Table Of ContentWHO Library Cataloguing-in-Publication Data
WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of
the New Millennium. (2003 : Geneva, Switzerland).
The burden of musculoskeletal conditions at the start of the new millennium : report of a
WHO scientific group.
(WHO technical report series ; 919)
1.Musculoskeletal diseases — epidemiology 2.Musculoskeletal diseases — classification
3.Health status indicators 4.Cost of illness 5.Quality of Life 6.Disability evaluation
I.Title II.Series
ISBN 92 4 120919 4 (NLM classification: WE 15)
ISSN 0512-3054
© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and
Dissemination, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22
791 2476; fax: +41 22 791 4857; e-mail:
Contents
1. Introduction 1
1.1 Introduction by the Director-General 1
1.2 Scope and aims 3
2. Global burden of disease 6
2.1 The Global Burden of Disease Study 6
2.1.1 Summary measures of population health 8
2.1.2 Health states 9
2.2 Estimating the global burden of musculoskeletal conditions 11
2.3 Methodology of estimating the burden of disease 16
3. Incidence and prevalence of musculoskeletal conditions 19
3.1 Introduction 19
3.1.1 Potential further sources of data 20
3.1.2 Recommendations for making estimates of incidence and
prevalence of musculoskeletal conditions 21
3.2 Rheumatoid arthritis 21
3.2.1 Definition 21
3.2.2 Incidence 23
3.2.3 Prevalence 23
3.2.4 Potential sources of further data 23
3.2.5 Recommendations for making estimates of incidence and
prevalence rates of the global burden 23
3.3 Osteoarthritis 24
3.3.1 Definition 24
3.3.2 Incidence 25
3.3.3 Prevalence 25
3.3.4 Potential sources of further data 26
3.3.5 Recommendations for making estimates of incidence and
prevalence rates of the global burden 27
3.4 Osteoporosis 27
3.4.1 Definition 27
3.4.2 Incidence 30
3.4.3 Prevalence 33
3.4.4 Potential sources of further data 36
3.4.5 Recommendations for making estimates of incidence and
prevalence rates of the global burden 36
3.5 Spinal disorders 37
3.5.1 Definition 37
3.5.2 Incidence 41
3.5.3 Prevalence 43
3.5.4 Potential sources of further data 44
3.5.5 Recommendations for making estimates of incidence and
prevalence rates of the global burden 44
3.6 Severe limb trauma 44
3.6.1 Definition 44
3.6.2 Incidence 45
3.6.3 Prevalence 48
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3.6.4 Potential sources of further data 48
3.6.5 Recommendations for making estimates of incidence and
prevalence rates of the global burden 49
4. Severity and course of the conditions 50
4.1 Introduction 50
4.2 Rheumatoid arthritis 52
4.2.1 Model of the condition 52
4.2.2 How has loss of health been described and quantified? 54
4.2.3 What is the role of geographical and socioeconomic
factors? 55
4.3 Osteoarthritis 55
4.3.1 Model of the condition 55
4.3.2 How has loss of health been described and quantified? 56
4.3.3 What is the role of geographical and socioeconomic
factors? 57
4.4 Osteoporosis 57
4.4.1 Model of the condition 57
4.4.2 How has loss of health been described and quantified? 59
4.4.3 What is the role of geographical and socioeconomic
factors? 59
4.5 Spinal disorders 60
4.5.1 Model of the conditions 60
4.5.2 How has the loss of health been described and
quantified? 64
4.5.3 What is the role of geographical and socioeconomic
factors? 65
4.5.4 Spinal pain and disability 65
4.6 Severe limb trauma 66
4.6.1 Model of the conditions 66
4.6.2 How has loss of health been described and quantified? 68
4.6.3 Role of geographical and socioeconomic factors 70
5. Health and economic indicators 71
5.1 The need for health indicators 71
5.2 What should be measured by indicators for musculoskeletal
conditions? 75
5.2.1 General indicators 75
5.2.2 Risk factors 76
5.2.3 Specific interventions and treatments 76
5.2.4 Consequences of musculoskeletal conditions for the
individual and society 76
5.2.5 Choice of indicators 78
5.3 Economic indicators 78
5.4 Summary 85
6. Measuring the health impact and economic burden of
musculoskeletal conditions on the population 85
6.1 Introduction 85
6.2 Rheumatoid arthritis 92
6.2.1 Health indicators 92
6.2.2 Economic indicators 94
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6.3 Osteoarthritis 94
6.3.1 Health indicators 94
6.3.2 Economic indicators 95
6.4 Osteoporosis 96
6.4.1 Health indicators 96
6.4.2 Economic indicators 98
6.5 Spinal disorders 99
6.5.1 Health indicators 99
6.5.2 Economic indicators 102
6.6 Severe limb trauma 103
6.6.1 Health indicators 103
6.6.2 Economic indicators 108
7. Describing health status and the consequences of illness or injury for
the individual 109
7.1 Introduction 109
7.1.1 Uses of data collected 109
7.1.2 Multidimensional health concept 109
7.1.3 Limitations of currently available measures 112
7.1.4 Boundary between health and well-being 113
7.1.5 Need for a common language and profile to describe
health 114
7.1.6 Description versus valuation of health 115
7.1.7 Next steps 116
7.2 Multidimensional approach to measuring health status for
musculoskeletal conditions 117
7.3 Rheumatoid arthritis 120
7.3.1 Health domains 120
7.3.2 Possible health states 123
7.3.3 Suggested instruments for measuring selected health
domains 123
7.4 Osteoarthritis 125
7.4.1 Health domains 125
7.4.2 Possible health states 125
7.4.3 Suggested instruments for measuring selected health
domains 126
7.5 Osteoporosis 127
7.5.1 Health domains 127
7.5.2 Possible health states 128
7.5.3 Suggested instruments for measuring selected health
domains 130
7.5.4 Issues relating to children 131
7.6 Spinal disorders 131
7.6.1 Health domains 131
7.6.2 Possible health states 133
7.6.3 Suggested instruments for measuring selected health
domains 133
7.7 Severe limb trauma 133
7.7.1 Health domains 133
7.7.2 Possible health states 138
7.7.3 Suggested instruments for measuring selected health
domains 140
v
8. Inventory of published assessment instruments for musculoskeletal
conditions 142
8.1 Introduction 142
8.2 Data collected 142
8.2.1 Instrument name 142
8.2.2 Bibliographic citation 142
8.2.3 Instruments designed for or used with various populations 142
8.2.4 Disease conditions 143
8.2.5 Reliability data 143
8.2.6 Validity data 143
8.2.7 Type of indicator 143
8.2.8 Areas measured 144
8.2.9 Administration 144
8.2.10 Time to complete 144
8.2.11 Language 144
8.2.12 Copy available 144
8.3 Search methodology 144
8.3.1 Experts in musculoskeletal conditions 144
8.3.2 Existing databases 145
8.3.3 Review text 145
8.4 Selected instrument listings 145
9. Conclusions and recommendations 158
9.1 Incidence and prevalence 159
9.2 Severity and course of the conditions 160
9.2.1 Rheumatoid arthritis 160
9.2.2 Osteoarthritis 160
9.2.3 Osteoporosis 160
9.2.4 Spinal disorders 160
9.2.5 Severe limb trauma 161
9.3 Health and economic indicators 161
9.4 Measuring health impact and economic burden at the
population level 162
9.5 Describing health status as a consequence of illness or
injury: impact on the individual 162
9.6 Recommendations of the Scientific Group 163
Acknowledgements 164
References 165
Annex
Estimates of incidence or prevalence of key musculoskeletal disorders
considered for each WHO Region 177
vi
WHO Scientific Group on the Burden of Musculoskeletal
Conditions at the Start of the New Millennium
Geneva, 13–15 January 2000
Members
Dr J. Agel, Department of Orthopaedics, University of Minnesota, Minneapolis, MN,
USA
Dr K. Akesson, Department of Orthopaedic Surgery, Malmö University Hospital,
Malmö, Sweden (Joint Vice-Chairman)
Dr P.C. Amadio, Mayo Clinic, Rochester, MN, USA
Mrs M. Anderson, International Osteoporosis Foundation, Hofstetten, Switzerland
Dr E. Badley, Director, Arthritis Community Research and Evaluation Unit, Univer-
sity Health Network (Princess Margaret Hospital), Toronto, Ontario, Canada
Dr G. Balint, Head of Rheumatology Department, National Institute of Rheumatol-
ogy and Physiotherapy, Budapest, Hungary
Professor N. Bellamy, Director, Center of National Research on Disability & Reha-
bilitation Medicine, Department of Medicine, Royal Brisbane Hospital,
Brisbane, Queensland, Australia
Dr S. Bigos, Department of Orthopedics, University of Washington, Seattle, WA,
USA
Professor N. Bishop, Sheffield Children’s Hospital, Sheffield, England
Mr B. Bivans, Coordinator, Global Road Safety Partnership, International Federa-
tion of Red Cross and Red Crescent Societies, Geneva, Switzerland
Mr P.A. Bjorke, Arthritis and Rheumatism International, Norwegian Rheumatism
Association, Oslo, Norway
Professor P. Brooks, Executive Dean of Health Sciences, University of Queensland,
Brisbane, Queensland, Australia
Professor B.D. Browner, Department of Orthopedic Surgery, University of Con-
necticut Health Center, Farmington, CT, USA
Dr J. Buckwalter, University of Iowa Hospitals, Department of Orthopedics, Iowa
City, IA, USA
Dr L. Callahan, Research Member, Thurston Arthritis Research Centre, University
of Carolina, Chapel Hill, NC, USA
Professor W.H. Chahade, Director, Rheumatology Department, Hospital do
Servidor Publico, São Paulo, Brazil
Dr A. Chopra, Pune, India
Professor M. Cimmino, Department of Internal Medicine, General Medicine and
Therapy Clinic, University of Genoa, Genoa, Italy (Joint Rapporteur)
Professor C. Cooper, Medical Research Council, Environmental Epidemiology
Unit, Southampton General Hospital, Southampton, England
Dr J. Darmawan, Seroja Rheumatic Center, Semarang, Indonesia
vii
Dr K.C. de Mesquita, Panema, Rio de Janeiro, Brazil
Dr M. De Smedt, Head of Health and Safety Statistics, European Commission,
Luxembourg
Professor P. Delmas, Research Unit, Institut National de la Santé et de la
Recherche Médicale, Lyon, France
Professor J. Dequeker, Catholic University of Louvain, Louvain, Belgium
Professor P. Dieppe, Health Services Research Collaboration, University of Bristol,
Bristol, England (Joint Rapporteur)
Professor M. Dougados, Department of Rheumatology, Cochin Hospital, Paris,
France
Dr K.E. Dreinhofer, Department of Orthopaedics, Ulm University, Ulm, Germany
Dr G.E. Ehrlich, Adjunct Professor of Medicine, University of Pennsylvania School
of Medicine, Philadelphia, PA, USA
Dr B.M. Gans, New York, NY, USA
Professor H.K. Genant, Executive Director, Osteoporosis and Arthritis Research
Group, University of California, San Francisco, CA, USA
Dr D. Grob, Schulthess Clinic, Zurich, Switzerland
Professor F. Guillemin, School of Public Health, Vandouvre-les-Nancy, France
Dr K. Hamelynk, Department of Orthopaedics, Slotervaart Hospital, Amsterdam,
Netherlands
Dr E. Hazan, Attending Surgeon and Chief of Orthopaedic Traumatology Service,
National Institute of Orthopaedics, Mexico City, Mexico
Professor J.M. Hazes, Department of Rheumatology, University Hospital of
Rotterdam, Rotterdam, Netherlands (Joint Vice-Chairman)
Professor M.C. Hochberg, Division of Rheumatology and Clinical Immunology,
University of Maryland School of Medicine, Baltimore, MD, USA
Professor O. Johnell, Professor of Orthopaedics, Department of Orthopaedic Sur-
gery, Malmö University Hospital, Malmö, Sweden
Professor J. Kanis, Centre for Metabolic Bone Diseases at Sheffield, Sheffield,
England
Dr A.D. Kinasha, Head of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es
Salaam, United Republic of Tanzania
Mr A.U. Kuder, Kuder, Smollar & Friedman, Washington, DC, USA
Professor E.M.C. Lau, Department of Community and Family Medicine, The
Chinese University of Hong Kong, Hong Kong Special Administrative Region,
China
Dr R.C. Lawrence, Epidemiology/Data Systems Program Officer, National Institute
of Arthritis and Musculoskeletal and Skin Diseases/National Institutes of Health,
Bethesda, MD, USA
Professor L. Lidgren, Department of Orthopaedics, University Hospital, Lund,
Sweden
viii
Professor P. Lips, Department of Endocrinology, Academic Hospital, Vrije Univer-
sity, Amsterdam, Netherlands (Joint Rapporteur)
Professor S. Lohmander, Department of Orthopaedics, University Hospital, Lund,
Sweden
Mr S. Luchter, Department of Transportation Administrator, National Highway
Traffic Safety Administration, Washington, DC, USA
Dr E.J. Mackenzie, Center for Injury Research and Policy, Johns Hopkins
University School of Hygiene and Public Health, Baltimore, MD, USA (Joint
Rapporteur)
Dr J.C. Marini, Head, Heritable Disorders Branch, National Institutes of Health,
Bethesda, MD, USA
Professor J. Melton, Department of Health Sciences Research, Mayo Clinic,
Rochester, MN, USA
Dr A. Mithal, Senior Consultant Endocrinologist, Indraprastha Apollo Hospitals,
New Delhi, India
Dr C. Mock, Assistant Professor, Department of Surgery, Harborview Medical
Centre, Seattle, WA, USA
Professor D. Mohan, Coordinator, Transportation Research and Injury Prevention
Programme, Indian Institute of Technology, New Delhi, India
Dr R. Moser, Association for the Study of Internal Fixation (AO), Clinical Investiga-
tion and Documentation, Davos, Switzerland
Professor V.A. Nassonova, Director of Institute of Rheumatology, Russian Acad-
emy of Medical Sciences, Moscow, Russian Federation
Professor M. Nordin, Director, Occupational and Industrial Orthopedic Center,
Hospital for Joint Diseases Orthopedic Institute, School of Medicine, New York
University, New York, NY, USA
Professor H.-J. Oestern, Klinik für Unfall- und Wiederstellungschirurgie,
Allgemeines Krankenhaus, Celle, Germany
Ms D. Pattison, Bone and Joint Monitor Project, Duke of Cornwall Rheumatology
Department, Royal Cornwall Hospital, Truro, England
Professor R.E. Petty, Department of Pediatrics, British Colombia’s Children’s Hos-
pital, Vancouver, British Columbia, Canada
Dr G. Poor, National Institute of Rheumatology and Physiotherapy, Budapest,
Hungary
Professor J.J.H. Rasker, Department of Rheumatology and Communication
Studies, University of Twente, Enschede, Netherlands
Professor H. Raspe, Institute for Social Medicine, Medical University, Lübeck,
Germany
Professor J.Y. Reginster, Bone Cartilage Unit, University of Liège, Liège, Belgium
Professor R. Rizzoli, Division of Bone Disease, Department of Internal Medicine,
Cantonal Hospital, Geneva, Switzerland
Dr D. Sethi, Health Policy Unit, London School of Hygiene and Tropical Medicine,
London, England
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