 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82520 FootȱFractureȱ(Closed)ȬUnspecifiedȱ(Instep) 82021 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82521 FootȱFractureȱ(Closed)ȬAstragalus 82022 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82522 FootȱFractureȱ(Closed)ȬNavicularȱ(Scaphoid) 82080 HipȱFractureȱ(Closed)ȬNeckȱofȱFemur 82523 FootȱFractureȱ(Closed)ȬCuboid 82524 FootȱFractureȱ(Closed)ȬCuneiform 82525 FootȱFractureȱ(Closed)ȬMetatarsalȱBone(s) 82529 FootȱFractureȱ(Closed)ȬOtherȱ(TarsalȱwithȱMetatarsal)

StressȱandȱPathologicalȱFractures LowerȱLimb,ȱexcludingȱfootȱandȱankle 73310UnspecifiedȱPathologicalȱFracture 82100 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬThigh/UpperȱLeg 73311PathologicalȱFractureȬHumerus 82101 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬThigh/UpperȱLeg 73312PathologicalȱFractureȬWrist 82120 LowerȱlimbȱFractureȱ(Closed)ȬLowerȱEndȱFemurȱUnspecified 73313PathologicalȱFractureȬVertebrae 82121 LowerȱlimbȱFractureȱ(Closed)ȬLowerȱEndȱFemurȱCondoyle 73314PathologicalȱFractureȬFemurȱNeck 82122 LowerȱlimbȱFractureȱ(Closed)ȬLowerȱEndȱFemurȱEepiphysis 73315PathologicalȱFractureȬOtherȱFemur 82123 LowerȱlimbȱFractureȱ(Closed)ȬLowerȱEndȱFemurȱSupracondylar 73316PathologicalȱFractureȬTibia/Fibulaȱ 82129 LowerȱlimbȱFractureȱ(Closed)ȬLowerȱEndȱFemurȱMultipleȱFractures 73319OtherȱSpecifiedȱPathologicalȱFracture 82200 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬPatella 73393StressȱFractureȱofȱTibiaȱorȱFibula 82300 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibula 73394StressȱFractureȱofȱtheȱMetatarsals 82301 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibula 73395StressȱFractureȱofȱOtherȱBone 82302 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibula 82320 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibulaȱShaft ExcludeȱallȱcasesȱwithȱEȬcodeȱof:ȱ 82321 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibulaȱShaft E800ȬE807ȱȱRailway 82322 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibulaȱShaft E810ȬE819ȱȱMotorȱVehicleȱTraffic 82380 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibulaȱUnspecified E820ȬE825ȱȱMotorȱVehicleȱNontraffic 82381 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibulaȱUnspecified E826ȬE829ȱȱOtherȱRoadȱVehicles 82382 Lowerȱlimbȱfractureȱ(ClosedȱOnly)ȬTibiaȱandȱFibulaȱUnspecified E830ȬE838ȱȱWater E840ȬE845ȱȱAirȱandȱSpace E846ȬE848ȱȱOtherȱVehicleȱAccidentsȱNotȱElsewhereȱClssified Tableȱ5.1ȱcontinuedȱnextȱpage. E990ȬE999ȱȱOperationsȱofȱWar

Tableȱ5.1:ȱOsteoporosisȱandȱBoneȱHealth:ȱAnalysisȱCodesȱ (continued)

CODE ICDȬ9ȬCMȱCODEȱDESCRIPTION CODE ICDȬ9ȬCMȱCODEȱDESCRIPTION SECONDARYȱOSTEOPOROSISȱ DiagnosisȱThatȱMayȱLeadȱtoȱOsteoporosis 24290 ThyrotoxȱNOSȬNoȱCrisis 25720 TesticularȱHypofunctionȱNEC 24291 ThyrotoxȱNOSȬwithȱCrisis 25930 EctopicȱHormoneȱSecondaryȱNEC 25200 HyperparathyroidismȱNOS 25990 EndocrineȱDisorderȱNOS 25201 PrimaryȱHyperparathyroid 26820ȱ OsteomalaciaȱNOS 25202 SecondaryȱHyperparathyroidȬNonrenal 26890 VitaminȱDȱDeficiencyȱNOS 25208 HyperparathyroidismȱNEC 58800 RenalȱOsteodystrophy 25500 CushingȇsȱSyndrome 58881 SecondaryȱHyperparathyroidȬRenal 25530 CorticoadrenȱOveractȱNEC 62720 FemaleȱClimactericȱState 25620 PostablativȱOvarianȱFailure 62740 ArtificialȱMenopauseȱStates 25631 PrematureȱMenopause 62780 MenopausalȱDisorderȱNEC 25639 OtherȱOvarianȱFailure 62790 MenopausalȱDisorderȱNOS 25710 PostblatȱTesticȱHypofun

VertebralȱFracturesȱwithȱSpinalȱCordȱInjury 80600 C1ȬC4ȱFractureȬClosed/CordȱInjuryȱNOS 80626 T7ȬT12ȱFractureȬClosed/CompleteȱLesionȱofȱCord 80601 C1ȬC4ȱFractureȬClosed/CompleteȱLesionȱofȱCord 80627 T7ȬT12ȱFractureȬClosed/AnteriorȱCordȱSyndrome 80602 C1ȬC4ȱFractureȬClosed/AnteriorȱCordȱSyndrome 80628 T7ȬT12ȱFractureȬClosed/CentralȱCordȱSyndrome 80603 C1ȬC4ȱFractureȬClosed/CentralȱCordȱSyndrome 80629 T7ȬT12ȱFractureȬClosed/CordȱInjuryȱNEC 80604 C1ȬC4ȱFractureȬClosed/CordȱInjuryȱNEC 80630 T1ȬT6ȱFractureȬOpen/CordȱInjuryȱNOS 80605 C5ȬC7ȱFractureȬClosed/CordȱInjuryȱNOS 80631 T1ȬT6ȱFractureȬOpen/CompleteȱLesionȱofȱCord 80606 C5ȬC7ȱFractureȬClosed/CompleteȱLesionȱofȱCord 80632 T1ȬT6ȱFractureȬOpen/AnteriorȱCordȱSyndrome 80607 C5ȬC7ȱFractureȬClosed/AnteriorȱCordȱSyndrome 80633 T1ȬT6ȱFractureȬOpen/CentralȱCordȱSyndrome 80608 C5ȬC7ȱFractureȬClosed/CentralȱCordȱSyndrome 80634 T1ȬT6ȱFractureȬOpen/CordȱInjuryȱNEC 80609 C5ȬC7ȱFractureȬClosed/CordȱInjuryȱNEC 80635 T7ȬT12ȱFractureȬOpen/CordȱInjuryȱNOS 80610 C1ȬC4ȱFractureȬOpen/CordȱInjuryȱNOS 80636 T7ȬT12ȱFractureȬOpen/CompleteȱLesionȱofȱCord 80611 C1ȬC4ȱFractureȬOpen/CompleteȱLesionȱofȱCord 80637 T7ȬT12ȱFractureȬOpen/AnteriorȱCordȱSyndrome 80612 C1ȬC4ȱFractureȬOpen/AnteriorȱCordȱSyndrome 80638 T7ȬT12ȱFractureȬOpen/CentralȱCordȱSyndrome 80613 C1ȬC4ȱFractureȬOpen/CentralȱCordȱSyndrome 80639 T7ȬT12ȱFractureȬOpen/CordȱInjuryȱNEC 80614 C1ȬC4ȱFractureȬOpen/CordȱInjuryȱNEC 80640ȱ ClosedȱLumbarȱFractureȱwithȱCordȱInjury 80615 C5ȬC7ȱFractureȬOpen/CordȱInjuryȱNOS 80650ȱ OpenȱLumbarȱFractureȱwithȱCordȱInjury 80616 C5ȬC7ȱFractureȬOpen/CompleteȱLesionȱofȱCord 80660 FractureȱSacrumȬClosed/CordȱInjuryȱNOS 80617 C5ȬC7ȱFractureȬOpen/AnteriorȱCordȱSyndrome 80661 FractureȱSacrumȬClosed/CaudaȱEquinaȱLesion 80618 C5ȬC7ȱFractureȬOpen/CentralȱCordȱSyndrome 80662 FractureȱSacrumȬClosed/CaudaȱInjuryȱNEC 80619 C5ȬC7ȱFractureȬOpen/CordȱInjuryȱNEC 80669 FractureȱSacrumȬClosed/CordȱInjuryȱNEC 80620 T1ȬT6ȱFractureȬClosed/CordȱInjuryȱNOS 80670 FractureȱSacrumȬClosed/CordȱInjuryȱNOS 80621 T1ȬT6ȱFractureȬClosed/CompleteȱLesionȱofȱCord 80671 FractureȱSacrumȬClosed/CaudaȱEquinaȱLesion 80622 T1ȬT6ȱFractureȬClosed/AnteriorȱCordȱSyndrome 80672 FractureȱSacrumȬClosed/CaudaȱInjuryȱNEC 80623 T1ȬT6ȱFractureȬClosed/CentralȱCordȱSyndrome 80679 FractureȱSacrumȬOpen/CordȱInjuryȱNEC 80624 T1ȬT6ȱFractureȬClosed/CordȱInjuryȱNEC 80680 VertebraeȱFractureȱNOSȬClosedȱwithȱCordȱInjury 80625 T7ȬT12ȱFractureȬClosed/CordȱInjuryȱNOS 80690 VertebraeȱFractureȱNOSȬOpenȱwithȱCordȱInjury

Tableȱ5.2:ȱSelfȬReportedȱRateȱofȱOsteoporosisȱandȱHipȱFractureȱforȱPersonsȱ Agedȱ65ȱandȱOver,ȱUnitedȱStatesȱ1988Ȭ1994ȱandȱ2001Ȭ2006

Prevalenceȱ(Rateȱperȱ100ȱPersons)

Osteoporosisȱ[1] HipȱFractureȱ[2] EitherȱCondition 1988Ȭ 2001Ȭȱ 1988Ȭ 2001Ȭȱ 1988Ȭ 2001Ȭȱ 1994ȱ[3] 2006ȱ[4] 1994ȱ[3] 2006ȱ[4] 1994ȱ[3] 2006ȱ[4] Females 65ȱtoȱ74ȱYears 10.9 25.0 4.5 1.6 14.2 26.0 75ȱtoȱ84ȱYears 12.1 33.0 7.3 3.4 17.7 34.2 85ȱYearsȱ&ȱOver 9.7 29.6 11.8 11.5 19.1 34.6 AllȱFemalesȱ65ȱYearsȱ&ȱOver 11.1 28.4 6.1 3.6 15.8 30.0

Males 65ȱtoȱ74ȱYears 1.3 3.1 2.1 2.8 3.3 5.7 75ȱtoȱ84ȱYears 1.3 6.9 2.4 3.2 3.0 9.6 85ȱYearsȱ&ȱOver 1.6 5.3 4.1 7.4 5.4 10.9 AllȱMalesȱ65ȱYearsȱ&ȱOver 1.3 4.5 2.3 3.3 3.5 7.5

Totalȱ 65ȱtoȱ74ȱYears 6.7 15.0 3.4 2.2 10.0 16.8 75ȱtoȱ84ȱYears 8.0 22.2 5.4 3.3 13.4 24.1 85ȱYearsȱ&ȱOver 7.0 21.7 9.4 10.2 16.4 26.9 AllȱPersonsȱ65ȱYearsȱ&ȱOver 7.0 18.3 4.5 3.5 10.7 20.5

[1]ȱHasȱaȱdoctorȱeverȱtoldȱyouȱthatȱyouȱhadȱosteoporosis,ȱsometimesȱcalledȱthinȱorȱbrittleȱbones? [2]ȱHasȱaȱdoctorȱeverȱtoldȱyouȱthatȱyouȱhadȱbrokenȱorȱfracturedȱyourȱhip? [3]ȱSource:ȱPraemerȱA,ȱFurnerȱS,ȱRiceȱDP.ȱMusculoskeletalȱConditionsȱinȱtheȱUnitedȱStates .ȱRosemont,ȱIL.ȱ1999,ȱAmericanȱ AcademyȱofȱOrthopaedicȱSurgeons.

[4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurveyȱData,ȱ12001Ȭ2006

Tableȱ5.3:ȱSelfȬReportedȱPrevalenceȱofȱOsteoporosis,ȱOsteoporosisȱTreatmentȱorȱRelatedȱFractureȱ[1]ȱforȱPersonsȱ Agedȱ45ȱandȱOver,ȱUnitedȱState,ȱ2001Ȭ2006

PrevalenceȱRateȱ Prevalenceȱ(inȱ000s) OccurrenceȱbyȱSex DistributionȱbyȱAge (%ȱofȱpopulationȱwithinȱageȱgroup) Totalȱ Totalȱ AgeȱGroup Females Males Population Females Males Females Males Females Males Population

Everȱbeenȱtoldȱhadȱosteoporosis? 45Ȭ64ȱȱȱȱȱȱȱȱȱȱȱ 3,073 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ653 ȱȱȱȱȱȱȱȱȱȱȱ3,726 82.5% 17.5% 35.6% 50.0% 8.9% 2.0% 5.5% 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱ 2,507 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ256 ȱȱȱȱȱȱȱȱȱȱȱ2,763 90.7% 9.3% 29.1% 19.6% 25.0% 3.1% 15.0% 75Ȭ84ȱȱȱȱȱȱȱȱȱȱȱ 2,264 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ330 ȱȱȱȱȱȱȱȱȱȱȱ2,594 87.3% 12.7% 26.2% 25.3% 33.0% 6.9% 22.2% 85+ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 780 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ67 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ847 92.1% 7.9% 9.0% 5.1% 29.6% 5.3% 21.7% TotalȱAgedȱ45ȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱ 8,623 ȱȱȱȱȱȱȱȱȱȱȱ1,306 ȱȱȱȱȱȱȱȱȱȱȱ9,929 86.8% 13.2% 100.0% 100.0% 15.9% 2.7% 9.7%

Everȱbeenȱtreatedȱforȱosteoporosis?ȱ(ifȱrespondedȱȈYesȈȱtoȱosteoporosis) Proportionȱw/OsteoporosisȱTreated 45Ȭ64ȱȱȱȱȱȱȱȱȱȱȱ 2,075 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ384 ȱȱȱȱȱȱȱȱȱȱȱ2,459 84.4% 15.6% 32.4% 45.6% 67.5% 58.7% 66.0% 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱ 1,904 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ154 ȱȱȱȱȱȱȱȱȱȱȱ2,057 92.5% 7.5% 29.7% 18.3% 76.6% 59.9% 75.0% 75Ȭ84ȱȱȱȱȱȱȱȱȱȱȱ 1,844 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ274 ȱȱȱȱȱȱȱȱȱȱȱ2,118 87.1% 12.9% 28.7% 32.6% 81.5% 83.0% 81.7% 85+ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 592 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ622 95.2% 4.8% 9.2% 3.5% 75.9% 44.6% 73.4% TotalȱAgedȱ45ȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱ 6,414 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ841 ȱȱȱȱȱȱȱȱȱȱȱ7,255 88.4% 11.6% 100.0% 100.0% 74.6% 64.4% 73.2%

Everȱbeenȱtoldȱhadȱbrokenȱorȱfracturedȱyourȱhip? PrevalenceȱRate 45Ȭ64ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 208 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ499 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ706 29.4% 70.6% 22.9% 50.8% 0.6% 1.5% 1.0% 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 162 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ233 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ396 41.1% 58.9% 17.9% 23.8% 1.6% 2.8% 2.2% 75Ȭ84ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 235 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ156 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ390 60.1% 39.9% 25.8% 15.9% 3.4% 3.2% 3.3% 85+ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 304 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ94 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ397 76.5% 23.5% 33.4% 9.5% 11.5% 7.4% 10.2% TotalȱAgedȱ45ȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 909 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ981 ȱȱȱȱȱȱȱȱȱȱȱ1,889 48.1% 51.9% 100.0% 100.0% 1.7% 2.1% 1.9%

Everȱbeenȱtoldȱhadȱbrokenȱorȱfracturedȱyourȱspine? PrevalenceȱRate 45Ȭ64ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 625 ȱȱȱȱȱȱȱȱȱȱȱ1,255 ȱȱȱȱȱȱȱȱȱȱȱ1,881 33.2% 66.8% 47.0% 73.3% 1.8% 3.8% 2.8% 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 256 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ224 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ480 53.3% 46.7% 19.3% 13.1% 2.6% 2.7% 2.6% 75Ȭ84ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 226 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ188 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ415 54.6% 45.4% 17.0% 11.0% 3.3% 3.9% 3.5% 85+ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 221 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ265 83.5% 16.5% 16.7% 2.5% 8.4% 3.5% 6.8% TotalȱAgedȱ45ȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱ 1,329 ȱȱȱȱȱȱȱȱȱȱȱ1,712 ȱȱȱȱȱȱȱȱȱȱȱ3,040 43.7% 56.3% 100.0% 100.0% 2.5% 3.6% 3.0%

Everȱbeenȱtoldȱhadȱbrokenȱorȱfracturedȱyourȱwrist? PrevalenceȱRate 45Ȭ64ȱȱȱȱȱȱȱȱȱȱȱ 2,827 ȱȱȱȱȱȱȱȱȱȱȱ4,178 ȱȱȱȱȱȱȱȱȱȱȱ7,005 40.4% 59.6% 53.1% 72.9% 8.2% 12.5% 10.3% 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱ 1,139 ȱȱȱȱȱȱȱȱȱȱȱ1,044 ȱȱȱȱȱȱȱȱȱȱȱ2,183 52.2% 47.8% 21.4% 18.2% 11.4% 12.5% 11.9% 75Ȭ84ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 931 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ426 ȱȱȱȱȱȱȱȱȱȱȱ1,357 68.6% 31.4% 17.5% 7.4% 13.6% 8.8% 11.6% 85+ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 424 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ82 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ506 83.8% 16.3% 8.0% 1.4% 16.1% 6.5% 13.0% TotalȱAgedȱ45ȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱ 5,320 ȱȱȱȱȱȱȱȱȱȱȱ5,731 ȱȱȱȱȱȱȱȱ11,051 48.1% 51.9% 100.0% 100.0% 9.8% 12.0% 10.8%

Everȱbeenȱtoldȱhadȱosteoporosis,ȱbeenȱtreatedȱforȱosteoporosis,ȱorȱhadȱbrokenȱorȱfracturedȱhip,ȱspineȱorȱwrist? PrevalenceȱRate 45Ȭ64ȱȱȱȱȱȱȱȱȱȱȱ 6,125 ȱȱȱȱȱȱȱȱȱȱȱ5,854 ȱȱȱȱȱȱȱȱ11,979 51.1% 48.9% 44.8% 68.3% 17.7% 17.5% 17.6% 65Ȭ74ȱȱȱȱȱȱȱȱȱȱȱ 3,360 ȱȱȱȱȱȱȱȱȱȱȱ1,553 ȱȱȱȱȱȱȱȱȱȱȱ4,193 80.1% 37.0% 24.6% 18.1% 33.5% 18.6% 26.7% 75Ȭ84ȱȱȱȱȱȱȱȱȱȱȱ 2,956 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ910 ȱȱȱȱȱȱȱȱȱȱȱ3,867 76.5% 23.5% 21.6% 10.6% 43.1% 18.9% 33.1% 85+ȱȱȱȱȱȱȱȱȱȱȱ 1,237 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ256 ȱȱȱȱȱȱȱȱȱȱȱ1,493 82.9% 17.1% 9.0% 3.0% 47.0% 20.3% 38.3% TotalȱAgedȱ45ȱ&ȱOverȱȱȱȱȱȱȱȱ 13,678 ȱȱȱȱȱȱȱȱȱȱȱ8,573 ȱȱȱȱȱȱȱȱ22,251 61.5% 38.5% 100.0% 100.0% 25.2% 17.9% 21.8%

[1]ȱRepliedȱȈYesȈȱwhenȱaskedȱifȱeverȱbeenȱtoldȱbyȱaȱdoctorȱthatȱyouȱhadȱosteoporosis,ȱbeenȱtreatedȱforȱosteoporosis,ȱorȱhadȱbrokenȱorȱfracturedȱyourȱ(hip)(spine)(wrist).

Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurveyȱData,ȱ2001Ȭ2006

Tableȱ5.4:ȱHealthȱCareȱVisitsȱforȱOsteoporosisȱandȱRelatedȱConditionsȱ[1]ȱforȱPersonsȱAgedȱ 45ȱandȱOlderȱbyȱSite,ȱUnitedȱStatesȱ2006/2007

Visitsȱ(inȱ000s)

Inpatientȱ Emergencyȱ TotalȱAllȱ Hospitalizationȱ Physicianȱ Roomȱ Outpatientȱ HealthȱCareȱ [4] Visitsȱ[5] Encountersȱ[6] Visitsȱ[7] Resources

PrimaryȱOsteoporosisȱorȱLowȱBoneȱDen 802.4 4,413.6 ȱȱȱȱȱ*ȱ 204.4 5,442.2 %ȱofȱTotalȱOsteoporosisȱVisits 14.7% 81.1% 0.7% 3.8%

LowȱEnergyȱFractureȱ[2] Hip 205.8 ȱȱȱȱ*ȱ 232.1 ȱȱȱȱȱ*ȱ 772.5 Wrist/ȱHand 47.3 ȱȱȱȱȱ*ȱ 213.7 125.1 1,855.9 Vertebrae/ȱPelvic 128.8 ȱȱȱȱȱ*ȱ 133.5 ȱȱȱȱȱ*ȱ 756.0 UpperȱLimbȱ(Arm/ȱShoulder) 66.6 ȱȱȱȱȱ*ȱ 218.3 ȱȱȱȱȱ*ȱ 1,027.4 LowerȱLimbȱ(Leg) 68.9 ȱȱȱȱȱ*ȱ 133.5 89.5 1,194.6 Foot/Ankle 76.7 ȱȱȱȱȱ*ȱ 270.8 102.9 1,254.2 AllȱLowȱEnergyȱFractures 678.1 4,819.7 1,192.0 423.3 7,113.1 %ȱofȱTotalȱLowȱEnergyȱFractureȱVisits 9.5% 67.8% 16.8% 6.0% %ȱofȱLowȱEnergyȱFractureȱPatientsȱwithȱ 20.8% 1.4% 1.0% 2.5% 3.3% ȱȱȱȱȱOsteoporosisȱDiagonsis

Osteoporosisȱ&ȱLowȱEnergyȱFractureȱVisitsȱ 3.7% 1.0% 1.0% 0.6% 1.1% asȱProportionȱofȱTotalȱVisits

SecondaryȱOsteoporosisȱDiagnosisȱ[3] ContributingȱCondition 212.0 4,880.6 ȱȱȱȱȱ*ȱ 300.7 5,436.0

VertebralȱFractureȱw/SpinalȱCordȱInjuryȱ 0.0 55.8 (resultingȱfromȱlowȱenergyȱimpact) ȱȱȱȱȱ*ȱ ȱȱȱȱȱ*ȱ ȱȱȱȱȱ*ȱ

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability. [1]ȱOsteoporosisȱandȱrelatedȱconditionȱICDȬ9ȬCMȱcodesȱshownȱinȱtheȱTableȱ5.1. [2]ȱTreatmentȱforȱfractures,ȱexcludingȱthoseȱwithȱhighȱenergyȱcausesȱ(i.e.,ȱvehicularȱ[auto,ȱair,ȱwater]ȱaccidents,ȱwarȱinjuries,ȱ violence/abuse). [3]ȱDiagnosisȱofȱanotherȱmedicalȱconditionȱthatȱmayȱleadȱtoȱorȱcontributeȱtoȱtheȱdevelopmentȱofȱosteoporosis. [4]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [5]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006 [6]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergency,ȱ2006 [7]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱOutpatientȱCenters,ȱ2006ȱ

Tableȱ5.5:ȱInpatientȱResourceȱUtilizationȱforȱOsteoporosisȱandȱRelatedȱConditionsȱ[1]ȱforȱPersonsȱAgeȱ45ȱ andȱOlderȱbyȱAgeȱandȱSex,ȱUnitedȱStatesȱ2007

Totalȱ Females %ȱbyȱAgeȱGroup DistributionȱbyȱGender TotalȱAgedȱ45ȱ Mean Inpatientȱ 75ȱ&ȱ &ȱOlder Age Hospitalizationsȱ 45Ȭ64 65Ȭ74 Older (inȱ000s) (inȱyears) Females Males (inȱ000s)ȱ

PrimaryȱOsteoporosis 18.4% 26.7% 54.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 712.8 ȱȱȱȱȱȱȱȱȱȱȱȱ73.4 89% 11% 802.4

LowȱEnergyȱFractureȱ[2] Hip 12.3% 20.9% 66.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 140.0 ȱȱȱȱȱȱȱȱȱȱȱȱ75.8 68% 32% 205.8 Wrist/ȱHand 29.8% 23.9% 46.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 33.0 ȱȱȱȱȱȱȱȱȱȱȱȱ70.6 70% 30% 47.3 Vertebrae/ȱPelvic 17.3% 21.9% 60.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 81.9 ȱȱȱȱȱȱȱȱȱȱȱȱ74.1 64% 36% 128.8 UpperȱLimbȱ(Arm/ȱShoulder) 25.4% 26.6% 48.1%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.1 ȱȱȱȱȱȱȱȱȱȱȱȱ71.6 69% 31% 66.6 LowerȱLimbȱ(Leg) 37.3% 24.6% 38.1%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.7 ȱȱȱȱȱȱȱȱȱȱȱȱ68.6 68% 32% 68.9 Foot/Ankle 50.9% 23.7% 25.4%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 51.4 ȱȱȱȱȱȱȱȱȱȱȱȱ64.8 67% 33% 76.7 AllȱLowȱEnergyȱFractures 23.6% 23.2% 53.2%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 459.3 ȱȱȱȱȱȱȱȱȱȱȱȱ72.4 68% 32% 678.1 LowȱEnergyȱFractureȱwithȱOsteoporosisȱDiagnosis

%ȱLowȱEnergyȱFractureȱPatientsȱwithȱ ȱȱȱȱȱOsteoporosisȱDiagnosis 14.7% 26.4% 32.7% 20.8% 26.9% 8.0% 20.8%

SecondaryȱOsteoporosisȱDiagnosisȱ[3] ContributingȱCondition 46.6% 25.5% 27.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 133.6 ȱȱȱȱȱȱȱȱȱȱȱȱ65.6 63% 37% 212.0 VertebralȱFractureȱw/SpinalȱCordȱInjury ȱȱȱȱȱ*ȱ ȱȱȱȱ*ȱ ȱȱȱȱ*ȱ 0.0 NA 35% 65% ȱȱȱȱ*ȱ

Males PrimaryȱOsteoporosis 24.5% 25.5% 49.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 89.5 ȱȱȱȱȱȱȱȱȱȱȱȱ71.7

LowȱEnergyȱFractureȱ[2] Hip 20.6% 22.5% 56.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.6 ȱȱȱȱȱȱȱȱȱȱȱȱ73.2 Wrist/ȱHand 62.4% 18.0% 19.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 14.1 ȱȱȱȱȱȱȱȱȱȱȱȱ61.4 Vertebrae/ȱPelvic 39.8% 21.3% 38.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.8 ȱȱȱȱȱȱȱȱȱȱȱȱ67.8 UpperȱLimbȱ(Arm/ȱShoulder) 45.9% 21.5% 32.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 20.4 ȱȱȱȱȱȱȱȱȱȱȱȱ66.2 LowerȱLimbȱ(Leg) 62.3% 18.1% 19.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 22.0 ȱȱȱȱȱȱȱȱȱȱȱȱ61.7 Foot/Ankle 68.4% 17.7% 13.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 25.0 ȱȱȱȱȱȱȱȱȱȱȱȱ59.9 AllȱLowȱEnergyȱFractures 38.9% 21.8% 39.4%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 217.8 ȱȱȱȱȱȱȱȱȱȱȱȱ68.0 LowȱEnergyȱFractureȱwithȱOsteoporosisȱDiagnosis

%ȱLowȱEnergyȱFractureȱPatientsȱwithȱ OsteoporosisȱDiagnosis 4.0% 7.9% 12.0% 8.0%

SecondaryȱOsteoporosisȱDiagnosisȱ[3] ContributingȱCondition 50.0% 25.3% 24.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 78.3 ȱȱȱȱȱȱȱȱȱȱȱȱ64.7

VertebralȱFractureȱw/SpinalȱCordȱInjury ȱȱȱȱȱ*ȱ ȱȱȱȱȱ*ȱ ȱȱȱȱȱ*ȱ 0.0 NA

*ȱDoesȱnotȱmeetȱstandardsȱofȱreliability. [1]ȱOsteoporosisȱandȱrelatedȱconditionȱICDȬ9ȬCMȱcodesȱshownȱinȱtheȱTableȱ5.1. [2]ȱTreatmentȱforȱfractures,ȱexcludingȱthoseȱwithȱhighȱenergyȱcausesȱ(i.e.,ȱvehicularȱ[auto,ȱair,ȱwater]ȱaccidents,ȱwarȱinjuries,ȱviolence/abuse). [3]ȱDiagnosisȱofȱanotherȱmedicalȱconditionȱthatȱmayȱleadȱtoȱorȱcontributeȱtoȱtheȱdevelopmentȱofȱosteoporosis. Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ5.6:ȱHospitalȱEmergencyȱRoomȱResourceȱUtilizationȱforȱLowȱEnergyȱFracturesȱ [1]ȱforȱ PersonsȱAgedȱ45ȱandȱOlderȱbyȱAgeȱandȱSex,ȱUnitedȱStatesȱ2006

%ȱbyȱAgeȱGroup Totalȱ Meanȱ DistributionȱbyȱGender TotalȱEmergencyȱ 45ȱ&ȱOlderȱ Age RoomȱTreatmentsȱ FEMALES 45Ȭ64 65Ȭȱ74 75ȱȱ&ȱOlder (inȱ000s) ȱ(inȱyears) Females Males (inȱ000s)ȱ LowȱEnergyȱFractureȱ[2] Hip 12.7% 1.9% 85.4%ȱȱȱȱȱȱȱȱȱȱ 156.4 ȱȱȱȱȱȱȱȱȱȱȱȱ80.9 67% 33% 232.1 Wrist/Hand 47.5% 22.7% 29.8%ȱȱȱȱȱȱȱȱȱȱ 161.8 ȱȱȱȱȱȱȱȱȱȱȱȱ68.2 76% 24% 213.7 Vertebrae/Pelvic 13.3% 27.2% 59.6%ȱȱȱȱȱȱȱȱȱȱȱȱ 67.8 ȱȱȱȱȱȱȱȱȱȱȱȱ77.6 51% 49% 133.5 UpperȱLimbȱ(Arm/ȱShoulder) 37.7% 17.8% 44.5%ȱȱȱȱȱȱȱȱȱȱ 124.5 ȱȱȱȱȱȱȱȱȱȱȱȱ72.2 57% 43% 218.3 LowerȱLimbȱ(Leg) 38.1% 20.9% 40.9%ȱȱȱȱȱȱȱȱȱȱȱȱ 74.6 ȱȱȱȱȱȱȱȱȱȱȱȱ69.7 56% 44% 133.5 Foot/Ankle 49.2% 31.3% 19.4%ȱȱȱȱȱȱȱȱȱȱ 203.6 ȱȱȱȱȱȱȱȱȱȱȱȱ63.6 75% 25% 270.8 AllȱLowȱEnergyȱFractures 34.7% 18.5% 46.8%ȱȱȱȱȱȱȱȱȱȱ 809.0 ȱȱȱȱȱȱȱȱȱȱȱȱ71.7 68% 32% 1,192.0 %ȱw/OsteoporosisȱDx 0.0% 0.0% 3.1% 1.5%

MALES LowȱEnergyȱFractureȱ[2] Hip 19.8% 3.0% 77.3%ȱȱȱȱȱȱȱȱȱȱȱȱ 75.7 ȱȱȱȱȱȱȱȱȱȱȱȱ78.2 Wrist/Hand 53.7% 40.4% 6.0%ȱȱȱȱȱȱȱȱȱȱȱȱ 52.0 ȱȱȱȱȱȱȱȱȱȱȱȱ61.6 Vertebrae/Pelvic 42.5% 23.8% 33.7%ȱȱȱȱȱȱȱȱȱȱȱȱ 65.7 ȱȱȱȱȱȱȱȱȱȱȱȱ66.7 UpperȱLimbȱ(Arm/ȱShoulder) 54.0% 28.1% 17.9%ȱȱȱȱȱȱȱȱȱȱȱȱ 93.8 ȱȱȱȱȱȱȱȱȱȱȱȱ64.5 LowerȱLimbȱ(Leg) 65.6% 19.2% 15.2%ȱȱȱȱȱȱȱȱȱȱȱȱ 59.0 ȱȱȱȱȱȱȱȱȱȱȱȱ59.4 Foot/Ankle 92.1% 7.9% 0.0%ȱȱȱȱȱȱȱȱȱȱȱȱ 67.2 ȱȱȱȱȱȱȱȱȱȱȱȱ52.8 AllȱLowȱEnergyȱFractures 53.1% 19.3% 27.5%ȱȱȱȱȱȱȱȱȱȱ 383.0 ȱȱȱȱȱȱȱȱȱȱȱȱ65.0 %ȱw/OsteoporosisȱDx 0.0% 0.0% 0.0% 0.0%

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability

[1]ȱOsteoporosisȱandȱrelatedȱconditionȱICDȬ9ȬCMȱcodesȱshownȱinȱtheȱTableȱ5.1. [2]ȱTreatmentȱforȱfractures,ȱexcludingȱthoseȱwithȱhighȱenergyȱcausesȱ(i.e.,ȱvehicularȱ[auto,ȱair,ȱwater]ȱaccidents,ȱwarȱinjuries,ȱviolence/abuse). Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergencyȱRoom,ȱ2006

Tableȱ5.7:ȱHospitalȱDischargeȱtoȱShort/Intermediate/SkilledȱNursingȱCareȱforȱPersonsȱwithȱ OsteoporosisȱandȱRelatedȱConditionsȱ[1]ȱAgedȱ45ȱandȱOlderȱbyȱAgeȱandȱSex,ȱ UnitedȱStatesȱ2007

%ȱofȱTotalȱWITHȱȱCondition %ȱofȱTotalȱWITHOUTȱCondition

Allȱ45ȱ&ȱ Allȱ45ȱ&ȱ FEMALES 45Ȭ64 65Ȭ74 75ȱ&ȱOlder Over 45Ȭ64 65Ȭ74 75ȱ&ȱOlder Over PrimaryȱOsteoporosisȱȱ 16.5% 25.5% 40.0% 31.8% 10.9% 21.7% 34.5% 20.6%

LowȱEnergyȱFractureȱ[2] Hip 53.7% 76.7% 86.0% 80.5% 10.9% 21.4% 33.6% 20.5% Wrist/Hand 15.9% 37.1% 58.8% 40.8% 11.1% 22.0% 35.0% 21.3% Vertebrae/Pelvic 30.2% 49.1% 63.7% 54.7% 11.0% 21.9% 34.7% 21.1% UpperȱLimbȱ(Arm/Shoulder) 21.5% 42.1% 62.7% 46.8% 11.1% 22.0% 34.9% 21.3% LowerȱLimbȱ(Leg) 37.7% 65.0% 80.8% 60.9% 11.0% 21.9% 34.9% 21.2% Foot/Ankle 21.4% 49.2% 70.6% 40.4% 11.0% 21.9% 35.0% 21.3% AllȱLowȱEnergyȱFractures 29.4% 52.6% 69.5% 56.2% 10.6% 20.7% 31.3% 19.7%

MALES PrimaryȱOsteoporosisȱȱ 21.4% 28.0% 38.9% 31.7% 12.5% 19.1% 29.2% 17.5%

LowȱEnergyȱFractureȱ[2] Hip 53.7% 72.6% 84.2% 75.2% 12.4% 18.7% 28.5% 18.2% Wrist/Hand 18.5% 37.6% 54.1% 28.9% 12.5% 19.2% 29.4% 18.6% Vertebrae/Pelvic 27.6% 42.0% 57.9% 42.4% 12.4% 19.1% 29.2% 18.5% UpperȱLimbȱ(Arm/Shoulder) 22.6% 41.9% 58.7% 38.8% 12.5% 19.2% 29.3% 18.6% LowerȱLimbȱ(Leg) 27.1% 55.2% 72.7% 41.2% 12.4% 19.2% 29.3% 18.6% Foot/Ankle 16.2% 34.7% 59.1% 25.5% 12.5% 19.2% 29.4% 18.6% AllȱLowȱEnergyȱFractures 26.7% 49.2% 66.6% 47.2% 12.2% 18.6% 27.9% 17.9%

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ5.8:ȱOsteoporosisȱandȱRelatedȱConditionsȱ [1]ȱinȱNursingȱHomeȱPopulationȱAgedȱ65ȱandȱ Over,ȱUnitedȱStatesȱ2004

Prevalenceȱ(inȱ00s) Totalȱ ȱ65Ȭ74ȱ ȱ75Ȭ84ȱ ȱ85ȱ&ȱOverȱ ȱMaleȱ ȱFemaleȱ Populationȱ

DiagnosisȱatȱTimeȱofȱAdmittanceȱ(basedȱonȱageȱatȱtimeȱofȱadmission) PrimaryȱOsteoporosis ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ21.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ49.9 ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ71.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ76.4 LowȱEnergyȱFractureȱ(All) ȱȱȱȱȱȱȱȱȱȱȱȱȱ90.8 ȱȱȱȱȱȱȱȱȱȱȱ387.8 ȱȱȱȱȱȱȱȱȱȱȱ650.5 ȱȱȱȱȱȱȱȱȱȱȱ207.5 ȱȱȱȱȱȱȱȱȱȱȱ973.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,180.6 Hipȱȱȱȱȱȱȱȱȱȱȱȱȱ 35.0 ȱȱȱȱȱȱȱȱȱȱȱ171.6 ȱȱȱȱȱȱȱȱȱȱȱ302.6 ȱȱȱȱȱȱȱȱȱȱȱ103.4 ȱȱȱȱȱȱȱȱȱȱȱ411.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ515.1 Vertebrae/Pelvic ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ49.3 ȱȱȱȱȱȱȱȱȱȱȱ106.3 ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱ148.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ173.1 UpperȱLimbȱ(Arm,ȱShoulder) ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ35.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ32.9 ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ66.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ77.8 LowerȱLimbȱ(Leg)ȱȱȱȱȱȱȱȱȱȱȱȱȱ 25.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱ98.9 ȱȱȱȱȱȱȱȱȱȱȱ135.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47.0ȱ ȱȱȱȱȱȱȱȱȱȱȱ235.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ282.9 Ankle/Foot ȱȱ*ȱȱȱ*ȱȱȱ*ȱȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ42.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ51.7 SecondaryȱOsteoporosisȱConditionȱPresent ȱȱ*ȱ ȱȱȱ*ȱȱȱ*ȱ CurrentȱPrimaryȱDiagnosisȱ(basedȱonȱageȱatȱtimeȱofȱinterview) PrimaryȱOsteoporosis ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ33.8 ȱȱȱȱȱȱȱȱȱȱȱ104.4 ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱ149.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ152.5 LowȱEnergyȱFractureȱ(All) ȱȱȱȱȱȱȱȱȱȱȱȱȱ22.3 ȱȱȱȱȱȱȱȱȱȱȱ113.2 ȱȱȱȱȱȱȱȱȱȱȱ234.6 104.6ȱȱȱȱȱȱȱȱȱȱȱ 297.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ401.6 Hip ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ47.4 ȱȱȱȱȱȱȱȱȱȱȱ102.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱ36.8 ȱȱȱȱȱȱȱȱȱȱȱ122.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ159.5 Vertebrae/Pelvic ȱȱ*ȱȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ46.7 ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ52.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73.6 UpperȱLimbȱ(Arm,ȱShoulder) ȱȱ*ȱȱȱ*ȱȱȱ*ȱȱȱ*ȱ ȱȱȱ*ȱȱȱ*ȱ LowerȱLimbȱ(Leg) ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ29.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ47.3 ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ73.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ98.8 Ankle/Foot ȱȱ*ȱȱȱ*ȱȱȱ*ȱȱȱ*ȱ ȱȱȱ*ȱȱȱ*ȱ SecondaryȱOsteoporosisȱConditionȱPresent ȱȱ*ȱȱȱ*ȱȱȱ*ȱȱȱ*ȱ ȱȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29.0 CurrentȱSecondaryȱDiagnosisȱȱ(basedȱonȱageȱatȱtimeȱofȱinterview) PrimaryȱOsteoporosis ȱȱȱȱȱȱȱȱȱȱȱ155.9 ȱȱȱȱȱȱȱȱȱȱȱ666.7 ȱȱȱȱȱȱȱȱ1,272.0 ȱȱȱȱȱȱȱȱȱȱȱ170.6 ȱȱȱȱȱȱȱȱ2,018.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,188.8 SecondaryȱOsteoporosisȱConditionȱPresent ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ42.5ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ164.4ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ297.8ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ68.3 ȱȱȱȱȱȱȱȱȱȱȱ479.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ548.1 FallsȱandȱFracturesȱ(basedȱonȱageȱatȱtimeȱofȱinterview) ReportedȱFallȱWithinȱPastȱ6ȱMonths ȱȱ*ȱ ȱȱȱȱȱȱȱȱ1,849.0 ȱȱȱȱȱȱȱȱ2,560.0 ȱȱȱȱȱȱȱȱ1,498.0 ȱȱȱȱȱȱȱȱ3,719.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,217.0 SustainedȱHipȱFractureȱWithinȱPastȱ180ȱDays ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ95.0 ȱȱȱȱȱȱȱȱȱȱȱ141.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ69.0 ȱȱȱȱȱȱȱȱȱȱȱ206.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ276.0 SustainedȱOtherȱFractureȱWithinȱPastȱ180ȱDays ȱȱ*ȱ ȱȱȱȱȱȱȱȱȱȱȱ107.0 ȱȱȱȱȱȱȱȱȱȱȱ159.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ78.0 ȱȱȱȱȱȱȱȱȱȱȱ260.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ339.0

TotalȱNursingȱHomeȱPopulationȱAgedȱ65ȱ&ȱOlder,ȱ2004 ȱȱȱȱȱȱȱȱȱ1,741.2ȱ ȱȱȱȱȱȱȱȱ4,688.7 ȱȱȱȱȱȱȱȱ6,742.1 ȱȱȱȱȱȱȱȱ3,368.2 ȱȱȱȱȱȱȱȱ9,803.9 ȱȱȱȱȱȱȱȱȱȱȱȱ13,172.1

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability. [1]ȱOsteoporosisȱandȱrelatedȱconditionȱICDȬ9ȬCMȱcodesȱshownȱinȱtheȱTableȱ5.1. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱNursingȱHomeȱSurvey,ȱ2004

Tableȱ5.9:ȱSelfȬReportedȱFractureȱ(Ever)ȱforȱPersonsȱAgedȱ45ȱandȱ OverȱbyȱAgeȱandȱSex,ȱUnitedȱStatesȱ2001Ȭ2006

FEMALES Rateȱperȱ100ȱPersons 45Ȭ64 65Ȭ74 75Ȭ84 85ȱ&ȱOlder ȱ45ȱ&ȱOver BrokenȱorȱFracturedȱHip 0.6 1.6 3.4 11.5 1.7 BrokenȱorȱFracturedȱWrist 8.2 11.4 13.6 16.1 9.8 BrokenȱorȱFracturedȱSpine 1.8 2.6 3.3 8.4 2.5

%ȱofȱFirstȱFracturesȱCausedȱbyȱaȱFallȱ[1] BrokenȱorȱFracturedȱHip 66% 76% 87% 98% 88% BrokenȱorȱFracturedȱWrist 88% 99% 97% 98% 95% BrokenȱorȱFracturedȱSpine 72% 82% 82% 88% 83%

MeanȱAgeȱofȱFirstȱFractureȱCausedȱbyȱaȱFallȱ(inȱyears) BrokenȱorȱFracturedȱHipȱȱȱȱȱȱȱȱȱȱȱȱ 55.3 ȱȱȱȱȱȱȱȱȱȱȱȱ62.8 ȱȱȱȱȱȱȱȱȱȱȱȱ73.4 ȱȱȱȱȱȱȱȱȱȱȱȱ79.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73.4 BrokenȱorȱFracturedȱWristȱȱȱȱȱȱȱȱȱȱȱȱ 53.9 ȱȱȱȱȱȱȱȱȱȱȱȱ61.4 ȱȱȱȱȱȱȱȱȱȱȱȱ67.3 ȱȱȱȱȱȱȱȱȱȱȱȱ74.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ63.3 BrokenȱorȱFracturedȱSpineȱȱȱȱȱȱȱȱȱȱȱȱ 59.2 ȱȱȱȱȱȱȱȱȱȱȱȱ66.2 ȱȱȱȱȱȱȱȱȱȱȱȱ67.9 ȱȱȱȱȱȱȱȱȱȱȱȱ80.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ71.2

MALES Rateȱperȱ100ȱPersons 45Ȭ64 65Ȭ74 75Ȭ84 85ȱ&ȱOlder ȱ45ȱ&ȱOver BrokenȱorȱFracturedȱHip 1.5 2.8 3.2 7.4 2.1 BrokenȱorȱFracturedȱWrist 12.5 12.5 8.8 6.5 12.0 BrokenȱorȱFracturedȱSpine 3.8 2.7 3.9 3.5 3.6

%ȱofȱFirstȱFracturesȱCausedȱbyȱaȱFallȱ[1] BrokenȱorȱFracturedȱHip 41% 43% 81% 82% 64% BrokenȱorȱFracturedȱWrist 72% 79% 89% 100% 79% BrokenȱorȱFracturedȱSpine 54% 12% 62% 86% 58%

MeanȱAgeȱofȱFirstȱFractureȱCausedȱbyȱaȱFallȱ(inȱyears) BrokenȱorȱFracturedȱHipȱȱȱȱȱȱȱȱȱȱȱȱ 59.6 ȱȱȱȱȱȱȱȱȱȱȱȱ63.6 ȱȱȱȱȱȱȱȱȱȱȱȱ73.5 ȱȱȱȱȱȱȱȱȱȱȱȱ82.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ72.9 BrokenȱorȱFracturedȱWristȱȱȱȱȱȱȱȱȱȱȱȱ 53.5 ȱȱȱȱȱȱȱȱȱȱȱȱ61.2 ȱȱȱȱȱȱȱȱȱȱȱȱ61.6 ȱȱȱȱȱȱȱȱȱȱȱȱ74.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ60.0 BrokenȱorȱFracturedȱSpineȱȱȱȱȱȱȱȱȱȱȱȱ 56.7 ȱȱȱȱȱȱȱȱȱȱȱȱ52.0 ȱȱȱȱȱȱȱȱȱȱȱȱ67.2 ȱȱȱȱȱȱȱȱȱȱȱȱ82.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ63.6

[1]ȱSelfȬreportedȱcauseȱasȱaȱȈfall/tripped/slipped/fellȱoutȱofȱbedȈȱorȱȈhardȱfallȱoffȱ ladder/stool/downstairs.Ȉ

Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱ SurveyȱData,ȱ2001Ȭ2006

Tableȱ5.10:ȱLowȱEnergyȱFracturesȱ[1]ȱTreatedȱasȱInpatientȱorȱEmergencyȱRoomȱVisitsȱforȱPersonsȱ Agedȱ45ȱandȱOverȱbyȱAnatomicȱSiteȱbyȱSex,ȱUnitedȱStatesȱ2006/2007ȱ

InpatientȱTreatmentȱ[2] Females Males Total %ȱofȱTotalȱ %ȱofȱTotalȱ %ȱofȱTotalȱ Prevalence Prevalence Prevalence Fractureȱ Fractureȱ Fractureȱ ȱ(inȱ000s)ȱ[4] ȱ(inȱ000s)ȱ[4] ȱ(inȱ000s)ȱ[4] Sites Sites Sites Hipȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 140.0 35.1%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.6 33.8% 205.6 34.7% Wrist/Handȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 33.0 8.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 14.1 7.3% 47.1 7.9% Vertebrae/Pelvicȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 81.9 20.5%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.8 24.1% 128.7 21.7% UpperȱLimbȱ(Arm/Shoulder)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.0 11.5%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 20.4 10.5% 66.4 11.2% LowerȱLimbȱ(Leg)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.7 11.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 22.0 11.3% 68.7 11.6% Foot/Ankleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 51.4 12.9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 25.0 12.9% 76.4 12.9% AllȱLowȱEnergyȱFracturesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 459.3 100.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 217.8 100.0% 677.1 100.0%

EmergencyȱRoomȱTreatmentȱ[3] Females Males Total %ȱofȱTotalȱ %ȱofȱTotalȱ %ȱofȱTotalȱ Prevalence Prevalence Prevalence Fractureȱ Fractureȱ Fractureȱ ȱ(inȱ000s)ȱ[4] ȱ(inȱ000s)ȱ[4] ȱ(inȱ000s)ȱ[4] Sites Sites Sites Hipȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 156.5 19.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 75.7 19.2% 232.2 19.6% Wrist/Handȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 161.8 20.5%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 52.0 13.2% 213.8 18.1% Vertebrae/Pelvicȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.8 8.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 65.7 16.7% 133.5 11.3% UpperȱLimbȱ(Arm/Shoulder)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 124.5 15.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 73.8 18.8% 198.3 16.8% LowerȱLimbȱ(Leg)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 74.6 9.5%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 59.0 15.0% 133.6 11.3% Foot/Ankleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 203.6 25.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.2 17.1% 270.8 22.9% AllȱLowȱEnergyȱFracturesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 809.0 100.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 383.0 100.0% 1192.0 100.0%

[1]ȱTreatmentȱforȱfractures,ȱexcludingȱthoseȱwithȱhighȱenergyȱcausesȱ(i.e.,ȱvehicularȱ[auto,ȱair,ȱwater]ȱaccidents,ȱwarȱinjuries) [2]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱHospitalȱEmergencyȱRoom,ȱ2006 [4]ȱMultipleȱfracturesȱsitesȱperȱpatientȱpossible.

Tableȱ5.11:ȱInpatientȱCostȱAssociatedȱwithȱOsteoporosisȱ[1]ȱandȱLowȱEnergyȱFracturesȱ [2]ȱforȱPersonsȱAgedȱ45ȱandȱOlder,ȱUnitedȱStatesȱ2007ȱ

Prevalenceȱ MeanȱLengthȱofȱ MeanȱCostȱperȱ EstimatedȱTotalȱ (inȱ000s) Stayȱ(inȱdays) PatientȱStay Costȱ(inȱbillions) OsteoporosisȱDiagnosisȱPatients OsteoporosisȱWithoutȱFracture 658.8 5.0 ȱ$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27,737ȱ $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.27 OsteoporosisȱWithȱLowȱEnergyȱFractureȱ[2] 140.9 5.4 ȱ$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ32,176ȱ $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.53 OsteoporosisȱWithȱHighȱEnergyȱFractureȱ[2] 2.6 5.7 ȱ$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ38,202ȱ $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.10 AllȱOsteoporosisȱDiagnosis 802.4 5.1 ȱ$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ28,549ȱ $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22.91

NonȬOsteoporosisȱPatientsȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 18,710.4 5.3$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 34,204 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ639.97

LowȱEnergyȱFractureȱPatients Hipȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 205.8 6.6$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 42,390 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.72 Wrist/Handȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 47.3 4.9$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 32,330 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.53 Vertebrae/Pelvicȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 128.8 6.4$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 38,508 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.96 UpperȱLimbȱ(Arm/Shoulder)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.6 5.4$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 35,688 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.38 LowerȱLimbȱ(Leg)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 68.9 5.8$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 39,303 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.71 Foot/Ankleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 76.7 4.4$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 27,667 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.12 AllȱLowȱEnergyȱFracturesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 678.1 6.1$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 37,982 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25.76

AllȱHighȱEnergyȱFractures 64.6 7.7$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 61,827 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.99 NonȬFractureȱPatientsȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 18,767.6 5.2$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 33,739 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ633.20

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Chapter 6 Musculoskeletal Injuries

More than three of every fi ve unintentional accidents, motor vehicle crashes, civilian injuries that occur annually in the United States interpersonal violence, war injuries, stress injuries, are to the musculoskeletal system. Although the over-exertion, and repetitive workplace injuries. incidence of total unintentional injuries is diffi cult to estimate, numerous databases and reports have In 2006/2007, more than 61.2 million annual shown that a consistent 60% to 67% of injuries episodes of treatment for musculoskeletal injuries that occur annually involve the musculoskeletal were recorded in physician offi ces, emergency system. (Table 6.1 and Graph 6.0.1) rooms, outpatient clinics, and hospitalizations. This compares to 100.4 million episodes of Graph 6.0.1: Musculoskeletal Injuries as Propotion treatment for all kinds of injuries, including burns, of Total Injuries, United States 1992-1994, 2000, 2005, and 2006/2007 poisoning, and drowning. 100

80 Section 6.1: Prevalence of 63.7% 66.8% 67.1% 60.9% Musculoskeletal Injuries 60

40 While the number of self-reported injury Musculoskeletal 20 episodes has been declining since 1997 and is % of Total Injuries that are % of Total believed to be under-reported,1 the distribution 0 Self-Reported Musculo- Self-Reported Injury of types of musculoskeletal injuries is similar Injury skeletal Injury Treatment for both self-reported and injury treatment Episodes, Injuries, Episodes, Episodes, 1992-1994 [1] 2000 [2] 2005 [3] 2006/2007 [4] episodes. In 2008, persons in the civilian [1] Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the non-institutionalized population self-reported United States, 1999. American Academy of Orthopaedic Surgeons, Rosemont, IL. P. 83. 22.8 million musculoskeletal injury episodes in [2] Finkelstein EA, Corso PS, Miller TR. The Incidence and the annual National Health Interview Survey. This Economic Burden of Injuries in the United States. 2006. Oxford University Press, New York, NY. P. 13. compares to an annual average of 36.9 million [3] National Center for Health Statistics. National Health Interview Survey, 2005 musculoskeletal injury episodes reported in [4] National Center for Health Statistics. National Ambulatory the same survey 1992-1994,2 and to 61.2 million Medical Care Survey, 2006; National Hospital Ambulatory Medical Care Survey, Emergency Room Visits, 2006; National Hospital musculoskeletal injury treatment episodes in Ambulatory Medical Visits, Outpatient Department Visits, 2006; Agency for Healthcare Research and Quality, Healthcare Cost and physician offi ces, emergency rooms, outpatient Utilization Project, Nationwide Inpatient Sample, 2007. clinics, and hospitalizations reported in 2006/2007. (Table 6.2) Injury treatment episodes in 2006/2007 Musculoskeletal injuries are injuries occurring refl ect actual injury burden more reliably than to the neck, spine, pelvis and extremities; they self-reported injury episodes and will defi ne the include fractures, derangements, dislocations, musculoskeletal injury burden in this chapter. sprains and strains, contusions, crushing injuries, open wounds, and traumatic amputations. The Section 6.1.1: Musculoskeletal Injuries by Type most common cause of musculoskeletal injuries is falls. Additional major causes of musculoskeletal Among self-reported musculoskeletal injuries, injuries are sports injuries, playground sprains and strains were the most frequent, accounting for 44%. Fractures, representing 25%

of self-reported musculoskeletal injuries, were the Sprains and strains accounted for nearly 18.4 second most frequent. Among musculoskeletal million musculoskeletal injury treatment episodes injury treatment episodes, these two types of in 2006/2007, with 7.5 million treated in persons injuries were nearly equal, accounting for 30% aged 18 to 44, the most common age in which a and 26% of the total injury treatment episodes, sprain or strain is reported and treated. respectively. Open wounds and contusions accounted for 16% to 17% of both self-reported Open wounds are the third most frequently treated and injury treatment episodes, while dislocations musculoskeletal injury, accounting for more than accounted for 5% of injury treatment episodes and 10.2 million injury treatment episodes in 2006/2007. only 2% of self-reported injury episodes. (Table 6.3 Open wounds were treated in the highest number and Graph 6.1.1) among persons aged 18 to 44 years, but the rate was highest among the persons aged 65 years and Nearly 16.2 million fractures were treated in older. Open wounds are more commonly treated in physician oﬃ ces, emergency and outpatient clinics, males (6.0 million treatment episodes) than females and hospitals in 2006/2007. (Table 6.4) Nearly 3.0 (4.2 million treatment episodes). million of these occurred in young males under the age of 18, while another 2.5 million occurred in Nearly as many treatment episodes were for females aged 65 and over. contusions (10.0 million) as for open wounds in 2006/2007. Treatment for contusions is highest among persons aged 65 and over, with females accounting for the bulk of this higher rate.

Graph 6.1.1: Distribution of Injury Treatment Episodes and Self-Reported Injuries by Type of Musculoskeletal Injury by Sex and Age, United States 2006/2007 and 2008

100%

80%

60%

40%

% Total Treatment Episodes Treatment % Total 20%

0% Total Females Males <18 18-44 45-64 65 & Total Females Males <18 18-44 45-64 65 & Years Years Years Over Years Years Years Over

Injury Treatment Episodes [1-4] Self-Reported Injury Episodes [5]

[1] Source: National Center for Health Statistics, National Fractures Ambulatory Medical Care Survey, 2006 [2] Source: National Center for Health Statistics, National Dislocations Hospital Ambulatory Medical Care Survey, Emergency Room Visits, 2006 Sprains and Strains [3] Source: National Center for Health Statistics, National Hospital Ambulatory Medical Visits, Outpatient Department Visits, 2006 Contusions [4] Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Open Wounds Sample, 2007 [5] National Center for Health Statistics. National Health All Other Musculoskeletal Injuries Interview Survey, 2008

Graph 6.1.2: Rate of Musculoskeletal Injury Treatment 100 persons. Among males under the age of 18, Episodes by Sex and Age, United States 2006/2007 the fracture injury treatment rate was 7.9 per 100 35 persons, while females of this age were treated 30 25 for fractures at a rate of 4.3 per 100 persons. 20 Among females aged 65 and older, fracture injury 15 treatment rates were 11.7 per 100, while men in 10 5 this age group were treated for fractures at a much Rate per 100 Persons 0 <18 18-44 45-64 65 & All lower (6.8 per 100 persons) rate. (Table 6.4) Years Years Years Over Ages Females Males Females aged 65 and older were treated at higher Sources: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006; National Hospital Ambulatory Medical rates than males of the same age for fractures, Care Survey, Emergency Room Visits, 2006; National Hospital Ambulatory Medical Visits, Outpatient Department Visits, 2006; sprains and strains, and contusions. Males aged Agency for Healthcare Research and Quality, Healthcare Cost and 65 and older were treated for dislocations, open Utilization Project, Nationwide Inpatient Sample, 2007 wounds, and other musculoskeletal injuries at higher rates than females, although the diff erences Section 6.1.2: Rate of Musculoskeletal Injuries by were less pronounced. (Table 6.4) Age and Sex Among the young, aged 18 and under, males had The 2006/2007 annual rate of all injury, and of higher rates of injury treatment for all types of musculoskeletal injury treatment episodes, was injury than did females with the exceptions of slightly higher for males than for females. (Table dislocations and other types of musculoskeletal 6.4 and Graph 6.1.2) Overall in 2006/2007, persons injuries, which had similar rates. Overall, aged 65 and over were more likely to sustain musculoskeletal treatment rates of 20.0 and 14.3 any type of injury (43.6 per 100 persons) or a per 100 persons in males and females, respectively, musculoskeletal injury (26.6 per 100 persons) than occurred in this age group. (Table 6.4) were persons of any other age group. Males between the ages of 18 and 44 were treated In 2006/2007, musculoskeletal injury rates among for musculoskeletal injuries at substantially males was similar between all age groups; a steady higher rates than females in this age group, increase in the rate of injury was found among 23.4 versus 14.9 per 100 persons, respectively. females as they aged. Injury rates by age group Rates of treatment in males were higher for all were fairly consistent among males, ranging from types of injuries, with the fractures, sprains and 20.0 per 100 males under the age of 18 to 23.4 per strains, and open wounds showing the greatest 100 males aged 18 to 44. Among females, the rate diff erence in treatment rate. Between the ages of of injury by age group varied from 14.3 per 100 45 and 64, the musculoskeletal injury rate between females under the age of 18 to 30.4 per 100 females females and males began to converge, but only aged 65 and over. Fractures are the most common contusions and open wounds were reported at a musculoskeletal injury in both young males and higher level among females than males. Overall older females, while sprains and strains are more in this age group, males show a higher rate of common among males and females between the musculoskeletal injury treatment (23.0 per 100 ages of 18 and 64. persons) than females (21.0 per 100). (Table 6.4) In 2006/2007, fractures accounted for 26% of the 61.2 million musculoskeletal injuries treated in physician offi ces, emergency and outpatient clinics, and hospitalizations. The overall fracture injury treatment rate in 2006/2007 was 5.4 per

Graph 6.1.3: Total Fracture Treatment Episodes by Selected Anatomic Wrist, hand, and ﬁ nger fractures Site , United States, 1998-2006 accounted for about one-half or more of 15,000 upper limb fractures across the years, with forearm fractures accounting for 12,000 more than 90% of the remaining upper

9,000 limb fractures. Fractures to the upper arm, or humerus, accounted for 8% or 6,000 less of all reported treatment episodes for upper limb fractures. Fractures of 3,000 the ankle, foot or toes accounted for Fracture Treatment Visits (in 000s) Visits Fracture Treatment 0 approximately three-fourths of treated 1998 2000 2002 2004 2006 lower limb fractures. The majority of Total Upper Total Lower All Fractures of fractures, 62% to 71%, were treated in a Limb Fractures Limb Fractures Upper/Lower Limb physician’s offi ce. Fewer than one in ten Sources: National Center for Health Statistics, National Hospital Discharge Survey, 1998-2006; National Center for Health Statistics, National Hospital Ambulatory fractures (8% or less) were treated with Medical Care Survey, Emergency Room Visits, 1998-2006; National Center for Health Statistics, National Hospital Ambulatory Medical Visits, Physician Visits, 1998-2006 inpatient hospitalization in any given year. (Table 6.5a) Section 6.1.3: Fracture Trends Section 6.2: Location and Causes of The total number of fractures of the upper and Musculoskeletal Injuries lower extremities treated in physician offi ces, emergency departments, and hospitals, while fl uctuating year to year, has remained fairly The most common location where musculoskeletal constant since 1998. (Table 6.5 and Graph 6.1.3) injury episodes occur is in the home. In 2008, In 1998, 13.65 million treatment episodes for nearly one in two of the 22.1 million self-reported fractures of the upper and lower limbs were injury episodes occurred in or around the home. reported; in 2004, 12.91 million were treated. Musculoskeletal injury episodes that occurred Upper limb fractures account for 53% to 59% of the in automobile or pedestrian related incidents— total fractures treated, while lower limb fractures injuries that occurred on the streets or highways— accounted for 42% to 48% across the years. (Table accounted for only 7% of the reported injury 6.5a) episodes. An additional 9% of musculoskeletal injury episodes occurred while participating in sport activities, while 9% occurred in schools. The remaining 26% occurred in other Graph 6.2.1: Location of Musculoskeletal Injury Episode Occurrence, locations, including shopping centers and United States 2008 30% restaurants. (Table 6.6 and Graph 6.2.1)

25% Falls were the leading cause of nonfatal 20% unintentional injuries treated in hospital 15% emergency departments in 2008 for all age 10% groups. (Table 6.7 and Graph 6.2.2) Falls Injury Episodes 5% occurred at a rate of 25.0 per 1,000 persons % of Total Musculoskeletal % of Total 0% and accounted for 8.5 million of the 27.9 Inside Outside School Street Sport or Shopping Other Unknown Home Home or Recreation Center/ million nonfatal unintentional injuries Highway Facility Restaurant reported by the Centers for Disease Source: National Center for Health Statistics. National Health Interview Survey, Control as treated in hospital emergency Injury Database, 2008

Graph 6.2.2: Nonfatal Unintentional Injuries more than one-third (37%) of the reported 188,000 Treated in Hospital Emergency Departments, incidents in which a pedestrian was struck. (Table United States 2008 6.11) 3% Falls Struck By/ Contusion or bruising injuries were reported in 22% 31% Against 18% of all accidents, with a high level occurring in Overexertion incidents that involved motor vehicles, either as Motor Vehicle 7% Occupant a passenger or as a pedestrian struck by a motor 9% 16% Cut/Pierce vehicle. 12% Other Causes Unknown Section 6.3: Musculoskeletal Injury Source: Centers for Disease Control, National Sites Center for Injury Prevention and Control, WISQARSTM (Web-based Injury Statistics Query and Reporting System), Nonfatal Unintentional Injury Reports treated in Emergency Department. The Centers for Disease Control estimates that Available at: ĴǱȦȦ ǯǯȦ ȦȦȱ ęŘŖŖŗǯǯȱȱȱȱŗŖǰȱŘŖŖşǯ more than 50 million injuries occurred in 2000.4 Traumatic brain injuries, injuries to the torso, departments in the United States in 2008. Falls systemwide injuries, and unspecifi ed injuries accounted for 64% of the nonfatal injuries treated represented nearly all the fatal injuries; however, 3 for persons aged 65 and older. (Table 6.8) injuries to the upper and lower extremities accounted for the greatest number of hospitalized Falls were also the leading cause of death in and non-hospitalized injury episodes. (Table 6.12) unintentional injuries for persons aged 75 and 3 over in 2008, accounting for nearly 14,258 of the Fractures occur most frequently in the upper 20,823 deaths due to unintentional injury in this limb, including the hand, fi ngers, wrist, and arm. age group. The rate of death from falls for persons Of the 10.4 million fractures (9.9 million fracture aged 75 to 84 years was 47.7 per 100,000 persons; episodes) treated in physician offi ces in 2006, that rate jumped to 152.1 per 100,000 among 38% were fractures of the upper limb. (Table 6.13 persons aged 85 years and older. (Table 6.9) In and Graph 6.3.1) Lower limb fractures treated in 1984, 54% of falls resulting in death occurred in the physician home; by 2004, the proportion had risen to 63%. offi ces, ȱȱ ȱŜǯřǯŗǱȱȱȱ¢ȱȱĜȬȱ (Table 6.10) including ȱȱȱȱȱȱȱȱǰ ȱȱȱȱŘŖŖŜ the leg, The most frequently self-reported type of injury is knee cap, Radius and Ulna (Arm) a sprain, strain or twist, accounting for one-third Hand and Fingers ankle, Ankle (32%) of all self-reported injury episodes, including and foot Humerus (Shoulder) burns and bites, in 2008. (Table 6.11) Motor vehicle and toes, Foot and Toes incidents were the cause of more sprain, strain or accounted Wrist Tibia and Fibula (Leg) * twist injuries than any other reported mechanism, for 36% with more than one-half (56%) of persons involved Femur * of treated Vertebral Column * in a motor vehicle incident reporting a sprain/ fractures. Clavicle or Scapula * strain injury. Fractures Ribs and Sternum * of the Neck of Femur (Hip) & Pelvis * Fractures occurred in one-in-four (27%) of the 1.5 Patella (Knee) ankle 0% 3% 6% 9% 12% 15% million accidents involving sports equipment (e.g., and foot All listed diagnoses. * Data does not meet standards of reliability. bikes, scooters, skate-boards, skis, skates) and in and toes Source: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 29% of the 11.1 million falls. Fractures occurred in accounted

for nearly two-thirds (64%) of lower limb fractures. ankle and knee were the most commonly reported The shoulder was the third most frequently injury sites. Persons aged 18 to 44 years reported fractured site, accounting for 12% of all fractures. injury to their ankle and back about equally, accounting for about one-fourth of all reported ȱȱ ȱŜǯřǯŘǱȱȱȱ¢ȱȱĜȬȱ ȱȱȱȱȱȱȱȱȱ More than musculoskeletal injuries. Persons aged 45 to 64 ȱȱǰȱȱȱŘŖŖŜ one-third years reported back, knee, and foot/toe injuries 5% (38%) of the most frequently. Injuries among persons aged

18% the 16.6 65 and over were reported among all sites more 38% million evenly than for other age groups. ŗŖ% sprain 8% and strain 22% Section 6.4: Musculoskeletal Injury injuries Limitations All listed diagnoses. treated in Source: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 physician offi ces in Musculoskeletal injuries are oft en a cause of 2006 were physical limitations in the ability to perform to the back and sacroiliac. Shoulder (22%) and activities of daily living (e.g., eating, personal care, ankle and foot injuries (18%) represented the other and dressing). In 2006, more than four out of every two most common anatomic sites for sprains and 100 persons (4.3) reported they were currently strains treated in physician offi ces. (Table 6.13 and experiencing limitations in their ability to perform Graph 6.3.2) daily activities as a result of a fracture or bone/ joint injury. (Table 6.15 and Graph 6.4.1) Among A substantial majority of the 3.4 million dislocation persons aged 65 and over, the rate with limitations injury episodes (74%) treated in 2006 were treated was nearly 13 out of 100 due to fracture or bone/ in physician offi ces. Dislocation of the knee or joint injury. With the exception of persons aged 18 leg joint represented 77% of these injuries, with to 44, males are more likely to report a limitation the shoulder (8%) the only other anatomic site in ability to perform activities of daily living due to to account for more than a very small fraction of fracture or other bone/joint injury than are women. dislocations. (Table 6.13) This fi nding is likely an artifact of an ICD-9 coding anomaly. Isolated acute Many common chores around the house are ligamentous injuries of the knee, (i.e., anterior reported as diffi cult to perform by persons with a cruciate ligament [ACL], medial collateral ligament musculoskeletal injury. As many as 82% of persons [MCL], posterior cruciate ligament [PCL], and Graph 6.4.1 : Rate of Activity Limitations due to Fracture lateral collateral ligament [LCL] disruptions) are or Bone/Joint Injury [1] by Gender and Age for Persons coded as dislocations using ICD-9 methodology, Aged 18 and Over, United States 2005-2006 whereas equivalent injuries in other joints are Female Male Total 15 coded as sprains or strains rather than dislocations. 12 True complete dislocations of the knee joint are actually quite rare, and associated with marked 9 morbidity. 6 3 fracture or bone/joint injury (per 100 persons) The annual National Health Interview Survey Rate of limitations due to 0 18-44 45-64 65-74 75 & All (NHIS) provides data on self-reported injuries. In years years years over ages the 2008 NHIS, injuries to the ankle, back and knee [1] Responded “yes” to fracture or bone/joint injury when asked "What ȱȱȱȱȱ¢ȱȱȱĜ¢ȱ ȱȱȱ were reported by approximately 10% of persons, help with the following activities." the most frequent of all anatomic sites. (Table 6.14) Source: National Center for Health Statistics. National Health and Nutrition Examination Survey, 2005-2006 Among persons under the age of 18, injuries to the

Graph 6.4.2: Activities "Unable to Perform" due to Fracture However, “standing on their feet for two hours of Bone/Joint Injury for Persons Aged 18 and Over, or more” was reported by the highest percentage United States 2001-2006 (19%) as “unable to perform.” ȱȱȱȱǻǯǯǰȱŘȱǼ ǰȱǰȱȱ In 2008, 6.8 million persons over the age of 18 Push or pull large objects like a chair [3] reported spending a mean of 11.8 days in bed due ĞȦ¢ȱŗŖȱȱ to a fracture or bone/joint injury, resulting in a total Doing chores around the houe ȱȱȱȱȱ of 76.4 million bed days. Bed days are deﬁ ned as Participating in social activities illness or injury that kept a person in bed more ȱǰȱȱȱȱ than one-half of a day, excluding hospitalization. ĴȱȱǲȱȱǻǯǯǰȱŘȱǼ An additional 18.7 million reported a mean of 15.4 Walking quarter mile (2-3 blocks) bed days due to back or neck problems, for a total Reaching over head

ȱȱ¢ȱȱǽŗǾ of 288.1 million bed days. Overall, musculoskeletal Managing money or paying bills Moving around rooms on same level conditions, including arthritis and rheumatism, Preparing own meals were responsible for 67% of all bed days reported Waking up 10 steps without resting for seven chronic or traumatic health conditions 0% 5% 10% 15% 20% in the United States in 2008, with musculoskeletal Ɩȱȱȱȱ¢ȱǽŘǾ ǽŗǾȱȈȱȱȱȱȱȱ¢ȱȱȱĜ¢ȱ ȱȱ injuries accounting for 10% of 2008 bed days. ȱȱ ȱȱ ȱȈȱ (Tables 6.17 and 6.19 and Graph 6.4.3) ǽŘǾȱȈ¢ȱ¢ȱȱ ȱȱ¢ȱȱǰȱ ȱȱĜȱ ȱ¢ȱȱǯǯǯȈȱ Ǳȱȱȱȱ ȱǯȱȱ ȱȱȱ Sixteen percent (16%) of persons reporting they ¡ȱ¢ǰȱŘŖŖŗȬŘŖŖŜǯ had been in the paid workforce over the previous reporting a musculoskeletal injury reported 12 months also reported missing a mean of 15.1 they are “some(what)” unable or “unable to do” days from work due to fractures, bone, or joint twenty common tasks of daily living. (Table 6.16 injury, for a total of 64.4 million lost work days. and Graph 6.4.2) The most frequently mentioned A missed work day is deﬁ ned as absence from limitation due to a fracture or bone/joint injury work due to illness or injury in the past 12 months, was “stooping, crouching or kneeling,” with 82% excluding maternity or family leave. Although reporting some degree of diﬃ culty doing this. other types of injuries were reported by only 9% of

Graph 6.4.3: Proportion of Bed Days Resulting from Graph 6.4.4: Proportion of Lost Work Days Resulting Selected Health Conditions for Persons Aged 18 and from Selected Health Conditions for Persons Aged 18 Over, United States 2008 and Over, United States 2008

67% 73%

Respondents reported 'Yes' when asked "Are you limited in any way in Respondents reported 'Yes' when asked "Are you limited in any way in any activities because of physical, mental or emotional problems." any activities because of physical, mental or emotional problems."

Respondents reported the number of days illness or injury kept them Respondents reported the number of days absent from work due to illness or injury in the past 12 months, excluding maternity or family in bed more than half of the day, including overnight hospitalization. leave. [1] Includes back/neck pain, arthritis/rheumatism, and [1] Includes back/neck pain, arthritis/rheumatism, and fracture/bone/joint pain. fracture/bone/joint pain.

Source: National Center for Health Statistics. National Health Source: National Center for Health Statistics. National Health Interview Survey, Adult Sample 2008 Interview Survey, Adult Sample 2008

the workforce, mean lost work days were much Section 6.5.1: Trends in Workplace Musculoskeletal higher at 28.7 days, for a total of 34.4 million lost Disorders work days due to non-musculoskeletal types of injuries. (Tables 6.18 and 6.19 and Graph 6.4.4) Although the rate of nonfatal occupational injuries and illnesses has decreased over the past 15 years, Section 6.5: Workplace Injuries the relative percentage of MSD cases fl uctuated within a narrow range of 30% to 34% from 1992 to 2006. In 2007, the ratio dropped below 30% Cumulative and repetitive motion injuries, also for the fi rst time (29%). (Table 6.20 and Graph described as musculoskeletal disorders (MSDs), 6.5.1) During this same time frame, total cases occur when the body reacts to strenuous motion of work-related injuries and illnesses dropped (i.e., bending, climbing, crawling, reaching, from 2.33 million in 1992 to 1.16 million in 2007, a twisting), overexertion, or repetitive motion. MSD change of 50%. At the same time, MSDs declined injuries include sprains, strains, tears, back pain, from 784,100 to 335,400, a change of 57%. soreness, carpal tunnel syndrome, hernia, and musculoskeletal system and connective diseases. The distribution of MSD injuries by type of MSD cases are more severe than the average injury has remained essentially constant over the nonfatal workplace injury or illness, typically past six years, as has the distribution between involving an average of 2 additional days away males (62%-64%) and females (36%-38%). (Table from work.5 In 2007, the median number of days 6.22) Slightly more than one-half (56%) of all away from work for all workplace injuries was 7 sprain, strain, and tear injuries resulting in days days; for MSD injuries, the median was 9 days. away from work in 2007 were classifi ed as an MSD injury. Although sprains, strains and tears In addition to MSD injuries as defi ned above, represent about 40% of total workplace injuries musculoskeletal workplace injuries include and illnesses involving days away from work, fractures, bruises/contusions, and amputations. they represent three-fourths (75.3%) of all MSD

Graph 6.5.1: Trend in Number and Proportion of Nonfatal Musculoskeletal Disorders (MSD) Occupational Injuries and Illnesses Involving Days Away from Work, United States 1992-2007 100 35% % Away From Work Due to MSD Injuries 90

50 30%

Total MSD Workplace Injuries (in 10,000s) MSD Workplace Total 10

0 25% 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

All MSD Workplace Injuries % of All Full Time Workers Away From Work Source (1992 to 1997): U.S. Department of Labor, Bureau of Labor Statistics: Worker Health Chartbook 2004. Available at: hĴp:ȦȦwww2a.cc.ovȦnioshȬChartbookȦimaeetail.aspǵimiƽ77. Accesse Auust 24, 2007.

Source (1998 to 2007): U.S. Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses an Fatalities roram: Case an Demoraphic Characteristics for WorkȬrelate Injuries an Illnesses Involvin Days Away from Work. Table 10. umber, percent, an incience rate of nonfatal occupational injuries an illnesses involvin ays away from work by selecte worker an case characteristics an musculoskeletal isorers, All Unite States, private inustry, 2006 an 2007. Available at: hĴp:ȦȦwww.bls.ovȦiifȦoshwcȦoshȦcaseȦostb1790.pf an hĴp:ȦȦwww.bls.ovȦiifȦoshwcȦoshȦcaseȦostb1941.pf. Accesse ovember 11, 2009.

Graph 6.5.2: Proportion of Musculoskeletal Disorders (MSD) sprains/strains/ Graph 6.5.3: Rate of Nonfatal Occupational by Type for Nonfatal Occupational Injuries [1] and Illnesses tears, while Injuries Involving Days Away from Work Involving Days Away from Work, United States 2007 Asians report for Full Time Workers by Sex, United States 2007 tendonitis 150 injuries in Total a higher 120 Female proportion than 90 75.3% overall injuries. Male (Table 6.24 and 60

Graph 6.5.4) 30

[1] Multiple injuries per case possible; percentages based on total injuries, Rate per 10,000 Full Time Workers 0 which may be > total cases. The rate per All Nonfatal All MSD All Sprains, [2] Includes MS system and connective diseases and disorders and hernia. Injuries and Injuries Strains & Source: U.S. Department of Labor, Bureau of Labor Statistics, Injuries, 10,000 full-time Illnesses Tears [1] Illnesses and Fatalities Program: Case and Demographic Characteristics for Work-related Injuries and Illnesses Involving Days Away from Work. Table 10. workers of [1] Totals are greater than shown in Table 6.21 for Number, percent, and incidence rate of nonfatal occupational injuries and non-fatal MDS sprains & strains due to inclusion of all sprains illnesses involving days away from work by selected worker and case and strains. characteristics and musculoskeletal disorders, All United States, private workplace Source: U.S. Department of Labor, Bureau of Labor industry, 2006 and 2007. Available at: ĴǱȦȦ ǯǯȦȦ ȦȦȦȱ Statistics, Injuries, Illnesses and Fatalities Program: ostb1790.pdf and ĴǱȦȦ ǯǯȦȦ ȦȦȦŗşŚŗǯ. injuries, MSD Case and Demographic Characteristics for Accessed November 11, 2009. Work-related Injuries and Illnesses Involving Days injuries and Away from Work. Table 8a. Number and incidence rate of nonfatal occupational injuries and illnesses injuries. (Tables 6.21 and 6.23 and Graph 6.5.2) sprain/strain involving days away from work by selected worker injuries peaks and case characteristics and selected natures of injury Back pain, carpal tunnel syndrome, tendonitis, or illness, All United States, private industry, 2007. among workers Available at: soreness and pain (other than back pain), and a ĴǱȦȦ ǯǯȦȦ ȦȦȦŗşřŞǯ. range of other conditions comprise the remaining between the Accessed November 11, 2009. MSD injuries. ages of 35 and 44 years, tapering oﬀ both as workers are younger or older. Carpal tunnel syndrome injuries has the Section 6.5.2: Demographic Characteristics of highest rate among workers aged 45 to 64, while MSD Workplace Injuries

Workplace injuries resulting in days away from Graph 6.5.4: Proportion of Musculoskeletal Disorders (MSD) by Type for Nonfatal Occupational Injuries and Illnesses Involving work, both overall and for MSD injuries, are far Days Away from Work by Race, United States 2007 more likely to be sustained by males than by White Black/African American Hispanic or Latino females (1.6:1 ratio). This is most likely due to the Asian Other/Mixed Not Reported diﬀ erences in work environments, with males 100%

more likely employed in workplace sett ings with 80% diﬀ erent risks and exposures. However, the ratio of full-time workers sustaining a carpal tunnel 60% syndrome injury severe enough to result in days 40%

away from work is 3:1 for females versus males; Cases % of Total 20% 61% of the 2007 tendonitis injuries were incurred 0% by females. (Table 6.23 and Graph 6.5.3) Nonfatal MSDs Sprains, Carpal Tendonitis Injuries and Strains Tunnel Illnesses [1] & Tears Syndrome Two-thirds or more of all workplace injuries and [1] Nonfatal injuries and illnesses include the total of all nonfatal injuries and MSD injuries resulting in days away from work illnesses involving days away from work Source: U.S. Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses and in 2007 were sustained by white workers for those Fatalities Program: Case and Demographic Characteristics for Work-related Injuries and Illnesses Involving Days Away from Work. Table 8b. Number and percent of workers declaring a race. Carpal tunnel syndrome nonfatal occupational injuries and illnesses involving days away from work by selected worker and case characteristics and nature of injury or illness, All United injuries occur almost exclusively to whites (78%). States, private industry, 2007. Available at: Hispanics or Latinos are most likely to sustain hĴp://www.bls.gov/iif/oshwc/osh/case/ostb1şřş.pdf. Accessed November 11, 200ş.

Graph 6.5.5: Rate per 10,000 full Time Workers of Nonfatal Occupational Injuries and Illnesses While workplace injuries Involving Days Away from Work by Age, United States 2007 aﬀ ect all parts of the Nonfatal Injuries Sprains, Strains MSDs anatomy, in 2007, both and Illnesses & Tears 150 MSD workplace injuries Carpal Tunnel and non-MSD injuries 120 Syndrome Tendonitis 2.0 occurred most oft en to the

90 1.5 back (rate of 17.0 injuries per 10,000 workers). Back 60 1.0 injuries accounted for

Rate per 10,000 Workers 30 0.5 48% of all MSD injuries.

Rate per 10,000 Workers Carpal tunnel syndrome 0 0.0 16 20 25 35 45 55 65 16 20 25 35 45 55 65 is an injury exclusively of to to to to to to Years to to to to to to Years 19 24 34 44 54 64 & Older 19 24 34 44 54 64 & Older the wrist, while tendonitis Age Group Age Group focuses primarily in the Source: U.S. Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses and Fatalities Program: Case and arm, wrist, hand, fi ngers, Demographic Characteristics for Work-related Injuries and Illnesses Involving Days Away from Work. Table 8a. Number and incidence rate of nonfatal occupational injuries and illnesses involving days away from work by and shoulder. Sprains and selected worker and case characteristics and selected natures of injury or illness, All United States, private industry, 2007. Available at: hĴp:ȦȦwww.bls.govȦiifȦoshwcȦoshȦcaseȦostb1938.pdf. Accessed November 11, 2009. strains also occur primarily in the back (40%), with tendonitis is reported at similar rates for all ages the shoulder (11%), knee except the very young and oldest workers. (Table (12%), and ankle (9%) joints the other primary 6.25 and Graph 6.5.5) joints aff ected by sprains and strains. (Table 6.26 and Graph 6.5.6) Section 6.5.3: Incidence Rates for Workplace Injuries by Type of Injury and Body Part Aff ected In the last decade, 1997 to 2007, the incidence rate for nonfatal occupational injuries involving days away from work has decreased by 42%. Graph 6.5.6: Proportion of Nonfatal Occupational Injuries and While the incidence of sprain, strain and Illnesses Inolin a¢s a¢ fro or ¢ od¢ Part ěectedǰ tear injuries is much higher than any other United States 2007 type of injury, it has dropped by 49%, from 100% Multiple & Other a rate of 92.5 per 10,000 workers in 1997 to Lower 47.3 per 10,000 in 2007. 80% Extremities Upper Extremities The highest rates of decline in nonfatal 60% occupational injuries over the past decade Back have been for tendonitis (76% decline) and 40%

% of Total Cases % of Total Shoulder carpal tunnel syndrome (62%). The result is very low rates of less than 2 injuries per 20% Trunk 10,000 workers reported in 2007. This is Neck likely due to awareness of how these inju- 0% All MSDs Sprains, Carpal Tendonitis ries occur and safety measures to reduce Nonfatal Strains Tunnel Head Injuries & Tears Syndrome their occurrence. The injury rates for bruis- & Illnesses es/contusions and fractures in the workplace Source: U.S. Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses and Fatalities Program: Case and Demographic Characteristics for Work-related Injuries were around 10 per 10,000 workers in 2007. and Illnesses Involving Days Away from Work. Table 8a. Number and incidence rate of nonfatal occupational injuries and illnesses involving days away from work by (Table 6.27 and Graph 6.5.7) selected worker and case characteristics and selected natures of injury or illness, All United States, private industry, 2007. Available at: hĴp:ȦȦwww.bls.govȦiifȦoshwcȦoshȦcaseȦostb1şř8.pdf. Accessed November 11, 200ş.

Graph 6.5.7: Incidence Rates per 10,000 Full-time Workers for Nonfatal Occupational or oﬃ ce/administrative support Injuries and Illnesses Involving Days Away from Work by Type of Injury , occupations, which account for United States 1997-2007 55% of carpal tunnel syndrome 20 100 Sprains, Strains injuries. (Table 6.29) Incidence Rate per 10,000 Full Time Workers Multiple 80 Traumatic Injuries 15 Section 6.5.5: Days Away from for Sprains & Strains) Amputations Work 60

10 Chemical Burns In 2007, MSD injuries, as

40 in most years since 1998, Tendonitis involved 2 additional days, (all except sprains & strains) 5 Carpal Tunnel 9 versus 7, away from work 20 Syndrome Incidence Rate per 10,000 Full Time Workers when compared to all nonfatal workplace injury cases. (Table Heat Burns 0 0 6.30 and Graph 6.5.8) Both 1997 1999 2001 2003 2005 2007 Source: U.S. Department of Labor, Bureau of Labor Statistics: Survey of Occupational Fractures carpal tunnel syndrome Injuries and Illnesses. Table 6 (1997-2001) or 7 (2003-2005): Incidence rates for (median of 28 days) and nonfatal occupational injuries and illnesses involving days away from work per Cuts, Lacerations, 10,000 full-time workers for selected characteristics and major industry sector: Punctures tendonitis (10 days) contributed Nature of injury or illness. Lost work time.pdf:1995-2005. Available at: www.bls.gov/iif/oshcdnew.htm. Accessed July 7, 2007. to the higher time away Bruises, Contusions Source: (2007) U.S. Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses from work. The diﬀ erence in and Fatalities Program: Case and Demographic Characteristics for Work-related median days away from work Injuries and Illnesses Involving Days Away from Work. Table 10. Number, percent, and incidence rate of nonfatal occupational injuries and illnesses involving days due to sprain/strain injuries away from work by selected worker and case characteristics and musculoskeletal disorders, All United States, private industry, 2007. Available at: that are classiﬁ ed as MSD ĴǱȦȦ ǯǯȦȦ ȦȦȦŗşŚŗǯ. Accessed November 11, 2009. injuries and those other than The incidence rate per 10,000 full-time workers in 2007 of injuries to the trunk (40.6, including the Graph 6.5.8: Median Days Away from Work for Nonfatal Occupational Injuries and Illnesses shoulder, 8.0, and back, 24.9), upper extremities Involving Days Away from Work by Type of Injury, (28.4), and lower extremities (27.5, including the United States 2007 knee, 10.0), were all high and accounted for a Fractures majority of nonfatal occupational injuries in all Carpal Tunnel Syndrome Amputations industries. The overall incidence of all nonfatal Tendonitis occupational injuries involving days away from Multiple Traumatic Injuries work for all industries was 122.2 per 10,000 Sprains, Strains full-time workers. (Table 6.28) Soreness, Pain (except Back) Back Pain Heat Burns Section 6.5.4: MSD Injuries by Occupation Bruises, Contusions Cuts, Lacerations, Punctures Chemical Burns MSD injuries occur in relatively equal proportion to all nonfatal workplace injuries with respect to Musculoskeletal Disorders 9 worker occupation, but occur at much higher rates Total All Cases 7 0 5 10 15 20 25 30 in construction, maintenance, production and Mean Days Away from Work transportation industries than in service industries. Source (2007): U.S. Department of Labor, Bureau of Labor Statistics, Injuries, Illnesses and Fatalities Program: Case and Demographic (Table 6.29) However, carpal tunnel syndrome Characteristics for Work-related Injuries and Illnesses Involving Days injuries are more likely to occur in production Away from Work. 2007 nonfatal occupational injuries and illnesses: case and demographics. November 20, 2008, reissued March 2009. Available at: ĴǱȦȦ ǯǯȦȦ ȦȦȦŖŖřŞǯ. Accessed November 13, 2009.

MSD injuries is not available. Fractures Graph 6.6.1: Resource Utilization for Traumatic Musculoskeletal Injuries (median of 30 days) and amputation by Treatment Location for All Diagnoses, United States 2006/2007

injuries (median 21 days), which are not 12,000 included in the MSD classiﬁ cation, add Fractures Dislocations signiﬁ cantly to the nonfatal workplace 10,000 Sprains Contusions musculoskeletal injury burden. Shoulder, and Strains 8,000 wrist, and knee injuries involved the Open Other highest median number of days away Wounds MS Injuries 6,000 from work (18, 14, and 15, respectively).

(Table 6.31) 4,000

2,000 Overall, musculoskeletal workplace Episodes (in 000s) Injury Treatment injuries are a major concern, accounting 0 for a large proportion of all nonfatal Physician Emergency Hospital Hospital OĜce Room Outpatient Inpatient injuries that result in days away from Visits [1] Visits [2] Visits [3] Stays [4]

work. Even through long term trends [1] Source: National Center for Health Statistics, National Ambulatory Medical Care show signifi cant reductions in the total Survey, 2006 [2] Source: National Center for Health Statistics, National Hospital Ambulatory number of worker injuries each year, Medical Care Survey, Emergency Room Visits, 2006 [3] Source: National Center for Health Statistics, National Hospital Ambulatory the proportion that are musculoskeletal Medical Visits, Outpatient Department Visits, 2006 related (MSD, fractures, bruises/ [4] Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 contusions, and amputations) continues to account for more than one-half of all represented 29% of all hospitalizations for an worker nonfatal injury cases involving days away injury; musculoskeletal injuries accounted for 61% from work. In addition to the cost of medical of all injury treatment episodes. care for these injuries, the cost of lost wages and the potential for long term impacts on worker Males and females show only slight diff erences in productivity are enormous. where they are treated for a musculoskeletal injury. However, males were slightly more likely to be Section 6.6: Health Care Resource treated in a physicians’ offi ce (61% of male injury Utilization for Musculoskeletal Injuries visits), while females were slightly more likely to be treated in an emergency room (31% of female injury visits). Injury treatment episodes for 2006/2007, for purposes of this study, have been defi ned as the The age of a person seeking treatment for a accumulative total of cases for all injury diagnoses musculoskeletal injury is a factor in where treated in 2006 in physician offi ces, emergency treatment is given. (Table 6.33) Persons aged 65 rooms, outpatient clinics, and in 2007 in hospitals, and over are the most likely to be hospitalized for as identifi ed in four major national health care a musculoskeletal injury of any type, accounting databases. Of the 61.2 million musculoskeletal for 34% of hospitalized musculoskeletal injury injury treatment episodes that occurred, 60% treatment episodes in 2007, but representing only were treated in a physician’s offi ce. (Table 6.32 16% of all musculoskeletal injuries. Persons under and Graph 6.6.1) Another one-third (30%) were the age of 18 are the least likely to be hospitalized, treated in emergency rooms. Only 8% were treated representing only 6% of hospitalized episodes in outpatient clinics, with 3% of persons with while accounting for 21% of all musculoskeletal musculoskeletal injuries admitt ed to a hospital. injury treatment episodes. Persons aged 18 to Persons hospitalized for a musculoskeletal injury 44 years are more likely to seek treatment in an

Graph 6.6.2: Percent of All Traumatic Musculoskeletal Injuries by Treatment Location that are (Dx1) diagnosis of First Diagnosis, United States 2006/2007 a musculoskeletal

100 injury. Hospitalization for a fracture is 90 Other MS Injuries usually the primary 80 (Dx1) diagnosis (76%). 70 Open Wounds

60 Contusions Fractures and 50 Sprains and Strains open wounds are 40 Dislocations commonly the 30 primary (Dx1) 20 Fractures % Injury Treatment Episodes Dx1 % Injury Treatment diagnosis (87% and 10 84%, respectively) 0 Physician Emergency Hospital Hospital Total All regardless of the OĜce Room Outpatient Inpatient Treatment Visits [1] Visits [2] Visits [3] Stays [4] Sites [1-4] treatment site, while dislocations were less [1] Source: National Center for Health Statistics, National Ambulatory Medical Care Survey, 2006 [2] Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, Emergency Room frequently a primary Visits, 2006 [3] Source: National Center for Health Statistics, National Hospital Ambulatory Medical Visits, Outpatient Department (Dx1) diagnosis (65%). Visits, 2006 [4] Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 The 1.0 million persons hospitalized emergency room, while those aged 45 to 64 are for a primary (Dx1) more likely to seek treatment in a physician’s oﬃ ce diagnosis of a musculoskeletal injury in 2007 spent or outpatient clinic. an average of 4.8 days in the hospital, representing 4.7 million hospitalized days and total estimated In 85% of the 2006/2007 musculoskeletal injury hospital costs of $32.43 billion. (Table 6.35 and treatment episodes, or 51.9 million injury episodes, Graph 6.6.3) The mean hospital cost per patient for the primary (Dx1) diagnosis was a musculoskeletal treatment of a musculoskeletal injury was $33,260. injury. (Table 6.34 and Graph 6.6.2) Among the 1.6 (Graph 6.6.4) Eighty-four percent (84%) of persons million persons hospitalized for a musculoskeletal hospitalized with a primary (Dx1) diagnosis injury, 62% were hospitalized with a primary of a musculoskeletal injury were treated for a fracture, and fractures Graph 6.6.3: Mean Hospital Patient Stay Graph 6.6.4: Mean Hospital Charge for represented 90% of the for Dx1 [1] Musculoskeletal Injury Patients, Dx1 [1] Musculoskeletal Injury Patients, estimated total cost of United States 2007 United States 2007 treatment. The average Fractures Fractures hospital length of stay Dislocations Dislocations for a fracture was 5.0 Derangement Derangement days, for a total of 4.2 Sprains and Strains Sprains and Strains million hospital days; Contusions Contusions the average hospital Open Wounds Open Wounds charge per patient was Other MS Injuries Other MS Injuries $35,000, for a total cost 012345 $0 $7 $14 $21 $28 $35 Length of Stay in Days Mean Charge (in 000s) of $29.08 billion. [1] First listed diagnosis for inpatients discharged [1] First listed diagnosis for inpatients discharged from short-stay hospitals from short-stay hospitals Source: Agency for Healthcare Research and Quality, Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007 Inpatient Sample, 2007

Section 6.7: Economic Cost of medical providers. The Insurance Component Musculoskeletal Injuries is a separate survey of employers that provides data on employer-based health insurance. MEPS also includes a Medical Provider Component Chapter 9 (Health Care Utilization and Economic (MPC), which covers hospitals, physicians, home Costs of Musculoskeletal Diseases) summarizes health care providers, and pharmacies identiﬁ ed the cost of musculoskeletal conditions based on by MEPS-HC respondents. Its purpose is to analysis of the Medical Expenditures Panel Survey supplement and/or replace information received (MEPS) from 1996 to 2004. The MEPS, which began from the MEPS-HC respondents.6 in 1996, is a set of large-scale surveys of families and individuals, their medical providers (doctors, As with the National Health Interview Survey hospitals, pharmacies, etc.), and employers across (NHIS), data in the household component is the United States. MEPS collects data on the self-reported. As noted earlier, the NHIS is speciﬁ c health services that Americans use, how believed to underreport the incidence of injuries. frequently they use them, the cost of these services, Comparison of incidence between the two and how they are paid for, as well as data on databases indicates injuries in the MEPS may also the cost, scope, and breadth of health insurance be under-reported. In 2008, the NHIS reported held by and available to U.S. workers. Currently 22.1 million persons sustained a musculoskeletal MEPS collects data from two major components: injury. An annual average of 24.7 million persons households and insurance companies. The reported a musculoskeletal injury between 2002 Household Component (HC) provides data and 2004 in the MEPS, a relatively stable number from individual households and their members, since the 1996 to 1998 MEPS data. (Table 6.36) which is supplemented by data from their This compares to the 61.2 million injury treatment episodes reported in the Graph 6.7.1: Total Visits for Musculoskeletal Injuries by Expenditure Type and Total four major health care Musculoskeletal Injury Costs, United States 1996-2004 databases for physician

350 $150 oﬃ ces, emergency rooms, hospital outpatient clinics, 300 $120 and inpatient care for Total Costs (in billions) 250 2006/2007.

$90 200 The estimated annual

150 cost for medical care of $60 musculoskeletal injuries 100 in 2004 utilizing the MEPS $30 50 data was $127.4 billion or

Health Care Cost for Injuries (in millions) an average of $5,160 for 0 0 each of the 24.7 million 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 persons who sustained a 3-Year Average Total Cost musculoskeletal injury. Source: Agency for Healthcare Research and Physician Visits A breakdown of the Quality: Medical Expenditures Panel Survey ER and Outpatient Visits (MEPS) 1996-2004 $127.4 billion cost due to Prescriptions Filled musculoskeletal injuries Home Health Care Visits shows 33% for ambulatory Hospital Discharges care, 31% for emergency Total Costs (in billions) room or inpatient care, 17% for prescription drugs, and

18% for other expenses. The cost of musculoskeletal 3. Centers for Disease Control, National Center for Injury injuries, in 2004 dollars, rose from $93 billion in Prevention and Control, WISQARSTM (Web-based Injury 1996 to $127.4 billion in 2004, an increase of 37%. Statistics Query and Reporting System), Leading Causes The increasing cost of prescription drugs accounts of Nonfatal Injuries Reports, 2008. Available at: htt p:// for the largest percentage of this total cost increase, webappa.cdc.gov/sasweb/ncipc/nﬁ lead.html. Accessed on rising from 11% of total cost to 17% over the 9-year November 10, 2009. period. (Graph 6.7.1) 4. Finkelstein EA, Corso PS, Miller TR: The Incidence and 1. Centers for Disease Control and Prevention (CDC): 2003 Economic Burden of Injuries in the United States. New York, National Health Interview Survey (NHIS) Public Use NY: Oxford University Press, Inc., 2006, p 187. Data Release. Available at: htt p://www.cdc.gov/nchs/ about/major/nhis/quest_data_related_1997_forward.htm. 5. National Institute for Occupational Safety and Health Accessed May 10, 2007. (NIOSH): Workers Health Chartbook. Cincinnati, OH: Department of Health and Human Services, Centers for 2. Praemer A, Furner S, Rice DP: Musculoskeletal Conditions in Disease Control and Prevention, 2004, p 58. the United States, ed 2. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1999, p 182. 6. Agency for Health Care Quality and Research: Medical Expenditure Panel Survey Background, 2007. Available at: htt p://www.meps.ahrq.gov/mepsweb/about_meps/survey_ back.jsp. Accessed May 7, 2007.

Section 6.8: Musculoskeletal Injuries Data Tables

Tableȱ6.1:ȱComparisonȱofȱIncidenceȱofȱUnintentionalȱInjuries,ȱUnitedȱStatesȱ1985,ȱ1992Ȭ1994,ȱ2000,ȱandȱ2006

IncidenceȱofȱInjuriesȱ(inȱ000s) Rice,ȱ1985ȱ[1] MSCUS,ȱ1992Ȭ1994ȱ[2] Finkelstein,ȱ2000ȱ[3] BMUSȱ2009 %ȱofȱ %ȱofȱ %ȱofȱ %ȱofȱ ȱIncidenceȱ Total ȱIncidenceȱ Total ȱIncidenceȱ Total ȱIncidenceȱ Total

TotalȱInjuriesȱȱȱȱȱȱȱȱ 56,443 ȱȱȱȱȱȱȱȱ57,885 ȱȱȱȱȱȱȱȱ50,127 ȱȱȱȱȱȱ100,561 FatalȱUnintentionalȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱ 143 0.3% NAȱȱȱȱȱȱȱȱȱȱȱȱȱ 149 0.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 122 [4] 0.1% HospitalizedȱInjuriesȱȱȱȱȱȱȱȱȱȱ 2,300 4.1% NAȱȱȱȱȱȱȱȱȱȱ 1,870 3.7%ȱȱȱȱȱȱȱȱȱȱ 5,527 [5] 5.5% NonȬhospitalized,ȱMedicallyȱTreatedȱInjuriesȱȱȱȱȱȱȱȱ 54,000 95.7% NAȱȱȱȱȱȱȱȱ 48,108 96.0%ȱȱȱȱȱȱȱȱ 94,912 [6] 94.4%

ȱMusculoskeletalȱInjuries NAȱȱȱȱȱȱȱȱ 36,901 ȱȱȱȱȱȱȱȱ33,460 ȱȱȱȱȱȱȱȱ61,210 FatalȱUnintentionalȱInjuries NA NAȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 33 [7] 0.1%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 21 [8] 0.0% HospitalizedȱInjuries NA NAȱȱȱȱȱȱȱȱȱȱ 1,273 [7] 3.8%ȱȱȱȱȱȱȱȱȱȱ 1,589 [5] 2.6% NonȬhospitalized,ȱMedicallyȱTreatedȱInjuries NA NAȱȱȱȱȱȱȱȱ 32,154 [7] 96.1%ȱȱȱȱȱȱȱȱ 59,600 [9] 97.4%

Musculoskeletalȱasȱ%ȱofȱAllȱUnintentionalȱInjuries NA 63.7% 66.8% 60.9%

[1]ȱRiceȱDP,ȱMacKenzieȱEJ:ȱCostȱofȱInjuryȱinȱtheȱUnitedȱStates:ȱAȱReportȱtoȱCongress ,ȱ1989.ȱSanȱFrancisco,ȱCA:ȱInstituteȱforȱHealthȱ&ȱAging,ȱUniversityȱofȱCaliforniaȱ andȱInjuryȱPreventionȱCenter,ȱTheȱJohnsȱHopkinsȱUniversity,ȱ1989. [2]ȱPraemerȱA,ȱFurnerȱS,ȱRiceȱDP.ȱMusculoskeletalȱConditionsȱinȱtheȱUnitedȱStates. ȱRosemont,ȱIL:ȱAmericanȱAcademyȱofȱOrthopaedicȱSurgeons,ȱ1999,ȱpȱ83. [3]ȱFinkelsteinȱEA,ȱCorsoȱPS,ȱMillerȱTR.ȱTheȱIncidenceȱandȱEconomicȱBurdenȱofȱInjuriesȱinȱtheȱUnitedȱStates .ȱNewȱYork,ȱNY:ȱOxfordȱUniversityȱPress,ȱ2006,ȱpȱ8.

[8]ȱCentersȱforȱDiseaseȱControl,ȱNationalȱCenterȱforȱInjuryȱPreventionȱandȱControl,ȱWISQARSTMȱ(WebȬbasedȱInjuryȱStatisticsȱQueryȱandȱReportingȱSystem),ȱ20ȱ LeadingȱCausesȱofȱDeath,ȱUnintentionalȱInjuries,ȱ2006.ȱAvailableȱat:ȱhttp://webappa.cdc.gov/cgiȬbin/broker.exe.ȱAccessedȱonȱNovemberȱ10,ȱ2009. [5]ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007 [6]ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006;ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱ Visits,ȱ2006;ȱȱȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱDepartmentȱVisits,ȱ2006 [7]ȱDefinedȱasȱspinalȱcord,ȱvertebralȱcolumn,ȱtorso,ȱupperȱextremity,ȱlowerȱextremityȱinjuries.ȱFinkelsteinȱEA,ȱCorsoȱPS,ȱMillerȱTR.ȱTheȱIncidenceȱandȱEconomicȱ BurdenȱofȱInjuriesȱinȱtheȱUnitedȱStates .ȱNewȱYork,ȱNY:ȱOxfordȱUniversityȱPress,2006,ȱpȱ13.

[8]ȱDefinedȱasȱfalls.ȱCentersȱforȱDiseaseȱControl,ȱNationalȱCenterȱforȱInjuryȱPreventionȱandȱControl,ȱWISQARSTMȱ(WebȬbasedȱInjuryȱStatisticsȱQueryȱandȱ ReportingȱSystem),ȱFatalȱInjuriesȱReport,ȱUnintentionalȱInjuriesȱOnly,ȱ2006.ȱAvailableȱat:ȱhttp://webappa.cdc.gov/cgiȬbin/broker.exe;ȱallȱagesȱpercentages.ȱAccessedȱ onȱNovemberȱ10,ȱ2009.

[9]ȱDefinedȱasȱfracture,ȱderangement,ȱdislocation,ȱsprain/strain,ȱcontusion,ȱcrushingȱinjury,ȱopenȱwound,ȱtraumaticȱamputation,ȱandȱlateȱeffectsȱofȱinjury.ȱȱNationalȱ CenterȱforȱHealthȱStatistics.ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006;ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ2006;ȱ NationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱDepartmentȱVisits,ȱ2006

Tableȱ6.2ȱ:ȱResourceȱUtilizationȱforȱTraumaticȱInjuriesȱbyȱTreatmentȱLocationȱandȱSex,ȱ UnitedȱStatesȱ2006/2007

TotalȱVisitsȱ(inȱ000s)ȱ[1]

%ȱAllȱ Totalȱ Diagnosesȱ Physicianȱ Emergencyȱ Hospitalȱ Allȱ forȱAllȱ Officeȱ Roomȱ Outpatientȱ Inpatientȱ Treatmentȱ Treatmentȱ Visitsȱ[2] Visitsȱ[3] Visitsȱ[4] Staysȱ[5] Sites Locations

Fractures ȱȱȱȱȱȱȱȱȱȱ9,919ȱ ȱȱȱȱȱȱȱȱȱȱȱ3,877ȱ ȱȱȱȱȱȱȱȱȱȱ1,264ȱ ȱȱȱȱȱȱȱȱȱ1,095 ȱȱȱȱȱȱȱ16,155 26%

Dislocations ȱȱȱȱȱȱȱȱȱȱ2,470ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ520ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ319ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ46 ȱȱȱȱȱȱȱȱȱ3,355 5%

SprainsȱandȱStrainsȱ ȱȱȱȱȱȱȱ12,023 ȱȱȱȱȱȱȱȱȱȱ4,869 ȱȱȱȱȱȱȱȱȱ1,367 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ94 ȱȱȱȱȱȱȱ18,353 30%

Contusionsȱȱȱȱȱȱȱȱȱ 4,578 ȱȱȱȱȱȱȱȱȱȱ4,680 ȱȱȱȱȱȱȱȱȱȱȱȱ599 ȱȱȱȱȱȱȱȱȱȱȱȱ183 ȱȱȱȱȱȱȱ10,040 16%

OpenȱWoundsȱȱȱȱȱȱȱȱȱ 4,550 ȱȱȱȱȱȱȱȱȱȱ4,540 ȱȱȱȱȱȱȱȱȱȱȱȱ888 ȱȱȱȱȱȱȱȱȱȱȱȱ220 ȱȱȱȱȱȱȱ10,198 17%

AllȱOtherȱMusculoskeletalȱInjuries ȱȱȱȱȱȱȱȱ5,454ȱ ȱȱȱȱȱȱȱȱȱ1,272ȱ ȱȱȱȱȱȱȱȱȱȱȱ492ȱ ȱȱȱȱȱȱȱȱȱȱȱ148ȱ ȱȱȱȱȱȱȱȱ7,366ȱ 12%

TotalȱAllȱMusculoskeletalȱTraumaticȱInjuriesȱȱȱȱȱȱȱ 36,617 ȱȱȱȱȱȱȱȱ18,264 ȱȱȱȱȱȱȱȱȱ4,719 ȱȱȱȱȱȱȱȱȱ1,589 ȱȱȱȱȱȱȱ61,189

AllȱInjuryȱTreatmentȱEpisodesȱȱȱȱȱȱȱ 57,162 ȱȱȱȱȱȱȱȱ30,940 ȱȱȱȱȱȱȱȱȱ6,810 ȱȱȱȱȱȱȱȱȱ5,527 ȱȱȱȱȱ100,439 ProportionȱofȱTotalȱDiagnosesȱThatȱAreȱMusculoskeleta 64% 59% 69% 29% 61%

[1]ȱAllȱlistedȱdiagnosesȱforȱinpatientsȱdischargedȱfromȱshortȬstayȱhospitals. [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006

[3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ2006

[4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱDepartmentȱVisits,ȱ2006

[5]Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ6.3ȱ:ȱDistributionȱofȱInjuryȱTreatmentȱEpisodes,ȱ2006/2007,ȱandȱSelfȬ ReportedȱInjuries,ȱ2008,ȱȱbyȱTypeȱofȱMusculoskeletalȱInjury,ȱ UnitedȱStatesȱ

InjuryȱTreatmentȱEpisodesȱ[1] ProportionȱInjuryȱTreatmentȱEpisodes <18ȱ 18Ȭ44ȱ 45Ȭ64ȱ 65ȱ&ȱ Total Females Males Years Years Years Over Fractures 26% 25% 28% 36% 18% 23% 36% Dislocations 5% 5% 6% 4% 5% 6% 8% SprainsȱandȱStrainsȱ 30% 31% 29% 25% 34% 36% 18% Contusions 16% 19% 14% 17% 19% 11% 19% OpenȱWounds 17% 15% 18% 15% 19% 15% 17% AllȱOtherȱMusculoskeletalȱInjuries 12% 13% 12% 10% 12% 16% 8% TotalȱInjuryȱTreatmentȱEpisodesȱ(inȱ000s)ȱ TotalȱAllȱMusculoskeletalȱTraumaticȱInjuriesȱȱ 61,189 ȱȱ28,324 ȱȱ32,855 ȱȱ12,710 ȱȱ21,842 ȱȱ16,459 ȱȱȱȱ9,929

SelfȬReportedȱInjuryȱEpisodesȱ[2] ProportionȱSelfȬReportedȱInjuryȱEpisodes Fractures 25% 24% 27% 30% 19% 23% 35% Dislocations 2% 2% 3% 2% 4% 2% 1% SprainsȱandȱStrainsȱ 44% 46% 42% 47% 44% 45% 30% Contusions 17% 22% 11% 10% 15% 23% 22% OpenȱWounds 16% 13% 19% 10% 22% 13% 15% AllȱOtherȱMusculoskeletalȱInjuries 4% 4% 4% 2% 3% 5% 7% SelfȬReportedȱInjuryȱEpisodesȱ(inȱ000s) TotalȱAllȱMusculoskeletalȱTraumaticȱInjuriesȱȱ 22,107 ȱȱ11,577 ȱȱ10,530 ȱȱȱȱ5,509 ȱȱȱȱ7,966 ȱȱȱȱ5,700 ȱȱȱȱ2,932

[2]ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱInterviewȱSurvey,ȱInjuryȱFile,ȱ2008

Tableȱ6.4:ȱInjuryȱTreatmentȱEpisodesȱandȱRateȱbyȱTypeȱofȱMusculoskeletalȱInjuryȱbyȱSexȱandȱAge,ȱUnitedȱStatesȱ2006/2007

TOTALȱPOPULATION InjuryȱTreatmentȱEpisodesȱ(inȱ000s)ȱ[1] ȱTotalȱ Underȱ18ȱYears 18Ȭ44ȱYears 45Ȭ64ȱyears 65ȱYearsȱ&ȱOver

Injuryȱ Rateȱ Injuryȱ Rateȱ Injuryȱ Rateȱ Injuryȱ Rateȱ Injuryȱ Rateȱ Treatmentȱ perȱ100ȱ Treatmentȱ perȱ100ȱ Treatmentȱ perȱ100ȱ Treatmentȱ perȱ100ȱ Treatmentȱ perȱ100ȱ Episodes Population Episodes Population Episodes Population Episodes Population Episodes Population Fracturesȱȱȱȱȱȱȱȱȱ 16,155 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.4 ȱȱȱȱȱȱȱȱȱȱȱȱ4,528 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.1 ȱȱȱȱȱȱȱȱȱȱȱ4,015 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.5 ȱȱȱȱȱȱȱȱȱȱȱ3,815 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.1 ȱȱȱȱȱȱȱȱȱȱȱ3,603 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.7 Dislocationsȱȱȱȱȱȱȱȱȱȱȱ 3,355 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ566 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ985 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.9 ȱȱȱȱȱȱȱȱȱȱȱ1,057 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ746 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.0 SprainsȱandȱStrainsȱ ȱȱȱȱȱȱȱȱȱ18,353 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.1 ȱȱȱȱȱȱȱȱȱȱȱȱ3,114 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.2 ȱȱȱȱȱȱȱȱȱȱȱ7,482 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.6 ȱȱȱȱȱȱȱȱȱȱȱ5,930 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.9 ȱȱȱȱȱȱȱȱȱȱȱ1,818 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.9 Contusionsȱȱȱȱȱȱȱȱȱ 10,040 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.4 ȱȱȱȱȱȱȱȱȱȱȱȱ2,173 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.9 ȱȱȱȱȱȱȱȱȱȱȱ4,160 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.7 ȱȱȱȱȱȱȱȱȱȱȱ1,795 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.4 ȱȱȱȱȱȱȱȱȱȱȱ1,878 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.0 OpenȱWoundsȱȱȱȱȱȱȱȱȱ 10,198 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.4 ȱȱȱȱȱȱȱȱȱȱȱȱ1,845 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.5 ȱȱȱȱȱȱȱȱȱȱȱ4,179 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.7 ȱȱȱȱȱȱȱȱȱȱȱ2,504 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.3 ȱȱȱȱȱȱȱȱȱȱȱ1,652 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.4 AllȱOtherȱMusculoskeletalȱInjuriesȱȱȱȱȱȱȱȱȱȱȱ 7,366 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.5 ȱȱȱȱȱȱȱȱȱȱȱȱ1,295 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.8 ȱȱȱȱȱȱȱȱȱȱȱ2,697 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.4 ȱȱȱȱȱȱȱȱȱȱȱ2,615 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ749 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.0 TotalȱAllȱMusculoskeletalȱTraumaticȱInjurieȱȱȱȱȱȱȱȱȱ 61,189 ȱȱȱȱȱȱȱȱȱȱȱȱȱ20.4 ȱȱȱȱȱȱȱȱȱȱ12,710 ȱȱȱȱȱȱȱȱȱȱȱȱȱ17.2 ȱȱȱȱȱȱȱȱȱ21,842 ȱȱȱȱȱȱȱȱȱȱȱȱȱ19.2 ȱȱȱȱȱȱȱȱȱ16,459 ȱȱȱȱȱȱȱȱȱȱȱȱȱ22.0 ȱȱȱȱȱȱȱȱȱȱȱ9,929 ȱȱȱȱȱȱȱȱȱȱȱȱȱ26.6

AllȱInjuriesȱȱȱȱȱȱȱ 100,439 ȱȱȱȱȱȱȱȱȱȱȱȱȱ33.5 ȱȱȱȱȱȱȱȱȱȱ21,468 ȱȱȱȱȱȱȱȱȱȱȱȱȱ29.1 ȱȱȱȱȱȱȱȱȱ35,430 ȱȱȱȱȱȱȱȱȱȱȱȱȱ31.2 ȱȱȱȱȱȱȱȱȱ26,752 ȱȱȱȱȱȱȱȱȱȱȱȱȱ35.7 ȱȱȱȱȱȱȱȱȱ16,243 ȱȱȱȱȱȱȱȱȱȱȱȱȱ43.6 TotalȱPopulationȱ(inȱ000s)ȱ[2]ȱȱȱȱȱȱȱ 299,398 ȱȱȱȱȱȱȱȱȱȱ73,736 ȱȱȱȱȱȱȱ113,538 ȱȱȱȱȱȱȱȱȱ74,865 ȱȱȱȱȱȱȱȱȱ37,260

MALES InjuryȱTreatmentȱEpisodesȱMalesȱ(inȱ000s)ȱ[1] Fracturesȱȱȱȱȱȱȱȱȱȱȱ 9,061 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.1 ȱȱȱȱȱȱȱȱȱȱȱȱ2,987 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.9 ȱȱȱȱȱȱȱȱȱȱȱ2,800 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.9 ȱȱȱȱȱȱȱȱȱȱȱ2,168 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱȱȱ1,065 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.8 Dislocationsȱȱȱȱȱȱȱȱȱȱȱ 1,877 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ291 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ626 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ628 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ333 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.1 SprainsȱandȱStrainsȱ ȱȱȱȱȱȱȱȱȱȱȱ9,584 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.5 ȱȱȱȱȱȱȱȱȱȱȱȱ1,664 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.4 ȱȱȱȱȱȱȱȱȱȱȱ4,345 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.5 ȱȱȱȱȱȱȱȱȱȱȱ3,173 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ400 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6 Contusionsȱȱȱȱȱȱȱȱȱȱȱ 4,601 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.1 ȱȱȱȱȱȱȱȱȱȱȱȱ1,202 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.2 ȱȱȱȱȱȱȱȱȱȱȱ2,256 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ520 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ513 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.3 OpenȱWoundsȱȱȱȱȱȱȱȱȱȱȱ 6,008 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.1 ȱȱȱȱȱȱȱȱȱȱȱȱ1,152 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.1 ȱȱȱȱȱȱȱȱȱȱȱ2,892 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.0 ȱȱȱȱȱȱȱȱȱȱȱ1,168 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ790 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.0 AllȱOtherȱMusculoskeletalȱInjuriesȱȱȱȱȱȱȱȱȱȱȱ 3,796 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ635 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.7 ȱȱȱȱȱȱȱȱȱȱȱ1,188 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.1 ȱȱȱȱȱȱȱȱȱȱȱ1,314 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ357 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3 TotalȱAllȱMusculoskeletalȱTraumaticȱInjurieȱȱȱȱȱȱȱȱȱ 32,855 ȱȱȱȱȱȱȱȱȱȱȱȱȱ22.3 ȱȱȱȱȱȱȱȱȱȱȱȱ7,543 ȱȱȱȱȱȱȱȱȱȱȱȱȱ20.0 ȱȱȱȱȱȱȱȱȱ13,501 ȱȱȱȱȱȱȱȱȱȱȱȱȱ23.4 ȱȱȱȱȱȱȱȱȱȱȱ8,404 ȱȱȱȱȱȱȱȱȱȱȱȱȱ23.0 ȱȱȱȱȱȱȱȱȱȱȱ3,355 ȱȱȱȱȱȱȱȱȱȱȱȱȱ21.4

AllȱInjuriesȱȱȱȱȱȱȱȱȱ 52,394 ȱȱȱȱȱȱȱȱȱȱȱȱȱ35.5 ȱȱȱȱȱȱȱȱȱȱ12,345 ȱȱȱȱȱȱȱȱȱȱȱȱȱ32.7 ȱȱȱȱȱȱȱȱȱ20,192 ȱȱȱȱȱȱȱȱȱȱȱȱȱ35.1 ȱȱȱȱȱȱȱȱȱ13,699 ȱȱȱȱȱȱȱȱȱȱȱȱȱ37.5 ȱȱȱȱȱȱȱȱȱȱȱ5,982 ȱȱȱȱȱȱȱȱȱȱȱȱȱ38.2 TotalȱPopulationȱ(inȱ000s)ȱ[2]ȱȱȱȱȱȱȱ 147,512 ȱȱȱȱȱȱȱȱȱȱ37,735 ȱȱȱȱȱȱȱȱȱ57,607 ȱȱȱȱȱȱȱȱȱ36,514 ȱȱȱȱȱȱȱȱȱ15,657

FEMALES InjuryȱTreatmentȱEpisodesȱFemalesȱ(inȱ000s)ȱ[1] Fracturesȱȱȱȱȱȱȱȱȱȱȱ 7,087 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.7 ȱȱȱȱȱȱȱȱȱȱȱȱ1,539 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.3 ȱȱȱȱȱȱȱȱȱȱȱ1,212 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.2 ȱȱȱȱȱȱȱȱȱȱȱ1,647 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.3 ȱȱȱȱȱȱȱȱȱȱȱ2,537 ȱȱȱȱȱȱȱȱȱȱȱȱȱ11.7 Dislocationsȱȱȱȱȱȱȱȱȱȱȱ 1,478 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ274 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ361 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ429 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ412 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.9 SprainsȱandȱStrainsȱ ȱȱȱȱȱȱȱȱȱȱȱ8,770 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.8 ȱȱȱȱȱȱȱȱȱȱȱȱ1,451 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.0 ȱȱȱȱȱȱȱȱȱȱȱ3,137 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.6 ȱȱȱȱȱȱȱȱȱȱȱ2,757 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.2 ȱȱȱȱȱȱȱȱȱȱȱ1,417 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.6 Contusionsȱȱȱȱȱȱȱȱȱȱȱ 5,438 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ971 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.7 ȱȱȱȱȱȱȱȱȱȱȱ1,802 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.2 ȱȱȱȱȱȱȱȱȱȱȱ1,273 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.3 ȱȱȱȱȱȱȱȱȱȱȱ1,364 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.3 OpenȱWoundsȱȱȱȱȱȱȱȱȱȱȱ 4,199 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ695 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.9 ȱȱȱȱȱȱȱȱȱȱȱ1,287 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3 ȱȱȱȱȱȱȱȱȱȱȱ1,335 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ860 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.0 AllȱOtherȱMusculoskeletalȱInjuriesȱȱȱȱȱȱȱȱȱȱȱ 3,569 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.8 ȱȱȱȱȱȱȱȱȱȱȱ1,209 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.2 ȱȱȱȱȱȱȱȱȱȱȱ1,300 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ393 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.8 TotalȱAllȱMusculoskeletalȱTraumaticȱInjurieȱȱȱȱȱȱȱȱȱ 28,324 ȱȱȱȱȱȱȱȱȱȱȱȱȱ18.6 ȱȱȱȱȱȱȱȱȱȱȱȱ5,165 ȱȱȱȱȱȱȱȱȱȱȱȱȱ14.3 ȱȱȱȱȱȱȱȱȱȱȱ8,339 ȱȱȱȱȱȱȱȱȱȱȱȱȱ14.9 ȱȱȱȱȱȱȱȱȱȱȱ8,054 ȱȱȱȱȱȱȱȱȱȱȱȱȱ21.0 ȱȱȱȱȱȱȱȱȱȱȱ6,577 ȱȱȱȱȱȱȱȱȱȱȱȱȱ30.4

AllȱInjuriesȱȱȱȱȱȱȱȱȱ 48,045 ȱȱȱȱȱȱȱȱȱȱȱȱȱ31.6 ȱȱȱȱȱȱȱȱȱȱȱȱ9,120 ȱȱȱȱȱȱȱȱȱȱȱȱȱ25.3 ȱȱȱȱȱȱȱȱȱ15,234 ȱȱȱȱȱȱȱȱȱȱȱȱȱ27.2 ȱȱȱȱȱȱȱȱȱ13,051 ȱȱȱȱȱȱȱȱȱȱȱȱȱ34.0 ȱȱȱȱȱȱȱȱȱ10,262 ȱȱȱȱȱȱȱȱȱȱȱȱȱ47.5 TotalȱPopulationȱ(inȱ000s)ȱ[2]ȱȱȱȱȱȱȱ 151,886 ȱȱȱȱȱȱȱȱȱȱ36,001 ȱȱȱȱȱȱȱȱȱ55,931 ȱȱȱȱȱȱȱȱȱ38,351 ȱȱȱȱȱȱȱȱȱ21,603

[1]ȱSourcesȱ:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006;ȱȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ2006;ȱ NationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱDepartmentȱVisits,ȱ2006;ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱ InpatientȱSample,ȱ2007 [2]ȱSource:ȱU.S.ȱCensusȱBureau,ȱNationalȱPopulationȱEstimates:ȱNationalȱSexȱandȱAge.ȱAvailableȱat:ȱhttp://www.census.gov/popest/national/asrh/NCȬEST2006Ȭsa.html.ȱAccessedȱNovemberȱ 6,ȱ2009.

Tableȱ6.5:ȱTrendsȱinȱFractureȱTreatmentȱEpisodesȱforȱSelectedȱAnatomicȱSitesȱbyȱTreatmentȱLocation,ȱUnitedȱ Statesȱ1998Ȭ2004

EmergencyȱRoomȱVisits TotalȱVisitsȱ(roundedȱtoȱnearestȱ000)ȱ[1] ICDȬ9ȬCM Description 1998 1999 2000 2001 2002 2003 2004 2006 UpperȱLimb 812 FractureȱofȱUpperȱArmȱ(Humerus) 261 346 417 297 329 398 342ȱȱȱȱȱȱȱȱȱȱȱȱȱ 270 813 FractureȱofȱLowerȱArmȱ(Radius/Ulna) 647 628 588 745 583 563 763ȱȱȱȱȱȱȱȱȱȱȱȱȱ 505 814ȱȬȱ817 Wrist/Hand/Fingersȱ 832 1,007 1,033 1,079 970 895 1,093ȱȱȱȱȱȱȱȱȱȱȱȱȱ 974 LowerȱLimb 820ȱȬȱ821 FractureȱofȱHip/UpperȱLegȱ(Femur) 324 313 297 298 282 302 307ȱȱȱȱȱȱȱȱȱȱȱȱȱ 326 823 FractureȱofȱLowerȱLegȱ(Tibia/Fibula) 244 234 209 292 212 197 264ȱȱȱȱȱȱȱȱȱȱȱȱȱ 195 824ȱȬȱ826 FractureȱofȱAnkle/Foot/Toes 787 697 836 968 740 816 783ȱȱȱȱȱȱȱȱȱȱȱȱȱ 944 AllȱAnatomicȱȱSitesȱ[2] 812ȱȬȱ817 FractureȱofȱUpperȱLimb 1,726 1,965 2,009 2,097 1,853 1,841 2,163ȱȱȱȱȱȱȱȱȱȱ 1,743 820ȱȬȱ821,ȱ823ȱȬȱ826 FractureȱofȱLowerȱLimb 1,339 1,233 1,331 1,551 1,217 1,311 1,348ȱȱȱȱȱȱȱȱȱȱ 1,429 812ȱȬȱ817,ȱ820ȱȬȱ821,ȱ AllȱFractureȱofȱUpper/LowerȱLimb 3,041 3,190 3,308 3,624 3,058 3,148 3,495ȱȱȱȱȱȱȱȱȱȱ 3,135 823ȱȬȱ826

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ1998Ȭ2006

PhysicianȱOfficeȱVisits TotalȱVisitsȱ(roundedȱtoȱnearestȱ000)ȱ[1] ICDȬ9ȬCM Description 1998 1999 2000 2001 2002 2003 2004 2006 UpperȱLimb 812 FractureȱofȱUpperȱArmȱ(Humerus) * * * ***** 813 FractureȱofȱLowerȱArmȱ(Radius/Ulna) 2,429 1,437 1,852 1,685 2,710 1,116 1,485ȱȱȱȱȱȱȱȱȱȱ 1,567 814ȱȬȱ817 Wrist/Hand/Fingersȱ 2,691 1,846 2,450 2,675 2,740 2,464 1,988ȱȱȱȱȱȱȱȱȱȱ 2,423 LowerȱLimb 820ȱȬȱ821 FractureȱofȱHip/UpperȱLegȱ(Femur)******** 823 FractureȱofȱLowerȱLegȱ(Tibia/Fibula) ******** 824ȱȬȱ826 FractureȱofȱAnkle/Foot/Toes 2,170 1,804 1,883 2,210 2,555 2,228 2,100ȱȱȱȱȱȱȱȱȱȱ 2,355 AllȱAnatomicȱȱSitesȱ[2] 812ȱȬȱ817 TotalȱUpperȱLimbȱFractures 5,718 3,963 5,203 5,005 5,915 4,234 4,203ȱȱȱȱȱȱȱȱȱȱ 5,169 820ȱȬȱ821,ȱ823ȱȬȱ826 TotalȱLowerȱLimbȱFractures 4,027 2,750 3,244 3,344 4,008 3,692 3,862ȱȱȱȱȱȱȱȱȱȱ 3,753 812ȱȬȱ817,ȱ820ȱȬȱ821,ȱ AllȱFractureȱofȱUpper/LowerȱLimb 9,746 6,644 8,349 8,184 9,816 7,731 7,976ȱȱȱȱȱȱȱȱȱȱ 8,923 823ȱȬȱ826

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱPhysicianȱVisits,ȱ1998Ȭ2006

InpatientȱHospitalization TotalȱVisitsȱ(roundedȱtoȱnearestȱ000)ȱ[1] ICDȬ9ȬCM Description 1998 1999 2000 2001 2002 2003 2004 2006 UpperȱLimb 812 FractureȱofȱUpperȱArmȱ(Humerus) 90 98 91 105 89 102 102ȱȱȱȱȱȱȱȱȱȱȱȱȱ 108 813 FractureȱofȱForearmȱ(Radius/Ulna) 96 98 98 106 92 108 94ȱȱȱȱȱȱȱȱȱȱȱȱȱ 111 814ȱȬȱ817 Wrist/Hand/Fingersȱ 42 43 41 38 37 35 39ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 43 LowerȱLimb 820ȱȬȱ821 FractureȱofȱHip/UpperȱLegȱ(Femur) 445 443 423 434 431 422 449ȱȱȱȱȱȱȱȱȱȱȱȱȱ 425 823 FractureȱofȱLowerȱLegȱ(Tibia/Fibula) 91 99 94 95 86 91 88ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 85 824ȱȬȱ826 FractureȱofȱAnkle/Foot/Toes 164 172 169 176 166 170 173ȱȱȱȱȱȱȱȱȱȱȱȱȱ 159 AllȱAnatomicȱȱSitesȱ[2] 812ȱȬȱ817 TotalȱUpperȱLimbȱFractures 216 225 221 237 209 231 224ȱȱȱȱȱȱȱȱȱȱȱȱȱ 245 820ȱȬȱ821,ȱ823ȱȬȱ826 TotalȱLowerȱLimbȱFractures 682 694 663 686 665 664 689ȱȱȱȱȱȱȱȱȱȱȱȱȱ 654 812ȱȬȱ817,ȱ820ȱȬȱ821,ȱ AllȱFractureȱofȱUpper/LowerȱLimb 863 887 850 889 843 867 885ȱȱȱȱȱȱȱȱȱȱȱȱȱ 863 823ȱȬȱ826

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability. [1]ȱAllȱdiagnosesȱȱȱȱȱȱȱȱȱ[2]ȱTotalsȱmayȱnotȱaddȱdueȱtoȱroundingȱandȱinclusionȱofȱadditionalȱanatomicȱsites. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,1998Ȭ2006

Tableȱ6.5a:ȱFractureȱTreatmentȱEpisodeȱTrendsȱforȱTotalȱPhysicianȱOfficeȱVisits,ȱEmergencyȱRoomȱ Visits,ȱandȱInpatientȱHospitalizationȱforȱSelectedȱAnatomicȱSites,ȱUnitedȱStatesȱ1998Ȭ2006

TotalȱVisitsȱ(roundedȱtoȱnearestȱ0000)ȱ[1] ICDȬ9ȬCM Description 1998 1999 2000 2001 2002 2003 2004 2006 UpperȱLimb 812 FractureȱofȱUpperȱArmȱ(Humerus) 351 444 509 401 418 500 444 378 813 FractureȱofȱForearmȱ(Radius/Ulna) 3,172 2,164 2,539 2,536 3,385 1,786 2,342 2,183 814ȱȬȱ817 Wrist/Hand/Fingersȱ 3,564 2,896 3,524 3,793 3,746 3,394 3,120 3,440 LowerȱLimb 820ȱȬȱ821 FractureȱofȱHip/UpperȱLegȱ(Femur) 769 756 720 732 713 724 756 751 823 FractureȱofȱLowerȱLegȱ(Tibia/Fibula) 334 333 303 387 298 288 352 280 824ȱȬȱ826 FractureȱofȱAnkle/Foot/Toes 3,121 2,673 2,888 3,354 3,461 3,213 3,057 3,458 AllȱAnatomicȱȱSitesȱ[2] 812ȱȬȱ817 TotalȱUpperȱLimbȱFractures 7,661 6,153 7,433 7,339 7,977 6,307 6,591 7,157 820Ȭ821,ȱ823Ȭ826 TotalȱLowerȱLimbȱFractures 6,049 4,678 5,237 5,582 5,890 5,666 5,898 5,836 812Ȭ817,ȱ820Ȭ821,ȱ AllȱFractureȱofȱUpper/LowerȱLimb 13,650 10,722 12,507 12,696 13,718 11,746 12,356 12,921 823Ȭ826

ProportionȱofȱTotalȱVisits ICDȬ9ȬCM Description 1998 1999 2000 2001 2002 2003 2004 2006 UpperȱLimb ProportionȱofȱUpperȱLimbȱFractures 812 FractureȱofȱUpperȱArmȱ(Humerus) 5.0% 8.1% 7.7% 6.0% 5.5% 8.8% 7.5% 6.3% 813 FractureȱofȱForearmȱ(Radius/Ulna) 44.8% 39.3% 38.6% 37.7% 44.8% 31.4% 39.7% 36.4% 814ȱȬȱ817 Wrist/Hand/Fingersȱ 50.3% 52.6% 53.6% 56.4% 49.6% 59.8% 52.8% 57.3% %ȱUpper/LowerȱLimbȱFractures 56.1% 57.4% 59.4% 57.8% 58.2% 53.7% 53.3% 55.4%

LowerȱLimb ProportionȱofȱUpperȱLimbȱFractures 820ȱȬȱ821 FractureȱofȱHip/UpperȱLegȱ(Femur) 18.2% 20.1% 18.4% 16.4% 15.9% 17.1% 18.2% 16.7% 823 FractureȱofȱLowerȱLegȱ(Tibia/Fibula) 7.9% 8.9% 7.7% 8.7% 6.7% 6.8% 8.5% 6.2% 824ȱȬȱ826 FractureȱofȱAnkle/Foot/Toes 73.9% 71.1% 73.8% 75.0% 77.4% 76.0% 73.4% 77.0% %ȱUpper/LowerȱLimbȱFractures 44.3% 46.6% 41.9% 44.0% 42.9% 48.2% 47.7% 45.2%

ProportionȱofȱFracturesȱTreatedȱbyȱSite Location EmergencyȱRoomȱVisits 22.3% 29.8% 26.5% 28.5% 22.3% 26.8% 28.3% 24.3% PhysicianȱOfficeȱVisits 71.4% 62.0% 66.8% 64.5% 71.6% 65.8% 64.6% 69.1% InpatientȱHospitalization 6.3% 8.3% 6.8% 7.0% 6.1% 7.4% 7.2% 6.7%

*ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability. [1]ȱAllȱdiagnosesȱȱȱȱȱȱȱȱȱ[2]ȱTotalsȱmayȱnotȱaddȱdueȱtoȱroundingȱandȱinclusionȱofȱadditionalȱanatomicȱsites.

Sources:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱDischargeȱSurvey,ȱ1998Ȭ2006;ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱ AmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ1998Ȭ2006;ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱ PhysicianȱVisits,ȱ1998Ȭ2006

Tableȱ6.6:ȱLocationȱofȱMusculoskeletalȱ InjuryȱEpisodeȱOccurrence,ȱUnitedȱStatesȱ 2008

ȱTotalȱ Occurrencesȱ %ȱofȱTotalȱ (inȱ000s)ȱ[1]ȱ Occurrences InsideȱHomeȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,092 23.0% OutsideȱHomeȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,219 19.1% Schoolȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,954 8.8% StreetȱorȱHighwayȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,580 7.1% SportȱorȱRecreationȱFacilityȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,079 9.4% ShoppingȱCenter/Restaurantȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,048 4.7% Otherȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,743 26.0% Unknownȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 392 1.8% AllȱMusculoskeletalȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱ 22,107 100.0%

*ȱTotalsȱmayȱnotȱaddȱdueȱtoȱroundingȱ

[1]ȱAllȱlistedȱdiagnosesȱforȱpersonsȱreportingȱaȱ musculoskeletalȱinjuryȱinȱtheȱ3Ȭmonthȱperiodȱpriorȱtoȱtheȱ interview,ȱweightedȱtoȱannualȱoccurrences. Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱ InterviewȱSurvey,ȱInjuryȱDatabase,ȱ2008

Tableȱ6.7:ȱNonfatalȱUnintentionalȱInjuriesȱTreatedȱinȱHospitalȱEmergencyȱ Departments,ȱUnitedȱStatesȱ2008

TotalȱNonfatalȱ %ȱofȱTotalȱ ȱRateȱofȱNonfatalȱ ȱTotalȱNonfatalȱ %ȱofȱTotalȱ Unintentionalȱ Nonfatalȱ Unintentionalȱ Unintentionalȱ Nonfatalȱ InjuriesȱTreatedȱ Unintentionalȱ InjuriesȱTreatedȱandȱ Injuries Unintentionalȱ andȱReleasedȱ InjuriesȱTreatedȱ Releasedȱperȱ1,000ȱ CauseȱofȱInjury (inȱ000s)ȱ Injuriesȱ (inȱ000s)ȱ andȱReleasedȱ Persons Fallsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8,551 31%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7,615 89%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 25.0 StruckȱBy/Againstȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,492 16%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,374 97%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 14.4 Overexertionȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,278 12%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,229 99%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 10.6 MotorȱVehicleȱOccupantȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,582 9%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,365 92%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7.8 Cut/Pierceȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,073 7%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,024 98%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6.7 OtherȱCausesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6,095 22%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,233 86%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 17.2 Unknownȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 807 3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 735 91%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2.4 TotalȱAllȱCausesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 27,878 100%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 25,575 92%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 84.1

Source:ȱCentersȱforȱDiseaseȱControl,ȱNationalȱCenterȱforȱInjuryȱPreventionȱandȱControl,ȱWISQARSTMȱ(WebȬbasedȱInjuryȱ StatisticsȱQueryȱandȱReportingȱSystem),ȱNonfatalȱUnintentionalȱInjuryȱReportsȱtreatedȱinȱEmergencyȱDepartment.ȱAvailableȱ at:ȱhttp://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html.ȱAccessedȱonȱNovemberȱ10,ȱ2009.

Tableȱ6.8:ȱNonfatalȱUnintentionalȱInjuriesȱTreatedȱinȱ EmergencyȱDepartmentsȱbyȱAge,ȱUnitedȱStatesȱ2008

%ȱofȱTotalȱ FallsȱRankȱasȱ Total Nonfatalȱ LeadingȱCauseȱofȱ Nonfatalȱ TotalȱNonfatalȱ Unintentionalȱ Nonfatalȱ Unintentionalȱ Unintentionalȱ Injuries Unintentionalȱ Age Injuriesȱ Falls thatȱareȱFalls Injuryȱ 0Ȭ4ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ2,246,139 ȱȱȱȱȱȱȱȱȱȱȱȱ1,003,709 45%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 5Ȭ9ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ1,693,564 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ639,091 38%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 10Ȭ14ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ2,151,639 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ607,365 28%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 15Ȭ24ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ5,170,713 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ918,574 18%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2 25Ȭ34ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ4,143,130 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ813,125 20%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 35Ȭ44ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ3,680,896 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ798,775 22%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 45Ȭ54ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ3,433,363 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ913,341 27%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 55Ȭ64ȱyears ȱȱȱȱȱȱȱȱȱȱȱȱ2,070,337 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ742,735 36%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 65ȱyearsȱ&ȱover ȱȱȱȱȱȱȱȱȱȱȱȱ3,284,671 ȱȱȱȱȱȱȱȱȱȱȱȱ2,114,113 64%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 Unknownȱage ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,297 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ208 6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1 TotalȱAllȱAges ȱȱȱȱȱȱȱȱȱȱ27,877,748 ȱȱȱȱȱȱȱȱȱȱȱȱ8,551,037 31%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1

Source:ȱCentersȱforȱDiseaseȱControl,ȱNationalȱCenterȱforȱInjuryȱPreventionȱandȱControl,ȱ WISQARSTMȱ(WebȬbasedȱInjuryȱStatisticsȱQueryȱandȱReportingȱSystem),ȱLeadingȱCausesȱofȱ NonfatalȱInjuriesȱReports,ȱ2008.ȱAvailableȱat:ȱ http://webappa.cdc.gov/sasweb/ncipc/nfilead.html.ȱAccessedȱonȱNovemberȱ10,ȱ2009.

Tableȱ6.9:ȱDeathsȱDueȱtoȱFallsȱfromȱUnintentionalȱInjuryȱ EpisodesȱbyȱAge,ȱUnitedȱStatesȱ2006

Rateȱofȱ Unintentionalȱ InjuryȱDeathsȱ %ȱofȱTotalȱ ȱTotalȱ ȱTotalȱ DueȱtoȱFallsȱ Unintentionalȱ Populationȱ Unintentionalȱ ȱTotalȱDeathsȱ (perȱ100,000ȱ InjuryȱDeathsȱ Age (inȱ000s)ȱ InjuryȱDeathsȱ DueȱtoȱFallsȱ persons) DueȱtoȱFallsȱ <18ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 73,594 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,966 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ130 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.2 1.6% 18Ȭ24ȱȱȱȱȱȱȱȱȱȱȱȱ 29,236 ȱȱȱȱȱȱȱȱȱȱȱȱ13,278 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ211 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.7 1.6% 25Ȭ34ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 40,020 ȱȱȱȱȱȱȱȱȱȱȱȱ14,954 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ318 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.8 2.1% 35Ȭ44ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 43,481 ȱȱȱȱȱȱȱȱȱȱȱȱ17,534 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ628 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.4 3.6% 45Ȭ54ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 43,210 ȱȱȱȱȱȱȱȱȱȱȱȱ19,675 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,290 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.0 6.6% 55Ȭ64ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 31,558 ȱȱȱȱȱȱȱȱȱȱȱȱ11,446 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,592 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.0 13.9% 65Ȭ74ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 18,915 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,420 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,392 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12.6 28.4% 75Ȭ84ȱyearsȱȱȱȱȱȱȱȱȱȱȱȱ 13,068 ȱȱȱȱȱȱȱȱȱȱȱȱ13,708 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,227 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47.7 45.4% 85ȱyearsȱ&ȱoverȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5,281 ȱȱȱȱȱȱȱȱȱȱȱȱ14,561 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,031 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ152.1 55.2% TotalȱAllȱAgesȱȱȱȱȱȱȱȱȱȱ 298,363 ȱȱȱȱȱȱȱȱȱȱ121,599 ȱȱȱȱȱȱȱȱȱȱȱȱ20,823 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.0 17.1%

Source:ȱCentersȱforȱDiseaseȱControl,ȱNationalȱCenterȱforȱInjuryȱPreventionȱandȱControl,ȱ WISQARSTMȱ(WebȬbasedȱInjuryȱStatisticsȱQueryȱandȱReportingȱSystem),ȱFatalȱInjuriesȱReport,ȱ InjuryȱMortalityȱReports,ȱ1999Ȭ2006.ȱAvailableȱat:ȱ http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html.ȱAccessedȱonȱNovemberȱ10,ȱ2009.

Tableȱ6.10:ȱTrendsȱinȱDeathsȱDueȱtoȱFalls,ȱUnitedȱStatesȱ1984Ȭ2006

TotalȱUnintentionalȱInjuryȱDeathsȱ ȱTotalȱUnintentionalȱInjuryȱDeathsȱ %ȱAllȱDeathsȱ OccurringȱAllȱLocationsȱ[1] OccurringȱinȱtheȱHomeȱ[2]ȱ DueȱtoȱFallsȱ ȱTotalȱ thatȱOccurredȱ Unintentionalȱ ȱDeathȱdueȱtoȱ %ȱofȱDeathsȱ TotalȱHomeȱ Deathȱdueȱtoȱ %ȱofȱDeathsȱ inȱtheȱHome Year InjuryȱDeathsȱ Fallsȱ dueȱtoȱFalls InjuryȱDeathsȱ Fallsȱ dueȱtoȱFalls 1984ȱȱȱȱȱȱȱȱȱȱȱȱ 92,911 ȱȱȱȱȱȱȱȱȱȱȱȱ11,937 12.8%ȱȱȱȱȱȱȱȱȱȱȱȱ 21,200 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,400 30.2% 53.6% 1985ȱȱȱȱȱȱȱȱȱȱȱȱ 93,457 ȱȱȱȱȱȱȱȱȱȱȱȱ12,001 12.8%ȱȱȱȱȱȱȱȱȱȱȱȱ 21,600 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,500 30.1% 54.2% 1986ȱȱȱȱȱȱȱȱȱȱȱȱ 95,277 ȱȱȱȱȱȱȱȱȱȱȱȱ11,444 12.0%ȱȱȱȱȱȱȱȱȱȱȱȱ 21,700 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,100 28.1% 53.3% 1987ȱȱȱȱȱȱȱȱȱȱȱȱ 95,020 ȱȱȱȱȱȱȱȱȱȱȱȱ11,733 12.3%ȱȱȱȱȱȱȱȱȱȱȱȱ 21,400 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,300 29.4% 53.7% 1988ȱȱȱȱȱȱȱȱȱȱȱȱ 97,100 ȱȱȱȱȱȱȱȱȱȱȱȱ12,096 12.5%ȱȱȱȱȱȱȱȱȱȱȱȱ 22,700 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,600 29.1% 54.6% 1989ȱȱȱȱȱȱȱȱȱȱȱȱ 95,028 ȱȱȱȱȱȱȱȱȱȱȱȱ12,151 12.8%ȱȱȱȱȱȱȱȱȱȱȱȱ 22,500 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,600 29.3% 54.3% 1990ȱȱȱȱȱȱȱȱȱȱȱȱ 91,983 ȱȱȱȱȱȱȱȱȱȱȱȱ12,313 13.4%ȱȱȱȱȱȱȱȱȱȱȱȱ 21,500 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,700 31.2% 54.4% 1991ȱȱȱȱȱȱȱȱȱȱȱȱ 89,347 ȱȱȱȱȱȱȱȱȱȱȱȱ12,662 14.2%ȱȱȱȱȱȱȱȱȱȱȱȱ 22,100 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,900 31.2% 54.5% 1992ȱȱȱȱȱȱȱȱȱȱȱȱ 86,777 ȱȱȱȱȱȱȱȱȱȱȱȱ12,646 14.6%ȱȱȱȱȱȱȱȱȱȱȱȱ 24,000 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,700 32.1% 60.9% 1993ȱȱȱȱȱȱȱȱȱȱȱȱ 90,523 ȱȱȱȱȱȱȱȱȱȱȱȱ13,141 14.5%ȱȱȱȱȱȱȱȱȱȱȱȱ 26,100 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,900 30.3% 60.1% 1994ȱȱȱȱȱȱȱȱȱȱȱȱ 91,437 ȱȱȱȱȱȱȱȱȱȱȱȱ13,450 14.7%ȱȱȱȱȱȱȱȱȱȱȱȱ 26,300 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,100 30.8% 60.2% 1995ȱȱȱȱȱȱȱȱȱȱȱȱ 93,320 ȱȱȱȱȱȱȱȱȱȱȱȱ13,986 15.0%ȱȱȱȱȱȱȱȱȱȱȱȱ 27,200 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,400 30.9% 60.1% 1996ȱȱȱȱȱȱȱȱȱȱȱȱ 94,948 ȱȱȱȱȱȱȱȱȱȱȱȱ14,986 15.8%ȱȱȱȱȱȱȱȱȱȱȱȱ 27,500 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,000 32.7% 60.1% 1997ȱȱȱȱȱȱȱȱȱȱȱȱ 95,644 ȱȱȱȱȱȱȱȱȱȱȱȱ15,447 16.2%ȱȱȱȱȱȱȱȱȱȱȱȱ 27,700 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,100 32.9% 58.9% 1998ȱȱȱȱȱȱȱȱȱȱȱȱ 97,835 ȱȱȱȱȱȱȱȱȱȱȱȱ16,274 16.6%ȱȱȱȱȱȱȱȱȱȱȱȱ 29,000 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,500 32.8% 58.4% 1999ȱȱȱȱȱȱȱȱȱȱȱȱ 97,860 ȱȱȱȱȱȱȱȱȱȱȱȱ13,162 13.4%ȱȱȱȱȱȱȱȱȱȱȱȱ 30,500 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,600 24.9% 57.7% 2000ȱȱȱȱȱȱȱȱȱȱȱȱ 97,900 ȱȱȱȱȱȱȱȱȱȱȱȱ13,322 13.6%ȱȱȱȱȱȱȱȱȱȱȱȱ 29,200 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,100 24.3% 53.3% 2001ȱȱȱȱȱȱȱȱȱȱ 101,537 ȱȱȱȱȱȱȱȱȱȱȱȱ15,019 14.8%ȱȱȱȱȱȱȱȱȱȱȱȱ 33,200 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8,600 25.9% 57.3% 2002ȱȱȱȱȱȱȱȱȱȱ 106,742 ȱȱȱȱȱȱȱȱȱȱȱȱ16,257 15.2%ȱȱȱȱȱȱȱȱȱȱȱȱ 36,200 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,700 26.8% 59.7% 2003ȱȱȱȱȱȱȱȱȱȱ 108,900 ȱȱȱȱȱȱȱȱȱȱȱȱ19,800 18.2%ȱȱȱȱȱȱȱȱȱȱȱȱ 37,600 ȱȱȱȱȱȱȱȱȱȱȱȱ11,900 31.6% 60.1% 2004ȱȱȱȱȱȱȱȱȱȱ 111,000 ȱȱȱȱȱȱȱȱȱȱȱȱ20,200 18.2%ȱȱȱȱȱȱȱȱȱȱȱȱ 37,400 ȱȱȱȱȱȱȱȱȱȱȱȱ12,800 34.2% 63.4% 2005ȱ[3]ȱȱȱȱȱȱȱȱȱȱ 117,800 ȱȱȱȱȱȱȱȱȱȱȱȱ19,700 16.7% NA NA NA NA 2006ȱ[3]ȱȱȱȱȱȱȱȱȱȱ 121,600 ȱȱȱȱȱȱȱȱȱȱȱȱ20,800 17.1% NA NA NA NA

[1]ȱȱSource:ȱNationalȱSafetyȱCouncil.ȱInjuryȱFacts,ȱ2009 .ȱItasca,ȱIL:ȱNationalȱSafetyȱCouncil,ȱ2009,ȱpȱ42. [2]ȱSource:ȱȱNationalȱSafetyȱCouncil.ȱInjuryȱFacts,ȱ2009 .ȱItasca,ȱIL:ȱNationalȱSafetyȱCouncil,ȱ2009,ȱpȱ127. [3]ȱCentersȱforȱDiseaseȱControl,ȱNationalȱCenterȱforȱInjuryȱPreventionȱandȱControl,ȱWISQARSTMȱ(WebȬbasedȱInjuryȱ StatisticsȱQueryȱandȱReportingȱSystem),ȱFatalȱInjuriesȱReport,ȱUnintentionalȱInjuriesȱOnly,ȱ2005ȱ&ȱ2006.ȱAvailableȱat:ȱ http://webappa.cdc.gov/cgiȬbin/broker.exe;ȱallȱagesȱpercentages.ȱAccessedȱonȱNovemberȱ10,ȱ2009.

Tableȱ6.11:ȱProportionȱofȱUnintentionalȱInjuryȱEpisodesȱbyȱTypeȱandȱCauseȱofȱInjury,ȱ UnitedȱStatesȱ2008

ProportionȱofȱInjuryȱEpisodesȱbyȱInjuryȱTypeȱforȱSelectedȱCausesȱȱ[1] Bike,ȱ Scooter,ȱ TotalȱInjuryȱ Motorȱ Skateboard,ȱ Pedestrianȱ Boat,ȱTrain,ȱ Episodesȱ[2] Vehicleȱ Skis,ȱetc.ȱ (Struck)ȱ Planeȱ ȱFallȱ Burn Spain,ȱStrainȱorȱTwist 31.9% 55.7% 41.9% 26.5% 51.5% 37.6% 3.1% CutȱorȱScrape 16.0% 11.8% 15.1% 26.7% 32.9% 14.1% 0.0% Fracture 19.9% 18.0% 27.3% 36.7% 0.0% 29.3% 0.0% BruiseȱorȱContusion 18.0% 32.9% 20.3% 74.0% 49.3% 23.8% 0.0% Other 13.6% 18.6% 11.1% 15.6% 0.0% 10.0% 7.2% Biteȱ(InsectȱorȱAnimal) 2.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Burn 1.3% 0.9% 1.6% 0.0% 0.0% 0.5% 89.7% TotalȱInjuryȱEpisodesȱ(inȱ000s)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 30,702 ȱȱȱȱȱȱȱȱȱȱ2,092 ȱȱȱȱȱȱȱȱȱȱ1,540 ȱȱȱȱȱȱȱȱȱȱȱȱȱ188 ȱȱȱȱȱȱȱȱȱȱȱȱȱ163 ȱȱȱȱȱȱȱȱ11,074 ȱȱȱȱȱȱȱȱȱȱȱȱȱ263

[1]ȱSelfȬreportedȱinjuryȱtypeȱinȱtheȱ3Ȭmonthȱperiodȱpriorȱtoȱtheȱinterview,ȱweightedȱtoȱannualȱepisodes. [2]ȱMultipleȱinjuryȱtypesȱandȱbodyȱpartsȱinjuredȱperȱinjuryȱepisodeȱpossible.ȱTotalsȱmayȱnotȱequalȱ100%. Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱInterviewȱSurvey,ȱInjuryȱDatabase,ȱ2008

Tableȱ6.12:ȱIncidenceȱandȱRatesȱofȱInjuriesȱbyȱBodyȱRegion,ȱUnitedȱStatesȱ2000

Fatal Hospitalized Nonhospitalized Total Incidenceȱ Rate/ȱ Incidenceȱ Rate/ȱ Incidenceȱ Rate/ȱ Incidenceȱ Rate/ȱ (inȱ000s) 100,000 (inȱ000s) 100,000 (inȱ000s) 100,000 (inȱ000s) 100,000 TraumaticȱBrainȱInjury 40 15 156 56 1,147 415 1,343 486 OtherȱHeadȱ/NeckȱInjury 5 2 144 52 6,392 2,312 6,541 2,366 SpinalȱCordȱInjury 1 0 10 4 16 6 27 10 VertebralȱColumnȱInjury 1 0 86 31 4,619 1,671 4,706 1,702 Torso 23 8 245 89 3,888 1,406 4,155 1,503 UpperȱExtremity 1 0 275 100 13,047 4,720 13,324 4,820 LowerȱExtremity 7 3 656 237 10,584 3,829 11,247 4,069 Other/Unspecified 32 12 18 7 5,789 2,094 5,839 2,113 SystemwideȱInjuries 39 14 279 101 2,626 950 2,945 1,065 Total 149 54 1,870 676 48,108 17,405 50,127 18,135

Source:ȱFinkelsteinȱEA,ȱCorsoȱPS,ȱMillerȱTR.ȱTheȱIncidenceȱandȱEconomicȱBurdenȱofȱInjuriesȱinȱtheȱUnitedȱStates .ȱNewȱYork,ȱNY:ȱ OxfordȱUniversityȱPress,ȱ2006,ȱpȱ12.

Tableȱ6.13:ȱVisitsȱtoȱPhysiciansȱinȱOfficeȬBasedȱPracticeȱforȱFractures,ȱSprainsȱandȱStrains,ȱandȱDislocationȱ InjuriesȱatȱSelectedȱAnatomicȱSitesȱbyȱGender,ȱUnitedȱStatesȱ2006

VisitsȱforȱFractures VisitsȱforȱSprainsȱandȱStrains

ȱTotalȱVisitsȱ(inȱ000s)ȱ[1]ȱȱ %ȱofȱTotalȱ TotalȱVisitsȱ(inȱ000s)ȱ[1]ȱ %ȱofȱTotalȱ Male Female Total Visits Male Female Total Visits HandȱandȱFingersȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 581 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ717 ȱȱȱȱȱȱȱȱȱȱȱȱ1,298 12.5% BackȱandȱSacroiliacȱȱȱȱȱȱȱȱȱȱ 2,803 ȱȱȱȱȱȱȱȱȱȱ3,503 ȱȱȱȱȱȱȱȱȱȱ6,307 38.0% RadiusȱandȱUlnaȱ(Arm)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 498 ȱȱȱȱȱȱȱȱȱȱȱȱ1,069 ȱȱȱȱȱȱȱȱȱȱȱȱ1,567 15.0% Shoulderȱȱȱȱȱȱȱȱȱȱ 1,324 ȱȱȱȱȱȱȱȱȱȱ2,254 ȱȱȱȱȱȱȱȱȱȱ3,578 21.6% Ankleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 337 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ920 ȱȱȱȱȱȱȱȱȱȱȱȱ1,257 12.1% ElbowȱandȱArmȱ* ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȬ ȱȱȱȱȱȱȱȱȱȱȱȱȱ134 ȱȱȱȱȱȱȱȱȱȱȱȱȱ134 0.8% RibsȱandȱSternumȱ*94ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ250 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ344 3.3% HandȱandȱWristȱȱȱȱȱȱȱȱȱȱȱȱȱ 534 ȱȱȱȱȱȱȱȱȱȱȱȱȱ781 ȱȱȱȱȱȱȱȱȱȱ1,315 7.9% TibiaȱandȱFibulaȱ(Leg)ȱ*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 193 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ475 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ668 6.4% HipȱandȱThighȱȱȱȱȱȱȱȱȱȱȱȱȱ 905 ȱȱȱȱȱȱȱȱȱȱȱȱȱ680 ȱȱȱȱȱȱȱȱȱȱ1,585 9.6% FootȱandȱToesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 546 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ590 ȱȱȱȱȱȱȱȱȱȱȱȱ1,136 10.9% KneeȱandȱLegȱ*ȱȱȱȱȱȱȱȱȱȱȱȱȱ 214 ȱȱȱȱȱȱȱȱȱȱȱȱȱ427 ȱȱȱȱȱȱȱȱȱȱȱȱȱ642 3.9% Humerusȱ(Shoulder)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 734 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ508 ȱȱȱȱȱȱȱȱȱȱȱȱ1,242 11.9% AnkleȱandȱFootȱȱȱȱȱȱȱȱȱȱ 1,597 ȱȱȱȱȱȱȱȱȱȱ1,422 ȱȱȱȱȱȱȱȱȱȱ3,019 18.2% VertebralȱColumnȱ*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 227 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ179 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ406 3.9% AllȱSprainsȱandȱStrainsȱ[2]ȱȱȱȱȱȱȱȱ 16,580 100.0%

NeckȱofȱFemurȱ(Hip)ȱ*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 161 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ144 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ305 2.9%TotalȱSprainȱandȱStrainȱEpisodesȱTreatedȱinȱ ȱȱȱȱȱȱȱȱ 12,023 Wristȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ468 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ657 ȱȱȱȱȱȱȱȱȱȱȱȱ1,124 10.8% PhysicianȇsȱOffice Femurȱ*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 235 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ190 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ425 4.1% Pelvisȱ*27ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 0.3% VisitsȱforȱDislocationȱInjuries

ClavicleȱorȱScapulaȱ*87ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ301 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ388 3.7% TotalȱVisitsȱ(inȱ000s)ȱ[1]ȱ %ȱofȱTotalȱ Patellaȱ(Knee)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 199 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ238 2.3% Male Female Total Visits AllȱFracturesȱ[2] ȱȱȱȱȱȱȱȱȱȱ10,425 100.0% KneeȱandȱLegȱJointȱ[3]ȱȱȱȱȱȱȱȱȱȱȱȱȱ 708 ȱȱȱȱȱȱȱȱȱȱ1,137 ȱȱȱȱȱȱȱȱȱȱ1,845 76.8% TotalȱFractureȱEpisodesȱTreatedȱinȱPhysicianȇsȱ ȱȱȱȱȱȱȱȱȱȱȱȱ9,919 Shoulder*ȱȱȱȱȱȱȱȱȱȱȱȱȱ 117 ȱȱȱȱȱȱȱȱȱȱȱȱȱ165 ȱȱȱȱȱȱȱȱȱȱȱȱȱ182 7.6% Office AllȱOtherȱSitesȱȱȱȱȱȱȱȱȱȱȱȱȱ 210 ȱȱȱȱȱȱȱȱȱȱȱȱȱ167 ȱȱȱȱȱȱȱȱȱȱȱȱȱ377 15.7% AllȱDislocationsȱ[2] ȱȱȱȱȱȱȱȱȱȱ2,404 100.0% TotalȱDislocationȱEpisodesȱTreatedȱinȱPhysicianȇsȱ ȱȱȱȱȱȱȱȱȱȱ2,470 *ȱEstimateȱdoesȱnotȱmeetȱstandardsȱforȱreliability Office [1]ȱAllȱlistedȱdiagnosesȱ [2]ȱMultipleȱanatomicȱsitesȱperȱinjuryȱepisodeȱpossible

[3]ȱTheȱhighȱproportionȱofȱdislocationȱinjuriesȱattributedȱtoȱtheȱkneeȱisȱdueȱtoȱanȱICDȬ9ȱcodingȱanomaly.ȱȱIsolatedȱacuteȱligamentousȱinjuriesȱofȱtheȱkneeȱ(ACL,ȱ MCL,ȱPCL,ȱLCLȱdisruptions)ȱareȱcodedȱasȱdislocationsȱusingȱICDȬ9ȱmethodology,ȱwhereasȱequivalentȱinjuriesȱinȱotherȱjointsȱareȱcodedȱasȱsprains/strains.ȱȱTrueȱ completeȱdislocationsȱofȱtheȱkneeȱjointȱareȱactuallyȱquiteȱrare,ȱandȱassociatedȱwithȱmarkedȱmorbidity.

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006

Tableȱ6.14:ȱPrevalenceȱofȱSelfȬReportedȱMusculoskeletalȱInjuryȱEpisodesȱbyȱAnatomicȱSiteȱbyȱAge,ȱUnitedȱSt

ȱTotalȱIdentifiedȱ ȱPrevalenceȱofȱSelfȬReportedȱInjuryȱSitesȱforȱAllȱ ProportionȱofȱAllȱInjuryȱSitesȱforȱAllȱ AnatomicȱSiteȱ %ȱofȱTotalȱ MusculoskeletalȱInjuryȱEpisodesȱ(inȱ000s)ȱ[2]ȱ MusculoskeletalȱInjuryȱEpisodesȱ[2]ȱ Injuries Injuriesȱbyȱ ȱ(inȱ000s)ȱ[1]ȱ AnatomicȱSite <ȱ18 18ȱtoȱ44 45ȱtoȱ64 65ȱ&ȱolder <ȱ18 18ȱtoȱ44 45ȱtoȱ64 65ȱ&ȱolder Ankleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,600 10.1%ȱȱȱȱȱȱȱȱȱȱ 1,047 ȱȱȱȱȱȱȱȱȱȱ1,511ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ756 ȱȱȱȱȱȱȱȱȱȱȱȱȱ286 12.7% 12.1% 7.9% 5.4% Backȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,429 9.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 318 ȱȱȱȱȱȱȱȱȱȱ1,564ȱ ȱȱȱȱȱȱȱȱȱȱ1,035 ȱȱȱȱȱȱȱȱȱȱȱȱȱ515 3.8% 12.5% 10.8% 9.8% Kneeȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,408 9.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 754 ȱȱȱȱȱȱȱȱȱȱ1,097ȱ ȱȱȱȱȱȱȱȱȱȱ1,088 ȱȱȱȱȱȱȱȱȱȱȱȱȱ468 9.1% 8.8% 11.4% 8.9% Finger/Thumbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,689 7.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 598 ȱȱȱȱȱȱȱȱȱȱ1,211ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ660 ȱȱȱȱȱȱȱȱȱȱȱȱȱ220 7.2% 9.7% 6.9% 4.2% Footȱorȱtoeȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,654 7.5%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 532 ȱȱȱȱȱȱȱȱȱȱȱȱȱ911ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ946 ȱȱȱȱȱȱȱȱȱȱȱȱȱ265 6.4% 7.3% 9.9% 5.0% Shoulderȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,253 6.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 292 ȱȱȱȱȱȱȱȱȱȱȱȱȱ769ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ830 ȱȱȱȱȱȱȱȱȱȱȱȱȱ362 3.5% 6.2% 8.7% 6.9% Handȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,772 5.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 389 ȱȱȱȱȱȱȱȱȱȱȱȱȱ767ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ466 ȱȱȱȱȱȱȱȱȱȱȱȱȱ151 4.7% 6.1% 4.9% 2.9% Wristȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,659 4.7%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 545 ȱȱȱȱȱȱȱȱȱȱȱȱȱ531ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ226 ȱȱȱȱȱȱȱȱȱȱȱȱȱ357 6.6% 4.3% 2.4% 6.8% Lowerȱlegȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,630 4.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 196 ȱȱȱȱȱȱȱȱȱȱȱȱȱ435ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ549 ȱȱȱȱȱȱȱȱȱȱȱȱȱ450 2.4% 3.5% 5.7% 8.6% Forearmȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,503 4.2%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 449 ȱȱȱȱȱȱȱȱȱȱȱȱȱ444ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ263 ȱȱȱȱȱȱȱȱȱȱȱȱȱ348 5.4% 3.6% 2.7% 6.6% Elbowȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,074 3.0%ȱȱȱȱȱȱȱȱȱȱȱȱȱ 518 ȱȱȱȱȱȱȱȱȱȱȱȱȱ188ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ290 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ79 6.3% 1.5% 3.0% 1.5% Hipȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 919 2.6%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 96 ȱȱȱȱȱȱȱȱȱȱȱȱȱ154ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ325 ȱȱȱȱȱȱȱȱȱȱȱȱȱ344 1.2% 1.2% 3.4% 6.5% Thighȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ632 1.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 86 ȱȱȱȱȱȱȱȱȱȱȱȱȱ234ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ150 ȱȱȱȱȱȱȱȱȱȱȱȱȱ162 1.0% 1.9% 1.6% 3.1% UpperȱArmȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 458 1.3%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 95 ȱȱȱȱȱȱȱȱȱȱȱȱȱ118ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ118 ȱȱȱȱȱȱȱȱȱȱȱȱȱ127 1.1% 0.9% 1.2% 2.4% Otherȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7,901 22.2%ȱȱȱȱȱȱȱȱȱȱ 2,358 ȱȱȱȱȱȱȱȱȱȱ2,544ȱ ȱȱȱȱȱȱȱȱȱȱ1,871 ȱȱȱȱȱȱȱȱȱȱ1,128 28.5% 20.4% 19.5% 21.4% AllȱMSȱInjuryȱEpisodesȱbyȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ35,581 100.0%ȱȱȱȱȱȱȱȱȱȱ 8,273 ȱȱȱȱȱȱȱȱ12,478 ȱȱȱȱȱȱȱȱȱȱ9,573 ȱȱȱȱȱȱȱȱȱȱ5,262 100.0% 100.0% 100.0% 100.0% AnatomicȱSites*

TotalȱPopulationȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30,702 ȱȱȱȱȱȱȱȱȱȱ7,998 ȱȱȱȱȱȱȱȱ10,931 ȱȱȱȱȱȱȱȱȱȱ7,804 ȱȱȱȱȱȱȱȱȱȱ3,968 ReportingȱanȱInjury

*ȱTotalsȱmayȱnotȱaddȱdueȱtoȱroundingȱ [1]ȱAllȱlistedȱdiagnosesȱforȱpersonsȱreportingȱaȱmusculoskeletalȱinjuryȱinȱtheȱ3ȱmonthȱperiodȱpriorȱtoȱtheȱinterview,ȱweightedȱtoȱannualȱepisodes.ȱ [2]ȱMultipleȱanatomicȱsitesȱperȱinjuryȱepisodeȱpossible. Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱInterviewȱSurvey,ȱInjuryȱDatabase,ȱ2008

Tableȱ6.15:ȱActivityȱLimitationsȱdueȱ toȱFractureȱorȱBone/JointȱInjuryȱbyȱ GenderȱandȱAgedȱforȱPersonsȱAgeȱ 18ȱandȱOver,ȱUnitedȱStatesȱ2005Ȭ 2006

ȱRateȱofȱReportedȱLimitationsȱdueȱtoȱ FractureȱorȱBone/JointȱInjuryȱ[1]ȱ (perȱ100ȱpersons)ȱ Male Female Total 18Ȭ44ȱyears 1.7 2.3 2.0 45Ȭ64ȱyears 5.5 4.7 5.1 65Ȭ74ȱyears 6.7 6.5 6.6 75ȱ&ȱover 13.5 12.6 12.9 Allȱages 4.1 4.4 4.3

[1]ȱȈWhatȱconditionȱorȱhealthȱproblemȱcausesȱyouȱtoȱ haveȱdifficultyȱwithȱorȱneedȱhelpȱwithȱtheȱfollowingȱ activities?ȈȱResponse:ȱȈFractures,ȱbone/jointȱinjury.Ȉ

Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱ HealthȱandȱNutritionȱExaminationȱSurvey,ȱ 2005Ȭ2006

Tableȱ6.16:ȱActivityȱLimitationsȱDueȱtoȱFractureȱorȱBone/JointȱInjuryȱforȱPersonsȱ Agedȱ18ȱandȱOver,ȱUnitedȱStatesȱ2005Ȭ2006

DegreeȱofȱLimitationȱforȱPersonsȱReportingȱLimitationȱ[1]

Some Much Unableȱ Totalȱ%ȱWithȱ ActivityȱLimitationȱReportedȱ[2] Difficulty Difficulty toȱDo Difficulty Stooping,ȱcrouching,ȱorȱkneeling 41.2% 22.8% 18.3% 82.3% Standingȱforȱlongȱperiodsȱ(e.g.,ȱ2ȱhours) 26.4% 19.1% 19.1% 64.6% Pushȱorȱpullȱlargeȱobjectsȱlikeȱaȱchairȱ[3] 29.9% 11.6% 17.3% 58.7% Sittingȱforȱlongȱperiodsȱ(e.g.,ȱ2ȱhours) 31.6% 11.9% 5.3% 48.8% Doingȱchoresȱaroundȱtheȱhouse 28.3% 9.5% 8.3% 46.1% Lifting/carryingȱ10ȱpoundȱitem 23.7% 10.6% 11.2% 45.5% Standingȱupȱfromȱarmlessȱstraightȱchair 29.0% 8.0% 6.2% 43.2% Gettingȱinȱandȱoutȱofȱbed 29.4% 9.8% 1.5% 40.7% Reachingȱoverȱhead 25.8% 9.8% 4.9% 40.5% Goingȱshopping,ȱtoȱmoviesȱorȱevents 24.5% 9.6% 5.5% 39.6% Participatingȱinȱsocialȱactivities 17.2% 7.9% 5.9% 45.5% Walkingȱquarterȱmileȱ(2Ȭ3ȱblocks) 26.1% 7.4% 5.3% 38.8% Dressingȱselfȱ(tyingȱshoes,ȱzippers,ȱbuttons) 26.1% 5.1% 0.8% 32.0% Usingȱfingersȱtoȱgraspȱsmallȱobjects 22.3% 7.2% 0.9% 30.4% Wakingȱupȱ10ȱstepsȱwithoutȱresting 20.4% 6.7% 2.1% 29.2% Movingȱaroundȱroomsȱonȱsameȱlevel 16.0% 2.9% 3.0% 21.9% Managingȱmoneyȱorȱpayingȱbills 13.0% 3.2% 3.4% 19.6% Preparingȱownȱmeals 12.8% 3.4% 3.0% 19.2% Relaxingȱatȱhome,ȱwatchingȱTV,ȱsewing 12.6% 3.0% 1.5% 17.1% Eatingȱwithȱutensilsȱorȱdrinkingȱfromȱaȱglass 9.6% 2.3% 0.1% 12.0%

[1]ȱRespondedȱȈyesȈȱtoȱfractureȱorȱbone/jointȱinjuryȱwhenȱaskedȱȈWhatȱconditionȱorȱhealthȱproblemȱcausesȱyouȱtoȱhaveȱ difficultyȱwithȱorȱneedȱhelpȱwithȱtheȱfollowingȱactivitiesȱ.ȱ.ȱ.ȱ?Ȉ

[2]ȱȈByȱyourselfȱandȱwithoutȱusingȱanyȱspecialȱequipment,ȱhowȱmuchȱdifficultyȱdoȱyouȱhaveȱ.ȱ.ȱ.?Ȉ [3]ȱNotȱincludedȱinȱ2001Ȭ2002ȱsurvey;ȱavailableȱonlyȱforȱ4ȱyearȱperiodȱ2003Ȭ2006. Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱandȱNutritionȱExaminationȱSurvey,ȱ2001Ȭ2006

Tableȱ6.17:ȱBedȱDaysȱDueȱtoȱMajorȱHealthȱConditionsȱbyȱGenderȱforȱPersonsȱAgedȱ 18ȱandȱOver,ȱUnitedȱStatesȱ2008

BedȱDaysȱ[1] BedȱDaysȱ

Personsȱ Personsȱ Reportingȱ TotalȱBedȱ Reportingȱ TotalȱBedȱ BedȱDaysȱ MeanȱBedȱ Days BedȱDaysȱ MeanȱBedȱ Days (inȱ000s) Days ȱ(inȱ000s) (inȱ000s) Days ȱ(inȱ000s) AllȱCausesȱ[2] OtherȱMajorȱHealthȱConditions HeartȱProblemȱ[7] TotalȱPopulationȱȱȱȱȱȱȱȱ 71,338 ȱȱȱȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱ784,718 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 3,703 ȱȱȱȱȱȱȱȱȱȱȱȱ22.9 ȱȱȱȱȱȱȱȱ84,799 Maleȱȱȱȱȱȱȱȱ 28,947 ȱȱȱȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱ318,417 Maleȱȱȱȱȱȱȱȱȱȱ 1,901 ȱȱȱȱȱȱȱȱȱȱȱȱ21.7 ȱȱȱȱȱȱȱȱ41,252 Femaleȱȱȱȱȱȱȱȱ 42,390 ȱȱȱȱȱȱȱȱȱȱȱȱ10.9 ȱȱȱȱȱȱ462,051 Femaleȱȱȱȱȱȱȱȱȱȱ 1,802 ȱȱȱȱȱȱȱȱȱȱȱȱ24.0 ȱȱȱȱȱȱȱȱ43,248 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱ 19,554 ȱȱȱȱȱȱȱȱȱȱȱȱ11.9 ȱȱȱȱȱȱ232,693 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 361 ȱȱȱȱȱȱȱȱȱȱȱȱ17.1 ȱȱȱȱȱȱȱȱȱȱ6,173 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 29,339 ȱȱȱȱȱȱȱȱȱȱȱȱ12.2 ȱȱȱȱȱȱ357,936 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,384 ȱȱȱȱȱȱȱȱȱȱȱȱ31.7 ȱȱȱȱȱȱȱȱ43,873 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱ 22,445 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.4 ȱȱȱȱȱȱ188,538 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱ 1,958 ȱȱȱȱȱȱȱȱȱȱȱȱ17.6 ȱȱȱȱȱȱȱȱ34,461 MusculoskeletalȱConditions AllȱMusculoskeletalȱInjuriesȱorȱConditionsȱ[3] Strokeȱ[8] TotalȱPopulationȱȱȱȱȱȱȱȱ 51,334 ȱȱȱȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱ523,607 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 1,540 ȱȱȱȱȱȱȱȱȱȱȱȱ34.1 ȱȱȱȱȱȱȱȱ52,514 Maleȱȱȱȱȱȱȱȱ 20,682 ȱȱȱȱȱȱȱȱȱȱȱȱ10.0 ȱȱȱȱȱȱ206,820 Maleȱȱȱȱȱȱȱȱȱȱȱȱȱ 769 ȱȱȱȱȱȱȱȱȱȱȱȱ30.3 ȱȱȱȱȱȱȱȱ23,301 Femaleȱȱȱȱȱȱȱȱ 30,652 ȱȱȱȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱ312,650 Femaleȱȱȱȱȱȱȱȱȱȱȱȱȱ 770 ȱȱȱȱȱȱȱȱȱȱȱȱ37.9 ȱȱȱȱȱȱȱȱ29,183 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱ 12,786 ȱȱȱȱȱȱȱȱȱȱȱȱ11.6 ȱȱȱȱȱȱ148,318 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 77 ȱȱȱȱȱȱȱȱȱȱȱȱ49.4 ȱȱȱȱȱȱȱȱȱȱ3,804 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 22,258 ȱȱȱȱȱȱȱȱȱȱȱȱ11.1 ȱȱȱȱȱȱ247,064 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 650 ȱȱȱȱȱȱȱȱȱȱȱȱ33.9 ȱȱȱȱȱȱȱȱ22,035 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱ 16,200 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.6 ȱȱȱȱȱȱ123,120 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 813 ȱȱȱȱȱȱȱȱȱȱȱȱ32.8 ȱȱȱȱȱȱȱȱ26,666

Fracture/Bone/JointȱInjury[4] Hypertensionȱ[9] TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 6,821 ȱȱȱȱȱȱȱȱȱȱȱȱ11.2 ȱȱȱȱȱȱȱȱ76,395 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 2,314 ȱȱȱȱȱȱȱȱȱȱȱȱ24.9 ȱȱȱȱȱȱȱȱ57,619 Maleȱȱȱȱȱȱȱȱȱȱ 3,500 ȱȱȱȱȱȱȱȱȱȱȱȱ12.3 ȱȱȱȱȱȱȱȱ43,050 Maleȱȱȱȱȱȱȱȱȱȱȱȱȱ 892 ȱȱȱȱȱȱȱȱȱȱȱȱ16.4 ȱȱȱȱȱȱȱȱ14,629 Femaleȱȱȱȱȱȱȱȱȱȱ 3,320 ȱȱȱȱȱȱȱȱȱȱȱȱ10.0 ȱȱȱȱȱȱȱȱ33,200 Femaleȱȱȱȱȱȱȱȱȱȱ 1,422 ȱȱȱȱȱȱȱȱȱȱȱȱ30.2 ȱȱȱȱȱȱȱȱ42,944 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 2,317 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.1 ȱȱȱȱȱȱȱȱ18,768 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 149 ȱȱȱȱȱȱȱȱȱȱȱȱ26.5 ȱȱȱȱȱȱȱȱȱȱ3,949 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 2,920 ȱȱȱȱȱȱȱȱȱȱȱȱ15.0 ȱȱȱȱȱȱȱȱ43,800 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,309 ȱȱȱȱȱȱȱȱȱȱȱȱ28.8 ȱȱȱȱȱȱȱȱ37,699 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱ 1,584 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7 ȱȱȱȱȱȱȱȱ13,781 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 857 ȱȱȱȱȱȱȱȱȱȱȱȱ18.5 ȱȱȱȱȱȱȱȱ15,855

Back/NeckȱProblemȱ[5] OtherȱInjuryȱ[10] TotalȱPopulationȱȱȱȱȱȱȱȱ 18,705 ȱȱȱȱȱȱȱȱȱȱȱȱ15.4 ȱȱȱȱȱȱ288,057 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 2,139 ȱȱȱȱȱȱȱȱȱȱȱȱ10.1 ȱȱȱȱȱȱȱȱ21,604 Maleȱȱȱȱȱȱȱȱȱȱ 8,256 ȱȱȱȱȱȱȱȱȱȱȱȱ16.7 ȱȱȱȱȱȱ137,875 Maleȱȱȱȱȱȱȱȱȱȱ 1,165 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7 ȱȱȱȱȱȱȱȱ10,136 Femaleȱȱȱȱȱȱȱȱ 10,449 ȱȱȱȱȱȱȱȱȱȱȱȱ14.3 ȱȱȱȱȱȱ149,421 Femaleȱȱȱȱȱȱȱȱȱȱȱȱȱ 974 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱ11,493 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 6,094 ȱȱȱȱȱȱȱȱȱȱȱȱ14.1 ȱȱȱȱȱȱȱȱ85,925 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 919 ȱȱȱȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱȱȱ10,109 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 8,326 ȱȱȱȱȱȱȱȱȱȱȱȱ17.0 ȱȱȱȱȱȱ141,542 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 865 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.2 ȱȱȱȱȱȱȱȱȱȱ5,363 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱ 4,285 ȱȱȱȱȱȱȱȱȱȱȱȱ14.0 ȱȱȱȱȱȱȱȱ59,990 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 358 ȱȱȱȱȱȱȱȱȱȱȱȱ17.1 ȱȱȱȱȱȱȱȱȱȱ6,122

Arthritis/Rheumatismȱ[6] TotalȱPopulationȱȱȱȱȱȱȱȱ 23,517 ȱȱȱȱȱȱȱȱȱȱȱȱ10.4 ȱȱȱȱȱȱ244,577 [1]ȱAȱbedȱdayȱisȱdefinedȱasȱ1/2ȱorȱmoreȱdaysȱinȱbedȱdueȱtoȱ Maleȱȱȱȱȱȱȱȱȱȱ 7,893 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.9 ȱȱȱȱȱȱȱȱ62,355 injuryȱorȱillnessȱinȱpastȱ12ȱmonths,ȱexcludingȱhospitalization. Femaleȱȱȱȱȱȱȱȱ 15,624 ȱȱȱȱȱȱȱȱȱȱȱȱ12.7 ȱȱȱȱȱȱ198,425 [2]ȱRespondentsȱreportedȱȈYesȈȱwhenȱaskedȱȈAreȱyouȱlimitedȱinȱ 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 2,645 ȱȱȱȱȱȱȱȱȱȱȱȱ16.6 ȱȱȱȱȱȱȱȱ43,907 anyȱwayȱinȱanyȱactivitiesȱbecauseȱofȱphysical,ȱmentalȱorȱ 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 10,645 ȱȱȱȱȱȱȱȱȱȱȱȱ12.6 ȱȱȱȱȱȱ134,127 emotionalȱproblems.ȈȱANDȱrespondentsȱreportingȱaȱlimitationȱ 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱ 10,227 ȱȱȱȱȱȱȱȱȱȱȱȱ10.4 ȱȱȱȱȱȱ106,361 reportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱ Ȉarthritis/rheumatism,ȱback/neckȱproblem,ȱfracture/bone/jointȱ injury,ȱotherȱinjury,ȱheartȱproblem,ȱstroke,ȱhypertension.Ȉ [3]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈFracture/bone/jointȱinjury;ȱ Back/neckȱproblem;ȱArthritis/Rheumatism;ȱAmputatedȱlimb/finger/digit;ȱorȱMusculoskeletal/connectiveȱtissueȱproblem.Ȉ [4]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈFracture/bone/jointȱinjury.Ȉ [5]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈBack/neckȱproblem.Ȉ [6]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈArthritis/rheumatism.Ȉ [7]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈHeartȱproblem.Ȉ [8]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈStroke.Ȉ [9]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈHypertension.Ȉ [10]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈOtherȱinjury.Ȉ Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱInterviewȱSurvey,ȱ2008

Tableȱ6.18:ȱLostȱWorkȱDaysȱDueȱtoȱMajorȱHealthȱConditionsȱbyȱGenderȱforȱPersonsȱ Agedȱ18ȱandȱOver,ȱUnitedȱStatesȱ2008

WorkȱDaysȱLostȱ[1] WorkȱDaysȱLostȱ

Personsȱ Personsȱ Reportingȱ Reportingȱ LostȱWorkȱ Meanȱ TotalȱWorkȱ LostȱWorkȱ Meanȱ TotalȱWorkȱ Days WorkȱDaysȱ DaysȱLostȱ Days WorkȱDaysȱ DaysȱLostȱ (inȱ000s) Lost (inȱ000s) (inȱ000s) Lost (inȱ000s) AllȱCausesȱ[2] OtherȱMajorȱHealthȱConditions HeartȱProblemȱ[7] TotalȱPopulationȱȱȱȱȱȱȱȱ 36,408 ȱȱȱȱȱȱȱȱȱȱȱȱ10.8 ȱȱȱȱȱȱ393,206 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱȱȱȱ 745 ȱȱȱȱȱȱȱȱȱȱȱȱ24.6 ȱȱȱȱȱȱȱȱ18,327 Maleȱȱȱȱȱȱȱȱ 16,182 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.9 ȱȱȱȱȱȱ160,202 Maleȱȱȱȱȱȱȱȱȱȱȱȱȱ 317 ȱȱȱȱȱȱȱȱȱȱȱȱ21.5 ȱȱȱȱȱȱȱȱȱȱ6,816 Femaleȱȱȱȱȱȱȱȱ 20,226 ȱȱȱȱȱȱȱȱȱȱȱȱ11.4 ȱȱȱȱȱȱ230,576 Femaleȱȱȱȱȱȱȱȱȱȱȱȱȱ 427 ȱȱȱȱȱȱȱȱȱȱȱȱ26.9 ȱȱȱȱȱȱȱȱ11,486 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱ 15,072 ȱȱȱȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱ177,850 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 180 ȱȱȱȱȱȱȱȱȱȱȱȱ14.2 ȱȱȱȱȱȱȱȱȱȱ2,556 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 18,494 ȱȱȱȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱ203,434 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 373 ȱȱȱȱȱȱȱȱȱȱȱȱ35.4 ȱȱȱȱȱȱȱȱ13,204 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱ 2,842 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.8 ȱȱȱȱȱȱȱȱ10,800 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 192 ȱȱȱȱȱȱȱȱȱȱȱȱ13.6 ȱȱȱȱȱȱȱȱȱȱ2,611 MusculoskeletalȱConditions AllȱMusculoskeletalȱInjuriesȱorȱConditionsȱ[3] Strokeȱ[8] TotalȱPopulationȱȱȱȱȱȱȱȱ 27,227 ȱȱȱȱȱȱȱȱȱȱȱȱ10.6 ȱȱȱȱȱȱ288,606 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱȱȱȱ 120 ȱȱȱȱȱȱȱȱȱȱȱȱ27.2 ȱȱȱȱȱȱȱȱȱȱ3,264 Maleȱȱȱȱȱȱȱȱ 12,537 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.3 ȱȱȱȱȱȱ116,594 Maleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 79 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱ253 Femaleȱȱȱȱȱȱȱȱ 14,690 ȱȱȱȱȱȱȱȱȱȱȱȱ11.6 ȱȱȱȱȱȱ170,404 Femaleȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 41 ȱȱȱȱȱȱȱȱȱȱȱȱ73.2 ȱȱȱȱȱȱȱȱȱȱ3,001 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱ 10,312 ȱȱȱȱȱȱȱȱȱȱȱȱ12.0 ȱȱȱȱȱȱ123,744 18ȱtoȱ44ȱYears ȱȱȱȱȱȱȱȱȱȱȱȱȱȬ ȱȱȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱȱȱ Ȭ 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 14,645 ȱȱȱȱȱȱȱȱȱȱȱȱ10.6 ȱȱȱȱȱȱ155,237 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 116 ȱȱȱȱȱȱȱȱȱȱȱȱ28.3 ȱȱȱȱȱȱȱȱȱȱ3,283 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱ 2,270 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.6 ȱȱȱȱȱȱȱȱȱȱ8,172 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5 ȱȱȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱȱȱ Ȭ

Fracture/Bone/JointȱInjuryȱ[4] Hypertensionȱ[9] TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 4,263 ȱȱȱȱȱȱȱȱȱȱȱȱ15.1 ȱȱȱȱȱȱȱȱ64,371 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱȱȱȱ 496 ȱȱȱȱȱȱȱȱȱȱȱȱ15.2 ȱȱȱȱȱȱȱȱȱȱ7,539 Maleȱȱȱȱȱȱȱȱȱȱ 2,524 ȱȱȱȱȱȱȱȱȱȱȱȱ13.2 ȱȱȱȱȱȱȱȱ33,317 Maleȱȱȱȱȱȱȱȱȱȱȱȱȱ 177 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7 ȱȱȱȱȱȱȱȱȱȱ1,540 Femaleȱȱȱȱȱȱȱȱȱȱ 1,739 ȱȱȱȱȱȱȱȱȱȱȱȱ17.8 ȱȱȱȱȱȱȱȱ30,954 Femaleȱȱȱȱȱȱȱȱȱȱȱȱȱ 318 ȱȱȱȱȱȱȱȱȱȱȱȱ18.9 ȱȱȱȱȱȱȱȱȱȱ6,010 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,928 ȱȱȱȱȱȱȱȱȱȱȱȱ10.7 ȱȱȱȱȱȱȱȱ20,630 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 40 ȱȱȱȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ440 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 2,059 ȱȱȱȱȱȱȱȱȱȱȱȱ19.0 ȱȱȱȱȱȱȱȱ39,121 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 395 ȱȱȱȱȱȱȱȱȱȱȱȱ17.2 ȱȱȱȱȱȱȱȱȱȱ6,794 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 275 ȱȱȱȱȱȱȱȱȱȱȱȱ17.4 ȱȱȱȱȱȱȱȱȱȱ4,785 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 61 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱ329

Back/NeckȱProblemȱ[5] OtherȱInjuryȱ[10] TotalȱPopulationȱȱȱȱȱȱȱȱ 10,127 ȱȱȱȱȱȱȱȱȱȱȱȱ14.8 ȱȱȱȱȱȱ149,880 TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 1,198 ȱȱȱȱȱȱȱȱȱȱȱȱ28.7 ȱȱȱȱȱȱȱȱ34,383 Maleȱȱȱȱȱȱȱȱȱȱ 5,016 ȱȱȱȱȱȱȱȱȱȱȱȱ13.1 ȱȱȱȱȱȱȱȱ65,710 Maleȱȱȱȱȱȱȱȱȱȱȱȱȱ 680 ȱȱȱȱȱȱȱȱȱȱȱȱ43.7 ȱȱȱȱȱȱȱȱ29,716 Femaleȱȱȱȱȱȱȱȱȱȱ 5,110 ȱȱȱȱȱȱȱȱȱȱȱȱ16.4 ȱȱȱȱȱȱȱȱ83,804 Femaleȱȱȱȱȱȱȱȱȱȱȱȱȱ 518 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.1 ȱȱȱȱȱȱȱȱȱȱ4,714 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 4,570 ȱȱȱȱȱȱȱȱȱȱȱȱ17.9 ȱȱȱȱȱȱȱȱ81,803 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 651 ȱȱȱȱȱȱȱȱȱȱȱȱ31.2 ȱȱȱȱȱȱȱȱ20,311 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 5,030 ȱȱȱȱȱȱȱȱȱȱȱȱ12.9 ȱȱȱȱȱȱȱȱ64,887 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 535 ȱȱȱȱȱȱȱȱȱȱȱȱ26.3 ȱȱȱȱȱȱȱȱ14,071 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 527 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.4 ȱȱȱȱȱȱȱȱȱȱ2,846 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 11 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29

Arthritis/Rheumatismȱ[6] TotalȱPopulationȱȱȱȱȱȱȱȱȱȱ 9,422 ȱȱȱȱȱȱȱȱȱȱȱȱ10.4 ȱȱȱȱȱȱȱȱ97,989 [1]ȱAȱbedȱdayȱisȱdefinedȱasȱ1/2ȱorȱmoreȱdaysȱinȱbedȱdueȱtoȱ Maleȱȱȱȱȱȱȱȱȱȱ 3,672 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6.8 ȱȱȱȱȱȱȱȱ24,970 injuryȱorȱillnessȱinȱpastȱ12ȱmonths,ȱexcludingȱhospitalization. Femaleȱȱȱȱȱȱȱȱȱȱ 5,750 ȱȱȱȱȱȱȱȱȱȱȱȱ12.7 ȱȱȱȱȱȱȱȱ73,025 [2]ȱRespondentsȱreportedȱȈYesȈȱwhenȱaskedȱȈAreȱyouȱlimitedȱ 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,823 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.4 ȱȱȱȱȱȱȱȱ17,136 inȱanyȱwayȱinȱanyȱactivitiesȱbecauseȱofȱphysical,ȱmentalȱorȱ 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 6,420 ȱȱȱȱȱȱȱȱȱȱȱȱ12.2 ȱȱȱȱȱȱȱȱ78,324 emotionalȱproblems.ȈȱANDȱrespondentsȱreportingȱaȱlimitationȱ 65ȱYearsȱ&ȱOverȱȱȱȱȱȱȱȱȱȱ 1,178 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.2 ȱȱȱȱȱȱȱȱȱȱ2,592 reportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱ Ȉarthritis/rheumatism,ȱback/neckȱproblem,ȱfracture/bone/jointȱ injury,ȱotherȱinjury,ȱheartȱproblem,ȱstroke,ȱhypertension.Ȉ [3]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈFracture/bone/jointȱinjury;ȱ Back/neckȱproblem;ȱArthritis/Rheumatism;ȱAmputatedȱlimb/finger/digit;ȱorȱMusculoskeletal/connectiveȱtissueȱproblem.Ȉ [4]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈFracture/bone/jointȱinjury.Ȉ [5]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈBack/neckȱproblem.Ȉ [6]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈArthritis/rheumatism.Ȉ [7]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈHeartȱproblem.Ȉ [8]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈStroke.Ȉ [9]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈHypertension.Ȉ [10]ȱRespondentsȱreportingȱaȱlimitationȱreportedȱȈYesȈȱwhenȱaskedȱifȱlimitationȱwasȱcausedȱbyȱȈOtherȱinjury.Ȉ Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱInterviewȱSurvey,ȱ2008

Tableȱ6.19:ȱSummaryȱofȱBedȱandȱLostȱWorkȱDaysȱ DueȱtoȱHealthȱProblemsȱforȱPersonsȱAgeȱ18ȱandȱ Over,ȱUnitedȱStatesȱ2008

BedȱDaysȱ[2] LostȱWorkȱDaysȱ[3] CauseȱofȱBed/LostȱWorkȱ Total %ȱofȱ Totalȱ %ȱofȱ Daysȱ[1] (inȱ000s) Total (inȱ000s) Total

MusculoskeletalȱInjury ȱȱȱ523,607 67%ȱȱȱ 288,606 73% ȱȱȱȱȱorȱCondition HeartȱProblemȱȱȱȱȱ 84,799 11% ȱȱȱȱȱ18,327 5% Hypertensionȱȱȱȱȱ 57,619 7% ȱȱȱȱȱȱȱ7,539 2% Strokeȱȱȱȱȱ 52,514 7% ȱȱȱȱȱȱȱ3,264 1% OtherȱInjuryȱȱȱȱȱ 21,604 3% ȱȱȱȱȱ34,383 9% OtherȱHealthȱConditionsȱȱȱȱȱ 44,576 6% ȱȱȱȱȱ41,087 10% AllȱCausesȱȱȱ 784,718 100%ȱȱȱ 393,206 100%

MUSCULOSKELETALȱINJURYȱORȱCONDITION Back/NeckȱPainȱȱȱ 288,057 37%ȱȱȱ 149,880 38% Arthritis/Rheumatismȱȱȱ 244,577 31%ȱȱȱȱȱ 97,989 25% Fracture/Bone/JointȱPainȱȱȱȱȱ 76,395 10%ȱȱȱȱȱ 64,371 16%

[1]ȱRespondentsȱreportedȱȈYesȈȱwhenȱaskedȱȈAreȱyouȱlimitedȱinȱanyȱwayȱ inȱanyȱactivitiesȱbecauseȱofȱphysical,ȱmentalȱorȱemotionalȱproblems.Ȉ [2]ȱAȱbedȱdayȱisȱdefinedȱasȱ1/2ȱorȱmoreȱdaysȱinȱbedȱdueȱtoȱinjuryȱorȱillnessȱ inȱpastȱ12ȱmonths,ȱexcludingȱhospitalization. [3]ȱAȱmissedȱworkȱdayȱisȱdefinedȱasȱabsenceȱfromȱworkȱdueȱtoȱillnessȱorȱ injuryȱinȱtheȱpastȱ12ȱmonths,ȱexcludingȱmaternityȱorȱfamilyȱleave.ȱ Source:ȱNationalȱCenterȱforȱHealthȱStatistics.ȱNationalȱHealthȱInterviewȱ Survey,ȱ2008

Tableȱ6.20:ȱȱMusculoskeletalȱDisordersȱ(MSDs)ȱforȱ WorkȬRelatedȱInjuriesȱandȱIllnessesȱInvolvingȱ DaysȱAwayȱfromȱWork,ȱUnitedȱStatesȱ1992Ȭ2007

AllȱCasesȱofȱ %ȱofȱ WorkȬrelatedȱ MSDȱCasesȱ InjuriesȱandȱIllnesses MSDs toȱAllȱCases 1992ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,331,098 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ784,145 33.6% 1993ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,252,591 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ762,727 33.9% 1994ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,236,639 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ755,594 33.8% 1995ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,040,929 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ695,789 34.1% 1996ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,880,525 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ647,355 34.4% 1997ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,833,380 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ626,352 34.2% 1998ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,730,534 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ592,544 34.2% 1999ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,702,420 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ582,340 34.2% 2000ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,664,018 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ577,814 34.7% 2001ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,537,567 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ522,528 34.0% 2002ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,436,194 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ487,915 34.0% 2003ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,315,920 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ435,180 33.1% 2004ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,259,320 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ402,700 32.0% 2005ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,234,860 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ375,540 30.4% 2006ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,183,500 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ357,160 30.2% 2007ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,158,870 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ335,390 28.9%

Sourceȱ(1992ȱtoȱ1997):ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics:ȱ WorkerȱHealthȱChartbookȱ2004.ȱAvailableȱat:ȱhttp://www2a.cdc.gov/nioshȬ Chartbook/imagedetail.asp?imgid=77.ȱAccessedȱAugustȱ24,ȱ2007.

Sourceȱ(1998ȱtoȱ2007):ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱ Injuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱ CharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱ AwayȱfromȱWork.ȱTableȱ10.ȱNumber,ȱpercent,ȱandȱincidenceȱrateȱofȱnonfatalȱ occupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱworkȱbyȱ selectedȱworkerȱandȱcaseȱcharacteristicsȱandȱmusculoskeletalȱdisorders,ȱAllȱ UnitedȱStates,ȱprivateȱindustry,ȱ2006ȱandȱ2007.ȱAvailableȱat:ȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1790.pdfȱandȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1941.pdf.ȱAccessedȱNovemberȱ 11,ȱ2009.

Tableȱ6.21:ȱȱMusculoskeletalȱDisordersȱforȱWorkȬRelatedȱInjuriesȱandȱIllnessesȱ InvolvingȱDaysȱAwayȱfromȱWorkȱbyȱNatureȱofȱInjury,ȱUnitedȱStatesȱ2000Ȭ2007

Carpalȱ Sorenessȱ& Sprains,ȱ Tunnelȱ Painȱ(exclȱ NatureȱofȱInjuryȱȱ[1] Strains Syndrome Tendonitis backȱpain) BackȱPain AllȱOtherȱ[2] TotalȱCases 2000 Number 442,839 27,571 12,577 25,454 31,685 50,265 577,814 Percent 75.0% 4.7% 2.1% 4.3% 5.4% 8.5% 100.0%

2001 Number 399,722 26,522 12,131 22,346 27,894 33,913 522,528 Percent 76.5% 5.1% 2.3% 4.3% 5.3% 6.5% 100.0%

2002 Number 369,785 22,583 8,105 25,934 30,953 38,660 487,915 Percent 74.6% 4.6% 1.6% 5.2% 6.2% 7.8% 100.0%

2003 Number 331,020 22,110 6,740 21,930 23,650 29,740 435,180 Percent 76.1% 5.1% 1.5% 5.0% 5.4% 6.8% 100.0%

2004 Number 306,210 18,760 5,940 22,460 23,770 1,790 378,930 Percent 80.8% 5.0% 1.6% 5.9% 6.3% 0.5% 100.0%

2005 Number 287,970 16,440 5,040 19,880 22,050 24,170 375,540 Percent* 76.7% 4.4% 1.3% 5.3% 5.9% 6.4% 100.0%

2006 Number 274,730 12,990 4,020 21,810 21,950 21,660 357,160 Percent* 76.9% 3.6% 1.1% 6.1% 6.1% 6.1% 100.0%

2007 Number 252,590 11,920 3,530 22,520 23,430 21,400 335,390 Percent* 75.3% 3.6% 1.1% 6.7% 7.0% 6.4% 100.0%

[1]ȱMultipleȱinjuriesȱperȱcaseȱpossible;ȱpercentagesȱbasedȱonȱtotalȱinjuries,ȱwhichȱmayȱbeȱ>ȱtotalȱcases. [2]ȱIncludesȱMSȱsystemȱandȱconnectiveȱdiseasesȱandȱdisordersȱandȱhernia.

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱ DemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTableȱ10.ȱNumber,ȱ percent,ȱandȱincidenceȱrateȱofȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱworkȱbyȱselectedȱ workerȱandȱcaseȱcharacteristicsȱandȱmusculoskeletalȱdisorders,ȱAllȱUnitedȱStates,ȱprivateȱindustry,ȱ2006ȱandȱ2007.ȱAvailableȱ at:ȱhttp://www.bls.gov/iif/oshwc/osh/case/ostb1790.pdfȱandȱhttp://www.bls.gov/iif/oshwc/osh/case/ostb1941.pdf.ȱAccessedȱ Novemberȱ11,ȱ2009.

Tableȱ6.22:ȱTrendsȱinȱMSDȱInjuriesȱ InvolvingȱDaysȱAwayȱfromȱWorkȱinȱ PrivateȱIndustryȱbyȱSex,ȱUnitedȱStatesȱ 2000ȱtoȱ2007

AllȱMSDȱInjuries Male Female Total 2000 Number 358,949 216,014 574,963 Percent 62.4% 37.6%

2001 Number 324,935 194,910 519,845 Percent 62.5% 37.5%

2002 Number 300,128 186,966 487,915 Percent 61.6% 38.4%

2003 Number 267,530 166,780 435,180 Percent 61.6% 38.4%

2004 Number 254,220 147,750 402,700 Percent 63.2% 36.8%

2005 Number 238,630 136,340 375,540 Percent 63.5% 36.3%

2006 Number 222,880 133,710 357,160

Percent 62.4% 37.4%

2007 Number 207,770 127,010 335,390

Percent 61.9% 37.9%

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱ Injuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱ DemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱ IllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTableȱ10.ȱ Number,ȱpercent,ȱandȱincidenceȱrateȱofȱnonfatalȱ occupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱ fromȱworkȱbyȱselectedȱworkerȱandȱcaseȱcharacteristicsȱandȱ musculoskeletalȱdisorders,ȱAllȱUnitedȱStates,ȱprivateȱ industry,ȱ2006ȱandȱ2007.ȱAvailableȱat:ȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1790.pdfȱandȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1941.pdf.ȱ AccessedȱNovemberȱ11,ȱ2009.

Tableȱ6.23:ȱDistributionȱofȱNonfatalȱInjuryȱandȱ IllnessȱCasesȱInvolvingȱDaysȱAwayȱfromȱWorkȱ inȱPrivateȱIndustryȱforȱMusculoskeletalȱ DisordersȱbyȱSex,ȱUnitedȱStatesȱ2007

NonfatalȱInjuriesȱby ȱInjuryȱType,ȱ2007 Male Female Total AllȱNonfatalȱInjuriesȱ Number 744,860 409,040 1,158,870 andȱIllnesses Rateȱperȱ ȱȱȱȱȱȱȱȱȱ134.1 ȱȱȱȱȱȱȱȱȱ105.2 ȱȱȱȱȱȱȱȱȱ122.2 10,000ȱ

ȱAllȱMSDȱInjuries Number 207,770 127,010 335,390 Rateȱperȱ 37.4 32.7ȱȱȱȱȱȱȱȱȱȱȱ 35.4 10,000ȱ AllȱSprains,ȱStrains Number 280,670 165,550 448,380 ȱ&ȱTearsȱ[1] Rateȱperȱ ȱȱȱȱȱȱȱȱȱȱȱ50.5 ȱȱȱȱȱȱȱȱȱȱȱ42.6 ȱȱȱȱȱȱȱȱȱȱȱ47.3 10,000ȱ

CarpalȱTunnelȱ Number 3,750 8,180 11,940 Syndrome Rateȱperȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ0.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ2.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ1.3 10,000ȱ

Tendonitis Number 1,693 2,680 4,380 Rateȱperȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ0.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱ0.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ0.5 10,000ȱ

[1]ȱTotalsȱareȱgreaterȱthanȱshownȱinȱTableȱ6.21ȱforȱMDSȱsprainsȱ&ȱ strainsȱdueȱtoȱinclusionȱofȱallȱsprainsȱandȱstrains.

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱ IllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱ forȱWorkȬrelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱ Work.ȱTableȱ8a.ȱNumberȱandȱincidenceȱrateȱofȱnonfatalȱoccupationalȱ injuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱworkȱȱbyȱselectedȱ workerȱandȱcaseȱcharacteristicsȱandȱselectedȱnaturesȱofȱinjuryȱorȱillness,ȱ AllȱUnitedȱStates,ȱprivateȱindustry,ȱ2007.ȱAvailableȱat:ȱȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1938.pdf.ȱAccessedȱ Novemberȱ11,ȱ2009.

Tableȱ6.24:ȱȱMusculoskeletalȱDisordersȱ(MSDs)ȱforȱWorkȬRelatedȱInjuriesȱandȱIllnessesȱInvolvingȱ DaysȱAwayȱfromȱWorkȱbyȱRace,ȱUnitedȱStatesȱ2007

NonfatalȱInjuriesȱ Sprains,ȱStrainsȱ&ȱ CarpalȱTunnelȱ andȱIllnessesȱ[1] MSDs Tears Syndrome Tendonitis RaceȱorȱEthnicity Number Percent Number Percent Number Percent Number Percent Number Percent Whiteȱȱȱȱȱȱ 519,330 65.0%ȱȱȱ 151,850 68.3%ȱȱȱ 198,820 67.0%ȱȱȱȱȱȱȱ 6,710 77.6%ȱȱȱȱȱȱȱ 2,030 71.7% Black/AfricanȱAmericanȱȱȱȱȱȱȱȱ 94,200 11.8%ȱȱȱȱȱ 27,050 12.2%ȱȱȱȱȱ 37,670 12.7%ȱȱȱȱȱȱȱȱȱȱ 780 9.0%ȱȱȱȱȱȱȱȱȱȱ 270 9.5% HispanicȱorȱLatinoȱȱȱȱȱȱ 157,320 19.7%ȱȱȱȱȱ 36,250 16.3%ȱȱȱȱȱ 51,010 17.2%ȱȱȱȱȱȱȱȱȱȱ 960 11.1%ȱȱȱȱȱȱȱȱȱȱ 390 13.8% Asianȱȱȱȱȱȱȱȱ 16,220 2.0%ȱȱȱȱȱȱȱ 4,090 1.8%ȱȱȱȱȱȱȱ 4,820 1.6%ȱȱȱȱȱȱȱȱȱȱ 150 1.7%ȱȱȱȱȱȱȱȱȱȱȱȱ 90 3.2% Other/Mixedȱȱȱȱȱȱȱȱ 12,110 1.5%ȱȱȱȱȱȱȱ 3,140 1.4%ȱȱȱȱȱȱȱ 4,450 1.5%ȱȱȱȱȱȱȱȱȱȱȱȱ 50 0.6%ȱȱȱȱȱȱȱȱȱȱȱȱ 50 1.8% NotȱReportedȱȱȱȱȱȱ 359,690 ȱȱȱ113,010 ȱȱȱ151,620 ȱȱȱȱȱȱȱ3,280 ȱȱȱȱȱȱȱ1,530 Totalȱȱȱ 1,158,870 100.0%ȱȱȱ 335,390 100.0%ȱȱȱ 448,380 100.0%ȱȱȱȱȱ 11,940 100.0%ȱȱȱȱȱȱȱ 4,380 100.0%

[1]ȱNonfatalȱinjuriesȱandȱillnessesȱincludeȱtheȱtotalȱofȱallȱnonfatalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱwork

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱforȱ WorkȬrelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTableȱ8b.ȱNumberȱandȱpercentȱofȱnonfatalȱoccupationalȱinjuriesȱandȱ illnessesȱinvolvingȱdaysȱawayȱfromȱworkȱbyȱselectedȱworkerȱandȱcaseȱcharacteristicsȱandȱnatureȱofȱinjuryȱorȱillness,ȱAllȱUnitedȱStates,ȱprivateȱ industry,ȱ2007.ȱAvailableȱat:ȱhttp://www.bls.gov/iif/oshwc/osh/case/ostb1939.pdf.ȱAccessedȱNovemberȱ11,ȱ2009.

Tableȱ6.25:ȱȱMusculoskeletalȱDisordersȱ(MSDs)ȱforȱWorkȬRelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱ AwayȱfromȱWorkȱbyȱAge,ȱUnitedȱStatesȱ2007

NonfatalȱInjuriesȱ Sprains,ȱStrainsȱ&ȱ CarpalȱTunnelȱ andȱIllnesses MSDs Tears Syndrome Tendonitis

Rateȱperȱ Rateȱperȱ Rateȱperȱ Rateȱperȱ Rateȱperȱ Number 10,000ȱ Number 10,000ȱ Number 10,000ȱ Number 10,000ȱ Number 10,000ȱ Workers Workers Workers Workers Workers

Underȱ14ȱȱYears 20 * * * * * * * * * 14ȱtoȱ15ȱ 400 * 30 * 30 * * * * * 16ȱtoȱ19ȱ 35,250ȱȱȱȱȱȱȱ 124.0 6,400ȱȱȱȱȱȱȱȱȱ 22.5 9,790ȱȱȱȱȱȱȱȱȱ 34.4 30ȱȱȱȱȱȱȱȱȱȱȱ 0.1 80ȱȱȱȱȱȱȱȱȱȱȱ 0.3 20ȱtoȱ24ȱ 124,550ȱȱȱȱȱȱȱ 134.4 30,320ȱȱȱȱȱȱȱȱȱ 32.7 43,740ȱȱȱȱȱȱȱȱȱ 47.2 380ȱȱȱȱȱȱȱȱȱȱȱ 0.4 340ȱȱȱȱȱȱȱȱȱȱȱ 0.4 25ȱtoȱ34ȱ 260,080ȱȱȱȱȱȱȱ 118.4 74,780ȱȱȱȱȱȱȱȱȱ 34.0 101,840ȱȱȱȱȱȱȱȱȱ 46.4 1,710ȱȱȱȱȱȱȱȱȱȱȱ 0.8 1,320ȱȱȱȱȱȱȱȱȱȱȱ 0.6 35ȱtoȱ44ȱ 283,660ȱȱȱȱȱȱȱ 123.9 93,440ȱȱȱȱȱȱȱȱȱ 40.8 118,550ȱȱȱȱȱȱȱȱȱ 51.8 3,300ȱȱȱȱȱȱȱȱȱȱȱ 1.4 890ȱȱȱȱȱȱȱȱȱȱȱ 0.4 45ȱtoȱ54ȱ 271,300ȱȱȱȱȱȱȱ 123.0 84,410ȱȱȱȱȱȱȱȱȱ 38.3 109,730ȱȱȱȱȱȱȱȱȱ 49.7 4,170ȱȱȱȱȱȱȱȱȱȱȱ 1.9 1,010ȱȱȱȱȱȱȱȱȱȱȱ 0.5 55ȱtoȱ64ȱ 138,960ȱȱȱȱȱȱȱ 119.9 35,470ȱȱȱȱȱȱȱȱȱ 30.6 50,220ȱȱȱȱȱȱȱȱȱ 43.3 2,170ȱȱȱȱȱȱȱȱȱȱȱ 1.9 570ȱȱȱȱȱȱȱȱȱȱȱ 0.5 65ȱYearsȱ&ȱOlder 25,140ȱȱȱȱȱȱȱȱȱ 96.2 4,900ȱȱȱȱȱȱȱȱȱ 18.8 7,400ȱȱȱȱȱȱȱȱȱ 28.3 90ȱȱȱȱȱȱȱȱȱȱȱ 0.4 60ȱȱȱȱȱȱȱȱȱȱȱ 0.2 Total 1,158,870ȱȱȱȱȱȱȱ 122.2 335,390ȱȱȱȱȱȱȱȱȱ 35.4 448,380ȱȱȱȱȱȱȱȱȱ 47.3 11,940ȱȱȱȱȱȱȱȱȱȱȱ 1.3 4,380ȱȱȱȱȱȱȱȱȱȱȱ 0.5

*ȱDataȱdoesȱnotȱmeetȱpublicationȱguidelines

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱforȱWorkȬ relatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTableȱ8a.ȱNumberȱandȱincidenceȱrateȱofȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱ involvingȱdaysȱawayȱfromȱworkȱbyȱselectedȱworkerȱandȱcaseȱcharacteristicsȱandȱselectedȱnaturesȱofȱinjuryȱorȱillness,ȱAllȱUnitedȱStates,ȱprivateȱindustry,ȱ 2007.ȱAvailableȱat:ȱhttp://www.bls.gov/iif/oshwc/osh/case/ostb1938.pdf.ȱAccessedȱNovemberȱ11,ȱ2009.

Tableȱ6.26:ȱȱMusculoskeletalȱDisordersȱ(MSD)ȱforȱWorkȬRelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱ fromȱWorkȱbyȱBodyȱPartȱAffected,ȱUnitedȱStatesȱ2007

Musculoskeletal Sprains,ȱStrainsȱ&ȱ CarpalȱTunnelȱ AllȱNatures Disorders Tears Syndrome Tendonitis Rateȱperȱ Rateȱperȱ Rateȱperȱ Rateȱperȱ Rateȱperȱ 10,000ȱ 10,000ȱ 10,000ȱ 10,000ȱ 10,000ȱ BodyȱPartȱAffected Number Workers Number Workers Number Workers Number Workers Number Workers Headȱ(total) ȱȱȱȱȱ78,370 ȱȱȱȱȱȱȱȱȱȱ8.3 ȱȱȱȱȱȱȱȱȱȱȱȱ90 *ȱȱȱȱȱȱȱȱȱȱ 220 ***** Eyeȱȱȱȱȱ 33,010 ȱȱȱȱȱȱȱȱȱȱ3.5 ȱȱȱȱȱȱȱȱ 50 *ȱȱȱȱȱȱȱȱȱȱ 110 ***** Headȱ(exceptȱeye)ȱ[1]ȱȱȱȱȱ 45,360 ȱȱȱȱȱȱȱȱȱȱ4.8 ȱȱȱȱȱȱȱȱȱȱȱȱ40 *ȱȱȱȱȱȱȱȱȱȱ 110 *****

Neck ȱȱȱȱȱ17,050 ȱȱȱȱȱȱȱȱȱȱ1.8 ȱȱȱȱȱȱȱ5,420 ȱȱȱȱȱȱȱȱȱȱ0.6 ȱȱȱȱȱ11,730 ȱȱȱȱȱȱȱȱȱȱ1.2 ** **

Trunkȱ(total) ȱȱȱ384,650 ȱȱȱȱȱȱȱȱ40.6 ȱȱȱ237,330 ȱȱȱȱȱȱȱȱ25.0 ȱȱȱ248,480 ȱȱȱȱȱȱȱȱ26.2 * *ȱȱȱȱȱȱȱ 1,100 ȱȱȱȱȱȱȱȱȱȱ0.1 Shoulderȱȱȱȱȱ 75,580 ȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱ43,620 ȱȱȱȱȱȱȱȱȱȱ4.6 ȱȱȱȱȱ51,180 ȱȱȱȱȱȱȱȱȱȱ5.4 * *ȱȱȱȱȱȱȱ 1,100 ȱȱȱȱȱȱȱȱȱȱ0.1 Backȱȱȱ 235,960 ȱȱȱȱȱȱȱȱ24.9 ȱȱȱ160,880 ȱȱȱȱȱȱȱȱ17.0 ȱȱȱ177,480 ȱȱȱȱȱȱȱȱ18.7 ** ** Trunkȱ(exceptȱshoulderȱandȱback)ȱ[1]ȱȱȱȱȱ 73,110 ȱȱȱȱȱȱȱȱȱȱ7.7 ȱȱȱȱȱ32,830 ȱȱȱȱȱȱȱȱȱȱ3.4 ȱȱȱȱȱ19,820 ȱȱȱȱȱȱȱȱȱȱ2.1 ** **

UpperȱExtremitiesȱ(total) ȱȱȱ269,240 ȱȱȱȱȱȱȱȱ28.4 ȱȱȱȱȱ48,650 ȱȱȱȱȱȱȱȱȱȱ5.1 ȱȱȱȱȱ40,740 ȱȱȱȱȱȱȱȱȱȱ4.3 ȱȱȱȱȱ11,940 ȱȱȱȱȱȱȱȱȱȱ1.3 ȱȱȱȱȱȱȱ2,910 ȱȱȱȱȱȱȱȱȱȱ0.3 Armȱȱȱȱȱ 54,260 ȱȱȱȱȱȱȱȱȱȱ5.7 ȱȱȱȱȱ14,020 ȱȱȱȱȱȱȱȱȱȱ1.5 ȱȱȱȱȱ13,590 ȱȱȱȱȱȱȱȱȱȱ1.4 * *ȱȱȱȱȱȱȱȱȱȱ 840 ȱȱȱȱȱȱȱȱȱȱ0.1 Wristȱȱȱȱȱ 51,620 ȱȱȱȱȱȱȱȱȱȱ5.4 ȱȱȱȱȱ25,270 ȱȱȱȱȱȱȱȱȱȱ2.7 ȱȱȱȱȱ15,710 ȱȱȱȱȱȱȱȱȱȱ1.7 ȱȱȱȱȱ11,940 ȱȱȱȱȱȱȱȱȱȱ1.3 ȱȱȱȱȱȱȱ1,460 ȱȱȱȱȱȱȱȱȱȱ0.2 Handȱ(exceptȱfinger)ȱȱȱȱȱ 47,920 ȱȱȱȱȱȱȱȱȱȱ5.1 ȱȱȱȱȱȱȱ3,010 ȱȱȱȱȱȱȱȱȱȱ0.3 ȱȱȱȱȱȱȱ3,680 ȱȱȱȱȱȱȱȱȱȱ0.4 * *ȱȱȱȱȱȱȱȱȱȱ 170 * Fingerȱȱȱ 101,650 ȱȱȱȱȱȱȱȱ10.7 ȱȱȱȱȱȱȱ3,090 ȱȱȱȱȱȱȱȱȱȱ0.3 ȱȱȱȱȱȱȱ4,510 ȱȱȱȱȱȱȱȱȱȱ0.5 * *ȱȱȱȱȱȱȱȱȱȱ 170 * UpperȱExtremitiesȱ(exceptȱarm,ȱwrist,ȱ ȱȱȱȱȱ13,790 ȱȱȱȱȱȱȱȱȱȱ1.5 ȱȱȱȱȱȱȱ3,260 ȱȱȱȱȱȱȱȱȱȱ0.3 ȱȱȱȱȱȱȱ3,250 ȱȱȱȱȱȱȱȱȱȱ0.3 * *ȱȱȱȱȱȱȱȱȱȱ 270 * ȱȱȱhandȱ&ȱfinger)ȱ[1]

LowerȱExtremitiesȱ(total) ȱȱȱ260,580 ȱȱȱȱȱȱȱȱ27.5 ȱȱȱȱȱ27,260 ȱȱȱȱȱȱȱȱȱȱ2.9 ȱȱȱ112,980 ȱȱȱȱȱȱȱȱ11.9 * *ȱȱȱȱȱȱȱȱȱȱ 260 * Kneeȱȱȱȱȱ 94,500 ȱȱȱȱȱȱȱȱ10.0 ȱȱȱȱȱ17,630 ȱȱȱȱȱȱȱȱȱȱ1.9 ȱȱȱȱȱ52,340 ȱȱȱȱȱȱȱȱȱȱ5.5 **ȱȱȱȱȱȱȱȱȱȱȱȱ 80* Ankleȱȱȱȱȱ 62,660 ȱȱȱȱȱȱȱȱȱȱ6.6 ȱȱȱȱȱȱȱ3,930 ȱȱȱȱȱȱȱȱȱȱ0.4 ȱȱȱȱȱ41,730 ȱȱȱȱȱȱȱȱȱȱ4.4 **ȱȱȱȱȱȱȱȱȱȱȱȱ 60* Foot,ȱToeȱȱȱȱȱ 55,600 ȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱ1,520 ȱȱȱȱȱȱȱȱȱȱ0.2 ȱȱȱȱȱȱȱ7,160 ȱȱȱȱȱȱȱȱȱȱ0.8 **ȱȱȱȱȱȱȱȱȱȱȱȱ 90* LowerȱExtremitiesȱ(exceptȱknee,ȱ ȱȱȱȱȱ47,820 ȱȱȱȱȱȱȱȱȱȱ5.0 ȱȱȱȱȱȱȱ4,180 ȱȱȱȱȱȱȱȱȱȱ0.4 ȱȱȱȱȱ11,750 ȱȱȱȱȱȱȱȱȱȱ1.2 **ȱȱȱȱȱȱȱȱȱȱȱȱ 30* ȱȱȱfootȱ&ȱtoe)ȱ[1]

BodyȱSystems ȱȱȱȱȱ17,710 ȱȱȱȱȱȱȱȱȱȱ1.9 ** ** ** **

MultipleȱParts ȱȱȱ120,950 ȱȱȱȱȱȱȱȱ12.8 ȱȱȱȱȱ15,780 ȱȱȱȱȱȱȱȱȱȱ1.7 ȱȱȱȱȱ33,050 ȱȱȱȱȱȱȱȱȱȱ3.5 **ȱȱȱȱȱȱȱȱȱȱȱȱ 80*

AllȱOther ȱȱȱȱȱ10,330 ȱȱȱȱȱȱȱȱȱȱ1.1 ȱȱȱȱȱȱȱȱȱȱ850 ȱȱȱȱȱȱȱȱȱȱ0.1 ȱȱȱȱȱȱȱ1,170 ȱȱȱȱȱȱȱȱȱȱ0.1 **ȱȱȱȱȱȱȱȱȱȱȱȱ 20*

TotalȱCases 1,158,870ȱȱȱȱȱȱ 122.2 ȱȱȱ335,390 ȱȱȱȱȱȱȱȱ35.4 ȱȱȱ448,380 ȱȱȱȱȱȱȱȱ47.3 ȱȱȱȱȱ11,940 ȱȱȱȱȱȱȱȱȱȱ1.3 ȱȱȱȱȱȱȱ4,380 ȱȱȱȱȱȱȱȱȱȱ0.5

[1]ȱComputedȱvalue

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱ andȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTableȱ8a.ȱNumberȱandȱincidenceȱrateȱofȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱworkȱbyȱ selectedȱworkerȱandȱcaseȱcharacteristicsȱandȱselectedȱnaturesȱofȱinjuryȱorȱillness,ȱAllȱUnitedȱStates,ȱprivateȱindustry,ȱ2007.ȱAvailableȱat:ȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1938.pdf.ȱAccessedȱNovemberȱ11,ȱ2009.

Tableȱ6.27:ȱIncidenceȱRatesȱperȱ10,000ȱFullȬtimeȱWorkersȱforȱInjuriesȱandȱ IllnessesȱbyȱNatureȱofȱInjuryȱorȱIllnessȱforȱNonfatalȱOccupationalȱInjuriesȱ InvolvingȱDaysȱAwayȱfromȱWork,ȱUnitedȱStatesȱ1997Ȭ2007

Incidenceȱperȱ10,000ȱFullȬTimeȱWorkers Incidenceȱ RateȱChangeȱ 1997 1999 2001 2003 2005 2007 1997Ȭ2007 Sprains,ȱStrainsȱȱȱȱȱȱȱȱȱ 92.5 ȱȱȱȱȱȱȱȱȱ81.8 ȱȱȱȱȱȱȱȱȱ73.7 ȱȱȱȱȱȱȱȱȱ64.3 ȱȱȱȱȱȱȱȱȱ55.3 ȱȱȱȱȱȱȱȱȱ47.3 Ȭ48.9% Bruises,ȱContusionsȱȱȱȱȱȱȱȱȱ 19.2 ȱȱȱȱȱȱȱȱȱ17.3 ȱȱȱȱȱȱȱȱȱ15.0 ȱȱȱȱȱȱȱȱȱ13.5 ȱȱȱȱȱȱȱȱȱ11.8 ȱȱȱȱȱȱȱȱȱ10.7 Ȭ44.3% Cuts,ȱLacerations,ȱPuncturesȱȱȱȱȱȱȱȱȱ 15.5 ȱȱȱȱȱȱȱȱȱ14.6 ȱȱȱȱȱȱȱȱȱ12.6 ȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱȱȱȱ11.2 ȱȱȱȱȱȱȱȱȱ11.3 Ȭ27.1% Fracturesȱȱȱȱȱȱȱȱȱ 13.8 ȱȱȱȱȱȱȱȱȱ12.6 ȱȱȱȱȱȱȱȱȱ11.9 ȱȱȱȱȱȱȱȱȱ10.8 ȱȱȱȱȱȱȱȱȱ10.5 ȱȱȱȱȱȱȱȱȱ10.0 Ȭ27.5% HeatȱBurnsȱȱȱȱȱȱȱȱȱȱȱ 3.5 ȱȱȱȱȱȱȱȱȱȱȱ3.0 ȱȱȱȱȱȱȱȱȱȱȱ2.8 ȱȱȱȱȱȱȱȱȱȱȱ2.2 ȱȱȱȱȱȱȱȱȱȱȱ1.9 ȱȱȱȱȱȱȱȱȱȱȱ1.8 Ȭ48.6% CarpalȱTunnelȱSyndromeȱȱȱȱȱȱȱȱȱȱȱ 3.4 ȱȱȱȱȱȱȱȱȱȱȱ3.1 ȱȱȱȱȱȱȱȱȱȱȱ3.0 ȱȱȱȱȱȱȱȱȱȱȱ2.5 ȱȱȱȱȱȱȱȱȱȱȱ1.8 ȱȱȱȱȱȱȱȱȱȱȱ1.3 Ȭ61.8% Tendonitisȱȱȱȱȱȱȱȱȱȱȱ 2.1 ȱȱȱȱȱȱȱȱȱȱȱ1.8 ȱȱȱȱȱȱȱȱȱȱȱ1.6 ȱȱȱȱȱȱȱȱȱȱȱ0.9 ȱȱȱȱȱȱȱȱȱȱȱ0.6 ȱȱȱȱȱȱȱȱȱȱȱ0.5 Ȭ76.2% ChemicalȱBurnsȱȱȱȱȱȱȱȱȱȱȱ 1.4 ȱȱȱȱȱȱȱȱȱȱȱ1.3 ȱȱȱȱȱȱȱȱȱȱȱ1.0 ȱȱȱȱȱȱȱȱȱȱȱ0.9 ȱȱȱȱȱȱȱȱȱȱȱ0.7 ȱȱȱȱȱȱȱȱȱȱȱ0.6 Ȭ57.1% Amputationsȱȱȱȱȱȱȱȱȱȱȱ 1.3 ȱȱȱȱȱȱȱȱȱȱȱ1.1 ȱȱȱȱȱȱȱȱȱȱȱ1.0 ȱȱȱȱȱȱȱȱȱȱȱ0.9 ȱȱȱȱȱȱȱȱȱȱȱ0.9 ȱȱȱȱȱȱȱȱȱȱȱ0.8 Ȭ38.5% MultipleȱTraumaticȱInjuriesȱȱȱȱȱȱȱȱȱȱȱ 6.9 ȱȱȱȱȱȱȱȱȱȱȱ6.6 ȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱȱȱ5.5 ȱȱȱȱȱȱȱȱȱȱȱ5.5 ȱȱȱȱȱȱȱȱȱȱȱ4.9 Ȭ29.0% Soreness,ȱPain ȱȱȱȱȱȱȱȱȱ12.2 NA AllȱOther ȱȱȱȱȱȱȱȱȱ20.8 NA MSDȱInjuriesȱAllȱCasesȱȱȱȱȱȱȱ 212.3 ȱȱȱȱȱȱȱ188.3 ȱȱȱȱȱȱȱ169.1 ȱȱȱȱȱȱȱ150.0 ȱȱȱȱȱȱȱ135.7 ȱȱȱȱȱȱȱ122.2 Ȭ42.4%

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics:ȱSurveyȱofȱOccupationalȱInjuriesȱandȱIllnesses.ȱ Tableȱ6ȱ(1997Ȭ2001)ȱorȱ7ȱ(2003Ȭ2005):ȱIncidenceȱratesȱforȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱ daysȱawayȱfromȱworkȱperȱ10,000ȱfullȬtimeȱworkersȱforȱselectedȱcharacteristicsȱandȱmajorȱindustryȱsector:ȱ Natureȱofȱinjuryȱorȱillness.ȱLostȱworkȱtime.pdf:1995Ȭ2005.ȱAvailableȱat:ȱwww.bls.gov/iif/oshcdnew.htm.ȱ AccessedȱJulyȱ7,ȱ2007.

Source:ȱ(2007)ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱ CaseȱandȱDemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱ Work.ȱTableȱ10.ȱNumber,ȱpercent,ȱandȱincidenceȱrateȱofȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱ daysȱawayȱfromȱworkȱbyȱselectedȱworkerȱandȱcaseȱcharacteristicsȱandȱmusculoskeletalȱdisorders,ȱAllȱUnitedȱ States,ȱprivateȱindustry,ȱ2007.ȱAvailableȱat:ȱȱhttp://www.bls.gov/iif/oshwc/osh/case/ostb1941.pdf.ȱAccessedȱ Novemberȱ11,ȱ2009.

Tableȱ6.28:ȱIncidenceȱRatesȱforȱInjuriesȱandȱIllnessesȱbyȱIndustryȱforȱNonfatalȱOccupationalȱInjuriesȱInvolvingȱDaysȱ AwayȱfromȱWorkȱbyȱBodyȱPartȱAffected,ȱUnitedȱStatesȱ2007

GoodsȱProducing ServiceȱProviding

Naturalȱ Trade, Professional Education Totalȱ Totalȱ Resource Transport andȱ and Leisure Privateȱ Goodsȱ and ConȬ ManuȬ Totalȱ and InforȬȱ Financial Businessȱ Health and Otherȱ Industry Producing Mining struction facturing Service Utilities mation Activities Services Services Hospitality Services Headȱ(total) 8.3 11.8 14.5 14.9 9.9 7.1 10.3 4.1 3.5 4.4 6.3 8.2 8.7 Eye 3.5 6.4 7.3 7.3 5.8 2.6 3.7 1.0 1.6 1.4 1.7 3.1 5.7

Neck 1.8 1.8 1.8 2.6 1.4 1.8 2.6 0.6 1.0 1.1 2.5 0.8 1.8

Trunkȱ(total) 40.6 46.9 48.3 58.0 41.2 38.5 56.5 20.6 14.1 19.8 54.9 27.0 25.6 Shoulder 8.0 10.2 8.5 11.6 9.7 7.3 11.9 3.9 1.9 3.6 9.1 4.8 4.4 Back 24.9 25.4 26.3 31.8 22.1 24.7 34.4 12.6 9.3 12.5 38.9 16.5 16.9

UpperȱExtremitiesȱ(total) 28.4 43.5 33.9 44.8 43.9 23.6 31.9 12.8 10.2 14.9 21.5 31.8 28.8 Arm 5.7 7.8 7.0 9.7 6.9 5.1 7.3 2.6 2.2 2.6 5.0 5.0 9.5 Wrist 5.4 6.5 3.2 5.3 7.5 5.1 6.5 3.7 2.9 4.0 5.7 5.0 3.6 Handȱ(exceptȱfinger) 5.1 8.1 6.1 10.5 7.1 4.1 5.4 2.1 1.5 2.6 3.1 7.0 4.9 Finger 10.7 19.1 15.8 17.6 20.3 8.0 11.2 3.5 3.0 4.8 6.0 13.4 9.5

LowerȱExtremitiesȱ(total) 27.5 33.6 45.5 48.3 24.7 25.5 37.6 16.4 10.6 14.6 27.0 25.8 22.1 Knee 10.0 11.7 15.3 16.8 8.7 9.4 12.9 6.0 3.8 4.9 11.5 9.9 9.7 Ankle 6.6 7.3 9.2 11.9 4.7 6.4 9.1 4.0 2.3 4.2 6.7 6.9 5.1 Footȱ(exceptȱtoe) 4.6 6.4 9.2 8.3 5.1 4.1 6.6 2.5 2.2 2.2 3.6 3.9 2.7 Toe 1.2 1.6 1.4 2.2 1.3 1.1 2.2 1.0 0.2 0.3 0.9 0.6 1.1

BodyȱSystems 1.9 1.8 1.6 2.3 1.6 1.9 2.2 2.6 0.9 1.6 2.1 1.4 3.1

MultipleȱParts 12.8 12.6 16.0 18.1 9.3 12.8 15.8 11.7 5.9 8.1 18.8 10.4 10.7

RateȱAllȱCases 122.2 152.9 163.3 190.3 132.8 112.4 158.4 69.3 47.0 64.9 134.2 106.5 102.3

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱ IllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTABLEȱ7.ȱIncidenceȱrates(1)ȱforȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱwork(2)ȱperȱ10,000ȱfullȬtimeȱ workersȱforȱselectedȱcharacteristicsȱandȱmajorȱindustryȱsector,ȱ2007.ȱAvailableȱat:ȱhttp://www.bls.gov/news.release/osh2.t07.htm.ȱAccessedȱNovemberȱ13,ȱ2009.

Tableȱ6.29:ȱȱMusculoskeletalȱDisordersȱ(MSDs)ȱforȱWorkȬRelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱ fromȱWorkȱbyȱOccupation,ȱUnitedȱStatesȱ2007

AllȱNatures Sprains,ȱStrainsȱandȱ CarpalȱTunnelȱ PrivateȱIndustry MSDs Tears Syndrome Tendonitis

Rateȱperȱ Rateȱperȱ Rateȱperȱ Rateȱperȱ Rateȱperȱ 10,000ȱ 10,000ȱ 10,000ȱ 10,000ȱ 10,000ȱ Industry Number Workers Number Workers Number Workers Number Workers Number Workers Management,ȱBusiness,ȱFinancialȱȱȱȱȱ 29,600 ȱȱȱȱȱȱȱȱȱ30.5 ȱȱȱȱȱȱȱ7,020 ȱȱȱȱȱȱȱȱȱȱȱ7.2 ȱȱȱȱȱȱȱ9,770 ȱȱȱȱȱȱȱȱȱ10.1 ȱȱȱȱȱȱȱȱȱȱ890 ȱȱȱȱȱȱȱȱȱȱȱ0.9 ȱȱȱȱȱȱȱȱȱȱ260 ȱȱȱȱȱȱȱȱȱȱȱ0.3 ProfessionalȱandȱRelatedȱȱȱȱȱ 79,260 ȱȱȱȱȱȱȱȱȱ54.7 ȱȱȱȱȱ26,140 ȱȱȱȱȱȱȱȱȱ18.0 ȱȱȱȱȱ38,240 ȱȱȱȱȱȱȱȱȱ26.4 ȱȱȱȱȱȱȱȱȱȱ650 ȱȱȱȱȱȱȱȱȱȱȱ0.5 ȱȱȱȱȱȱȱȱȱȱ330 ȱȱȱȱȱȱȱȱȱȱȱ0.2 Serviceȱȱȱ 251,490 ȱȱȱȱȱȱȱ162.9 ȱȱȱȱȱ73,060 ȱȱȱȱȱȱȱȱȱ47.3 ȱȱȱ102,060 ȱȱȱȱȱȱȱȱȱ66.1 ȱȱȱȱȱȱȱȱȱȱ980 ȱȱȱȱȱȱȱȱȱȱȱ0.6 ȱȱȱȱȱȱȱȱȱȱ520 ȱȱȱȱȱȱȱȱȱȱȱ0.3 SalesȱandȱRelatedȱȱȱȱȱ 78,070 ȱȱȱȱȱȱȱȱȱ70.1 ȱȱȱȱȱ23,300 ȱȱȱȱȱȱȱȱȱ20.9 ȱȱȱȱȱ30,610 ȱȱȱȱȱȱȱȱȱ27.5 ȱȱȱȱȱȱȱȱȱȱ560 ȱȱȱȱȱȱȱȱȱȱȱ0.5 ȱȱȱȱȱȱȱȱȱȱ290 ȱȱȱȱȱȱȱȱȱȱȱ0.3 OfficeȱandȱAdministrativeȱSupportȱȱȱȱȱ 85,190 ȱȱȱȱȱȱȱȱȱ54.2 ȱȱȱȱȱ27,430 ȱȱȱȱȱȱȱȱȱ17.4 ȱȱȱȱȱ33,760 ȱȱȱȱȱȱȱȱȱ21.5 ȱȱȱȱȱȱȱ2,860 ȱȱȱȱȱȱȱȱȱȱȱ1.8 ȱȱȱȱȱȱȱȱȱȱ430 ȱȱȱȱȱȱȱȱȱȱȱ0.3 Farming,ȱFishing,ȱȱandȱForestryȱȱȱȱȱ 13,950 ȱȱȱȱȱȱȱ149.8 ȱȱȱȱȱȱȱ2,190 ȱȱȱȱȱȱȱȱȱ23.5 ȱȱȱȱȱȱȱ4,390 ȱȱȱȱȱȱȱȱȱ47.2 ȱȱȱȱȱȱȱȱȱȱȱȱ20 ȱȱȱȱȱȱȱȱȱȱȱ0.3 ȱȱȱȱȱȱȱȱȱȱȱȱ40 ȱȱȱȱȱȱȱȱȱȱȱ0.4 ConstructionȱandȱExtractiveȱȱȱ 134,010 ȱȱȱȱȱȱȱ238.7 ȱȱȱȱȱ30,050 ȱȱȱȱȱȱȱȱȱ53.5 ȱȱȱȱȱ44,150 ȱȱȱȱȱȱȱȱȱ78.6 ȱȱȱȱȱȱȱȱȱȱ420 ȱȱȱȱȱȱȱȱȱȱȱ0.7 ȱȱȱȱȱȱȱȱȱȱ330 ȱȱȱȱȱȱȱȱȱȱȱ0.6 Installation,ȱMaintenanceȱandȱRepairȱȱȱȱȱ 98,390 ȱȱȱȱȱȱȱ217.5 ȱȱȱȱȱ26,950 ȱȱȱȱȱȱȱȱȱ59.6 ȱȱȱȱȱ35,590 ȱȱȱȱȱȱȱȱȱ78.7 ȱȱȱȱȱȱȱȱȱȱ670 ȱȱȱȱȱȱȱȱȱȱȱ1.5 ȱȱȱȱȱȱȱȱȱȱ120 ȱȱȱȱȱȱȱȱȱȱȱ0.3 Productionȱȱȱ 160,350 ȱȱȱȱȱȱȱ175.7 ȱȱȱȱȱ49,020 ȱȱȱȱȱȱȱȱȱ53.7 ȱȱȱȱȱ51,860 ȱȱȱȱȱȱȱȱȱ56.8 ȱȱȱȱȱȱȱ3,700 ȱȱȱȱȱȱȱȱȱȱȱ4.1 ȱȱȱȱȱȱȱ1,340 ȱȱȱȱȱȱȱȱȱȱȱ1.5 TransportationȱandȱMaterialȱMovingȱȱȱ 225,780 ȱȱȱȱȱȱȱ285.0 ȱȱȱȱȱ69,900 ȱȱȱȱȱȱȱȱȱ88.2 ȱȱȱȱȱ97,240 ȱȱȱȱȱȱȱ122.7 ȱȱȱȱȱȱȱ1,170 ȱȱȱȱȱȱȱȱȱȱȱ1.5 ȱȱȱȱȱȱȱȱȱȱ720 ȱȱȱȱȱȱȱȱȱȱȱ0.9

Total 1,158,870ȱȱȱȱȱȱȱ 122.2 335,390ȱȱȱȱȱȱȱȱȱ 35.4 448,380ȱȱȱȱȱȱȱȱȱ 47.3 11,940ȱȱȱȱȱȱȱȱȱȱȱ 1.3 4,380ȱȱȱȱȱȱȱȱȱȱȱ 0.5

Industry ProportionȱofȱTotalȱInjuriesȱwithinȱOccupation Management,ȱBusiness,ȱFinancial 2.6% 2.1% 2.2% 7.5% 5.9% ProfessionalȱandȱRelated 6.9% 7.8% 8.5% 5.5% 7.5% Service 21.8% 21.8% 22.8% 8.2% 11.9% SalesȱandȱRelated 6.8% 7.0% 6.8% 4.7% 6.6% OfficeȱandȱAdministrativeȱSupport 7.4% 8.2% 7.5% 24.0% 9.8% Farming,ȱFishing,ȱȱandȱForestry 1.2% 0.7% 1.0% 0.2% 0.9% ConstructionȱandȱExtractive 11.6% 9.0% 9.9% 3.5% 7.5% Installation,ȱMaintenanceȱandȱRepair 8.5% 8.0% 8.0% 5.6% 2.7% Production 13.9% 14.6% 11.6% 31.0% 30.6% TransportationȱandȱMaterialȱMoving 19.5% 20.9% 21.7% 9.8% 16.4%

Source:ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱforȱWorkȬrelatedȱ InjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTableȱ10.ȱNumber,ȱpercent,ȱandȱincidenceȱrateȱofȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱ awayȱfromȱworkȱbyȱselectedȱworkerȱandȱcaseȱcharacteristicsȱandȱmusculoskeletalȱdisorders,ȱAllȱUnitedȱStates,ȱprivateȱindustry,ȱ2007.ȱAvailableȱat:ȱ http://www.bls.gov/iif/oshwc/osh/case/ostb1941.pdf .ȱAccessedȱNovemberȱ11,ȱ2009.

Tableȱ6.30:ȱMedianȱDaysȱAwayȱfromȱWorkȱforȱNonfatalȱInjuriesȱandȱ IllnessesȱbyȱNatureȱofȱInjuryȱorȱIllnesses,ȱUnitedȱStatesȱ1997Ȭ2007

MedianȱDaysȱAwayȱfromȱWork 1997 1999 2001 2003 2005 2007 Fracturesȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 21 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ21 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 30 CarpalȱTunnelȱSyndromeȱ(MSDȱ&ȱOther)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 25 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ32 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 28 Amputationsȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22 21 Tendonitisȱ(MSDȱ&ȱOther)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 11 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ12 10 MultipleȱTraumaticȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 10 Sprains,ȱStrainsȱ(MSDȱ&ȱOther)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 8 Soreness,ȱPainȱ(exceptȱBack) NANANANANA8 BackȱPain NA NA NA NA NA 8 HeatȱBurnsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5 5 Bruises,ȱContusionsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4 4 Cuts,ȱLacerations,ȱPuncturesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4 4 ChemicalȱBurnsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 1 MusculoskeletalȱDisorders *ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9 9 TotalȱAllȱCasesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7 7

MusculoskeletalȱDisorderȱCases *ȱȱȱȱȱȱȱȱȱ 582.3 ȱȱȱȱȱȱȱȱȱ522.5 ȱȱȱȱȱȱȱȱȱ435.2 ȱȱȱȱȱȱȱȱȱ375.5 335.4 AllȱCasesȱ ȱȱȱȱȱȱ1,833.3 ȱȱȱȱȱȱ1,702.5 ȱȱȱȱȱȱ1,537.6 ȱȱȱȱȱȱ1,315.9 ȱȱȱȱȱȱ1,234.7 1158.9

*ȱDataȱnotȱavailable

Sourceȱ(1997ȱtoȱ2005):ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱSurveyȱofȱOccupationalȱInjuriesȱandȱ Illnesses.ȱTableȱ9ȱ(1997Ȭ2001)ȱorȱ11ȱ(2003Ȭ2005):ȱPercentȱdistributionȱofȱnonfatalȱoccupationalȱinjuriesȱandȱillnessesȱ involvingȱdaysȱawayȱfromȱworkȱbyȱselectedȱinjuryȱorȱillnessȱcharacteristicsȱandȱȱnumberȱofȱdaysȱawayȱfromȱwork:ȱ Natureȱofȱinjuryȱorȱillness.ȱLostȱworkȱtime:1996Ȭ2005.ȱAvailableȱat:ȱwww.bls.gov/iif/oshcdnew.htm.ȱȱAccessedȱJulyȱ 7,ȱ2007.

Sourceȱ(2007):ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱFatalitiesȱProgram:ȱCaseȱ andȱDemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱIllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱ2007ȱ nonfatalȱoccupationalȱinjuriesȱandȱillnesses:ȱcaseȱandȱdemographics.ȱNovemberȱ20,ȱ2008,ȱreissuedȱMarchȱ2009.ȱ Availableȱat:ȱhttp://www.bls.gov/iif/oshwc/osh/case/osch0038.pdf.ȱAccessedȱNovemberȱ13,ȱ2009.

Tableȱ6.31:ȱMedianȱDaysȱAwayȱfromȱWorkȱforȱNonfatalȱ InjuriesȱandȱIllnessesȱbyȱPartȱofȱBodyȱAffected,ȱUnitedȱStatesȱ 1997Ȭ2007

1997 1999 2001 2003 2005 2007 Neck 565876

Trunk 777988 Shoulder 91012181518 Back 666777

UpperȱExtremities 666777 Arm NA NA NA NA NA 9 Wrist 12 12 13 17 14 14 Handȱ(exceptȱfinger)554555 Finger 545555

LowerȱExtremities 6779910 Knee 91011141215 Ankle NA NA NA NA NA 8 Footȱ(exceptȱtoe)556777 Toe 555657

MultipleȱParts 8881089

TotalȱAllȱCases 566877

TotalȱCasesȱ(inȱ000s) 1,833 1,703 1,538 1,316 1,235 1,159

Sourceȱ(1997ȱtoȱ2005):ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱSurveyȱofȱ OccupationalȱInjuriesȱandȱIllnesses.ȱTableȱ11:ȱPercentȱdistributionȱofȱnonfatalȱoccupationalȱ injuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱworkȱbyȱselectedȱinjuryȱorȱillnessȱ characteristicsȱandȱȱnumberȱofȱdaysȱawayȱfromȱwork:ȱPartȱofȱbodyȱaffectedȱbyȱtheȱinjuryȱorȱ illness.ȱLostȱworkȱtime:1996Ȭ2005.ȱAvailableȱat:ȱwww.bls.gov/iif/oshcdnew.htm.ȱAccessedȱ Julyȱ7,ȱ2007.

Sourceȱ(2007):ȱU.S.ȱDepartmentȱofȱLabor,ȱBureauȱofȱLaborȱStatistics,ȱInjuries,ȱIllnessesȱandȱ FatalitiesȱProgram:ȱCaseȱandȱDemographicȱCharacteristicsȱforȱWorkȬrelatedȱInjuriesȱandȱ IllnessesȱInvolvingȱDaysȱAwayȱfromȱWork.ȱTABLEȱR67.ȱNumberȱandȱpercentȱdistributionȱofȱ nonfatalȱoccupationalȱinjuriesȱandȱillnessesȱinvolvingȱdaysȱawayȱfromȱwork1ȱbyȱnatureȱofȱ injuryȱorȱillnessȱandȱnumberȱofȱdaysȱawayȱfromȱwork,ȱ2007.ȱReissuedȱMarchȱ2009.ȱAvailableȱ at:ȱhttp://www.bls.gov/iif/oshwc/osh/case/ostb2009.pdf.ȱAccessedȱNovemberȱ13,ȱ2009.

Tableȱ6.32:ȱResourceȱUtilizationȱforȱTraumaticȱMusculoskeletalȱ(MS)ȱInjuriesȱbyȱTreatmentȱLocationȱandȱ Sex,ȱUnitedȱStatesȱ2006/2007

TotalȱVisitsȱ(inȱ000s)ȱ[1] %ȱTotalȱDiagnosesȱbyȱTreatmentȱLocation

Dislocations AllȱDislocations ȱȱȱȱȱȱȱȱȱȱ2,470ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ520ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ319ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ46 ȱȱȱȱȱȱȱȱȱȱ3,355 5.5% 74% 15% 10% 1% Males ȱȱȱȱȱȱȱȱȱȱ1,369ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ309ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ172ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 ȱȱȱȱȱȱȱȱȱȱ1,877 5.7% 73% 16% 9% 1% Females ȱȱȱȱȱȱȱȱȱȱ1,101ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ212ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ146ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ19 ȱȱȱȱȱȱȱȱȱȱ1,478 5.2% 74% 14% 10% 1%

SprainsȱandȱStrains AllȱSprainsȱandȱStrainsȱȱȱȱȱȱȱȱ 12,023 ȱȱȱȱȱȱȱȱȱȱȱ4,869 ȱȱȱȱȱȱȱȱȱȱ1,367 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ94 ȱȱȱȱȱȱȱȱ18,353 30.0% 66% 27% 7% 1% Malesȱȱȱȱȱȱȱȱȱȱ 6,659 ȱȱȱȱȱȱȱȱȱȱȱ2,279 ȱȱȱȱȱȱȱȱȱȱȱȱȱ600 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ46 ȱȱȱȱȱȱȱȱȱȱ9,584 29.2% 69% 24% 6% 0% Femalesȱȱȱȱȱȱȱȱȱȱ 5,365 ȱȱȱȱȱȱȱȱȱȱȱ2,590 ȱȱȱȱȱȱȱȱȱȱȱȱȱ767 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ48 ȱȱȱȱȱȱȱȱȱȱ8,770 31.0% 61% 30% 9% 1%

Contusions AllȱContusionsȱȱȱȱȱȱȱȱȱȱ 4,578 ȱȱȱȱȱȱȱȱȱȱȱ4,680 ȱȱȱȱȱȱȱȱȱȱȱȱȱ599 ȱȱȱȱȱȱȱȱȱȱȱȱȱ183 ȱȱȱȱȱȱȱȱ10,040 16.4% 46% 47% 6% 2% Malesȱȱȱȱȱȱȱȱȱȱ 2,003 ȱȱȱȱȱȱȱȱȱȱȱ2,178 ȱȱȱȱȱȱȱȱȱȱȱȱȱ346 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74 ȱȱȱȱȱȱȱȱȱȱ4,601 14.0% 44% 47% 8% 2% Femalesȱȱȱȱȱȱȱȱȱȱ 2,575 ȱȱȱȱȱȱȱȱȱȱȱ2,502 ȱȱȱȱȱȱȱȱȱȱȱȱȱ253 ȱȱȱȱȱȱȱȱȱȱȱȱȱ108 ȱȱȱȱȱȱȱȱȱȱ5,438 19.2% 47% 46% 5% 2%

OpenȱWounds AllȱOpenȱWoundsȱȱȱȱȱȱȱȱȱȱ 4,550 ȱȱȱȱȱȱȱȱȱȱȱ4,540 ȱȱȱȱȱȱȱȱȱȱȱȱȱ888 ȱȱȱȱȱȱȱȱȱȱȱȱȱ220 ȱȱȱȱȱȱȱȱ10,198 16.7% 45% 45% 9% 2% Malesȱȱȱȱȱȱȱȱȱȱ 2,597 ȱȱȱȱȱȱȱȱȱȱȱ2,829 ȱȱȱȱȱȱȱȱȱȱȱȱȱ444 ȱȱȱȱȱȱȱȱȱȱȱȱȱ138 ȱȱȱȱȱȱȱȱȱȱ6,008 18.3% 43% 47% 7% 2% Femalesȱȱȱȱȱȱȱȱȱȱ 1,953 ȱȱȱȱȱȱȱȱȱȱȱ1,711 ȱȱȱȱȱȱȱȱȱȱȱȱȱ444 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ81 ȱȱȱȱȱȱȱȱȱȱ4,189 14.8% 47% 41% 11% 2%

OtherȱMusculoskeletalȱInjuries AllȱOtherȱMSȱInjuriesȱȱȱȱȱȱȱȱȱȱ 5,454 ȱȱȱȱȱȱȱȱȱȱȱ1,272 ȱȱȱȱȱȱȱȱȱȱȱȱȱ492 ȱȱȱȱȱȱȱȱȱȱȱȱȱ148 ȱȱȱȱȱȱȱȱȱȱ7,366 12.0% 74% 17% 7% 2% Malesȱȱȱȱȱȱȱȱȱȱ 2,777 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ617 ȱȱȱȱȱȱȱȱȱȱȱȱȱ323 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ79 ȱȱȱȱȱȱȱȱȱȱ3,796 11.6% 73% 16% 9% 2% Femalesȱȱȱȱȱȱȱȱȱȱ 2,677 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ655 ȱȱȱȱȱȱȱȱȱȱȱȱȱ169 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ68 ȱȱȱȱȱȱȱȱȱȱ3,569 12.6% 75% 18% 5% 2%

TotalȱMusculoskeletalȱTraumaticȱInjuries AllȱMSȱTraumaticȱInjuriesȱȱȱȱȱȱȱȱ 36,617 ȱȱȱȱȱȱȱȱȱ18,264 ȱȱȱȱȱȱȱȱȱȱ4,719 ȱȱȱȱȱȱȱȱȱȱ1,589 ȱȱȱȱȱȱȱȱ61,189 60% 30% 8% 3% Malesȱȱȱȱȱȱȱȱ 20,100 ȱȱȱȱȱȱȱȱȱȱȱ9,541 ȱȱȱȱȱȱȱȱȱȱ2,499 ȱȱȱȱȱȱȱȱȱȱȱȱȱ715 ȱȱȱȱȱȱȱȱ32,855 61% 29% 8% 2% Femalesȱȱȱȱȱȱȱȱ 16,517 ȱȱȱȱȱȱȱȱȱȱȱ8,723 ȱȱȱȱȱȱȱȱȱȱ2,220 ȱȱȱȱȱȱȱȱȱȱȱȱȱ864 ȱȱȱȱȱȱȱȱ28,324 58% 31% 8% 3%

AllȱInjuryȱTreatmentȱEpisodes AllȱInjuriesȱȱȱȱȱȱȱȱ 57,162 ȱȱȱȱȱȱȱȱȱ30,940 ȱȱȱȱȱȱȱȱȱȱ6,810 ȱȱȱȱȱȱȱȱȱȱ5,527 ȱȱȱȱȱȱ100,439 57% 31% 7% 6% Malesȱȱȱȱȱȱȱȱ 30,095 ȱȱȱȱȱȱȱȱȱ16,197 ȱȱȱȱȱȱȱȱȱȱ3,418 ȱȱȱȱȱȱȱȱȱȱ2,710 ȱȱȱȱȱȱȱȱ52,420 57% 31% 7% 5% Femalesȱȱȱȱȱȱȱȱ 27,067 ȱȱȱȱȱȱȱȱȱ14,743 ȱȱȱȱȱȱȱȱȱȱ3,392 ȱȱȱȱȱȱȱȱȱȱ2,817 ȱȱȱȱȱȱȱȱ48,019 56% 31% 7% 6%

[1]ȱAllȱlistedȱdiagnosesȱforȱinpatientsȱdischargedȱfromȱshortȬstayȱhospitals.ȱMultipleȱdiagnosesȱperȱcaseȱpossible;ȱpercentagesȱbasedȱonȱtotalȱdiagnoses.

[2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ2006 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱDepartmentȱVisits,ȱ2006 [5]Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ6.33:ȱResourceȱUtilizationȱforȱTraumaticȱMusculoskeletalȱ(MS)ȱInjuriesȱbyȱTreatmentȱLocationȱandȱ Age,ȱUnitedȱStatesȱ2006/2007

TotalȱVisitsȱ(inȱ000s)ȱ[1] %ȱTotalȱVisitsȱatȱTreatmentȱLocation

Totalȱ Physicianȱ Emergencyȱ Hospitalȱ Allȱ %ȱAllȱMSȱ Physicianȱ Emergencyȱ Hospitalȱ Officeȱ Roomȱ Outpatientȱ Inpatientȱ Treatmentȱ InjuriesȱAllȱ Officeȱ Roomȱ Outpatientȱ Inpatientȱ Visitsȱ[2] Visitsȱ[3] Visitsȱ[4] Staysȱ[5]* Sites Locations Visitsȱ[2] Visitsȱ[3] Visitsȱ[4] Staysȱ[5] Fractures AllȱFractures ȱȱȱȱȱȱȱȱȱȱȱ9,919ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ3,877ȱ ȱȱȱȱȱȱȱȱȱȱȱ1,264ȱ ȱȱȱȱȱȱȱȱ1,095 ȱȱȱȱȱȱ16,155 26.4% 61% 24% 8% 7% Underȱ18ȱYears ȱȱȱȱȱȱȱȱȱȱȱ2,824ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ1,204ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ433ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ67 ȱȱȱȱȱȱȱȱ4,528 35.6% 62% 27% 10% 1% 18ȱtoȱ44ȱYears ȱȱȱȱȱȱȱȱȱȱȱ2,328ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ1,092ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ387ȱ ȱȱȱȱȱȱȱȱȱȱȱ208 ȱȱȱȱȱȱȱȱ4,015 18.4% 58% 27% 10% 5% 45ȱtoȱ64ȱYears ȱȱȱȱȱȱȱȱȱȱȱ2,519ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ777ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ289ȱ ȱȱȱȱȱȱȱȱȱȱȱ230 ȱȱȱȱȱȱȱȱ3,815 23.2% 66% 20% 8% 6% 65ȱYearsȱandȱOver ȱȱȱȱȱȱȱȱȱȱȱ2,249ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ804ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ155ȱ ȱȱȱȱȱȱȱȱȱȱȱ395 ȱȱȱȱȱȱȱȱ3,603 36.3% 62% 22% 4% 11%

Dislocations AllȱDislocations ȱȱȱȱȱȱȱȱȱȱȱ2,470ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ520ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ319ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ46 ȱȱȱȱȱȱȱȱ3,355 5.5% 74% 15% 10% 1% Underȱ18ȱYears ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ347ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ140ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ76ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱȱȱȱ566 4.5% 61% 25% 13% 1% 18ȱtoȱ44ȱYears ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ589ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ250ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ128ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ18 ȱȱȱȱȱȱȱȱȱȱȱ985 4.5% 60% 25% 13% 2% 45ȱtoȱ64ȱYears ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ852ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ104ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ88ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ13 ȱȱȱȱȱȱȱȱ1,057 6.4% 81% 10% 8% 1% 65ȱYearsȱandȱOver ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ682ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ10 ȱȱȱȱȱȱȱȱȱȱȱ746 7.5% 91% 4% 4% 1%

SprainsȱandȱStrains AllȱSprainsȱandȱStrainsȱȱȱȱȱȱȱȱ 12,023 ȱȱȱȱȱȱȱȱȱȱ4,869 ȱȱȱȱȱȱȱȱȱȱ1,367 ȱȱȱȱȱȱȱȱȱȱȱȱȱ94 ȱȱȱȱȱȱ18,353 30.0% 66% 27% 7% 1% Underȱ18ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,815 ȱȱȱȱȱȱȱȱȱȱ1,036 ȱȱȱȱȱȱȱȱȱȱȱȱȱ260 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3 ȱȱȱȱȱȱȱȱ3,114 24.5% 58% 33% 8% 0% 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 4,392 ȱȱȱȱȱȱȱȱȱȱ2,553 ȱȱȱȱȱȱȱȱȱȱȱȱȱ513 ȱȱȱȱȱȱȱȱȱȱȱȱȱ24 ȱȱȱȱȱȱȱȱ7,482 34.3% 59% 34% 7% 0% 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 4,551 ȱȱȱȱȱȱȱȱȱȱȱȱȱ916 ȱȱȱȱȱȱȱȱȱȱȱȱȱ435 ȱȱȱȱȱȱȱȱȱȱȱȱȱ28 ȱȱȱȱȱȱȱȱ5,930 36.0% 77% 15% 7% 0% 65ȱYearsȱandȱOverȱȱȱȱȱȱȱȱȱȱ 1,265 ȱȱȱȱȱȱȱȱȱȱȱȱȱ363 ȱȱȱȱȱȱȱȱȱȱȱȱȱ159 ȱȱȱȱȱȱȱȱȱȱȱȱȱ31 ȱȱȱȱȱȱȱȱ1,818 18.3% 70% 20% 9% 2%

Contusions AllȱContusionsȱȱȱȱȱȱȱȱȱȱ 4,578 ȱȱȱȱȱȱȱȱȱȱ4,680 ȱȱȱȱȱȱȱȱȱȱȱȱȱ599 ȱȱȱȱȱȱȱȱȱȱȱ183 ȱȱȱȱȱȱ10,040 16.4% 46% 47% 6% 2% Underȱ18ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 864 ȱȱȱȱȱȱȱȱȱȱ1,094 ȱȱȱȱȱȱȱȱȱȱȱȱȱ207 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8 ȱȱȱȱȱȱȱȱ2,173 17.1% 40% 50% 10% 0% 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,786 ȱȱȱȱȱȱȱȱȱȱ2,120 ȱȱȱȱȱȱȱȱȱȱȱȱȱ220 ȱȱȱȱȱȱȱȱȱȱȱȱȱ34 ȱȱȱȱȱȱȱȱ4,160 19.0% 43% 51% 5% 1% 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 793 ȱȱȱȱȱȱȱȱȱȱȱȱȱ867 ȱȱȱȱȱȱȱȱȱȱȱȱȱ129 ȱȱȱȱȱȱȱȱȱȱȱȱȱ36 ȱȱȱȱȱȱȱȱ1,825 11.1% 43% 48% 7% 2% 65ȱYearsȱandȱOverȱȱȱȱȱȱȱȱȱȱ 1,136 ȱȱȱȱȱȱȱȱȱȱȱȱȱ628 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44 ȱȱȱȱȱȱȱȱȱȱȱȱȱ70 ȱȱȱȱȱȱȱȱ1,878 18.9% 60% 33% 2% 4%

OpenȱWounds AllȱOpenȱWoundsȱȱȱȱȱȱȱȱȱȱ 4,550 ȱȱȱȱȱȱȱȱȱȱ4,540 ȱȱȱȱȱȱȱȱȱȱȱȱȱ888 ȱȱȱȱȱȱȱȱȱȱȱ220 ȱȱȱȱȱȱ10,198 16.7% 45% 45% 9% 2% Underȱ18ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 718 ȱȱȱȱȱȱȱȱȱȱȱȱȱ918 ȱȱȱȱȱȱȱȱȱȱȱȱȱ189 ȱȱȱȱȱȱȱȱȱȱȱȱȱ20 ȱȱȱȱȱȱȱȱ1,845 14.5% 39% 50% 10% 1% 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,512 ȱȱȱȱȱȱȱȱȱȱ2,212 ȱȱȱȱȱȱȱȱȱȱȱȱȱ355 ȱȱȱȱȱȱȱȱȱȱȱ100 ȱȱȱȱȱȱȱȱ4,179 19.1% 36% 53% 8% 2% 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,306 ȱȱȱȱȱȱȱȱȱȱȱȱȱ923 ȱȱȱȱȱȱȱȱȱȱȱȱȱ228 ȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱ2,504 15.2% 52% 37% 9% 2% 65ȱYearsȱandȱOverȱȱȱȱȱȱȱȱȱȱ 1,104 ȱȱȱȱȱȱȱȱȱȱȱȱȱ486 ȱȱȱȱȱȱȱȱȱȱȱȱȱ116 ȱȱȱȱȱȱȱȱȱȱȱȱȱ36 ȱȱȱȱȱȱȱȱ1,742 17.5% 63% 28% 7% 2%

OtherȱMusculoskeletalȱInjuries AllȱOtherȱMSȱInjuriesȱȱȱȱȱȱȱȱȱȱ 5,454 ȱȱȱȱȱȱȱȱȱȱ1,272 ȱȱȱȱȱȱȱȱȱȱȱȱȱ492 ȱȱȱȱȱȱȱȱȱȱȱ148 ȱȱȱȱȱȱȱȱ7,366 12.0% 74% 17% 7% 2% Underȱ18ȱYearsȱȱȱȱȱȱȱȱȱȱȱȱȱ 867 ȱȱȱȱȱȱȱȱȱȱȱȱȱ320 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ98 ȱȱȱȱȱȱȱȱȱȱȱȱȱ10 ȱȱȱȱȱȱȱȱ1,295 10.2% 67% 25% 8% 1% 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱȱȱ 1,756 ȱȱȱȱȱȱȱȱȱȱȱȱȱ659 ȱȱȱȱȱȱȱȱȱȱȱȱȱ238 ȱȱȱȱȱȱȱȱȱȱȱȱȱ44 ȱȱȱȱȱȱȱȱ2,697 12.3% 65% 24% 9% 2% 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱȱȱ 2,239 ȱȱȱȱȱȱȱȱȱȱȱȱȱ212 ȱȱȱȱȱȱȱȱȱȱȱȱȱ120 ȱȱȱȱȱȱȱȱȱȱȱȱȱ46 ȱȱȱȱȱȱȱȱ2,617 15.9% 86% 8% 5% 2% 65ȱYearsȱandȱOverȱȱȱȱȱȱȱȱȱȱȱȱȱ 593 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ81 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ36 ȱȱȱȱȱȱȱȱȱȱȱȱȱ39 ȱȱȱȱȱȱȱȱȱȱȱ749 7.5% 79% 11% 5% 5%

TotalȱMusculoskeletalȱTraumaticȱInjuries AllȱMSȱTraumaticȱInjuriesȱȱȱȱȱȱȱȱ 36,617 ȱȱȱȱȱȱȱȱ18,264 ȱȱȱȱȱȱȱȱȱȱ4,719 ȱȱȱȱȱȱȱȱ1,589 ȱȱȱȱȱȱ61,189 60% 30% 8% 3% Underȱ18ȱYearsȱȱȱȱȱȱȱȱȱȱ 7,027 ȱȱȱȱȱȱȱȱȱȱ4,382 ȱȱȱȱȱȱȱȱȱȱ1,202 ȱȱȱȱȱȱȱȱȱȱȱȱȱ99 ȱȱȱȱȱȱ12,710 55% 34% 9% 1% 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱ 11,560 ȱȱȱȱȱȱȱȱȱȱ8,156 ȱȱȱȱȱȱȱȱȱȱ1,777 ȱȱȱȱȱȱȱȱȱȱȱ349 ȱȱȱȱȱȱ21,842 53% 37% 8% 2% 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 11,388 ȱȱȱȱȱȱȱȱȱȱ3,503 ȱȱȱȱȱȱȱȱȱȱ1,216 ȱȱȱȱȱȱȱȱȱȱȱ352 ȱȱȱȱȱȱ16,459 69% 21% 7% 2% 65ȱYearsȱandȱOverȱȱȱȱȱȱȱȱȱȱ 6,643 ȱȱȱȱȱȱȱȱȱȱ2,223 ȱȱȱȱȱȱȱȱȱȱȱȱȱ524 ȱȱȱȱȱȱȱȱȱȱȱ539 ȱȱȱȱȱȱȱȱ9,929 67% 22% 5% 5%

AllȱInjuryȱTreatmentȱEpisode AllȱInjuriesȱȱȱȱȱȱȱȱ 57,162 ȱȱȱȱȱȱȱȱ30,940 ȱȱȱȱȱȱȱȱȱȱ6,810 ȱȱȱȱȱȱȱȱ5,527 ȱȱȱȱ100,439 57% 31% 7% 6% Underȱ18ȱYearsȱȱȱȱȱȱȱȱ 11,279 ȱȱȱȱȱȱȱȱȱȱ8,057 ȱȱȱȱȱȱȱȱȱȱ1,822 ȱȱȱȱȱȱȱȱȱȱȱ310 ȱȱȱȱȱȱ21,468 53% 38% 8% 1% 18ȱtoȱ44ȱYearsȱȱȱȱȱȱȱȱ 18,557 ȱȱȱȱȱȱȱȱ13,263 ȱȱȱȱȱȱȱȱȱȱ2,474 ȱȱȱȱȱȱȱȱ1,136 ȱȱȱȱȱȱ35,430 52% 37% 7% 3% 45ȱtoȱ64ȱYearsȱȱȱȱȱȱȱȱ 17,491 ȱȱȱȱȱȱȱȱȱȱ5,942 ȱȱȱȱȱȱȱȱȱȱ1,763 ȱȱȱȱȱȱȱȱ1,556 ȱȱȱȱȱȱ26,752 65% 22% 7% 6% 65ȱYearsȱandȱOverȱȱȱȱȱȱȱȱȱȱ 9,835 ȱȱȱȱȱȱȱȱȱȱ3,678 ȱȱȱȱȱȱȱȱȱȱȱȱȱ750 ȱȱȱȱȱȱȱȱ1,980 ȱȱȱȱȱȱ16,243 61% 23% 5% 12%

*ȱDistributionȱbyȱageȱgroupȱdoesȱnotȱmeetȱstandardsȱofȱreliability.ȱIncludedȱtoȱinformationȱpurposesȱonly.ȱ [1]ȱAllȱlistedȱdiagnosesȱforȱinpatientsȱdischargedȱfromȱshortȬstayȱhospitals.ȱMultipleȱdiagnosesȱperȱcaseȱpossible;ȱpercentagesȱbasedȱonȱtotalȱdiagnoses. [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱEmergencyȱRoomȱVisits,ȱ2006 [4]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱDepartmentȱVisits,ȱ2006 [5]Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ6.34:ȱPercentȱResourceȱUtilizationȱforȱTraumaticȱMusculoskeletalȱ (MS)ȱInjuriesȱbyȱTreatmentȱLocationȱforȱAllȱInjuryȱDiagnosesȱversusȱ Primaryȱ(Dx1)ȱDiagnosis,ȱUnitedȱStatesȱ2006/2007

PercentȱofȱAllȱInjuryȱDiagnosesȱthatȱareȱPrimaryȱ(1st)ȱDiagnosis

Physicianȱ Emergencyȱ Hospitalȱ TotalȱAll Officeȱ Roomȱ Outpatientȱ Inpatientȱ Treatmentȱ Visitsȱ[1] Visitsȱ[2] Visitsȱ[3] Staysȱ[4] Sites Fractures 89% 86% 86% 76% 87% Dislocations 59% 87% 79% 28% 65% SprainsȱandȱStrainsȱ 80% 79% 76% 31% 79% Contusions 69% 75% 84% 15% 72% OpenȱWounds 79% 90% 91% 24% 84% AllȱOtherȱMSȱInjuries 72% 83% 74% 26% 73% TotalȱAllȱMSȱTraumaticȱInjuries 84% 89% 86% 62% 85%

[1]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ2006 [2]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱCareȱSurvey,ȱ EmergencyȱRoomȱVisits,ȱ2006 [3]ȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱHospitalȱAmbulatoryȱMedicalȱVisits,ȱOutpatientȱ DepartmentȱVisits,ȱ2006

[4]ȱSource:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱ NationwideȱInpatientȱSample,ȱ2007

Tableȱ6.35ȱ:ȱPatientȱDaysȱandȱEstimatedȱTotalȱCostȱforȱHospitalȱCareȱforȱPrimaryȱ(Dx1)ȱTraumaticȱ Musculoskeletalȱ(MS)ȱInjuryȱPatients,ȱUnitedȱStatesȱ2007

HospitalȱStay HospitalȱCost MeanȱLength TotalȱPatient %ȱofȱTotalȱ EstimatedȱTotal TotalȱPatients ofȱStay Daysȱ Patient MeanȱChargeȱ Costȱ %ȱofȱTotalȱ (inȱ000s)ȱ[1] (inȱdays)ȱ (inȱ000s)ȱ Daysȱ[2] perȱPatientȱ[3] (inȱbillions) Costȱ[2] Fractures FractureȱofȱUpperȱLimbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 100 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ520 11.1%$ȱȱȱȱȱȱȱȱȱȱȱ 28,970 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.897 8.9% FractureȱofȱLowerȱLimbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 158 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ506 10.8%$ȱȱȱȱȱȱȱȱȱȱȱ 37,300 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.893 18.1% FractureȱofȱTrunkȱandȱMultipleȱSitesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 573 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,094 66.2%$ȱȱȱȱȱȱȱȱȱȱȱ 38,180 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ21.877 67.1% AllȱFracturesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 831 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,155 89.0%$ȱȱȱȱȱȱȱȱȱȱȱ 35,000 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ29.085 89.1% DerangementȱInjuries DerangementȱofȱKneeȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11 0.2%$ȱȱȱȱȱȱȱȱȱȱȱ 24,420 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.122 0.4% OtherȱJointȱDerangementȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 13 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ35 0.8%$ȱȱȱȱȱȱȱȱȱȱȱ 25,850 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.336 1.0% AllȱDerangementȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 17 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44 0.9%$ȱȱȱȱȱȱȱȱȱȱȱ 25,450 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.433 1.3% DislocationȱInjuries DislocationsȱofȱUpperȱLimbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ15 0.3%$ȱȱȱȱȱȱȱȱȱȱȱ 19,470 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.097 0.3% DislocationsȱofȱLowerȱLimbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26 0.6%$ȱȱȱȱȱȱȱȱȱȱȱ 23,710 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.190 0.6% AllȱDislocationȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 13 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ40 0.9%$ȱȱȱȱȱȱȱȱȱȱȱ 22,310 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.290 0.9% SprainȱandȱStrainȱInjuries SprainsȱofȱUpperȱLimbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 11 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ22 0.5%$ȱȱȱȱȱȱȱȱȱȱȱ 20,570 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.226 0.7% SprainsȱofȱLowerȱLimbȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ26 0.6%$ȱȱȱȱȱȱȱȱȱȱȱ 23,710 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.190 0.6% AllȱSprainsȱandȱStrainȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 21 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ53 1.1%$ȱȱȱȱȱȱȱȱȱȱȱ 21,020 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.441 1.4%

Contusionsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 27 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ103 2.2%$ȱȱȱȱȱȱȱȱȱȱȱ 17,210 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.465 1.4% CrushingȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 0.7%$ȱȱȱȱȱȱȱȱȱȱȱ 42,520 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.255 0.8% OpenȱWoundsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 53 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ186 4.0%$ȱȱȱȱȱȱȱȱȱȱȱ 22,820 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.209 3.7% TraumaticȱAmputationȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ37 0.8%$ȱȱȱȱȱȱȱȱȱȱȱ 39,520 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.316 1.0% OtherȱMusculoskeletalȱInjuriesȱ]4\ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ21 0.4%$ȱȱȱȱȱȱȱȱȱȱȱ 18,830 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.132 0.4% AllȱOtherȱMSȱInjuriesȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 101 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ379 8.1%$ȱȱȱȱȱȱȱȱȱȱȱ 23,540 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.378 7.3%

TotalȱAllȱMSȱTraumaticȱInjuries ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ975 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,680 100.0%$ȱȱȱȱȱȱȱȱȱȱȱ 33,260 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ32.429 100.0%

AllȱTraumaticȱInjuries ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,735 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱ14,496 $ȱȱȱȱȱȱȱȱȱȱȱ36,650 $ȱȱȱȱȱȱȱȱȱȱȱ100.238 %ȱMSȱTraumaticȱInjuriesȱofȱAllȱTraumaticȱInjuries 36% 32% 32%

[1]ȱFirstȱlistedȱdiagnosesȱforȱinpatientsȱdischargedȱfromȱshortȬstayȱhospitals [2]ȱDueȱtoȱrounding,ȱtotalsȱmayȱnotȱequalȱsumȱofȱtheȱindividualȱcomponents [3]ȱRoundedȱtoȱnearestȱten [4]ȱIncludesȱlateȱeffectsȱandȱconsequencesȱofȱtraumaticȱmusculoskeletalȱinjuries Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱHealthcareȱCostȱandȱUtilizationȱProject,ȱNationwideȱInpatientȱSample,ȱ2007

Tableȱ6.36:ȱNumberȱandȱPercentȱofȱPopulationȱwithȱMusculoskeletalȱ InjuriesȱandȱDistributionȱofȱPersonsȱwithȱSuchȱConditionsȱbyȱAgeȱandȱ ExpenditureȱType,ȱUnitedȱStatesȱ1996Ȭ2004

PersonsȱwithȱMSȱInjury AgeȱDistributionȱofȱPersonsȱwithȱMSȱInjuries

TotalȱPopulation #Individuals %ȱTotalȱ Year ȱ(inȱmillions) (inȱmillions) Population ȱ<ȱ18 ȱ18Ȭ44 45Ȭ64 ȱ65ȱ&ȱOver 1996Ȭ1998 271.2 23.4 8.6% 24.2% 43.4% 19.4% 13.0% 1997Ȭ1999 273.7 22.5 8.2% 24.8% 41.8% 20.0% 13.3% 1998Ȭ2000 276.1 21.6 7.8% 24.5% 41.8% 21.0% 12.7% 1999Ȭ2001 279.7 21.4 7.7% 23.0% 41.8% 22.4% 12.8% 2000Ȭ2002 283.6 22.3 7.9% 21.4% 41.8% 23.4% 13.4% 2001Ȭ2003 287.7 23.6 8.2% 21.0% 41.1% 24.1% 13.8% 2002Ȭ2004 290.8 24.7 8.5% 21.2% 40.2% 24.6% 14.0%

TotalȱVisitsȱforȱMusculoskeletalȱInjuriesȱbyȱExpenditureȱType ȱ(inȱmillions)

ERȱandȱ Homeȱ Physicianȱ Outpatientȱ PrescripȬȱ Healthȱ Hospitalȱ TotalȱCostsȱ Visits Visits tionsȱFilled CareȱVisits Disharges (inȱbillions) 1996Ȭ1998ȱȱȱȱȱȱȱȱȱȱȱ 112.1 ȱȱȱȱȱȱȱȱȱȱȱ53.7 ȱȱȱȱȱȱȱȱȱ200.9 ȱȱȱȱȱȱȱȱȱȱȱ63.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3 $ȱȱȱȱȱȱȱȱȱȱȱ93.20 1997Ȭ1999ȱȱȱȱȱȱȱȱȱȱȱ 110.2 ȱȱȱȱȱȱȱȱȱȱȱ58.5 ȱȱȱȱȱȱȱȱȱ209.2 ȱȱȱȱȱȱȱȱȱȱȱ69.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3 $ȱȱȱȱȱȱȱȱȱȱȱ95.72 1998Ȭ2000ȱȱȱȱȱȱȱȱȱȱȱ 108.0 ȱȱȱȱȱȱȱȱȱȱȱ60.5 ȱȱȱȱȱȱȱȱȱ215.9 ȱȱȱȱȱȱȱȱȱȱȱ69.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ2.2 $ȱȱȱȱȱȱȱȱȱȱȱ94.72 1999Ȭ2001ȱȱȱȱȱȱȱȱȱȱȱ 111.5 ȱȱȱȱȱȱȱȱȱȱȱ60.0 ȱȱȱȱȱȱȱȱȱ235.9 ȱȱȱȱȱȱȱȱȱȱȱ70.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱ4.3 $ȱȱȱȱȱȱȱȱȱȱȱ99.21 2000Ȭ2002ȱȱȱȱȱȱȱȱȱȱȱ 118.1 ȱȱȱȱȱȱȱȱȱȱȱ66.9 ȱȱȱȱȱȱȱȱȱ269.7 ȱȱȱȱȱȱȱȱȱȱȱ80.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱ4.5 $ȱȱȱȱȱȱȱȱȱ108.60 2001Ȭ2003ȱȱȱȱȱȱȱȱȱȱȱ 124.9 ȱȱȱȱȱȱȱȱȱȱȱ77.8 ȱȱȱȱȱȱȱȱȱ311.1 ȱȱȱȱȱȱȱȱȱȱȱ80.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱ4.7 $ȱȱȱȱȱȱȱȱȱ122.04 2002Ȭ2004ȱȱȱȱȱȱȱȱȱȱȱ 128.3 ȱȱȱȱȱȱȱȱȱȱȱ91.3 ȱȱȱȱȱȱȱȱȱ340.6 ȱȱȱȱȱȱȱȱȱȱȱ79.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ4.9 $ȱȱȱȱȱȱȱȱȱ127.45

Source:ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS)ȱ1996Ȭ2004ȱ

Chapter 7 Congenital and Infantile Developmental Conditions of the Musculoskeletal System

Congenital and infantile developmental conditions were analyzed and prepared by the Division of of the musculoskeletal system include a variety Birth Defects and Developmental Disabilities, of defects and range from clinically minor Centers for Disease Control and Prevention, anomalies, such as extra fi ngers or toes, to more Atlanta, Georgia. serious and disabling conditions, such as spina bifi da. This chapter focuses on musculoskeletal Section 7.1: Prevalence of Congenital conditions among infants for which population- and Infantile Developmental based surveillance data are available. Although Conditions of the Musculoskeletal the overall birth prevalence of these conditions System is relatively low in comparison to other types of musculoskeletal conditions, due to the seriousness of some of these conditions (e.g., spina bifi da, Estimated prevalence of selected musculoskeletal limb defi ciencies, skeletal dysplasias, and cerebral conditions at birth using a 95% confi dence interval palsy), they place a lifetime burden on patients, ranges from a low of 1.2 cases per 10,000 births for their families, and the medical community. Further skeletal dysplasias to 15.5 cases per 10,000 births surveillance and research eff orts are needed: (1) for polydactyly. (Table 7.1 and Graph 7.1.1) For to gain a bett er understanding of the magnitude the few conditions reported by both the national of the public health impact of these conditions, NBDPN and Atlanta based MACDP studies, including morbidity, mortality, and health services prevalence is slightly higher in the NBDPN study needs, and of possible disparities in prevalence than found in the MACDP. and outcomes by race/ethnicity, socioeconomic status, and geography; (2) to identify possible ȱȱ ȱŝǯŗǯŗǱȱşśƖȱęȱ ȱȱȱȱȱ causes and factors that may infl uence health ȱȱȱȱȱȱȱȱȱ ȱȱǰȱŗşşşȬŘŖŖř status, development, and level of functioning; ¢¢¢ range: 12.5-15.5 and (3) to develop and evaluate potential 16 ȱę Skeletal interventions for prevention. without anencephalus 12 ¢ range: 2.0-3.3 range: 1.2-2.2 8 The primary data sources available on congenital 4 and developmental conditions are the National Birth Defects Prevention Network (NBDPN), Developmental Transverse ¢ȱȱȱ ȱę¢ from which estimates of prevalence for selected range: 4.9-6.9 range: 1.9-3.2 defects are drawn based on state birth defects surveillance programs; the Centers for Disease ȱ[1] Control and Prevention (CDC) Metropolitan range: 8.9-11.5 ȱę¢ range: 1.1-2.1 Atlanta Congenital Defects Program (MACDP), ȱȱę which collects data on birth defects; and the CDC range: 3.9-5.7 Metropolitan Atlanta Developmental Disabilities şśƖȱ ȱǽŘǾȱȱȱȱŗŖǰŖŖŖȱȱ

Surveillance Program (MADDSP), which ǽŗǾȱȱȱȱȱȱęȱ¢ȱ ȱȱȱȱ ǽŘǾȱşśƖȱęȱȱȱȱȱȱȱȱȱ monitors the occurrence of selected develop- ǰȱŗşşşȬŘŖŖř Ǳȱȱǰȱȱ ǰȱ ȱ ǰȱȱǯǱȱȱȱȱȱȱ mental disabilities in school-age children. Data ŗşŜŞȮŘŖŖřǯȱȱȱȱA Clin Mol Teratol 2007;79(2):65–186.

Utilizing data from the NBDPN or MACDP and dysplasia of the hip, the prevalence was again the average number of births in the United States highest among whites (8.8 per 10,000) and lowest of 4.05 million for the years 1999 to 2003, the among blacks/African Americans (1.5 per 10,000). estimated number of infants born each year with a congenital musculoskeletal or developmental Among those conditions presented only in the condition is greater than 17,000 identifi ed for MACDP data, the prevalence of clubfoot without the conditions presented. (Table 7.2) During this NTD and skeletal dysplasia was highest among time period, there were between 1,030 and 1,500 whites (12.2 per 10,000 and 2.1 per 10,000, births with spina bifi da without anencephalus, respectively), while both were lowest among 2,300 and 2,500 with development dysplasia of others (8.5 per 10,000 total births and 1.3 per the hip (DDH), 4,100 with clubfoot without neural 10,000, respectively.) Polydactyly shows the highest tube defect (NTD), 1,900 with limb defi ciencies, prevalence among blacks/African Americans (18.7 600 with skeletal dysplasias, and 5,600 with per 10,000) and lowest among whites (10.4 per polydactyly each year. (Graph 7.1.2) 10,000). The prevalence of all limb defi ciencies varied litt le by race and ethnicity. Graph 7.1.2: Estimated Number of Infants Born per Year in the United States with Selected Congenital Musculoskeletal Defects, 1999 -2003 Cerebral palsy (CP), which is reported only in Spina bięda ithout anencephalus

Developmental dysplasia of the hip the MADDSP, had a prevalence of 3.1 per 1000 Clubfoot [3] among children aged 8 years in 2000. (Table 7.4) All limb deęciencies The prevalence of cerebral palsy is slightly higher onitdinal limb deęciency

ransverse limb deęciency among blacks/African Americans than among

Skeletal dysplasias whites (3.6/1000 versus 2.9/1000), and among males Polydactyly than females (3.6 per 1000 versus 2.6 per 1000). 0 1000 2000 3000 4000 5000 6000 Estimated Number of Infants Born The majority of children in the study had spastic per Year Estimate based on NBDPN [1] prevalence cerebral palsy (61%) compared with nonspastic CP Estimate based on MACDP [2] prevalence (5%) and CP not otherwise speciﬁ ed (33%).1 [1] National Birth Defects Prevention Net ork [2] Metropolitan Atlanta Congenital Defects Program [3] alipes euinovarus and clubfoot of unspecięed type ithout a neural tube defect Sources Ǳ ǻ1Ǽ National Birth Defects Prevention Net orkǯ Birth defects surveillance data from selected statesǰ 1şşşȬ2003ǯ Birth Defects esearch A ClinMol Teratol Graph 7.1.3: Prevalence of Selected Congenital Musculoskeletal Defects per 2006ǲŝ6ǻ12ǼǱŞş4Ȭş60ǯ ǻ2Ǽ Correa Aǰ Cragan Dǰ ucik Eǰ et alǯǱ eporting birth defects surveillance data 10,000 Total Births, by Race and Ethnicity, Metropolitan Atlanta Congenital 1ş6ŞȮ2003ǯ Birth Defects esearch A Clin Mol Teratol 200ŝǲŝşǻ2ǼǱ65Ȯ1Ş6ǯ Defects Program, Atlanta, Georgia, 1999 - 2003 20 Congenital musculoskeletal defects show some variation by race and ethnicity. (Table 7.3) Based 16 on NBDPN data, the prevalence of spina biﬁ da 12 without anencephalus was highest among

Hispanics/Latinos (4.3 per 10,000 total births) and 8 lowest among births of “other” race or ethnicity (3.2 per 10,000). The prevalence of developmental per 10,000 Births Prevalence 4

dysplasia of the hip, or developmental hip 0 White Black/ Hispanic\ Other [1] dislocation, was highest among whites (7.5 African American Latino

per 10,000) and lowest among blacks/African Spina bięda ithout anencephalus Developmental dysplasia of the hip

Americans (3.0 per 10,000). Clubfoot [2] ll li deęciecies

oitdial li deęciecy asese li deęciecy

Based on MACDP data, the prevalence of spina Skeletal dysplasias Polydactyly

biﬁ da without anencephalus was also highest [1] Data for races other than White, Black or African American, Hispanic or Latino, or race not specięed ere combined because the data, hen analy£ed separately, ere too small for among Hispanics/Latinos (5.2 per 10,000 total meaningful analysis. [2] alipes euinovarus and clubfoot of unspecięed type ithout a neural tube defect. births) and lowest among others (0.7 per 10,000). Source: Correa A, Cragan JD, Kucik JE et al.: Reporting birth defects surveillance data 1968–2003. Birth Defects Research A Clin Mol Teratol 2007;79(2):65–186. (Table 7.4 and Graph 7.1.3) For developmental

Section 7.2: Selected Congenital and and spina bifi da. As a result, in 1992, the U.S. Infantile Development Conditions of Public Health Service recommended that all the Musculoskeletal System women of childbearing age who are capable of becoming pregnant consume 4.0 mg of folic acid daily to reduce their risk of having a baby with Section 7.2.1: Spina Bifi da anencephaly or spina bifi da.13 Subsequently, in 1996, the U.S. Food and Drug Administration Spina bifi da consists of a bony defect in the spine established regulations requiring that fl our and through which the cerebrospinal fl uid, meninges, other enriched grain products be fortifi ed with nerves, spinal cord, or a combination thereof can 140 micrograms of folic acid per 100 grams of herniate. It results from failure of the neural tube grain by January 1, 1998.14 Since these regulations to close during the fi rst 28 days aft er conception were implemented, serum and red blood cell and is classifi ed embryologically as a congenital folate levels have increased among women of anomaly of the central nervous system. The most reproductive age in the United States, and declines common types of spina bifi da are meningocele in the prevalence of anencephaly and spina bifi da and myelomeningocele. In meningocele, only the have been observed.9,15-18 meninges and cerebrospinal fl uid herniate through the spinal defect. In myelomeningocele, the nerves, Section 7.2.2: Developmental Dysplasia of the Hip the spinal cord, or both also herniate. The spinal defect in spina bifi da can be either covered by Developmental dysplasia of the hip (DDH) refers normal skin (closed) or in communication with the to a spectrum of abnormalities that includes environment (open). Additional defects of other an unstable, subluxed, or dislocated hip, or organs are present in about 20% of infants with malformed acetabulum. DDH can originate early spina bifi da.2 in gestation as the lower limbs develop, during the second trimester as the hip muscles develop, or Spina bifi da can be diagnosed prenatally through late in the third trimester as a result of mechanical screening for elevated alpha-fetoprotein in forces associated with oligohydramnios or maternal serum and prenatal ultrasonography. breech presentation. It also can develop in the While many spina bifi da defects can be repaired weeks following delivery or during infancy surgically, aff ected children have lifelong and childhood. The clinical symptoms of DDH complications such as hydrocephalus, neurologic can change and evolve over time. If untreated, defi cit, bowel and bladder incontinence, and persistent subluxation or dislocation can lead to 2,3 decreased long-term survival. A decline in the permanent changes in the hip, including a shallow prevalence of spina bifi da since the mid-1970s acetabulum, muscle contractures, and constriction has been reported in the United States, Europe, of the hip capsule. Newborns and young infants 4,5 Australia, and New Zealand. Spina bifi da is can be treated eff ectively with a Pavlik harness, seen more frequently at birth among females while older infants and children can require closed than males, and most frequently among infants or open surgical reduction. of Hispanic or Latino ethnicity, particularly those born in Mexico.6-10 Diagnosing DDH can be diffi cult, particularly among newborns. It is usually detected by physical In the early 1990s, randomized clinical trials in examination, radiography, or ultrasound, although Great Britain and Hungary demonstrated that false positives and false negatives occur with all consumption of the vitamin folic acid during of these methods. Among older infants, limited the periconceptional period (before and during abduction of the hip is usually the most consistent the early weeks of pregnancy) could prevent the fi nding. The Committ ee on Quality Improvement, recurrence11 and occurrence12 of anencephaly

Subcommitt ee on Developmental Dysplasia of with a family history of clubfoot.26 However, the the Hip, American Academy of Pediatrics has corresponding decline in smoking over this period developed clinical practice guidelines for pediatric probably was not suffi cient to fully explain the health care providers on the early detection of decline in clubfoot. DDH.19 Section 7.2.4: Limb Defi ciencies DDH can occur unilaterally or bilaterally. When unilateral, the left side is involved approximately Limb defi ciencies, also known as limb reduction three times more oft en than the right. DDH is defects, are defi ned by the absence (or severe more common among girls, fi rst-born children, hypoplasia) of part or all of bony structures of the and those with a positive family history in a parent extremities. The most common type of this defect is or sibling. It can occur as part of a more general a transverse terminal limb defi ciency, characterized neuromuscular disorder or clinical syndrome. by the absence of the distal segments of any limb However, “typical” hip dislocation occurs among while the proximal segments remain intact. People 19 otherwise healthy infants. The prevalence of with transverse digital defi ciencies are missing DDH can diff er depending on the age of the child part or all of any phalanx with intact metacarpal at diagnosis, the type of examination used for or metatarsal bones and proximal segments. The screening, the experience of the examiner, and the functional consequences of these defects can diagnostic criteria and terminology used. be considerable when the thumb and multiple fi ngers are involved. Other categories include Section 7.2.3: Clubfoot preaxial and postaxial defi ciencies, oft en grouped together as longitudinal limb defi ciencies, as well Congenital talipes equinovarus (TEV), more as split hand or split foot malformations. The least commonly referred to as clubfoot, is a common common category of defi ciency is the intercalary congenital disorder of the lower limb. A clubfoot type (classic phocomelia), defi ned by the absence is fi xed in adduction, supination, and varus, that of proximal parts of limbs with distal structures is, the forefoot turned in, the ankle turned inward, totally or partially present. and the foot pointed down.20 True TEV requires active treatment, including casting, manipulation, Although specifi c genetic loci for several limb and sometimes surgery to place the foot in the defect syndromes have been identifi ed in recent correct anatomical position.21 Clubfoot can occur years, the causes of limb defi ciencies currently as an isolated fi nding, as a result of another cannot be easily identifi ed for many aff ected abnormality such as spina bifi da, or as part of a infants.27 Certain phenotypes, particularly those clinical syndrome. The treatment of clubfoot can be involving split hand or split foot, intercalary, radial particularly challenging if an infant has associated ray, or postaxial defi ciencies, have been associated abnormalities.22 with single-gene mutations (e.g., the Holt-Oram “heart/hand” syndrome or familial split hand or Isolated TEV occurs almost twice as oft en among split foot malformation). Other rare causes include males as in females, regardless of ethnicity.23 It is chromosome abnormalities such as aneuploidies or bilateral in 50% or more of cases. When unilateral, exposure to known teratogens such as thalidomide the right side is involved more frequently than and valproic acid. Because chromosomal the left .24 In metropolitan Atlanta, the prevalence abnormalities account for a small proportion of of clubfoot not associated with an NTD declined limb defi ciencies overall, advancing maternal age remarkably from 1968 through 2003.25 Studies has not been shown to be a risk factor for these have suggested that maternal smoking might be a defects.28 The hypothesis of a vascular pathogenesis risk factor for clubfoot, particularly among those for transverse terminal limb defi ciencies is

supported by animal, epidemiologic, autopsy, Severity of skeletal dysplasias ranges from mild and family studies, but oft en specifi c vasoactive forms (nonlethal) to severe (lethal) forms.37 The exposures cannot be identifi ed for individual most common lethal skeletal dysplasias include infants. However, even for the distinctive amniotic thanatophoric dysplasia, achondrogenesis, and band phenotype, there is controversy regarding osteogenesis imperfecta.38 Achondroplasia is the intrinsic versus extrinsic nature of limb the most common nonlethal skeletal dysplasia. disruption.29 Prognosis and life expectancy of children with nonlethal skeletal dysplasias depend on the degree Prenatal ultrasonography has resulted in early of skeletal abnormalities and other associated identifi cation of a signifi cant proportion of limb anomalies. defi ciencies among countries where this procedure has become routine, but primary prevention of Treatment is usually supportive. With early most of these defects has remained elusive.30 intervention from specialists, patients with There is some suggestion from limb defi ciency nonlethal skeletal dysplasias can avoid or case-control studies that periconceptional minimize the many complications associated with multivitamin use might be protective for these disorders.39 Orthopaedic surgery is one of longitudinal or transverse terminal defi ciencies,31,32 the pillars of treatment to prevent neurologic and this hypothesis is being further investigated and orthopaedic complications due to spinal along with studies of gene-environment cord compression, joint instability, and long bone interactions that might shed light on mechanisms deformity. The International Skeletal Dysplasia of nutritional protective factors or vasoactive risk Registry is a referral center for the diagnosis, factors. management, and the etiology of skeletal dysplasia.40 Section 7.2.5: Skeletal Dysplasias Section 7.2.6: Polydactyly Skeletal dysplasias belong to a heterogeneous group of birth defects. They include over Polydactyly is a heterogeneous group of anomalies 200 disorders (e.g., chondrodystrophies, described by excessive partition of the digital osteodystrophies, dwarfi sms, and generalized rays of the hands and feet that can appear in skeletal dysplasias) characterized by abnormalities isolation or in association with other birth defects. of cartilage and bone growth resulting in an Clinically, it generally manifests as an extra digit. abnormal shape and size of the skeleton and a It is the most common congenital digital anomaly disproportion of the long bones, spine, and head.33 of the hand and foot. Isolated polydactyly is oft en Most of them are genetic conditions. Most fetuses autosomal dominant or occasionally sporadic, with skeletal dysplasia now can be diagnosed while polydactyly associated with other major prenatally.34 However, some skeletal dysplasias defects can be autosomal recessive.41 Polydactyly do not manifest until short stature and other is classifi ed into postaxial and preaxial types. complications arise during childhood. Skeletal Postaxial polydactyly, the most common type in dysplasias diff er in inheritance patt erns, severity, the United States, typically involves an extra digit natural histories, and prognoses. Modes of on the ulnar or fi bular side of the limb. Preaxial inheritance include both autosomal and X-linked polydactyly refers to duplication on the radial dominant and recessive forms. Several genetic or tibial side. Central polydactyly is a term used mutations have been described and associated primarily in clinical sett ings, usually in the rare with skeletal dysplasias.35,36 Males are primarily situation when syndactyly is associated with aff ected in X-linked recessive disorders; X-linked duplication of the second, third, or fourth digit. dominant disorders can be lethal in males.

In general, there is a signifi cant racial predilection infections, and multiple gestation.46,47 However, for polydactyly. Postaxial polydactyly is more anywhere from 17% to 60% of cases of CP have no frequent among blacks/African Americans than known perinatal or neonatal complications.46 among whites, and is more frequent among male children.42 This higher prevalence among African The prevalence of CP, estimated to occur in slightly Americans is largely due to a higher prevalence over 3 persons in 1,000, has been generally stable of postaxial skin tags, which generally are not for several decades except for a modest increase considered to be a major abnormality. Postaxial in recent years. This recent increase in prevalence skin tags in African Americans are not included in has been att ributed to an increase among very the data from MACDP on polydactyly presented low birth weight infants, which, in turn, has been in the tables and graphs. Other factors associated att ributed to their increased survival resulting with postaxial hand polydactyly in one study from newborn intensive care.48 CP occurs more included twinning, low maternal education, frequently in males than in females, and is higher parental consanguinity, and recurrence in fi rst- among blacks/African Americans than found in degree relatives.43 other race or ethnic groups. (Table 7.5 and Graph 7.2.1) All types of polydactylies are rarely associated with other congenital anomalies. In a recent Graph 7.2.1: Prevalence of Cerebral Palsy Among Children Aged 8 Years per 1,000 Population, by Sex and 13 study, trisomy , Meckel syndrome, and Down Race, Metropolitan Atlanta Developmental Disabilities syndrome accounted for most cases of syndromic Surveillance Program, Atlanta, Georgia, 2000 5 polydactyly.44 Treatment of polydactyly depends greatly on the complexity of the malformation 4 and varies from tying the base of the fi nger with a 3 suture to complex surgical correction. 2

Section 7.2.7: Cerebral Palsy per 1,000 Population Prevalence 0 Female Male Total

[1] Data for races other than black /African White Cerebral palsy (CP) describes a group of American and white were combined due to small sample size. Black or permanent disorders of movement and posture Source: Centers for Disease Control and African Americn Prevention. Prevalence of four developmental that are att ributed to nonprogressive disturbances disabilities among children aged 8 years, Other [1] Metropolitan Atlanta Developmental Disabilities Surveillance Program, 1996 and 2000. In: in the developing brain of the fetus or infant. The Total Surveillance Summaries, January 27, 2006. motor disorders of CP are oft en accompanied by: MMWR Surveill Summ 2006:55;1-9. (1) disturbances of sensation, perception, cognition, communication, and behavior; (2) epilepsy; and Section 7.3: Birth Defects Surveillance (3) secondary musculoskeletal problems.45 This Programs defi nition of CP covers a wide array of clinical presentations and degrees of activity limitation. Traditional classifi cation schemes have focused The National Birth Defects Prevention Network principally on the distributional patt erns of (NBDPN) is composed of state-based birth aff ected limbs (e.g., hemiplegia or diplegia), with defects surveillance programs and individuals an added modifi er describing the predominant working in birth defects surveillance, research, type of tone or movement abnormality (e.g., spastic and prevention at the local, state, and national or dyskinetic).45 The etiology of CP is not fully levels. NBDPN publishes an annual report of understood. Factors associated with an increased surveillance data from participating programs. risk for CP include low birth weight, intrauterine In 2006, prevalence data for selected birth defects from 11 states with active case-fi nding for births in 1999-2003 were published, from which data

were pooled to calculate prevalence estimates for 4. Elwood JM, Litt le J, Elwood JH: Epidemiology and Control spina bifi da without anencephaly and develop- of Neural Tube Defects. New York, NY: Oxford University mental dysplasia of the hip (developmental hip Press, 1992. dislocation) used in this chapter.49 5. Yen IH, Khoury MJ, Erickson JD, et al: The changing The CDC’s Metropolitan Atlanta Congenital epidemiology of neural tube defects, United States, Defects Program (MACDP) is a population- 1968-1989. Am J Dis Child 1992;146:857-861. based surveillance system for birth defects that was established in 1967. Since that time, the 6. Canfi eld MA, Annegers JF, Brender JD, et al: Hispanic program has conducted ongoing surveillance origin and neural tube defects in Houston/Harris County, for birth defects among infants, fetuses, and Texas: II. Risk factors. Am J Epidemiol 1996;143:12-24. children born to residents of the fi ve central counties of metropolitan Atlanta through the use 7. Khoury M, Erickson JD, James LM: Etiologic heterogeneity of active case-fi nding methods and multi-source of neural tube defects: Clues from epidemiology. Am J ascertainment.36 Prevalence data from MACDP are Epidemiol 1982;115:538-548. presented for the period 1999-2003 for comparison with prevalence estimates from the NBDPN for the 8. Shaw GM, Velie EM, Wasserman CR: Risk for neural tube same period. In 2003, there were 51,676 live births defect-aff ected pregnancies among women of Mexican to residents of the fi ve counties. descent and white women in California. Am J Public Health 1997;87:1467-1471. The CDC’s Metropolitan Atlanta Developmental Disabilities Program (MADDSP) is a 9. Williams LJ, Rasmussen SA, Flores A, et al: Decline in population-based surveillance system that has the prevalence of spina bifi da and anencephaly by race/ been monitoring the occurrence of selected ethnicity: 1995-2002. Pediatrics 2005;116:580-586. developmental disabilities, including cerebral palsy, among school-aged children since 1991 10. Canfi eld MA, Honein MA, Yuskiv N, et al: National in the same population as MACDP. Prevalence estimates and race/ethnic-specifi c variations of selected data on CP are presented for children aged 8 birth defects in the United States, 1991-2001. Birth Defects years during 2000.1 In 2000, the population in Research A Clin Mol Teratol 2006;76:747-756. Metropolitan Atlanta included 43,593 children aged 8 years. 11. MRC Vitamin Study Research Group: Prevention of neural tube defects: results of the Medical Research Council 1. Centers for Disease Control and Prevention (CDC): Vitamin Study. Lancet 1991;338:131-137. Prevalence of four developmental disabilities among children aged 8 years Metropolitan Atlanta Developmental 12. Czeizel AE, Dudas I: Prevention of the fi rst occurrence Disabilities Surveillance Program, 1996 and 2000. MMWR of neural-tube defects by periconceptional vitamin Surveill Summ;2006;55:1-9. supplementation. N Engl J Med 1992;327:1832-1835.

2. Bott o LD, Moore CA, Khoury MJ, et al: Neural-tube 13. Centers for Disease Control and Prevention (CDC): defects. N Engl J Med 1999;341:1509-1519. Recommendations for the use of folic acid to reduce the number of cases of spina biﬁ da and other neural tube 3. Wong LC, Paulozzi LJ: Survival of infants with spina defects. MMWR Recomm Rep 1992;41:1-7. biﬁ da: A population study, 1979-1994. Paediatr Perinat Epidemiol 2001;15:374-378. 14. U.S. Food and Drug Administration: Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Fed Regist 1996;61:8781-8797.

15. Centers for Disease Control and Prevention (CDC): Foliate 26. Honein MA, Paulozzi LJ, Moore CA: Family history, status in women of childbearing age, by race/ethnicity, maternal smoking, and clubfoot: An indication of a United States, 1999-2000. MMWR Morb Mortal Wkly Rep gene-environment interaction. Am J Epidemiol 2000;152:658- 2002;51:808-810. 665.

16. Honein MA, Paulozzi LJ, Mathews TJ, et al: Impact of folic 27. McGuirk CK, Westgate MN, Holmes LB: Limb defi ciencies acid fortifi cation of the US food supply on the occurrence in newborn infants. Pediatrics 2001;108:E64. of neural tube defects. JAMA 2001;285:2981-2986. 28. Reefh uis J, Honein MA: Maternal age and 17. Honein MA, Paulozzi LJ, Mathews TJ, et al: Erratum on: non-chromosomal birth defects, Atlanta, 1968-2000. Birth impact of folic acid fortifi cation of the US food supply on Defects Research A Clin Mol Teratol 2004;70:572-579. the occurrence of neural tube defects. JAMA 2001;286:2236. 29. Orioli IM, Ribeiro MG, Castilla EE: Clinical and 18. Williams LJ, Mai CT, Edmonds LD, et al: Prevalence of epidemiological studies of amniotic deformity, adhesion, spina bifi da and anencephaly during the transition to and mutilation (ADAM) sequence in a South American mandatory folic acid fortifi cation in the United States. (ECLAMC) population. Am J Med Genet 2003;118:135-145. Teratology 2002;66:33-39. 30. Stoll C, Wiesel A, Queisser-Luft A, et al: Evaluation of 19. Committ ee on Quality Improvement, Subcommitt ee on the prenatal diagnosis of limb reduction defi ciencies: Developmental Dysplasia of the Hip, American Academy EUROSCAN Study Group. Prenat Diagn 2000;20:811-818. of Pediatrics: Clinical practice guidelines: early detection of developmental dysplasia of the hip. Pediatrics 2000;105:896- 31. Shaw GM, O’Malley CD, Wasserman CR, et al: Maternal 905. periconceptional use of multivitamins and reduced risk for conotruncal heart defects and limb defi ciencies among 20. Miedzybrodzka Z: Congenital talipes equinovarus off spring. Am J Med Genet 1995;59:536-545. (clubfoot): a disorder of the foot but not hand. J Anat 2003;202:37-42. 32. Yang Q, Khoury MJ, Olney RS, et al: Does periconceptional multivitamin use reduce the risk for limb defi ciency in 21. Dietz F: The genetics of idiopathic clubfoot. Clin Orthop off spring? Epidemiology 1997;8:157-161. Relat Res 2002;401:39-48. 33. Romero R, Athanassiadis AP, Jeanty P: Fetal skeletal 22. Cummings RJ, Davidson RS, Armstrong PF, et al: anomalies. Radiol Clin North Am 1990;28:75-99. Congenital clubfoot. J Bone Joint Surg Am 2002;84:290-308. 34. Mortier G: The diagnosis of skeletal dysplasias: A 23. Lochmiller C, Johnston D, Scott A, et al: Genetic multidisciplinary approach. Eur J Radiol 2001;40:161-167. epidemiology of idiopathic talipes equinovarus. Am J Med Genet 1998;79:90-96. 35. Baitner AC, Maurer SG, Gruen MB, et al: The genetic basis of the osteochondrodysplasias. Journal of Pediatric 24. Paulozzi LJ, Lary JM: Laterality patt erns in infants with Orthopaedics 2000;20:594-605. external birth defects. Teratology 1999;60:265-271. 36. Superti-Furga A, Bonafe L, Rimoin DL: Molecular- 25. Correa A, Cragan JD, Kucik JE, et al: Reporting birth pathogenetic classifi cation of genetic disorders of the defects surveillance data 1968-2003. Birth Defects Research A skeleton. Am J Med Genet 2001;106:282-293. Clin Mol Teratol 2007;79:65-186. 37. Azouz EM, Teebi AS, Eydoux P, et al: Bone dysplasias: an introduction. Can Assoc Radiol J 1998;49:105-109.

38. Lemyre E, Azouz EM, Teebi AS, et al: Bone dysplasia 44. Castilla EE, Lugarinho R, da Graca Dutra M, et al: series. Achondroplasia, hypochondroplasia and Associated anomalies in individuals with polydactyly. Am thanatophoric dysplasia: review and update. Can Assoc J Med Genet 1998;80:459-465. Radiol J 1999;50:185-197. 45. Rosenbaum P, Panet N, Leviton A, et al: A report: the 39. Hurst JA, Firth HV, Smithson S: Skeletal dysplasias. Semin deﬁ nition and classiﬁ cation of cerebral palsy. Dev Med Fetal Neonatal Med 2005;10:233-241. Child Neurol Suppl 2007;49:8-14.

40. International Skeletal Dysplasia Registry, Cedars-Sinai 46. Davis D: Review of cerebral palsy, part I: description, Medical Center. Available at: htt p://www.csmc.edu/9934. incidence, and etiology. Neonatal Netw 1997;16:7-12. html. Accessed October 12, 2007. 47. Odding E, Roebroeck ME, Stam HJ: The epidemiology of 41. Hosalkar HS, Shah H, Gujar P, et al: Crossed polydactyly. J cerebral palsy: incidence, impairments, and risk factors. Postgrad Med 1999;45:90-92. Disabil Rehabil 2006;28:183-191.

42. Finley WH, Gustavson KH, Hall TM, et al: Birth defects 48. Paneth N, Hong T, Korzeniewski S: The descriptive surveillance: Jeﬀ erson County, Alabama, and Uppsala epidemiology of cerebral palsy. Clinical Perinatology County, Sweden. South Med J 1994;87:440-445. 2006;33:251-267.

43. Castilla EE, da Graca Dutra M, Lugarinho da Fonseca R, 49. National Birth Defects Prevention Network: Birth defects et al: Hand and foot postaxial polydactyly: Two diﬀ erent surveillance data from selected states, 1999-2003. Birth traits. Am J Med Genet 1997;73:48-54. Defects Research A Clin Mol Teratol 2006;76:894-960.

Section 7.4: Congenital and Infantile Developmental Conditions of the Musculoskeletal System Data Tables

Tableȱ7.1:ȱEstimatedȱPrevalenceȱofȱSelectedȱCongenitalȱ MusculoskeletalȱDefects,ȱNationalȱBirthȱDefectsȱPreventionȱ NetworkȱandȱMetropolitanȱAtlantaȱCongenitalȱDefectsȱ Program,ȱ1999Ȭ2003

NBDPNȱ[1],ȱ1999Ȭ2003 MACDPȱ[2],ȱ1999Ȭ2003 Prevalenceȱ Prevalenceȱ perȱ10,000ȱ perȱ10,000ȱ MusculoskeletalȱDefect TotalȱBirths 95%ȱCIȱ[3] TotalȱBirths 95%ȱCIȱ[3]

SpinaȱBifidaȱwithoutȱAnencephalus 3.7 3.5ȱ–ȱ3.9 2.6 2.0ȱȬȱ3.3

DevelopmentalȱDysplasiaȱofȱtheȱHip 6.2 5.9ȱ–ȱ6.4 5.8 4.9ȱȬȱ6.9

Clubfootȱ[4] 10.2 8.9ȱȬȱ11.5

AllȱLimbȱDeficiencies 4.7 3.9ȱȬȱ5.7

LongitudinalȱLimbȱDeficiency 1.5 1.1ȱȬ2.1

TransverseȱLimbȱDeficiency 2.5 1.9ȱȬ3.2

SkeletalȱDysplasias 1.6 1.2ȱȬ2.2

Polydactyly 13.9 12.5ȱȬ15.5

[1]ȱNationalȱBirthȱDefectsȱPreventionȱNetwork [2]ȱMetropolitanȱAtlantaȱCongenitalȱDefectsȱProgram [3]ȱConfidenceȱinterval [4]ȱTalipesȱequinovarusȱandȱclubfootȱofȱunspecifiedȱtypeȱwithoutȱaȱneuralȱtubeȱdefect Sourceȱ1:ȱNationalȱBirthȱDefectsȱPreventionȱNetwork.ȱBirthȱdefectsȱsurveillanceȱdataȱfromȱ selectedȱstates,ȱ1999Ȭ2003.ȱBirthȱDefectsȱResearchȱAȱClinȱMolȱTeratol ȱ2006;76(12):894Ȭ960.ȱ

Sourceȱ2:ȱCorreaȱA,ȱCraganȱJD,ȱKucikȱJE,ȱetȱal:ȱReportingȱbirthȱdefectsȱsurveillanceȱdataȱ 1968–2003.ȱBirthȱDefectsȱResearchȱAȱClinȱMolȱTeratolȱ 2007;79(2):65–186.

Tableȱ7.2:ȱEstimatedȱNumberȱofȱInfantsȱBornȱperȱYearȱinȱtheȱUnitedȱStatesȱ withȱSelectedȱCongenitalȱMusculoskeletalȱDefects,ȱ1999ȱȬ2003

Estimate Estimate Based on Based on NBDPN [1] MACDP [3] Musculoskeletal Defect Prevalence 95% CI [2] Prevalence 95% CI [2]

SpinaȱBifidaȱwithoutȱAnencephalus 1,486 1,411 – 1,564 1,032 970 – 1,097

DevelopmentalȱDysplasiaȱofȱtheȱHip 2,503 2,406 – 2,603 2,354 2,260 – 2,451

Clubfootȱ[4] 4,096 3,971 – 4,223

AllȱLimbȱDeficiencies 1,903 1,818 – 1,990

LongitudinalȱLimbȱDeficiency 613 565 – 663

TransverseȱLimbȱDeficiency 1,016 954 – 1,080

SkeletalȱDysplasias 661 612 – 713

Polydactyly 5,611 5,466 – 5,760

[1]ȱNationalȱBirthȱDefectsȱPreventionȱNetwork [2]ȱConfidenceȱinterval [3]ȱMetropolitanȱAtlantaȱCongenitalȱDefectsȱProgram [4]ȱTalipesȱequinovarusȱandȱclubfootȱofȱunspecifiedȱtypeȱwithoutȱaȱneuralȱtubeȱdefect

Sourceȱ1:ȱNationalȱBirthȱDefectsȱPreventionȱNetwork.ȱBirthȱdefectsȱsurveillanceȱdataȱfromȱselectedȱstates,ȱ1999Ȭ 2003.ȱBirthȱDefectsȱResearchȱAȱClinȱMolȱTeratol ȱ2006;76(12):894Ȭ960.ȱ

Sourceȱ2:ȱCorreaȱA,ȱCraganȱJD,ȱKucikȱJE,ȱetȱal:ȱReportingȱbirthȱdefectsȱsurveillanceȱdataȱ1968–2003.ȱ BirthȱDefectsȱ ResearchȱAȱClinȱMolȱTeratolȱ 2007;79(2):65–186.

Tableȱ7.3:ȱPrevalenceȱofȱSelectedȱCongenitalȱandȱInfantileȱDevelopmentalȱMusculoskeletalȱDefectsȱ perȱ10,000ȱTotalȱBirthsȱbyȱRaceȱandȱEthnicity,ȱNationalȱBirthȱDefectsȱPreventionȱNetwork,ȱ11ȱStatesȱ WithȱActiveȱSurveillanceȱSystems,ȱ1999Ȭ2003 ȱȱ White Black/AfricanȱAmerican HispanicȱorȱLatino Otherȱ[1] MusculoskeletalȱDefect Prevalence 95%ȱCIȱ[2] Prevalence 95%ȱCIȱ[2] Prevalence 95%ȱCIȱ[2] Prevalence 95%ȱCIȱ[2]

SpinaȱBifidaȱwithoutȱAnencephalusȱ[3] 3.4 3.2ȱȬȱ3.7 3.4 2.9ȱȬȱ3.9 4.3 4.0ȱȬȱ4.7 3.2 2.6ȱȬ4.0

DevelopmentalȱDysplasiaȱofȱtheȱHipȱ (developmentalȱhipȱdislocation)ȱ[4] 7.5 7.1ȱȬȱ7.9 3.0 2.6ȱȬȱ3.5 5.9 5.4ȱȬȱ6.4 5.5 4.5ȱȬ6.6 ȱȱ ȱȱ ȱȱ [1]ȱDataȱforȱracesȱotherȱthanȱwhite,ȱblackȱorȱAfricanȱAmerican,ȱHispanicȱorȱLatinoȱwereȱcombinedȱdueȱtoȱsmallȱsampleȱsize. [2]ȱConfidenceȱinterval

[3]ȱPrevalenceȱestimatesȱbasedȱonȱpooledȱdataȱfromȱ11ȱstatesȱwithȱactiveȱcaseȱfindingȱduringȱthisȱtimeȱperiod:ȱAlabama,ȱArkansas,ȱCalifornia,ȱGeorgia,ȱ Hawaii,ȱIowa,ȱMassachusetts,ȱNorthȱCarolina,ȱOklahoma,ȱTexas,ȱandȱUtah.ȱȱ

[4]ȱPrevalenceȱestimatesȱbasedȱonȱpooledȱdataȱfromȱ8ȱstatesȱwithȱactiveȱcaseȱfindingȱduringȱthisȱtimeȱperiod:ȱAlabama,ȱArkansas,ȱGeorgia,ȱHawaii,ȱIowa,ȱ NorthȱCarolina,ȱOklahoma,ȱandȱTexas.

Source:ȱȱNationalȱBirthȱDefectsȱPreventionȱNetwork:ȱBirthȱdefectsȱsurveillanceȱdataȱfromȱselectedȱstates,ȱ1999Ȭ2003.ȱBirthȱDefectsȱResearchȱAȱClinȱMolȱ Teratol ȱ2006;76(12):894Ȭ960.ȱȱȱȱȱȱȱȱȱȱȱȱȱ

Tableȱ7.4:ȱPrevalenceȱofȱSelectedȱCongenitalȱandȱInfantileȱDevelopmentalȱMusculoskeletalȱDefectsȱperȱ 10,000ȱTotalȱBirthsȱbyȱRaceȱandȱEthnicity,ȱMetropolitanȱAtlantaȱCongenitalȱDefectsȱProgram,ȱ Atlanta,ȱGeorgia,ȱ1999ȱȬȱ2003

White Black/AfricanȱAmerican HispanicȱorȱLatino Otherȱ[1] MusculoskeletalȱDefect Prevalence 95%ȱCIȱ[2] Prevalence 95%ȱCIȱ[2] Prevalence 95%ȱCIȱ[2] Prevalence 95%ȱCIȱ[2]

SpinaȱBifidaȱwithoutȱAnencephalus ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.0ȱ 1.2ȱ–ȱ3.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3ȱ 1.4ȱ–ȱ3.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5.2ȱ 3.2ȱ–ȱ7.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.7ȱ 0.0ȱ–ȱ3.6

DevelopmentalȱDysplasiaȱofȱtheȱHip ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.8ȱ 7.0ȱ–ȱ10.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.5ȱ 0.8ȱ–ȱ2.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.7ȱ 6.1ȱ–ȱ12.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7.2ȱ 3.6ȱ–ȱ12.9

Clubfootȱ[3] ȱȱȱȱȱȱȱȱȱȱȱȱȱ12.2ȱ 10.1ȱ–ȱ14.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.6ȱ 6.9ȱ–ȱ10.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9.6ȱ 6.9ȱ–ȱ13.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ8.5ȱ 4.5ȱ–ȱ14.6

AllȱLimbȱDefiencies ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.7ȱ 3.4ȱ–ȱ6.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.7ȱ 3.4ȱ–ȱ6.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.9ȱ 3.1ȱ–ȱ7.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4.6ȱ 1.8ȱ–ȱ9.4

LongitudinalȱLimbȱDeficiency ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.6ȱ 0.9ȱ–ȱ2.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.6ȱ 0.9ȱ–ȱ2.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.9ȱ 0.8ȱ–ȱ3.7 ȱȬȱ Ȭ

TransverseȱLimbȱDeficiency ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.3ȱ 1.4ȱ–ȱ3.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6ȱ 1.7ȱ–ȱ3.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.8ȱ 1.5ȱ–ȱ4.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.6ȱ 0.7ȱ–ȱ6.7

SkeletalȱDysplasias ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.1ȱ 1.3ȱ–ȱ3.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.4ȱ 0.7ȱ–ȱ2.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.4ȱ 0.5ȱ–ȱ3.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.3ȱ 0.2ȱ–ȱ4.7

Polydactyly ȱȱȱȱȱȱȱȱȱȱȱȱȱ10.4ȱ 8.4ȱ–ȱ12.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ18.7ȱ 16.1ȱ–ȱ21.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱ12.2ȱ 9.1ȱ–ȱ16.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱ11.1ȱ 6.5ȱ–ȱ17.8

[1]ȱDataȱforȱracesȱotherȱthanȱwhite,ȱblackȱorȱAfricanȱAmerican,ȱHispanicȱorȱLatinoȱwereȱcombinedȱdueȱtoȱsmallȱsampleȱsize. [2]ȱConfidenceȱinterval [3]ȱTalipesȱequinovarusȱandȱclubfootȱofȱunspecifiedȱtypeȱwithoutȱaȱneuralȱtubeȱdefect.

Source:ȱCorreaȱA,ȱCraganȱJD,ȱKucikȱJEȱetȱal:ȱReportingȱbirthȱdefectsȱsurveillanceȱdataȱ1968–2003.ȱBirthȱDefectsȱResearchȱAȱClinȱMolȱTeratolȱ 2007;79(2):65–186.

Tableȱ7.5:ȱȱPrevalenceȱofȱCerebralȱPalsyȱAmongȱ ChildrenȱAgedȱ8ȱYearsȱperȱ1,000ȱPopulationȱbyȱSexȱandȱ Race,ȱMetropolitanȱAtlantaȱDevelopmentalȱDisabilitiesȱ SurveillanceȱProgram,ȱAtlanta,ȱGeorgia,ȱ2000

Number Prevalence 95%ȱCIȱ[1] Male White 33 ȱȱȱȱȱȱȱȱȱ3.6ȱ 2.6ȱ–ȱ5.1 Black/AfricanȱAmerican 40 ȱȱȱȱȱȱȱȱȱ4.1ȱ 3.0ȱ–ȱ5.6 Otherȱ[2] 4 ȱȱȱȱȱȱȱȱȱ1.2ȱ 0.5ȱ–ȱ3.3 Total 79 ȱȱȱȱȱȱȱȱȱ3.6ȱ 2.9ȱ–ȱ4.5

Female White 20 ȱȱȱȱȱȱȱȱȱ2.2ȱ 1.4ȱ–ȱ3.5 Black/AfricanȱAmerican 30 ȱȱȱȱȱȱȱȱȱ3.1ȱ 2.2ȱ–ȱ4.5 Otherȱ[2] 6 ȱȱȱȱȱȱȱȱȱ2.0ȱ 0.9ȱ–ȱ4.4 Total 56 ȱȱȱȱȱȱȱȱȱ2.6ȱ 2.0ȱ–ȱ3.4

Total White 53 ȱȱȱȱȱȱȱȱȱ2.9ȱ 2.2ȱ–ȱ3.8 Black/AfricanȱAmerican 70 ȱȱȱȱȱȱȱȱȱ3.6ȱ 2.9ȱ–ȱ4.6 Otherȱ[2] 10 ȱȱȱȱȱȱȱȱȱ1.6ȱ 0.9ȱ–ȱ3.0 TOTALȱ[3] 135 ȱȱȱȱȱȱȱȱȱ3.1ȱ 2.6ȱ–ȱ3.7

[1]ȱConfidenceȱinterval.

[2]ȱDataȱforȱracesȱotherȱthanȱwhiteȱorȱblack/AfricanȱAmericanȱwereȱcombinedȱdueȱtoȱ smallȱsampleȱsize. [3]ȱTotalȱȱincludesȱtwoȱchildrenȱwhoseȱraceȱwasȱnotȱindicated. Source:ȱCentersȱforȱDiseaseȱControlȱandȱPrevention.ȱPrevalenceȱofȱfourȱ developmentalȱdisabilitiesȱamongȱchildrenȱagedȱ8ȱyears,ȱMetropolitanȱAtlantaȱ DevelopmentalȱDisabilitiesȱSurveillanceȱProgram,ȱ1996ȱandȱ2000.ȱ MMWRȱSurveillȱ Summȱ 2006;55:1Ȭ9.

Chapter 8 Neoplasms of Bone and Connective Tissue

Bone and connective tissue neoplasms, which to report all patients with cancer treated at their include bones and joints, myeloma, and soft institution, including annual follow-up data. Site tissues, are rare when compared with other visits and interaction between American College of cancers and with other musculoskeletal Surgeons cancer database personnel and the local conditions, accounting for about 1.9% of annual reporting institutions verifi es a minimum of 90% cancer cases between 2002 and 2006. However, case capture and reporting for each institution. it is estimated that in 2009, 2,570 persons will be Multiple internal checks verify the data accuracy. diagnosed with cancer of the bones and joints, It is estimated the approximately 1,700 reporting with more than one in four diagnoses for children institutions each year treat approximately 75% of and youth under the age of 20. Myeloma, a all patients with malignancies in the United States. malignant tumor of the bone marrow, will be diagnosed in 20,580 persons, while 10,660 men Section 8.1: Incidence of Neoplasms of and women will be diagnosed with soft tissue Bone and Connective Tissue cancers, including the heart. In addition, 1,470 persons will die of cancer of the bone and joints, 10,580 will die of myeloma, and 3,820 of soft tissue Musculoskeletal cancers are classifi ed into bone cancers in 2009. 1 and joint cancers and myeloma. The three most common classifi cations of cancers of bones Data from the Surveillance Epidemiology and and joints are osteosarcoma, Ewing’s sarcoma, End Results (SEER) program of the National and chondrosarcoma. The ages at which these Cancer Institute, used to present the burden of cancers are most prevalent vary. Osteosarcoma, a bone and connective tissue neoplasms, is the most malignant bone tissue tumor, is the most common, comprehensive source of information on cancer occurring most frequently in teens and young incidence, prevalence, mortality, survival, and adults. Ewing’s sarcoma, a tumor oft en located in lifetime risks. Data is currently available from the shaft of long bones and in the pelvic bones, 1974 to 2006. The SEER program is one of the occurs most frequently in children and youth. most comprehensive sources of neoplasm data; it Chondrosarcoma, a sarcoma of malignant cartilage is based on data representing approximately 10% cells, oft en occurs as a secondary cancer by of the U.S. population. In addition, data from the malignant degeneration of pre-existing cartilage American College of Surgeons’ Commission on cells within bone, including chondromas (a benign Cancer National Cancer Data Base (NCDB) was tumor), and is primarily found among older utilized in the analysis of the three main bone adults. However, the vast majority of chondromas sarcomas: osteosarcoma, chondrosarcoma and never undergo malignant change and, therefore, Ewing’s sarcoma. This database is maintained by the routine resection of benign chondromas is the American College of Surgeons and contains unwarranted. Of these three, Ewing’s sarcoma is the same standardized data as that collected generally considered to have the worst prognosis. by the SEER database. Data are collected from By defi nition, all cases of Ewing’s sarcoma are all institutions wishing to be accredited by the high grade, the most aggressive category of cancer, American College of Surgeons Commission on with full potential to metastasize and bring about Cancer. Each accredited institution is required death. Approximately 6% to 20% of osteosarcomas

are of lower grade; chondrosarcoma has a higher Graph 8.1.2: Incidence of Myeloma, by Sex and Race, United States 1996-2006

proportion of low grade cases than the other two 150 Black Females bone and joint cancers. Black Males 120 White Bone cancers are found more frequently in males Females

than females, and more frequently among whites White 90 than those of any other race. However, rates have Males All varied for both genders and by race for the past Persons

decade. (Table 8.1 and Graph 8.1.1) The average Incidence per 1,000,000 Persons 60 annual incidence of bone cancers between 2002

and 2006 was 9 in one million persons; the rate 30 1996 1998 2000 2002 2004 2006

among all males was 10 in one million, while Source: Ries LAG, Harkins D, Krapcho M, et. al. (eds): SEER Cancer Statistics Review, 1975-2004, Overview. Bethesda, MD: National Cancer Institute, 2007. Available at: ĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŚȦ. Accessed June among all females it was 8 in one million. Among 19, 2007. white males, the overall incidence jumped to 11 in Source 2005 data: Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, et. al. (eds). SEER Cancer Statistics Review, 1975-2005, National Cancer Institute. Bethesda, MD, ĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖśȦ, based on November one million persons. The incidence of cancer of the 2007 SEER data submission, posted to the SEER web site, 2008. Accessed December 8, 2009. Source 2006 data: Horner MJ, Ries LAG, Krapcho M, et. al. (eds). SEER Cancer Statistics Review, 1975-2006, bones and joints in the United States is comparable National Cancer Institute. Bethesda, MD,ȱĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŜȦ, based on November 2008 SEER data submission, posted to the SEER web site, 2009. Accessed December 8, 2009. to several site-specifi c oral cancers (i.e., lip, salivary gland, fl oor of the mouth), cancers of the bile duct, was 56 cases in one million persons, an annual cancers of the eye, and Kaposi’s sarcoma, which averaged rate that has been relatively constant for aff ects the skin and mucous membranes and is the past decade. (Table 8.2 and Graph 8.1.2) Again, oft en associated with immunodefi cient individuals males have a higher incidence of myeloma than do with AIDS. females, with an average of 71 cases in one million Graph 8.1.1: Incidence of Cancers of Bones and Joints, by Sex and Race, United States males to 46 cases in one million females. Blacks 1996-2006 13 have a much higher incidence rate of myeloma Hispanic Females than whites. The incidence of myeloma in the

Hispanic United States is comparable to esophageal, liver, 11 Males cervical, ovarian, brain, and lymphocytic leukemia Black Females cancers. 9 Black Males

White The isolated single bone version of myeloma is Females

Incidence per 1,000,000 Persons 7 called plasmacytoma, but virtually all cases of White Males isolated plasmacytoma develop into full-ﬂ edged

5 multiple myeloma over the subsequent 5 to 10 1996 1998 2000 2002 2004 2006 years aft er diagnosis. Source 1995 to 2004 data: Ries LAG, Harkins D, Krapcho M, et. al. (eds): SEER Cancer Statistics Review, 1975-2004, Overview. Bethesda, MD: National Cancer Institute, 2007. Available at: ĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŚȦ. Accessed June 19, 2007.

Source 2005 data: Ries LAG, Melbert D, Krapcho M, et. al. (eds). SEER Cancer Statistics Review, 1975-2005, Although annual rates of cancers of the bones and National Cancer Institute. Bethesda, MD, ĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖśȦ, based on November 2007 SEER data submission, posted to the SEER web site, 2008. Accessed December 8, 2009. joints and myeloma vary somewhat, the overall Source 2006 data: Horner MJ, Ries LAG, Krapcho M, et. al. (eds). SEER Cancer Statistics Review, 1975-2006, National Cancer Institute. Bethesda, MD, ĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŜȦ, based on November 2008 SEER incidence has remained relatively constant since data submission, posted to the SEER web site, 2009. Accessed December 8, 2009. the mid-1970s.2

Myeloma, a malignant primary tumor of the bone With a median age of 39 years at time of diagnosis, marrow that can form in any of the bone-marrow cancers of the bones and joints att ack younger cells and usually involves multiple bones at the patients than most other broad categories of cancer. same time, occurs ﬁ ve to six times as frequently as (Table 8.3) Males are typically diagnosed with bone cancers. It occurs most frequently in adults bone cancers several years younger than females. between the ages of 50 and 70. The average annual Myeloma, on the other hand, is primarily a cancer incidence of myeloma between 2002 and 2006

Graph 8.2.1: Age-Adjusted 5-Year Relative Cancer Survival Rates by Sex, The overall 5-year relative survival rate for United States 1999-2005 bones and joints cancers has been 68% for the Male Genital System last few years, and is comparable to a number Endocrine System Skin (excl basal and squam) of more common cancers such as lymphoma, Breast (incl breast in situ) Lymphoma (Hodgkin) urinary, cervical/ovarian, and soft tissue Urinary System cancers. (Table 8.4 and Graph 8.2.1) The annual Female Genital System Bones & Joints population-based mortality rate of myeloma ĞȱȱǻȱǼ Lymphoma (Non-Hodgkin) was an average of 36 persons per one million Oral Cavity & Pharynx population between 2002 and 2006.1 The Kaposi Sarcoma Leukemia mortality rate from myeloma has remained Digestive system 1 Brain & Nervous System relatively constant since the mid-1970s. The Myeloma (bone marrow) 5-year survival rate for myeloma, 34%, is one of Respiratory System the lowest for all cancers. All Sites 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 5-Year Survival Rate Section 8.3: Bone and Joint Cancer [1] Age-adjusted to the U.S. Standard Population (19 age groups - Census P25-1130) Among Children and Young Adults Source: Horner MJ, Ries LAG, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2006, National ȱ ǯȱǰȱǯȱȱ ȬŚȱȬȱ Ȭ ȱȱ ȱȱǯǯȱ ȱȱȱśȬȱ ȱ ȱȱ¢ȱ¢ȱȱǰȱ¡ȱȱȱǯȱ Available at: ĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŜȦȏȦȱȏǯ, based on November 2008 SEER data submission, posted to the SEER web site, 2009. Accessed December 8, 2009. While myeloma is primarily a cancer of middle found among elderly persons, with a median age aged to older adults, cancers of bones and of 70 at the time of diagnosis. Again, males are joints are found among persons under the age typically diagnosed with myeloma at ages several of 30 in higher proportion than expected for the years younger than females. overall incidence. In 2002-2006, 45% of bone and joint cancers were diagnosed in persons under the age of 35, with more than 29% occurring among Section 8.2: Mortality and Survival children and adolescents under the age of 20. This Rates for Neoplasms of Bones and Connective Tissue Graph 8.3.1: Age Distribution for Musculoskeletal Neoplasms at Time of Diagnosis, United States 2002-2006

30%

Annual population-based mortality rates due to 25%

cancers of bones and joints are low, averaging 20%

four deaths per one million persons per year 15% between 2002 and 2006.1 Over the past 35 years, 10% the mortality rate from bone and joint cancer 5%

dropped by approximately 50% from that of the ȱȱȱ ȱȱ 1 0% late 1970s. However, there has been no signiﬁ cant < 20 20-34 35-44 45-54 55-64 65-74 75-84 85+ improvement over the past 20 years.3 Males ȱȱȱȱ Bones & Myeloma Ğȱ All have a higher mortality rate than females for all Joints (bone marrow) (incl heart) Sites races. The overall 5-year survival rate is 54% for ǽŗǾȱȬȱȱȱǯǯȱȱȱǻŗşȱȱȱȬȱȱŘśȬŗŗřŖǼ Ǳȱ ȱ ǰȱȱ ǰȱ ȱǰȱȱȱǻǼǯȱȱȱȱ ǰȱŗşŝśȬŘŖŖŜǰȱȱȱ osteosarcoma, 75% for chondrosarcoma, and 51% ǯȱǰȱǰȱĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŜȦǰȱȱȱȱŘŖŖŞȱȱȱǰȱ ȱȱȱȱ ȱǰȱŘŖŖşǯȱȱȱŞǰȱŘŖŖşǯ for Ewing’s sarcoma. The osteosarcoma survival rate varies with age: 5-year survival was 60% for persons under 30 years of age, 50% for those aged compares to less than 4% of all cancer sites in 30 to 49, and 30% for those 50 years old and older.3 persons aged 35 and younger, and only 1% in those younger than 20 years. (Table 8.5 and Graph 8.3.1)

Graph 8.3.2: Age Distribution for Musculoskeletal Neoplasms at Time of Death, During the time period 2000-2003, osteosarcoma United States 2002-2006

35% accounted for 59% of the malignant bone tumors

30% diagnosed in persons under the age of 20, with

25% 46% of osteosarcoma diagnoses occurring in

20% persons younger than 20 years of age. The majority

15% of the remaining tumors in the age 20 and under

10% group were Ewing’s sarcoma (31%, accounting for

5% 66% of Ewing’s sarcoma diagnoses.) In the young ȱȱȱ ȱȱ

0% adult population (aged 20 to 34 years) diagnosed ǀȱŘŖ 20-34 35-44 ȱŚśȬśŚȱ 55-64 65-74 75-84 85+ ȱȱȱȱ with malignant bone tumors, chondrosarcoma ȱǭ ¢ Ğȱ All accounted for 37% and osteosarcoma for 36%, Joints ǻȱ Ǽ ǻȱǼ Sites

ǽŗǾȱȬȱȱȱǯǯȱȱȱǻŗşȱȱȱȬȱȱŘśȬŗŗřŖǼ Ewing’s sarcoma was diagnosed 17% of the Ǳȱ ȱ ǰȱȱ ǰȱ ȱǰȱȱȱǻǼǯȱȱȱȱ ǰȱŗşŝśȬŘŖŖŜǰȱȱȱ time; this represented 16%, 17%, and 21% of all ǯȱǰȱǰȱĴǱȦȦǯǯȦȦŗşŝśȏŘŖŖŜȦǰȱȱȱȱŘŖŖŞȱȱȱǰȱ ȱȱȱȱ ȱǰȱŘŖŖşǯȱȱȱŞǰȱŘŖŖşǯ diagnoses for these tumors, respectively. (Table 8.7 and Graph 8.3.3) Deaths from bone and joint cancer follow a similar patt ern. (Table 8.6 and Graph 8.3.2) Between 2002 The overall incidence of malignant bone tumors and 2006, 15% of deaths from bone and joint cancer from 1975 to 2000 in persons under the age of 30 occurred in children and youth under the age of peaked between the ages of 15-19 years and 10-14 20, and an additional 14% among young adults years at 14.8 aged 20 to 34. The mortality rate among younger and 13.1 Graph 8.3.4: Malignant Bone Tumors in Persons Younger persons from bone and joint cancer comprises only than 30 Years of Age, United States, 1975-2000 per million 15 0.12% of deaths from all types of cancer, but is 9% persons, of cancer deaths in persons under the age of 20 and respectively. 12 2.5% of deaths among young persons aged 20 to 34 The years. The relative proportion of deaths from bones 9 incidence of and joints cancer was higher in children, youth, osteosarcoma 6 and young adults than all other cancer types peaks in that disproportionately aﬀ ect younger people, 3 these ages at

including brain and nervous system, leukemia and Annual Incidence per Million (1975-2000) Average 8.2 and 7.6 0 soft tissue cancers. <5 5-9 10-14 15-19 20-24 25-29 per million, Source: Mascarenhas L, Siegel S, Spector All Malignant L, et. al.: Malignant Bone Tumors, in Bone Tumors Bleyer A, O'Leary M, Barr R, Ries LAG respectively, (eds.): Cancer Epidemiology in Older Osteosarcoma Adolescents and Young Adults 15 to 29 Graph 8.3.3: Distribution of Malignant Bone Tumors by Type and Age, United States while Ewing’s Years of Age, Including SEER Incidence and Chondrosarcoma Survival: 1975-2000. Bethesda, MD: 2000-2003 National Cancer Institute, NIH Pub. No. Ewing's Sarcoma sarcoma 06-5767, p 101. 80% peaks at 70%

60% 4.6 and 4.3,

50% respectively. (Graph 8.3.4)

40% 30% The high incidence and mortality rate of bone 20%

Proportion Diagnoses by Type cancers among children, youth, and young adults 10% creates a signifi cant burden on the productivity 0% under 20 20 to 34 35 to 54 55 to 74 75 and and life of future generations. Apart from the over Age at Time of Disgnosis fi nancial costs, emotional toil, and lost lives from Osteosarcoma Ewing's sarcoma the initial treatments, survivors carry signifi cant ȱȱę Chrondosarcoma bone tumors functional burdens and continuing care costs. Source: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov): Public-Use At least 75% of surviving bone and joint cancer Data (1973-2003). National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2006, based on the November 2005 submission. Accessed: March 19, 2007. patients are treated with limb salvaging surgery.

These surgeries most oft en require implantation trunk (15% to 20%), head and neck area (8% to of massive bone-replacing endoprostheses 10%), internal organs, or the retroperitoneum or that have limited life span and compromised back of the abdominal cavity (15%).5 function, requiring periodic surveillance and revision surgery to repair or replace worn parts. In terms of case numbers, the musculoskeletal The amputated survivors will require prosthetic health burden in the United States from soft tissue limbs, the function of which is clearly limiting in sarcomas is two to three times greater than that of comparison to normal activity. Both procedures bone and joint sarcomas. For the period 2002-2006, are expensive, with cost estimates of $25,000 per the annual average number of soft tissue year for replacement of an amputated limb in an neoplasms, including the heart, approximately active 20 to 30 year old man in 1997 dollars, and 11,700 cases were reported in the SEER database.6 estimates of $23,500 for implant, rehabilitation, Soft tissue sarcomas come in a wide variety of monitoring, and replacement with limb salvaging forms which aff ect diff erent age groups, but the endoprothesis.4 Due to chronic pain and overall most frequently encountered soft tissue sarcomas dysfunction, a large number of such survivors will aff ect older adults. end up on disability, requiring public support for the majority of their adult lifetime. As previously noted, the National Cancer Data Base (NCDB), a joint program of the Commission Section 8.4: Economic Cost of on Cancer and the American College of Surgeons, Malignant Bone Tumors maintains the most thorough database on the prevalence of soft tissue sarcomas. Although the NCDB was not created to serve as an incidence- Information on insurance coverage at time of based registry, it currently gathers data on treatment was only available for roughly one-third approximately 75% of the cancers treated in the of patients (8,342) and the patt erns of coverage United States. It should be noted this percentage were similar between osteosarcoma and Ewing’s varies from year to year based on the participation sarcoma. For chondrosarcoma, due to the older and reporting by hospitals to this voluntary mean age of the patients, relatively more patients database. were covered by Medicare (8.6%) or Medicare with supplement (16.7%). At the time of diagnosis, Over the past 20 years, 86,355 soft tissue sarcomas insurance coverage was most commonly through of the extremities, shoulders and pelvic girdles and managed care (38.5%) for all groups. Private trunk have been treated. This number excludes insurance was the next most common recorded approximately 32,250 soft tissue sarcomas of insurance coverage (27.4%), followed by Medicare the head and neck, thoracic, and abdominal with supplement (10%), although the majority of areas; these patients are generally cared for by those patients had chondrosarcoma. Only 0.3% of non-musculoskeletal specialists. Using a 20-year patients overall were covered by Medicaid. average and assuming 75% of annual cases are included in NCDB, over 5,700 cases of soft tissue Section 8.5: Soft Tissue Sarcomas sarcoma have been reported annually.

In 2006, soft tissue sarcomas, including those of Soft tissue sarcomas are malignant (cancerous) the head, neck, thoracic, and abdominal areas, tumors that develop in any part of the body, reported by NCDB was 7,200 cases, representing including fat, muscle, nerve, ﬁ brous tissues approximately 0.7% of all cancer cases. These surrounding joints, blood vessel, or deep skin numbers are comparable to the annual average tissues. Approximately 55% to 60% of sarcomas reported for the years 2000 to 2004.7 This compares develop in the arms or legs; the rest begin in the to 2,070 cases reported for 2006 by NCDB and an

average of 2,700 cases of bone and joint sarcomas and 54% for unstaged sarcomas. The 10-year between 2000 and 2004, representing 0.2% of all relative survival rate is only slightly worse for cancer cases. (Table 8.8) these stages, meaning that most people who survive 5 years are cured.9 In 2009, it is expected about 10,660 new soft tissue sarcomas will have been diagnosed in the United Using the staging criteria of soft tissue sarcomas of States. Of these, 5,780 cases will be diagnosed the American Joint Committ ee on Cancer (AJCC) in males, and 4,880 cases will be diagnosed produces similar results for sarcomas found in in females. During 2009, it is expected 3,8200 the limbs (arms or legs): 90% 5-year survival rate Americans will die of soft tissue sarcomas. These for stage 1 sarcomas; 81% for stage 2; and 56% for statistics include both adults and children.8 stage 3. Sarcomas identiﬁ ed as stage 4 have a very low 5-year survival rate. Sarcomas located in other 9 Section 8.5.1: Soft Tissue Sarcoma Survival Rates than a limb also have lower survival rates.

Graph 8.5.1: Site by Stage Distribution of Cases Reported to the National For high-grade soft tissue sarcomas, Caner Data ase for op 5 Caner Sitesǰ SoĞ issue Caners and one and the most important prognostic factor Joint Cancers, Diagnosis Year 2006 100% is the stage at which the tumor Stage IV is identiﬁ ed. Staging criteria for soft tissue sarcomas are primarily 80% Stage III determined by whether the Stage II 60% tumor has metastasized or spread Stage I

elsewhere in the body. Size is highly 40% correlated with risk of metastasis Stage 0 % of Known Stage Cases and survival. In general, the 20% prognosis for a soft tissue sarcoma is poorer if the sarcoma is large. 0% Breast Prostate Lung Colon Bladder SoĞ Bones All Cancer As a general rule, high-grade soft Tissue & Joints Cases tissue sarcomas over 10 centimeters Cancer Site Source: National Cancer Data Base (NCDB): Site by Stage Distribution of Cases Reported to the in diameter have an approximate NCDB: Diagnosis Year 2006. American College of Surgeons Commission on Cancer. Available at: 50% mortality rate and those over hĴp:ȦȦwww.facs.orgȦcancerȦncdbȦsiteȏstageȏ2006.htm. Accessed December 10, 2009. 15 centimeters in diameter have an approximate 75% mortality rate. Comparing soft tissue sarcomas by stage to the most common types of cancer shows a relatively The National Cancer Institute (NCI) has reported high proportion of cases that are not identifi ed the overall 5-year relative survival of people with until stage 3 or stage 4. (Table 8.8 and Graph 8.5.1) sarcomas is approximately 66%. The NCI statistics staging classifi cation of sarcomas is (1) confi ned Section 8.5.2: Types of Soft Tissue Sarcoma to the primary site (localized—54% of sarcomas are diagnosed at this stage), (2) spread to regional There are multiple soft tissue sarcomas with lymph nodes or directly beyond the primary site varying degrees of aggressive behavior (Table 8.9), (regional—22%), or (3) metastasized (distant— but virtually all have the capacity to metastasize 15%). For the remaining cases, the staging and cause death. Treatment for high-grade soft information was unknown. The corresponding tissue sarcomas is typically resection (removal) 5-year relative survival rates reported are 84% and radiation. Chemotherapy is playing an for localized sarcomas; 62% for regional stage ever-increasing role, especially in high-grade and sarcomas; 16% for sarcomas with distant spread; metastatic cases.

The most commonly encountered soft tissue Section 8.6: Benign Bone Tumors sarcoma is malignant fi brous histiocytoma, a tumor of the fi brous tissue most oft en occurring in the arms or legs. The least diff erentiated of the In addition to the burden of malignant bone and sarcomas, in many cases it represents a poorly soft tissue tumors, a plethora of benign tumors defi ned, high-grade soft tissue sarcoma that cannot and tumor-like conditions disable thousands of be further defi ned pathologically (histologically). Americans annually. (Table 8.10) No national A recent trend is to classify these poorly databases on which to base estimates of the diff erentiated sarcomas as pleomorphic sarcomas prevalence or incidence of such tumors exist. The or spindle cell sarcomas “not otherwise specifi ed, relative frequency of more common benign bone (NOS).“ Poorly diff erentiated sarcomas typically tumors can be discerned from prior publications aff ect older individuals. and extrapolation from the primary contributor’s ongoing case registry of consecutive surgical The next most commonly reported soft tissue cases treated between 1991 through 2004. Table sarcoma is liposarcoma, malignant tumors of the 8.11 refl ects the collected experience reported fat tissues. This sarcoma also is more common in in the Mayo Clinic publication of 1986, the older persons. There are several subtypes ranging University of Florida publication from 1983, the J. from the low-grade lipoma-like liposarcoma that Mirra experience reported in 1989, and the most rarely metastasizes to the high-grade pleomorphic recent updated case series refl ecting the practice liposarcoma and round cell liposarcoma, which of William G. Ward, a full-time orthopaedic have a prognosis similar to malignant fi brous oncologist in practice from 1991 to 2004 at Wake histiocytoma. Forest University Health Sciences in Winston- Salem, NC. The third most commonly encountered soft tissue sarcoma is synovial sarcoma, which is more It is believed that the experience of Dr. Ward, likely to aff ect younger adults than previously one of few orthopaedic oncologists in the state of mentioned sarcomas. Many of these cases respond North Carolina, is refl ective of the current general very favorably to chemotherapy with signifi cant prevalence of bone and soft tissue tumors as he shrinkage of the tumor, although resection and treats a wide variety of benign and malignant bone radiation remain the cornerstones of current tumors in a broad referral practice. All cases in therapy. The prognosis is similar to malignant his case registry refl ect recently treated patients, fi brous histiocytoma and the other high-grade soft i.e., none were “consult cases” in which only tissue sarcomas mentioned above. radiographs or pathology slides were reviewed for outside consulting physicians, such as the Rhabdomyosarcomas are primarily tumors of Mayo and Mirra series included. The earlier children. Clinically and behaviorally they are data sets were accumulated during time periods in a class by themselves. These are treated with prior to the full development of the subspecialty aggressive chemotherapy, as well as surgery of orthopaedic oncology; thus, only the more and/or radiation in many cases. The aggressive unusual cases of bone tumors were referred treatments oft en cause permanent life-altering to major medical centers, making estimates of disability, even in survivors. their incidence less reliable. It is believed that, except for bone cysts, few bone tumors have been treated by general orthopaedic surgeons or other musculoskeletal specialists in North Carolina over the past 15 years, as most are referred to orthopaedic oncologists. Practical experience has confi rmed that osteosarcoma is the least likely

sarcoma to be treated by anyone other than an are treated by other orthopaedic surgeons. The orthopaedic oncologist. Dr. Ward and a few other true incidence, therefore, is probably signifi cantly orthopaedic oncologists have treated nearly all higher than that estimated by extrapolation from patients with an osteosarcoma in North Carolina Dr. Ward’s practice experience. These cystic lesions for the past 15 years. Very few benign bone cause weakening of the bone and oft en require tumors have been treated by general orthopaedic multiple surgeries to rebuild the bone with bone surgeons. Thus, comparing the cases of benign graft s, injections, and other techniques. They occur bone tumors relative to the cases of osteosarcoma in children and typically recur multiple times until treated by Dr. Ward provides a relative index skeletal maturity is achieved. useful in generating a broad estimate of the prevalence of these tumors. By comparing this Giant cell tumor of bone, with an estimated estimate with the national estimate for the annual annual prevalence of >750 cases, is the third occurrence of osteosarcoma, the most commonly most commonly encountered benign bone encountered primary sarcoma of bone, a rough neoplasm, and accounts for signifi cant disability estimate of the prevalence of these benign bone and dysfunction. This bone-destroying tumor tumor diseases can be calculated. typically occurs near the end of the long bones, most commonly the lower femur or upper tibia, The most commonly encountered benign and causes destruction of the bone. The tumor may tumor of bone is osteochondroma, estimated extend through the cortex of the bone into the soft to have an annual prevalence of >1,500 cases. tissues and, if large enough, prior to treatment Osteochondroma typically arises near the long can be associated with pathologic fracture of the ends of bones. Osteochondromas are oft en painful involved bone. Smaller tumors can be treated with due to formation of bursa overlying the lesion, resection and reconstruction of the bone with bone interference with neurovascular function due to graft or cement fi ller. More complicated cases tenting of such structures over the osteochondroma require sophisticated reconstruction with massive surface, and the potential for deformity in the joint replacements and/or massive allograft s and involved and/or adjacent bones. Long-term can cause severe long-term disability. On rare complications are uncommon except for rare occasions, giant cell tumors can metastasize to cases of dediff erentiation into a chondrosarcoma. the lungs. In such cases, they typically respond There is no estimate of the number of patients seen poorly to chemotherapy and may cause death. with non-operatively managed osteochondroma, These tumors are infrequently treated by general as records are kept only for surgically treated orthopaedic surgeons. cases managed by Dr. Ward. The prevalence of osteochondroma, thus, is an estimate of only those A fourth commonly encountered tumor that cases requiring surgery. The estimate is further requires surgery is enchondroma, estimated at underestimated due to the fact that some general more than 725 annual cases. Bones typically form orthopaedic surgeons provide surgical treatment as cartilage models in embryos that ultimately of osteochondromas. convert into bone structure. The cartilage-based growth plates add length to the bones from bone The second most commonly encountered benign growth. Enchondromas are basically tumors bone lesions are unicameral bone cysts, with an derived from these cartilaginous tissues that estimated annual prevalence of >1,250 cases. The abnormally remain in the skeleton as remnants etiology of these fl uid-fi lled bone cysts, usually from the normal patt ern of maturation and found in the growing ends of children’s long bones development. If these achieve suffi cient size, they such as the proximal humerus or femur, is unclear. can cause pain or bony erosion and may present Because they never metastasize and are usually diagnostic challenges requiring biopsy. They oft en quite characteristic on radiographs, many of these require treatment by curett age and bone graft ing.

These lesions can dediff erentiate into malignant or chondroblastomas with curett age, resection and cartilage tumors, called chondrosarcomas. Many bone graft ing. Most cause some degree of disability small enchondromas are seen incidentally, cause and dysfunction of the involved extremity. no symptoms, and are treated with simple observation. Only the surgically treated cases were Section 8.7: Benign Soft Tissue Tumors recorded in Dr. Ward’s series, so the total incidence of enchondromas is much higher than that shown. The burden of enchondromas requiring surgical As with the benign bone tumors, there is no treatment is fairly accurately and conservatively national registry of benign soft tissue tumors. By estimated. comparing Dr. Ward’s 13 years of practice history from 1991 to 2004, and computing an incidence There are multiple other benign tumors that are index relative to that of osteosarcoma, some even less commonly encountered. Aneurysmal estimate of the prevalence of surgically treated bone cysts (ABCs) are more aggressive forms lesions may be obtained. (Table 8.12) From this of cystic lesions similar to unicameral bone index estimate, a baseline estimate of the national cysts. However, ABCs are more destructive, incidence can be calculated. However, benign expanding the weakened bone and causing soft tissue tumors are the most likely category greater bone destruction. They tend to be fi lled of tumors to be treated by other surgeons, such with blood and tissue, not simple fl uid. They as general orthopaedic surgeons and general usually respond favorably to curett age and surgeons; therefore, this national estimate is bone graft ing, but recur in at least 20% of cases. extremely conservative. The prevalence and Metaphyseal fi brous defects are defi ciencies in burden in the United States from benign soft tissue normal bone formation within the various bones tumors is signifi cantly higher than estimated that occur in 2% to 3% of children. Most resolve herein. without ever causing symptoms and may never even be detected, but many require surgery, The majority of benign soft tissue tumors such as bone graft ing, to prevent fracture and/ cause local growth and may require resection. or surgery to treat completed fractures that have Benign lesions rarely cause death, and it is occurred. Osteoid osteoma is a small tumor quite infrequent that an amputation is required. typically occurring in children that is associated However, depending on the site of involvement with severe unrelenting night pain. It usually and size of the lesion, signifi cant disability of the requires resection and may require bone graft ing. involved extremity and/or joint can occur. The true When located in the spine it can cause a painful cost of these otherwise benign neoplasms can be scoliosis. More recently, successful treatment quite high in terms of healthcare costs, lost work with radio-frequency ablation procedures under time, morbidity, emotional cost, and disability radiographic guidance has become the treatment expenses. of choice for accessible lesions. Chondroblastoma is an unusual neoplasm that occurs in the ends A summary of “Neoplasms of the Bones & Joints of growing bones in teenagers and young adults. and Soft Tissues, 20-Year Cumulative Case Counts, This requires resection of the lesion and bone 1985-2004, National Cancer Data Base of the graft ing. If untreated, it can cause collapse and American College of Surgeons Commission on degenerative arthritis in the associated joint and Cancer” is shown in Table 8.13. on rare occasion can metastasize to the lung. These usually are referred to orthopaedic oncologists. Numerous other less common benign bone tumors oft en are treated similar to giant cell tumors, ABCs,

1. Horner MJ, Ries LAG, Krapcho M, et. al. (eds). SEER 6. Horner MJ, Ries LAG, Krapcho M, et. al. (eds). SEER Cancer Statistics Review, 1975-2006, National Cancer Cancer Statistics Review, 1975-2006, National Cancer Institute. Bethesda, MD, htt p://seer.cancer.gov/ Institute. Bethesda, MD, htt p://seer.cancer.gov/ csr/1975_2006/, based on November 2008 SEER data csr/1975_2006/, based on November 2008 SEER data submission, posted to the SEER web site, 2009. Accessed submission, posted to the SEER web site, 2009. Accessed December 8, 2009. December 8, 2009.

2. Praemer A Furner S, Rice DP: Musculoskeletal Conditions in 7. National Cancer Data Base (NCDB): Site by Stage the United States. ed 2. Rosemont, IL: American Academy of Distribution of Cases Reported to the NCDB: Diagnosis Year Orthopaedic Surgeons, 1999, p 182. 2000 to 2004. Chicago, IL: American College of Surgeons Commission on Cancer. Available at: htt p://www.facs.org/ 3. Damron TA, Ward WG, Stewart A: Osteosarcoma, cancer/ncdb/publicaccess.html. Accessed October 10, 2007. chondrosarcoma and Ewing’s sarcoma: National Cancer Center Data Base Report. Clin Orthop Relat Res 2007;459:40- 8. Horner MJ, Ries LAG, Krapcho M, et. al. (eds). SEER 47. Cancer Statistics Review, 1975-2006, National Cancer Institute. Bethesda, MD, htt p://seer.cancer.gov/ 4. Grimer RJ, Carter SR, Pynsent PB: The cost-eﬀ ectiveness of csr/1975_2006/, based on November 2008 SEER data limb salvage bone tumors. J Bone Joint Surg Br 1997;79:558- submission, posted to the SEER web site, 2009. Accessed 561. December 8, 2009.

5. National Cancer Society (NCS): What Is a Soft Tissue 9. National Cancer Society (NCS): How Are Soft Tissue Sarcoma? Available at: htt p://www.cancer.org/docroot/cri/ Sarcomas Staged? Available at: htt p://www.cancer.org/ content/cri_2_4_1x_what_is_sarcoma_38.asp?sitearea=cri. docroot/CRI/content/CRI_2_4_3X_How_is_sarcoma_ Accessed October 10, 2007. staged_38.asp?rnav=cri. Accessed October 10, 2007.

Section 8.8: Neoplasms of Bone and Connective Tissue Data Tables

Tableȱ8.1:ȱIncidenceȱofȱCancerȱofȱBonesȱandȱJointsȱbyȱSexȱandȱRace,ȱUnitedȱStatesȱ1995Ȭ2006

Incidenceȱperȱ1,000,000ȱPersons AmericanȱIndian/ȱ AsianȱorȱPacificȱ Allȱ White Black Hispanic AlaskaȱNative Islander Yearȱ Persons Males Females Males Females Males Females Males Females Males Females 1995ȱȱȱȱȱȱȱȱȱ 11.6 ȱȱȱȱȱȱȱȱȱȱȱ7.8 ȱȱȱȱȱȱȱȱȱ10.2 ȱȱȱȱȱȱȱȱȱȱȱ6.8 ȱȱȱȱȱȱȱȱȱȱȱ9.6 ȱȱȱȱȱȱȱȱȱȱȱ8.9 ȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱ9.5 ȱȱȱȱȱȱȱȱȱȱȱ4.1 1996ȱȱȱȱȱȱȱȱȱ 10.9 ȱȱȱȱȱȱȱȱȱȱȱ7.5 ȱȱȱȱȱȱȱȱȱ11.2 ȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱȱȱ7.3 ȱȱȱȱȱȱȱȱȱȱȱ6.5 ȱȱȱȱȱȱȱȱȱȱȱ5.0 ȱȱȱȱȱȱȱȱȱ30.7 ȱȱȱȱȱȱȱȱȱȱȱ6.3 ȱȱȱȱȱȱȱȱȱȱȱ4.1 1997ȱȱȱȱȱȱȱȱȱ 11.5 ȱȱȱȱȱȱȱȱȱȱȱ9.3 ȱȱȱȱȱȱȱȱȱȱȱ9.9 ȱȱȱȱȱȱȱȱȱȱȱ5.6 ȱȱȱȱȱȱȱȱȱȱȱ7.5 ȱȱȱȱȱȱȱȱȱȱȱ7.3 ȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱ20.0 ȱȱȱȱȱȱȱȱȱȱȱ8.4 ȱȱȱȱȱȱȱȱȱȱȱ4.2 1998ȱȱȱȱȱȱȱȱȱ 10.6 ȱȱȱȱȱȱȱȱȱȱȱ8.1 ȱȱȱȱȱȱȱȱȱȱȱ6.7 ȱȱȱȱȱȱȱȱȱȱȱ7.4 ȱȱȱȱȱȱȱȱȱȱȱ7.7 ȱȱȱȱȱȱȱȱȱȱȱ7.0 ȱȱȱȱȱȱȱȱȱȱȱ4.8 ȱȱȱȱȱȱȱȱȱȱȱ3.6 ȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱȱȱ5.8 1999ȱȱȱȱȱȱȱȱȱ 10.4 ȱȱȱȱȱȱȱȱȱȱȱ8.2 ȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱȱȱ5.5 ȱȱȱȱȱȱȱȱȱȱȱ8.7 ȱȱȱȱȱȱȱȱȱȱȱ7.3 ȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱ Ȭ ȱȱȱȱȱȱȱȱȱȱȱ6.8 ȱȱȱȱȱȱȱȱȱȱȱ2.8 2000ȱȱȱȱȱȱȱȱȱ 10.4 ȱȱȱȱȱȱȱȱȱȱȱ8.3 ȱȱȱȱȱȱȱȱȱȱȱ9.3 ȱȱȱȱȱȱȱȱȱȱȱ5.6 ȱȱȱȱȱȱȱȱȱ10.1 ȱȱȱȱȱȱȱȱȱȱȱ9.4 ȱȱȱȱȱȱȱȱȱ27.1 ȱȱȱȱȱȱȱȱȱȱȱ6.7 ȱȱȱȱȱȱȱȱȱȱȱ8.5 ȱȱȱȱȱȱȱȱȱȱȱ7.7 2001ȱȱȱȱȱȱȱȱȱ 11.8 ȱȱȱȱȱȱȱȱȱȱȱ8.3 ȱȱȱȱȱȱȱȱȱȱȱ7.3 ȱȱȱȱȱȱȱȱȱȱȱ5.9 ȱȱȱȱȱȱȱȱȱ10.0 ȱȱȱȱȱȱȱȱȱȱȱ7.9 ȱȱȱȱȱȱȱȱȱȱȱ4.1 ȱȱȱȱȱȱȱȱȱ13.4 ȱȱȱȱȱȱȱȱȱȱȱ6.8 ȱȱȱȱȱȱȱȱȱȱȱ2.5 2002ȱȱȱȱȱȱȱȱȱ 11.6 ȱȱȱȱȱȱȱȱȱȱȱ8.2 ȱȱȱȱȱȱȱȱȱ12.1 ȱȱȱȱȱȱȱȱȱȱȱ6.7 ȱȱȱȱȱȱȱȱȱ10.6 ȱȱȱȱȱȱȱȱȱȱȱ6.2 ȱȱȱȱȱȱȱȱȱ15.6 ȱȱȱȱȱȱȱȱȱȱȱ6.6 ȱȱȱȱȱȱȱȱȱȱȱ6.4 ȱȱȱȱȱȱȱȱȱȱȱ7.5 2003ȱȱȱȱȱȱȱȱȱȱȱ 9.0 ȱȱȱȱȱȱȱȱȱ10.6 ȱȱȱȱȱȱȱȱȱȱȱ8.1 ȱȱȱȱȱȱȱȱȱȱȱ7.9 ȱȱȱȱȱȱȱȱȱȱȱ6.6 ȱȱȱȱȱȱȱȱȱ10.1 ȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱ15.7 ȱȱȱȱȱȱȱȱȱȱȱ2.6 ȱȱȱȱȱȱȱȱȱȱȱ6.9 ȱȱȱȱȱȱȱȱȱȱȱ7.1 2004ȱȱȱȱȱȱȱȱȱȱȱ 9.0 ȱȱȱȱȱȱȱȱȱȱȱ9.7 ȱȱȱȱȱȱȱȱȱȱȱ8.2 ȱȱȱȱȱȱȱȱȱȱȱ5.8 ȱȱȱȱȱȱȱȱȱȱȱ7.7 ȱȱȱȱȱȱȱȱȱȱȱ7.0 ȱȱȱȱȱȱȱȱȱȱȱ8.5 ȱȱȱȱȱȱȱȱȱȱȱ2.3 ȱȱȱȱȱȱȱȱȱȱȱ2.3 ȱȱȱȱȱȱȱȱȱȱȱ6.4 ȱȱȱȱȱȱȱȱȱȱȱ2.7 (basedȱonȱ5Ȭyearȱaverageȱforȱ2005ȱ&ȱ2006) 2005ȱȱȱȱȱȱȱȱȱȱȱ 9.0 ȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱȱȱ7.0 NA NA NA NA NA NA 2006ȱȱȱȱȱȱȱȱȱȱȱ 9.0 ȱȱȱȱȱȱȱȱȱ11.0 ȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱȱȱ8.0 ȱȱȱȱȱȱȱȱȱȱȱ7.0 ȱȱȱȱȱȱȱȱȱȱȱ9.0 ȱȱȱȱȱȱȱȱȱȱȱ7.0 NA NAȱȱȱȱȱȱȱȱȱȱȱ 6.0 ȱȱȱȱȱȱȱȱȱȱȱ6.0

Sourceȱ1995ȱtoȱ2004ȱdata:ȱRiesȱLAG,ȱHarkinsȱD,ȱKrapchoȱM,ȱet.ȱal.ȱ(eds):ȱSEERȱCancerȱStatisticsȱReview,ȱ1975Ȭ2004,ȱOvervie w.ȱBethesda,ȱMD:ȱ NationalȱCancerȱInstitute,ȱ2007.ȱAvailableȱat:ȱhttp://seer.cancer.gov/csr/1975_2004/.ȱAccessedȱJuneȱ19,ȱ2007.

Sourceȱ2005ȱdata:ȱRiesȱLAG,ȱMelbertȱD,ȱKrapchoȱM,ȱet.ȱal.ȱ(eds).ȱSEERȱCancerȱStatisticsȱReview,ȱ1975Ȭ2005,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱ MD,ȱhttp://seer.cancer.gov/csr/1975_2005/,ȱbasedȱonȱNovemberȱ2007ȱSEERȱdataȱsubmission,ȱpostedȱtoȱtheȱSEERȱwebȱsite,ȱ2008.ȱAccessedȱ Decemberȱ8,ȱ2009.

Sourceȱ2006ȱdata:ȱHornerȱMJ,ȱRiesȱLAG,ȱKrapchoȱM,ȱet.ȱal.ȱ(eds).ȱSEERȱCancerȱStatisticsȱReview,ȱ1975Ȭ2006,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱ MD,ȱhttp://seer.cancer.gov/csr/1975_2006/,ȱbasedȱonȱNovemberȱ2008ȱSEERȱdataȱsubmission,ȱpostedȱtoȱtheȱSEERȱwebȱsite,ȱ2009.ȱAccessedȱ Decemberȱ8,ȱ2009.

Tableȱ8.2:ȱIncidenceȱofȱMyelomaȱbyȱSexȱandȱRace,ȱ UnitedȱStatesȱ1995Ȭ2006

Incidenceȱperȱ1,000,000ȱPersons White Black

Year AllȱPersons Males Females Males Females 1995ȱȱȱȱȱȱȱȱȱȱȱ 57.0 ȱȱȱȱȱȱȱȱȱȱȱ67.0 ȱȱȱȱȱȱȱȱȱȱȱ43.0 ȱȱȱȱȱȱȱȱȱ150.0 ȱȱȱȱȱȱȱȱȱ101.0 1996ȱȱȱȱȱȱȱȱȱȱȱ 58.0 ȱȱȱȱȱȱȱȱȱȱȱ68.0 ȱȱȱȱȱȱȱȱȱȱȱ43.0 ȱȱȱȱȱȱȱȱȱ134.0 ȱȱȱȱȱȱȱȱȱ119.0 1997ȱȱȱȱȱȱȱȱȱȱȱ 61.0 ȱȱȱȱȱȱȱȱȱȱȱ70.0 ȱȱȱȱȱȱȱȱȱȱȱ47.0 ȱȱȱȱȱȱȱȱȱ142.0 ȱȱȱȱȱȱȱȱȱ118.0 1998ȱȱȱȱȱȱȱȱȱȱȱ 59.0 ȱȱȱȱȱȱȱȱȱȱȱ70.0 ȱȱȱȱȱȱȱȱȱȱȱ44.0 ȱȱȱȱȱȱȱȱȱ129.0 ȱȱȱȱȱȱȱȱȱ105.0 1999ȱȱȱȱȱȱȱȱȱȱȱ 55.0 ȱȱȱȱȱȱȱȱȱȱȱ66.0 ȱȱȱȱȱȱȱȱȱȱȱ40.0 ȱȱȱȱȱȱȱȱȱ149.0 ȱȱȱȱȱȱȱȱȱȱȱ99.0 2000ȱȱȱȱȱȱȱȱȱȱȱ 59.0 ȱȱȱȱȱȱȱȱȱȱȱ73.0 ȱȱȱȱȱȱȱȱȱȱȱ43.0 ȱȱȱȱȱȱȱȱȱ106.0 ȱȱȱȱȱȱȱȱȱ103.0 2001ȱȱȱȱȱȱȱȱȱȱȱ 57.0 ȱȱȱȱȱȱȱȱȱȱȱ67.0 ȱȱȱȱȱȱȱȱȱȱȱ43.0 ȱȱȱȱȱȱȱȱȱ137.0 ȱȱȱȱȱȱȱȱȱȱȱ99.0 2002ȱȱȱȱȱȱȱȱȱȱȱ 57.0 ȱȱȱȱȱȱȱȱȱȱȱ73.0 ȱȱȱȱȱȱȱȱȱȱȱ40.0 ȱȱȱȱȱȱȱȱȱ139.0 ȱȱȱȱȱȱȱȱȱȱȱ85.0 2003ȱȱȱȱȱȱȱȱȱȱȱ 53.0 ȱȱȱȱȱȱȱȱȱȱȱ65.0 ȱȱȱȱȱȱȱȱȱȱȱ40.0 ȱȱȱȱȱȱȱȱȱ132.0 ȱȱȱȱȱȱȱȱȱȱȱ80.0 (basedȱonȱ5Ȭyearȱaverageȱforȱ2004ȱtoȱ2006) 2004ȱȱȱȱȱȱȱȱȱȱȱ 56.0 ȱȱȱȱȱȱȱȱȱȱȱ66.0 ȱȱȱȱȱȱȱȱȱȱȱ41.0 ȱȱȱȱȱȱȱȱȱ140.0 ȱȱȱȱȱȱȱȱȱȱȱ95.0 2005ȱȱȱȱȱȱȱȱȱȱȱ 56.0 ȱȱȱȱȱȱȱȱȱȱȱ66.0 ȱȱȱȱȱȱȱȱȱȱȱ41.0 ȱȱȱȱȱȱȱȱȱ144.0 ȱȱȱȱȱȱȱȱȱȱȱ98.0 2006ȱȱȱȱȱȱȱȱȱȱȱ 56.0 ȱȱȱȱȱȱȱȱȱȱȱ66.0 ȱȱȱȱȱȱȱȱȱȱȱ41.0 ȱȱȱȱȱȱȱȱȱ143.0 ȱȱȱȱȱȱȱȱȱ100.0

Source:ȱRiesȱLAG,ȱHarkinsȱD,ȱKrapchoȱM,ȱet.ȱal.ȱ(eds):ȱSEERȱCancerȱStatisticsȱ Review,ȱ1975Ȭ2004,ȱOverview .ȱBethesda,ȱMD:ȱNationalȱCancerȱInstitute,ȱ2007.ȱ Availableȱat:ȱhttp://seer.cancer.gov/csr/1975_2004/.ȱAccessedȱJuneȱ19,ȱ2007.

Sourceȱ2005ȱdata:ȱRiesȱLAG,ȱMelbertȱD,ȱKrapchoȱM,ȱet.ȱal.ȱ(eds).ȱSEERȱCancerȱ StatisticsȱReview,ȱ1975Ȭ2005,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱMD,ȱ http://seer.cancer.gov/csr/1975_2005/,ȱbasedȱonȱNovemberȱ2007ȱSEERȱdataȱ submission,ȱpostedȱtoȱtheȱSEERȱwebȱsite,ȱ2008.ȱAccessedȱDecemberȱ8,ȱ2009.

Sourceȱ2006ȱdata:ȱHornerȱMJ,ȱRiesȱLAG,ȱKrapchoȱM,ȱet.ȱal.ȱ(eds).ȱSEERȱ CancerȱStatisticsȱReview,ȱ1975Ȭ2006,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱ MD,ȱhttp://seer.cancer.gov/csr/1975_2006/,ȱbasedȱonȱNovemberȱ2008ȱSEERȱ dataȱsubmission,ȱpostedȱtoȱtheȱSEERȱwebȱsite,ȱ2009.ȱAccessedȱDecemberȱ8,ȱ 2009.

Tableȱ8.3:ȱMedianȱAgeȱofȱPatientsȱatȱDiagnosisȱbyȱPrimaryȱCancerȱSiteȱbyȱSexȱandȱRace,ȱ UnitedȱStatesȱ2002Ȭ2006

MedianȱAgeȱatȱDiagnosis,ȱ MedianȱAgeȱatȱDiagnosis,ȱ MedianȱAgeȱatȱDiagnosis,ȱ AllȱRaces Whites Blacks Site Total Males Females Total Males Females Total Males Females Lymphomaȱ(Hodgkin) 38.0 40.0 36.0 39.0 40.0 37.0 37.0 39.0 34.5 Bonesȱ&ȱJoints 39.0 38.0 41.0 40.0 40.0 42.0 31.0 28.0 33.0 KaposiȇsȱSarcoma 43.0 42.0 79.0 45.0 44.0 80.0 39.0 38.0 44.5 EndocrineȱSystem 48.0 53.0 47.0 48.0 53.0 47.0 49.0 52.0 49.0 Brainȱ&ȱNervousȱSystem 56.0 55.0 57.0 57.0 56.0 58.0 50.0 50.0 50.0 SoftȱTissueȱ(inclȱheart) 57.0 57.0 57.0 59.0 59.0 58.0 48.0 46.0 50.0 Skin 60.0 63.0 55.0 60.0 63.0 56.0 53.5 55.0 51.0 Breastȱ(inclȱbreastȱinȱsitu) 61.0 68.0 61.0 62.0 68.0 62.0 57.0 63.0 57.0 FemaleȱGenitalȱSystem 61.0 61.0 61.0 61.0 60.0 60.0 OralȱCavityȱ&ȱPharynx 62.0 60.0 65.0 63.0 61.0 67.0 58.0 58.0 57.0 Leukemiaȱ 66.0 66.0 68.0 68.0 67.0 69.0 60.0 59.0 62.0 Lymphomaȱ(ȱNonȬHodgkin) 67.0 65.0 69.0 68.0 66.0 70.0 56.0 54.0 58.0 MaleȱGenitalȱSystem 67.0 67.0 67.0 67.0 65.0 65.0 Myelomaȱ(boneȱmarrow) 70.0 69.0 71.0 71.0 70.0 72.0 66.0 65.5 67.0 RespiratoryȱSystem 70.0 70.0 71.0 71.0 70.0 71.0 66.0 65.0 67.0 UrinaryȱSystem 70.0 70.0 70.0 70.0 70.0 71.0 65.0 64.0 67.0 Digestiveȱsystem 70.0 68.0 73.0 71.0 69.0 73.0 66.0 64.0 68.0

AllȱSites 66.0 67.0 65.0 67.0 68.0 66.0 63.0 64.0 62.0

Source:ȱHornerȱMJ,ȱRiesȱLAG,ȱKrapchoȱM,ȱetȱalȱ(eds).ȱSEERȱCancerȱStatisticsȱReview,ȱ1975Ȭ2006 ,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱMD.ȱ Tableȱ1.11:ȱMedianȱAgeȱofȱCancerȱPatientsȱatȱDiagnosis,ȱ2002Ȭ2006,ȱByȱPrimaryȱCancerȱSite,ȱRaceȱandȱSex.ȱAvailableȱat:ȱ http://seer.cancer.gov/csr/1975_2006/results_merged/topic_med_age.pdf ,ȱbasedȱonȱNovemberȱ2008ȱSEERȱdataȱsubmission,ȱpostedȱtoȱtheȱ SEERȱwebȱsite,ȱ2009.ȱAccessedȱDecemberȱ8,ȱ2009.

Tableȱ8.4:ȱAgeȬAdjustedȱ[1]ȱ5ȬYearȱRelativeȱCancerȱ SurvivalȱRatesȱbyȱSex,ȱUnitedȱStatesȱ1999Ȭ2005

ȱ5ȬYearȱRelativeȱSurvivalȱRateȱ (%,ȱ1999Ȭ2005)ȱ Site Total Males Females MaleȱGenitalȱSystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 98.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ98.1 EndocrineȱSystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 93.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ88.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ95.8 Skinȱ(exclȱbasalȱandȱsquam)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 90.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ88.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ93.3 Breastȱ(inclȱbreastȱinȱsitu ) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ88.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ85.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ88.6 Lymphomaȱ(Hodgkin)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 84.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ83.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ87.0 UrinaryȱSystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 73.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ75.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ70.2 FemaleȱGenitalȱSystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 69.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ69.7 Bonesȱ&ȱJointsȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 67.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ64.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ58.3 SoftȱTissueȱ(inclȱheart)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 66.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ66.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ66.0 Lymphomaȱ(NonȬHodgkin)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 63.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ60.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ66.4 OralȱCavityȱ&ȱPharynxȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 61.0 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ59.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ63.3 KaposiȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 56.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ55.8 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ63.7 Leukemiaȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ49.6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ49.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ49.4 Digestiveȱsystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 45.4 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47.5 Brainȱ&ȱNervousȱSystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 33.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ35.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ36.0 Myelomaȱ(boneȱmarrow)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 33.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ35.5 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ31.7 RespiratoryȱSystemȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 18.9 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ19.7 AllȱSitesȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 61.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ66.2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ66.0

[1]ȱAgeȬadjustedȱtoȱtheȱU.S.ȱStandardȱPopulationȱ(19ȱageȱgroupsȱȬȱCensusȱP25Ȭ1130)

Source:ȱHornerȱMJ,ȱRiesȱLAG,ȱKrapchoȱM,ȱetȱalȱ(eds).ȱSEERȱCancerȱStatisticsȱReview,ȱ 1975Ȭ2006 ,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱMD.ȱTableȱIȬ4ȱȬȱcontinued AGEȬADJUSTEDȱSEERȱINCIDENCEȱANDȱU.S.ȱDEATHȱRATESȱANDȱ5ȬYEARȱ RELATIVEȱSURVIVALȱRATESȱByȱPrimaryȱCancerȱSite,ȱSexȱandȱTimeȱPeriod.ȱ Availableȱat:ȱȱhttp://seer.cancer.gov/csr/1975_2006/results_merged/ȱ topic_survival.pdf,ȱbasedȱonȱNovemberȱ2008ȱSEERȱdataȱsubmission,ȱpostedȱtoȱtheȱ SEERȱwebȱsite,ȱ2009.ȱAccessedȱDecemberȱ8,ȱ2009.

Tableȱ8.5:ȱAgeȱDistributionȱ[1]ȱofȱPrimaryȱCancerȱSiteȱatȱTimeȱofȱDiagnosis,ȱUnitedȱStatesȱ 2002Ȭ2006

AgeȱDistributionȱ(%)ȱofȱIncidenceȱCasesȱbyȱSite,ȱ2002Ȭ2006 TotalȱCases,ȱ Site <ȱ20 20Ȭ34 35Ȭ44 45Ȭ54 55Ȭ64 65Ȭ74 75Ȭ84 85+ AllȱAgesȱ Bonesȱ&ȱJoints 29.4 16.1 10.7 12.8 10.3 8.8 8.2 3.8ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,396 Brainȱ&ȱNervousȱSystem 13.2 9.3 10.1 15.0 17.6 16.4 14.2 4.2ȱȱȱȱȱȱȱȱȱȱȱȱ 23,973 Lymphomaȱ(Hodgkin) 11.9 32.1 16.9 12.3 9.2 8.5 7.0 2.1ȱȱȱȱȱȱȱȱȱȱȱȱ 10,522 Leukemiaȱ 11.1 4.7 5.5 10.1 15.0 19.8 23.3 10.5ȱȱȱȱȱȱȱȱȱȱȱȱ 44,690 SoftȱTissueȱ(inclȱheart) 9.9 9.8 11.2 14.9 15.7 15.5 16.3 6.7ȱȱȱȱȱȱȱȱȱȱȱȱ 11,687 EndocrineȱSystem 3.2 16.2 21.3 23.1 16.9 11.3 6.4 1.5ȱȱȱȱȱȱȱȱȱȱȱȱ 39,088 Lymphomaȱ(NonȬHodgkin) 1.7 3.9 7.2 13.9 19.0 22.2 23.6 8.6ȱȱȱȱȱȱȱȱȱȱȱȱ 71,464 Skinȱ(exclȱbasalȱ&ȱsquamous) 0.9 7.7 12.0 18.3 19.4 17.8 17.6 6.3ȱȱȱȱȱȱȱȱȱȱȱȱ 79,398 UrinaryȱSystem 0.6 0.9 3.6 11.0 20.4 26.3 27.5 9.9ȱȱȱȱȱȱȱȱȱȱ 128,472 OralȱCavityȱ&ȱPharynx 0.6 2.4 6.8 20.9 26.2 21.3 16.1 5.8ȱȱȱȱȱȱȱȱȱȱȱȱ 38,632 FemaleȱGenitalȱSystem 0.4 4.4 10.1 19.5 24.6 19.4 15.6 5.9ȱȱȱȱȱȱȱȱȱȱȱȱ 96,539 DigestiveȱSystem 0.2 1.0 3.8 12.5 19.5 24.9 26.9 11.3ȱȱȱȱȱȱȱȱȱȱ 319,364 MaleȱGenitalȱSystem 0.2 1.8 1.7 8.9 27.9 34.2 20.7 4.5ȱȱȱȱȱȱȱȱȱȱ 267,411 KaposiȇsȱSarcoma 0.1 17.9 35.6 18.2 7.2 6.2 9.2 5.6ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,357 RespiratoryȱSystem 0.1 0.4 2.0 9.2 21.3 31.1 28.3 7.5ȱȱȱȱȱȱȱȱȱȱ 242,400 Breastȱ(inclȱbreastȱinȱsitu) 0.0 1.9 10.5 22.5 23.7 19.6 16.2 5.5ȱȱȱȱȱȱȱȱȱȱ 247,782 Myelomaȱ(boneȱmarrow) 0.0 0.5 3.3 11.9 20.7 26.5 27.6 9.5ȱȱȱȱȱȱȱȱȱȱȱȱ 20,399

AllȱSites 1.1 2.7 5.8 13.9 21.8 24.9 22.2 7.6ȱȱȱȱȱȱȱ 1,692,617

[1]ȱAgeȬadjustedȱtoȱtheȱU.S.ȱStandardȱPopulationȱ(19ȱageȱgroupsȱȬȱCensusȱP25Ȭ1130)

Source:ȱHornerȱMJ,ȱRiesȱLAG,ȱKrapchoȱM,ȱetȱalȱ(eds).ȱSEERȱCancerȱStatisticsȱReview,ȱ1975Ȭ2006,ȱNationalȱCancerȱInstitute.ȱBethesda,ȱMD,ȱ http://seer.cancer.gov/csr/1975_2006/,ȱbasedȱonȱNovemberȱ2008ȱSEERȱdataȱsubmission,ȱpostedȱtoȱtheȱSEERȱwebȱsite,ȱ2009.ȱAccessedȱ Decemberȱ8,ȱ2009.

Tableȱ8.6:ȱAgeȱDistributionȱ[1]ȱofȱPrimaryȱCancerȱSiteȱatȱTimeȱofȱDeath,ȱUnitedȱStatesȱ 2002Ȭ2006

AgeȱDistributionȱ(%)ȱofȱDeathsȱbyȱCancerȱSite,ȱ2002Ȭ2006 ȱTotalȱCases,ȱ Site <ȱ20 20Ȭ34 35Ȭ44 45Ȭ54 55Ȭ64 65Ȭ74 75Ȭ84 85+ AllȱAgesȱ Bonesȱ&ȱJoints 14.5 14.4 7.0 9.9 11.9 13.7 17.9 10.8ȱȱȱȱȱȱȱȱȱȱȱȱ 6,488 EndocrineȱSystem 8.2 2.6 4.4 10.5 16.3 21.2 24.3 12.5ȱȱȱȱȱȱȱȱȱȱ 11,416 Brainȱ&ȱNervousȱSystem 4.3 3.8 7.4 15.2 21.3 22.3 19.5 6.1ȱȱȱȱȱȱȱȱȱȱ 64,598 SoftȱTissueȱ(inclȱheart) 4.1 6.5 7.3 13.5 17.5 19.2 21.7 10.2ȱȱȱȱȱȱȱȱȱȱ 18,749 Leukemiaȱ 3.0 3.2 3.4 6.5 12.4 21.9 31.6 17.9ȱȱȱȱȱȱȱȱ 108,393 Lymphomaȱ(Hodgkin) 1.9 14.6 10.7 12.4 14.3 16.4 20.8 8.9ȱȱȱȱȱȱȱȱȱȱȱȱ 6,574 Lymphomaȱ(NonȬHodgkin) 0.5 1.6 2.8 7.1 13.9 22.8 33.7 17.6ȱȱȱȱȱȱȱȱ 105,789 OralȱCavityȱ&ȱPharynx 0.2 0.8 3.4 14.6 23.6 23.9 22.2 11.2ȱȱȱȱȱȱȱȱȱȱ 38,833 UrinaryȱSystem 0.2 0.3 1.6 7.0 15.4 23.4 32.7 19.5ȱȱȱȱȱȱȱȱ 129,846 Skinȱ(exclȱbasalȱ&ȱsquamous) 0.1 2.3 5.7 13.0 18.3 20.7 25.1 14.8ȱȱȱȱȱȱȱȱȱȱ 52,530 DigestiveȱSystem 0.1 0.5 2.4 9.3 17.3 24.2 29.8 16.4ȱȱȱȱȱȱȱȱ 666,908 FemaleȱGenitalȱSystem 0.0 1.3 4.7 12.0 19.3 23.3 26.0 13.4ȱȱȱȱȱȱȱȱ 136,258 Breastȱ(inclȱbreastȱinȱsitu) 0.0 1.0 6.2 15.1 20.3 19.8 22.8 14.9ȱȱȱȱȱȱȱȱ 206,023 MaleȱGenitalȱSystem 0.0 0.4 0.4 1.7 7.3 20.0 40.3 29.8ȱȱȱȱȱȱȱȱ 149,423 RespiratoryȱSystem 0.0 0.1 1.5 8.0 19.7 30.9 30.5 9.3ȱȱȱȱȱȱȱȱ 814,945 Myelomaȱ(boneȱmarrow) 0.0 0.1 1.3 6.4 15.7 26.8 34.9 14.9ȱȱȱȱȱȱȱȱȱȱ 53,770

AllȱSites 0.4 0.8 2.7 9.0 17.5 25.2 29.9 14.6ȱȱȱȱȱ 2,787,217

[1]ȱAgeȬadjustedȱtoȱtheȱU.S.ȱStandardȱPopulationȱ(19ȱageȱgroupsȱȬȱCensusȱP25Ȭ1130)

Source:ȱHornerȱMJ,ȱRiesȱLAG,ȱKrapchoȱM,ȱetȱalȱ(eds).ȱSEERȱCancerȱStatisticsȱReview,ȱ1975Ȭ2006,ȱNationalȱCancerȱInstitute.ȱ Bethesda,ȱMD,ȱhttp://seer.cancer.gov/csr/1975_2006/,ȱbasedȱonȱNovemberȱ2008ȱSEERȱdataȱsubmission,ȱpostedȱtoȱtheȱSEERȱwebȱ site,ȱ2009.ȱAccessedȱDecemberȱ8,ȱ2009.

Tableȱ8.7:ȱAnnualȱDistributionȱofȱMalignantȱBoneȱTumorsȱandȱMyelomaȱbyȱ TypeȱandȱAge,ȱUnitedȱStates,ȱ2000Ȭ2003 ȱTotalȱ Malignantȱ AnnualȱPrevalenceȱBoneȱTumorȱCases,ȱ2000Ȭ2003 Cases,ȱ <ȱ20 20Ȭ34 35Ȭ44 55Ȭ64 75+ AllȱAgesȱ MalignantȱBoneȱTumors Osteosarcoma 421 154 145 131 65 916 Chrondosarcoma 31 156 390 319 91 987 EwingȇsȱSarcoma 222 71 34 11 0 339 OtherȱandȱUnspecifiedȱBoneȱTumors 34 46 137 117 117 449 TotalȱMalignantȱBoneȱTumors 708 427 705 577 273 2691

Myeloma 0 92 2288 7217 5743ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 15,341

Proportionȱ(%)ȱofȱTotalȱBoneȱTumorȱCasesȱbyȱType,ȱ Malignantȱ 2000Ȭ2003 Cases,ȱ <ȱ20 20Ȭ34 35Ȭ44 55Ȭ64 75+ AllȱAgesȱ MalignantȱBoneȱTumors Osteosarcoma 46.0% 16.8% 15.8% 14.3% 7.1% 100% Chrondosarcoma 3.2% 15.9% 39.5% 32.3% 9.2% 100% EwingȇsȱSarcoma 65.5% 21.0% 10.1% 3.4% 0.0% 100% OtherȱandȱUnspecifiedȱBoneȱTumors 7.6% 10.1% 30.4% 25.9% 25.9% 100% TotalȱMalignantȱBoneȱTumors 26.3% 15.9% 26.2% 21.5% 10.1% 100%

Myeloma 0.0% 0.6% 14.9% 47.0% 37.4% 100%

Distributionȱ(%)ȱofȱTotalȱBoneȱTumorȱCasesȱbyȱAge,ȱ Malignantȱ 2000Ȭ2003 Cases,ȱ <ȱ20 20Ȭ34 35Ȭ44 55Ȭ64 75+ AllȱAgesȱ MalignantȱBoneȱTumors Osteosarcoma 59.4% 36.0% 20.6% 22.7% 24% 916 Chrondosarcoma 4.4% 36.7% 55.2% 55.2% 33% 987 EwingȇsȱSarcoma 31.3% 16.7% 4.8% 2.0% 0% 339 OtherȱandȱUnspecifiedȱBoneȱTumors 4.8% 10.7% 19.4% 20.2% 43% 449 TotalȱMalignantȱBoneȱTumors 100.0% 100.0% 100.0% 100.0% 100.0% 2691

Source:ȱSurveillance,ȱEpidemiology,ȱandȱEndȱResultsȱ(SEER)ȱProgramȱ(www.seer.cancer.gov):ȱPublicȬUseȱDataȱ (1973Ȭ2003).ȱNationalȱCancerȱInstitute,ȱDCCPS,ȱSurveillanceȱResearchȱProgram,ȱCancerȱStatisticsȱBranch,ȱreleasedȱ Aprilȱ2006,ȱbasedȱonȱtheȱNovemberȱ2005ȱsubmission.ȱAccessed:ȱMarchȱ19,ȱ2007.

Tableȱ8.8:ȱSiteȱbyȱStageȱDistributionȱofȱCasesȱforȱTopȱ12ȱCancerȱSites,ȱSoftȱTissueȱCancersȱandȱBoneȱ andȱJointȱCancers,ȱDiagnosisȱYearsȱ2000Ȭ2004ȱandȱ2006

NationalȱCancerȱDataȱBase,ȱDiagnosisȱYearsȱ2006 ProportionȱofȱTotalȱCasesȱwithȱKnownȱStage,ȱ2006 ȱStageȱ Unknownȱ %ȱofȱTotalȱ PrimaryȱSite ȱStageȱ0ȱ ȱStageȱIȱ ȱStageȱIIȱ ȱStageȱIIIȱ ȱStageȱIVȱ Casesȱ ȱTotalȱCasesȱ Casesȱ Breast 20.3% 39.8% 26.6% 9.8% 3.5% ȱȱȱȱȱȱȱȱȱȱȱȱ13,083ȱ ȱȱȱȱȱȱȱȱȱȱȱ178,764ȱ 17.3% Prostate 0.0% 1.4% 84.9% 8.5% 5.2% ȱȱȱȱȱȱȱȱȱȱȱȱ12,812ȱ ȱȱȱȱȱȱȱȱȱȱȱ126,058ȱ 12.2% Lung,ȱBronchusȱȬȱNSCC 0.3% 26.4% 7.5% 26.5% 39.3% ȱȱȱȱȱȱȱȱȱȱȱȱ13,878ȱ ȱȱȱȱȱȱȱȱȱȱȱ112,095ȱ 10.8% Colon 7.6% 21.7% 27.0% 24.9% 18.8% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,278ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ70,537ȱ 6.8% Bladder 50.9% 22.8% 13.0% 5.6% 7.6% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,202ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ40,507ȱ 3.9% NonȬHodgkinsȱLymphoma 0.0% 29.3% 16.3% 17.8% 36.5% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,319ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ38,280ȱ 3.7% MelanomaȱȬȱSkin 25.1% 48.5% 13.4% 8.8% 4.3% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,413ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ37,314ȱ 3.6% KidneyȱandȱRenalȱPelvis 0.0% 58.4% 9.8% 14.5% 17.4% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,746ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ33,927ȱ 3.3% Uterus 1.3% 69.7% 8.7% 13.6% 6.6% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,840ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ31,876ȱ 3.1% Thyroid 0.0% 68.8% 10.2% 12.6% 8.5% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,572ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ25,210ȱ 2.4% Pancreas 0.6% 8.7% 25.7% 13.9% 51.1% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,560ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ24,956ȱ 2.4% Rectum 8.4% 29.1% 23.0% 24.4% 15.1% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,030ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ22,202ȱ 2.1% SoftȱTissue 0.0% 32.4% 22.0% 27.2% 18.4% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,657ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ7,167ȱ 0.7% BonesȱandȱJoints 0.0% 40.9% 36.9% 3.5% 18.8% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ945ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,070ȱ 0.2% AllȱCancerȱCases 8.8% 27.9% 28.9% 16.0% 18.4% ȱȱȱȱȱȱȱȱȱȱ858,270ȱ ȱȱȱȱȱȱȱȱ1,035,937ȱ 72.5%

NationalȱCancerȱDataȱBase,ȱDiagnosisȱYearsȱ2000ȱtoȱ2004 ProportionȱofȱTotalȱCasesȱwithȱKnownȱStage,ȱ2000Ȭ2004 ȱStageȱ Unknownȱ %ȱofȱTotalȱ PrimaryȱSite ȱStageȱ0ȱ ȱStageȱIȱ ȱStageȱIIȱ ȱStageȱIIIȱ ȱStageȱIVȱ Casesȱ ȱTotalȱCasesȱ Casesȱ Breast 18.0% 40.7% 29.9% 7.9% 3.5% ȱȱȱȱȱȱȱȱȱȱȱȱȱ35,762ȱ ȱȱȱȱȱȱȱȱȱȱȱ839,265ȱ 17.8% Prostate 0.0% 2.1% 84.1% 8.5% 5.3% ȱȱȱȱȱȱȱȱȱȱȱȱȱ38,727ȱ ȱȱȱȱȱȱȱȱȱȱȱ612,414ȱ 13.0% Lung,ȱBronchusȱȬȱNSCC 0.3% 25.2% 8.1% 27.7% 38.7% ȱȱȱȱȱȱȱȱȱȱȱȱȱ38,309ȱ ȱȱȱȱȱȱȱȱȱȱȱ490,609ȱ 10.4% Colon 7.9% 22.1% 27.5% 24.2% 18.3% ȱȱȱȱȱȱȱȱȱȱȱȱȱ25,862ȱ ȱȱȱȱȱȱȱȱȱȱȱ353,444ȱ 7.5% Bladder 50.6% 23.7% 12.7% 6.0% 7.0% ȱȱȱȱȱȱȱȱȱȱȱȱȱ15,466ȱ ȱȱȱȱȱȱȱȱȱȱȱ190,144ȱ 4.0% NonȬHodgkinsȱLymphoma 0.0% 32.0% 17.5% 15.9% 34.6% ȱȱȱȱȱȱȱȱȱȱȱȱȱ35,954ȱ ȱȱȱȱȱȱȱȱȱȱȱ172,269ȱ 3.7% MelanomaȱȬȱSkin 25.8% 43.2% 15.9% 11.0% 4.1% ȱȱȱȱȱȱȱȱȱȱȱȱȱ20,605ȱ ȱȱȱȱȱȱȱȱȱȱȱ158,558ȱ 3.4% Uterus 1.4% 70.3% 8.9% 12.5% 6.9% ȱȱȱȱȱȱȱȱȱȱȱȱȱ17,235ȱ ȱȱȱȱȱȱȱȱȱȱȱ139,009ȱ 3.0% KidneyȱandȱRenalȱPelvis 0.0% 52.9% 11.3% 15.0% 20.8% ȱȱȱȱȱȱȱȱȱȱȱȱȱ15,380ȱ ȱȱȱȱȱȱȱȱȱȱȱ132,380ȱ 2.8% Rectum 9.1% 31.0% 22.3% 23.3% 14.3% ȱȱȱȱȱȱȱȱȱȱȱȱȱ17,304ȱ ȱȱȱȱȱȱȱȱȱȱȱ109,971ȱ 2.3% Pancreas 0.5% 9.0% 15.1% 14.3% 61.1% ȱȱȱȱȱȱȱȱȱȱȱȱȱ17,105ȱ ȱȱȱȱȱȱȱȱȱȱȱ102,399ȱ 2.2% Lung,ȱBronchusȱȬȱSCC 0.3% 6.7% 4.0% 30.3% 58.7% ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,779ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ96,167ȱ 2.0% SoftȱTissue 0.0% 28.3% 30.4% 24.8% 16.6% ȱȱȱȱȱȱȱȱȱȱȱȱȱ12,310ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ32,622ȱ 0.7% BonesȱandȱJoints 0.0% 43.7% 34.6% 2.9% 18.8%ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,339 ȱȱȱȱȱȱȱȱȱȱȱȱȱ10,002 0.2% AllȱCancerȱCases 8.8% 27.9% 28.9% 16.0% 18.4% ȱȱȱȱȱȱȱȱȱȱȱ858,270ȱ ȱȱȱȱȱȱȱȱ4,708,118ȱ

Source:ȱNationalȱCancerȱDataȱBaseȱ(NCDB):ȱSiteȱbyȱStageȱDistributionȱofȱCasesȱReportedȱtoȱtheȱNCDB:ȱDiagnosisȱYearȱ2006.ȱAmericanȱCollegeȱofȱ SurgeonsȱCommissionȱonȱCancer.ȱAvailableȱat:ȱhttp://www.facs.org/cancer/ncdb/site_stage_2006.htm.ȱAccessedȱDecemberȱ10,ȱ2009.ȱȱȱ

Tableȱ8.9:ȱMalignantȱSoftȱTissueȱTumorsȱ(Sarcomas)

TumorsȱofȱFatȱTissueȱ Malignantȱtumorsȱofȱfatȱtissue.ȱTheyȱcanȱdevelopȱanywhereȱinȱtheȱbody,ȱbutȱtheyȱmostȱoftenȱdevelopȱinȱtheȱthigh,ȱbehindȱtheȱknee,ȱandȱinsideȱtheȱbackȱofȱtheȱ Liposarcomaseȱ abdomen.ȱTheyȱoccurȱmostlyȱinȱadultsȱbetweenȱ50ȱandȱ65ȱyearsȱold.ȱSomeȱliposarcomasȱgrowȱveryȱslowly,ȱwhereasȱothersȱcanȱgrowȱquickly.ȱYourȱdoctorȱcanȱ tellȱyouȱwhichȱkindȱyouȱhave. TumorsȱofȱMuscleȱTissueȱ Smoothȱmuscleȱsarcomasȱ(Foundȱinȱinternalȱorgansȱsuchȱasȱstomach,ȱintestines,ȱbloodȱvessels,ȱorȱuterusȱ(womb)ȱandȱcausesȱthemȱtoȱcontract.ȱTheseȱmusclesȱareȱinvoluntary.) Malignantȱtumorsȱofȱinvoluntaryȱmuscleȱtissue.ȱTheyȱcanȱgrowȱalmostȱanywhereȱinȱtheȱbodyȱbutȱareȱmostȱoftenȱfoundȱinȱtheȱretroperitoneumȱandȱtheȱ Leiomyosarcomasȱ internalȱorgansȱandȱbloodȱvesselsȱwhereȱleiomyomasȱalsoȱarise.ȱLessȱoften,ȱtheyȱdevelopȱinȱtheȱdeepȱsoftȱtissuesȱofȱtheȱlegsȱorȱarms.ȱTheyȱtendȱtoȱoccurȱinȱ adults,ȱparticularlyȱtheȱelderly. Skeletalȱmuscleȱsarcomasȱ(Muscleȱthatȱallowsȱmovementȱofȱarmsȱandȱlegsȱandȱotherȱbodyȱparts;ȱvoluntaryȱmovement.) Malignantȱtumorsȱofȱskeletalȱmuscle.ȱTheseȱtumorsȱcommonlyȱgrowȱinȱtheȱarmsȱorȱlegs,ȱbutȱtheyȱcanȱalsoȱbeginȱinȱtheȱheadȱandȱneckȱareaȱandȱinȱ Rhabdomyosarcomasȱ reproductiveȱandȱurinaryȱorgansȱsuchȱasȱtheȱvaginaȱorȱbladder.ȱChildrenȱareȱaffectedȱmuchȱmoreȱoftenȱthanȱadults.ȱForȱmoreȱinformation,ȱseeȱtheȱAmericanȱ CancerȱSocietyȱdocument,ȱȈRhabdomyosarcoma.Ȉ TumorsȱofȱPeripheralȱNerveȱTissueȱ Malignantȱschwannomas,ȱ neurofibrosarcomas,ȱorȱ Malignantȱtumorsȱofȱtheȱcellsȱthatȱsurroundȱaȱnerve.ȱAȱnewȱnameȱforȱtheseȱisȱmalignantȱperipheralȱnerveȱsheathȱtumors neurogenicȱsarcomasȱ TumorsȱofȱJointȱTissueȱ

Malignantȱtumorȱofȱtheȱtissueȱaroundȱjoints.ȱTheȱmostȱcommonȱlocationȱisȱtheȱthigh.ȱDespiteȱtheȱnameȱSynovialȱSarcoma,ȱmostȱdoȱnotȱoccurȱinȱjoints.ȱItȱtendsȱ Synovialȱsarcomaȱ toȱoccurȱmostlyȱinȱyoungȱadults,ȱbutȱcanȱalsoȱoccurȱinȱchildrenȱandȱinȱolderȱpeople. TumorsȱofȱBloodȱVesselsȱandȱLymphȱVesselsȱ Aȱtumorȱofȱperivascularȱtissue.ȱItȱmostȱoftenȱdevelopsȱinȱtheȱlegs,ȱpelvis,ȱandȱretroperitoneumȱ(theȱbackȱofȱtheȱabdominalȱcavity).ȱItȱisȱmostȱcommonȱinȱ adults.ȱTheseȱcanȱbeȱeitherȱbenignȱorȱmalignant.ȱTheyȱdon’tȱoftenȱspreadȱtoȱdistantȱsites,ȱbutȱtendȱtoȱcomeȱbackȱwhereȱtheyȱstarted,ȱevenȱafterȱsurgery,ȱunlessȱ Hemangiopericytomaȱ widelyȱexcised. AȱbloodȱvesselȱtumorȱthatȱisȱlessȱaggressiveȱthanȱhemangiosarcomaȱbutȱstillȱconsideredȱaȱlowȬgradeȱcancer.ȱItȱusuallyȱinvadesȱnearbyȱtissuesȱandȱsometimesȱ Hemangioendotheliomaȱ canȱspreadȱtoȱdistantȱpartsȱofȱtheȱbodyȱ(metastasize).ȱItȱmayȱdevelopȱinȱsoftȱtissuesȱorȱinȱinternalȱorgans,ȱsuchȱasȱtheȱliverȱorȱlungs.

Malignantȱtumorsȱthatȱcanȱdevelopȱeitherȱfromȱbloodȱvesselsȱ(hemangiosarcomas)ȱorȱfromȱlymphȱvesselsȱ(lymphangiosarcomas).ȱTheseȱtumorsȱcanȱ sometimesȱdevelopȱinȱaȱpartȱofȱtheȱbodyȱthatȱhasȱbeenȱexposedȱtoȱradiation.ȱAngiosarcomasȱareȱsometimesȱseenȱinȱtheȱbreastȱafterȱradiationȱtherapyȱforȱbreastȱ Angiosarcomasȱ cancerȱorȱinȱtheȱarmȱonȱtheȱsameȱsideȱasȱaȱbreastȱthatȱhasȱbeenȱirradiatedȱorȱremovedȱbyȱmastectomy.ȱTheyȱareȱdifficultȱtoȱcure.

Aȱcancerȱformedȱbyȱcellsȱsimilarȱtoȱthoseȱliningȱbloodȱorȱlymphȱvessels.ȱInȱtheȱpast,ȱKaposi’sȱsarcomaȱwasȱanȱuncommonȱcancerȱmostlyȱseenȱinȱolderȱpeopleȱ withȱnoȱapparentȱimmuneȱsystemȱproblems.ȱItȱisȱmostȱcommonȱinȱpeopleȱwithȱhumanȱimmunodeficiencyȱvirusȱ(HIV)ȱinfectionȱandȱtheȱacquiredȱ immunodeficiencyȱsyndromeȱ(AIDS),ȱbutȱitȱcanȱalsoȱdevelopȱinȱorganȱtransplantȱpatientsȱwhoȱareȱtakingȱmedicationȱtoȱsuppressȱtheirȱimmuneȱsystem.ȱItȱisȱ Kaposiȱsarcomaȱ probablyȱrelatedȱtoȱinfectionȱwithȱaȱvirusȱcalledȱhumanȱherpesvirusȬ8ȱ(HHVȬ8).ȱ TumorsȱofȱFibrousȱTissueȱ Fibrousȱtissueȱformsȱtendonsȱandȱligamentsȱandȱcoversȱbonesȱasȱwellȱasȱotherȱorgansȱinȱtheȱbody.ȱ

Fibrosarcomaȱ Cancerȱofȱfibrousȱtissue.ȱItȱusuallyȱaffectsȱtheȱlegs,ȱarms,ȱorȱtrunk.ȱItȱisȱmostȱcommonȱbetweenȱtheȱagesȱofȱ20ȱandȱ60,ȱbutȱcanȱoccurȱatȱanyȱage,ȱevenȱinȱinfancy.

Theȱnameȱgivenȱtoȱfibrousȱtissueȱtumorȱwithȱfeaturesȱinȱbetweenȱfibrosarcomaȱandȱbenignȱtumorsȱsuchȱasȱfibromasȱandȱsuperficialȱfibromatosis.ȱTheyȱtendȱtoȱ growȱslowlyȱbut,ȱoften,ȱsteadily.ȱAtȱoneȱtimeȱtheyȱwereȱcalledȱdesmoidȱtumors,ȱwhenȱtheyȱwereȱcloselyȱattachedȱtoȱskeletalȱmuscles.ȱNowȱtheyȱareȱcalledȱ musculoaponeuroticȱfibromatosis.ȱTheyȱdoȱnotȱmetastasize,ȱbutȱtheyȱcanȱinvadeȱnearbyȱtissuesȱandȱareȱsometimesȱfatal.ȱSomeȱdoctorsȱconsiderȱtheseȱtoȱbeȱaȱ typeȱofȱlowȬgradeȱfibrosarcoma;ȱothersȱbelieveȱtheyȱareȱaȱuniqueȱtypeȱofȱfibrousȱtissueȱtumors.ȱCertainȱhormones,ȱparticularlyȱestrogen,ȱincreaseȱtheȱgrowthȱ Fibromatosisȱ ofȱsomeȱdesmoidȱtumors.ȱAntiestrogenȱdrugsȱareȱsometimesȱusefulȱinȱtreatingȱdesmoidsȱthatȱcannotȱbeȱcompletelyȱremovedȱbyȱsurgery. Dermatofibrosarcomaȱ protuberansȱ(DFSP)ȱ AȱslowȬgrowingȱcancerȱofȱtheȱfibrousȱtissueȱbeneathȱtheȱskin,ȱusuallyȱinȱtheȱtrunkȱorȱlimbs.ȱItȱinvadesȱnearbyȱtissuesȱbutȱrarelyȱmetastasizes. Malignantȱfibrousȱ Mostȱoftenȱfoundȱinȱtheȱarmsȱorȱlegs.ȱLessȱoften,ȱitȱcanȱdevelopȱinsideȱtheȱbackȱofȱtheȱabdomen.ȱThisȱsarcomaȱisȱmostȱcommonȱinȱolderȱadults.ȱAlthoughȱitȱ histiocytomaȱ(MFH)ȱ mostlyȱtendsȱtoȱgrowȱlocally,ȱitȱcanȱspreadȱtoȱdistantȱsites.ȱItȱisȱtheȱmostȱcommonlyȱdiagnosedȱsoftȱtissueȱsarcoma. TumorsȱofȱUncertainȱTissueȱTypeȱ sarcomasȱhaveȱnotȱbeenȱlinkedȱtoȱaȱspecificȱtypeȱofȱnormalȱsoftȱtissue.ȱ Malignantȱmesenchymomaȱ Aȱrareȱtypeȱofȱsarcomaȱthatȱcontainsȱsomeȱareasȱshowingȱfeaturesȱofȱfibrosarcomaȱandȱotherȱareasȱwithȱfeaturesȱofȱatȱleastȱtwoȱotherȱtypesȱofȱsarcoma. AlveolarȱsoftȬpartȱsarcomaȱ Aȱrareȱcancerȱthatȱmostlyȱaffectsȱyoungȱadults.ȱTheȱlegsȱareȱtheȱmostȱcommonȱlocationȱofȱtheseȱtumors. Epithelioidȱsarcomaȱ Mostȱoftenȱdevelopsȱinȱtissuesȱunderȱtheȱskinȱofȱtheȱhands,ȱforearms,ȱfeet,ȱorȱlowerȱlegs.ȱAdolescentsȱandȱyoungȱadultsȱareȱoftenȱaffected. Aȱrareȱcancerȱthatȱoftenȱdevelopsȱinȱtendonsȱofȱtheȱarmsȱorȱlegs.ȱUnderȱtheȱmicroscope,ȱitȱsharesȱsomeȱfeaturesȱwithȱmalignantȱmelanoma,ȱaȱtypeȱofȱcancerȱ Clearȱcellȱsarcomaȱ thatȱdevelopsȱfromȱpigmentȬproducingȱskinȱcells.ȱHowȱcancersȱwithȱtheseȱfeaturesȱdevelopȱinȱpartsȱofȱtheȱbodyȱotherȱthanȱtheȱskinȱisȱnotȱknown. Desmoplasticȱsmallȱcellȱ Aȱrareȱsarcomaȱofȱadolescentsȱandȱyoungȱadults,ȱfoundȱmostȱoftenȱinȱtheȱabdomen.ȱItsȱnameȱmeansȱthatȱitȱisȱformedȱbyȱsmall,ȱroundȱcancerȱcellsȱsurroundedȱ tumorȱ byȱscarȬlikeȱtissue. OtherȱTypesȱofȱSarcomaȱ Thereȱareȱotherȱtypesȱofȱsoftȱtissueȱsarcomas,ȱhowever,ȱtheyȱareȱlessȱcommonlyȱencountered.

Octoberȱ10,ȱ2007.ȱEditorialȱrevisionsȱprovidedȱbyȱWilliamȱG.ȱWard,ȱMD

Tableȱ8.10:ȱBenignȱSoftȱTissueȱTumors

TumorsȱofȱFatȱTissueȱ Benignȱtumorsȱofȱfatȱtissue.ȱTheyȱareȱtheȱmostȱcommonȱbenignȱsoftȱtissueȱtumor.ȱMostȱareȱfoundȱunderȱtheȱskin,ȱbutȱtheyȱcanȱdevelopȱ Lipomasȱ anywhereȱinȱtheȱbody. Lipoblastomasȱ Benignȱfatȱtumorsȱthatȱoccurȱinȱinfantsȱandȱyoungȱchildren. Hibernomasȱ Likeȱlipomas,ȱareȱalsoȱbenignȱfatȱtissueȱtumors.ȱTheyȱareȱmuchȱlessȱcommonȱthanȱlipomas. TumorsȱofȱMuscleȱTissueȱ

Smoothȱmuscleȱsarcomasȱ(Foundȱinȱinternalȱorgansȱsuchȱasȱstomach,ȱintestines,ȱbloodȱvessels,ȱorȱuterusȱ(womb)ȱandȱcausesȱthemȱtoȱcontract.ȱTheseȱmusclesȱareȱ involuntary.) Benignȱtumorsȱofȱsmoothȱmuscleȱ(orȱinvoluntaryȱmuscle).ȱLeiomyomasȱcanȱariseȱalmostȱanywhereȱinȱtheȱbodyȱinȱeitherȱmenȱorȱwomenȱ becauseȱtheyȱcanȱstartȱinȱtissuesȱasȱwidespread,ȱforȱexample,ȱasȱbloodȱvesselsȱorȱintestine.ȱTheȱmostȱcommonȱofȱtheseȱisȱtheȱfibroidȱ Leiomyomasȱ tumorȱthatȱdevelopsȱinȱmanyȱwomen.ȱItȱisȱreallyȱaȱleiomyomaȱofȱtheȱuterus. Skeletalȱmuscleȱsarcomasȱ(Muscleȱthatȱallowsȱmovementȱofȱarmsȱandȱlegsȱandȱotherȱbodyȱparts;ȱvoluntaryȱmovement.) Rhabdomyomasȱ Benignȱtumorsȱofȱskeletalȱmuscleȱ(theȱmuscleȱthatȱisȱattachedȱtoȱboneȱandȱhelpsȱusȱtoȱmove).ȱTheyȱareȱrare. TumorsȱofȱPeripheralȱNerveȱTissueȱ

Neurofibromas,ȱ schwannomasȱ Benignȱtumorsȱofȱnerves.ȱTheseȱtumorsȱcanȱoccurȱalmostȱanywhereȱinȱtheȱbody.ȱAnȱinheritedȱconditionȱcalledȱneurofibromatosisȱorȱvonȱ (neurilemoma),ȱandȱ Recklinghausenȱdiseaseȱcausesȱpeopleȱtoȱdevelopȱmanyȱneurofibromasȱthroughoutȱtheirȱbody.ȱSomeȱofȱthese,ȱifȱtheyȱformedȱfromȱveryȱ neuromasȱ largeȱnervesȱsuchȱasȱthoseȱinȱtheȱupperȱarms,ȱneck,ȱpelvisȱorȱthighȱcanȱbecomeȱmalignant. TumorsȱofȱJointȱTissueȱ

Jointsȱareȱsurroundedȱbyȱtoughȱtissueȱcalledȱsynovium,ȱwhichȱproducesȱtheȱfluidȱthatȱlubricatesȱtheȱjointȱsurfacesȱsoȱthatȱtheyȱmoveȱsmoothly.ȱTumorsȱofȱjointsȱstartȱ inȱtheȱsynovium.ȱ Nodularȱtenosynovitisȱ Benignȱtumorȱofȱjointȱtissue.ȱItȱisȱmostȱcommonȱinȱtheȱhandsȱandȱisȱmoreȱcommonȱinȱwomenȱthanȱinȱmen. TumorsȱofȱBloodȱVesselsȱandȱLymphȱVesselsȱ Benignȱtumorsȱofȱbloodȱvessels.ȱTheyȱareȱratherȱcommon,ȱareȱoftenȱpresentȱatȱbirth,ȱandȱcanȱaffectȱtheȱskinȱorȱinternalȱorgans.ȱTheyȱ sometimesȱdisappearȱwithoutȱtreatment,ȱbutȱwhenȱlocatedȱinȱmusclesȱandȱotherȱdeepȱtissues,ȱcanȱbeȱquiteȱproblematicȱandȱrequireȱ Hemangiomasȱ surgicalȱtreatment. Glomusȱtumorsȱ Benignȱperivascularȱ(aroundȱbloodȱvessels)ȱtumors.ȱTheyȱusuallyȱareȱfoundȱunderȱtheȱskinȱandȱoftenȱunderȱfingernails. Aȱtumorȱofȱperivascularȱtissue.ȱItȱmostȱoftenȱdevelopsȱinȱtheȱlegs,ȱpelvis,ȱandȱretroperitoneumȱ(theȱbackȱofȱtheȱabdominalȱcavity).ȱItȱisȱ mostȱcommonȱinȱadults.ȱTheseȱcanȱbeȱeitherȱbenignȱorȱmalignant.ȱTheyȱdon’tȱoftenȱspreadȱtoȱdistantȱsites,ȱbutȱtendȱtoȱcomeȱbackȱwhereȱ Hemangiopericytomaȱ theyȱstarted,ȱevenȱafterȱsurgery,ȱunlessȱveryȱwidelyȱexcised. Benignȱlymphȱvesselȱtumorsȱthatȱareȱusuallyȱpresentȱatȱbirth.ȱLymphȱisȱaȱtypeȱofȱfluidȱthatȱcirculatesȱinȱeveryȱtissueȱofȱtheȱbody,ȱendingȱ upȱinȱtheȱvenousȱsystem.ȱItȱcontainsȱwasteȱproductsȱfromȱtissuesȱandȱimmuneȱsystemȱcells.ȱLymphangiosarcomasȱareȱtheȱmalignantȱ Lymphangiomas.ȱ lymphȱvesselȱformȱofȱangiosarcomas TumorsȱofȱFibrousȱTissueȱ Fibrousȱtissueȱformsȱtendonsȱandȱligamentsȱandȱcoversȱbonesȱasȱwellȱasȱotherȱorgansȱinȱtheȱbody.ȱ Fibromas,ȱelastofibromas,ȱ superficialȱfibromatosis,ȱ andȱfibrousȱhistiocytomasȱ Allȱareȱbenignȱtumors. TumorsȱofȱUncertainȱTissueȱTypeȱ

Throughȱmicroscopicȱexaminationȱandȱotherȱlaboratoryȱtests,ȱdoctorsȱcanȱusuallyȱfindȱsimilaritiesȱbetweenȱmostȱsarcomasȱandȱcertainȱtypesȱofȱnormalȱsoftȱtissues.ȱ However,ȱsomeȱsarcomasȱhaveȱnotȱbeenȱlinkedȱtoȱaȱspecificȱtypeȱofȱnormalȱsoftȱtissue.ȱ Aȱbenignȱtumorȱthatȱusuallyȱisȱlocatedȱinȱmusclesȱbutȱdoesȱnotȱdevelopȱfromȱmuscleȱcells.ȱTheȱcellsȱofȱaȱmyxomaȱproduceȱmucusȬlikeȱ Myxomaȱ material,ȱaȱfeatureȱthatȱdistinguishesȱthisȱtumor.ȱItȱalmostȱalwaysȱoccursȱinȱadults. Granularȱcellȱ Tumorsȱareȱusuallyȱbenignȱtumorsȱofȱadultsȱthatȱoccurȱoftenȱinȱtheȱtongueȱbutȱcanȱbeȱfoundȱalmostȱanywhereȱinȱtheȱbody. TumorȬlikeȱConditionsȱofȱSoftȱTissueȱ

Someȱconditionsȱofȱsoftȱtissuesȱareȱcausedȱbyȱinflammationȱorȱinjuryȱandȱcanȱformȱaȱmassȱthatȱlooksȱlikeȱaȱsoftȱtissueȱtumor.ȱUnlikeȱaȱtrueȱtumor,ȱtheyȱdoȱnotȱcomeȱ fromȱaȱsingleȱabnormalȱcell,ȱtheyȱhaveȱlimitedȱcapacityȱtoȱgrowȱorȱspreadȱtoȱnearbyȱtissues,ȱandȱneverȱspreadȱthroughȱtheȱbloodstreamȱorȱlymphȱsystem.ȱExamplesȱ includeȱnodularȱfasciitisȱandȱmyositisȱossificans,ȱwhichȱinvolveȱtissuesȱunderȱtheȱskinȱandȱmuscleȱtissues,ȱrespectively.

Source:ȱAmericanȱCancerȱSociety.ȱWhatȱisȱaȱsoftȱtissueȱsarcoma?ȱ2006ȱAvailableȱat:ȱ http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_is_sarcoma_38.asp?sitearea=cri.ȱAccessedȱOctoberȱ10,ȱ2007.

Tableȱ8.11:ȱRelativeȱIncidenceȱofȱBenignȱBoneȱTumors

Columnȱ1 Columnȱ2 Columnȱ3 Columnȱ4 Columnȱ5 Columnȱ6

PrevalenceȱRelativeȱNationalȱAnnualȱ toȱOsteosarcomaȱ Prevalence BenignȱBoneȱTumor Mayoȱ[1] UFLAȱ[2] Mirraȱ[3] Wardȱ[4] [5] [6,ȱ7] Osteochrondroma ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ727 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ98 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,937 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ124 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.65 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,511 UnicameralȱBoneȱCyst NAȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 56 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ583 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ102 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.36 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,246 [7] GiantȱCellȱTumorȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 425 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ107 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,182 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ63 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.84 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ769 Enchondromaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 245 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ37 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ829 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ60 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.80 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ733 AneurysmalȱBoneȱCystsȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 208 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ80 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ492 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ52 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.69 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ632 MetaphysealȱFibrousȱDefectȱȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ99 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ30 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ537 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.63 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ577 [8] OsteoidȱOsteomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 245 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ56 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ635 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ25 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.33 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ302 [7] Chondroblastomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 79 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ229 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.19 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ174 ChondromyxoidȱFibromasȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 39 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ101 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.08 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ73 Osteoblastomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 63 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ37 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ142 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.03 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ27 [7] MalignantȱBoneȱTumors Osteosarcomaȱ[9] ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,330 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ324 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,525 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ75 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.00 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ916 Chondrosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 732 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ173 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ746 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ47 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.63 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ987 EwingȇsȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 402 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ141 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ871 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.44 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ339

[1]ȱSource:ȱDahlinȱDC,ȱUnniȱKK:ȱIntroductionȱandȱScopeȱofȱStudyȱinȱBoneȱTumors:ȱGeneralȱAspectsȱandȱDataȱonȱ8,542ȱCases .ȱSpringfield,ȱIL:ȱCharlesȱ C.ȱThomasȱCo,ȱ1986,ȱpgȱ8,ȱTableȱ1Ȭ1.

[2]ȱSource:ȱEnnekingȱWF:ȱMusculoskeletalȱTumorȱSurgery ,ȱvolȱII.ȱNewȱYork,ȱNY:ȱChurchillȱLivingstone,ȱNewȱYork,ȱ1983.

[3]ȱSource:ȱMirraȱJM,ȱPicciȱP,ȱGoldȱRHȱ(eds):ȱBoneȱTumors:ȱClinical,ȱRadiologicȱandȱPathologicȱCorrelations .ȱPhiladelphia,ȱPA:ȱLeaȱ&ȱFebiger,ȱ1989.

[4]ȱWardȱWG.ȱSurgicalȱcaseȱfiles,ȱ1991Ȭ2004

[5]ȱȱWardȱWG.ȱComputationȱofȱrelativeȱprevalenceȱbasedȱonȱn=75ȱcasesȱȱofȱosteosarcomaȱ(i.e.,ȱ(columnȱ4)/(75)).

[6]ȱCalculatedȱasȱannualȱprevalenceȱofȱcasesȱrelativeȱtoȱosteosarcomaȱ(i.e.,ȱcolumnȱ5ȱ*ȱnationalȱcasesȱofȱosteosarcomaȱ(ȱnȱ=ȱ916)).ȱȱȱȱȱȱȱȱȱȱȱ

[7]ȱGrossȱunderestimateȱdueȱtoȱhighȱfrequencyȱofȱtreatmentsȱrenderedȱbyȱorthopaedicȱsurgeonsȱotherȱthanȱorthopaedicȱoncologists.

[8]ȱGrossȱunderestimateȱofȱprevalenceȱsinceȱpriorȱstudiesȱhaveȱindicatedȱ1%Ȭ3%ȱofȱchildrenȱhaveȱtheseȱatȱsomeȱpointȱinȱtheirȱchildhood.ȱȱOfȱtheȱ symptomaticȱonesȱrequiringȱsurgery,ȱmanyȱareȱmanagedȱbyȱorthopaedistsȱotherȱthanȱorthopaedicȱoncologists,ȱsoȱtrueȱincidenceȱisȱvastlyȱ higherȱthanȱthatȱdepictedȱbyȱthisȱconservativeȱestimate.

[9]ȱTheȱnationalȱprevalenceȱofȱosteosarcomaȱbetweenȱ2000ȱandȱ2003ȱwasȱ916ȱcases.ȱ(Tableȱȱ8.7)ȱThisȱvalueȱisȱusedȱasȱtheȱbaseȱforȱcomputingȱtheȱ estimatedȱnationalȱprevalenceȱofȱbenignȱboneȱtumors.

Tableȱ8.12:ȱSurgicallyȱTreatedȱBenignȱSoftȱTissueȱTumorȱIncidence

IncidenceȱRelativeȱtoȱ MinimalȱEstimatedȱ Tumor Numberȱ[1] Osteosarcomaȱ[2] NationalȱIncidenceȱ[3]

Lipoma 182 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2.43ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2,226ȱ Ganglion 95 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1.27ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,163ȱ Hemangioma 51 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.68ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ623ȱ PigmentedȱVillonodular Synovitis/GiantȱCell TumorȱofȱTendonȱSheath 45 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.60ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ550ȱ Myxoma 38 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.51ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ467ȱ Desmoid/Fibromatosis 39 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.52ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ476ȱ Neurilemmoma 30 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.40ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ366ȱ Neurofibroma 19 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.25ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ229ȱ MyositisȱOssificans 14 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.19ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ174ȱ Fibroma 14 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ0.19ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ174ȱ Other 293 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3.91ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,582ȱ

[1]ȱWardȱWG:ȱcaseȱseriesȱ1991Ȭ2004ȱbyȱpatients [2]ȱȱWardȱWG:ȱComputationȱofȱrelativeȱprevalenceȱbasedȱonȱn=75ȱcasesȱofȱosteosarcomaȱ(i.e.,ȱ(number/75).

[3]ȱCalculatedȱasȱannualȱprevalenceȱofȱcasesȱrelativeȱtoȱosteosarcomaȱ(i.e.,ȱcolumnȱ2ȱ*ȱnationalȱcasesȱofȱ osteosarcomaȱ(ȱnȱ=ȱ916)).ȱȱȱThisȱprovidesȱaȱgrossȱunderestimateȱofȱtheȱUSȱnationalȱburdenȱofȱtheseȱtumors,ȱasȱ manyȱ(perhapsȱmost)ȱareȱtreatedȱbyȱotherȱphysicians,ȱincludingȱfamilyȱphysicians,ȱgeneralȱsurgeonsȱandȱgeneralȱ orthopaedicȱsurgeons.ȱȱȱȱȱȱȱȱ

Tableȱ8.13:ȱNeoplasmsȱofȱtheȱBones,ȱJointsȱandȱSoftȱTissues,ȱ20ȬYearȱCumulativeȱ CaseȱCounts,ȱ1985Ȭ2004,ȱNationalȱCancerȱDataȱBaseȱofȱtheȱAmericanȱCollegeȱofȱ SurgeonsȱCommissionȱonȱCancer

Boneȱ&ȱJointȱTumors Number SoftȱTissueȱTumorsȱbyȱTypeȱ(continued) Number TotalȱBoneȱChondrosarcomasȱ ȱȱȱȱȱȱȱȱȱ11,585 ClearȱCellȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 809 TotalȱBoneȱ&ȱJointȱOsteosarcomasȱȱȱȱȱȱȱȱȱ 14,191 Dermatofibrosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,956 DesmoplasticȱSmallȱRoundȱCellȱTumorȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 162 Boneȱ&ȱJointȱTumorsȱbyȱType EpithelioidȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,271 AdamantinomaȱofȱLongȱBonesȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 196 EwingȇsȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,113 ChondrosarcomaȱDedifferentiatedȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ238 Fibromyxosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,523 ChondrosarcomaȱJuxtacorticalȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ103 FibrosarcomaȱInfantileȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ193 ChondrosarcomaȱMesenchymalȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ251 Fibrosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,421 ChondrosarcomaȱMyxoidȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ874 GiantȱCellȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,660 Chondrosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱ 10,119 GiantȱCellȱTumorȱofȱSoftȱPartsȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ132 Chordomaȱȱȱȱȱȱȱȱȱȱȱ 2,339 GranularȱCellȱtumorȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ106 EwingȇsȱSarcomaȱȱȱȱȱȱȱȱȱȱȱ 5,882 HemangioendotheliomaȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ162 Fibrosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 405 HemangioendotheliomaȱMalignantȱEpithelioidȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ171 GiantȱCellȱTumorȱofȱBoneȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ606 HemangiopericytomaȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ986 HemangioendotheliomaȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ141 Hemangiosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,345 Hemangiosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 322 KaposiȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,914 Leiomyosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 161 Leiomyosarcoma*ȱȱȱȱȱȱȱȱȱȱȱ 13,719 MalignantȱFibrousȱHistiocytomaȱȱȱȱȱȱȱȱȱȱȱ 1,266 LeiomyosarcomaȱEpithelioid*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 629 OsteosarcomaȱChondroblasticȱ ȱȱȱȱȱȱȱȱȱȱȱ1,564 LeiomyosarcomaȱMyxoid*ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 274 OsteosarcomaȱFibroblasticȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ676 LiposarcomaȱMixedȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ627 OsteosarcomaȱinȱPagetsȱDiseaseȱofȱBoneȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 285 LiposarcomaȱMyxoidȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ6,026 OsteosarcomaȱParostealȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ756 LiposarcomaȱPleomorphicȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ2,288 OsteosarcomaȱSmallȱCellȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ120 LiposarcomaȱRoundȱCellȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ612 OsteosarcomaȱTelangiectaticȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ354 LiposarcomaȱWellȱDifferentiatedȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ3,989 Osteosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱ 10,436 Liposarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,551 PrimitiveȱNeuroectodermalȱTumorȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 213 LipsosarcomaȱDedifferentiatedȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,013 Sarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 668 MalignantȱFibrousȱHistiocytomaȱȱȱȱȱȱȱȱȱȱȱ 25,559 SpindleȱCellȱSarcoma ȱȱȱȱȱȱȱȱȱȱȱȱȱ338ȱ MesenchymomaȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ253 Totalȱȱȱȱȱȱȱȱȱ 38,313 Myxosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 363 NeurilemmomaȱMalignantȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,343 SoftȱTissueȱTumors Number Neurofibrosarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,583 SoftȱTissueȱMalignantȱHemangioendotheliomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 333 Osteosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 571 SoftȱTissueȱChondrosarcomasȱȱȱȱȱȱȱȱȱȱȱ 1,711 PeripheralȱNeuroectodermalȱTumorȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 386 SoftȱTissueȱRhabdomyosarcomasȱȱȱȱȱȱȱȱȱȱȱ 5,092 PrimitiveȱNeuroectodermalȱTumorȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 581 SoftȱTissueȱSynovialȱSarcomasȱȱȱȱȱȱȱȱȱȱȱ 5,689 RhabdomyosarcomaȱAlveolarȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,419 SoftȱTissueȱLeiomyosarcomas*ȱȱȱȱȱȱȱȱȱ 14,622 RhabdomyosarcomaȱEmbryonalȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,801 SoftȱTissueȱLiposarcomasȱȱȱȱȱȱȱȱȱ 18,106 Rhabdomyosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,316 RhabdomysarcomaȱPleomorphicȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ556 SoftȱTissueȱTumorsȱ(byȱType) SarcomaȱRhabdoidȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ140 AlveolarȱSoftȱPartȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 517 Sarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱ 9,007 Carcinosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 187 SmallȱCellȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 501 ChondrosarcomaȱMesenchymalȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ227 SpindleȱCellȱSarcomaȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,181 ChondrosarcomaȱMyxoidȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ750 SynovialȱSarcomaȱBiphasicȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,116 Chondrosarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 734 SynovialȱSarcomaȱSpindleȱCellȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,168 Chordomaȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 303 SynovialȱSarcoma,ȱNOSȱȱȱȱȱȱȱȱȱȱȱȱȱ 3,405

*ȱTotalsȱincludeȱGynecologicȱLeiomyosarcomasȱofȱtheȱUterus Source:ȱAmericanȱCollegeȱofȱSurgeonsȱNationalȱCancerȱDataȱBase

Chapter 9 Health Care Utilization and Economic Cost of Musculoskeletal Diseases

The annual average proportion of the United costs for persons with a musculoskeletal disease, States population with a musculoskeletal including other comorbid conditions, the cost of disease requiring medical care has increased treating these individuals in addition to the cost to by more than two percentage points over the society in the form of decreased wages, is estimated past decade and now includes more than 30% to be nearly $950 billion per year, 7.4% of the 2006 of the population. The increasing prevalence GDP. of musculoskeletal diseases in a growing and aging population has resulted in a more than Treatments that mitigate the long-term impact 47% increase in total aggregate direct cost to treat of musculoskeletal diseases and return persons persons with a musculoskeletal disease during to full and active lives are needed. The following this same time frame. For the years 2004-2006, chapter explores the details of cost associated with the annual average direct cost, in 2006 dollars, for musculoskeletal diseases and establishes a baseline musculoskeletal health care, both as a direct result against which to assess future needs. of a musculoskeletal disease and for patients with a musculoskeletal disease in addition to other Section 9.1: Musculoskeletal Disease health issues, is estimated to be $576 billion, the Prevalence equivalent of 4.5% of the national gross domestic product (GDP). Incremental medical cost, that proportion of total direct cost associated with Over the period 2004-2006, an estimated treatment incurred beyond that of persons of 89.7 million persons annually reported a similar demographic and health characteristics musculoskeletal disease in the Medical but who do not have one or more musculoskeletal Expenditures Panel Survey (MEPS) as a primary diseases (i.e., most likely att ributable to a health concern (Table 9.1 and Graph 9.1.1), a musculoskeletal disease), is estimated to be $160.5 substantially lower number than the 110.34 million billion. musculoskeletal diseases self-reported by adults aged 18 and over in the National Health Interview Indirect cost, expressed primarily as wage losses Graph 9.1.1: Prevalence of Musculoskeletal Diseases and Proportion for persons aged 18 to 64 with a work history, of Total Population with Musculoskeletal Disease, United States add another $373.1 billion, or 2.9% of the GDP 1996-2006 [1] 100 35 in 2004-2006, to the cost for all persons with % of U.S. Population a musculoskeletal disease, either treated as a 80 60 primary condition or in addition to another 30 40 (in millions)

condition. Annual indirect costs att ributable to of Prevalence musculoskeletal disease alone (incremental cost) 20 Musculoskeletal Diseases 0 25 are estimated to account for $127 billion of these 1996 1997 1998 1999 2000 2001 2002 2003 2004 to to to to to to to to to indirect costs. 1998 1999 2000 2001 2002 2003 2004 2005 2006 Prevalence Musculoskeletal % US Population The annual estimated direct and indirect cost Conditions [1] Data smoothed across each three year period. att ributable to persons with a musculoskeletal Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research disease is $287 billion. Taking into account all and Quality, U.S. Department of Health and Human Services, 1996-2006

Survey (NHIS) in 2008 and reported in Chapter 1 Among the major subgroups of musculoskeletal (Burden of Musculoskeletal Disease Overview.) diseases, arthritis and joint pain have the highest A more expansive defi nition of musculoskeletal prevalence, refl ecting the overall aging population. diseases includes persons in whom the In 1996-1998, just under 30 million persons (11.0%) musculoskeletal disease is a by-product of another reported one or more conditions related to arthritis condition and, therefore, is oft en not the primary and joint pain; by 2002-2004, 37.6 million persons (Dx1) diagnosis (e.g., bone metastases from (12.9%) reported one or more such conditions. cancer), as well as musculoskeletal diseases as a The eff ect of the baby boom generation aging has primary health concern. Using this more expansive resulted in an increase in the proportion of arthritis defi nition of musculoskeletal diseases (discussed cases among those aged 45 to 64 as they reach the in Section 9.5 and Table 9.16), an average of 135.6 typical onset age for arthritis. As this wave ages, million persons, or 46.6% of the population, the proportion of persons with arthritis in the 65 reported a musculoskeletal disease annually for and older group will increase as well. In 1996-1998, the years 2002 to 2004. Assuming the proportion 24.8% of persons reporting arthritis were aged of musculoskeletal diseases among persons under 18 to 44; 36.4% were aged 45 to 64. By 2002-2004, the age of 18 is at least 10%, the incidence of the proportions had changed to 21.7% and musculoskeletal diseases in the NHIS and MEPS 41.6%, respectively. In the next decade, a higher are similar. prevalence of arthritis and joint pain is expected to occur in persons aged 65 and over. Between 1996-1998 and 2004-2006, the number of persons reporting a musculoskeletal disease The number of persons reporting a spine condition increased nearly 14 million from the 76 million increased by just under 5 million, from 27.4 reported in 1996. During this same time period, the million in 1996-1998 to 32.7 million in 2002-2004, prevalence of musculoskeletal diseases in the total while the prevalence rate increased by more than U.S. population increased by about 2%, from 28% one percentage point, from 10.1% to 11.3% of the to over 30%. (Table 9.1 and Graph 9.1.1) population. The majority of spine conditions occur in working age people, with 42% among persons Approximately 10% of all persons reporting aged 18 to 44 and another 37% among those musculoskeletal diseases in MEPS are under the aged 45 to 64. The higher prevalence rate among age of 18, primarily due to the higher prevalence working age persons is refl ected in the prominence of musculoskeletal injuries (21%) in this age group. of spine conditions in workers’ compensation and (Table 9.1 and Graph 9.1.2) Roughly one in four

(23%) musculoskeletal diseases occur in persons Graph 9.1.2: Age Distribution of Musculoskeletal Diseases, aged 65 and over. A relatively high proportion United States, 2002-2006 (54%) of the category that includes osteoporosis, All Musculoskeletal Conditions [1] “Other Disorders of Bone and Cartilage,” occurs

in this age group. In contrast, the proportion of Other Musculoskeletal injuries and spine conditions are signiﬁ cantly Conditions [2] lower in persons aged 65 and over (14% and 17%, Injuries [2] respectively). Approximately one-third (34%) of Osteoporosis [2] Arthritis and musculoskeletal diseases occur among persons Joint Pain [2] aged 45 to 64, yet this group accounts for 42% of Spine [2] the arthritis and joint pain conditions. Overall, 0% 20% 40% 60% 80% 100%

more than 75% of musculoskeletal diseases are Under 18 18-44 45-64 65 & Over

reported by persons under the age of 65. Source: [1] Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2004-2006 [2] Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2002-2004

disability claims. Nevertheless, about one in six treatment episodes include total cases treated spine conditions (17%) occurs among persons 65 in doctors’ oﬃ ces, outpatient clinics, emergency and older. rooms, and inpatient admissions in 2006/2007.

Population aging has also led to a dramatic The percentage of the population reporting other increase in the prevalence of the category that musculoskeletal diseases, which include a broad includes osteoporosis. In the period 1996-1998, range of conditions of less frequent prevalence, 3.2 million people (1.2%) indicated they had increased from 4.4% to 5.0% between 1996-1998 these conditions, but by 2002-2004, 6.8 million and 2002-2004. The total number of persons (2.3%) reported having them. These numbers are reporting one or more such conditions increased substantially lower than the 9.9 million persons from 12 million to 14.5 million. with self-reported osteoporosis presented in Chapter 5 (Osteoporosis and Bone Health), Over the period 1996-2004, the proportion of even though the category in this chapter is not persons with one or more of the major subgroups limited to osteoporosis-related conditions, and of musculoskeletal diseases, with the exception of by the National Osteoporosis Foundation, which injuries, has risen. Throughout the period under projected 44 million persons with osteoporosis in study, arthritis and joint pain has been the major 2002. Almost two-fi ft hs of persons in the MEPS condition subgroup with the highest prevalence with these conditions are aged 45 to 64, increasing rate, followed by spine conditions. (Table 9.1 and the likelihood that the more than two and a half Graph 9.1.3) million individuals in this age group will suff er from falls and fractures for the relatively long ȱȱ ȱşǯŗǯřǱȱęȱȱȱ ȱȱ¢ȱȱȱȱȱȱȱǰȱ future they can expect to live. ȱȱȱȱŗşşŜȬŘŖŖŜ 35% In contrast to spine conditions, arthritis, and joint 30% pain, and the category including osteoporosis, 25% the prevalence of musculoskeletal injuries has 20% remained steady. In 1996-1998, 23.4 million 15% 10% persons reported a musculoskeletal injury, while % of Total Population % of Total 5% 24.7 million reported such an injury in 2002-2004. 0% 1996 1997 1998 1999 2000 2001 2002 2003 2004 The prevalence of musculoskeletal injuries to to to to to to to to to remained relatively constant at 7.7% and 8.6% of 1998 1999 2000 2001 2002 2003 2004 2005 2006 the population. Age distribution of injuries may Source: Medical Expenditures All Musculoskeletal Panel Survey (MEPS), Agency for explain why the prevalence hasn’t increased. In Conditions Healthcare Research and Quality, Spine U.S. Department of Health and excess of 60% of injuries occur among persons Human Services, 1996-2006 Arthritis and Joint Pain younger than 45, a population segment growing Osteoporosis Note: Totals more than 100% due more slowly than those who are older. It is possible to multiple conditions reported. Injuries improvements in the safety of automobiles and Other MS other public health prevention activities have also played a role. However, although the MEPS Using the more expansive defi nition of reporting of musculoskeletal injury trends musculoskeletal diseases (Table 9.16), in the period supports trend data previously reported, the 2002-2004, 83.0 million persons (vs. 32.7 million overall prevalence is substantially lower than the using the more conservative defi nition) reported 61.2 million injury treatment episodes reported one or more spine conditions and 41.7 million (vs. in Chapter 6 (Musculoskeletal Injuries). Injury 37.6 million) reported arthritis and joint pain. The number reporting a condition within the category that includes osteoporosis was identical in the base

and expansive cases, but substantially lower than In contrast to the relatively stable number of reported in Chapter 5, as noted above. The number physician offi ce visits, there was an increase reporting musculoskeletal injuries was slightly in the proportion of the U.S. population with higher than in the more conservative defi nition visits to ambulatory providers other than (27.8 vs. 24.7 million). The increased prevalence in medical physicians; the average number of the “other” musculoskeletal diseases category was visits to non-physician providers by persons also substantial, with 45.1 million in the expansive with musculoskeletal diseases also increased. defi nition versus 14.5 million, as discussed above. Non-physician ambulatory health care providers include physical therapists, occupational Section 9.2: Musculoskeletal Health therapists, chiropractors, social workers, physician Care Utilization assistants, nurse practitioners, and other related health care workers. In 1996-1998, approximately 40% of persons with musculoskeletal diseases Persons with musculoskeletal diseases account visited an ambulatory health care resource at least for a large and growing share of health care once; by 2002-2004 the proportion had jumped to utilization. (Table 9.2 and Graph 9.2.1) In any given nearly 52%. At the same time, the average number year, abut 85% of persons with musculoskeletal of such visits increased from 2.6 per person to 3.8. diseases have at least one ambulatory care visit to The result was a 69% increase, from 197.5 million a physician’s offi ce, averaging just under six such to 332.8 million, in total non-physician ambulatory visits per year. Between 1996-1998 and 2002-2004, care visits between 1996-1998 and 2002-2004. The ambulatory physician visits increased from 425.5 aggregate total for all ambulatory care visits, million to 507.9 million. Growth in the number of including those to physicians and non-physicians, persons with musculoskeletal diseases, rather than thus increased over the 8 year period by 35%, from an increase in the number of visits by individuals, 623.0 million visits to 840.7 million visits. is primarily responsible for this increase. During this same time frame, the use of prescription medications among persons with musculoskeletal diseases rose substantially. While the proportion of persons with a musculoskeletal Graph 9.2.1: Total Units of Health Care Utilization for Persons with Musculoskeletal Diseases by Treatment Type, disease who fi lled at least one prescription United States, 1996-2004 changed only slightly, from 81.3% to 83.5%, the 2000 mean number of prescriptions fi lled per person increased from 13.1 to 18.6. The result was a 64% 1500 increase, from 995.3 million in 1996-1998 to more than 1.6 billion in 2002-2004, in the number of 1000 prescription medications fi lled by persons with a musculoskeletal disease. Prescriptions Filled 500 Total Visits, Discharges or Visits, Total Despite widespread concerns that an aging 0 1996 1997 1998 1999 2000 2001 2002 population would use an increasing amount of to to to to to to to 1998 1999 2000 2001 2002 2003 2004 home health care, there is no evidence that this is occurring. Both the proportion of persons with a Physician Visits Ambulatory Care musculoskeletal disease using home health care Prescription Meds Home Health Care Days and the average number of home health care visits Hospital Discharges declined slightly in the past 8 years. Only 4.7% of Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department of Health and persons reported any home health care visits in Human Services, 1996-2004 2002-2004, with an average of 3.5 visits incurred.

The total number of home health care visits to than twice the rate of all other musculoskeletal persons with a musculoskeletal disease rose diseases. This is most likely due to greater slightly, from 296.3 million to 306.5 million, and is awareness of these diseases and the impact of due to population increase. medications on mitigating long-term impacts.

A slight increase of 15%, from 15.2 to 17.5 million, Using the more expansive deﬁ nition of in the number of hospital discharges for persons musculoskeletal diseases, in 2002-2004 there with a musculoskeletal disease occurred in the were an estimated 705 million visits to physicians periods 1996-1998 to 2002-2004. This may be among persons with these diseases, as well as 420 due to the aging population. The percentage of million ambulatory visits to providers other than persons with a musculoskeletal disease who were physicians, 2.3 billion prescriptions ﬁ lled, 420 hospitalized one or more times rose by 5% in million home care visits, and 27.1 million hospital relative terms, from 11.1% to 11.7%. The average discharges. number of hospitalizations per person, at 0.2, did not change. Section 9.3: Musculoskeletal Medical Graph 9.2.2: Annual Change in Total Health Care Utilization Units for Care Expenditures Persons with Musculoskeletal Diseases by Treatment Type, United States, 1996-2004 20% Musculoskeletal medical care expenditures 15% are presented (1) for all persons with a 10% musculoskeletal disease, regardless of whether 5% the musculoskeletal disease was the reason for 0%

Year Average Year the expenditure (total cost), and (2) as a measure -5% of the expenditures beyond those expected for

Change in Utilization Units,3 -10% persons of similar characteristics but who do not -15% 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 1996-1998 to to to to to to to have a musculoskeletal disease (incremental cost). 1997-1999 1998-2000 1999-2001 2000-2002 2001-2002 2002-2004 2002-2004 Incremental cost, hence, is that share estimated

Source: Medical Expenditures Panel Physician Visits to be directly related to the musculoskeletal Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department Ambulatory Care condition. Both total and incremental costs are of Health and Human Services, Prescription Meds 1996-2004 expressed as the average cost per person with a Home Health Care Days Hospital Discharges musculoskeletal disease (Tables 9.4 and 9.4a) and the aggregate cost (total) for all persons with a Over the seven 3-year averaged periods, 1996-1998 musculoskeletal disease. (Table 9.5) Medical care to 2002-2004, for which the MEPS data is analyzed, costs are expressed in both the current year dollars prescription medications and non-physician care (i.e., the year the data was collected) and in 2004 visits increased more than other categories of dollars to provide a standard of comparison across health care percentage wise. (Table 9.3 and Graph years. 9.2.2) Both showed a mean rise of nearly 10% per year in total health care resource usage, with the Section 9.3.1: Total and Per Person Expenditures most rapid rise occurring in the last four years of for Musculoskeletal Diseases the study analysis. The greatest increase in health care resource use was for persons reporting a Overall, total average expenditures for persons condition in the category including osteoporosis, with musculoskeletal diseases increased from increasing by 13% or more annually for each of $5,151 in 1996-1998 to $6,429 in 2004-2006, in the past 7 years for all except hospital discharges. 2006 dollars, a 25% increase. (Table 9.5, Column Medications ﬁ lled for such diseases rose by more D and Graph 9.3.1) Aggregate total expenditures than 20% per year between 1996 and 2000, more

Graph 9.3.1: Mean Medical Care Cost Per Person with a Musculoskeletal Incremental average expenditures for persons with Disease in 2006 $s, United States, 1996-2006 musculoskeletal diseases was relatively constant $8,000 between 1996-1998 and 2004-2006, in 2006 dollars. $7,000 Estimated costs dropped slightly from $1,827 to $6,000 $1,790, or a 2% decrease. (Table 9.5, Column H and $5,000 Graph 9.3.1) Aggregate incremental expenditures, $4,000 due to the higher number of persons with a $3,000 musculoskeletal condition, increased from $138.8 Mean Cost Per Person Mean Cost Per $2,000 billion to $160.5 billion, in 2006 dollars, (Table $1,000 9.5, Column J and Graph 9.3.2), or by about 16%. $0 1996 1997 1998 1999 2000 2001 2002 2003 2004 Incremental cost associated with a musculoskeletal to to to to to to to to to 1998 1999 2000 2001 2002 2003 2004 2005 2006 condition represented the equivalent of 2.0% and

[1] Includes all medical expenditures for Total [1] 2.9% of the GDP, in 2006 dollars, for the respective persons with a musculoskeletal condition regardless of whether the time frames. To provide a basis for comparison, expenditure was to treat the musculosk- Incremental [2] eletal condition or another condition. the economy is said to be in a recession when GDP Source: Medical Expenditures [2] Estimated additional medical Panel Survey (MEPS), Agency for declines by at least 1% for two or more consecutive expenditures beyond those expected for Healthcare Research and Quality, persons of similar characteristics, but U.S. Department of Health and quarters. Accordingly, the aggregate economic without a musculoskeletal condition. Human Services, 1996-2006 impact of the medical expenditures on behalf of persons with musculoskeletal diseases is in excess increased from $391.4 billion to $576.4 billion, in of the amount used to deﬁ ne a recession and, 2006 dollars, during this time frame (Table 9.5, unlike a recession, occurs in perpetuity. Column F and Graph 9.3.2), an increase of 47%. In 1996-1998, aggregate total expenditures for Data for speciﬁ c musculoskeletal conditions has persons with a musculoskeletal disease, including been analyzed through the 2002-2004 time period, both primary (1st) and secondary (2nd or more) and is shown in 2004 dollars. Total per person diagnoses, represented 3.75% of the GDP, in 2006 medical care expenditures rose slightly for each dollars. By 2004-2006, the proportion had grown to of the major subconditions between 1996-1998 1 4.49% of the GDP. and 2002-2004 (Tables 9.4 and 9.5, Column D, and Graph 9.3.2: Aggregate Medical Care Cost for Person with a Graph 9.3.3), ranging from $5,161 per person for Musculoskeletal Disease in 2006 $s, United States, 1996-2006 musculoskeletal injuries to $8,565 for conditions $600 within the category including osteoporosis in

$500 2002-2004. Due to the higher prevalence and relatively high level of expenditures per person, $400 aggregate expenditures have consistently been

$300 greatest for arthritis and joint pain, accounting for $281.5 billion of musculoskeletal health care costs $200 in 2002-2004. (Table 9.5, Column F, and Graph Aggregate Cost (in billions) $100 9.3.4) As discussed previously, approximately one-third of the cost is for ambulatory care (33%), $0 1996 1997 1998 1999 2000 2001 2002 2003 2004 one-third for emergency room and inpatient care to to to to to to to to to 1998 1999 2000 2001 2002 2003 2004 2005 2006 (32%), and one-third for prescriptions and other

[1] Includes all medical expenditures for costs (36%). Spine conditions, with an estimated Total [1] persons with a musculoskeletal condition regardless of whether the $193.9 billion cost in 2002-2004, have held steady expenditure was to treat the musculosk- Incremental [2] eletal condition or another condition. as the second most expensive musculoskeletal Source: Medical Expenditures [2] Estimated additional medical Panel Survey (MEPS), Agency for health care condition. Spine costs also split evenly, expenditures beyond those expected for Healthcare Research and Quality, with 34%, 32%, and 34% going to ambulatory, persons of similar characteristics, but U.S. Department of Health and without a musculoskeletal condition. Human Services, 1996-2006

Graph 9.3.3: Total and Incremental per Person Medical Care emergency room category including osteoporosis. However, a Expenditures for Persons with Musculoskeletal Diseases, United States, 2002-2006 and inpatient, “back of the envelope” estimate of the ratio of All Musculoskeletal Diseases [4] and prescriptions/ incremental to total expenditures for persons other costs, with all forms of musculoskeletal diseases for the

Spine [5] respectively. period 2002-2004 is possible. Applying the same

Arthritis and Joint Pain [5] ratio to the category including osteoporosis yields

Osteoporosis [3, 5] The magnitude an estimate of about $18 billion in incremental

Injuries [5] of increase expenditures for these conditions.

Other Musculoskeleta in aggregate Conditions [5] $0 $2,000 $4,000 $6,000 $,8000 $10,000 expenditures Using the more expansive deﬁ nition of Per Person Expenditures between musculoskeletal diseases, aggregate total medical Total [1] Incremental [2]

[1] Includes all medical expenditures for persons with a musculoskel- 1996-1998 and care expenditures on behalf of persons with a etal disease regardless of whether the expenditure was to treat the musculoskeletal disease or another disease. 2002-2004 is musculoskeletal disease were $718.5 billion in [2] Estimated additional medical expenditures beyond those expected for persons of similar characteristics, but without a musculoskeletal disease. greatest for the 2002-2004, while the aggregate increment in [3] All individuals with osteoporisis had expenditures and total increment could not be calculated. [4] All musculoskeletal diseases per person medical cost calculated for diseases within expenditures was $322.2 in the same period. Total 2004-2006, based on 2006 $s. [5] Musculoskeletal conditions by type calculated for 2002-2004, based the category expenditures are the equivalent of 6.5% of GDP on 2004 $s. Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department of Health and including for those years, while the incremental cost is the Human Services, 2002-2006 osteoporosis equivalent of 2.9% of GDP. Graph 9.3.4: Aggregate Total and Incremental Medical (120%), but was Care Expenditures for Persons with Musculoskeletal Diseases, United States, 2002-2006 substantial for all Section 9.3.2: Medical Care Expenditures for All Musculoskeletal musculoskeletal Diseases [4] Persons with a Musculoskeletal Disease by diseases. Demographics Spine [5] (Table 9.6) The

Arthritis and aggregate cost of Joint Pain [5] Expenditures for musculoskeletal diseases are health care for Osteoporosis [3, 5] not distributed evenly across groups deﬁ ned by spine conditions Injuries [5] gender, race, ethnicity, marital status, and type increased by 49%; Other Musculoskeleta of insurance. (Table 9.7 and Graph 9.3.5) On an Conditions [5] arthritis and joint $0 $100 $200 $300 $400 $500 $600 unadjusted basis, women with musculoskeletal Aggregate Expenditures (in billions) pain by 53%; diseases have about a 20% higher level of Total [1] Incremental [2] musculoskeletal expenditures than men; whites have a 30% higher [1] Includes all medical expenditures for persons with a musculoskeletal disease regardless of whether the expenditure was to treat the injuries by musculoskeletal disease or another disease. level than non-whites; non-Hispanics report 67% [2] Estimated additional medical expenditures beyond those expected for persons of similar characteristics, but without a musculoskeletal 37%; and other disease. higher expenditures than Hispanics; those who [3] All individuals with osteoporisis had expenditures and total musculoskeletal increment could not be calculated. are married or divorced, separated, or widowed [4] All musculoskeletal diseases aggregate medical cost calculated for 2004-2006, based on 2006 $s. diseases by 44% [5] Musculoskeletal conditions by type calculated for 2002-2004, based have more than 87% higher expenditures than on 2004 $s. over the period Source: Medical Expenditures Panel Survey (MEPS), Agency for those who have never been married; and those Healthcare Research and Quality, U.S. Department of Health and Human Services, 2002-2006 1996-2004. with private and public health insurance have more than two and more than three times, Sampling variability limits inference about time respectively, the expenditures of those without any trends in incremental expenditures associated with health insurance. Thus, lack of health insurance is the subcondition groups. However, while estimates associated with dramatically lower expenditure do not have the same precision as those for all levels, inconsistent with the belief that persons musculoskeletal diseases, it is fair to conclude that who lack insurance are somehow able to obtain 2002-2004 aggregate incremental expenditures were care. In contrast to the diﬀ erences in expenditure between $24.5 billion for other musculoskeletal levels found for gender, race, ethnicity, marital diseases and $37.3 billion for arthritis and joint pain. We were unable to estimate an increment in expenditures att ributable to conditions in the

Graph 9.3.5: Per Person Total Medical Care Expenditures for Persons with Musculoskeletal insured had more Diseases by Select Demographics, United States, 2002-2004 than two times the expenditures $8,000 of those with $7,000 public insurance $6,000 and almost

$5,000 four times the expenditures of $4,000 those without $3,000 insurance.

$2,000 Education level presented no $1,000

Per Person Expenditures (in 2004 billion $s) Person Per clear picture of $0 All Female Male White Non- Non- Hispanic Married Never Public Private None diff erences due Persons White Hispanic Married to an anomalous with Divorced/ Musculoskeletal Widowed/ result among Disease Separated Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department those who have of Health and Human Services, 2002-2004 graduated Includes all medical expenditures for persons with a musculoskeletal disease regardless of whether the expenditure from college; was to treat the musculoskeletal condition or another disease. in general, expenditures status, and type of health insurance, there was rose with higher levels of education. In no discernible patt ern in expenditure levels by contrast, adjustment did eliminate diff erence in educational att ainment. expenditures between genders. Adjustment for other characteristics reduced the magnitude of the diff erences in expenditures found for most demographic Graph 9.3.6: Per Person Incremental Medical Care Expenditures for Persons with Musculoskeletal characteristics, Diseases by Select Demographics, United States, 2002-2004 but did not $2,500 eliminate them. (Table 9.7 and $2,000 Graph 9.3.6)

Thus, whites $1,500 experienced

about 55% $1,000 higher levels

of incremental $500 expenditures Per Person Expenditures (in 2004 billion $s) Person Per than non-whites; $0 All Female Male White Non- Non- Hispanic Married Never Public Private None non-Hispanics Persons White Hispanic Married with Divorced/ reported just Musculoskeletal Widowed/ under double Disease Separated Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department the expenditures of Health and Human Services, 2002-2004

of Hispanics; Includes estimated additional medical expenditures beyond those expected for persons of similar characteristics, but and the privately without a musculoskeletal disease.

Section 9.3.3: Medical Care Expenditures for Graph 9.3.8: Aggregate Total Medical Care Expenditures for Persons with a Musculoskeletal Disease by Age Persons with Musculoskeletal Diseases by Age, United States, 2002-2004 Total medical care expenditures for All Ages musculoskeletal diseases are disproportionately higher for persons 65 years of age or older, with a per person cost of nearly $10,000 in 2002-2004 compared to a per person cost of $5,824 for all 65 & Over ages. (Table 9.8 and Graph 9.3.7) Persons aged 65 45 to 64 and over represent more than one in ﬁ ve persons

with a musculoskeletal disease; this age group 18 to 44 accounted for 38%, or $195.2 billion, of total aggregate health care costs for musculoskeletal Under 18 diseases in 2002-2004. (Table 9.9 and Graph 9.3.8) $0 $100 $200 $300 $400 $500 $600 However, incremental aggregate musculoskeletal Total Aggregate Cost (in 2004 billion $s) Source: Medical Expenditures Panel Survey (MEPS), Agency for health care for the 65 and over population is Healthcare Research and Quality, U.S. Department of Health and estimated to comprise 25%, or $39.1 billion, of Human Services, 2002-2004 the total $156.4 billion cost. Persons aged 45 Includes all medical expenditures for persons with a musculoskeletal disease regardless of whether the expenditure was to treat to 64 accounted for an equal or slightly higher the musculoskeletal disease or another disease. proportion of the cost (39% of aggregate and 47% of incremental), but represent a substantially musculoskeletal diseases in that year. This share higher proportion of the population (34% aged 45 occurs disproportionately among the 45 to 64 age to 64; 23% aged 65 years and older). group, which accounted for 67% of the cost for persons aged 18 to 64, and had an 83% relative Estimated 2002-2004 aggregate total expenditures increase between 1996-1998 and 2002-2004 in total for persons aged 18 to 64 were $295.9 billion, or aggregate cost. This compares to a 12% to 30% 58% of total aggregate health care expenditures for relative increase in total cost for other age groups. Graph 9.3.7: Total per Person Medical Care Expenditures for Less than $19 billion of the total musculoskeletal Persons with Musculoskeletal Diseases by Age, United States, 2002-2004 health care costs went for persons under the age of 18, representing only 10% of total cost. All Ages With a 90% relative increase in incremental cost over the two periods 1996-1998 and 2002-2004, the

65 & Over 45 to 64 age group also accounts for the largest share of incremental aggregate health care cost for 45 to 64 musculoskeletal diseases. (Table 9.10) In contrast, incremental costs were relatively stable over this 18 to 44 same time period for both persons under the age of

Under 18 18 and those aged 18 to 44, while the 65 and over population saw a 15% relative decrease in total $0 $2,000 $4,000 $6,000 $8,000 $10,000 Mean per Person Cost (in 2004 $s) incremental musculoskeletal health care costs.

Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department of Health and As the population aged, both the proportion of Human Services, 2002-2004 total persons with a musculoskeletal disease and Includes all medical expenditures for persons with a musculoskeletal disease regardless of whether the expenditure was to treat the share of cost att ributed to the baby boomer the musculoskeletal disease or another disease. generation, the majority of whom are now 45 to

Graph 9.3.9: Proportion of Total Medical Care Expen- care costs devoted to prescription medications ditures for Persons with Musculoskeletal Diseases by increased the most, growing by 50%, from 14% Age, United States, 1996-2004 to 21% of total cost. Computed in 2004 dollars, the mean annual prescription cost per person 100% 65 & Over increased 83%, from $653 to $1,196. During this time, development of biologic agents for several 80% 45 to 64 inﬂ ammatory conditions, particularly rheumatoid

18 to 44 arthritis, occurred, as well as the widespread use of 60% the coxibs for musculoskeletal pain,i and may have < 18 accounted for some of the rapid increase. 40%

Percent of Total Cost of Total Percent Recent analysis for the years 2005 and 2006

20% has shown a slight decrease in the cost of prescriptions, resulting in a slight reduction in average mean cost. The authors has speculated 0% 1996 1997 1998 1999 2000 2001 2002 that the introduction of COX-2 inhibitors in late to to to to to to to 1998 1999 2000 2001 2002 2003 2004 1999 and the subsequent aggressive advertising Includes all medical expenditures for persons with a musculoskel- both increased prescription costs and brought etal disease regardless of whether the expenditure was to treat the more patients into doctors’ offi ce to request musculoskeletal disease or another disease. prescriptions. The withdrawal of Vioxx from the Source: Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research and Quality, U.S. Department of Health and market in late 2004 necessarily meant that many Human Services, 2002-2004 individuals with musculoskeletal conditions switched to cheaper, non-COX-2 medications 64 years of age, rose steadily, while the shares for pain management, or even over-the-counter att ributed to other ages declined. (Table 9.8 and medications, the cost of which is not captured in Graph 9.3.9) As the U.S. population aging trend MEPS.2 continues and boomers move into the 65 and over age group, the combination of a larger patient The increment in ambulatory care expenditures population with potentially higher cost of care for musculoskeletal diseases grew by 31% between is likely to refl ect increased cost associated with 1996 and 2004, from $702 to $923 in 2004 dollars. musculoskeletal diseases in the years to come. Meanwhile, the increment in emergency room and These increases are likely to surpass even the rapid inpatient care declined slightly, from $304 in the increases seen in the past decade. earlier years to $263 in 2002-2004, or by about 13% overall. It is noteworthy that almost no change Section 9.4: Impact of Musculoskeletal in the increment in prescription expenditures Diseases on the U.S. Economy was seen between 1996-1998 and 2002-2004, an indication that the growth in prescription medications overall did not aff ect those with Section 9.4.1: Overall Change in Musculoskeletal musculoskeletal diseases disproportionately. Diseases Health Care Cost Ambulatory care represents the largest component of the increment in expenditures, indicative of the Over the period 1996-2004, slight changes in the importance of ambulatory care in musculoskeletal proportion of total medical care expenditures diseases relative to other condition groups. devoted to ambulatory physicians visits (from

31% to 33% of total) and to emergency room i Rofecoxib [Vioxx©] was removed from the market in September and inpatient care (from 36% to 32%) occurred. 2004; valdecoxib [Bextra©] was taken oﬀ the market in 2005; the use of However, the share of musculoskeletal health celecoxib [Celebrex©] was curtailed starting in 2005.

The eroding share of total expenditures for the increase in medical costs (1960s and late emergency room and inpatient care between 1990s). Recent analysis of musculoskeletal direct 1996 and 2004 is consistent across the major and indirect cost (i.e., the cost of lost wages due sub-conditions, while in each of the same to musculoskeletal conditionsf or persons aged subconditions, prescriptions are responsible for 18 to 64 with a work history) as a proportion of a growing share of total expenditures. For spine GDP shows a slow, but steady, increase in the conditions, the increase in the share was from 13% share of GDP spent on musculoskeletal conditions to 20% of all expenditures, or an increase of 54% between 1998 and 2005. The slight decline found in relative terms. The analogous growth in the in 2006 is most likely the result of the reduction in share of medical care expenditures for arthritis prescription costs as discussed earlier and indirect and joint pain was 53%. For the category including cost related to earnings loss (discussed below). osteoporosis, it was 41%, while for injuries, it However, musculoskeletal diseases have cost more was 55%. As was the case with respect to the than 6% of the annual GDP since the year 2003. components of total expenditures, the increment (Table 9.14 and Graph 9.4.1) in expenditures for prescription medications was neither large nor consistent, another indication Trends in Graph 9.4.2: Total and Incremental Aggregate Indirect Cost [1] in 2004 Dollars for Persons Age 18 to 64 with that the growth of such expenditures did not earnings Musculoskeletal Diseases and a Work History, United States, 1996-2006 occur disproportionately among musculoskeletal losses diseases relative to other condition groups. associated 1996 to 1998 with musculo- 1997 to 1999 Section 9.4.2: Indirect Cost Related to skeletal 1998 to 2000 Musculoskeletal Diseases diseases, 1999 to 2001 which aﬀ ect 2000 to 2002

In the studies conducted by Rice and colleagues the share of 2001 to 2003 GDP cost, for starting in the early 1960s, indirect cost associated 2002 to 2004 the period with earnings losses due to musculoskeletal 2003 to 2005 1996-2006 diseases constituted between 38% and 59% of 2004 to 2006 3-7 show a steady the total cost of these diseases. The percentage $0 $50 $100 $150 $200 $250 $300 $350 $400 shift ed because in various eras, medical costs increase Indirect Costs/Earnings Loss (in 2006 billion $) were rapidly escalating while earnings stagnated through 2005, Total Incremental with a slight [1] Calculated as estimated earnings loss per wage earner due to a (1970s); in others times, wage growth exceeded musculoskeletal condition in 2006 $. decrease Graph 9.4.1: Costs of Musculoskeletal Diseases as a Percentage of Annual Source: Medical Expenditures Panel Survey (MEPS), Agency for in 2006, Healthcare Research and Quality, U.S. Department of Health and GDP by Year, United States, 1998-2006 Human Services, 1996-2006 8% believed to 7% be caused by ﬂ uctuations in the labor market and 6% the extension of work life by workers aged 65 and 5% older. (Table 9.12 and Graph 9.4.2) 4% 3% Estimates of earnings losses are limited to persons 2% aged 64 or younger, both because the number of Medical Costs as % of Annual GDP Medical Costs as % of 1% 1998 1999 2000 2001 2002 2003 2004 2005 2006 workers over 65 in MEPS is too small to permit

Total (raw) Source: Yelin E, Murphy MG, Cisternas MG, Foreman DJP, statistically reliable estimates in this age group Aggregate Helmick CG. Medical care expenditures and earnings Direct Cost losses among persons with arthritis and other rheumatic and because in the U.S. most workers retire by that conditions in 2003, and comparisons with 1997. Arthritis Total (raw) Rheum 2007; 56:1397-1407. Additional analysis of MEPS age. However, it is probable that some individuals Indirect 1996-2004 data conducted by Yelin E; 2005-2006 data Costs conducted by Cisternas, M. with musculoskeletal diseases would continue Total GDP: Gross Domestic Product Direct + working past the age of 65 in the absence of the Indirect condition. Similarly, the tabulation of earnings

losses is limited to those who have established a million persons with musculoskeletal diseases work history either prior to or aft er the onset of and a work history sustained average incremental disease. There may be some among those without earnings losses of $753, or $48.1 billion overall, a work history who would have begun to work in 2006 dollars, the equivalent of 0.5% of GDP in the absence of a musculoskeletal disease, but for 1996-1998. Average incremental earnings who never had the opportunity to do so. Thus, the losses more than double by 2003-2005, to $1,906; magnitude of earnings losses shown should be aggregate incremental earnings losses increased considered a conservative estimate. by 2.5 times to $141.6 billion, or 1.1% of GDP for 2003-2005. The slight drop for the years 2004-2006 As of 1996-1998, slightly fewer than 64 million to a mean of $1,696 and an aggregate of $126.9 persons with a musculoskeletal disease had billion is believed to be due to market changes. established a work history. On average, these individuals sustained $3,257 in earnings losses in Using the more expansive defi nition of 2006 dollars; their earnings losses aggregated to musculoskeletal diseases, average earnings losses $207.9 billion, or the equivalent of 2.0% of GDP for increased from $3,226 in 1996-1998 to $3,972 in that period. By 2004-2006, the number of persons 2002-2004, or by just under one-fourth in real with musculoskeletal diseases and a work history terms. At the same time, aggregate total earnings had grown to over 74.8 million. On average, these losses rose by almost 40%, from $306.0 billion nearly 75 million workers sustained earnings in 1996-1998 to $426.0 billion in 2002-2004. Over losses of $4,986 each, an increase of 53% compared the same time period, the average increment in to 1996-1998. Aggregate earnings losses grew earnings losses increased from $411 to $948, while to $373.1 billion, an increase of 79%, but down aggregate incremental earnings losses surged slightly from the $390 billion of the previous year. from $39.0 billion to $101.7 billion. Interestingly, Aggregate losses in 2004-2006 were the equivalent the aggregate incremental earnings losses are of 2.9% of GDP for that period. Wage growth in smaller for the conservative defi nition, presumably the late 1990s played a large role in the increase in because many persons with conditions of lesser the estimate of earnings losses. Average earnings severity are included. (Note: data on earnings losses grew by more than one-third between losses of persons meeting the expansive defi nition 1996-1998 and 1998-2000 (from $3,257 to $4,373 of musculoskeletal diseases not included in the in 2006 dollars); they stagnated through the next tables.) three 3-year periods due to the recession, before resuming their growth. Section 9.4.3: Medical Care Expenditures and Earnings Losses for Select Musculoskeletal Some of the estimated earnings losses of persons Diseases with musculoskeletal diseases might have occurred in the absence of these conditions due to other Medical conditions in MEPS are self-reported and factors. For example, older workers and women, may result in misreporting of some conditions. two groups with high rates of musculoskeletal With respect to musculoskeletal diseases, under- diseases, have lower employment rates and reporting might occur when physicians do not earnings than the average U.S. worker. The provide patients with a discrete diagnosis for incremental earnings loss measure takes into mild osteoarthritis, for example, because it may consideration many of the factors that might cause be too mild to be recognized or treatment is persons to have lower earnings even without the included with other conditions and not distinct. presence of the musculoskeletal disease. However, Over-reporting of a condition could occur when earnings losses using the incremental measure the respondent indicates they have a specifi c form also grew substantially between 1996-1998 and of arthritis, e.g., rheumatoid arthritis, even though 2004-2006. In the earlier triad of years, the 64

Graph 9.4.3: Total and Incremental Direct Cost and Earnings Losses in 2004 average incremental direct cost. Such is ȱȱȱȱȱȱŗŞȱȱŜŚȱ¢ȱęȱȱǰȱ not the case with rheumatoid arthritis ȱȱȱǰȱŘŖŖŖȬŘŖŖŚ $120 and osteoarthritis and allied disorders, where the diﬀ erences between total $100 and incremental cost are much smaller. $80 Aggregate total cost for the persons with

$60 one of the four musculoskeletal diseases ranged from $12.0 billion for rheumatoid $40

Cost (in 2004 billion $) arthritis to $97.4 billion for spine disorders, $20 while aggregate incremental cost ranged

$0 from $1.9 billion for gout to $15.6 billion for Direct Earnings Total Direct Earnings Total Loss Loss back disorders. Total Costs Incremental Costs Source: Medical Expenditures Panel Rheumatoid Gout Survey (MEPS), Agency for Healthcare Arthritis Average total earnings losses were highest Research and Quality, U.S. Department of Osteoarthritis and Disorders of Health and Human Services, 2000-2004 Allied Disorders the Spine for rheumatoid arthritis, $14,175 per year, followed by osteoarthritis at $10,369 per their physician did not so indicate. It should year. They were lowest for back disorders be noted that self-reporting of discrete medical at only $1,231 per year. As evidenced by the ratio conditions is lower than would be expected on of average total to average incremental earnings the basis of epidemiological studies,8 a conclusion losses, a much higher proportion of earnings losses that is supported by the higher prevalence are att ributable to rheumatoid arthritis and spine numbers reported in the previous chapters of The disorders (45% and 63%, respectively) than to Burden of Musculoskeletal Diseases. As a result osteoarthritis or gout. of potential misreporting, the measures of the aggregate economic impacts of discrete conditions On an unadjusted basis for total cost, the summarized in Table 9.13 and Graph 9.4.3 may not conditions have an aggregate economic impact be as reliable as the measures previously presented ranging from $29.1 billion for rheumatoid arthritis that are based on larger samples, such as all to $119.7 billion for spine disorders. (Table 9.13 musculoskeletal disease, or major subcategories, and Graph 9.4.4) The greater aggregate impact of such as all forms of arthritis. Nevertheless, they spine disorders over average earnings losses is do indicate in broad stroke the average economic likely due to demographics, with spine disorders impact for self-recognized disease and for occurring more frequently Graph 9.4.4: Total and Incremental Direct Cost conditions such as osteoarthritis, which are likely and Earnings Losses for Persons Aged 18 to 64 to be under-reported, a conservative estimate of in persons ȱ¢ȱęȱȱǰȱ aggregate economic impact. Estimates for discrete aged 18 to 64, ȱȱǰȱŘŖŖŖȬŘŖŖŚ

musculoskeletal diseases merged 5 years of MEPS prime working Gout data (2000-2004) to provide more stable estimates years, while Osteoarthritis and given the relatively few cases of each condition rheumatoid Allied Disorders arthritis has reported in individual years. Rheumatoid been shown to Arthritis

Average total direct cost for all four conditions aﬀ ect persons Disorders of studied—disorders of the spine, rheumatoid 65 and older the Spine $0 $20 $40 $60 $80 $100 $120 arthritis, osteoarthritis and allied disorders, and in greater Aggregate Cost for Health Care (in 2004 billion $) numbers. Aft er gout—are relatively large. In the case of gout Source: Medical Expenditures adjustment, Panel Survey (MEPS), Agency for Total Costs and spinal disorders, much of the health care Healthcare Research and Quality, expenditures would not occur in the absence of or the U.S. Department of Health and Incremental Costs Human Services, 1996-2004_ the condition, as evidenced by the much smaller incremental

cost impact, they have an aggregate impact of Comparing the cost of musculoskeletal diseases from $4.9 billion for gout to $29.6 billion for spine to the national gross domestic product (GDP) disorders. The incremental aggregate fi gure for provides a perspective on these total costs (Tables rheumatoid arthritis, $12.7 billion, is particularly 9.11 and 9.14). Earlier estimates summarize the striking given the relatively low prevalence of this evidence from the studies conducted by Dorothy condition and no doubt refl ects the growing use of Rice and colleagues, the last two of which were biological agents to treat this condition, along with from prior editions of the present volume,ii high work disability rates. while more recent comparisons for 1998-2006 summarize the data from the present analysis Section 9.4.4: Summary and Conclusions in 2006 constant dollars. As discussed in the methodology section, the estimates of incremental The economic impact of musculoskeletal diseases medical care expenditures and earnings losses are is increasing due to a combination of factors that roughly comparable to the estimates from Rice and include the aging of the U.S. population with colleagues in which costs are allocated on the basis the concomitant increase in the prevalence of of the primary diagnosis. musculoskeletal diseases, the growth in average total expenditures to treat musculoskeletal Notwithstanding the diff erent methods of the diseases, and the average total and incremental studies by Rice and colleagues and the analysis earnings losses that result from these conditions. of MEPS from the present volume, there is no question that the direct cost of musculoskeletal Between 1996 and 2006, the number of persons diseases has a profound economic impact on the with one or more musculoskeletal diseases grew nation, now at or in excess of 4.5% of GDP. Using from 76.0 million, or 28.0% of the population, to 2006 constant dollars, the impact has grown by 89.7 million, or 30.3% of the population. Over the 0.74% of GDP since the 1998-2000 period, and time period, average total expenditures for health is likely to continue to grow more severe due to care for persons with a musculoskeletal disease population aging, more intensive treatment— grew from $5,151 to $6,429 in 2006 dollars, while particularly with respect to prescription aggregate total expenditures grew from $391.4 medications, and growing displacement of older billion to $576.4 billion. Average incremental workers from industries in decline, a phenomenon expenditures for persons of similar characteristics that has been shown to aff ect those with 10 but without a musculoskeletal disease grew slower musculoskeletal diseases disproportionately. from $1,827 to $1,790, but due to population growth and increased prevalence of the conditions, Society has the option of passively accepting the aggregate incremental expenditures grew from increasing economic impact of musculoskeletal $138.8 to $160.5 billion, all in 2006 dollars. diseases, or it can seek to alleviate this impact by the use of primary, secondary, and tertiary Average per person earnings losses between 1996 preventive measures with strong evidence of and 2006 due to musculoskeletal diseases increased eff ectiveness. Such measures run the gamut from from $3,257 to $4,986, while total earnings losses weight loss and exercise programs designed to grew from $207.9 billion to $373.1 billion in reduce the prevalence of arthritic conditions, to constant 2006 dollars. Incremental earnings losses self-management classes designed to reduce the also increased dramatically, from $753 to $1,696 impact of existing conditions, to surgical and per person and from $48.1 to $126.9 billion on an ii The National Arthritis Data Task Force concluded that about half of aggregate basis. the increase between the 1972 and 1980 studies by Rice and colleagues was due to improvements in the data sources available to Rice and colleagues, but the remainder represented a real increase.8

medical interventions that return the individual to 1st, diagnosis were included in the model. The higher levels of functioning and quality of life.11- Rice model defi nes direct cost as those associated 13 In the discussion of demographic variations, with all components of medical care (i.e., inpatient disparities in medical care expenditures were and outpatient care, medications, devices, and identifi ed. This suggests the need for equal access costs associated with procuring medical care), and to eff ective interventions and treatment modalities indirect cost as those associated with wage loss to keep individuals participating in society due to morbidity or mortality, plus an estimate of through work and other meaningful activities intangible costs.

Section 9.5: Background and In the Rice model, mortality accounted for 7% of Methodology total indirect medical cost for all conditions. The MEPS data do not provide a comparable method for calculating wage loss associated with mortality. Economic cost for musculoskeletal-related health Hence, total cost presented here represents an care diseases presented in this book are based undercount by a similar percentage. Because on data from the Medical Expenditures Panel musculoskeletal diseases have a smaller impact Survey (MEPS) using a methodology developed on mortality than most other major categories of by the principal author and colleagues at the U.S. illness, the undercount will be an unknown, but Centers for Disease Control (CDC).14-17 The MEPS smaller, percentage. is a comprehensive data source designed for cost of illness studies.18-21 The MEPS uses a random Comparing total cost for 1995,7 updated to sample of the U.S. population and annually 1996 terms, the fi rst year for which MEPS data queries this sample three times about their is available, and omitt ing cost associated with medical conditions, health care utilization, and mortality, the current analysis results in $207 employment status. Two estimates are produced. billion in total cost associated with musculoskeletal The fi rst, total cost, is an indication of all medical diseases using the Rice method and about $173 care costs and earnings losses incurred by persons billion using the MEPS database. This suggests the with a musculoskeletal disease, regardless of two methods yield estimates of similar magnitude, the condition for which the cost was incurred. although the estimates based on MEPS may be The second, incremental cost, is an estimate of more conservative. A series of papers provide a the magnitude of cost that would be incurred detailed description of the methods of estimating beyond those experienced by persons of similar total and incremental direct and indirect cost demographic and health characteristics but who of conditions, and outline the regression model do not have one or more musculoskeletal disease. used to adjust for diff erences of persons with Cost estimates are produced as the mean per and without musculoskeletal diseases due to person medical care cost and as the aggregate, demographic characteristics and health status.14,16 or total cost, associated with all persons with musculoskeletal diseases. Conditions included in the musculoskeletal disease rubric include spine conditions, arthritis and Previous editions of this book based economic joint pain, the category that includes osteoporosis impact and cost of musculoskeletal diseases on (other diseases of bone and cartilage), injuries, the Rice cost of illness methodology.6,7 The Rice and an inclusive “other” category for the model utilized the National Hospital Discharge remaining conditions. Conditions selected for Survey (NHDS) and other available national the cost analysis presented above are based on health care data sources. All costs associated with preceding chapters in the book. Data are reported hospitalizations or treatments for persons with a primarily for base case ICD-9-CM codes, or those musculoskeletal disease listed as the primary, or codes for which musculoskeletal disease is the

principal etiology rather than a consequence of 5. Rice D, Hodgson T, Kopstein A: The economic costs of a condition for which the principal etiology is illness: A replication and update. Health Care Fin Rev another major health condition (e.g., cancer). 1985;7:61-80. (Table 9.15) Estimates are also provided for a more expansive list of codes of musculoskeletal-related 6. Rice D: Cost of musculoskeletal conditions, in Praemer diseases that includes the conditions for which A, Furner S, Rice D (eds): Musculoskeletal Conditions the musculoskeletal diseases are the primary and in the US, ed 1. Rosemont, IL: American Academy of secondary etiologies. (Table 9.16) Although this Orthopaedic Surgeons, 1992. more expansive list of conditions yields a vastly larger prevalence estimate than the base case list, it 7. Rice D: Cost of musculoskeletal conditions, in Praemer is reasonable to assume the cost of musculoskeletal A, Furner S, Rice D (eds): Musculoskeletal Conditions diseases probably exceeds the conservative in the US, ed 2. Rosemont, IL: American Academy of estimates presented here. For example, a person Orthopaedic Surgeons, 1999. with bone metastases would incur costs to treat the bone manifestation, even though the cancer, 8. Lawrence R, Helmick C, Arnett F, et al: Estimates of the not the bone condition, is the primary etiology. prevalence of arthritis and selected musculoskeletal ICD-9-CM codes included in each subcategory disorders in the United States. Arthritis Rheum for the base and expansive conditions are listed in 1998;41:788-799. Tables 9.15 and 9.16. 9. Yelin E, Callahan L: The economic cost and social and Although generally prevalence and cost associated psychological impact of musculoskeletal conditions. with musculoskeletal diseases increase over Arthritis Rheum 1995;38:1351-1362. time, sampling variability in the MEPS does not reﬂ ect this in each successive year. The impact 10. Yelin E, Katz P: Labor force participation among persons of sampling variability is partially mitigated with musculoskeletal conditions, 1970-1987: National by smoothing, or averaging, data across 3-year estimates derived from a series of cross sections. Arthritis periods. Rheum 1991;34:136-170.

1. US Bureau of the Census: Statistical Abstract of 11. Kruger J, Helmick C, Callahan L, Haddix A: the US, 2007. Available at: htt p://www.census.gov/ Cost-eﬀ ectiveness of the arthritis self-help course. Arch prod/2006pubs/07statab/income.pdf. Accessed July 6, 2007 Int Med 1998;158:1245-1249.

2. Cisternas MG, Murphy LB, Yelin EH, Foreman AJ, Pasta 12. Minor M: 2002 Exercise and Physical Activity Conference, DJ, Helmick CG. Trends in Medical Care Expenditures of St. Louis, Missouri: Exercise and arthritis “We know a US Adults with Arthritis and Other Rheumatic Conditions litt le bit about a lot of things.“ Arth Rheum 2003;49:1-2. 1997 to 2005. J Rheumatol 2009;36(11):2531-8. Epub 2009 Oct 1. 13. Redelmeier D, Lorig K: Assessing the clinical importance of symptomatic improvements: An illustration in 3. Rice D: Estimating the Cost of Illness. Hyatt sville, MD: rheumatology. Arch Int Med 1993;153:1337-1342. National Center for Health Statistics, Health Economic Series, 1966, No. 6. 14. Yelin E, Cisternas M, Pasta D, et al: Medical care expenditures and earnings losses of persons with arthritis 4. Cooper B, Rice D: The economic cost of illness revisited. and other rheumatic conditions in the United States in Health Economics Series No. 6. Social Security Bulletin 1997: Total and incremental estimates. Arthritis Rheum 1979;39:21-35. 2004;50(7):2317-2326.

15. Yelin E, Herrndorf A, Trupin L, Sonneborn D: A national 19. Cohen S: Sample Design of the 1996 Medical Expenditure study of medical care expenditures for musculoskeletal Panel Survey Household Component. Agency for Health conditions: The impact of health insurance and managed Care Policy and Research: U.S. Department of Health and care. Arthritis Rheum 2001;44:1160-1169. Human Services, 1997.

16. Yelin E, Murphy L, Cisternas MG, et al: Medical care 20. Cohen S: Sample Design of the 1997 Medical Expenditure expenditures and earnings losses among persons with Panel Survey Household Component. Agency for Health arthritis and other rheumatic conditions in 2003 and Care Policy and Research: U.S. Department of Health and comparisons with 1997. Arthritis Rheum 2007;56(5):1397- Human Services, 2000. 1407. 21. Cohen S, DiGaetano R, Goksel H: Estimation Procedures 17. Yelin E, Trupin L, Cisternas M: Direct and Indirect Costs of in the 1996 Medical Expenditure Panel Survey Household Musculoskeletal Conditions in 1997: Absolute and Incremental Component. Agency for Health Care Policy and Research: Estimates. Atlanta, GA: Centers for Disease Control, 2002. U.S. Department of Health and Human Services, 1999.

18. Cohen J, Monheit A, Beauregard K. The medical expenditures panel survey: A national information resource. Inquiry 1996/1997;33:373-389.

Section 9.6: Health Care Utilization and Economic Cost of Musculoskeletal Diseases Data Tables

Tableȱ9.1:ȱNumberȱandȱPercentȱofȱPopulationȱwithȱMusculoskeletalȱDiseasesȱbyȱAge,ȱUnitedȱStatesȱ 1996Ȭ2006

PersonsȱwithȱCondition AgeȱDistribution Totalȱ Populationȱ #ȱIndividualsȱ %ȱTotalȱ Condition Year SampleȱN (inȱmillions) (inȱmillions) Population Underȱ18 18Ȭ44 45Ȭ64 65ȱ&ȱOver 1996Ȭ1998 6,964 271.2 76.0 28.0% 11.6% 38.0% 28.7% 21.7% 1997Ȭ1999 7,004 273.7 75.2 27.5% 11.4% 36.7% 29.5% 22.4% 1998Ȭ2000 6,025 276.1 74.1 26.8% 11.2% 35.7% 30.5% 22.6% Allȱ 1999Ȭ2001 6,814 279.7 75.6 27.0% 10.5% 35.0% 31.6% 22.9% Musculoskeletalȱ 2000Ȭ2002 8,252 283.6 79.7 28.1% 9.8% 34.8% 32.5% 22.8% Diseases 2001Ȭ2003 9,166 287.7 84.3 29.3% 9.5% 34.3% 33.4% 22.7% 2002Ȭ2004 9,337 290.8 87.6 30.1% 9.5% 33.7% 34.0% 22.7% 2003Ȭ2005 8,874 293.4 88.9 30.3% 9.7% 32.7% 34.6% 23.0% 2004Ȭ2006 8,947 296.3 89.7 30.3% 9.7% 31.8% 35.3% 23.1%

1996Ȭ1998 2,510 271.2 27.4 10.1% 5.4% 47.5% 31.0% 16.1% 1997Ȭ1999 2,580 273.7 27.9 10.2% 5.4% 45.8% 32.0% 16.8% 1998Ȭ2000 2,199 276.1 27.2 9.9% 5.6% 44.6% 33.0% 16.9% Spine 1999Ȭ2001 2,411 279.7 27.3 9.8% 5.6% 44.4% 33.6% 16.4% 2000Ȭ2002 2,927 283.6 28.8 10.2% 5.2% 44.1% 34.0% 16.7% 2001Ȭ2003 3,258 287.7 30.6 10.6% 4.7% 42.8% 35.5% 17.0% 2002Ȭ2004 3,408 290.8 32.7 11.3% 4.5% 41.5% 36.7% 17.3%

1996Ȭ1998 2,804 271.2 29.9 11.0% 3.1% 24.8% 36.4% 35.7% 1997Ȭ1999 2,853 273.7 30.0 11.0% 3.1% 23.3% 37.4% 36.3% 1998Ȭ2000 2,498 276.1 30.3 11.0% 3.3% 22.0% 38.5% 36.2% Arthritisȱandȱ 1999Ȭ2001 2,936 279.7 32.2 11.5% 3.3% 21.4% 39.0% 36.2% JointȱPain 2000Ȭ2002 3,632 283.6 34.7 12.2% 3.1% 21.6% 39.9% 35.4% 2001Ȭ2003 4,058 287.7 36.9 12.8% 2.8% 22.1% 40.8% 34.3% 2002Ȭ2004 4,103 290.8 37.6 12.9% 2.7% 21.7% 41.6% 34.0%

1996Ȭ1998 299 271.2 3.2 1.2% 4.3% 10.7% 34.8% 50.1% 1997Ȭ1999 321 273.7 3.4 1.2% 3.1% 8.6% 32.8% 55.5% 1998Ȭ2000 308 276.1 3.8 1.4% 2.3% 7.3% 31.5% 58.9% Osteoporosis 1999Ȭ2001 395 279.7 4.4 1.6% 2.2% 6.5% 32.1% 59.2% 2000Ȭ2002 537 283.6 5.3 1.9% 1.9% 6.5% 34.7% 56.9% 2001Ȭ2003 645 287.7 6.1 2.1% 1.7% 6.3% 37.5% 54.5% 2002Ȭ2004 705 290.8 6.8 2.3% 1.3% 6.5% 38.2% 54.0%

1996Ȭ1998 2,093 271.2 23.4 8.6% 24.2% 43.4% 19.4% 13.0% 1997Ȭ1999 2,047 273.7 22.5 8.2% 24.8% 41.8% 20.0% 13.3% 1998Ȭ2000 1,698 276.1 21.6 7.8% 24.5% 41.8% 21.0% 12.7% Injuries 1999Ȭ2001 1,869 279.7 21.4 7.7% 23.0% 41.8% 22.4% 12.8% 2000Ȭ2002 2,235 283.6 22.3 7.9% 21.4% 41.8% 23.4% 13.4% 2001Ȭ2003 2,492 287.7 23.6 8.2% 21.0% 41.1% 24.1% 13.8% 2002Ȭ2004 2,545 290.8 24.7 8.5% 21.2% 40.2% 24.6% 14.0%

1996Ȭ1998 1,173 271.2 12.0 4.4% 11.8% 30.6% 31.5% 26.1% 1997Ȭ1999 1,174 273.7 11.8 4.3% 10.4% 30.4% 32.9% 26.3% Otherȱ 1998Ȭ2000 983 276.1 11.3 4.1% 9.7% 29.7% 34.2% 26.4% Musculoskeletalȱ 1999Ȭ2001 1,098 279.7 11.5 4.1% 9.7% 28.6% 35.5% 26.2% Conditions 2000Ȭ2002 1,345 283.6 12.4 4.4% 9.6% 28.3% 36.4% 25.7% 2001Ȭ2003 1,546 287.7 13.6 4.7% 9.8% 27.8% 37.1% 25.3% 2002Ȭ2004 1,618 290.8 14.5 5.0% 9.5% 27.0% 38.4% 25.1%

Note:ȱTotalsȱmayȱdifferȱbyȱordersȱofȱmagnitude,ȱe.g.ȱprescriptionsȱfilledȱvs.ȱhospitalȱdischargesȱ Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ 1996Ȭ2006

Tableȱ9.2:ȱHealthȱCareȱUtilizationȱbyȱTypeȱforȱPersonsȱwithȱMusculoskeletalȱDiseases,ȱUnitedȱStatesȱ1996Ȭ2004

AmbulatoryȱPhysicianȱVisits NonȬphysicianȱCareȱVisitsȱ PrescriptionȱMedicationȱFilled HomeȱHealthȱCareȱVisits HospitalȱDischarges oa oa oa oa Visitsȱ Visitsȱ Meds Visits Totalȱ %ȱWithȱ Meanȱ (inȱ %ȱWithȱ Meanȱ (inȱ %ȱWithȱ Meanȱ (inȱ %ȱWithȱ Meanȱ (inȱ %ȱWithȱ Meanȱ Dischargesȱ Condition Year Anyȱ Visits millions) Anyȱ Visits millions) Anyȱ Visits millions) Anyȱ Visits millions) Anyȱ Visits (inȱmillions) 1996Ȭ1998 84.8% 5.6 425.5 39.7% 2.6 197.5 81.3% 13.1 995.3 5.1% 3.9 296.3 11.1% 0.2 15.2 1997Ȭ1999 84.9% 5.6 421.0 40.9% 2.7 203.0 81.3% 13.8 1,037.4 5.0% 3.8 285.7 11.6% 0.2 15.0 Allȱ 1998Ȭ2000 85.3% 5.7 422.2 41.0% 2.8 207.4 82.5% 14.6 1,081.5 4.6% 3.4 251.9 11.6% 0.2 14.8 Musculoskeletalȱ 1999Ȭ2001 85.9% 5.7 430.9 42.0% 2.8 211.7 83.8% 15.7 1,186.9 4.6% 3.5 264.6 11.8% 0.2 15.1 Diseases 2000Ȭ2002 86.0% 5.8 462.5 45.1% 3.1 247.2 84.5% 16.8 1,339.8 4.7% 3.7 295.1 11.7% 0.2 15.9 2001Ȭ2003 85.8% 5.8 488.9 49.2% 3.5 295.0 84.5% 17.8 1,500.5 4.8% 3.5 295.0 11.8% 0.2 16.9 2002Ȭ2004 85.1% 5.8 507.9 51.5% 3.8 332.8 83.5% 18.6 1,628.9 4.7% 3.5 306.5 11.7% 0.2 17.5

1996Ȭ1998 83.2% 6.2 169.7 46.7% 3.7 101.3 80.3% 12.9 353.2 4.1% 2.7 73.9 10.7% 0.2 5.5 1997Ȭ1999 83.0% 6.1 170.2 48.4% 3.9 108.8 80.3% 13.3 371.0 3.9% 3.0 83.7 11.0% 0.2 5.6 1998Ȭ2000 84.0% 6.2 168.7 49.1% 4.1 111.5 81.5% 14.2 386.3 3.6% 2.8 76.2 11.1% 0.2 5.4 Spine 1999Ȭ2001 84.6% 6.2 169.0 49.5% 4.2 114.5 82.9% 15.4 419.9 3.5% 2.5 68.2 11.5% 0.2 5.5 2000Ȭ2002 84.7% 6.2 178.7 52.4% 4.5 129.7 83.5% 16.7 481.4 3.7% 2.2 63.4 11.4% 0.2 5.8 2001Ȭ2003 84.3% 6.1 186.7 56.1% 4.9 150.0 83.6% 17.8 544.8 3.9% 2.2 67.3 11.5% 0.2 6.1 2002Ȭ2004 83.6% 6.1 199.7 58.6% 5.3 173.5 82.6% 18.6 609.0 4.0% 2.3 75.3 11.6% 0.2 6.5

1996Ȭ1998 90.1% 6.8 203.3 42.4% 2.6 77.7 89.4% 18.9 565.0 7.9% 6.3 188.3 13.5% 0.2 6.0 1997Ȭ1999 90.4% 6.8 204.0 43.4% 2.6 78.0 89.1% 20.1 603.0 7.7% 6.3 189.0 14.2% 0.2 6.0 1998Ȭ2000 90.1% 6.8 205.7 43.2% 2.6 78.7 89.6% 21.0 635.3 7.0% 5.6 169.4 14.0% 0.2 6.1 Arthritisȱandȱ 1999Ȭ2001 90.3% 6.8 218.8 44.7% 2.8 90.1 90.5% 22.3 717.6 6.8% 5.4 173.8 14.4% 0.2 6.4 JointȱPain 2000Ȭ2002 90.5% 6.9 239.2 47.8% 3.3 114.4 91.3% 23.5 814.6 6.9% 5.3 183.7 14.4% 0.2 6.9 2001Ȭ2003 90.8% 7.0 258.6 52.5% 3.8 140.4 91.3% 24.8 916.1 7.1% 5.1 188.4 14.6% 0.2 7.4 2002Ȭ2004 90.3% 7.1 267.3 55.0% 4.1 154.3 90.7% 26.0 978.7 6.9% 5.2 195.7 14.5% 0.2 7.5

1996Ȭ1998 96.4% 9.5 30.0 54.1% 3.4 30.0 95.6% 27.8 87.8 10.3% 7.7 24.3 19.2% 0.3 0.9 1997Ȭ1999 97.3% 9.5 32.4 54.7% 4.0 32.4 95.5% 28.0 95.4 10.4% 8.5 28.9 18.5% 0.3 1.0 1998Ȭ2000 97.2% 9.2 34.8 54.6% 4.0 34.8 95.5% 27.9 105.7 8.7% 7.4 28.0 17.8% 0.3 1.1 Osteoporosis 1999Ȭ2001 96.6% 8.9 39.6 56.3% 3.6 39.6 95.9% 29.3 130.2 8.9% 7.8 34.7 17.2% 0.2 0.9 2000Ȭ2002 95.9% 8.8 46.3 58.9% 3.7 46.3 96.6% 31.4 165.3 9.4% 8.2 43.2 17.1% 0.2 1.1 2001Ȭ2003 95.2% 8.7 53.4 63.5% 4.2 53.4 97.2% 32.2 197.6 10.3% 8.6 52.8 17.1% 0.3 1.8 2002Ȭ2004 95.6% 8.4 57.3 64.8% 4.4 57.3 97.1% 31.3 213.5 9.7% 7.6 51.8 15.4% 0.2 1.4

1996Ȭ1998 83.0% 4.8 112.1 36.2% 2.3 53.7 76.3% 8.6 200.9 4.2% 2.7 63.1 10.3% 0.1 2.3 1997Ȭ1999 82.9% 4.9 110.2 37.4% 2.6 58.5 76.4% 9.3 209.2 4.1% 3.1 69.7 10.8% 0.1 2.2 1998Ȭ2000 83.5% 5.0 108.0 37.3% 2.8 60.5 77.6% 10.0 215.9 4.1% 3.2 69.1 11.1% 0.1 2.2 Injuries 1999Ȭ2001 84.0% 5.2 111.5 37.9% 2.8 60.0 78.7% 11.0 235.9 4.0% 3.3 70.8 11.4% 0.2 4.3 2000Ȭ2002 83.8% 5.3 118.1 40.3% 3.0 66.9 79.1% 12.1 269.7 4.2% 3.6 80.2 11.4% 0.2 4.5 2001Ȭ2003 83.6% 5.3 124.9 44.2% 3.3 77.8 78.5% 13.2 311.1 4.4% 3.4 80.1 11.3% 0.2 4.7 2002Ȭ2004 82.7% 5.2 128.3 46.3% 3.7 91.3 77.8% 13.8 340.6 4.3% 3.2 79.0 10.7% 0.2 4.9

1996Ȭ1998 89.8% 7.5 90.3 44.4% 3.4 41.0 86.6% 18.8 226.5 8.3% 6.7 80.7 14.0% 0.2 2.4 1997Ȭ1999 90.6% 7.6 89.8 45.5% 3.6 42.5 87.7% 19.9 235.0 8.1% 6.5 76.8 14.9% 0.2 2.4 Otherȱ 1998Ȭ2000 90.8% 7.5 84.9 44.8% 3.4 38.5 88.4% 21.2 240.0 7.4% 6.0 67.9 16.2% 0.3 3.4 Musculoskeletalȱ 1999Ȭ2001 90.8% 7.5 86.4 46.7% 3.4 39.2 89.6% 22.5 259.3 7.4% 6.5 74.9 16.3% 0.3 3.5 Conditions 2000Ȭ2002 90.6% 7.6 93.9 49.4% 3.7 45.7 89.8% 24.1 297.6 7.0% 6.8 84.0 16.0% 0.2 2.5 2001Ȭ2003 89.9% 7.7 105.1 54.4% 4.5 61.4 90.0% 25.4 346.5 6.7% 6.0 81.9 15.0% 0.2 2.7 2002Ȭ2004 90.2% 7.8 113.2 56.4% 4.9 71.1 89.5% 26.4 383.3 6.6% 5.8 84.2 15.3% 0.2 2.9

Note:ȱTotalsȱmayȱdifferȱbyȱordersȱofȱmagnitude,ȱe.g.ȱprescriptionsȱfilledȱvs.ȱhospitalȱdischargesȱ

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ2004

Tableȱ9.3:ȱAnnualȱAverageȱChangeȱinȱTotalȱUnitsȱofȱHealthȱUtilizationȱbyȱTypeȱofȱ CareȱforȱPersonsȱwithȱMusculoskeletalȱDiseases,ȱUnitedȱStatesȱ1996Ȭ2004

Ambulatoryȱ NonȬphysicianȱ Visitsȱ Prescriptionȱ Ambulatoryȱ (Ambulatoryȱ Medicationȱ HomeȱHealthȱ Hospitalȱ MEPSȱDataȱYearsȱAveraged PhysicianȱVisits Care) Filledȱ(Meds) CareȱDays Discharges 1996Ȭ1998 toȱ 1997Ȭ1999 Ȭ1.1% 2.7% 4.2% Ȭ3.6% Ȭ1.1% 1997Ȭ1999 toȱ 1998Ȭ2000 0.3% 2.2% 4.3% Ȭ11.8% Ȭ1.5% 1998Ȭ2000 toȱ 1999Ȭ2001 2.1% 2.1% 9.7% 5.1% 2.1% 1999Ȭ2001 toȱ 2000Ȭ2002 7.3% 16.8% 12.9% 11.5% 5.5% 2000Ȭ2002 toȱ 2001Ȭ2003 5.7% 19.3% 12.0% 0.0% 5.7% 2001Ȭ2003 toȱ 2002Ȭ2004 3.9% 12.8% 8.6% 3.9% 3.9%

1996Ȭ1998 to 2002Ȭ2004 2.8% 9.8% 9.1% 0.5% 2.2%

AnnualȱAverageȱChangeȱforȱSelectȱMusculoskeletalȱDiseases,ȱ1996Ȭ1998ȱtoȱ2002Ȭ2004 Spine 2.5% 10.2% 10.3% 0.3% 2.8% ArthritisȱandȱJointȱPain 4.5% 14.1% 10.5% 0.6% 3.7% Osteoporosis 13.0% 13.0% 20.4% 16.2% 6.3% MusculoskeletalȱInjuries 2.1% 10.0% 9.9% 3.6% 15.9% OtherȱMusculoskeletalȱConditions 3.6% 10.5% 9.9% 0.6% 2.9%

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱ HealthȱandȱHumanȱServices,ȱ1996Ȭ2004

Tableȱ9.4:ȱPerȱPersonȱComponentsȱofȱTotalȱandȱIncrementalȱDirectȱCostsȱinȱ2004ȱDollarsȱforȱ MusculoskeletalȱDiseases,ȱUnitedȱStatesȱ1996Ȭ2004

TotalȱMeanȱandȱ%ȱofȱAllȱCosts Condition Year AmbulatoryȱCare ERȱandȱInpatient Prescription Residual All 1996Ȭ1998 $1,496 31% $1,728 36% $653 14% $874 18% $4,751 1997Ȭ1999 $1,493 31% $1,791 37% $728 15% $858 18% $4,870 Allȱ 1998Ȭ2000 $1,525 31% $1,795 36% $798 16% $808 16% $4,925 Musculoskeletalȱ 1999Ȭ2001 $1,600 31% $1,762 34% $908 18% $853 17% $5,125 Diseases 2000Ȭ2002 $1,734 33% $1,742 33% $998 19% $858 16% $5,333 2001Ȭ2003 $1,823 33% $1,771 32% $1,119 20% $871 16% $5,584 2002Ȭ2004 $1,898 33% $1,865 32% $1,196 21% $864 15% $5,824

1996Ȭ1998 $1,675 35% $1,728 36% $638 13% $714 15% $4,756 1997Ȭ1999 $1,618 34% $1,692 35% $700 15% $782 16% $4,791 1998Ȭ2000 $1,697 34% $1,738 35% $767 15% $766 15% $4,967 Spine 1999Ȭ2001 $1,757 34% $1,786 34% $871 17% $775 15% $5,190 2000Ȭ2002 $1,895 36% $1,652 31% $973 19% $729 14% $5,249 2001Ȭ2003 $1,905 35% $1,724 31% $1,108 20% $738 13% $5,475 2002Ȭ2004 $2,022 34% $1,900 32% $1,200 20% $801 14% $5,923

1996Ȭ1998 $1,849 30% $2,272 37% $945 15% $1,100 18% $6,166 1997Ȭ1999 $1,831 29% $2,405 38% $1,065 17% $1,100 17% $6,400 1998Ȭ2000 $1,762 29% $2,233 36% $1,160 19% $1,004 16% $6,160 Arthritisȱand 1999Ȭ2001 $1,865 29% $2,168 34% $1,308 20% $1,044 16% $6,384 ȱJointȱPain 2000Ȭ2002 $2,072 31% $2,247 34% $1,397 21% $981 15% $6,697 2001Ȭ2003 $2,281 32% $2,299 32% $1,573 22% $993 14% $7,145 2002Ȭ2004 $2,393 32% $2,425 32% $1,684 23% $976 13% $7,477

1996Ȭ1998 $2,586 31% $3,040 36% $1,451 17% $1,344 16% $8,422 1997Ȭ1999 $2,603 31% $2,914 35% $1,570 19% $1,269 15% $8,357 1998Ȭ2000 $2,511 31% $2,857 35% $1,615 20% $1,168 14% $8,151 Osteoporosis 1999Ȭ2001 $2,689 33% $2,498 31% $1,769 22% $1,224 15% $8,179 2000Ȭ2002 $2,779 32% $2,588 30% $1,939 23% $1,310 15% $8,616 2001Ȭ2003 $2,776 31% $2,630 30% $2,092 24% $1,348 15% $8,845 2002Ȭ2004 $2,781 32% $2,488 29% $2,089 24% $1,207 14% $8,565

1996Ȭ1998 $1,332 33% $1,342 34% $420 11% $889 22% $3,983 1997Ȭ1999 $1,416 33% $1,485 35% $485 11% $868 20% $4,254 1998Ȭ2000 $1,451 33% $1,571 36% $542 12% $821 19% $4,384 Musculoskeletalȱ 1999Ȭ2001 $1,563 34% $1,540 33% $631 14% $902 19% $4,636 Injuries 2000Ȭ2002 $1,618 33% $1,565 32% $718 15% $969 20% $4,869 2001Ȭ2003 $1,718 33% $1,635 32% $835 16% $983 19% $5,171 2002Ȭ2004 $1,721 33% $1,588 31% $898 17% $953 18% $5,161

1996Ȭ1998 $1,918 30% $2,435 38% $914 14% $1,168 18% $6,435 1997Ȭ1999 $2,040 30% $2,639 39% $1,033 15% $1,140 17% $6,852 Otherȱ 1998Ȭ2000 $2,076 29% $2,915 41% $1,127 16% $1,039 15% $7,156 Musculoskeletalȱ 1999Ȭ2001 $2,181 30% $2,793 38% $1,283 17% $1,125 15% $7,382 Conditions 2000Ȭ2002 $2,229 30% $2,603 35% $1,421 19% $1,187 16% $7,440 2001Ȭ2003 $2,388 32% $2,261 30% $1,603 22% $1,188 16% $7,440 2002Ȭ2004 $2,447 32% $2,390 31% 1712 22% $1,120 15% $7,668

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ 2004

Tableȱ9.4a:ȱPerȱPersonȱComponentsȱofȱIncrementalȱDirectȱCostsȱ inȱ2004ȱDollarsȱforȱMusculoskeletalȱDiseases,ȱ UnitedȱStatesȱ1996Ȭ2004

MeanȱIncrement Ambulatoryȱ ERȱandȱ Condition Year Care Inpatient Prescription Residual 1996Ȭ1998 $702 $304 $210 $280 1997Ȭ1999 $714 $370 $196 $255 Allȱ 1998Ȭ2000 $783 $357 $206 $247 Musculoskeletalȱ 1999Ȭ2001 $798 $353 $188 $239 Diseases 2000Ȭ2002 $849 $281 $179 $245 2001Ȭ2003 $874 $275 $219 $247 2002Ȭ2004 $923 $263 $212 $258

1996Ȭ1998 $690 $209 $99 $111 1997Ȭ1999 $641 $253 $76 $100 1998Ȭ2000 $780 $364 $60 $108 Spine 1999Ȭ2001 $752 $473 $43 $101 2000Ȭ2002 $767 $282 $55 $105 2001Ȭ2003 $660 $155 $52 $90 2002Ȭ2004 $737 $176 $1 $101

1996Ȭ1998 $578 $26 $138 $137 1997Ȭ1999 $529 $125 $77 $135 1998Ȭ2000 $511 $4 $56 $139 Arthritisȱand 1999Ȭ2001 $478 $97 $69 $118 ȱJointȱPain 2000Ȭ2002 $508 $112 $59 $103 2001Ȭ2003 $548 $189 $145 $89 2002Ȭ2004 $560 $283 $88 $104

1996Ȭ1998 [1] [1] [1] [1] 1997Ȭ1999 [1] [1] [1] [1] 1998Ȭ2000 [1] [1] [1] [1] Osteoporosis 1999Ȭ2001 [1] [1] [1] [1] 2000Ȭ2002 [1] [1] [1] [1] 2001Ȭ2003 [1] [1] [1] [1] 2002Ȭ2004 [1] [1] [1] [1]

1996Ȭ1998 $486 $485 $36 $400 1997Ȭ1999 $547 $581 $19 $413 1998Ȭ2000 $587 $655 $52 $426 Musculoskeletalȱ 1999Ȭ2001 $624 $627 Ȭ$18 $455 Injuries 2000Ȭ2002 $581 $654 Ȭ$19 $442 2001Ȭ2003 $569 $644 $12 $417 2002Ȭ2004 $545 $593 $53 $411

1996Ȭ1998 $647 $742 $194 $247 1997Ȭ1999 $845 $744 $260 $252 Otherȱ 1998Ȭ2000 $845 $1,186 $293 $249 Musculoskeletalȱ 1999Ȭ2001 $843 $1,052 $245 $226 Conditions 2000Ȭ2002 $679 $840 $191 $253 2001Ȭ2003 $744 $412 $249 $245 2002Ȭ2004 $755 $532 $205 $225

[1]ȱDueȱtoȱtheȱsampleȱsize,ȱincrementȱnotȱcalculatedȱforȱthisȱsubcondition. Note:ȱDueȱtoȱestimationȱerrors,ȱincrementȱcomponentsȱdoȱnotȱalwaysȱequalȱtheȱtotal;ȱpercentagesȱ wereȱnotȱcalculatedȱdueȱtoȱthisȱunknownȱerror. Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱ Quality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ2004

Tableȱ9.5:ȱTotalȱandȱIncrementalȱDirectȱCostsȱforȱMusculoskeletalȱDiseasesȱinȱCurrentȱandȱ2004ȱDollars,ȱUnitedȱStatesȱ 1996Ȭ2004

Total Incremental Personsȱwithȱcondition Mean Aggregate [1] Mean Aggregate [1] Totalȱ Currentȱ 2006ȱ Currentȱ$sȱ 2006ȱ$sȱ Currentȱ 2006ȱ Currentȱ$sȱ 2006ȱ$sȱ Condition Year SampleȱN Population $sȱ[2] $sȱ[2] (inȱbillions) (inȱbillions) $sȱ[2] $sȱ[2] (inȱbillions) (inȱbillions)

ColumnȱA ColumnȱB ColumnȱC ColumnȱD ColumnȱE ColumnȱF ColumnȱG ColumnȱH ColumnȱI ColumnȱJ 1996Ȭ1998 6,964 75,978,133 $3,600 $5,151 $274 $391.4 $1,276 $1,827 $97 $138.8 1997Ȭ1999 7,004 75,173,840 $3,808 $5,280 $286 $396.9 $1,356 $1,879 $102 $141.3 1998Ȭ2000 6,025 74,077,194 $3,993 $5,340 $296 $395.6 $1,482 $1,978 $110 $146.5 Allȱ 1999Ȭ2001 6,814 75,600,394 $4,323 $5,556 $327 $420.0 $1,546 $1,993 $117 $150.7 Musculoskeletalȱ 2000Ȭ2002 8,252 79,748,298 $4,704 $5,782 $375 $461.1 $1,582 $1,952 $126 $155.7 Diseases 2001Ȭ2003 9,166 84,297,419 $5,142 $6,054 $433 $510.3 $1,638 $1,926 $138 $162.4 2002Ȭ2004 9,337 87,575,871 $5,594 $6,314 $490 $553.0 $1,715 $1,939 $150 $169.8 2003Ȭ2005 8,874 88,946,833 $6,439 $6,439 $573 $572.7 $1,937 $1,937 $172 $172.3 2004Ȭ2006 8,947 89,652,587 $6,429 $6,429 $576 $576.4 $1,790 $1,790 $160 $160.5

Total Incremental Personsȱwithȱcondition Mean Aggregate [1] Mean Aggregate [1] Totalȱ Currentȱ 2004ȱ Currentȱ$sȱ 2004ȱ$sȱ Currentȱ 2004ȱ Currentȱ$sȱ 2004ȱ$sȱ Condition Year SampleȱN Population $sȱ[3] $sȱ[3] (inȱbillions) (inȱbillions) $sȱ[3] $sȱ[3] (inȱbillions) (inȱbillions) ColumnȱA ColumnȱB ColumnȱC ColumnȱD ColumnȱE ColumnȱF ColumnȱG ColumnȱH ColumnȱI ColumnȱJ 1996Ȭ1998 2,510 27,376,436 $3,600 $4,756 $99 $130 $759 $1,006 $21 $28 1997Ȭ1999 2,580 27,893,654 $3,749 $4,791 $105 $134 $812 $1,033 $23 $29 1998Ȭ2000 2,199 27,203,474 $4,030 $4,967 $110 $135 $1,050 $1,286 $29 $35 Spine 1999Ȭ2001 2,411 27,263,245 $4,376 $5,190 $119 $141 $1,151 $1,370 $31 $37 2000Ȭ2002 2,927 28,825,976 $4,623 $5,249 $133 $151 $998 $1,148 $29 $33 2001Ȭ2003 3,258 30,607,329 $5,044 $5,475 $154 $168 $754 $826 $23 $25 2002Ȭ2004 3,408 32,740,018 $5,700 $5,923 $187 $194 $898 $927 $29 $30

1996Ȭ1998 2,804 29,893,915 $4,675 $6,166 $140 $184 $799 $1,057 $24 $32 1997Ȭ1999 2,853 29,998,123 $5,000 $6,400 $150 $192 $783 $1,007 $23 $30 1998Ȭ2000 2,498 30,254,301 $4,989 $6,160 $151 $186 $666 $823 $20 $25 Arthritisȱandȱ 1999Ȭ2001 2,936 32,177,862 $5,387 $6,384 $173 $205 $723 $857 $23 $28 JointȱPain 2000Ȭ2002 3,632 34,664,846 $5,914 $6,697 $205 $232 $757 $858 $26 $30 2001Ȭ2003 4,058 36,938,769 $6,580 $7,145 $243 $264 $916 $992 $34 $37 2002Ȭ2004 4,103 37,643,137 $7,181 $7,477 $270 $281 $951 $992 $36 $37

1996Ȭ1998 299 3,158,916 $6,391 $8,422 $20 $27 [4] [4] [4] [4] 1997Ȭ1999 321 3,405,501 $6,529 $8,357 $22 $28 [4] [4] [4] [4] 1998Ȭ2000 308 3,787,044 $6,587 $8,151 $25 $31 [4] [4] [4] [4] Osteoporosisȱ 1999Ȭ2001 395 4,444,849 $6,914 $8,179 $31 $36 [4] [4] [4] [4] 2000Ȭ2002 537 5,264,938 $7,605 $8,616 $40 $45 [4] [4] [4] [4] 2001Ȭ2003 645 6,136,560 $8,121 $8,845 $50 $54 [4] [4] [4] [4] 2002Ȭ2004 705 6,819,738 $8,212 $8,565 $56 $58 [4] [4] [4] [4]

1996Ȭ1998 2,093 23,358,073 $3,021 $3,983 $71 $93 $1,051 $1,386 $25 $32 1997Ȭ1999 2,047 22,495,891 $3,329 $4,254 $75 $96 $1,258 $1,604 $28 $36 1998Ȭ2000 1,698 21,590,412 $3,555 $4,384 $77 $95 $1,423 $1,751 $31 $38 Injuries 1999Ȭ2001 1,869 21,442,353 $3,912 $4,636 $84 $99 $1,438 $1,715 $31 $37 2000Ȭ2002 2,235 22,285,775 $4,297 $4,869 $96 $109 $1,378 $1,571 $31 $35 2001Ȭ2003 2,492 23,570,429 $4,763 $5,171 $112 $122 $1,392 $1,508 $33 $36 2002Ȭ2004 2,545 24,680,193 $4,947 $5,161 $122 $127 $1,404 $1,468 $35 $36

1996Ȭ1998 1,173 12,046,200 $4,876 $6,435 $59 $78 $1,426 $1,885 $17 $23 1997Ȭ1999 1,174 11,809,322 $5,362 $6,852 $63 $81 $1,727 $2,191 $20 $26 1998Ȭ2000 983 11,322,533 $5,811 $7,156 $66 $81 $2,142 $2,633 $24 $30 Residual 1999Ȭ2001 1,098 11,524,129 $6,217 $7,382 $72 $85 $2,049 $2,456 $24 $28 2000Ȭ2002 1,345 12,350,398 $6,550 $7,440 $81 $92 $1,719 $1,971 $21 $24 2001Ȭ2003 1,546 13,643,094 $6,853 $7,440 $93 $102 $1,500 $1,624 $20 $22 2002Ȭ2004 1,618 14,518,291 $7,359 $7,668 $107 $111 $1,615 $1,685 $23 $24

[1]ȱAllȱaggregatesȱ(includingȱtotal)ȱareȱcreatedȱbyȱmultiplyingȱsmoothedȱmeansȱbyȱsmoothedȱpopulationȱinȱyear. [2]ȱ2006ȱandȱcurrentȱ$ȱforȱyear=2006ȱ(allȱmusculoskeletalȱdiseasesȱonly)ȱareȱnoȱlongerȱequalȱdueȱtoȱsmoothing. [3]ȱ2004ȱandȱcurrentȱ$ȱforȱyear=2004ȱareȱnoȱlongerȱequalȱdueȱtoȱsmoothing. [3]ȱAllȱindividualsȱwithȱosteoporosisȱhadȱexpendituresȱandȱtotalȱincrementȱcouldȱnotȱbeȱcalculated. Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ2006

Tableȱ9.6:ȱAnnualȱAverageȱandȱTotalȱChangeȱinȱHealthȱCareȱCostȱforȱ PersonsȱwithȱMusculoskeletalȱDiseases,ȱUnitedȱStates,ȱ1996Ȭ2004

AverageȱAnnualȱIncrease Total Incrementalȱ

MEPSȱDataȱYearsȱAveraged Mean Aggregateȱ[1] Mean Aggregateȱ[1] 1996Ȭ1998 toȱ 1997Ȭ1999 2.5% 1.4% 2.8% 1.8% 1997Ȭ1999 toȱ 1998Ȭ2000 1.1% Ȭ0.3% 5.3% 3.7% 1998Ȭ2000 toȱ 1999Ȭ2001 4.1% 6.2% 0.8% 2.8% 1999Ȭ2001 toȱ 2000Ȭ2002 4.1% 9.8% Ȭ2.1% 3.3% 2000Ȭ2002 toȱ 2001Ȭ2003 4.7% 10.7% Ȭ1.3% 4.4% 2001Ȭ2003 toȱ 2002Ȭ2004 4.3% 8.4% 0.7% 4.6%

1996Ȭ1998 to 2002Ȭ2004 3.2% 5.9% 0.9% 3.2% TotalȱIncreaseȱ1996Ȭ1998ȱtoȱ2002Ȭ20 22.6% 41.3% 6.2% 22.4%

AnnualȱAverageȱChangeȱforȱSelectȱMusculoskeletalȱDiseases,ȱ1996Ȭ1998ȱtoȱ2002Ȭ2004 Spine 3.5% 7.0% Ȭ1.1% 1.5% ArthritisȱandȱJointȱPain 3.0% 7.5% Ȭ0.9% 2.6% Osteoporosis 0.2% 17.1% [2] [2] MusculoskelegalȱInjuries 4.2% 5.3% 0.8% 1.7% OtherȱMusculoskeletalȱConditions 2.7% 6.2% Ȭ1.5% 1.1%

TotalȱIncreaseȱinȱHealthȱCareȱCostȱforȱSelectȱMusculoskeletalȱDiseases,ȱ1996Ȭ1998ȱtoȱ2002Ȭ2004 Spine 24.5% 48.9% Ȭ7.9% 10.2% ArthritisȱandȱJointȱPain 21.3% 52.7% Ȭ6.1% 18.2% Osteoporosis 1.7% 119.6% [2] [2] MusculoskelekalȱInjuries 29.6% 36.9% 5.9% 11.9% OtherȱMusculoskeletalȱConditions 19.2% 43.6% Ȭ10.6% 7.7%

[1]ȱAllȱaggregatesȱ(includingȱtotal)ȱareȱcreatedȱbyȱmultiplyingȱsmoothedȱmeansȱbyȱsmoothedȱ populationȱinȱyear.

[2]ȱAllȱindividualsȱwithȱtheȱconditionsȱwithinȱtheȱcategoryȱincludingȱosteoporosisȱhadȱexpendituresȱ andȱtotalȱincrementȱcouldȱnotȱbeȱcalculated.

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱ DepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ2004

Tableȱ9.7:ȱTotalȱandȱIncrementalȱExpendituresȱforȱMusculoskeletalȱDiseasesȱbyȱDemographicȱCharacteristics,ȱ UnitedȱStates,ȱ2004ȱ

Numberȱof EstimatedȱPopulation Total Incremental Respondents (inȱ1000s) Expenditures Expenditures

Withȱ Withȱ Musculoskeletal Musculoskeletal Standardȱ Aggregate Aggregate DemographicȱCharacteristics Total Diseases Total Diseases Mean Errorȱ(±) (inȱmillions) Mean (inȱmillions) TotalȱPopulation 32,737 9,027 293,527 89,740 $6,018ȱ $213ȱ $540.1 $1,645ȱ $147.6ȱ

Gender Female 17,298 5,264 149,658 49,916 $6,506ȱ $225ȱ $324.8 $1,634ȱ $81.6ȱ Male 15,439 3,763 143,869 39,824 $5,407ȱ $371ȱ $215.3 $1,660ȱ $66.1ȱ

Race White 25,210 7,301 236,409 76,489 $6,227ȱ $244ȱ $476.3 $1,737ȱ $132.9ȱ Nonwhite 7,527 1,726 57,118 13,252 $4,809ȱ $261ȱ $63.7 $1,114ȱ $14.8ȱ

Ethnicityȱ Hispanic 9,022 1,523 42,212 7,668 $3,730ȱ $323ȱ $28.6 $874ȱ $6.7ȱ Nonhispanic 23,715 7,504 251,315 82,072 $6,232ȱ $229ȱ $511.5 $1,717ȱ $140.9ȱ

Educationȱ[1] LessȱthanȱHighȱSchool 8,359 2,299 49,087 16,141 $6,509ȱ $402ȱ $105.1 $1,056ȱ $17.0ȱ HighȱSchool 10,422 2,876 91,613 28,947 $6,165ȱ $297ȱ $178.5 $1,731ȱ $50.1ȱ SomeȱCollege 6,935 1,956 70,070 21,377 $5,847ȱ $384ȱ $125.0 $2,070ȱ $44.3ȱ CollegeȱGraduate 4,071 1,103 48,284 13,596 $4,762ȱ $334ȱ $64.7 $730ȱ $9.9ȱ GraduateȱSchool 2,681 737 32,730 9,256 $6,974ȱ $1,195ȱ $64.6 $2,770ȱ $25.6ȱ

Maritalȱstatusȱ[2] NeverȱMarried 7,012 1,469 62,411 14,975 $3,235ȱ $194ȱ $48.4 $687ȱ $10.3ȱ Marriedȱorȱw/Partner 19,205 5,043 175,791 51,417 $6,067ȱ $298ȱ $311.9 $1,964ȱ $101.0ȱ DivorcedȬWidowedȬSeparated 6,457 2,507 55,005 23,289 $7,708ȱ $426ȱ $179.5 $1,558ȱ $36.3ȱ

Insurance AnyȱPrivate 18,364 5,530 200,787 63,323 $6,062ȱ $284ȱ $383.9 $2,009ȱ $127.2ȱ Public 9,180 2,535 56,530 18,347 $7,679ȱ $313ȱ $140.9 $872ȱ $16.0ȱ None 5,193 962 36,211 8,071 $1,899 $192 $15.3 $529 $4.3

[1]ȱEducationȱstatusȱforȱindividualsȱ<ȱ18ȱwasȱsetȱtoȱtheȱhighestȱlevelȱinȱtheȱhousehold.ȱ*Educationȱstatusȱforȱindividualsȱ<ȱ18ȱwasȱsetȱtoȱtheȱhighestȱlevelȱinȱtheȱhousehold;ȱ maritalȱstatusȱforȱindividualsȱ<ȱ18ȱwereȱsetȱhierarchicallyȱbyȱhouseholdȱtoȱmarried,ȱdiv/wid/sep,ȱandȱneverȱmarried. [2]ȱMaritalȱstatusȱforȱindividualsȱ<ȱ18ȱwereȱsetȱhierarchicallyȱbyȱhouseholdȱtoȱmarried,ȱdiv/wid/sep,ȱandȱneverȱmarried. Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ2004

Tableȱ9.8:ȱAgeȱDistributionȱofȱTotalȱandȱIncrementalȱDirectȱCostsȱ(2004ȱ$ȇs)ȱofȱMusculoskeletalȱ Diseases,ȱUnitedȱStatesȱ1996Ȭ2004

YearsȱAveraged Age 1996Ȭ1998 1997Ȭ1999 1998Ȭ2000 1999Ȭ2001 2000Ȭ2002 2001Ȭ2003 2002Ȭ2004 TOTALȱCOST <ȱ18 858 849 715 762 893 989 1,002 PersonsȱwithȱConditionȱ 18Ȭ44 2,481 2,419 2,020 2,252 2,715 3,012 3,030 (SampleȱN) 45Ȭ64 2,118 2,171 1,922 2,243 2,765 3,102 3,179 65+ 1,506 1,564 1,368 1,557 1,879 2,063 2,127

<ȱ18 8,837,738 8,587,926 8,270,671 7,909,778 7,812,654 8,015,131 8,339,766 PersonsȱwithȱConditionȱ 18Ȭ44 28,857,105 27,582,172 26,465,903 26,434,506 27,764,847 28,914,760 29,523,069 (TotalȱPopulation) 45Ȭ64 21,794,220 22,136,282 22,574,221 23,930,631 25,951,528 28,209,432 29,802,135 65+ 16,489,070 16,867,460 16,766,399 17,325,479 18,219,269 19,158,096 19,910,901

<ȱ18$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,880 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,034 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,271 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,586 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,535 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ2,359 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,238 TotalȱMeanȱ 18Ȭ44$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,945 $ȱȱȱȱȱȱȱȱȱȱȱȱ3,019 $ȱȱȱȱȱȱȱȱȱȱȱȱ3,036 $ȱȱȱȱȱȱȱȱȱȱȱȱ3,101 $ȱȱȱȱȱȱȱȱȱȱȱȱ3,148 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ3,221 $ȱȱȱȱȱȱȱȱȱȱȱȱ3,278 inȱ2004ȱ$ 45Ȭ64$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 4,993 $ȱȱȱȱȱȱȱȱȱȱȱȱ5,062 $ȱȱȱȱȱȱȱȱȱȱȱȱ5,237 $ȱȱȱȱȱȱȱȱȱȱȱȱ5,598 $ȱȱȱȱȱȱȱȱȱȱȱȱ5,934 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ6,401 $ȱȱȱȱȱȱȱȱȱȱȱȱ6,682 65+$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 9,132 $ȱȱȱȱȱȱȱȱȱȱȱȱ9,092 $ȱȱȱȱȱȱȱȱȱȱȱȱ8,792 $ȱȱȱȱȱȱȱȱȱȱȱȱ8,712 $ȱȱȱȱȱȱȱȱȱȱȱȱ9,009 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ9,283 $ȱȱȱȱȱȱȱȱȱȱȱȱ9,806

<ȱ18$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 16.6 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ17.5 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.8 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ20.5 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ19.8 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.9 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ18.7 TotalȱAggregateȱ 18Ȭ44$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 85.0 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ83.3 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ80.4 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ82.0 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ87.4 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ93.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ96.8 inȱ2004ȱ$ȱ(inȱbillions) 45Ȭ64$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 108.8 $ȱȱȱȱȱȱȱȱȱȱȱȱ112.1 $ȱȱȱȱȱȱȱȱȱȱȱȱ118.2 $ȱȱȱȱȱȱȱȱȱȱȱȱ134.0 $ȱȱȱȱȱȱȱȱȱȱȱȱ154.0 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ180.6 $ȱȱȱȱȱȱȱȱȱȱȱȱ199.1 65+$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 150.6 $ȱȱȱȱȱȱȱȱȱȱȱȱ153.4 $ȱȱȱȱȱȱȱȱȱȱȱȱ147.4 $ȱȱȱȱȱȱȱȱȱȱȱȱ150.9 $ȱȱȱȱȱȱȱȱȱȱȱȱ164.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ177.8 $ȱȱȱȱȱȱȱȱȱȱȱȱ195.2

INCREMENTALȱCOST <ȱ18 858 849 715 762 893 989 1,002 PersonsȱwithȱConditionȱ 18Ȭ44 2,481 2,419 2,020 2,252 2,715 3,012 3,030 (SampleȱN) 45Ȭ64 2,118 2,171 1,922 2,243 2,765 3,102 3,179 65+ 1,506 1,564 1,368 1,557 1,879 2,063 2,127

<ȱ18$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,145 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,191 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,365 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,445 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,355 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,261 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,250 IncrementȱMeanȱ 18Ȭ44$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,140 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,251 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,185 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,208 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,175 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,156 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,105 inȱ2004ȱ$ȱ 45Ȭ64$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,794 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,884 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,186 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,336 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,364 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ2,577 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,492 65+$ȱȱȱȱȱȱȱȱȱȱȱȱȱ 2,797 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,598 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,569 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,289 $ȱȱȱȱȱȱȱȱȱȱȱȱ2,156 $ȱȱȱȱȱȱȱȱȱȱȱȱȱ1,735 $ȱȱȱȱȱȱȱȱȱȱȱȱ1,965

<ȱ18$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 10.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.2 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.3 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ11.4 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.6 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10.4 IncrementȱAggregateȱ 18Ȭ44$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 32.9 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ34.5 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ31.4 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ31.9 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ32.6 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33.4 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ32.6 inȱ2004ȱ$ȱ(inȱbillions) 45Ȭ64$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 39.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ41.7 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ49.3 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ55.9 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ61.3 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ72.7 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ74.3 65+$ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 46.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43.8 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ43.1 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39.7 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39.3 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ33.2 $ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ39.1

[1]ȱInȱ2004ȱ$.

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱ Services,ȱ1996Ȭ2004

Tableȱ9.9:ȱDistributionȱofȱTotalȱDirectȱ CostsȱforȱMusculoskeletalȱDiseasesȱbyȱ Age,ȱUnitedȱStatesȱ1996Ȭ2004

%ȱTotalȱAggregateȱCostȱ(inȱ2004ȱ$ȱ) <ȱ18 18Ȭ44 45Ȭ64 65+ 1996Ȭ1998 5% 24% 30% 42% 1997Ȭ1999 5% 23% 31% 42% 1998Ȭ2000 5% 22% 32% 40% 1999Ȭ2001 5% 21% 35% 39% 2000Ȭ2002 5% 21% 36% 39% 2001Ȭ2003 4% 20% 38% 38% 2002Ȭ2004 4% 19% 39% 38%

%ȱIncrementȱAggregateȱCostȱ(inȱ2004ȱ$) <ȱ18 18Ȭ44 45Ȭ64 65+ 1996Ȭ1998 8% 26% 30% 36% 1997Ȭ1999 8% 26% 32% 34% 1998Ȭ2000 8% 23% 37% 32% 1999Ȭ2001 8% 23% 40% 29% 2000Ȭ2002 7% 23% 43% 27% 2001Ȭ2003 7% 22% 49% 22% 2002Ȭ2004 7% 21% 47% 25%

py(),gy HealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱ andȱHumanȱServices,ȱ1996Ȭ2004

Tableȱ9.10:ȱAnnualȱȱChangeȱinȱTotalȱandȱ IncrementalȱHealthȱCareȱCostȱforȱPersonsȱwithȱ MusculoskeletalȱDiseasesȱbyȱAge,ȱUnitedȱStatesȱ 1996Ȭ2004

TotalȱAggregateȱCost MEPSȱDataȱYearsȱAveraged <18 18ȱtoȱ44 45ȱtoȱ64 65ȱ&ȱOver 1996Ȭ1998 to 1997Ȭ1999 5.1% Ȭ2.0% 3.0% 1.8% 1997Ȭ1999 to 1998Ȭ2000 7.5% Ȭ3.5% 5.5% Ȭ3.9% 1998Ȭ2000 to 1999Ȭ2001 8.9% 2.0% 13.3% 2.4% 1999Ȭ2001 to 2000Ȭ2002 Ȭ3.2% 6.6% 15.0% 8.7% 2000Ȭ2002 to 2001Ȭ2003 Ȭ4.5% 6.6% 17.3% 8.4% 2001Ȭ2003 to 2002Ȭ2004 Ȭ1.3% 3.9% 10.3% 9.8% AnnualȱAverageȱIncrease 1.8% 2.0% 11.9% 4.2% TotalȱIncrease 12.3% 13.9% 83.0% 29.7%

IncrementalȱAggregateȱCost MEPSȱDataȱYearsȱAveraged <18 18ȱtoȱ44 45ȱtoȱ64 65ȱ&ȱOver 1996Ȭ1998 to 1997Ȭ1999 1.1% 4.9% 6.7% Ȭ5.0% 1997Ȭ1999 to 1998Ȭ2000 10.4% Ȭ9.1% 18.3% Ȭ1.7% 1998Ȭ2000 to 1999Ȭ2001 1.2% 1.8% 13.3% Ȭ7.9% 1999Ȭ2001 to 2000Ȭ2002 Ȭ7.4% 2.2% 9.7% Ȭ1.0% 2000Ȭ2002 to 2001Ȭ2003 Ȭ4.5% 2.5% 18.5% Ȭ15.4% 2001Ȭ2003 to 2002Ȭ2004 3.1% Ȭ2.4% 2.2% 17.7% AnnualȱAverageȱIncrease 0.4% Ȭ0.1% 12.8% Ȭ2.2% TotalȱIncrease 3.0% Ȭ0.8% 89.9% Ȭ15.2%

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱ ResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ 2004

Tableȱ9.11:ȱCostsȱofȱMusculoskeletalȱ DiseasesȱasȱaȱPercentageȱofȱGDPȱ[1]ȱbyȱ Year,ȱUnitedȱStates,ȱSelectȱYears

Direct Indirect Year Costsȱ Costsȱ Total 1963 0.3 0.3 0.7 1972 0.3 0.4 0.7 1980 0.5 0.3 0.8 1988 1.2 1.3 2.5 1995 1.2 1.7 2.9

[1]ȱGDP:ȱGrossȱDomesticȱProduct,ȱinȱannualȱyearȱdollars

Source:ȱYelinȱE,ȱMurphyȱMG,ȱCisternasȱMG,ȱForemanȱDJP,ȱ HelmickȱCG.ȱMedicalȱcareȱexpendituresȱandȱearningsȱlossesȱ amongȱpersonsȱwithȱarthritisȱandȱotherȱrheumaticȱconditionsȱ inȱ2003,ȱandȱcomparisonsȱwithȱ1997.ȱArthritisȱRheum ȱ2007;ȱ 56:1397Ȭ1407.ȱ

Tableȱ9.12:ȱTotalȱandȱIncrementalȱIndirectȱCostȱ[1]ȱinȱ2006ȱ DollarsȱforȱPersonsȱAgeȱ18ȱtoȱ64ȱwithȱMusculoskeletalȱ DiseasesȱandȱaȱWorkȱHistory,ȱUnitedȱStatesȱ1996Ȭ2006

IndirectȱCostȱ(EarningsȱLoss,ȱinȱ2006ȱ$) Populationȱwithȱ Musculoskeletalȱ Total Increment DiseaseȱWhoȱEverȱ Aggregateȱ Aggregateȱ Year Worked Mean (inȱbillionȱ$) Mean (inȱbillionȱ$) 1996Ȭ1998 63,840,865 $3,257 $207.9 $753 $48.1 1997Ȭ1999 62,603,143 $4,027 $252.1 $1,049 $65.7 1998Ȭ2000 61,508,942 $4,373 $269.0 $1,070 $65.8 1999Ȭ2001 63,182,182 $4,328 $273.5 $1,041 $65.8 2000Ȭ2002 66,886,534 $4,334 $289.9 $1,042 $69.7 2001Ȭ2003 70,931,602 $4,447 $315.4 $1,262 $89.5 2002Ȭ2004 73,343,698 $4,928 $361.4 $1,607 $117.9 2003Ȭ2005 74,309,513 $5,248 $390.0 $1,906 $141.6 2004Ȭ2006 74,832,482 $4,986 $373.1 $1,696 $126.9

[1]ȱCalculatedȱasȱestimatedȱearningsȱlossȱperȱwageȱearnerȱdueȱtoȱaȱmusculoskeletalȱ conditionȱinȱ2006ȱ$.

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱ Quality,ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices,ȱ1996Ȭ2006

Tableȱ9.13:ȱAverageȱAnnualȱTotalȱandȱIncrementalȱDirectȱCostsȱandȱTotalȱandȱ IncrementalȱEarningsȱLossesȱofȱPersonsȱAgeȱ18ȱtoȱ64ȱforȱSelectȱMusculoskeletalȱ Diseases,ȱUnitedȱStatesȱ2000Ȭ2004

MusculoskeletalȱDisease Osteoarthritis Otherȱandȱ and Unspecifiedȱ Allied Rheumatoid Disordersȱofȱthe Goutȱ[1] Disordersȱ[2] Arthritisȱ[3] Backȱ[4] SampleȱNȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 227 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ206 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ128 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,860 #ȱindividualsȱȱȱȱȱȱȱȱȱȱȱȱ 2,309,103 ȱȱȱȱȱȱȱȱȱȱȱȱ2,120,057 ȱȱȱȱȱȱȱȱȱȱȱȱ1,205,328 ȱȱȱȱȱȱȱȱȱȱ18,160,441 %ȱtotalȱpop 0.8 0.7 0.4 6.3

Meanȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 7,389 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10,730 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ9,938 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ5,361 Total Aggregateȱ(inȱbillions) 17.1 22.7 12.0 97.4 DirectȱCosts Meanȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 834 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ3,883 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ4,116 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ857 Incremental Aggregateȱ(inȱbillions) 1.9 8.2 5.0 15.6

Meanȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6,594 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ10,369 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ14,175 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,231 Total Aggregateȱ(inȱbillions) 15.2 22.0 17.1 22.4 EarningsȱLosses Meanȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1,296 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ1,175 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ6,414 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ771 Incremental Aggregateȱ(inȱbillions) 3.0 2.5 7.7 14.0

Total Aggregateȱ(inȱbillions) ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ32.3 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ44.7 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ29.1 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ119.7 Total Incremental Aggregateȱ(inȱbillions) 4.9 10.7 12.7 29.6

[1]ȱICDȬ9ȬCMȱCodes:ȱGout=274 [2]ȱICDȬ9ȬCMȱCodes:ȱOsteoarthritisȱandȱAlliedȱDisorders=715 [3]ȱICDȬ9ȬCMȱCodes:ȱRheumatoidȱArthritis=714 [4]ȱICDȬ9ȬCMȱCodes:ȱOtherȱandȱUnspecifiedȱDisordersȱofȱtheȱBack=724

Source:ȱMedicalȱExpendituresȱPanelȱSurveyȱ(MEPS),ȱAgencyȱforȱHealthcareȱResearchȱandȱQuality,ȱU.S.ȱDepartmentȱofȱHealthȱ andȱHumanȱServices,ȱ2000Ȭ2004

Tableȱ9.14:ȱCostȱofȱMusculoskeletalȱConditionsȱAggregateȱandȱIndirectȱ(Earningsȱ Losses)ȱasȱaȱProportionȱofȱGrossȱDomesticȱProduct,ȱUnitedȱStatesȱ1996Ȭ2006

AggregateȱValuesȱinȱ2006ȱ$ %ȱofȱGDPȱinȱ2006ȱ$

GDPȱ Inflationȱ Totalȱ(raw)ȱ Totalȱ(raw)ȱ Totalȱ Totalȱ(raw) Totalȱ(raw) Total (currentȱ$,ȱ Factorȱtoȱ GDPȱ[1]ȱ Aggregateȱ Indirect Directȱ+ȱ Aggregate Indirect Directȱ+ inȱbillions) 2004 inȱ2006ȱ$ DirectȱCost Costs Indirect DirectȱCost Costs Indirect

1996 7,816.9 1.2849 1997 8,304.3 1.2561 1998 8,747.0 1.2368$ȱȱȱ 10,431.0 $391.4 $207.9 $599.3 3.75% 1.99% 5.75% 1999 9,268.4 1.2101$ȱȱȱ 10,821.6 $396.9 $252.1 $649.0 3.67% 2.33% 6.00% 2000 9,817.0 1.1707$ȱȱȱ 11,175.7 $395.6 $269.0 $664.6 3.54% 2.41% 5.95% 2001 10,128.0 1.1383$ȱȱȱ 11,412.6 $420.0 $273.5 $693.5 3.68% 2.40% 6.08% 2002 10,469.6 1.1206$ȱȱȱ 11,584.9 $461.1 $289.9 $751.0 3.98% 2.50% 6.48% 2003 10,960.8 1.0957$ȱȱȱ 11,756.9 $510.3 $315.4 $825.8 4.34% 2.68% 7.02% 2004 11,685.9 1.0672$ȱȱȱ 12,071.1 $553.0 $361.4 $914.4 4.58% 2.99% 7.58% 2005 12,433.9 1.0323$ȱȱȱ 12,438.6 $572.7 $390.0 $962.7 4.60% 3.14% 7.74% 2006 13,194.7 1.0000$ȱȱȱ 12,833.8 $576.4 $373.1 $949.5 4.49% 2.91% 7.40%

[1]ȱEarningsȱlossesȱdueȱtoȱmusculoskeletalȱconditionsȱforȱpersonsȱagedȱ18Ȭ64ȱwhoȱeverȱworkedȱ Source:ȱCisternas,ȱM.,ȱMGCȱDataȱServices,ȱwww.mgcdata.com

Tableȱ9.15:ȱBaseȱCaseȱICDȬ9ȬCMȱCodesȱbyȱMusculoskeletalȱDiseaseȱIncludedȱinȱEconomicȱImpactȱAnalysis

ICDȬ9ȬCMȱ ICDȬ9ȬCMȱ ConditionȱName ConditionȱName Code Code Spine MusculoskeletalȱInjuriesȱ(continued) 720 AnkylosingȱSpondylitisȱandȱOtherȱInflammatoryȱSpondylopathies 810 FractureȱofȱClavicle 721 SpondylosisȱandȱAlliedȱDisorders 811 FractureȱofȱScapula 722 IntervertebralȱDiscȱDisorders 812 FractureȱofȱHumerus 723 OtherȱDisordersȱofȱCervicalȱRegion 813 FractureȱofȱRadiusȱandȱUlna 724 OtherȱandȱUnspecifiedȱDisordersȱofȱBack 814 FractureȱofȱCarpalȱBone(s) 737 CurvatureȱofȱSpine 815 FractureȱofȱMetacarpalȱBone(s) 781 SymptomsȱInvolvingȱNervousȱandȱMusculoskeletalȱSystems 816 FractureȱofȱOneȱorȱMoreȱPhalangesȱofȱHand 805 FractureȱofȱVertebralȱColumnȱwithoutȱMentionȱofȱSpinalȱCordeȱ 817 MultipleȱFracturesȱofȱHandȱBones Injury 818 IllȬdefinedȱFracturesȱofȱUpperȱLimb 806 FractureȱofȱVertebralȱColumnȱwithȱSpinalȱCordȱInjury 819 MultipleȱFracturesȱInvolvingȱBothȱUpperȱLimbs,ȱandȱUpperȱLimbȱ 830 DislocationȱofȱJaw withȱRib(s)ȱandȱSternum 846 SprainsȱandȱStrainsȱofȱSacroiliacȱRegion 820 FractureȱofȱNeckȱofȱFemur 847 SprainsȱandȱStrainsȱofȱOtherȱandȱUnspecifiedȱPartsȱofȱBack 821 FractureȱofȱOtherȱandȱUnspecifiedȱPartsȱofȱFemur ArthritisȱandȱJointȱPain 822 FractureȱofȱPatella 274 Gout 823 FractureȱofȱTibiaȱandȱFibula 390 RheumaticȱFeverȱwithoutȱMentionȱofȱHeartȱInvolvementȱ(arthritis,ȱ 824 FractureȱofȱAnkle rheumatic,ȱacuteȱorȱsubacute) 825 FractureȱofȱOneȱorȱMoreȱTarsalȱandȱMetatarsalȱBones 391 RheumaticȱFeverȱwithȱHeartȱInvolvement 826 FractureȱofȱOneȱorȱMoreȱPhalangesȱofȱFoot 710 DiffuseȱDiseasesȱofȱConnectiveȱTissue 827 Other,ȱMultiple,ȱandȱIllȬdefinedȱFracturesȱofȱLowerȱLimb 711 ArthropathyȱAssociatedȱwithȱInfections 828 MultipleȱFracturesȱInvolvingȱBothȱLowerȱLimbs,ȱLowerȱwithȱ 712 CrystalȱArthropathies UpperȱȱLimb,ȱandȱLowerȱLimb(s)ȱwithȱRib(s)* 713 ArthropathyȱAssociatedȱwithȱOtherȱDisordersȱClassifiedȱElsewhere 829 FractureȱofȱUnspecifiedȱBones 714 RheumatoidȱArthritisȱandȱOtherȱInflammatoryȱPolyarthropathies 831 DislocationȱofȱShoulder 715 OsteoarthrosisȱandȱAlliedȱDisorders 832 DislocationȱofȱElbow 716 OtherȱandȱUnspecifiedȱArthropathies 833 DislocationȱofȱWrist 719 OtherȱandȱUnspecifiedȱDisordersȱofȱJoint 834 DislocationȱofȱFinger 725 PolymyalgiaȱRheumatica 835 DislocationȱofȱHip 726 PeripheralȱEnthesopathiesȱandȱAlliedȱSyndromes 836 DislocationȱofȱKnee 727 OtherȱDisordersȱofȱSynovium,ȱTendon,ȱandȱBursa 837 DislocationȱofȱAnkle Osteoporosis 838 DislocationȱofȱFoot 733 OtherȱDisordersȱofȱBoneȱandȱCartilage 839 Other,ȱMultiple,ȱandȱIllȬdefinedȱDislocations OtherȱMusculoskeletalȱConditions 840 SprainsȱandȱStrainsȱofȱShoulderȱandȱUpperȱArm 015 TuberculosisȱofȱBonesȱandȱJoints 841 SprainsȱandȱStrainsȱofȱElbowȱandȱforearm 135 Sarcoidosis;ȱLupoidȱofȱBoeck;ȱLupusȱPernio 842 SprainsȱandȱStrainsȱofȱWristȱandȱHand 170 MalignantȱNeoplasmȱofȱBoneȱandȱArticularȱCartilage 843 SprainsȱandȱStrainsȱofȱHipȱandȱThigh 171 MalignantȱNeoplasmȱofȱConnectiveȱandȱOtherȱSoftȱTissue 844 SprainsȱandȱStrainsȱofȱKneeȱandȱLeg 213 BenignȱNeoplasmȱofȱBoneȱandȱArticularȱCartilage 845 SprainsȱandȱStrainsȱofȱAnkleȱandȱFoot 268 VitaminȱDȱDeficiency 848 OtherȱandȱIllȬdefinedȱSprainsȱandȱStrains 728 DisordersȱofȱMuscle,ȱLigament,ȱandȱFascia 875 OpenȱWoundȱofȱChestȱ(wall) 729 OtherȱDisordersȱofȱSoftȱTissues 876 OpenȱWoundȱofȱBack 730 Osteomyelitis,ȱPeriostitis,ȱandȱOtherȱInfectionsȱInvolvingȱBone 877 OpenȱWoundȱofȱButtock 731 OsteitisȱDeformansȱ&ȱOsteopathiesȱAssocȱwithȱDisordersȱClassifiedȱ 880 OpenȱWoundȱofȱShoulderȱandȱUpperȱArm Elsewhere 881 OpenȱWoundȱofȱElbow,ȱforearm,ȱandȱWrist 732 Osteochondropathies 882 OpenȱWoundȱofȱHandȱExceptȱFinger(s)ȱAlone 734 FlatȱFootȱPesplanusȱ(acquired);ȱTalipesȱplanusȱ(acquired) 883 OpenȱWoundȱofȱFinger(s) 735 AcquiredȱDeformitiesȱofȱToe 884 MultipleȱandȱUnspecifiedȱOpenȱWoundȱofȱUpperȱLimb 736 OtherȱAcquiredȱDeformitiesȱofȱLimbs 885 TraumaticȱAmputationȱofȱThumbȱ(complete)ȱ(partial) 738 OtherȱAcquiredȱMusculoskeletalȱDeformity 886 TraumaticȱAmputationȱofȱOtherȱFinger(s)ȱ(complete)ȱ(partial) 739 NonallopathicȱLesions,ȱNEC 887 TraumaticȱAmputationȱofȱArmȱandȱHandȱ(complete)ȱ(partial) 741 SpinaȱBifida 890 OpenȱWoundȱofȱHipȱandȱThigh 754 CertainȱCongenitalȱMusculoskeletalȱDeformities 891 OpenȱWoundȱofȱKnee,ȱLegȱ(exceptȱThigh),ȱandȱAnkle 755 OtherȱCongenitalȱAnomaliesȱofȱLimbs 892 OpenȱWoundȱofȱFootȱExceptȱToe(s)ȱAlone 756 OtherȱCongenitalȱMusculoskeletalȱAnomalies 893 OpenȱWoundȱofȱToe(s) V49 OtherȱConditionsȱInfluencingȱHealthȱStatus 894 MultipleȱandȱUnspecifiedȱOpenȱWoundȱofȱLowerȱLimb V54 OtherȱOrthopaedicȱAftercare 895 TraumaticȱAmputationȱofȱToe(s)ȱ(complete)ȱ(partial) MusculoskeletalȱInjuries 896 TraumaticȱAmputationȱofȱFootȱ(complete)ȱ(partial) 717 InternalȱDerangementȱofȱKnee 897 TraumaticȱAmputationȱofȱLeg(s)ȱ(complete)ȱ(partial) 718 OtherȱDerangementȱofȱJoint 905 LateȱEffectsȱofȱMusculoskeletalȱandȱConnectiveȱTissueȱInjuries 807 FractureȱofȱRib(s),ȱSternum,ȱLarynx,ȱandȱTrachea 927 CrushingȱInjuryȱofȱUpperȱLimb 808 FractureȱofȱPelvis 928 CrushingȱInjuryȱofȱLowerȱLimb 809 IllȬdefinedȱFracturesȱofȱBonesȱofȱTrunk 929 CrushingȱInjuryȱofȱMultipleȱandȱUnspecifiedȱSites

Tableȱ9.16:ȱExpansiveȱListȱICDȬ9ȬCMȱCodesȱbyȱMusculoskeletalȱDiseaseȱIncludedȱinȱEconomicȱImpactȱ Analysis

ICDȬ9ȬCMȱ ICDȬ9ȬCMȱ Code ConditionȱName Code ConditionȱName Spine OtherȱMusculoskeletalȱConditions 307 SpecialȱSymptomsȱorȱSyndromes,ȱNEC 3 OtherȱSalmonellaȱInfections 346 Migraine 26 RatȬbiteȱFever 350 TrigeminalȱNerveȱDisorders 36 MeningococcalȱInfection 353 NerveȱRootȱandȱPlexusȱDisorders 56 Rubella 524 DentofacialȱAnomalies,ȱIncludingȱMalocclusion 88 OtherȱArthropodȬborneȱDiseases 625 PainȱandȱOtherȱSymptomsȱAssociatedȱwithȱFemaleȱGenitalȱorgans 91 EarlyȱSyphilis,ȱSymptomatic 627 MenopausalȱandȱPostmenopausalȱDisorders 95 OtherȱformsȱofȱLateȱSyphilis,ȱwithȱSymptoms 780 GeneralȱSymptoms 102 Yaws 782 SymptomsȱInvolvingȱSkinȱandȱOtherȱIntegumentaryȱTissue 137 LateȱEffectsȱofȱTuberculosis 784 SymptomsȱInvolvingȱHeadȱandȱNeck 195 MalignantȱNeoplasmȱofȱOtherȱandȱIllȬdefinedȱSites 786 SymptomsȱInvolvingȱRespiratoryȱSystemȱandȱOtherȱChestȱ 198 SecondaryȱMalignantȱNeoplasmȱofȱOtherȱSpecifiedȱSites Symptoms 202 OtherȱMalignantȱNeoplasmsȱofȱLymphoidȱandȱHistiocyticȱTissue 787 SymptomsȱInvolvingȱDigestiveȱSystem 203 MultipleȱMyelomaȱandȱImmunoproliferativeȱNeoplasms 789 OtherȱSymptomsȱInvolvingȱAbdomenȱandȱPelvis 215 OtherȱBenignȱNeoplasmȱofȱConnectiveȱandȱOtherȱSoftȱTissue 951 InjuryȱtoȱOtherȱCranialȱNerve(s) 238 NeoplasmȱofȱUncertainȱBehaviorȱofȱOtherȱandȱUnspecifiedȱSitesȱ 953 InjuryȱtoȱNerveȱRootsȱandȱSpinalȱPlexus andȱTissues ArthritisȱandȱJointȱPain 239 NeoplasmsȱofȱUnspecifiedȱNature 098 GonococcalȱInfections 252 DisordersȱofȱParathyroidȱGland 099 OtherȱVenerealȱDiseases 272 DisordersȱofȱLipoidȱMetabolism 136 OtherȱandȱUnspecifiedȱInfectiousȱandȱParasiticȱDiseases 275 DisordersȱofȱMineralȱMetabolism 277 OtherȱandȱUnspecifiedȱDisordersȱofȱMetabolism 282 HereditaryȱHemolyticȱAnemias 287 PurpuraȱandȱOtherȱHemorrhagicȱConditions 327 organicȱSleepȱDisorders 344 OtherȱParalyticȱSyndromes 355 MononeuritisȱofȱLowerȱLimbȱandȱUnspecifiedȱSite 354 MononeuritisȱofȱUpperȱLimbȱandȱMononeuritisȱMultiplex 567 Peritonitisȱandȱretroperitonealȱinfections 357 InflammatoryȱandȱToxicȱNeuropathy 682 OtherȱCellulitisȱandȱAbscess 437 OtherȱandȱIllȬdefinedȱCerebrovascularȱDisease 759 OtherȱandȱUnspecifiedȱCongenitalȱAnomaliesȱ 443 OtherȱPeripheralȱVascularȱDisease 906 LateȱEffectsȱofȱInjuriesȱtoȱSkinȱandȱSubcutaneousȱTissues 446 PolyarteritisȱNodosaȱandȱAlliedȱConditions 958 CertainȱEarlyȱComplicationsȱofȱTrauma 447 OtherȱDisordersȱofȱArteriesȱandȱArterioles 996 ComplicationsȱPeculiarȱtoȱCertainȱSpecifiedȱProcedures 696 PsoriasisȱandȱSimilarȱDisorders V13 PersonalȱHistoryȱofȱOtherȱDiseases MusculoskeletalȱInjuries V42 organȱorȱTissueȱReplacedȱByȱTransplant 874 OpenȱWoundȱofȱNeck V43 organȱorȱTissueȱReplacedȱByȱOtherȱMeans 879 OpenȱWoundȱofȱOtherȱandȱUnspecifiedȱSites,ȱExceptȱLimbs V45 OtherȱPostproceduralȱStates 922 ContusionȱofȱTrunk V48 ProblemsȱwithȱHead,ȱNeck,ȱandȱTrunk 923 ContusionȱofȱUpperȱLimb V53 FittingȱandȱAdjustmentȱofȱOtherȱDevice 924 ContusionȱofȱLowerȱLimbȱandȱofȱOtherȱandȱUnspecifiedȱSites V66 Convalescenceȱandȱpalliativeȱcare 926 CrushingȱInjuryȱofȱTrunk V67 FollowȬupȱExamination SpecialȱScreeningȱExaminationȱforȱBacterialȱandȱSpirochetalȱ V74 Diseases

Appendix A - Musculoskeletal Diseases Diagnosis Codes

TableȱA1:ȱICDȬ9ȬCMȱDiagnosisȱCodesȱforȱSpecificȱMusculoskeletalȱDiseases

Condition ICDȬ9ȬCMȱCode Description

Chapterȱ2:ȱSpinalȱDeformityȱandȱRelatedȱConditions 737 Curvatureȱofȱtheȱspine

Chapterȱ3:ȱSpine:ȱLowȱBackȱandȱNeckȱPain BackȱPainȱ(LumbarȱandȱLowȱBack) BackȱDisorders 720* Ankylosingȱspondylitisȱandȱotherȱinflammatoryȱ spondylopathies 721.2Ȭ.721.9 Spondylosisȱandȱalliedȱdisorders 724 Otherȱandȱunspecifiedȱdisordersȱofȱback

DiskȱDisorders 722.10,ȱ722.11 Displacementȱofȱintervetebralȱdisc 722.30Ȭ722.39 Schmorlȇsȱnodes 722.51,ȱ722.52,ȱ722.60 Degenerationȱofȱintervetebralȱdisc 722.72,ȱ722.73 Intervertebralȱdiscȱdisorderȱwithȱmyelopathy 722.80,ȱ722.82,ȱ722.83 Postlaminectomyȱsyndrome 722.90,ȱ722.92,ȱ722.93 Otherȱandȱunspecifiedȱdiscȱdisorder

BackȱInjury 805.20Ȭ805.80 Closedȱfractureȱofȱvertebraȱwithoutȱmentionȱofȱspinalȱ coardȱinjury 806.20Ȭ806.90 Closedȱfractureȱofȱvertebraȱwithȱspinalȱcordȱinjury 839.20Ȭ839.49 Closedȱdislocation,ȱbetebra 846 Sprainsȱandȱstrainsȱofȱsacroiliacȱregion 847.10Ȭ749.90 Otherȱsprainsȱandȱstrainsȱofȱback

Cervicalȱ(Neck)ȱPain NeckȱDisorders 721.00,ȱ721.11 Cervicalȱspondylosis 723.00Ȭ723.90 Disordersȱofȱcervicalȱregion

DiskȱDisorders 722.00 Displacementȱofȱcervicalȱintervertebralȱdisc 722.40 Degenerationȱofȱcervicalȱintervertebralȱdisc 722.71 Intervertebralȱdiscȱdisorder,ȱwithȱmyelopathy 722.81 Postlaminectomyȱsyndromeȱofȱcervicalȱregion 722.91 Otherȱandȱunspecifiedȱdiscȱdisordersȱofȱcervicalȱregion

NeckȱInjury 805 ClosedȱfFractureȱofȱcervicalȱvertebraȱwithoutȱmentionȱofȱ spinalȱcordȱinjury 806 Closedȱfractureȱofȱcervicalȱbertebraȱwithȱspinalȱcordȱ injury 839 Closedȱdislocation,ȱcervicalȱvertebra 847.00 Neckȱsprain

SpineȱProcedures 81.02,ȱ81.03 Cervicalȱfusion (ICDȬ9ȬCMȱProceduresȱ 81.04,ȱ81.05 Thoracicȱfusion Code) 81.06Ȭ81.08 Lumbarȱfusion 81.00,ȱ81.01 Otherȱfusion 81.62Ȭ81.64 Fusion/refusionȱmultipleȱvertebrae 81.30Ȭ81.39 Spineȱrefusion 03.09 Spinalȱdecompression 80.50,ȱ80.51 Spinalȱdiskectomy

TableȱA1ȱ(continued)ȱ:ȱICDȬ9ȬCMȱDiagnosisȱCodesȱforȱSpecificȱMusculoskeletalȱDiseasesȱ

Condition ICDȬ9ȬCMȱCode Description

Chapterȱ4:ȱArthritisȱandȱJointȱPain ArthritisȱandȱOtherȱ 715 Osteoarthritis RheumaticȱConditions 714 Rheumatoidȱarthritis 274,ȱ712 Goutȱandȱotherȱcrystalȱarthropathies 710.00 Systemicȱlupusȱerythematosusȱ(Lupus) 710.01 Sytemicȱsclerosis 710.20 Sjogrenȇsȱsyndrome 729.10 Fibromyalgia 446.50,ȱ725.00 Polymyalgiaȱrheumaticaȱandȱgiantȱcellȱarteritis 099.30,ȱ696.00,ȱ720,ȱ721 Spondylarthropathies 716,ȱ719 Jointȱpain 354,ȱ711,ȱ726,ȱ727,ȱ728,ȱ729.40 Allȱotherȱarthritisȱandȱrheumaticȱconditions

Jointȱreplacement 81.54,ȱ815.5,ȱ00.80Ȭ00.84 Kneeȱarthroplasty/revisionȱarthroplasty (ICDȬ9ȬCMȱProceduresȱ 81.51Ȭ81.53,ȱ00.70Ȭ00.76 Hipȱarthroplasty/revisionȱarthroplasty Code) 81.56,ȱ81.57,ȱ81.59 Ankle,ȱfoot,ȱtoeȱarthroplasty 81.71,ȱ81.72 Fingerȱarthroplasty 81.73Ȭ81.73,ȱ81.79 Wristȱarthroplasty 81.80,ȱ81.81,ȱ81.83 Shoulderȱarthroplas;ty 81.84,ȱ81.85 Elbowȱarthroplas;ty 81.97 Upperȱextremityȱunspecified

Chapterȱ5:ȱOsteoporosisȱandȱBoneȱHealth PrimaryȱOsteoporosis 733 Osteoporosis

LowȱEnergyȱFractures 805.00Ȭ805.08,ȱ805.20,ȱ805.40,ȱ805.60,ȱ805.80,ȱ808.00,ȱ Vertebralȱandȱpelvicȱfracture 808.41Ȭ808.49,ȱ808.80 810.00Ȭ810.03,ȱ811.00Ȭ811.03,ȱ811.09,ȱ812.00Ȭ812.03,ȱ Upperȱlimbȱfractureȱ(closed) 812.09,ȱ812.20,ȱ812.21,ȱ812.40Ȭ812.44,ȱ812.49

813.00Ȭ813.08,ȱ813.20Ȭ813.23,ȱ813.40Ȭ813.45,ȱ813.80Ȭ Wristȱfractureȱ(closed) 813.83,ȱ814.00Ȭ814.09,ȱ815.00Ȭ815.04,ȱ815.09 820.00Ȭ820.03,ȱ820.09,ȱ820.20Ȭ820.22,ȱ820.80 Hipȱfractureȱ(closed) 821.00Ȭ821.01,ȱ821.20Ȭ821.23,ȱ821.29,ȱ822.00,ȱ823.00Ȭ Lowerȱlimbȱfracture,ȱexcludingȱfootȱandȱankleȱ(closed) 823.02,ȱ823.20Ȭ823.22,ȱ823.80Ȭ823.82 824.00,ȱ824.20,ȱ824.40,ȱ824.60,ȱ824.80,ȱ825.00,ȱ825.20Ȭ Ankleȱandȱfootȱfractureȱ(closed) 825.25,ȱ825.29 733.10Ȭ733.16,ȱ733.19,ȱ733.93Ȭ733.95 Stressȱandȱpathologicalȱfractures E800ȬE807,ȱE810ȬE838,ȱE840ȬE848,ȱE990ȬE999 ExcludeȱcasesȱwithȱEȬcodeȱofȱhighȱenergyȱfracture

SecondaryȱOsteoporosis 242.90Ȭ242.91,ȱ252.00Ȭ252.02,ȱ252.08,ȱ255.00,ȱ255.30,ȱ Diagnosisȱthatȱmayȱleadȱtoȱosteoporosis 256.20,ȱ256.31,ȱ256.39,ȱ257.10,ȱ257.20,ȱ259.30,ȱ259.90,ȱ 268.20,ȱ268.90,ȱ588.00,ȱ588.81,ȱ627.20,ȱ627.40,ȱ627.80,ȱ 627.90

806.00Ȭ806.40,ȱ806.50,ȱ806.60Ȭ806.62,ȱ806.69,ȱ807.70Ȭ Vertebralȱfracturesȱwithȱspinalȱcordȱinjury 706.72,ȱ706.79,ȱ806.80,ȱ806.90

TableȱA1ȱ(continued)ȱ:ȱICDȬ9ȬCMȱDiagnosisȱCodesȱforȱSpecificȱMusculoskeletalȱDiseasesȱ

Condition ICDȬ9ȬCMȱCode Description

Chapterȱ6:ȱMusculoskeletalȱInjuries Fractures 807.00Ȭ807.4,ȱ808,ȱ809,ȱ819,ȱ828,ȱ829 Trunkȱandȱmultipleȱsiteȱfractures 810,ȱ811,ȱ812,ȱ813,ȱ814,ȱ815,ȱ816,ȱ817 Upperȱlimbȱfractures 820,ȱ821,ȱ822,ȱ823,ȱ824,ȱ825,ȱ826,ȱ827 Lowerȱlimbȱfractures Derangement 717 Kneeȱderangement 718 Otherȱjointȱderangement Dislocation 831,ȱ832,ȱ833 Upperȱlimbȱdislocation 834,ȱ835,ȱ836,ȱ837,ȱ838 Lowerȱlimbȱdislocatin 839 Otherȱsiteȱdislocation Sprains/Strains 840,ȱ841,ȱ842 Upperȱlimbȱsprain/strain 843,ȱ844,ȱ845 Lowerȱlimbȱsprain/strain 848 Otherȱsiteȱsprain/strain Contusions 922,ȱ923,ȱ924 CrushingȱInjury 926,ȱ927,ȱ928,ȱ929 OpenȱWound 874,ȱ875,ȱ876,ȱ877,ȱ879,ȱ880,ȱ881,ȱ882,ȱ883,ȱ884,ȱ890,ȱ 891,ȱ892,ȱ893,ȱ894 TraumaticȱAmputation 885,ȱ886,ȱ887,ȱ895,ȱ896,ȱ897 LateȱEffectȱofȱInjury 954,ȱ955,ȱ956,ȱ957,ȱ959

Chapterȱ7:ȱMusculoskeletalȱCongenitalȱandȱInfantileȱDevelopmentalȱConditions 741 Spinaȱbifida 754.1Ȭ754.9 Certainȱcongenitalȱmusculoskeletalȱdeformities 755 Otherȱcongenitalȱanomaliesȱofȱlimbs 756 Otherȱcongenitalȱmusculoskeletalȱanomalies

Chapterȱ8:ȱNeoplasmsȱofȱBoneȱandȱConnectiveȱTissue DataȱbasedȱonȱNationalȱCancerȱInstituteȱClassifications

Appendix B - Musculoskeletal Data Summaries

TableȱB1:ȱHospitalizationsȱforȱAllȱMusculoskeletalȱDiseasesȱbyȱ3ȬDigitȱICDȬ9ȬCMȱDiagnosisȱbyȱAgeȱCategory,ȱ UnitedȱStatesȱ2007

ICDȬ9ȬCM Description <ȱ18 18ȱȬȱ44 45ȱȬȱ64 64+ Total 99.3 Rieterȇsȱdisease ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ196 * 135 Sarcoidosis * ȱȱȱȱȱȱȱȱȱȱ14,950 ȱȱȱȱȱȱȱȱȱȱ35,956 ȱȱȱȱȱȱȱȱȱȱ17,017 ȱȱȱȱȱȱȱȱȱȱ68,865 170 Malignantȱneoplasmȱofȱboneȱandȱarticularȱcartilageȱȱȱȱȱȱȱȱȱȱ 10,122 ȱȱȱȱȱȱȱȱȱȱȱȱ7,334 ȱȱȱȱȱȱȱȱȱȱȱȱ3,658 ȱȱȱȱȱȱȱȱȱȱȱȱ2,913 ȱȱȱȱȱȱȱȱȱȱ24,398

171 Malignantȱneoplasmȱofȱconnectiveȱandȱotherȱsoftȱtissueȱȱȱȱȱȱȱȱȱȱȱȱ 4,516 ȱȱȱȱȱȱȱȱȱȱȱȱ6,417 ȱȱȱȱȱȱȱȱȱȱȱȱ9,255 ȱȱȱȱȱȱȱȱȱȱȱȱ7,851 ȱȱȱȱȱȱȱȱȱȱ29,125

199 Secondaryȱmalignantȱneoplasmȱofȱotherȱspecifiedȱsites;ȱBoneȱandȱboneȱmarrowȱȱȱȱȱȱȱȱȱȱȱȱ 5,031 ȱȱȱȱȱȱȱȱȱȱ19,627 ȱȱȱȱȱȱȱȱ103,248 ȱȱȱȱȱȱȱȱ134,769 ȱȱȱȱȱȱȱȱ279,450 203 Multipleȱmyelomaȱandȱimmunoproliferativeȱneoplasms * ȱȱȱȱȱȱȱȱȱȱȱȱ2,703 ȱȱȱȱȱȱȱȱȱȱ28,365 ȱȱȱȱȱȱȱȱȱȱ48,950 ȱȱȱȱȱȱȱȱȱȱ86,374 213 Benignȱneoplasmȱofȱboneȱandȱarticularȱcartilageȱȱȱȱȱȱȱȱȱȱȱȱ 1,060 ȱȱȱȱȱȱȱȱȱȱȱȱ1,797 ȱȱȱȱȱȱȱȱȱȱȱȱ2,086 ȱȱȱȱȱȱȱȱȱȱȱȱ1,336 ȱȱȱȱȱȱȱȱȱȱȱȱ6,421 215 Otherȱbenignȱneoplasmȱofȱconnectiveȱandȱotherȱsoftȱtissue * ȱȱȱȱȱȱȱȱȱȱȱȱ1,788 ȱȱȱȱȱȱȱȱȱȱȱȱ3,070 ȱȱȱȱȱȱȱȱȱȱȱȱ1,748 ȱȱȱȱȱȱȱȱȱȱȱȱ7,286 Neoplasmȱofȱuncertainȱbehaviorȱofȱotherȱandȱunspecifiedȱsitesȱandȱtissues;ȱConnectiveȱandȱ 238 ȱȱȱȱȱȱȱȱȱȱȱȱ2,129 ȱȱȱȱȱȱȱȱȱȱȱȱ1,984 ȱȱȱȱȱȱȱȱȱȱȱȱ1,685 ȱȱȱȱȱȱȱȱȱȱȱȱ6,475 otherȱsoftȱtissue,ȱBoneȱsoftȱtisueȱandȱskin * 239.2 Neoplasmsȱofȱunspecifiedȱnature;ȱBoneȱsoftȱtisueȱandȱskin ****ȱȱȱȱȱȱȱȱȱȱȱȱ2,235 274 Gout;ȱGoutyȱarthroplathy * ȱȱȱȱȱȱȱȱȱȱȱȱ5,075 ȱȱȱȱȱȱȱȱȱȱ26,441 ȱȱȱȱȱȱȱȱȱȱ51,773 ȱȱȱȱȱȱȱȱȱȱ95,078 354 Mononeuritisȱofȱupperȱlimbȱandȱmononeuritisȱmultiplex * ȱȱȱȱȱȱȱȱȱȱȱȱ7,818 ȱȱȱȱȱȱȱȱȱȱ14,369 ȱȱȱȱȱȱȱȱȱȱȱȱ9,523 ȱȱȱȱȱȱȱȱȱȱ33,754 710 Diffuseȱdiseasesȱofȱconnectiveȱtissueȱȱȱȱȱȱȱȱȱȱȱȱ 3,131 ȱȱȱȱȱȱȱȱȱȱ61,690 ȱȱȱȱȱȱȱȱȱȱ66,290 ȱȱȱȱȱȱȱȱȱȱ32,549 ȱȱȱȱȱȱȱȱ166,509

711 Arthropathyȱassociatedȱwithȱinfectionsȱȱȱȱȱȱȱȱȱȱȱȱ 4,136 ȱȱȱȱȱȱȱȱȱȱ11,284 ȱȱȱȱȱȱȱȱȱȱ20,895 ȱȱȱȱȱȱȱȱȱȱ18,475 ȱȱȱȱȱȱȱȱȱȱ57,849 712 Crystalȱarthropathies **ȱȱȱȱȱȱȱȱȱȱȱȱ1,960 ȱȱȱȱȱȱȱȱȱȱȱȱ6,488 ȱȱȱȱȱȱȱȱȱȱ11,128 713 Arthropathyȱassociatedȱwithȱotherȱdisordersȱclassifiedȱelsewhere * ȱȱȱȱȱȱȱȱȱȱȱȱ3,045 ȱȱȱȱȱȱȱȱȱȱ10,945 ȱȱȱȱȱȱȱȱȱȱȱȱ5,625 ȱȱȱȱȱȱȱȱȱȱ20,073 714 Rheumatoidȱarthritisȱandȱotherȱinflammatoryȱpolyarthropathiesȱȱȱȱȱȱȱȱȱȱȱȱ 2,127 ȱȱȱȱȱȱȱȱȱȱ35,508 ȱȱȱȱȱȱȱȱ129,480 ȱȱȱȱȱȱȱȱ210,145 ȱȱȱȱȱȱȱȱ409,702 715 Osteoarthrosisȱandȱalliedȱdisorders * ȱȱȱȱȱȱȱȱȱȱ66,785 ȱȱȱȱȱȱȱȱ597,801 ȱȱȱȱȱ1,207,890 ȱȱȱȱȱ2,202,259 716 Otherȱandȱunspecifiedȱarthroplasties * ȱȱȱȱȱȱȱȱȱȱ27,132 ȱȱȱȱȱȱȱȱ124,463 ȱȱȱȱȱȱȱȱ193,280 ȱȱȱȱȱȱȱȱ391,596 717 Internalȱderangementȱofȱknee * ȱȱȱȱȱȱȱȱȱȱȱȱ5,468 ȱȱȱȱȱȱȱȱȱȱȱȱ8,926 ȱȱȱȱȱȱȱȱȱȱȱȱ6,091 ȱȱȱȱȱȱȱȱȱȱ21,848 718 Otherȱderangementȱȱofȱjointȱȱȱȱȱȱȱȱȱȱȱȱ 4,703 ȱȱȱȱȱȱȱȱȱȱ12,043 ȱȱȱȱȱȱȱȱȱȱ19,805 ȱȱȱȱȱȱȱȱȱȱ20,904 ȱȱȱȱȱȱȱȱȱȱ62,051

719 Otherȱandȱunspecifiedȱdisordersȱofȱjointȱȱȱȱȱȱȱȱȱȱ 19,196 ȱȱȱȱȱȱȱȱȱȱ61,064 ȱȱȱȱȱȱȱȱȱȱ98,546 ȱȱȱȱȱȱȱȱ128,872 ȱȱȱȱȱȱȱȱ348,625 720 Ankylosingȱspondylitisȱandȱotherȱinflammatoryȱspondylopathies * ȱȱȱȱȱȱȱȱȱȱȱȱ3,494 ȱȱȱȱȱȱȱȱȱȱȱȱ6,861 ȱȱȱȱȱȱȱȱȱȱȱȱ6,057 ȱȱȱȱȱȱȱȱȱȱ17,679 721 Spondylosisȱandȱalliedȱdisorders * ȱȱȱȱȱȱȱȱȱȱ38,075 ȱȱȱȱȱȱȱȱ137,694 ȱȱȱȱȱȱȱȱ167,141 ȱȱȱȱȱȱȱȱ382,775 722 Intervertebralȱdiscȱdisordersȱȱȱȱȱȱȱȱȱȱȱȱ 1,222 ȱȱȱȱȱȱȱȱ172,067 ȱȱȱȱȱȱȱȱ293,506 ȱȱȱȱȱȱȱȱ196,873 ȱȱȱȱȱȱȱȱ692,653

723 Otherȱdisorderȱofȱcervicalȱregionȱȱȱȱȱȱȱȱȱȱȱȱ 4,135 ȱȱȱȱȱȱȱȱȱȱ34,838 ȱȱȱȱȱȱȱȱȱȱ65,689 ȱȱȱȱȱȱȱȱȱȱ45,824 ȱȱȱȱȱȱȱȱ157,958

724 Otherȱandȱunspecifiedȱdisordersȱofȱbackȱȱȱȱȱȱȱȱȱȱȱȱ 6,851 ȱȱȱȱȱȱȱȱ200,132 ȱȱȱȱȱȱȱȱ378,870 ȱȱȱȱȱȱȱȱ398,467 ȱȱȱȱȱ1,069,018 725 Polymyalgiaȱrheumatica **ȱȱȱȱȱȱȱȱȱȱȱȱ5,812 ȱȱȱȱȱȱȱȱȱȱ51,125 ȱȱȱȱȱȱȱȱȱȱ76,944 726 Peripheralȱenthesopathiesȱandȱalliedȱsyndromesȱȱȱȱȱȱȱȱȱȱȱȱ 1,545 ȱȱȱȱȱȱȱȱȱȱ16,106 ȱȱȱȱȱȱȱȱȱȱ42,578 ȱȱȱȱȱȱȱȱȱȱ48,235 ȱȱȱȱȱȱȱȱ116,619

727 Synovitisȱ&ȱtenosynovitis ȱȱȱȱȱȱȱȱȱȱȱȱ4,051 ȱȱȱȱȱȱȱȱȱȱ15,092 ȱȱȱȱȱȱȱȱȱȱ32,748 ȱȱȱȱȱȱȱȱȱȱ33,592 ȱȱȱȱȱȱȱȱȱȱ90,235

728 Disordersȱofȱmuscle,ȱligament,ȱandȱfasciaȱȱȱȱȱȱȱȱȱȱȱȱ 8,231 ȱȱȱȱȱȱȱȱȱȱ60,677 ȱȱȱȱȱȱȱȱȱȱ92,778 ȱȱȱȱȱȱȱȱ108,156 ȱȱȱȱȱȱȱȱ302,123

729 Otherȱdisordersȱofȱsoftȱtissueȱȱȱȱȱȱȱȱȱȱ 10,909 ȱȱȱȱȱȱȱȱ118,451 ȱȱȱȱȱȱȱȱ240,516 ȱȱȱȱȱȱȱȱ195,558 ȱȱȱȱȱȱȱȱ603,277

730 Acuteȱosteomyelitis ȱȱȱȱȱȱȱȱȱȱȱȱ7,008 ȱȱȱȱȱȱȱȱȱȱ35,496 ȱȱȱȱȱȱȱȱȱȱ87,385 ȱȱȱȱȱȱȱȱȱȱ70,498 ȱȱȱȱȱȱȱȱ213,555 731 Osteitisȱdeformansȱandȱosteopathiesȱassociatedȱwithȱotherȱdisordersȱclassifiedȱelsewhere * ȱȱȱȱȱȱȱȱȱȱȱȱ9,009 ȱȱȱȱȱȱȱȱȱȱ33,142 ȱȱȱȱȱȱȱȱȱȱ28,177 ȱȱȱȱȱȱȱȱȱȱ77,454 732 Osteochondropathies ȱȱȱȱȱȱȱȱȱȱȱȱ3,591 ȱȱȱȱȱȱȱȱȱȱȱȱ2,675 ȱȱȱȱȱȱȱȱȱȱȱȱ1,917 ȱȱȱȱȱȱȱȱȱȱȱȱ1,113 ȱȱȱȱȱȱȱȱȱȱȱȱ9,089 Otherȱdisordersȱofȱboneȱandȱcartilageȱ(Osteoporosis;ȱpathologicȱfracture,ȱcyst,ȱnecrosisȱofȱ 733 ȱȱȱȱȱȱȱȱȱȱ11,906 ȱȱȱȱȱȱȱȱȱȱ69,330 ȱȱȱȱȱȱȱȱ272,242 ȱȱȱȱȱȱȱȱ803,929 ȱȱȱȱȱ1,472,083 bone, malunion and nonunion of fracture) 734 Flatȱfoot **ȱȱȱȱȱȱȱȱȱȱȱȱ1,894 ȱȱȱȱȱȱȱȱȱȱȱȱ1,468 ȱȱȱȱȱȱȱȱȱȱȱȱ4,294 735 Acquiredȱdeformitiesȱofȱtoe * ȱȱȱȱȱȱȱȱȱȱȱȱ1,252 ȱȱȱȱȱȱȱȱȱȱȱȱ4,232 ȱȱȱȱȱȱȱȱȱȱȱȱ5,226 ȱȱȱȱȱȱȱȱȱȱ12,311

* Estimateȱdoesȱnotȱmeetȱstandardȱofȱreliabilityȱorȱprecision. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱInpatientȱSurvey,ȱ2007

TableȱB1ȱ(continued):ȱHospitalizationsȱforȱAllȱMusculoskeletalȱDiseasesȱbyȱ3ȬDigitȱICDȬ9ȬCMȱDiagnosisȱbyȱAgeȱ Category,ȱUnitedȱStatesȱ2007

ICDȬ9ȬCM Description <ȱ18 18ȱȬȱ44 45ȱȬȱ64 64+ Total 736 Acquiredȱdeformitiesȱofȱforearmȱȱȱȱȱȱȱȱȱȱȱȱ 3,994 ȱȱȱȱȱȱȱȱȱȱ10,856 ȱȱȱȱȱȱȱȱȱȱ27,982 ȱȱȱȱȱȱȱȱȱȱ35,028 ȱȱȱȱȱȱȱȱȱȱ82,099

737 Curvatureȱofȱspine ȱȱȱȱȱȱȱȱȱȱ16,445 ȱȱȱȱȱȱȱȱȱȱ35,511 ȱȱȱȱȱȱȱȱȱȱ33,246 ȱȱȱȱȱȱȱȱȱȱ63,693 ȱȱȱȱȱȱȱȱ174,706

738 Otherȱacquiredȱdeformityȱ(ofȱmusculoskeletalȱsystem),ȱspondylolisthesisȱȱȱȱȱȱȱȱȱȱȱȱ 2,005 ȱȱȱȱȱȱȱȱȱȱ11,380 ȱȱȱȱȱȱȱȱȱȱ31,987 ȱȱȱȱȱȱȱȱȱȱ34,321 ȱȱȱȱȱȱȱȱȱȱ82,861 739 Nonallopathicȱlesions,ȱnotȱelsewhereȱclassified * ȱȱȱȱȱȱȱȱȱȱȱȱ3,698 ȱȱȱȱȱȱȱȱȱȱȱȱ4,407 ȱȱȱȱȱȱȱȱȱȱȱȱ4,521 ȱȱȱȱȱȱȱȱȱȱ13,678 741 Spinaȱbifida ȱȱȱȱȱȱȱȱȱȱȱȱ8,639 ȱȱȱȱȱȱȱȱȱȱ13,461 ȱȱȱȱȱȱȱȱȱȱȱȱ4,665 * ȱȱȱȱȱȱȱȱȱȱ27,974 754 Certainȱcongenitalȱmusculoskeletalȱdeformitiesȱȱȱȱȱȱȱȱȱȱ 26,473 ȱȱȱȱȱȱȱȱȱȱȱȱ3,214 ȱȱȱȱȱȱȱȱȱȱȱȱ2,101 ȱȱȱȱȱȱȱȱȱȱȱȱ1,512 ȱȱȱȱȱȱȱȱȱȱ33,632

755 Otherȱcongenitalȱanomaliesȱofȱlimbsȱ(Polydactyly)ȱȱȱȱȱȱȱȱȱȱ 31,482 ȱȱȱȱȱȱȱȱȱȱȱȱ4,531 ȱȱȱȱȱȱȱȱȱȱȱȱ4,923 ȱȱȱȱȱȱȱȱȱȱȱȱ1,763 ȱȱȱȱȱȱȱȱȱȱ42,985

756 Otherȱcongenitalȱmusculoskeletalȱanomaliesȱȱȱȱȱȱȱȱȱȱȱȱ 7,011 ȱȱȱȱȱȱȱȱȱȱ10,482 ȱȱȱȱȱȱȱȱȱȱ14,849 ȱȱȱȱȱȱȱȱȱȱ14,619 ȱȱȱȱȱȱȱȱȱȱ48,560

805 Fractureȱofȱvertebralȱcolumnȱwithoutȱmentionȱofȱspinalȱcordȱinjuryȱȱȱȱȱȱȱȱȱȱȱȱ 5,421 ȱȱȱȱȱȱȱȱȱȱ37,886 ȱȱȱȱȱȱȱȱȱȱ34,157 ȱȱȱȱȱȱȱȱȱȱ62,321 ȱȱȱȱȱȱȱȱ166,276 806 Fractureȱofȱvertebralȱcolumnȱwithȱmentionȱofȱspinalȱcordȱinjury * ȱȱȱȱȱȱȱȱȱȱȱȱ5,154 ȱȱȱȱȱȱȱȱȱȱȱȱ2,826 ȱȱȱȱȱȱȱȱȱȱȱȱ2,418 ȱȱȱȱȱȱȱȱȱȱ11,613 807 Fractureȱofȱvertebralȱcolumnȱwithȱmentionȱofȱspinalȱcordȱinjuryȱȱȱȱȱȱȱȱȱȱȱȱ 5,066 ȱȱȱȱȱȱȱȱȱȱ39,606 ȱȱȱȱȱȱȱȱȱȱ46,357 ȱȱȱȱȱȱȱȱȱȱ44,970 ȱȱȱȱȱȱȱȱ152,562

808 Fractureȱofȱpelvisȱ(Acetabulum,ȱclosed)ȱȱȱȱȱȱȱȱȱȱȱȱ 4,650 ȱȱȱȱȱȱȱȱȱȱ22,716 ȱȱȱȱȱȱȱȱȱȱ16,627 ȱȱȱȱȱȱȱȱȱȱ31,591 ȱȱȱȱȱȱȱȱ105,335 809 IllȬdefinedȱfracturesȱofȱbonesȱandȱtrunk ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ357 * 810 Fractureȱofȱclavicleȱ(closed) ȱȱȱȱȱȱȱȱȱȱȱȱ3,386 ȱȱȱȱȱȱȱȱȱȱ11,006 ȱȱȱȱȱȱȱȱȱȱȱȱ9,046 ȱȱȱȱȱȱȱȱȱȱȱȱ6,596 ȱȱȱȱȱȱȱȱȱȱ32,714

811 Fractureȱofȱscapulaȱ(closed) ȱȱȱȱȱȱȱȱȱȱȱȱ1,038 ȱȱȱȱȱȱȱȱȱȱȱȱ7,647 ȱȱȱȱȱȱȱȱȱȱȱȱ5,345 ȱȱȱȱȱȱȱȱȱȱȱȱ2,872 ȱȱȱȱȱȱȱȱȱȱ17,584

812 Fractureȱofȱhumerusȱ(Upperȱend,ȱclosed)ȱȱȱȱȱȱȱȱȱȱ 13,687 ȱȱȱȱȱȱȱȱȱȱ13,908 ȱȱȱȱȱȱȱȱȱȱ21,024 ȱȱȱȱȱȱȱȱȱȱ41,379 ȱȱȱȱȱȱȱȱ106,334

813 Fractureȱofȱradiusȱandȱulnaȱ(Upperȱend,ȱclosed)ȱȱȱȱȱȱȱȱȱȱ 12,916 ȱȱȱȱȱȱȱȱȱȱ28,419 ȱȱȱȱȱȱȱȱȱȱ25,374 ȱȱȱȱȱȱȱȱȱȱ29,668 ȱȱȱȱȱȱȱȱ107,455 814 Fractureȱofȱcarpalȱbone(s)ȱ(Closed) * ȱȱȱȱȱȱȱȱȱȱȱȱ3,670 ȱȱȱȱȱȱȱȱȱȱȱȱ2,045 ȱȱȱȱȱȱȱȱȱȱȱȱ2,065 ȱȱȱȱȱȱȱȱȱȱȱȱ9,153 815 Fractureȱofȱmetacarpalȱbone(s)ȱ(Closed)ȱȱȱȱȱȱȱȱȱȱȱȱ 1,272 ȱȱȱȱȱȱȱȱȱȱȱȱ7,818 ȱȱȱȱȱȱȱȱȱȱȱȱ3,752 ȱȱȱȱȱȱȱȱȱȱȱȱ2,728 ȱȱȱȱȱȱȱȱȱȱ16,550

816 Fractureȱofȱoneȱorȱmoreȱphalangesȱofȱhandȱ(Closed)ȱȱȱȱȱȱȱȱȱȱȱȱ 1,674 ȱȱȱȱȱȱȱȱȱȱȱȱ9,298 ȱȱȱȱȱȱȱȱȱȱȱȱ6,141 ȱȱȱȱȱȱȱȱȱȱȱȱ3,764 ȱȱȱȱȱȱȱȱȱȱ22,150 817 Multipleȱfracturesȱofȱhandȱbones ****ȱȱȱȱȱȱȱȱȱȱȱȱ1,563 818 IllȬdefinedȱfracturesȱofȱupperȱlimb ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ205 * 819 Multipleȱfracturesȱinvolvingȱbothȱupperȱlimbs,ȱandȱupperȱlimbȱwithȱrib(s)ȱandȱsternum ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ57 * 820 Fractureȱofȱneckȱofȱfemurȱ(transcervicalȱfracture,ȱclosed)ȱȱȱȱȱȱȱȱȱȱȱȱ 2,556 ȱȱȱȱȱȱȱȱȱȱȱȱ9,506 ȱȱȱȱȱȱȱȱȱȱ34,567 ȱȱȱȱȱȱȱȱ178,256 ȱȱȱȱȱȱȱȱ336,338

821 Fractureȱofȱotherȱandȱunspecifiedȱpartsȱofȱfemurȱ(Shaftȱorȱunspecifiedȱpart,ȱclosed)ȱȱȱȱȱȱȱȱȱȱ 12,520 ȱȱȱȱȱȱȱȱȱȱ18,221 ȱȱȱȱȱȱȱȱȱȱ12,095 ȱȱȱȱȱȱȱȱȱȱ19,024 ȱȱȱȱȱȱȱȱȱȱ70,812 822 Fractureȱofȱpatella * ȱȱȱȱȱȱȱȱȱȱȱȱ5,096 ȱȱȱȱȱȱȱȱȱȱȱȱ5,850 ȱȱȱȱȱȱȱȱȱȱȱȱ7,887 ȱȱȱȱȱȱȱȱȱȱ21,064 823 Fractureȱofȱtibiaȱ&ȱfibula,ȱupperȱendȱ(closed)ȱȱȱȱȱȱȱȱȱȱȱȱ 8,346 ȱȱȱȱȱȱȱȱȱȱ36,242 ȱȱȱȱȱȱȱȱȱȱ31,381 ȱȱȱȱȱȱȱȱȱȱ17,693 ȱȱȱȱȱȱȱȱȱȱ98,310

824 Fractureȱofȱankle ȱȱȱȱȱȱȱȱȱȱȱȱ7,081 ȱȱȱȱȱȱȱȱȱȱ40,665 ȱȱȱȱȱȱȱȱȱȱ45,779 ȱȱȱȱȱȱȱȱȱȱ32,379 ȱȱȱȱȱȱȱȱ132,807

825 Fractureȱofȱoneȱorȱmoreȱtarsalȱandȱmetatarsalȱbonesȱȱȱȱȱȱȱȱȱȱȱȱ 1,988 ȱȱȱȱȱȱȱȱȱȱ18,903 ȱȱȱȱȱȱȱȱȱȱ13,370 ȱȱȱȱȱȱȱȱȱȱȱȱ7,148 ȱȱȱȱȱȱȱȱȱȱ73,183 826 Fractureȱofȱoneȱorȱmoreȱphalangesȱofȱfoot * ȱȱȱȱȱȱȱȱȱȱȱȱ3,189 ȱȱȱȱȱȱȱȱȱȱȱȱ3,252 ȱȱȱȱȱȱȱȱȱȱȱȱ2,432 ȱȱȱȱȱȱȱȱȱȱ10,294 827 Other,ȱmultiple,ȱandȱillȬdefinedȱfracturesȱofȱlowerȱlimb ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ317 * Multipleȱfracturesȱinvolvingȱbothȱlowerȱlimbs,ȱlowerȱwithȱupperȱlimb,ȱandȱlowerȱlimb(s)ȱwithȱ 828 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ185 rib(s)ȱandȱsternum **** * 829 Fracaturesȱofȱunspecifiedȱbones ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ494 * 831 Dislocationȱofȱshoulder * ȱȱȱȱȱȱȱȱȱȱȱȱ3,661 ȱȱȱȱȱȱȱȱȱȱȱȱ3,023 ȱȱȱȱȱȱȱȱȱȱȱȱ3,488 ȱȱȱȱȱȱȱȱȱȱ11,863 832 Dislocationȱofȱelbow * ȱȱȱȱȱȱȱȱȱȱȱȱ1,118 **ȱȱȱȱȱȱȱȱȱȱȱȱ2,719 833 Dislocationȱofȱwrist * ȱȱȱȱȱȱȱȱȱȱȱȱ1,432 **ȱȱȱȱȱȱȱȱȱȱȱȱ2,323 834 Dislocationȱofȱfinger * ȱȱȱȱȱȱȱȱȱȱȱȱ1,210 **ȱȱȱȱȱȱȱȱȱȱȱȱ3,182 835 Dislocationȱofȱhip * ȱȱȱȱȱȱȱȱȱȱȱȱ2,340 ȱȱȱȱȱȱȱȱȱȱȱȱ1,027 * ȱȱȱȱȱȱȱȱȱȱȱȱ5,240 836 Dislocationȱofȱknee * ȱȱȱȱȱȱȱȱȱȱȱȱ5,243 ȱȱȱȱȱȱȱȱȱȱȱȱ4,877 ȱȱȱȱȱȱȱȱȱȱȱȱ3,296 ȱȱȱȱȱȱȱȱȱȱ14,771 837 Dislocationȱofȱankle * ȱȱȱȱȱȱȱȱȱȱȱȱ1,414 **ȱȱȱȱȱȱȱȱȱȱȱȱ3,731 838 Dislocationȱofȱfoot * ȱȱȱȱȱȱȱȱȱȱȱȱ1,322 **ȱȱȱȱȱȱȱȱȱȱȱȱ2,888 839 Other,ȱmultiple,ȱandȱillȬdefinedȱdislocations * ȱȱȱȱȱȱȱȱȱȱȱȱ4,356 ȱȱȱȱȱȱȱȱȱȱȱȱ3,080 ȱȱȱȱȱȱȱȱȱȱȱȱ1,394 ȱȱȱȱȱȱȱȱȱȱȱȱ9,875

* Estimateȱdoesȱnotȱmeetȱstandardȱofȱreliabilityȱorȱprecision. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱInpatientȱSurvey,ȱ2007

TableȱB1ȱ(continued):ȱHospitalizationsȱforȱAllȱMusculoskeletalȱDiseasesȱbyȱ3ȬDigitȱICDȬ9ȬCMȱDiagnosisȱbyȱ AgeȱCategory,ȱUnitedȱStatesȱ2007

ICDȬ9ȬCM Description <ȱ18 18ȱȬȱ44 45ȱȬȱ64 64+ Total 840 Sprainsȱandȱstrainsȱofȱshoulderȱandȱupperȱarm * ȱȱȱȱȱȱȱȱȱȱȱȱ3,589 ȱȱȱȱȱȱȱȱȱȱȱȱ9,908 ȱȱȱȱȱȱȱȱȱȱ12,949 ȱȱȱȱȱȱȱȱȱȱ29,105 841 Sprainsȱandȱstrainsȱofȱelbowȱandȱforearm ****ȱȱȱȱȱȱȱȱȱȱȱȱ1,962 842 Sprainsȱandȱstrainsȱofȱwristȱandȱhand * ȱȱȱȱȱȱȱȱȱȱȱȱ1,609 ȱȱȱȱȱȱȱȱȱȱȱȱ1,409 ȱȱȱȱȱȱȱȱȱȱȱȱ1,556 ȱȱȱȱȱȱȱȱȱȱȱȱ5,387 843 Sprainsȱandȱstrainsȱofȱhipȱandȱthigh **ȱȱȱȱȱȱȱȱȱȱȱȱ1,509 ȱȱȱȱȱȱȱȱȱȱȱȱ2,927 ȱȱȱȱȱȱȱȱȱȱȱȱ6,892 844 Sprainsȱandȱstrainsȱofȱkneeȱandȱlegȱȱȱȱȱȱȱȱȱȱȱȱ 1,224 ȱȱȱȱȱȱȱȱȱȱȱȱ7,835 ȱȱȱȱȱȱȱȱȱȱȱȱ6,290 ȱȱȱȱȱȱȱȱȱȱȱȱ6,209 ȱȱȱȱȱȱȱȱȱȱ23,111 845 Sprainsȱandȱstrainsȱofȱankleȱandȱfoot * ȱȱȱȱȱȱȱȱȱȱȱȱ8,053 ȱȱȱȱȱȱȱȱȱȱȱȱ6,995 ȱȱȱȱȱȱȱȱȱȱȱȱ6,256 ȱȱȱȱȱȱȱȱȱȱ24,114 846 Sprainsȱandȱstrainsȱofȱsacroiliacȱregion * ȱȱȱȱȱȱȱȱȱȱȱȱ1,081 * ȱȱȱȱȱȱȱȱȱȱȱȱ1,208 ȱȱȱȱȱȱȱȱȱȱȱȱ3,640 847 Sprainsȱandȱstrainsȱofȱotherȱandȱunspecifiedȱpartsȱofȱback * ȱȱȱȱȱȱȱȱȱȱȱȱ4,167 ȱȱȱȱȱȱȱȱȱȱȱȱ4,154 ȱȱȱȱȱȱȱȱȱȱȱȱ4,192 ȱȱȱȱȱȱȱȱȱȱ14,281 848 OtherȱandȱillȬdefinedȱsprainsȱandȱstrains * ȱȱȱȱȱȱȱȱȱȱȱȱ1,081 ȱȱȱȱȱȱȱȱȱȱȱȱ1,983 ȱȱȱȱȱȱȱȱȱȱȱȱ1,802 ȱȱȱȱȱȱȱȱȱȱȱȱ6,295 875 Openȱwoundȱofȱchestȱ(wall) * ȱȱȱȱȱȱȱȱȱȱȱȱ5,661 ȱȱȱȱȱȱȱȱȱȱȱȱ1,539 * ȱȱȱȱȱȱȱȱȱȱȱȱ8,426 876 Openȱwoundȱofȱback * ȱȱȱȱȱȱȱȱȱȱȱȱ3,792 **ȱȱȱȱȱȱȱȱȱȱȱȱ5,712 877 Openȱwoundȱofȱbuttock * ȱȱȱȱȱȱȱȱȱȱȱȱ2,508 **ȱȱȱȱȱȱȱȱȱȱȱȱ4,836 879 Openȱwoundȱofȱotherȱandȱunspecifiedȱsitesȱ(exceptȱlimbs)ȱ ȱȱȱȱȱȱȱȱȱȱȱȱ1,753 ȱȱȱȱȱȱȱȱȱȱȱȱ9,960 ȱȱȱȱȱȱȱȱȱȱȱȱ3,403 ȱȱȱȱȱȱȱȱȱȱȱȱ1,637 ȱȱȱȱȱȱȱȱȱȱ17,421

880 Openȱwoundȱofȱshoulderȱandȱupperȱarmȱȱȱȱȱȱȱȱȱȱȱȱ 1,388 ȱȱȱȱȱȱȱȱȱȱȱȱ7,476 ȱȱȱȱȱȱȱȱȱȱȱȱ1,836 ȱȱȱȱȱȱȱȱȱȱȱȱ1,316 ȱȱȱȱȱȱȱȱȱȱ12,765

881 Openȱwoundȱofȱelbow,ȱforearm,ȱandȱwristȱȱȱȱȱȱȱȱȱȱȱȱ 5,303 ȱȱȱȱȱȱȱȱȱȱ28,967 ȱȱȱȱȱȱȱȱȱȱ10,667 ȱȱȱȱȱȱȱȱȱȱȱȱ9,331 ȱȱȱȱȱȱȱȱȱȱ60,247

882 Openȱwoundȱofȱhandȱexceptȱfinger(s)ȱaloneȱȱȱȱȱȱȱȱȱȱȱȱ 2,028 ȱȱȱȱȱȱȱȱȱȱ11,672 ȱȱȱȱȱȱȱȱȱȱȱȱ6,373 ȱȱȱȱȱȱȱȱȱȱȱȱ4,724 ȱȱȱȱȱȱȱȱȱȱ26,667

883 Openȱwoundȱofȱfinger(s)ȱȱȱȱȱȱȱȱȱȱȱȱ 1,867 ȱȱȱȱȱȱȱȱȱȱ12,891 ȱȱȱȱȱȱȱȱȱȱȱȱ7,224 ȱȱȱȱȱȱȱȱȱȱȱȱ3,098 ȱȱȱȱȱȱȱȱȱȱ26,098 884 Multipleȱandȱunspecifiedȱopenȱwoundȱofȱupperȱlimb * ȱȱȱȱȱȱȱȱȱȱȱȱ2,775 * ȱȱȱȱȱȱȱȱȱȱȱȱ1,288 ȱȱȱȱȱȱȱȱȱȱȱȱ6,597 885 Traumaticȱamputationȱofȱthumb ****ȱȱȱȱȱȱȱȱȱȱȱȱ1,885 886 Traumaticȱamputationȱofȱotherȱfinger(s) * ȱȱȱȱȱȱȱȱȱȱȱȱ2,979 ȱȱȱȱȱȱȱȱȱȱȱȱ2,149 * ȱȱȱȱȱȱȱȱȱȱȱȱ6,287 887 Traumaticȱamputationȱofȱarmȱandȱhandȱ(complete)ȱ(partial) ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ727 * 890 Openȱwoundȱofȱhipȱandȱthighȱȱȱȱȱȱȱȱȱȱȱȱ 1,591 ȱȱȱȱȱȱȱȱȱȱȱȱ7,817 ȱȱȱȱȱȱȱȱȱȱȱȱ2,425 ȱȱȱȱȱȱȱȱȱȱȱȱ1,014 ȱȱȱȱȱȱȱȱȱȱ13,141

891 Openȱwoundȱofȱknee,ȱlegȱ[exceptȱthigh],ȱandȱankleȱȱȱȱȱȱȱȱȱȱȱȱ 4,131 ȱȱȱȱȱȱȱȱȱȱ17,644 ȱȱȱȱȱȱȱȱȱȱȱȱ9,650 ȱȱȱȱȱȱȱȱȱȱȱȱ9,612 ȱȱȱȱȱȱȱȱȱȱ45,691

892 Openȱwoundȱofȱfootȱexceptȱtoe(s)ȱaloneȱȱȱȱȱȱȱȱȱȱȱȱ 2,211 ȱȱȱȱȱȱȱȱȱȱȱȱ4,686 ȱȱȱȱȱȱȱȱȱȱȱȱ4,100 ȱȱȱȱȱȱȱȱȱȱȱȱ2,095 ȱȱȱȱȱȱȱȱȱȱ13,582 893 Openȱwoundȱofȱtoe(s) * ȱȱȱȱȱȱȱȱȱȱȱȱ1,545 ȱȱȱȱȱȱȱȱȱȱȱȱ1,721 ȱȱȱȱȱȱȱȱȱȱȱȱ1,595 ȱȱȱȱȱȱȱȱȱȱȱȱ5,743 894 Multipleȱandȱunspecifiedȱopenȱwoundȱofȱlowerȱlimb ****ȱȱȱȱȱȱȱȱȱȱȱȱ2,374 895 Traumaticȱamputationȱofȱtoe(s) ****ȱȱȱȱȱȱȱȱȱȱȱȱ1,025 896 Traumaticȱamputationȱofȱfootȱ(complete)ȱ(partial) ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ349 * 897 Traumaticȱamputationȱofȱleg(s)ȱ(complete)ȱ(partial) ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ847 * 922 Contusionȱofȱtrunk ȱȱȱȱȱȱȱȱȱȱȱȱ3,482 ȱȱȱȱȱȱȱȱȱȱ15,797 ȱȱȱȱȱȱȱȱȱȱ16,661 ȱȱȱȱȱȱȱȱȱȱ25,138 ȱȱȱȱȱȱȱȱȱȱ71,143

923 Contusionȱofȱupperȱlimbȱȱȱȱȱȱȱȱȱȱȱȱ 2,294 ȱȱȱȱȱȱȱȱȱȱȱȱ9,789 ȱȱȱȱȱȱȱȱȱȱȱȱ9,505 ȱȱȱȱȱȱȱȱȱȱ19,041 ȱȱȱȱȱȱȱȱȱȱ50,928

924 Contusionȱofȱlowerȱlimbȱandȱofȱotherȱandȱunspecifiedȱsitesȱȱȱȱȱȱȱȱȱȱȱȱ 4,438 ȱȱȱȱȱȱȱȱȱȱ18,313 ȱȱȱȱȱȱȱȱȱȱ20,917 ȱȱȱȱȱȱȱȱȱȱ44,748 ȱȱȱȱȱȱȱȱ110,946 926 Crushingȱinjuryȱofȱtrunk ****ȱȱȱȱȱȱȱȱȱȱȱȱ1,011 927 Crushingȱinjuryȱofȱupperȱlimb * ȱȱȱȱȱȱȱȱȱȱȱȱ2,511 ȱȱȱȱȱȱȱȱȱȱȱȱ1,497 * ȱȱȱȱȱȱȱȱȱȱȱȱ4,603 928 Crushingȱinjuryȱofȱlowerȱlimb * ȱȱȱȱȱȱȱȱȱȱȱȱ2,022 ȱȱȱȱȱȱȱȱȱȱȱȱ1,356 * ȱȱȱȱȱȱȱȱȱȱȱȱ4,101 929 Crushingȱinjuryȱofȱmultipleȱandȱunspecifiedȱsites ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ113 * 954 Injuryȱtoȱotherȱnerve(s)ȱofȱtrunk,ȱexcludingȱshoulderȱandȱpelvicȱgirdles ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ289 * 955 Injuryȱtoȱperipheralȱnerve(s)ȱofȱshoulderȱgirdleȱandȱupperȱlimbȱȱȱȱȱȱȱȱȱȱȱȱ 1,055 ȱȱȱȱȱȱȱȱȱȱȱȱ7,145 ȱȱȱȱȱȱȱȱȱȱȱȱ3,006 * ȱȱȱȱȱȱȱȱȱȱ12,164 956 Injuryȱtoȱperipheralȱnerve(s)ȱofȱpelvicȱgirdleȱandȱlowerȱlimb * ȱȱȱȱȱȱȱȱȱȱȱȱ1,902 **ȱȱȱȱȱȱȱȱȱȱȱȱ3,781 959 Injury,ȱotherȱandȱunspecifiedȱ(toȱmusculoskeletalȱsystem)ȱȱȱȱȱȱȱȱȱȱȱȱ 3,187 ȱȱȱȱȱȱȱȱȱȱ13,233 ȱȱȱȱȱȱȱȱȱȱȱȱ9,597 ȱȱȱȱȱȱȱȱȱȱ10,529 ȱȱȱȱȱȱȱȱȱȱ41,067

996 Complicationsȱpeculiarȱtoȱcertainȱspecifiedȱproceduresȱȱȱȱȱȱȱȱȱȱȱȱ 2,067 ȱȱȱȱȱȱȱȱȱȱ17,442 ȱȱȱȱȱȱȱȱȱȱ52,479 ȱȱȱȱȱȱȱȱȱȱ69,344 ȱȱȱȱȱȱȱȱ153,066

V43.6 Organȱorȱtissueȱreplacedȱbyȱotherȱmeansȱ(joint)ȱȱȱȱȱȱȱȱȱȱ 21,342 ȱȱȱȱȱȱȱȱ179,862 ȱȱȱȱȱȱȱȱ472,380 ȱȱȱȱȱȱȱȱ783,154

V54 Otherȱorthopaedicȱaftercareȱȱȱȱȱȱȱȱȱȱȱȱ 3,543 ȱȱȱȱȱȱȱȱȱȱ20,144 ȱȱȱȱȱȱȱȱȱȱ41,608 ȱȱȱȱȱȱȱȱȱȱ97,796 ȱȱȱȱȱȱȱȱ196,480 V67 FollowȬupȱexamination,ȱfollowingȱsurgery ****ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ208 *

* Estimateȱdoesȱnotȱmeetȱstandardȱofȱreliabilityȱorȱprecision. Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱInpatientȱSurvey,ȱ2007

TableȱB2:ȱMusculoskeletalȱDiseasesȱwithȱ50,000ȱorȱMoreȱHospitalȱDiagnosesȱbyȱ 3ȬDigitȱICDȬ9ȬCMȱCode,ȱUnitedȱStatesȱ2007

3ȬDigitȱ ICDȬ9ȬCMȱ Hospitalȱ Code Description Diagnoses 715 Osteoarthrosisȱandȱalliedȱdisorders ȱȱȱȱȱȱȱȱȱ 2,202,259

Otherȱdisordersȱofȱboneȱandȱcartilageȱ(Osteoporosis;ȱpathologicȱfracture,ȱcyst,ȱnecrosisȱofȱbone,ȱ 733 ȱȱȱȱȱȱȱȱȱ 1,472,083 malunionȱandȱnonunionȱofȱfracture)

724 Otherȱandȱunspecifiedȱdisordersȱofȱbackȱȱȱȱȱȱȱȱȱ 1,069,018

V43.6 Organȱorȱtissueȱreplacedȱbyȱotherȱmeansȱ(joint)ȱȱȱȱȱȱȱȱȱȱȱȱ 783,154

722 Intervertebralȱdiscȱdisorders ȱȱȱȱȱȱȱȱȱȱȱȱ 692,653

729 Otherȱdisordersȱofȱsoftȱtissue ȱȱȱȱȱȱȱȱȱȱȱȱ 603,277

714 Rheumatoidȱarthritisȱandȱotherȱinflammatoryȱpolyarthropathiesȱȱȱȱȱȱȱȱȱȱȱȱ 409,702

716 Otherȱandȱunspecifiedȱarthroplasties ȱȱȱȱȱȱȱȱȱȱȱȱ 391,596

721 Spondylosisȱandȱalliedȱdisorders ȱȱȱȱȱȱȱȱȱȱȱȱ 382,775

719 Otherȱandȱunspecifiedȱdisordersȱofȱjoint ȱȱȱȱȱȱȱȱȱȱȱȱ 348,625

820 Fractureȱofȱneckȱofȱfemurȱ(transcervicalȱfracture,ȱclosed)ȱȱȱȱȱȱȱȱȱȱȱȱ 336,338

728 Disordersȱofȱmuscle,ȱligament,ȱandȱfasciaȱȱȱȱȱȱȱȱȱȱȱȱ 302,123

199 Secondaryȱmalignantȱneoplasmȱofȱotherȱspecifiedȱsites;ȱBoneȱandȱboneȱmarrowȱȱȱȱȱȱȱȱȱȱȱȱ 279,450

730 Acuteȱosteomyelitis ȱȱȱȱȱȱȱȱȱȱȱȱ 213,555

V54 Otherȱorthopaedicȱaftercare ȱȱȱȱȱȱȱȱȱȱȱȱ 196,480

737 Curvatureȱofȱspine ȱȱȱȱȱȱȱȱȱȱȱȱ 174,706

710 Diffuseȱdiseasesȱofȱconnectiveȱtissue ȱȱȱȱȱȱȱȱȱȱȱȱ 166,509

805 Fractureȱofȱvertebralȱcolumnȱwithoutȱmentionȱofȱspinalȱcordȱinjuryȱȱȱȱȱȱȱȱȱȱȱȱ 166,276

723 Otherȱdisorderȱofȱcervicalȱregion ȱȱȱȱȱȱȱȱȱȱȱȱ 157,958

996 Complicationsȱpeculiarȱtoȱcertainȱspecifiedȱproceduresȱȱȱȱȱȱȱȱȱȱȱȱ 153,066

807 Fractureȱofȱvertebralȱcolumnȱwithȱmentionȱofȱspinalȱcordȱinjuryȱȱȱȱȱȱȱȱȱȱȱȱ 152,562

824 Fractureȱofȱankle ȱȱȱȱȱȱȱȱȱȱȱȱ 132,807

726 Peripheralȱenthesopathiesȱandȱalliedȱsyndromesȱȱȱȱȱȱȱȱȱȱȱȱ 116,619

924 Contusionȱofȱlowerȱlimbȱandȱofȱotherȱandȱunspecifiedȱsitesȱȱȱȱȱȱȱȱȱȱȱȱ 110,946

813 Fractureȱofȱradiusȱandȱulnaȱ(Upperȱend,ȱclosed)ȱȱȱȱȱȱȱȱȱȱȱȱ 107,455

812 Fractureȱofȱhumerusȱ(Upperȱend,ȱclosed)ȱȱȱȱȱȱȱȱȱȱȱȱ 106,334

808 Fractureȱofȱpelvisȱ(Acetabulum,ȱclosed) ȱȱȱȱȱȱȱȱȱȱȱȱ 105,335

823 Fractureȱofȱtibiaȱ&ȱfibula,ȱupperȱendȱ(closed)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 98,310

274 Gout;ȱGoutyȱarthroplathy ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 95,078

727 Synovitisȱ&ȱtenosynovitis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 90,235

203 Multipleȱmyelomaȱandȱimmunoproliferativeȱneoplasmsȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 86,374

738 Otherȱacquiredȱdeformityȱ(ofȱmusculoskeletalȱsystem),ȱspondylolisthesisȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 82,861

736 Acquiredȱdeformitiesȱofȱforearm ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 82,099

731 Osteitisȱdeformansȱandȱosteopathiesȱassociatedȱwithȱotherȱdisordersȱclassifiedȱelsewhereȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 77,454

725 Polymyalgiaȱrheumatica ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 76,944

825 Fractureȱofȱoneȱorȱmoreȱtarsalȱandȱmetatarsalȱbonesȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 73,183

922 Contusionȱofȱtrunk ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 71,143

821 Fractureȱofȱotherȱandȱunspecifiedȱpartsȱofȱfemurȱ(Shaftȱorȱunspecifiedȱpart,ȱclosed)ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 70,812

135 Sarcoidosis ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 68,865

718 Otherȱderangementȱȱofȱjoint ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 62,051

881 Openȱwoundȱofȱelbow,ȱforearm,ȱandȱwristȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 60,247

711 Arthropathyȱassociatedȱwithȱinfections ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 57,849

923 Contusionȱofȱupperȱlimb ȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 50,928

Source:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱInpatientȱSurvey,ȱ2007

TableȱB3:ȱMusculoskeletalȱSystemȱProceduresȱPerformedȱMoreȱthanȱ20,000ȱTimes,ȱUnitedȱStatesȱ2007

ICDȬ9ȬCMȱ Code Description Procedures 81.54 Totalȱkneeȱreplacement 551,259 80.51 Excisionȱofȱintervertebralȱdiscȱ(diskectomy) 331,282 81.62 Fusionȱorȱrefusionȱofȱ2Ȭ3ȱvertebrae 293,709 81.51 Totalȱhipȱreplacement 252,680 84.51 Insertionȱofȱinterbodyȱspinalȱfusionȱdeviceȱ(codedȱwithȱspinalȱfusionȱorȱrefusion) 180,977 79.35 Openȱreductionȱofȱfractureȱwithȱinternalȱfixation,ȱFemur 157,162 81.08 Lumbarȱandȱlumbosacralȱfusion,ȱposteriorȱtechnique 150,446 79.36 Openȱreductionȱofȱfractureȱwithȱinternalȱfixation,ȱTibiaȱandȱfibula 148,758 81.02 Otherȱcervicalȱfusion,ȱanteriorȱtechniqueȱ(arthrodesisȱofȱC2ȱlevelȱorȱbelow) 135,455 81.52 Partialȱhipȱreplacement 103,748 84.52 Insertionȱofȱrecombinantȱboneȱmorphogeneticȱprotein 103,194 77.79 Excisionȱofȱboneȱforȱgraft,ȱOtherȱ(pelvicȱbones,ȱphalanges,ȱvertebrae) 86,611 81.91 Arthrocentesisȱ(jointȱaspiration) 70,800 79.15 Closedȱreductionȱofȱfractureȱwithȱinternalȱfixation,ȱFemur 69,000 81.63 Fusionȱorȱrefusionȱofȱ4Ȭ8ȱvertebrae 54,793 84.11 Amputationȱofȱtoe 53,090 Allȱcodes Revisionȱofȱkneeȱreplacement 52,124 00.80 Revisionȱofȱkneeȱreplacement,ȱtotalȱ(allȱcomponents) ȱȱȱȱȱȱȱ18,657ȱ 00.81 Revisionȱofȱkneeȱreplacement,ȱtibialȱcomponent ȱȱȱȱȱȱȱ11,411ȱ 00.82 Revisionȱofȱkneeȱreplacement,ȱfemoralȱcomponent ȱȱȱȱȱȱȱȱȱ7,307ȱ 00.83 Revisionȱofȱkneeȱreplacement,ȱpatellarȱcomponent ȱȱȱȱȱȱȱȱȱ3,918ȱ 00.84 Revisionȱofȱtotalȱkneeȱreplacement,ȱtibialȱinsertȱ(linear) ȱȱȱȱȱȱȱȱȱ6,687ȱ 81.55 Revisionȱofȱkneeȱreplacement,ȱnotȱotherwiseȱspecified ȱȱȱȱȱȱȱȱȱ4,144ȱ 79.32 Openȱreductionȱofȱfractureȱwithȱinternalȱfixation,ȱRadiusȱandȱulna 51,536 81.66 Percutaneousȱvertebralȱaugmentationȱ(Arcuplasty,ȱKyphoplasty,ȱSkyphoplasty,ȱSpineoplasty) 45,878 81.92 Injectionȱofȱtherapeuticȱsubstanceȱintoȱjointȱorȱligament 45,614 77.49 Biopsyȱofȱboneȱ(other) 42,479 Allȱcodes Revisionȱofȱhipȱreplacement 39,010 00.70 Revisonȱofȱhipȱreplacement,ȱbothȱacetabularȱandȱfemoralȱcomponents ȱȱȱȱȱȱȱ17,710ȱ 00.71 Revisionȱofȱhipȱreplacement,ȱacetabularȱcomponent ȱȱȱȱȱȱȱȱȱ6,299ȱ 00.72 Revisionofȱhipȱreplacement,ȱfemoralȱcomponent ȱȱȱȱȱȱȱȱȱ6,543ȱ 00.73 Revisionȱofȱhipȱreplacement,ȱacetabularȱlinerȱand/orȱfemoralȱheadȱonly ȱȱȱȱȱȱȱȱȱ5,736ȱ 81.53 Revisionȱhipȱreplacement,ȱnotȱotherwiseȱspecified ȱȱȱȱȱȱȱȱȱ2,722ȱ 78.69 Removalȱofȱimplantedȱdevicesȱfromȱbone,ȱOtherȱ(pelvicȱbones,ȱphalanges,ȱvertebrae) 37,871 78.55 Internalȱfixationȱofȱboneȱwithoutȱfractureȱreduction,ȱFemur 37,843 79.31 Openȱreductionȱofȱfractureȱwithȱinternalȱfixation,ȱHumerus 37,609 84.15 Otherȱamputationsȱbelowȱknee 32,033 81.06 Lumbarȱandȱlumbosacralȱfusion,ȱanteriorȱtechnique 31,882 83.45 Otherȱexcisionȱofȱmuscle,ȱtendon,ȱandȱfascia,otherȱmyectomyȱ(debridementȱofȱmuscleȱNOS) 29,168 79.06 Closedȱreductionȱofȱfractureȱwithoutȱinternalȱfixation,ȱTibiaȱandȱFibulaȱ(LegȱNOS) 28,530 84.17 Amputationȱaboveȱknee 26,353 78.67 Removalȱofȱimplantedȱdevicesȱfromȱbone,ȱFemur 24,685 78.65 Removalȱofȱimplantedȱdevicesȱfromȱbone,ȱTibiaȱandȱFibula 24,467 81.80 Totalȱshoulderȱreplacement 23,358 79.66 Debridmentȱofȱopenȱfractureȱsite,ȱTibiaȱandȱFibulaȱ(LegȱNOS) 22,555 77.69 Localȱexcisionȱofȱtissueȱorȱbone,ȱOtherȱ(pelvic,ȱphalangesȱofȱfootȱorȱhand,ȱvertebrae) 22,416 81.05 Dorsalȱandȱdorsolumbarȱfusion,ȱposteriorȱtechnique 22,206 83.63 Rotatorȱcuffȱrepair 21,976 79.02 Closedȱreductionȱofȱfractureȱwithoutȱinternalȱfixation,ȱRadiusȱandȱUlnaȱ(ArmȱNOS) 20,630 83.09 Otherȱincisionȱofȱsoftȱtissue 20,346

ȱȱȱSource:ȱNationalȱCenterȱforȱHealthȱStatistics,ȱNationalȱInpatientȱSurvey,ȱ2004

Appendix C - Data Sources The primary sources of data used in this publication analysis of multiple databases limits the time span were the National Health Care Surveys (NHCS) for data presented in the book. In recent years, the family of provider-based surveys conducted by release of NCHS databases has shortened. the National Center for Health Statistics (NCHS). NCHS surveys are designed to meet the need for NHCS surveys used in the Burden of Musculoskeletal objective, reliable information about the organiza- Diseases, Second Edition in the United States tions and providers that supply health care, the include: services rendered, and the patients they serve. [1] The National Health Interview Survey The National Health Care Surveys are designed (NHIS), a nationwide cross-sectional survey to answer key questions of interest to health care of the non-institutional population conducted policy makers, public health professionals, and by household interview, designed to moni- researchers. Key questions can include the factors tor the health of the United States population that infl uence the use of health care resources, the through the collection and analysis of data on quality of health care, including safety, and dispari- a broad range of health topics. 2008 survey ties in health care services provided to population data used; sample size of the person fi le subgroups in the United States. 73,973; sample size of the adult fi le 21,781.

Collectively, NCHS surveys have a combination [1a] The National Health Interview Survey Injury of design features that make them unique. The Database (NHIS-Injury). A subset of vari- surveys are nationally representative, provider- ables in the NHIS. based, and cover a broad spectrum of health care sett ings. Within each sett ing, data are collected [2] The National Hospital Discharge Survey from a sample of organizations that provide care (NHDS), is a national probability survey (such as home health care agencies, inpatient designed to meet the need for information hospital units, or physician offi ces) and from on characteristics of inpatients discharged samples of patient (or discharge) encounters from non-Federal short-stay hospitals in the within the sampled organizations. United States. The NHDS collects data from a sample of approximately 270,000 inpatient Each of the National Health Care Surveys collects records acquired from a national sample core information which remains stable over time. of about 500 hospitals. Only hospitals with Consequently, trends in the types of care delivered an average length of stay of fewer than 30 in each sett ing can be monitored in an objective days for all patients, general hospitals, or and reliable manner, and can be examined in children’s general hospitals are included in relation to characteristics of providers, patients, the survey. Federal, military, and Department and clinical management of patients’ care. In of Veterans Aff airs hospitals, as well as addition, the surveys are fl exible enough to hospital units of institutions (such as prison accommodate special data collection modules hospitals), and hospitals with fewer than six and to sample provider organizations as new beds staff ed for patient use, are excluded. information is needed. For most databases, the 2006 survey data used; sample size 376,328. most current year of data available at the time of analysis was for the year 2006 or 2007. Timeliness [3] The National Ambulatory Medical Care of data releases and the time required for thorough Survey (NAMCS), based on a sample of visits to non-federally employed offi ce- based physicians who are primarily engaged in direct patient care (physicians in the

specialties of anesthesiology, pathology, and [8] The Healthcare Cost and Utilization Project radiology are excluded from the survey). Nationwide Inpatient Sample (HCUP-NIS), 2006 survey data used; sample size 39,392. conducted by the Agency for Healthcare Research and Quality (AHRQ), a family [4]&[5] The National Hospital Ambulatory Medical of health care databases that brings Care Survey (NHAMCS) collects data on together the data collection eff orts of state the utilization and provision of ambulatory data organizations, hospital associations, care services in hospital emergency (ER) private data organizations, and the Federal and outpatient departments (OP). Findings government to create a national information are based on a national sample of visits to resource of patient-level health care data. 2006 the emergency departments and outpatient survey data used; sample size 8,043,415. departments of non-institutional general and short-stay hospitals, exclusive of Federal, [9] The Medical Expenditures Panel Survey military, and Veterans Administration (MEPS) , conducted by the Agency for hospitals, located in the 50 States and the Healthcare Research and Quality, a set District of Columbia. 2006 survey data used; of large-scale surveys of families and sample size 35,849 (ER) and 35,105 (OP). individuals, their medical providers, and employers across the United States, and the [6] The National Health and Nutrition most complete source of data on the cost Examination Survey (NHANES), the only and use of health care and health insurance national survey that collects extensive coverage. Data averaged for seven 3-year health information from both face-to-face periods from 1996 to 2004 in included for the interviews and medical examinations, majority of economic cost analysis. Updated providing unique opportunities to study estimates are provided for the period 1996 to major nutrition, infection, environmental, and 2006. Data analyzed by MGC Data Services. chronic health conditions in the U.S. Because of the smaller sample size in the NHANES, [10] The Survey of Occupational Injuries and data is merged for several years to provide Illnesses, conducted by the Bureau of Labor statistically reliable data. In the Burden of Statistics, U.S. Department of Labor, that Musculoskeletal Diseases, Second Edition, provides data on illnesses and injuries on the NHANES data for the period 2005-2006 was job and data on worker fatalities. Published merged with two prior data releases (2001- data summaries for 2007 used. 2002 and 2003-2004). Sample size for the combined period 2001-2006 was 31,509 for [11] The National Birth Defects Prevention the Medical Conditions and 15,429 for the Network (NBDPN), from which estimates Osteoporosis sample. of prevalence for selected defects are drawn based on state birth defects surveillance [7] The National Nursing Home Survey (NNHS), programs. one in a continuing series of nationally representative sample surveys of United [12] The Centers for Disease Control and States nursing homes, their services, their Prevention (CDC) Metropolitan Atlanta staff , and their residents. This survey had not Congenital Defects Program (MACDP), which released new data from the fi rst edition. 2004 collects data on birth defects. survey data used; sample size 13,507.

The following surveys were also used:

[13] The CDC Metropolitan Atlanta of disease and injury is not dependent on the Developmental Disabilities Surveillance subjective reporting of symptoms. However, the Program (MADDSP), which monitors objective evidence used to establish the presence the occurrence of selected developmental or absence of a condition does not always correlate disabilities in school-age children. with reported symptoms. It is clear that numerous individuals who report symptoms do not have [14] The Surveillance, Epidemiology, and End evidence of disease upon examination and, Results (SEER) Program of the National conversely, some individuals who have objective Cancer Institute, DCCPS, Surveillance evidence of disease do not experience symptoms. Research Program, Cancer Statistics Branch, Thus, although objective measures are valuable an authoritative source of information on tools, they may yield an incomplete picture of the cancer incidence and survival in the United impact of a given disease. This type of study is States, including cancer incidence and also more expensive, involves a smaller number survival data from population-based cancer of individuals, and may under-represent less registries covering approximately 26% of the frequently occurring disorders. U.S. population. Published summary data from 2006 data submission. Data obtained from medical records are also subject to certain limitations. Many persons [15] National Cancer Data Base (NCDB), aff ected with certain musculoskeletal diseases do maintained by the American College of not seek medical care. Although records of visits to Surgeons Commission on Cancer. physicians and hospitals provide estimates of the volume of visits, these records do not include those The small size of some databases precludes who do not seek medical care. Therefore, data analysis at a detailed level. In general, ICD-9-CM based on existing records, will yield only a partial codes were combined into major musculoskeletal representation of how various musculoskeletal disease classifi cations to provide suffi cient sample diseases aff ect the population. size for reliable estimates. Medical records do not necessarily indicate Extensive use was also made of published the underlying musculoskeletal condition. For studies in scientifi c and epidemiologic journals as instance, fractures at various sites, especially hip secondary sources of data. fractures, are a major consequence of osteoporosis. When admitt ed to the hospital, a fracture diagnosis It is important to recognize that any one source of is usually listed rather than osteoporosis. Medical data provides an incomplete view of the frequency records may also be subject to “upcoding” to and impact of a disease or condition. Interview maximize reimbursement and may overstate the surveys, for instance, generally underestimate frequency of more severe conditions. the frequency of most musculoskeletal diseases. However, information obtained through the use By analyzing and including data from a wide of interviews is essential to assess an individual’s range of sources, each with its own strength and symptoms or how that individual indicates he or weaknesses, it is hoped that the results presented she has been aff ected by a disease. In addition, have been integrated into a comprehensive for some conditions, this may be the only possible and reasonable understanding of the impact of means of collection of data. musculoskeletal diseases on the United States population. In contrast, the use of objective methods such as physical examination, laboratory measurements, and radiographs for the detection and diagnosis

Index

A Bone mass, 103-105 Bracing, 58-64, 66 Activities of daily living, 1. See also Bed days, Lost work days Burden, 1, 2, 6, 231 Related-arthritis, 87 Arthritis, 75, 76, 77, 87 Related-injury, 134 Back pain, 27, 66 Related-medical conditions, 1, 4, 5 Congenital conditions, 181 Related-osteoporosis, 105 Musculoskeletal injury, 129, 140 Related-spine problems, 29 Neoplasms, 195, 198, 199, 201, 203 Activity restrictions. See Activities of daily living; Osteoporosis, 105, 110, Impairment; Limitations Adolescent idiopathic scoliosis. See Scoliosis C Aging, 6, 23, 30, 64, 66, 103, 110, 219-223, 228, 232 Allergies, 21 Carpal tunnel syndrome, 136-139 Ambulatory care, 222-224, 228. See also Centers for Disease Control and Prevention (CDC), 181, 233 Outpatient care Cerebral palsy, 62, 181, 182, 186, 187 Arthritis, 77-82, 87 Cervical pain. See Neck pain Injuries, 142 Chondrosarcoma. See Neoplasms Spine, 33 Chronic conditions American College of Surgeons, 195, 199, 200, 203 Chronic circulatory conditions, 2, 3, 6 Amputation. See Injuries Chronic joint pain, 3, 4, 6, 82 Ankylosing spondylitis, 82 Chronic musculoskeletal conditions, 2, 3 Arthritis, 3, 5, 6, 66, 75-102, 103, 135, 203, 220, 221, 224, Chronic respiratory conditions, 2, 5, 6 225, 228, 229, 331, 332. See also Fibromyalgia; Clubfoot, 182, 184 Giant cell arteritis; Gout; Juvenile Arthritis; Lupus; Cobb angle, 58 Osteoarthritis; Polymyalgia rheumatica; Rheumatoid; Congenital Sclerosis; Sjögren’s syndrome Cerebral palsy, 62, 181, 182, 186, 187 Arthroplasty, 77, 83-87 Clubfoot, 182, 184 Dysplasia of the hip, 182-184, 187 B Limb deﬁ ciencies, 181, 182, 184-185 Metropolitan Atlanta Congenital Defects Program Back pain, 3, 6, 21-29, 31, 33, 59, 63, 64, 111, 136, 37, 139. See (MACDP), 181, 182, 186, 187 also Low back pain; Neck pain National Birth Defects Prevention Network (NBDPN), Bed days, 6, 28 181, 182, 186, 187 Burden, 27-28 Polydactyly, 181, 182, 185, 186 Cervical (neck), 3, 21, 25-26, 27, 29-32 Prevalence, 57, 61-62, 181-186 Length of stay (days in hospital), 24, 28, 31 Skeletal dysplasias, 181, 182, 185 Limitations, 21, 27-28 Spina biﬁ da, 62, 181-184 Lost work, 28 Surveillance 181, 182, 186-187 Lumbar (low back), 3, 6, 21-25, 26, 27, 28, 31, 33 Contusion. See Injuries Procedures (spine), 29-32 Cost, 1, 219-234 Prevalence, 3, 6 Arthritis, 76, 86, 87 Radiating leg pain, 6, 21, 28 Back pain. See Cost: Spine Direct cost, 1, 6, 7, 219, 231-233 Bed days, due to Incremental, 7, 21, 219, 223-227, 230-233 Chronic conditions, 5, 6 Indirect cost, 1, 7, 83, 219, 229, 233 Musculoskeletal injuries, 135 Joint replacement, 86 Spine conditions, 28, 29 Morbidity, 1, 59, 79, 103, 134, 181, 203, 233 Bone and Joint Decade, 1 Musculoskeletal injuries, 140-143

Neoplasm, 199, 203 G Osteoporosis, 103, 110, 112, 113 Prescription drugs, 1, 33, 143 Giant cell arteritis, 81 Spinal deformity, 66 Gout, 75, 80, 231 Spine, 21, 27, 30-33 Cost, 231, 232 Diskectomy, 31-32 Gross Domestic Product (GDP), 7, 87, 219, 224, 225, 229, 230 Spinal fusion, 30, 31 Cox-2 inhibitors, 82, 228 H Crushing injury. See Injuries Crystal arthropathies. See Gout Headache, 21, 28, 32 Health care utilization, 6 D Arthritis, 76, 78, 79, 87 Costs, 219-234 DMARD, 82 Osteoporosis, 107 Death, 1. See also Mortality Health care visits. See also Health care utilization; Treatment Arthritis, 76 episodes Injuries, 133 Arthritis, 77 Low energy fracture, 110 Spine, 22-27 Neoplasms, 195, 197, 198, 200, 202, 203 Hemiepiphysiodesis, 60 Derangement. See Injuries Herniation/Herniated, 23-25, 28, 31, 32, 62 Developmental. See Congenital Hip pain, 4 Disc degeneration, 22-25, 27, 30, 31 Hispanics, 75, 76, 137, 182, 225, 226 Discharge, 32, 62, 83, 84, 112, 223 Home health care, 1, 33, 142, 222, 223 Disk displacement. See Herniation Hospitalization. See Inpatient Diskectomy, 29, 31-32 Dislocation, 23, 129-131, 134, 141, 182-184 I Division of Birth Defects and Developmental Disabilities, 181 Dysplasia, 181, 182, 185 Idiopathic scoliosis. See Scoliosis Hip, 182, 183, 184, 187 Impairment, 1, 5. See also Activities of daily living; Activity restrictions; Limitations E Incidence, 1, 220 Arthritis, 77 Emergency room care, 221, 224, 225, 228, 229 Arthroplasty, 83, 84 Arthritis, 87 Fracture Injuries, 129, 140-142 Hip, 83, 84 Osteoporosis, 107, 109, 112 Spine, 110 Spine, 23, 33 Trends, 132 Enteropathic arthritis, 82 Injuries, 129, 142 Ewing’s sarcoma. See Neoplasms Workplace, 138, 139 Neoplasms, 195,-199, 201-203 F Osteoporosis, 104, 106, 110, 111 Spinal deformity, 62-64 Falls, 221 Spine (pain), 21, 23, 32, 33 Osteoporosis, 103, 110-112 Injuries, 23-26, 107, 110, 129-143, 220-222, 224, 226, 229, 233 Injuries, 129, 132, 133 Activities of daily living, 134 Fibromyalgia, 81 Amputation (amputated limb), 129, 130, 140, 203 Folic acid, 62, 183 Back, 22-24, 138 Fracture, 5, 23, 25, 62, 83, 129-134, 139-141. See also Injuries Bed days, 135 Low energy fractures, 103-113 Contusion, 129-131, 133, 136, 138-140 Pathologic, 222, 223 Cost, 140-143 Funding (research), 2, 80 Crushing injuries, 129 Derangements, 129 Dislocation, 23, 129-131, 134, 141, 182 Falls, 23, 103, 129, 132, 133, 221

Fractures, 5, 23, 25, 62, 83-86, 129-136, 138, 140, 141 Spine, 28 Health care utilization, 140, 141 Low back pain. See Back pain Incidence, 129, 138, 139, 142 Lower limb pain, 28, 64 Limitations, 134-136 Lumbago, 23 Lost wages, 140 Lumbar pain. See Back pain Lower limb, 132, 133, 134 Lupus (Systemic lupus erythematosus), 75, 50, 51 Neck, 25, 26, 129 Open wounds, 129-131, 141 M Pelvis, 129 Prevalence, 129, 130 Medical care. See Emergency room; Hospitalization; Inpatient; Spine, 129 Outpatient; Physician offi ce Sprains and strains, 23, 32, 129-131, 134, 138 Medical conditions. See Chronic conditions Treatment episodes, 129-132, 140-142, 221 Medical Expenditures Panel Survey (MEPS), 33, 142, 219-221, Upper limb, 112, 132, 133 223, 228-233 Work days (lost), 135, 136 Medications, 66, 82, 104, 222, 223, 228, 229, 232, 233. See also Workplace, 129, 136-140 Prescriptions Inpatient, 1, 221, 224, 225, 228, 229, 233 Metropolitan Atlanta Developmental Disabilities Surveillance Arthritis, 83, 84, 87 Program (MADDS), 181, 182, 187 Injuries, 132, 141, 142 Migraine. See Headache Osteoporosis, 103, 107-109, 112, 113 Morbidity, 1, 233 Spine, 25, 29, 31, 33 Arthritis, C-79 Intermediate care, 84, 109 Congenital conditions, 181 Injuries, 134 J Neoplasms, 203 Osteoporosis, 103 Juvenile Arthritis, 80 Spinal deformity, 59 Joint pain, 3, 4, 6, 21, 22, 28, 82, 87. See also Back pain; Hip Mortality, 1, 233. See also Deaths pain; Knee pain; Leg pain; Shoulder pain Arthritis, 79 Cost, 220, 221, 224, 225, 229, 233 Congenital, 181 Joint replacement. See Arthroplasty Neoplasms, 195, 197-199, 200 Osteoporosis, 103 Low energy falls, 110, 111 K Spinal deformity, 59 Muscular dystrophy, 61, 62 Knee pain, 4 Myeloma. See Neoplasms Kyphosis, 57, 62-65. See also Sheuermann kyphosis N L NSAID, 77, 78, 79, 82 Laminectomy, 23 National Arthritis Data Workgroup (NADW), 75, 76, 78-82 Leg pain, 64 National Birth Defects Prevention Network (NBDPN), 181, Radiating, 28 182, 186, 187 Length of stay, 84, 85, 86, 141 National Cancer Data Base, 195, 199 Lenke classifi cation, 59 National Cancer Institute, 195, 200 Limb reduction defects. See Limb defi ciencies National Health and Nutrition Examination Survey Limitations, 4, 5, 110, 186. See also Activities of daily living; (NHANES), 78, 104 Activity restrictions; Impairment National Health Interview Survey (NHIS), 2, 4, 22, 33, 76, 134, Arthritis, 75, 76, 78 142, 220 Back pain, 21, 27, 28 National Hospital Discharge Survey (NHDS), 84, 85, 233 Injury, 134-136 National Institute of Arthritis and Musculoskeletal and Skin Spine, 21, 27, 28 Diseases (NIAMS), 2 Lordosis, 65 National Institutes of Health (NIH), 1, 2 Lost work days, 1, 5, 6 National Osteoporosis Foundation (NOF), 103, 105, 221 Injuries, 135, 136 Neck pain. See Back pain

Neoplasms Physician offi ce visit (ambulatory physician visits), 1, 3, 222, Benign tumors 223, 225, 230, 231 Bone, 201, 203 Arthritis, 77 Soft tissue, 201 Injuries, 129, 130-134, 140-142 Bone and connective tissue, 195-199 Osteoporosis, 107, 109 Children, 195, 197-199 Spinal deformity, 65, 66 Chondrosarcoma, 195-199, 202, 203 Spine, 21, 22, 24, 25-27, 32, 33 Cost, 198-200, 203 Utilization, 198, 207 Deaths, 197-199 Polydactyly, 181, 182, 185-186 Endoprostheses, 199 Polymyalgia rheumatica, 81-82 Ewing’s sarcoma, 195, 197, 198, 199 Prescriptions, 222-225, 228. See also Medications Incidence, 195-199, 201-203 Prevalence Kaposi’s sarcoma, 196 Arthritis, 75, 76, 79-82 Morbidity, 203 Osteoarthritis, 77-78 Mortality, 195, 197-199, 200 Rheumatoid arthritis, 78-79 Myeloma, 195-197 Congenital conditions (birth defects), 181, 182, 186, National Cancer Data Base, 195, 199, 203 187 National Cancer Institute, 195, 200, Cerebral palsy, 186 Osteosarcoma, 195, 197-199, 201-203 Club foot, 184 Soft tissue sarcomas, 199-201 Developmental dysplasia of the hip, 184 Surveillance Epidemiology and End Results Program Limb defi ciencies, 164 (SEER), 195 Polydactyly, 186 Survival rate, 197-199 Spina bifi da, 183 Neuromusculoskeletal, 32-33 Injuries, 129-130 Nursing home, 1, 76, 110 Musculoskeletal conditions, 1, 2-4, 5, 6, 219-222, 224, 231, 232, 234 O Neoplasms, 195 Bone tumors Osteoarthritis, 77-78, 79, 83, 84, 88 Benign, 201, 202 Cost, 230, 231 Malignant, 195-197, 199 Osteoporosis, 57, 64, 75, 105-113 Soft tissue tumors Cost, 112, 113, 220, 221, 223-225, 229 Benign, 203 Diagnosis, 103-112 Malignant, 195-197, 199 Age, 107, 108 Osteoporosis, 104-106, 111 Health care utilization, 106, 107 Spinal deformity, 57, 58, 59, 62, 64 Incidence, 104, 106, 110, 111 Spine, 21, 22, 24, 25, 33 Low energy fracture, 104, 106-113. See also Fracture: Hip; Prevention, 1, 82, 113, 181, 185, 221 Vertebral (spine); Wrist Psoriatic arthritis, 82 Prevalence, 104-106, 111 Primary osteoporosis, 104, 106-108, 110, 113 R Secondary osteoporosis, 104, 106 Osteosarcoma. See Neoplasms Rheumatic diseases, 79 Outpatient, 1, 221, 233 Rheumatism, 5, 76, 135 Arthritis, 77 Rheumatoid arthritis, 75, 78-79, 81, 82, 83 Arthroplasty, 83 Cost, 84, 228, 231, 232 Injuries, 129-131, 140-142 Juvenile rheumatoid arthritis, 80 Osteoporosis, 103, 109 Rib vertebral angle degree (RVAD), 60 Spinal deformity, 65 Reiter’s syndrome, 82 Spine, 22-26 S P Scheuermann kyphosis, 57, 62, 63-64 Pain. See Back pain; Hip pain; Joint pain; Knee pain; Lower Sciatica, 23 limb pain; Neck pain; Upper limb pain Sclerosis (Systemic sclerosis), 81

Scoliosis, 57-62 V Adolescent idiopathic scoliosis, 57, 58-59 Congenital scoliosis, 61 Vertical expandable prosthetic titanium rib (VETPR), 61 Cost, 66 Degenerative scoliosis, 64, 65, 66 W Infantile idiopathic scoliosis, 57, 60-61 Juvenile idiopathic scoliosis, 57, 60 Wage, lost, 7, 21, 140, 219, 229, 233. See also Costs: Indirect Neuromuscular scoliosis, 61-62 Whites, 2, 75, 80, 81, 137, 182, 187, 196, 225, 226 Scoliosis Research Society, 58 Work limitations. See also Lost work days Short-term care, 84 Arthritis, 75 Shoulder pain, 4 Back pain, 21, 28 Sjögren’s syndrome, 81 Workplace (injuries), 129, 136-140 Skeletal dysplasias, 181, 182, 185 World Health Organization, 103 Skilled nursing, 84, 109 Spina biﬁ da, 62, 181-184 Spinal deformity, 57-66 Spinal fusion, 29-31, 60, 62, 63 Spinal muscular atrophy, 62 Spinal stenosis, 23, 24, 25, 28, 30, 31, 64 Spine, 21-33 Arthroplasty, 83, 85 Cost, 21, 24, 27, 220, 221, 224, 225, 229, 231, 232 Deformity, 57-66 Fractures of, 110, 111, 112 Neuromusculoskeletal, 32-33 Neoplasm, 203 Osteopoprosis of, 105, 106, 110 Procedures, 29-32 Diskectomy, 31-32 Spinal fusion, 29-31 Spondylarthropathies, 82 Spondylolisthesis, 30, 57, 62, 63 Spondylolysis, 30, 57, 62, 63 Spondylosis, 23, 25, 828 Sprain and strain. See Injuries Surveillance Congenital, 181, 186-187 Neoplasms, 195, 199 Surveillance Epidemiology and End Results Program (SEER), 195 Survival rate (neoplasms), 197, 200

Tendonitis, 137-139

Upper limb pain, 22, 112, 113 Arm, 21, 22 Elbow, 22 Hand, 22 Shoulder, 4, 21, 22, 27 Wrist, 22