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Incidence, Prevalence, Costs, and Impact on Disability of Common Conditions Requiring Rehabilitation in the United States: Stroke, Spinal Cord Injury, Traumatic Brain Injury, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Limb Loss, and Back Pain

Published:January 23, 2014DOI:https://doi.org/10.1016/j.apmr.2013.10.032

      Abstract

      Objective

      To determine the relative incidence, prevalence, costs, and impact on disability of 8 common conditions treated by rehabilitation professionals.

      Data Sources

      Comprehensive bibliographic searches using MEDLINE, Google Scholar, and UpToDate, (June, 2013).

      Data Extraction

      Two review authors independently screened the search results and performed data extraction. Eighty-two articles were identified that had relevant data on the following conditions: Stroke, Spinal Cord Injury, Traumatic Brain Injury, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Limb Loss, and Back Pain.

      Data Synthesis

      Back pain and arthritis (osteoarthritis, rheumatoid arthritis) are the most common and costly conditions we analyzed, affecting more than 100 million individuals and costing greater than $200 billion per year. Traumatic brain injury, while less common than arthritis and back pain, carries enormous per capita direct and indirect costs, mostly because of the young age of those involved and the severe disability that it may cause. Finally, stroke, which is often listed as the most common cause of disability, is likely second to both arthritis and back pain in its impact on functional limitations.

      Conclusions

      Of the common rehabilitation diagnoses we studied, musculoskeletal conditions such as back pain and arthritis likely have the most impact on the health care system because of their high prevalence and impact on disability.

      Keywords

      List of abbreviations:

      NHANES (National Health and Nutrition Examination Survey), NHIS (National Health Interview Survey), TBI (traumatic brain injury)
      In 2011, an estimated 37.9 million people, 12.2% of the U.S. population, were living with a disability.
      • Houtenville A.J.
      • Ruiz T.
      2012 annual compendium of disability statistics.
      The impact of disability is significant. Aside from the enormous direct medical costs related to disability,
      • Chan L.
      • Beaver S.
      • Maclehose R.F.
      • et al.
      Disability and health care costs in the Medicare population.
      which were estimated at $160 billion in 1994,
      medical problems have considerable personal and societal impact. Medical costs account for more than 60% of all personal bankruptcies.
      • Himmelstein D.U.
      • Thorne D.
      • Warren E.
      • et al.
      Medical bankruptcy in the United States, 2007: results of a national study.
      • Relyea-Chew A.
      • Hollingworth W.
      • Chan L.
      • et al.
      Personal bankruptcy after traumatic brain or spinal cord injury: the role of medical debt.
      Government and private payments to support employment-aged individuals with disabilities who do not have jobs are also estimated at $232 billion per year.
      The Surgeon General's Call to action to improve the health and wellness of persons with disabilities.
      These figures may rise with the aging of the U.S. population.
      With many demographic changes looming, it is important to understand the ongoing impact of disability. Quantifying the national burden of disability is integral to understanding its impact on society and can help direct clinical resources. In addition, given the increasingly limited funding for research, these data may help us direct rehabilitation research funds to specific areas.
      Toward this end, we have assessed 8 common disabling conditions that might be treated in an inpatient or outpatient rehabilitation setting. Our overall purpose was to (1) characterize the incidence, prevalence, and costs across 8 disabling conditions; and (2) compare the impact of disability attributable to these conditions on activity and work limitation.

      Methods

      The 8 conditions covered in this review were chosen because they commonly require inpatient and outpatient rehabilitation care.
      • Chan L.
      • Koepsell T.D.
      • Deyo R.A.
      • et al.
      The effect of Medicare's payment system for rehabilitation hospitals on length of stay, charges, and total payments.
      They include spinal cord injury, traumatic brain injury (TBI), back pain, osteoarthritis, rheumatoid arthritis, multiple sclerosis, stroke, and limb loss.
      There are few national guidelines for assessing the economic and social burden of disability. This article is an attempt to organize the differing methods, cost measures, and data sources in the available literature. The authors conducted a MEDLINE search for reviews and primary studies. Multiple search terms were used: cost, disability, socioeconomic, work, impact, burden, epidemiology, United States, as well as the particular condition being studied. Titles and abstracts were read to exclude duplicates and studies that did not address the research questions. The authors supplemented their MEDLINE search with Google Scholar, UpToDate, information from the Centers for Disease Control and Prevention, and other data available online. The overall search results and selection methods are presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart in figure 1. Details for each condition, as well as the specific search terms applied, are included in supplemental appendix S1 (available online only at http://www.archives-pmr.org/).
      Figure thumbnail gr1
      Fig 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
      The inclusion criteria for articles included in the review were as follows: (1) published (not in press or online before print publication) between 2008 and 2013 (older publications found within the references of articles from this period were included if they were primary sources for the most recent figures available); (2) selected conditions (stroke, spinal cord injury, TBI, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain); (3) presence of disability-relevant outcome measure; (4) presence of work-relevant outcome measure; (5) presence of cost-relevant outcome measure; (6) original research with primary data; and (7) review articles. Exclusion criteria were as follows: (1) non-English language; (2) non-U.S. subject population; and (3) studies without an outcome measure relevant to incidence, prevalence, work, disability, or cost.
      Because the data we present span more than a decade, we inflation-adjusted selected dollar figures to April 2013 values using the Consumer Price All-Items Index when assessing indirect and total costs, and the April 2013 Consumer Price Medical Index for direct costs.
      This gives the reader a better ability to compare costs between one condition and the next.

      Results

      After our structured review of the literature, we identified 173 articles of interest, over 85 of which are cited here. Almost all were analyses of national or regional surveys. Pertinent results for all 8 conditions may be found in table 1.
      Table 1Incidence, prevalence, costs, and impact on disability of 8 common conditions
      ConditionPrevalenceIncidenceAnnual Direct Cost (2013 Values in Parentheses)Annual Indirect Cost (2013 Values in Parentheses)Annual Total Cost (2013 Values in Parentheses)Activity LimitationWork Limitation
      Back pain59.1 million adults (age ≥18y) have had back pain within the last 3mo (Lawrence,
      • Lawrence R.C.
      • Felson D.T.
      • Helmick C.G.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.
      2008).

      Of all those in U.S. aged >18y living in the community, 28.9% have had low back pain and 15.5% have had neck pain within the last 3mo (NCHS,
      • National Center for Health Statistics
      Health, United States, 2011: with special feature on socioeconomic status and health.
      2011).
      139/100,000 person-years (Waterman,
      • Waterman B.R.
      • Belmont Jr., P.J.
      • Schoenfeld A.J.
      Low back pain in the United States: incidence and risk factors for presentation in the emergency setting.
      2012)
      $33.3–$66.7 ($41.2–$82.6) billion (Katz,
      • Katz J.N.
      Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
      2006)

      $12.2 ($22.7) billion (Druss,
      • Druss B.G.
      • Marcus S.C.
      • Olfson M.
      • Pincus H.A.
      The most expensive medical conditions in America.
      2002)

      $17.9 ($23.4) billion (Smith,
      • Smith M.
      • Davis M.A.
      • Stano M.
      • et al.
      Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for years 2000 to 2007.
      2013)
      $66.7–$133.3 ($79.4–$158.7) billion (Katz,
      • Katz J.N.
      Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
      2006)

      $7.4 ($9.1) billion (Ricci,
      • Ricci J.A.
      • Stewart W.F.
      • Chee E.
      • et al.
      Back pain exacerbations and lost productive time costs in United States workers.
      2006)

      $13.9 ($21.2) billion (Guo,
      • Guo H.R.
      • Tanaka S.
      • Halperin W.E.
      • et al.
      Back pain prevalence in US industry and estimates of lost workdays.
      1999)

      $19.8 ($25.6) billion (Stewart,
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • et al.
      Lost productive time and cost due to common pain conditions in the US workforce.
      2003)
      $100–$200 ($119.1–$238.1) billion (Katz,
      • Katz J.N.
      Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
      2006)

      $90.6 ($129.2) billion (Luo,
      • Luo X.
      • Pietrobon R.
      • Sun S.X.
      • et al.
      Estimates and patterns of direct health care expenditures among individuals with back pain in the United States.
      2004)
      24.7% of people with back pain self-report functional limitations (Martin,
      • Martin B.I.
      • Deyo R.A.
      • Mirza S.K.
      • et al.
      Expenditures and health status among adults with back and neck problems.
      2008).

      7.1 million adults aged ≥18y have activity limitation due to chronic back conditions (Lawrence,
      • Lawrence R.C.
      • Felson D.T.
      • Helmick C.G.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.
      2008).
      149 million lost workdays per year (Guo,
      • Guo H.R.
      • Tanaka S.
      • Cameron L.L.
      • et al.
      Back pain among workers in the United States: national estimates and workers at high risk.
      1995)
      Osteoarthritis49.9 million adults aged ≥17y in 2009 (Cheng,
      • Cheng Y.J.
      for the Centers for Disease Control and Prevention
      Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2007–2009.
      2010)

      46.4 million adults aged ≥18y in 2000; 21.6% of adults (Hootman,
      • Barbour K.E.
      • Helmick C.G.
      • Theis K.A.
      • et al.
      Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation–United States, 2010-2012.
      2006)

      26.9 million adults aged ≥ 25y in 2005 (Lawrence,
      • Lawrence R.C.
      • Felson D.T.
      • Helmick C.G.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.
      2008)

      Main cause of disability in 8.6 million adults aged ≥18y (Hootman,
      • Hootman J.M.
      • Helmick C.G.
      • Brady T.J.
      A public health approach to addressing arthritis in older adults: the most common cause of disability.
      2012)
      88/100,000 person-years (hip); 240/100,000 person-years (knee); 100/100,000 person-years (hand) (Oliveria,
      • Oliveria S.A.
      • Felson D.T.
      • Reed J.I.
      • et al.
      Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization.
      1995)
      $80.8 ($115.3) billion (Yelin,
      • Yelin E.
      for the Centers for Disease Control and Prevention
      National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions—United States, 2003.
      2007)
      $10.3 ($11.6) billion (Kotlarz,
      • Kotlarz H.
      • Gunnarsson C.L.
      • Fang H.
      • et al.
      Osteoarthritis and absenteeism costs: evidence from US National Survey Data.
      2010)

      $8.3 ($13.0) billion (Leigh,
      • Leigh J.P.
      • Seavey W.
      • Leistikow B.
      Estimating the costs of job related arthritis.
      2001)
      $128 ($161.8) billion (Yelin,
      • Yelin E.
      for the Centers for Disease Control and Prevention
      National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions—United States, 2003.
      2007)

      $89.1 ($139.8) billion (Leigh,
      • Leigh J.P.
      • Seavey W.
      • Leistikow B.
      Estimating the costs of job related arthritis.
      2001)
      42% of people with osteoarthritis report arthritis-attributable activity limitations (Cheng,
      • Cheng Y.J.
      for the Centers for Disease Control and Prevention
      Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2007–2009.
      2010).
      5.3% of working- age adults have arthritis-attributable work limitations (Theis,
      • Theis K.A.
      • Murphy L.
      • Hootman J.M.
      • et al.
      Prevalence and correlates of arthritis-attributable work limitation in the US population among persons ages 18-64: 2002 National Health Interview Survey Data.
      2007).

      3 lost workdays per year per person (Kotlarz,
      • Kotlarz H.
      • Gunnarsson C.L.
      • Fang H.
      • et al.
      Osteoarthritis and absenteeism costs: evidence from US National Survey Data.
      2010)
      Rheumatoid arthritis1.3 million adults aged ≥18y in 2005 (Helmick,
      • Helmick C.G.
      • Felson D.T.
      • Lawrence R.C.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I.
      2008)

      2% of adults in North America (Jacobs,
      • Jacobs P.
      • Bissonnette R.
      • Guenther L.C.
      Socioeconomic burden of immune-mediated inflammatory diseases—focusing on work productivity and disability.
      2011)

      0.5%–1.0% of general population (Silman,
      2001)
      41/100,000 person-years (Myasoedova,
      • Myasoedova E.
      • Crowson C.S.
      • Kremers H.M.
      • et al.
      Is the incidence of rheumatoid arthritis rising? Results from Olmsted County, Minnesota, 1955-2007.
      2010)
      $8.4 ($10.6) billion (Birnbaum,
      • Birnbaum H.
      • Pike C.
      • Kaufman R.
      • et al.
      Societal cost of rheumatoid arthritis patients in the US.
      2010)
      $30.8 ($36.7) billion (Birnbaum,
      • Birnbaum H.
      • Pike C.
      • Kaufman R.
      • et al.
      Societal cost of rheumatoid arthritis patients in the US.
      2010)
      $39.2 ($46.7) billion (Birnbaum,
      • Birnbaum H.
      • Pike C.
      • Kaufman R.
      • et al.
      Societal cost of rheumatoid arthritis patients in the US.
      2010)
      30% more likely to need help with personal care; twice as likely to have a health-related activity limitation (Dominick,
      • Dominick K.L.
      • Ahern F.M.
      • Gold C.H.
      • et al.
      Health-related quality of life among older adults with arthritis.
      2004)
      44% 10-y work disability prevalence (Sokka,
      • Sokka T.
      • Kautiainen H.
      • Mottonen T.
      • et al.
      Work disability in rheumatoid arthritis 10 years after diagnosis.
      1999)

      39% unable to work 10y after early-stage rheumatoid arthritis (Eberhardt,
      • Eberhardt K.
      • Larsson B.-M.
      • Nived K.
      • et al.
      Work disability in rheumatoid arthritis—development over 15 years and evaluation of predictive factors over time.
      2007)
      Stroke6.8 million adults aged ≥20y; 2.8% of adult population (Go,
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      2013)
      795,000/y (610,000/y for first stroke) (Go,
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      2013)
      $28.3 ($33.0) billion (Heidenreich,
      • Heidenreich P.A.
      • Trogdon J.G.
      • Khavjou O.A.
      • et al.
      Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
      2011)

      $18.8 ($21.9) billion (Roger,
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics-2012 update: A report from the American Heart Association.
      2012)
      $25.6 ($27.3) billion (Heidenreich,
      • Heidenreich P.A.
      • Trogdon J.G.
      • Khavjou O.A.
      • et al.
      Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
      2011)

      $15.5 ($16.5) billion (Roger,
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics-2012 update: A report from the American Heart Association.
      2012)
      $65.5 ($72.7) billion (Rosamond,
      • Rosamond W.
      • Flegal K.
      • Friday G.
      • et al.
      Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      2007)

      $34.3 ($36.6) billion (Roger,
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics-2012 update: A report from the American Heart Association.
      2012)
      Among stroke survivors aged ≥65y, 26% were dependent in activities of daily living, 50% had hemiparesis, 30% were unable to walk without assistance, 19% had aphasia, 26% were in a nursing home 6mo poststroke (Kelly-Hayes,
      • Kelly-Hayes M.
      • Beiser A.
      • Kase C.S.
      • et al.
      The influence of gender and age on disability following ischemic stroke: the Framingham study.
      2003)
      35% unable to work at 1y after a first cerebral infarct (Camerlingo,
      • Camerlingo M.
      • Casto L.
      • Censori B.
      • et al.
      Recurrence after first cerebral infarction in young adults.
      2000)
      TBI3.32 million with long-term disability; 1.1% of total population in 2005 (Zaloshnja,
      • Zaloshnja E.
      • Miller T.
      • Langlois J.A.
      • et al.
      Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005.
      2008)
      1.7 million/y resulting in 52,000 deaths, 275,000 hospitalizations, and 1.365 million emergency department visits (Faul,

      Faul M, Xu L, Wald MM, et al. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

      2010)

      538.2 cases per 100,000 population; 1,565,000 in 2003 (Rutland-Brown,
      • Rutland-Brown W.
      • Langlois J.A.
      • Thomas K.E.
      • et al.
      Incidence of traumatic brain injury in the United States, 2003.
      2006)
      $9.2 ($13.1) billion (Rutland-Brown,
      • Rutland-Brown W.
      • Langlois J.A.
      • Thomas K.E.
      • et al.
      Incidence of traumatic brain injury in the United States, 2003.
      2006)
      $51.2 ($63.9) billion (Rutland-Brown,
      • Rutland-Brown W.
      • Langlois J.A.
      • Thomas K.E.
      • et al.
      Incidence of traumatic brain injury in the United States, 2003.
      2006)
      $76.5 ($78.1) billion (Coronado,
      • Coronado V.G.
      • Xu L.
      • Basavaraju S.V.
      • et al.
      Surveillance for traumatic brain injury-related deaths—United States, 1997-2007.
      2011)

      $56 ($69.9) billion (Selassie,
      • Selassie A.W.
      • Zaloshnja E.
      • Langlois J.A.
      • et al.
      Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003.
      2008)

      $48.3 ($62.2) billion (Finkelstein,
      • Finkelstein E.
      • Corso P.
      • Miller T.
      The incidence and economic burden of injuries in the United States.
      2006)
      43% of persons discharged after acute TBI hospitalizations develop long-term disability (Rutland-Brown,
      • Rutland-Brown W.
      • Langlois J.A.
      • Thomas K.E.
      • et al.
      Incidence of traumatic brain injury in the United States, 2003.
      2006).
      Return-to-work rates of 12%–70% depending on the population (Shames,
      • Shames J.
      • Teger I.
      • Ring H.
      • et al.
      Return to work following traumatic brain injury: trends and challenges.
      2007)
      Amputation1.6 million in 2005 (Ziegler-Graham,
      • Ziegler-Graham K.
      • MacKenzie E.J.
      • Ephraim P.L.
      • et al.
      Estimating the prevalence of limb loss in the United States: 2005 to 2050.
      2008)
      30,000–50,000 lower limb amputations per year (Ziegler-Graham,
      • Ziegler-Graham K.
      • MacKenzie E.J.
      • Ephraim P.L.
      • et al.
      Estimating the prevalence of limb loss in the United States: 2005 to 2050.
      2008)

      330/100,000 in people with diabetes (CDC,

      Centers for Disease Control and Prevention. Hospital discharge rates for nontraumatic lower extremity amputation per 1,000 diabetic population, United States, 1988-2009. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig3.htm. Accessed June 12, 2013.

      2009)
      Partial foot: $30,493 ($45,250)

      Through knee: $81,086 ($120,320) (MacKenzie,
      • MacKenzie E.J.
      • Jones A.S.
      • Bosse M.J.
      • et al.
      Health-care costs associated with amputation or reconstruction of a limb-threatening injury.
      2007)

      $38,077 ($54,317) average for diabetes-related amputation (Shearer,
      • Shearer A.
      • Scuffham P.
      • Gordois A.
      • et al.
      Predicted costs and outcomes from reduced vibration detection in people with diabetes in the U.S.
      2003)
      $64,000 ($75,000) per person over 3 years (Shearer,
      • Shearer A.
      • Scuffham P.
      • Gordois A.
      • et al.
      Predicted costs and outcomes from reduced vibration detection in people with diabetes in the U.S.
      2003)
      $8.3 billion ($9.0 billion) (Amputee Coalition,

      Amputee Coalition. Limb loss statistics. Available at: http://www.amputee-coalition.org/limb-loss-resource-center/limb-loss-statistics/. Accessed June 19, 2013.

      2013)

      $509,275 ($649,953) lifetime health care cost after lower extremity amputation (MacKenzie,
      • MacKenzie E.J.
      • Jones A.S.
      • Bosse M.J.
      • et al.
      Health-care costs associated with amputation or reconstruction of a limb-threatening injury.
      2007)
      31% of patients unable to live independently at 24mo; 49% loss of ambulation (Taylor,
      • Taylor S.M.
      • Kalbaugh C.A.
      • Blackhurst D.W.
      • et al.
      Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients.
      2005)

      43%–74% 5-y mortality after lower extremity amputation (Robbins,
      • Robbins J.M.
      • Strauss G.
      • Aron D.
      • et al.
      Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration?.
      2008)
      42% unable to work 7y postamputation for lower extremity trauma (MacKenzie,
      • MacKenzie E.J.
      • Bosse M.J.
      • Kellam J.F.
      • et al.
      Early prediction of long-term work disability after major limb trauma.
      2006)
      Multiple sclerosis400,000 (National Multiple Sclerosis Society,

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      2009)

      350,000 (Frohman,
      • Frohman E.M.
      Multiple sclerosis.
      2003)

      58–95/100,000 individuals , (Noonan,
      • Noonan C.W.
      • Williamson D.M.
      • Henry J.P.
      • et al.
      The prevalence of multiple sclerosis in 3 US communities.
      2010)
      10,400 cases per year (National Multiple Sclerosis Society,

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      2009)

      3.6/100,000 person-years in women; 2.0/100,000 person-years in men (Alonso,
      • Alonso A.
      • Hernan M.A.
      Temporal trends in the incidence of multiple sclerosis: A systematic review.
      2008)
      $16 ($18) billion (National Multiple Sclerosis Society,

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      2009)

      $54,244 per person ($60,078) (Adelman,
      • Adelman S.
      • Rane S.G.
      • Villa V.F.
      The cost burden of multiple sclerosis in the United States: a systematic review of the literature.
      2013)

      $39,000 per person (Fox,
      • Fox R.
      Multiple sclerosis. Cleveland Clinic Foundation Disease Management Project.
      2010)
      $12 ($13) billion (National Multiple Sclerosis Society,

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      2009)
      $28 ($30) billion (National Multiple Sclerosis Society,

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      2009)
      Average time from disease onset to difficulty walking is 8y; 15y for cane use; 30y for wheelchair use (Fox,
      • Fox R.
      Multiple sclerosis. Cleveland Clinic Foundation Disease Management Project.
      2010)
      Overall, 56.5% unemployment in MS population. Ability of people with MS to remain in the labor force declines 3% per year after diagnosis (Minden,
      • Minden S.L.
      • Frankel D.
      • Hadden L.
      • et al.
      The Sonya Slifka Longitudinal Multiple Sclerosis Study: methods and sample characteristics.
      2006)
      Spinal cord injury236,000–327,000 in 2012 (National Spinal Cord Injury Statistical Center,
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.
      2013)
      43–77 per million; 12,000–20,000 per year (Bernhard,
      • Bernhard M.
      • Gries A.
      • Kremer P.
      • et al.
      Spinal cord injury (SCI)—prehospital management.
      2005)
      $7.1 ($10.0) billion (Berkowitz,
      • Berkowitz M.
      • O'Leary P.
      • Kruse D.L.
      • Harvey C.
      Spinal cord injury: an analysis of medical and social costs.
      1998)

      $7.73 ($21.5) billion (DeVivo,
      • DeVivo M.J.
      Causes and costs of spinal cord injury in the United States.
      1997)

      $500,000 to $2 million over a lifetime (Sekhon,
      • Sekhon L.H.
      • Fehlings M.G.
      Epidemiology, demographics, and pathophysiology of acute spinal cord injury.
      2001)

      Mean first-year charges $523,089, subsequent annual charges $79,759 (DeVivo,
      • DeVivo M.J.
      • Chen Y.
      • Mennemeyer S.T.
      • Deutsch A.
      Cost of care following spinal cord injury.
      2011)
      $2.6 ($3.7) billion (Berkowitz,
      • Berkowitz M.
      • O'Leary P.
      • Kruse D.L.
      • Harvey C.
      Spinal cord injury: an analysis of medical and social costs.
      1998)
      $9.7 ($13.7) billion (Berkowitz,
      • Berkowitz M.
      • O'Leary P.
      • Kruse D.L.
      • Harvey C.
      Spinal cord injury: an analysis of medical and social costs.
      1998)
      Functional recovery after SCI depends on severity and spinal level of injury (Braddom,
      • Braddom R.
      Physical medicine and rehabilitation.
      2000)
      81% of previously employed people were unemployed at 1y post-SCI; 39.5% remained unemployed by 25y postinjury (National Spinal Cord Injury Statistical Center,
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.
      2013)
      Abbreviations: CDC, Centers for Disease Control and Prevention; MS, multiple sclerosis; NCHS, National Center for Health Statistics.

       Back pain

      Back pain is a very common condition, with an incidence of 139 per 100,000 person-years in the United States based on data from the National Electronic Injury Surveillance System.
      • Waterman B.R.
      • Belmont Jr., P.J.
      • Schoenfeld A.J.
      Low back pain in the United States: incidence and risk factors for presentation in the emergency setting.
      A 2012 publication by the Centers for Disease Control and Prevention's National Center for Health Statistics reported that 28.4% of adults older than 18 years had experienced lower back pain in the previous 3 months.
      • National Center for Health Statistics
      Health, United States, 2011: with special feature on socioeconomic status and health.
      This figure is at the high end of the findings of a systematic review
      • Dagenais S.
      • Caro J.
      • Haldeman S.
      A systematic review of low back pain cost of illness studies in the United States and internationally.
      of 15 studies between 1997 and 2007, in which reported annual rates of low back pain were in the range of 5% to 22%. Based on data from the 2005 Survey of Income and Program Participation, 7.6 million adults with disabilities identified back or spine problems as the main cause of their disability.
      • Hootman J.M.
      • Helmick C.G.
      • Brady T.J.
      A public health approach to addressing arthritis in older adults: the most common cause of disability.
      Back pain significantly limits work and daily activity. According to data from the 1998 National Health Interview Survey (NHIS), Americans lost a cumulative 149 million workdays because of back pain in 1988.
      • Guo H.R.
      • Tanaka S.
      • Cameron L.L.
      • et al.
      Back pain among workers in the United States: national estimates and workers at high risk.
      In the nationally representative Medical Expenditure Panel Survey, 24.7% of people with back problems reported limitations in their physical functions.
      • Martin B.I.
      • Deyo R.A.
      • Mirza S.K.
      • et al.
      Expenditures and health status among adults with back and neck problems.
      More than 7 million adults have activity limitations because of chronic back conditions,
      • Lawrence R.C.
      • Felson D.T.
      • Helmick C.G.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.
      according to the National Arthritis Data Workgroup's analyses of the National Health and Nutrition Examination Survey (NHANES) and the NHIS.
      The high prevalence of lower back pain comes with considerable economic costs. In 2006, Katz
      • Katz J.N.
      Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
      estimated the total cost of back pain in the United States to be $100 to $200 billion ($119–$238 billion in 2013 dollars), with one third accounted for by direct medical expenses and the remaining two thirds due to indirect costs from productivity loss and absenteeism. However, the authors made this estimate by extrapolating data from a 15-year-old study.
      • Frymoyer J.W.
      • Cats-Baril W.L.
      An overview of the incidences and costs of low back pain.
      Perhaps for this reason, these cost breakdowns produce higher estimates for direct cost than a more recent study
      • Smith M.
      • Davis M.A.
      • Stano M.
      • et al.
      Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for years 2000 to 2007.
      that estimated direct costs at $46.8 billion per year in 2013 dollars, although this study counted only ambulatory services for chronic pain. An earlier study
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • et al.
      Lost productive time and cost due to common pain conditions in the US workforce.
      produced lower estimates for indirect costs as well, using data from the American Productivity Audit of 28,902 working adults to derive an annual figure of $19.8 billion ($25.6 billion in 2013 dollars).

       Arthritis (osteoarthritis and rheumatoid arthritis)

      Osteoarthritis is one of the most common diagnoses in general practice and is probably the leading cause of disability in adults. Based on national census data and the NHANES I, osteoarthritis affected 26.9 million adults in 2005.
      • Lawrence R.C.
      • Felson D.T.
      • Helmick C.G.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.
      The most recent report published by the Centers for Disease Control and Prevention estimated that 52.5 million adults, or 22.7% of the population, self-reporting a diagnosis of arthritis.
      • Barbour K.E.
      • Helmick C.G.
      • Theis K.A.
      • et al.
      Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation–United States, 2010-2012.
      An analysis of the 2005 Survey of Income and Program Participation established that 8.6 million U.S. adults with disabilities attributed the main cause of their disability to arthritis or rheumatism.
      • Hootman J.M.
      • Helmick C.G.
      • Brady T.J.
      A public health approach to addressing arthritis in older adults: the most common cause of disability.
      Disability attributable to osteoarthritis can be assessed by lost workdays and limitations in activities of daily living. According to the Centers for Disease Control and Prevention, the impact of osteoarthritis is substantial: 80% of afflicted individuals experience some degree of movement limitation and 25% are restricted in major activities of daily living. In those with knee osteoarthritis specifically, 14% require assistance with routine needs and 11% with personal care.

      Centers for Disease Control and Prevention. Osteoarthritis. Available at: http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Accessed June 25, 2013.

      A study
      • Cheng Y.J.
      for the Centers for Disease Control and Prevention
      Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2007–2009.
      based on NHIS data from 2007 to 2009 reported that 21.1 million, or 42% of the 49.9 million adults with physician-diagnosed arthritis, had arthritis-attributable activity limitations. Arthritis-attributable activity limitations were defined as any limitations in an individual's usual activities as a result of arthritis or joint symptoms.
      Rheumatoid arthritis is estimated to be present in 1.3 million U.S. adults 18 years or older, representing 0.6% of the population, based on NHIS- and NHANES-derived analyses from the National Arthritis Data Workgroup.
      • Helmick C.G.
      • Felson D.T.
      • Lawrence R.C.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I.
      In 2011, Jacobs et al
      • Jacobs P.
      • Bissonnette R.
      • Guenther L.C.
      Socioeconomic burden of immune-mediated inflammatory diseases—focusing on work productivity and disability.
      reported higher estimates of 2% of adults in North America. The most recent estimate of the incidence of rheumatoid arthritis is 41 per 100,000 person-years based on the Rochester Epidemiology Project.
      • Myasoedova E.
      • Crowson C.S.
      • Kremers H.M.
      • et al.
      Is the incidence of rheumatoid arthritis rising? Results from Olmsted County, Minnesota, 1955-2007.
      Rheumatoid arthritis is also associated with significant disability. People with rheumatoid arthritis are 30% more likely to need help with personal care and are limited in daily activities at twice the rate of disease-free individuals.
      • Dominick K.L.
      • Ahern F.M.
      • Gold C.H.
      • et al.
      Health-related quality of life among older adults with arthritis.
      One study
      • Eberhardt K.
      • Larsson B.-M.
      • Nived K.
      • et al.
      Work disability in rheumatoid arthritis—development over 15 years and evaluation of predictive factors over time.
      followed up employees with early-stage rheumatoid arthritis and found a 39% prevalence of work disability after 10 years.
      The economic burden of all arthritis is significant. In 2007, the cost attributable to arthritis and other rheumatic conditions in the United States was estimated at $128 billion ($162 billion in 2013 dollars).
      • Yelin E.
      for the Centers for Disease Control and Prevention
      National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions—United States, 2003.
      This estimate, derived from national Medical Expenditure Panel Survey data, was partitioned into $80.8 billion ($115 billion in 2013 dollars) in direct medical expenditures and $47.0 billion ($59.4 billion in 2013 dollars) in indirectly lost earnings. In 2010, Kotlarz et al
      • Kotlarz H.
      • Gunnarsson C.L.
      • Fang H.
      • et al.
      Osteoarthritis and absenteeism costs: evidence from US National Survey Data.
      used Medical Expenditure Panel Survey data from the same period and estimated that the costs caused by absenteeism from osteoarthritis alone are $10.3 billion per year ($11.6 billion in 2013 dollars) because of an estimated 3 lost workdays per year.
      The functional and work limitations of persons with rheumatoid arthritis contribute to an estimated $10.9 billion ($13.0 billion in 2013 dollars) in indirect costs from lost wages and costs to employers, based on 2005 administrative claims databases covering private and Medicare/Medicaid beneficiaries in the United States.
      • Birnbaum H.
      • Pike C.
      • Kaufman R.
      • et al.
      Societal cost of rheumatoid arthritis patients in the US.
      On top of this figure, the group attributed an additional $10.3 billion ($12.3 billion in 2013 dollars) in intangible quality-of-life deterioration as estimated by legal system jury awards, as well as $9.6 billion lost ($11.4 billion in 2013 dollars) in lifetime earnings because of early mortality. Excess health care costs, in the form of copays and medications, amounted to $8.4 billion ($10.6 billion in 2013 dollars), for a total indirect cost of $39.2 billion per year ($46.7 billion in 2013 dollars).

       Stroke

      Stroke is a leading cause of serious long-term disability in the United States. According to the National Heart, Lung, and Blood Institute, the incidence of stroke is 795,000 annually, with 610,000 being first-time strokes and 185,000 related to a recurrence.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics-2014 update: a report from the American Heart Association.
      The American Heart Association also estimated an overall stroke prevalence of 6.8 million Americans ≥20 years of age, accounting for 2.8% of the population, based on NHANES data from 2007 to 2010.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      Among older survivors of ischemic stroke who were followed up in the Framingham Study, 26% were dependent in activities of daily living 6 months poststroke. Half had reduced mobility or hemiparesis, including 30% who were unable to walk without assistance. In addition, a significant number had associated aphasia (19%), symptoms of depression (35%), and other impairments that contributed to a 26% rate of nursing home placement.
      • Kelly-Hayes M.
      • Beiser A.
      • Kase C.S.
      • et al.
      The influence of gender and age on disability following ischemic stroke: the Framingham study.
      The economic burden of stroke is impacted by initial hospitalization, medications, continuing medical care, and work limitations. The average cost of a stroke hospitalization in 2005 was $9500.
      • Russo C.A.
      • Andrews R.M.
      Hospital stays for stroke and other cerebrovascular diseases, 2005. Healthcare cost and utilization cost statistical brief no. 51.
      Over a lifetime, the cost of an ischemic stroke in the United States is more than $140,000 including inpatient care, rehabilitation, and long-term care for lasting deficits.
      • Taylor T.N.
      • Davis P.H.
      • Torner J.C.
      • Holmes J.
      • Meyer J.W.
      • Jacobson M.F.
      Lifetime cost of stroke in the United States.
      A 2011 estimate divided the total cost of stroke in the United States into $28.3 billion ($33.0 billion in 2013 dollars) for direct costs and $25.6 billion ($27.3 billion in 2013 dollars) in indirect costs.
      • Heidenreich P.A.
      • Trogdon J.G.
      • Khavjou O.A.
      • et al.
      Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
      Estimates for the total costs for strokes in the United States range from $34.3 billion ($36.6 billion in 2013 dollars)

      National Heart, Lung, and Blood Institute. Morbidity and mortality: 2012 chart book on cardiovascular, lung, and blood disorders. Available at: http://www.nhlbi.nih.gov/resources/docs/2012_ChartBook_508.pdf. Accessed February 13, 2014.

      to $65.5 billion ($72.7 billion in 2013 dollars).
      • Rosamond W.
      • Flegal K.
      • Friday G.
      • et al.
      Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.

       Traumatic brain injury

      A 2010 report from the Centers for Disease Control and Prevention estimated that TBI requiring a physician visit occurs with an incidence of 1.74 million per year in the United States, based on calculations from NHIS data by Waxweiler et al
      • Waxweiler R.J.
      • Thurman D.
      • Sniezek J.
      • et al.
      Monitoring the impact of traumatic brain injury—a review and update.
      in 1995. The severity of TBI ranges from mild (80%) to severe (10%), with most long-term disability caused by moderate to severe injury.

      Dennis KC. Current perspectives on traumatic brain injury. Available at: http://www.asha.org/aud/articles/CurrentTBI/. Accessed June 24, 2013.

      The prevalence of long-term disability resulting from TBI has been estimated at 3.32 million
      • Zaloshnja E.
      • Miller T.
      • Langlois J.A.
      • et al.
      Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005.
      to 5.3 million
      • Thurman D.J.
      • Alverson C.
      • Dunn K.A.
      • et al.
      Traumatic brain injury in the United States: a public health perspective.
      in the United States.
      Survivors of TBI often have limitations in activities of daily living, instrumental activities of daily living, social integration, and financial independence.
      • Thurman D.
      • Alverson C.
      • Browne D.
      Traumatic brain injury in the United States: a report to Congress.
      • Silver J.M.
      • Kramer R.
      • Greenwald S.
      • et al.
      The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study.
      About 43% of people discharged with TBI after acute hospitalization develop TBI-related long-term disability.
      • Rutland-Brown W.
      • Langlois J.A.
      • Thomas K.E.
      • et al.
      Incidence of traumatic brain injury in the United States, 2003.
      Individuals with a history of TBI are 66% more likely to receive welfare or disability payments.
      • Silver J.M.
      • Kramer R.
      • Greenwald S.
      • et al.
      The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study.
      In addition, a history of TBI is strongly associated with subsequent neurologic disorders that are disabling in their own right, including Alzheimer disease and Parkinson's disease.
      • Bazarian J.J.
      • Cernak I.
      • Noble-Haeusslein L.
      • et al.
      Long-term neurologic outcomes after traumatic brain injury.
      The direct costs of TBI have been estimated at $9.2 billion per year ($13.1 billion in 2013 dollars). An additional $51.2 billion ($64.7 billion in 2013) dollars is lost through missed work and lost productivity.
      • Rutland-Brown W.
      • Langlois J.A.
      • Thomas K.E.
      • et al.
      Incidence of traumatic brain injury in the United States, 2003.
      Total medical costs range from $48.3 billion to $76.5 billion ($63.4–$79.1 billion in 2013 dollars).
      • Coronado V.G.
      • Xu L.
      • Basavaraju S.V.
      • et al.
      Surveillance for traumatic brain injury-related deaths—United States, 1997-2007.
      • Selassie A.W.
      • Zaloshnja E.
      • Langlois J.A.
      • et al.
      Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003.
      • Finkelstein E.
      • Corso P.
      • Miller T.
      The incidence and economic burden of injuries in the United States.

       Limb loss

      The loss of a lower or upper extremity is associated with variable degrees of disability, given the wide range of comorbidities and inciting factors leading to amputation. Approximately 185,000 amputations occur in the United States annually,
      • Owings M.F.
      • Kozak L.J.
      Ambulatory and inpatient procedures in the United States, 1996.
      and an estimated 2 million Americans currently live with limb loss.
      • Ziegler-Graham K.
      • MacKenzie E.J.
      • Ephraim P.L.
      • et al.
      Estimating the prevalence of limb loss in the United States: 2005 to 2050.
      The most common causes of limb loss are diabetes and peripheral artery disease, with an age-adjusted incidence rate of 3.1 per 1000 for people with diabetes in 2009.

      Centers for Disease Control and Prevention. Hospital discharge rates for nontraumatic lower extremity amputation per 1,000 diabetic population, United States, 1988-2009. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig3.htm. Accessed June 12, 2013.

      In 2006, about 65,700 nontraumatic lower limb amputations were performed in people with diabetes.

      Staff N. Amputee coalition fact sheet. Available at: http://www.amputee-coalition.org/fact_sheets/diabetes_leamp.html. Accessed June 28, 2013.

      Trauma accounts for 45% of all cases, with cancer accounting for <1% of amputations.
      • Ziegler-Graham K.
      • MacKenzie E.J.
      • Ephraim P.L.
      • et al.
      Estimating the prevalence of limb loss in the United States: 2005 to 2050.
      Cardiovascular disease is itself a significant cause of disability and mortality in the United States, and when present as a comorbid condition in people with limb loss, contributes to worse disability and mortality outcomes. Nearly half of people who have an amputation because of vascular disease will die within 5 years.
      • Robbins J.M.
      • Strauss G.
      • Aron D.
      • et al.
      Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration?.
      In addition to serious comorbidities such as vascular disease, a number of risk factors have been found to be significantly associated with poorer functional outcomes and decreased rates of independent living status after amputation. These include age >60 years, above-knee amputation, baseline homebound status, and dementia.

      Amputee Coalition. Limb loss statistics. Available at: http://www.amputee-coalition.org/limb-loss-resource-center/limb-loss-statistics/. Accessed June 19, 2013.

      However, most patients who lived independently before major lower limb amputation remained independent postoperatively.
      • Taylor S.M.
      • Kalbaugh C.A.
      • Blackhurst D.W.
      • et al.
      Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients.
      In 2003, an average diabetes-related amputation procedure carried $38,077 ($54,317 in 2013 dollars) in associated costs.
      • Shearer A.
      • Scuffham P.
      • Gordois A.
      • et al.
      Predicted costs and outcomes from reduced vibration detection in people with diabetes in the U.S.
      In 2009, cumulative national hospital costs associated with amputation amounted to more than $8.3 billion ($9.0 billion in 2013 dollars).

      Amputee Coalition. Limb loss statistics. Available at: http://www.amputee-coalition.org/limb-loss-resource-center/limb-loss-statistics/. Accessed June 19, 2013.

      Staff N. Amputee coalition fact sheet. Available at: http://www.amputee-coalition.org/fact_sheets/diabetes_leamp.html. Accessed June 28, 2013.

       Multiple sclerosis

      A recent study
      • Alonso A.
      Hernán MA. Temporal trends in the incidence of multiple sclerosis: a systematic review.
      found a rate of approximately 2.0 cases of multiple sclerosis per 100,000 person-years in men and 3.6 cases per 100,000 person-years in women. In 2007, the National Multiple Sclerosis Society estimated the prevalence at 400,000 by using Census 2000 data to extrapolate from earlier estimates.

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      Disability attributable to multiple sclerosis is highly variable given its wide range of clinical presentations. The average time between disease onset and difficulty in ambulation is 8 years. Without disease-modifying treatment, patients require a cane, on average, after 15 years, and are using a wheelchair, on average, after 30 years.
      • Fox R.
      Multiple sclerosis. Cleveland Clinic Foundation Disease Management Project.
      During the period of decline in functional ability, there is an accompanying decline in the ability to remain in the labor force, with employment rates declining an average of 3% per year after diagnosis.
      • Minden S.L.
      • Frankel D.
      • Hadden L.
      • et al.
      The Sonya Slifka Longitudinal Multiple Sclerosis Study: methods and sample characteristics.
      Annual health care costs for patients with multiple sclerosis have been reported to be between $18,000 (National Multiple Sclerosis Society) and $39,000 per person.
      • Fox R.
      Multiple sclerosis. Cleveland Clinic Foundation Disease Management Project.
      The National Multiple Sclerosis Society estimates that the annual economic cost in the United States is approximately $28 billion.

      National Multiple Sclerosis Society. MS prevalence. Available at: http://www.nationalmssociety.org/about-the-society/ms-prevalence/index.aspx. Accessed June 10, 2013.

      Among patients with health care insurance, out-of-pocket costs are close to $2000 per year. However, 25% of people pay more than this amount each year.
      • Minden S.L.
      • Frankel D.
      • Hadden L.
      • et al.
      Access to health care for people with multiple sclerosis.
      A survey of 2314 randomly selected bankruptcy filers in 2007 found that out-of-pocket expenditures for neurologic diseases such as multiple sclerosis accounted for the highest medical bills, at an average of $34,167 per person, exceeding expenditures for diabetes, stroke, mental illness, and heart disease.
      • Himmelstein D.U.
      • Thorne D.
      • Warren E.
      • et al.
      Medical bankruptcy in the United States, 2007: results of a national study.

       Spinal cord injury

      Based on several regional studies, the annual incidence of spinal cord injury in the United States is estimated to be between 24
      • Burke D.A.
      • Linden R.D.
      • Zhang Y.P.
      • et al.
      Incidence rates and populations at risk for spinal cord injury: a regional study.
      and 77
      • Bernhard M.
      • Gries A.
      • Kremer P.
      • et al.
      Spinal cord injury (SCI)—prehospital management.
      per million people, or roughly 12,000 to 20,000 new cases per year.
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.
      Motor vehicle collisions account for most cases, and 80% of affected individuals are male. It is estimated that there are approximately 270,000 living survivors of spinal cord injury in the United States, with a range of 238,000 to 332,000 people.
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.
      The limitations of a spinal cord injury on activities of daily living are largely determined by the location and completeness of the injury sustained.
      • Braddom R.
      Physical medicine and rehabilitation.
      The higher the level of spinal cord injury, the more assistance the patient will need for activities of daily living and locomotion. Although there are many exceptions, patients are generally independent in all self-care if their injury occurs at spinal level T1 or below. Patients with a low cervical injury (C6-8) may require additional bowel and bladder care and bathing with adaptive equipment, while patients with high cervical injury have an increased dependency on oral functioning for hygiene, writing, typing, and operating a power wheelchair.
      • Braddom R.
      Physical medicine and rehabilitation.
      In 1 model system, more than half (57.1%) of all people with spinal cord injury reported being employed before their injury, but this number fell to 11.8% 1 year later.
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.
      With physical and occupational therapy, many patients are able to regain much of their ability to care for themselves and reenter the workforce. By 20 years postinjury, the same cohort of patients had a 35.2% employment rate.
      Costs associated with spinal cord injury are greatly influenced by the patient's severity of injury and resultant degree of disability.
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.
      In 2011, average per-person yearly expenses ranged from $334,170 in the first year and $40,589 in each subsequent year for patients with incomplete injury, versus $1,023,924 in the first year and $177,808 in each subsequent year for patients with C1-4 tetraplegia.
      • DeVivo M.J.
      • Chen Y.
      • Mennemeyer S.T.
      • Deutsch A.
      Cost of care following spinal cord injury.
      The total annual cost attributed to spinal cord injury in the United States is approximately $14.5 billion ($21.5 billion in 2013 dollars).
      • Berkowitz M.
      • O'Leary P.
      • Kruse D.L.
      • Harvey C.
      Spinal cord injury: an analysis of medical and social costs.
      Estimates for direct costs range from $7.73 billion ($14.0 billion in 2013 dollars)
      • DeVivo M.J.
      Causes and costs of spinal cord injury in the United States.
      to $9.73 billion ($18.1 billion in 2013 dollars),
      • Berkowitz M.
      • O'Leary P.
      • Kruse D.L.
      • Harvey C.
      Spinal cord injury: an analysis of medical and social costs.
      while estimates for indirect costs range from $2.59 billion ($3.83 billion in 2013 dollars)
      • Berkowitz M.
      • O'Leary P.
      • Kruse D.L.
      • Harvey C.
      Spinal cord injury: an analysis of medical and social costs.
      to $5.5 billion ($7.0 billion in 2013 dollars).
      • National Spinal Cord Injury Statistical Center
      Spinal cord injury facts and figures at a glance.

      Discussion

      Our review of the literature suggests that back pain and arthritis are the most common and costly conditions that we examined, affecting over 100 million individuals and costing more than $200 billion per year. Another condition to note is TBI, which, while less common than arthritis and back pain, carries enormous per capita costs, mostly because of the disability that it may cause. Finally, stroke, which is often listed as the most common cause of disability (unpublished data from National Heart, Lung, and Blood Institute. Unpublished tabulation of the NHANES, 1971–1975, 1976–1980, 1988–1994, 1999–2004, and 2005–2008 and extrapolation to the U.S. population, 2008), is likely second to both arthritis and back pain in its impact on functional limitations. This is consistent with evidence from the United Kingdom.
      • Adamson J.
      • Beswick A.
      • Ebrahim S.
      Is stroke the most common cause of disability.
      Back pain and arthritis make their impact by sheer numbers in the population. Even if affected individuals miss just a few days of work on average, or have their productivity slightly impaired, the cumulative results across the affected population can amount to tens of billions of dollars in lost wages and reduced work capacity each year. Conversely, interventions that make small improvements in the onset and progression of these chronically disabling diseases may result in significant overall health care cost savings.
      Other conditions may affect fewer people but can severely limit their ability to work, ambulate, or take care of themselves. In conditions like spinal cord injury or limb loss, the degree of each person's specific impairments results in widely differing costs of care and levels of disability. Because conclusions are relatively difficult to make about conditions such as spinal cord injury and amputation as an aggregate group, it is important for future research to focus on the evaluation of, and creation of specific interventions for, thoughtfully delineated subsets of these populations.
      The high direct and indirect costs of disability are likely related to the chronic nature of functional loss. A comparison of the rates of first-time versus recurrent stroke, or the incidence versus prevalence rates of spinal cord injury and TBI highlight the continual burden of these conditions beyond their initial impact. Although direct medical costs tend to be highest in the first year after event onset, they can remain high throughout a patient's lifetime. Without a comprehensive view of the lifelong costs of chronic disability, medical costs may continue to account for most bankruptcies in this country.

       Study limitations

      This article has several limitations. First, while we searched for the latest and best available research, some of the data we examined are more than a decade old. Inflation adjustments over this period may be less accurate. In addition, the costs were not estimated in a uniform fashion, raising the possibility that there might be differential error between diagnostic groups. We also used a single inflation adjustment metric, and there is no question that inflation may have been different for different conditions. Although subtle variations in disease-specific inflation may exist, it is unlikely that adjusting for the “true” inflation rates (if this were even possible) would change our conclusion related to the question of which diseases are most expensive. Back pain and arthritis are clearly the most expensive, and this is primarily on the basis of their high prevalence rather than their per capita cost. Finally, patients often present with more than 1 diagnosis. While table 1 does appear to attribute all the cost and disability to a single diagnosis, this may not be the case. Individuals with stroke may also have an amputation or arthritis, and this may be the source for some of their disability. Thus, there is likely a much more subtle interplay at work that is beyond the scope of this article.

      Conclusions

      The limitations noted above highlight the problems in performing this sort of review. In many cases, the data are old, and there is a lack of uniformity in how certain elements, particularly costs and disability burden, are measured. Thus, it is problematic when one wants to compare one time point to the next as well as one disease to another. One solution, although an expensive one, would be to invest more resources in comprehensive national surveys that address the issues raised in this article. In particular, data on the measurement of disability seemed to be the most lacking in our search, and this may be a topic that deserves special focus.

      Supplemental Appendix S1. Search Strategy and Results for Study Conditions

       Search Terms

      “back pain”[Title] AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      (“rheumatoid arthritis”[Title] OR rheumatism[Title] OR rheumatic[Title]) AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      (amputation[Title] OR amputee[Title] OR limb loss[Title]) AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      (osteoarthritis[Title] OR arthritis [Title] not rheumatoid[Title]) AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      stroke[Title] AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      “traumatic brain injury”[Title] AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      “multiple sclerosis”[Title] AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      “spinal cord injury”[Title] AND (cost[Title] OR disability[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title] OR burden[Title] OR epidemiology[Title] OR incidence[Title] OR prevalence[Title])
      Article Types
      Clinical trial
      Journal article
      Meta-analysis
      Randomized controlled trial
      Review
      Systematic reviews
      Text availability
      Abstract available
      Publication dates
      Within 5 years
      Species
      Supplemental Table S1Data Extraction
      ConditionIdentified Citations Within 5yAdditional Records IdentifiedExcluded CitationsSelected Studies for Detailed ReviewStudies Included in Analysis
      Back pain443244333413
      Rheumatoid arthritis/rheumatism/rheumatic60713594268
      Amputation/limb loss5724503110
      Osteoarthritis/arthritis NOT rheumatoid544145322610
      Multiple sclerosis5478537189
      Traumatic brain injury23062211514
      Spinal cord injury148314477
      Stroke1170711611611
      Total374699367217382

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