This study was supported by the The Head Office of Research, Studies, Evaluation and Statistics (DREES) of the Social Affairs Ministry of France and Pfizer. S. Poiraudeau received fees from Pfizer for consultancy. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.
Conceived and designed the experiments: CP SP PR JFR. Performed the experiments: CP AP. Analyzed the data: CP. Contributed reagents/materials/analysis tools: CP. Wrote the paper: CP SP.
Despite the burden of rheumatic and musculoskeletal diseases (RMDs), these conditions probably deserve more attention from public health authorities in several countries including developed ones. We assessed their contribution to disability.
Data on disabilities associated with RMDs were extracted from the national 2008–2009 Disability-Health Survey of 29,931 subjects representative of the population in France. We used the core set of disability categories for RMDs of the World Health Organization's International Classification of Functioning, Disability and Health for analysis. Diagnosis and disabilities were self-reported. We assessed the risk of disability associated with RMDs using odds ratios (ORs) and the societal impact of RMDs using the average attributable fraction (AAF).
Overall 27.7% (about 17.3 million people) (95% CI 26.9–28.4%) of the population reported having RMDs. The most prevalent RMDs were low back pain (12.5%, 12.1–13.1) and osteoarthritis (12.3%, 11.8–12.7). People reporting osteoarthritis were more disabled in walking (adjusted OR 1.9, 1.7–2.2) than those without. People reporting inflammatory arthritis were more limited in activities of daily living (from 1.4, 1.2–1.8 for walking to 2.1, 1.5–2.9 for moving around). From a societal perspective, osteoarthritis was the main contributor to activity limitations (AAF 22% for walking difficulties). Changing jobs was mainly attributed to neck pain (AAF 13%) and low back pain (11.5%).
RMDs are highly prevalent and significantly affect activity limitations and participation restrictions. More effort is needed to improve care and research in this field.
Rheumatic and musculoskeletal diseases (RMDs) are a major cause of disability
Despite the burden of RMDs and the WHO's Joint and Bone decade initiative extension until 2020
Studies describing disabilities in RMDs are common, but they often focus on one condition, such as rheumatoid arthritis or OA
A population-based, self-reported disability survey, the 2008–2009 Disability-Health (DH) Survey, was conducted in France. We previously extracted data from this dataset to assess the respective contribution of chronic conditions to disability in the non-institutionalized population and showed that RMDs, neurological, cardiovascular, and psychiatric disorders were the main contributors
This study was planned as a research project. It was performed in collaboration with the French National Institute of Statistics. This study was declared of public interest by the CNIS (Conseil National d'Information Statistique) and was approved by the CNIL (Commission Nationale de l'Informatique et des Libertés, French law no. 78-17). According to the French law, written informed consent was not required for this type of study.
The data for this study were from the 2008–2009 DH survey (available at
INSEE = French National Institute of Statistics and Economic Studies.
The DH survey methodology has been described in detail elsewhere
Second, for DH sample selection, randomisation involved a high sampling rate for the most severely disabled group (in order to include people who are disabled, and so to have enough data on disability) and a low sampling rate for people without daily living restrictions (the largest group). Consequently, the survey respondents were not representative of the French population, but a weighting method, described in the statistic analysis section, allows for estimating representative results at a national level: each of the resulting groups was allocated a specific sampling coefficient that increased with the probability or severity of the presumed handicap. The sampling rate was higher for people living in the geographic areas that were more intensively sampled. From March to July 2008, data were collected for 39 065 subjects across the administrative departments in France. Trained investigators used the computer-assisted interview (CAPI) format to collect data from people in their homes. The questionnaire was 160 pages long and each interview lasted between 2 and 3 hours. A household member or a proxy could answer for identified survey respondents not able to answer alone. The response rate was 76.6%, corresponding to 29 931 subjects with complete data (age range 0–106 years old). Each respondent was assigned a weight reflecting the probability of being investigated and answering the questionnaire, which allowed for estimating representative results at a national level.
RMDs were self-reported. Participants were asked to identify their diseases from a list of 52 disorders, which is known to improve the accuracy of self-reporting
The survey also collected data on co-morbidities with the same list, which included cardiovascular, neurological, psychiatric, respiratory, sensorial, endocrine, digestive, urologic, dermatologic disorders, and sequelae of injury (
Disabilities were considered from subjects' reports. With a 160-page questionnaire, respondents were asked about 1) difficulties in performing activities, 2) restrictions in participations, and 3) environmental factors. Experts (AP, CP, SP) provided the linkage between the WHO-ICF core-set categories for musculoskeletal diseases
The final weighting factors combined design weights and non-response weights. Design weights were the inverse of the sampling fraction, depending on presumed disability severity and geographic area of residence. Probability of non-response was estimated by logistic regression, with age, sex, type of household, marital status, and questions about health and disability as independent variables. Finally, calibration was based on geographic area of residence, age and sex.
For the descriptive analysis, we reported the prevalence of diseases, summarized socio-demographic characteristics and described disabilities by frequencies, means and 95% confidence intervals (95% CIs) estimated using sampling weight.
We assessed the contribution of RMDs at both the individual and societal level. To describe the individual risk of disability with a RMD, multiple regression analysis was used to estimate the strength of association between RMDs and disability categories, controlling for age, sex, number of RMDs and co-morbidities, and educational attainment. Results are expressed as odds ratios (ORs) and 95% CIs.
To assess the contribution of RMDs at the societal level, we used the average attributable fraction (AAF), defined as the expected proportion of disability preventable by the additional elimination of the condition of interest, after adjustment for a random collection of other disorders (here other RMDs and co-morbidities)
Statistical analyses involved use of SAS 9.2 (SAS Inst., Cary, NC). Sampling weights were accounted for by specific SAS procedures for handling complex sample designs. AAFs were computed with use of the macro developed by Rückinger et al.
Overall, 27.7% (95% CI 26.9–28.4%) of the population living in a household reported at least one RMD, corresponding to 17.3 million people. LBP (12.5%, 12.1–13.1%) and OA (12.3%, 11.8–12.7%) were the most prevalent disorders (
Osteoarthritis | Low back pain | Neck pain | Inflammatory arthritis | Spine deformity | Osteoporosis | At least 1 RMD | No RMD | |
Age (years, mean) | 64.2 (63.6–64.8) | 53.7 (53.0–54.4) | 55.3 (54.4–56.2) | 59.8 (58.7–61.0) | 45.0 (43.9–46.2) | 68.6 (67.6–69.6) | 55.4 (54.8–55.9) | 32.8 (32.4–33.2) |
Sex: women (%) | 63.0 (61.1–64.9) | 53.5 (51.3–55.7) | 68.7 (66.0–71.4) | 62.1 (58.4–65.7) | 63.3 (59.9–66.8) | 91.1 (88.1–94.1) | 59.7 (58.3–61.2) | 48.5 (47.4–49.6) |
Co–morbidity (mean) | 2.5 (2.4–2.5) | 2.2 (2.2–2.3) | 2.7 (2.6–2.8) | 2.6 (2.5–2.8) | 2.1 (2.0–2.3) | 2.8 (2.6–2.9) | 2.1 (2.0–2.1) | 0.8 (0.8–0.8) |
Number of RMDs (mean) | 1.9 (1.8–1.9) | 1.9 (1.9–2.0) | 2.4 (2.3–2.4) | 2.2 (2.2–2.3) | 2.1 (2.0–2.1) | 2.4 (2.3–2.5) | 1.5 (1.5–2.1) | – |
Educational attainment: no diploma (%) | 53.1 (51.2–55.1) | 34.8 (32.9–36.8) | 37.6 (35.0–40.2) | 44.2 (40.7–47.8) | 30.0 (27.2–32.9) | 51.7 (46.9–56.6) | 39.2 (37.8–40.5) | 42.8 (41.6–43.7) |
Data are % (95% confidence intervals).
Regarding the results of the descriptive analysis (
Disability category | Osteoarthritis | Low back pain | Neck pain | Inflammatory arthritis | Spine deformity | Osteoporosis | No RMD |
Changing basic body positiona | 1.0 (0.8–1.2) | 0.7 (0.5–0.9) |
0.6 (0.5–0.8) |
1.7 (1.3–2.4) |
1.4 (1.1–1.9) |
1.0 (0.7–1.3) | 1.1 (0.8–1.4) |
Lifting and carrying objectsa | 1.7 (1.5–2.0)** | 0.6 (0.5–0.7)** | 0.5 (0.4–0.6)** | 1.7 (1.4–2.1)** | 0.7 (0.6–0.8)** | 2.1 (1.6–2.8)** | 1.0 (0.9–1.2) |
Walkinga | 1.9 (1.7–2.2)** | 0.6 (0.5–0.7)** | 0.5 (0.4–0.6)** | 1.4 (1.2–1.8) |
0.7 (0.6–0.9) |
1.4 (1.1–1.8) |
0.9 (0.8–1.0) |
Moving arounda | 0.9 (0.7–1.0) | 0.6 (0.5–0.8)** | 0.6 (0.5–0.8) |
2.1 (1.5–2.9)** | 1.6 (1.2–2.2) |
1.2 (0.9–1.5) | 1.3 (1.0–1.7) |
Using transportationa | 1.0 (0.8–1.2) | 0.7 (0.6–0.8) |
0.7 (0.5–0.9) |
1.5 (1.2–1.9) |
1.5 (1.2–1.9) |
1.3 (1.0–1.7) |
1.3 (1.0–1.5) |
Drivinga | 0.8 (0.7–1.0) | 0.9 (0.7–1.2) | 0.8 (0.6–1.1) | 1.5 (1.1–2.1) |
1.2 (0.9–1.7) | 1.2 (0.9–1.6) | 1.3 (1.0–1.6) |
Washing oneselfa | 1.0 (0.9–1.2) | 0.6 (0.5–0.7) |
0.8 (0.6––1.0) |
1.9 (1.4–2.4)** | 1.2 (0.9–1.5) | 1.1 (0.9–1.5) | 1.2 (1.0–1.5) |
Dressinga | 1.1 (0.9–1.4) | 0.7 (0.5–0.8) |
0.7 (0.5–0.9) |
1.7 (1.3–2.3)** | 1.2 (0.9–1.6) | 1.0 (0.7–1.3) | 1.0 (0.8–1.3) |
Shoppinga | 0.9 (0.8–1.1) | 0.8 (0.7–1.0) |
0.6 (0.5–0.8)** | 1.5 (1.2–1.9) |
1.5 (1.2–1.9) |
1.2 (1.0–1.5) | 1.0 (0.9–1.2) |
Doing houseworka | 1.0 (0.9–1.1) | 0.8 (0.7–0.9) |
0.7 (0.6–0.9) |
1.5 (1.2–1.8) |
1.3 (1.1–1.7) |
1.0 (0.8–1.3) | 1.0 (0.8–1.2) |
Changing jobb | 0.5 (0.2–1.1) | 2.2 (1.0–4.5) |
2.8 (0.9–9.2) | 0.3 (0.1–1.0) | 0.5 (0.1–1.7) | 0.5 (0.2–1.4) | 0.9 (0.4–2.0) |
Community lifeb | 1.0 (0.8–1.1) | 1.2 (1.0–1.4) |
0.9 (0.7–1.0) | 1.1 (0.9–1.4) | 0.8 (0.7–1.0) |
1.0 (0.8–1.3) | 1.0 (0.9–1.2) |
Recreation and leisureb | 1.1 (0.9–1.4) | 0.9 (0.8–1.2) | 0.8 (0.6–1.0) |
1.2 (0.9–1.5) | 1.1 (0.9–1.4) | 0.9 (0.6–1.2) | 0.7 (0.6–0.9) |
Help from immediate familyc | 1.0 (0.9–1.1) | 0.8 (0.7–0.9) |
0.7 (0.6–0.8)** | 1.4 (1.2–1.8) |
1.4 (1.2–1.8) |
1.2 (0.9–1.5) | 1.0 (0.9–1.2) |
Help from health professionalsc | 1.1 (1.0–1.3) | 0.7 (0.6–0.9) |
0.6 (0.5–0.8)** | 1.4 (1.1–1.7) |
1.0 (0.8–1.2) | 1.3 (1.1–1.7) |
1.1 (0.9–1.3) |
Discrimination from the familyc | 0.8 (0.5–1.4) | 1.5 (0.9–2.3) | 1.0 (0.5–1.7) | 0.5 (0.3–1.0) | 1.2 (0.7–2.1) | 1.1 (0.6–2.2) | 1.1 (0.6–1.8) |
Discrimination from the societyc | 0.9 (0.7–1.1) | 1.1 (0.8–1.4) | 0.8 (0.6–1.1) | 0.9 (0.7–1.3) | 1.4 (1.0–1.9) |
0.7 (0.5–1.0) |
0.8 (0.7–1.1) |
Health services deliveryc | 1.0 (0.8–1.2) | 1.0 (0.8–1.2) | 0.8 (0.7–1.1) | 1.1 (0.9–1.5) | 1.3 (1.0–1.7) | 0.7 (0.5–1.0) |
0.7 (0.6–0.8) |
Data are odds ratios (95% confidence intervals) controlling for age, sex, number of RMDs, number of co-morbidities, and educational attainment. Reference categories are: no osteoarthritis for osteoarthritis, no low back pain for low back pain, no neck pain for neck pain, no inflammatory arthritis for inflammatory arthritis, no spine deformity for spine deformity, no osteoporosis for osteoporosis, and at least 1 RMD for no RMD. aReference category = no limitation in activities, bReference category = no restriction of participations, cReference category = no help, no discrimination, no need of resource.
*p<0.05, **p<0.0001.
The AAFs for RMDs for disability categories are presented in
Osteoarthritis | Low back pain | Neck pain | Inflammatory arthritis | Spine deformity | Osteoporosis | |
Changing basic body position | 11.9 | 1.4 | 0.9 | 8.5 | 5.7 | 1.5 |
Lifting and carrying objects | 18.6 | 0.0 | 1.0 | 5.2 | 0.0 | 4.1 |
Walking | 22.0 | 0.0 | 0.0 | 5.0 | 0.4 | 2.8 |
Moving around | 4.4 | 0.0 | 0.0 | 7.4 | 4.2 | 1.7 |
Using transportation | 6.0 | 0.0 | 0.0 | 4.0 | 3.0 | 2.3 |
Driving | 0.0 | 0.0 | 0.0 | 3.6 | 1.3 | 0.7 |
Washing oneself | 10.2 | 0.0 | 1.6 | 6.9 | 2.7 | 1.6 |
Dressing | 12.8 | 0.0 | 0.6 | 7.3 | 3.5 | 1.1 |
Shopping | 8.3 | 0.4 | 0.0 | 5.0 | 3.7 | 2.7 |
Doing housework | 11.0 | 1.7 | 2.2 | 5.0 | 3.6 | 2.5 |
Changing job | 0.0 | 11.5 | 13.0 | 0.0 | 0.0 | 0.0 |
Community life | 2.6 | 0.7 | 0.0 | 0.3 | 0.0 | 0.1 |
Recreation and leisure | 11.7 | 6.4 | 3.6 | 4.7 | 4.0 | 1.4 |
Help from immediate family | 9.2 | 0.6 | 0.7 | 4.4 | 3.3 | 2.1 |
Help from health professionals | 11.8 | 0.0 | 0.0 | 4.5 | 1.4 | 3.7 |
Discrimination from the family | 3.4 | 6.7 | 3.4 | 0.0 | 2.2 | 1.8 |
Discrimination from the society | 3.4 | 4.4 | 1.8 | 1.9 | 3.6 | 0.0 |
Health service delivery | 8.9 | 6.5 | 3.0 | 4.5 | 4.6 | 0.2 |
Neck pain and LBP were the main contributors to changing jobs because of a health problem (AAF 13% and 11.5%, respectively).
As expected, the impact of RMDs on disabilities was influenced by age categories (
The overall contribution of RMDs to disability was greater for women than men (for OA: AAF for walking, 24.1% for women
We show for the first time the frequency and impact of RMDs on disability at the individual and societal levels in a developed country, using data representative of the whole non-institutionalized population. Our findings highlight that RMDs are highly prevalent and have a significant impact on limitations in activities and restriction in participations, which suggests the need for more efforts to improve care and research in this field.
One strength of our study is that we assessed disabilities encountered with RMDs from an individual perspective by presenting ORs, which is probably useful for patients and clinicians, as well as a societal perspective by presenting AAFs, which is more useful for a general audience and policymakers. Other strengths of this work are that our results are representative of the population living in a household and are therefore valuable to policymakers. We also considered 18 different disability categories for an overview of disabilities encountered in RMDs from the WHO-ICF perspective
LBP and OA were the RMDs most frequently reported. Comparison of disease prevalence with those from previous studies is cautioned because of variations in methodology, cultural context, and definition of diseases
From an individual perspective, because we used the common WHO-ICF core set for RMDs, our findings allow for a more detailed picture of disabilities encountered with RMDs than do previous studies
From a societal perspective, our results could help health policymakers develop plans to address and prioritize disabilities in the population living in a household. Regarding the growing prevalence of OA and the walking difficulties associated with this disease, increased emphasis should be placed on accessibility in public places and transportation. Regarding the high contribution of inflammatory arthritis to limitations in activities, efforts are needed to improve and diffuse technical aids by reducing the cost, for example. The impact of LBP on changing jobs and the feeling of being discriminated could be alleviated by population-based information campaigns providing positive messages about back pain, which has been efficacious in improving general beliefs about back pain and influencing medical management in Australia
Data of the DH survey are not redundant with those of the recently published 2010 WHO GBD study
This study has limitations that are common to this type of survey. The main limitation is that data were self-reported and not physician-confirmed, which is likely to be accurate for disability assessment but may lack accuracy for diagnosis. However, this type of approach is relevant from a public health perspective because many people with chronic illness do not seek a health care provider
Even if RMDs are not fatal, they are highly prevalent and disabling, having a significant impact on limitations in activities and restrictions in participations. Our findings may help convince policymakers of the need to focus on RMDs to improve population health. The lack of standardisation in data recording and the absence of detailed national data on disability in other developed and developing countries prevent us from comparing results with other populations, and emphasize the need to support international and national efforts to better address the main challenge of disability associated with RMDs with the increasing aging of the populations.
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