Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2014;95:986-95

REVIEW ARTICLE

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
Vincent Y. Ma, BA,a,b Leighton Chan, MD, MPH,a Kadir J. Carruthers, BSa,b
From the aRehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD; and bCase Western University
School of Medicine, Cleveland, OH.

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.
Archives of Physical Medicine and Rehabilitation 2014;95:986-95
ª 2014 by the American Congress of Rehabilitation Medicine

In 2011, an estimated 37.9 million people, 12.2% of the U.S. impact. Medical costs account for more than 60% of all personal
population, were living with a disability.1 The impact of disability bankruptcies.4,5 Government and private payments to support
is significant. Aside from the enormous direct medical costs employment-aged individuals with disabilities who do not have
related to disability,2 which were estimated at $160 billion in jobs are also estimated at $232 billion per year.6 These figures
1994,3 medical problems have considerable personal and societal may rise with the aging of the U.S. population.
With many demographic changes looming, it is important to
Supported by resources from the National Institutes of Health Intramural Research Program. understand the ongoing impact of disability. Quantifying the
No commercial party having a direct financial interest in the results of the research supporting national burden of disability is integral to understanding its
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.
impact on society and can help direct clinical resources. In

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.10.032
Incidence, prevalence, and costs of common rehabilitation conditions 987

addition, given the increasingly limited funding for research, Results

these data may help us direct rehabilitation research funds to
specific areas. After our structured review of the literature, we identified 173
Toward this end, we have assessed 8 common disabling con- articles of interest, over 85 of which are cited here. Almost all
ditions that might be treated in an inpatient or outpatient reha- were analyses of national or regional surveys. Pertinent results for
bilitation setting. Our overall purpose was to (1) characterize the all 8 conditions may be found in table 1.
incidence, prevalence, and costs across 8 disabling conditions; and
(2) compare the impact of disability attributable to these condi-
tions on activity and work limitation.
Back pain

Back pain is a very common condition, with an incidence of 139

Methods per 100,000 person-years in the United States based on data from
the National Electronic Injury Surveillance System.11 A 2012
publication by the Centers for Disease Control and Prevention’s
The 8 conditions covered in this review were chosen because they
National Center for Health Statistics reported that 28.4% of adults
commonly require inpatient and outpatient rehabilitation care.7
older than 18 years had experienced lower back pain in the pre-
They include spinal cord injury, traumatic brain injury (TBI),
vious 3 months.10 This figure is at the high end of the findings of a
back pain, osteoarthritis, rheumatoid arthritis, multiple sclerosis,
systematic review72 of 15 studies between 1997 and 2007, in
stroke, and limb loss.
which reported annual rates of low back pain were in the range of
There are few national guidelines for assessing the economic
5% to 22%. Based on data from the 2005 Survey of Income and
and social burden of disability. This article is an attempt to
Program Participation, 7.6 million adults with disabilities identi-
organize the differing methods, cost measures, and data sources in
fied back or spine problems as the main cause of their disability.23
the available literature. The authors conducted a MEDLINE
Back pain significantly limits work and daily activity. Ac-
search for reviews and primary studies. Multiple search terms
cording to data from the 1998 National Health Interview Survey
were used: cost, disability, socioeconomic, work, impact, burden,
(NHIS), Americans lost a cumulative 149 million workdays
epidemiology, United States, as well as the particular condition
because of back pain in 1988.20 In the nationally representative
being studied. Titles and abstracts were read to exclude duplicates
Medical Expenditure Panel Survey, 24.7% of people with back
and studies that did not address the research questions. The au-
problems reported limitations in their physical functions.19 More
thors supplemented their MEDLINE search with Google Scholar,
than 7 million adults have activity limitations because of chronic
UpToDate, information from the Centers for Disease Control and
back conditions,9 according to the National Arthritis Data Work-
Prevention, and other data available online. The overall search
group’s analyses of the National Health and Nutrition Examina-
results and selection methods are presented in the Preferred
tion Survey (NHANES) and the NHIS.
Reporting Items for Systematic Reviews and Meta-Analyses
The high prevalence of lower back pain comes with consid-
(PRISMA) flowchart in figure 1. Details for each condition, as
erable economic costs. In 2006, Katz12 estimated the total cost of
well as the specific search terms applied, are included in supple-
back pain in the United States to be $100 to $200 billion ($119e
mental appendix S1 (available online only at http://www.archives-
$238 billion in 2013 dollars), with one third accounted for by
pmr.org/).
direct medical expenses and the remaining two thirds due to in-
The inclusion criteria for articles included in the review were
direct costs from productivity loss and absenteeism. However, the
as follows: (1) published (not in press or online before print
authors made this estimate by extrapolating data from a 15-year-
publication) between 2008 and 2013 (older publications found
old study.73 Perhaps for this reason, these cost breakdowns pro-
within the references of articles from this period were included if
duce higher estimates for direct cost than a more recent study14
they were primary sources for the most recent figures available);
that estimated direct costs at $46.8 billion per year in 2013 dol-
(2) selected conditions (stroke, spinal cord injury, TBI, multiple
lars, although this study counted only ambulatory services for
sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back
chronic pain. An earlier study17 produced lower estimates for
pain); (3) presence of disability-relevant outcome measure; (4)
indirect costs as well, using data from the American Productivity
presence of work-relevant outcome measure; (5) presence of cost-
Audit of 28,902 working adults to derive an annual figure of $19.8
relevant outcome measure; (6) original research with primary
billion ($25.6 billion in 2013 dollars).
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, prev- Arthritis (osteoarthritis and rheumatoid arthritis)
alence, work, disability, or cost.
Because the data we present span more than a decade, we Osteoarthritis is one of the most common diagnoses in general
inflation-adjusted selected dollar figures to April 2013 values practice and is probably the leading cause of disability in adults.
using the Consumer Price All-Items Index when assessing indirect Based on national census data and the NHANES I, osteoarthritis
and total costs, and the April 2013 Consumer Price Medical Index affected 26.9 million adults in 2005.9 The most recent report
for direct costs.8 This gives the reader a better ability to compare published by the Centers for Disease Control and Prevention
costs between one condition and the next. estimated that 52.5 million adults, or 22.7% of the population,
self-reporting a diagnosis of arthritis.22 An analysis of the 2005
Survey of Income and Program Participation established that 8.6
List of abbreviations:
million U.S. adults with disabilities attributed the main cause of
NHANES National Health and Nutrition Examination Survey
their disability to arthritis or rheumatism.23
NHIS National Health Interview Survey
Disability attributable to osteoarthritis can be assessed by lost
TBI traumatic brain injury
workdays and limitations in activities of daily living. According to

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988 V.Y. Ma et al

Fig 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

the Centers for Disease Control and Prevention, the impact of twice the rate of disease-free individuals.34 One study36 followed
osteoarthritis is substantial: 80% of afflicted individuals experi- up employees with early-stage rheumatoid arthritis and found a
ence some degree of movement limitation and 25% are restricted 39% prevalence of work disability after 10 years.
in major activities of daily living. In those with knee osteoarthritis The economic burden of all arthritis is significant. In 2007, the
specifically, 14% require assistance with routine needs and 11% cost attributable to arthritis and other rheumatic conditions in the
with personal care.74 A study21 based on NHIS data from 2007 to United States was estimated at $128 billion ($162 billion in 2013
2009 reported that 21.1 million, or 42% of the 49.9 million adults dollars).25 This estimate, derived from national Medical Expen-
with physician-diagnosed arthritis, had arthritis-attributable ac- diture Panel Survey data, was partitioned into $80.8 billion ($115
tivity limitations. Arthritis-attributable activity limitations were billion in 2013 dollars) in direct medical expenditures and $47.0
defined as any limitations in an individual’s usual activities as a billion ($59.4 billion in 2013 dollars) in indirectly lost earnings. In
result of arthritis or joint symptoms. 2010, Kotlarz et al26 used Medical Expenditure Panel Survey data
Rheumatoid arthritis is estimated to be present in 1.3 million from the same period and estimated that the costs caused by
U.S. adults 18 years or older, representing 0.6% of the population, absenteeism from osteoarthritis alone are $10.3 billion per year
based on NHIS- and NHANES-derived analyses from the National ($11.6 billion in 2013 dollars) because of an estimated 3 lost
Arthritis Data Workgroup.29 In 2011, Jacobs et al30 reported workdays per year.
higher estimates of 2% of adults in North America. The most The functional and work limitations of persons with rheuma-
recent estimate of the incidence of rheumatoid arthritis is 41 per toid arthritis contribute to an estimated $10.9 billion ($13.0 billion
100,000 person-years based on the Rochester Epidemiology in 2013 dollars) in indirect costs from lost wages and costs to
Project.32 Rheumatoid arthritis is also associated with significant employers, based on 2005 administrative claims databases
disability. People with rheumatoid arthritis are 30% more likely to covering private and Medicare/Medicaid beneficiaries in the
need help with personal care and are limited in daily activities at United States.33 On top of this figure, the group attributed an

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www.archives-pmr.org

Incidence, prevalence, and costs of common rehabilitation conditions

Table 1 Incidence, prevalence, costs, and impact on disability of 8 common conditions
Annual Indirect Cost Annual Total Cost
Annual Direct Cost (2013 (2013 Values in (2013 Values in
Condition Prevalence Incidence Values in Parentheses) Parentheses) Parentheses) Activity Limitation Work Limitation
Back pain 59.1 million adults (age 139/100,000 $33.3e$66.7 ($41.2 $66.7e$133.3 $100e$200 ($119.1 24.7% of people with 149 million lost
18y) have had back person-years e$82.6) billion ($79.4e$158.7) e$238.1) billion back pain self-report workdays per year
pain within the last (Waterman,11 (Katz,12 2006) billion (Katz,12 (Katz,12 2006) functional limitations (Guo,20 1995)
9
3mo (Lawrence, 2008). 2012) $12.2 ($22.7) billion 2006) $90.6 ($129.2) billion (Martin,19 2008).
Of all those in U.S. aged (Druss,13 2002) $7.4 ($9.1) billion (Luo,18 2004) 7.1 million adults aged
>18y living in the $17.9 ($23.4) billion (Ricci,15 2006) 18y have activity
community, 28.9% have (Smith,14 2013) $13.9 ($21.2) billion limitation due to
had low back pain and (Guo,16 1999) chronic back
15.5% have had neck $19.8 ($25.6) billion conditions (Lawrence,9
17
pain within the last (Stewart, 2003) 2008).
3mo (NCHS,10 2011).
Osteoarthritis 49.9 million adults aged 88/100,000 person- $80.8 ($115.3) billion $10.3 ($11.6) billion $128 ($161.8) billion 42% of people with 5.3% of working- age
17y in 2009 (Cheng,21 years (hip); 240/ (Yelin,25 2007) (Kotlarz,26 2010) (Yelin,25 2007) osteoarthritis report adults have
2010) 100,000 person- $8.3 ($13.0) billion $89.1 ($139.8) billion arthritis-attributable arthritis-
46.4 million adults aged years (knee); (Leigh,27 2001) (Leigh,27 2001) activity limitations attributable work
18y in 2000; 21.6% of 100/100,000 (Cheng,21 2010). limitations
adults (Hootman,22 person-years (Theis,28 2007).
2006) (hand) 3 lost workdays per
26.9 million adults aged  (Oliveria,24 1995) year per person
25y in 2005 (Lawrence,9 (Kotlarz,26 2010)
2008)
Main cause of disability in
8.6 million adults aged
18y (Hootman,23
2012)
Rheumatoid 1.3 million adults aged 41/100,000 person- $8.4 ($10.6) billion $30.8 ($36.7) billion $39.2 ($46.7) billion 30% more likely to need 44% 10-y work
arthritis 18y in 2005 years (Birnbaum,33 2010) (Birnbaum,33 (Birnbaum,33 2010) help with personal disability
(Helmick,29 2008) (Myasoedova,32 2010) care; twice as likely to prevalence
2% of adults in North 2010) have a health-related (Sokka,35 1999)
America (Jacobs,30 activity limitation 39% unable to work
2011) (Dominick,34 2004) 10y after early-
0.5%e1.0% of general stage rheumatoid
population (Silman,31 arthritis
2001) (Eberhardt,36
2007)
Stroke 6.8 million adults aged 795,000/y $28.3 ($33.0) billion $25.6 ($27.3) billion $65.5 ($72.7) billion Among stroke survivors 35% unable to work
20y; 2.8% of adult (610,000/y for (Heidenreich,38 2011) (Heidenreich,38 (Rosamond,40 aged 65y, 26% were at 1y after a first
population (Go,37 2013) first stroke) $18.8 ($21.9) billion 2011) 2007) dependent in activities cerebral infarct
(Go,37 2013) (Roger,39 2012) $15.5 ($16.5) billion $34.3 ($36.6) billion of daily living, 50% had (Camerlingo,42
(Roger,39 2012) (Roger,39 2012)

989
hemiparesis, 30% were 2000)
(continued on next page)
 990
Table 1 (continued )
Annual Indirect Cost Annual Total Cost
Annual Direct Cost (2013 (2013 Values in (2013 Values in
Condition Prevalence Incidence Values in Parentheses) Parentheses) Parentheses) Activity Limitation Work Limitation
unable to walk without
assistance, 19% had
aphasia, 26% were in a
nursing home 6mo
poststroke (Kelly-
Hayes,41 2003)
TBI 3.32 million with long- 1.7 million/y $9.2 ($13.1) billion $51.2 ($63.9) billion $76.5 ($78.1) billion 43% of persons Return-to-work rates
term disability; 1.1% of resulting in (Rutland-Brown,45 (Rutland-Brown,45 (Coronado,46 2011) discharged after acute of 12%e70%
total population in 52,000 deaths, 2006) 2006) $56 ($69.9) billion TBI hospitalizations depending on the
2005 (Zaloshnja,43 275,000 (Selassie,47 2008) develop long-term population
2008) hospitalizations, $48.3 ($62.2) billion disability (Rutland- (Shames,49 2007)
and 1.365 million (Finkelstein,48 45
Brown, 2006).
emergency 2006)
department visits
(Faul,44 2010)
538.2 cases per
100,000
population;
1,565,000 in
2003 (Rutland-
Brown,45 2006)
Amputation 1.6 million in 2005 30,000e50,000 Partial foot: $30,493 $64,000 ($75,000) $8.3 billion ($9.0 31% of patients unable to 42% unable to work
(Ziegler-Graham,50 lower limb ($45,250) per person over 3 billion) (Amputee live independently at 7y postamputation
2008) amputations per Through knee: $81,086 years (Shearer,53 Coalition,54 2013) 24mo; 49% loss of for lower extremity
year (Ziegler- ($120,320) 2003) $509,275 ($649,953) ambulation (Taylor,55 trauma
Graham,50 2008) (MacKenzie,52 2007) lifetime health care 2005) (MacKenzie,57
330/100,000 in $38,077 ($54,317) cost after lower 43%e74% 5-y mortality 2006)
people with average for diabetes- extremity after lower extremity
diabetes (CDC,51 related amputation amputation amputation (Robbins,56
2009) (Shearer,53 2003) (MacKenzie,52 2008)
2007)
Multiple 400,000 (National 10,400 cases per $16 ($18) billion $12 ($13) billion $28 ($30) billion Average time from disease Overall, 56.5%
sclerosis Multiple Sclerosis year (National (National Multiple (National Multiple (National Multiple onset to difficulty unemployment in
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Society,58 2009) Multiple Sclerosis Sclerosis Society,58 Sclerosis Society,58 Sclerosis Society,58 walking is 8y; 15y for MS population.
59 58
350,000 (Frohman, Society, 2009) 2009) 2009) 2009) cane use; 30y for Ability of people
2003) 3.6/100,000 $54,244 per person wheelchair use (Fox,63 with MS to remain

V.Y. Ma et al
58e95/100,000 person-years in ($60,078) (Adelman,62 2010) in the labor force
individuals , (Noonan,60 women; 2.0/ 2013) declines 3% per
2010) 100,000 person- $39,000 per person year after
years in men (Fox,63 2010) diagnosis
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Incidence, prevalence, and costs of common rehabilitation conditions 991

additional $10.3 billion ($12.3 billion in 2013 dollars) in intan-

unemployed by 25y
gible quality-of-life deterioration as estimated by legal system

(Minden,64 2006)

were unemployed
employed people

(National Spinal
39.5% remained
Functional recovery after 81% of previously

Center,65 2013)
at 1y post-SCI;
jury awards, as well as $9.6 billion lost ($11.4 billion in 2013
Work Limitation dollars) in lifetime earnings because of early mortality. Excess

Cord Injury
postinjury

Statistical
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).
SCI depends on severity

Stroke
injury (Braddom,71
and spinal level of
Activity Limitation

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
2000)

being first-time strokes and 185,000 related to a recurrence.75 The

American Heart Association also estimated an overall stroke
prevalence of 6.8 million Americans 20 years of age, accounting
(Berkowitz,67 1998)

for 2.8% of the population, based on NHANES data from 2007

$9.7 ($13.7) billion
Annual Total Cost

to 2010.37
(2013 Values in

Among older survivors of ischemic stroke who were followed

Parentheses)

up in the Framingham Study, 26% were dependent in activities of

daily living 6 months poststroke. Half had reduced mobility or
Abbreviations: CDC, Centers for Disease Control and Prevention; MS, multiple sclerosis; NCHS, National Center for Health Statistics.

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
Annual Indirect Cost

$2.6 ($3.7) billion

contributed to a 26% rate of nursing home placement.41

(2013 Values in

(Berkowitz,67

The economic burden of stroke is impacted by initial hospi-

Parentheses)

talization, medications, continuing medical care, and work limi-

tations. The average cost of a stroke hospitalization in 2005 was
1998)

$9500.76 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.77 A 2011
annual charges $79,759
Annual Direct Cost (2013

$523,089, subsequent

estimate divided the total cost of stroke in the United States into
$500,000 to $2 million

Mean first-year charges

Values in Parentheses)

(Berkowitz,67 1998)
$7.73 ($21.5) billion

$28.3 billion ($33.0 billion in 2013 dollars) for direct costs and
$7.1 ($10.0) billion

(Sekhon,69 2001)
(DeVivo,68 1997)

(DeVivo,70 2011)

$25.6 billion ($27.3 billion in 2013 dollars) in indirect costs.38

over a lifetime

Estimates for the total costs for strokes in the United States
range from $34.3 billion ($36.6 billion in 2013 dollars)78 to $65.5
billion ($72.7 billion in 2013 dollars).40

Traumatic brain injury

236,000e327,000 in 2012 43e77 per million;
(Alonso, 2008)

12,000e20,000

A 2010 report from the Centers for Disease Control and Preven-
(Bernhard,66

tion estimated that TBI requiring a physician visit occurs with an

61

per year

incidence of 1.74 million per year in the United States, based on

Incidence

2005)

calculations from NHIS data by Waxweiler et al79 in 1995. The

severity of TBI ranges from mild (80%) to severe (10%), with
most long-term disability caused by moderate to severe injury.80
The prevalence of long-term disability resulting from TBI has
(National Spinal Cord

been estimated at 3.32 million43 to 5.3 million81 in the

United States.
Injury Statistical
Center,65 2013)

Survivors of TBI often have limitations in activities of daily

living, instrumental activities of daily living, social integration,
Prevalence

and financial independence.82,83 About 43% of people discharged

with TBI after acute hospitalization develop TBI-related long-
Table 1 (continued )

term disability.45 Individuals with a history of TBI are 66% more

likely to receive welfare or disability payments.83 In addition, a
history of TBI is strongly associated with subsequent neurologic
Spinal cord
Condition

disorders that are disabling in their own right, including Alz-

injury

heimer disease and Parkinson’s disease.84

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

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992 V.Y. Ma et al

($64.7 billion in 2013) dollars is lost through missed work and lost bills, at an average of $34,167 per person, exceeding expenditures
productivity.45 Total medical costs range from $48.3 billion to for diabetes, stroke, mental illness, and heart disease.4
$76.5 billion ($63.4e$79.1 billion in 2013 dollars).46-48
Spinal cord injury
Limb loss
Based on several regional studies, the annual incidence of spinal
The loss of a lower or upper extremity is associated with variable cord injury in the United States is estimated to be between 2489
degrees of disability, given the wide range of comorbidities and and 7766 per million people, or roughly 12,000 to 20,000 new
inciting factors leading to amputation. Approximately 185,000 cases per year.65 Motor vehicle collisions account for most cases,
amputations occur in the United States annually,85 and an esti- and 80% of affected individuals are male. It is estimated that there
mated 2 million Americans currently live with limb loss.50 The are approximately 270,000 living survivors of spinal cord injury in
most common causes of limb loss are diabetes and peripheral the United States, with a range of 238,000 to 332,000 people.65
artery disease, with an age-adjusted incidence rate of 3.1 per 1000 The limitations of a spinal cord injury on activities of daily
for people with diabetes in 2009.51 In 2006, about 65,700 non- living are largely determined by the location and completeness of
traumatic lower limb amputations were performed in people with the injury sustained.71 The higher the level of spinal cord injury,
diabetes.86 Trauma accounts for 45% of all cases, with cancer the more assistance the patient will need for activities of daily
accounting for <1% of amputations.50 living and locomotion. Although there are many exceptions, pa-
Cardiovascular disease is itself a significant cause of disability tients are generally independent in all self-care if their injury
and mortality in the United States, and when present as a comorbid occurs at spinal level T1 or below. Patients with a low cervical
condition in people with limb loss, contributes to worse disability injury (C6-8) may require additional bowel and bladder care and
and mortality outcomes. Nearly half of people who have an bathing with adaptive equipment, while patients with high cervical
amputation because of vascular disease will die within 5 years.56 injury have an increased dependency on oral functioning for hy-
In addition to serious comorbidities such as vascular disease, a giene, writing, typing, and operating a power wheelchair.71
number of risk factors have been found to be significantly asso- In 1 model system, more than half (57.1%) of all people with
ciated with poorer functional outcomes and decreased rates of spinal cord injury reported being employed before their injury, but
independent living status after amputation. These include age >60 this number fell to 11.8% 1 year later.65 With physical and
years, above-knee amputation, baseline homebound status, and occupational therapy, many patients are able to regain much of
dementia.54 However, most patients who lived independently their ability to care for themselves and reenter the workforce. By
before major lower limb amputation remained independent post- 20 years postinjury, the same cohort of patients had a 35.2%
operatively.55 In 2003, an average diabetes-related amputation employment rate.
procedure carried $38,077 ($54,317 in 2013 dollars) in associated Costs associated with spinal cord injury are greatly influenced
costs.53 In 2009, cumulative national hospital costs associated by the patient’s severity of injury and resultant degree of
with amputation amounted to more than $8.3 billion ($9.0 billion disability.65 In 2011, average per-person yearly expenses ranged
in 2013 dollars).54,86 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
Multiple sclerosis C1-4 tetraplegia.70 The total annual cost attributed to spinal cord
injury in the United States is approximately $14.5 billion ($21.5
A recent study87 found a rate of approximately 2.0 cases of billion in 2013 dollars).67 Estimates for direct costs range from
multiple sclerosis per 100,000 person-years in men and 3.6 cases $7.73 billion ($14.0 billion in 2013 dollars)68 to $9.73 billion
per 100,000 person-years in women. In 2007, the National Mul- ($18.1 billion in 2013 dollars),67 while estimates for indirect costs
tiple Sclerosis Society estimated the prevalence at 400,000 by range from $2.59 billion ($3.83 billion in 2013 dollars)67 to $5.5
using Census 2000 data to extrapolate from earlier estimates.58 billion ($7.0 billion in 2013 dollars).65
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. Discussion
Without disease-modifying treatment, patients require a cane, on
average, after 15 years, and are using a wheelchair, on average, Our review of the literature suggests that back pain and arthritis
after 30 years.63 During the period of decline in functional ability, are the most common and costly conditions that we examined,
there is an accompanying decline in the ability to remain in the affecting over 100 million individuals and costing more than $200
labor force, with employment rates declining an average of 3% per billion per year. Another condition to note is TBI, which, while
year after diagnosis.64 less common than arthritis and back pain, carries enormous per
Annual health care costs for patients with multiple sclerosis capita costs, mostly because of the disability that it may cause.
have been reported to be between $18,000 (National Multiple Finally, stroke, which is often listed as the most common cause of
Sclerosis Society) and $39,000 per person.63 The National Mul- disability (unpublished data from National Heart, Lung, and Blood
tiple Sclerosis Society estimates that the annual economic cost in Institute. Unpublished tabulation of the NHANES, 1971e1975,
the United States is approximately $28 billion.58 Among patients 1976e1980, 1988e1994, 1999e2004, and 2005e2008 and
with health care insurance, out-of-pocket costs are close to $2000 extrapolation to the U.S. population, 2008), is likely second to
per year. However, 25% of people pay more than this amount each both arthritis and back pain in its impact on functional limitations.
year.88 A survey of 2314 randomly selected bankruptcy filers in This is consistent with evidence from the United Kingdom.90
2007 found that out-of-pocket expenditures for neurologic dis- Back pain and arthritis make their impact by sheer numbers in
eases such as multiple sclerosis accounted for the highest medical the population. Even if affected individuals miss just a few days of

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Incidence, prevalence, and costs of common rehabilitation conditions 993

work on average, or have their productivity slightly impaired, the Keywords

cumulative results across the affected population can amount to
tens of billions of dollars in lost wages and reduced work capacity Amputation; Back pain; Cost of disease; Cost of illness; Direct
each year. Conversely, interventions that make small improve- service costs; Disabled persons; Disease costs; Incidence;
ments in the onset and progression of these chronically disabling Multiple sclerosis; Osteoarthritis; Prevalence; Rehabilitation;
diseases may result in significant overall health care cost savings. Rheumatoid arthritis; Spinal cord injuries; Traumatic brain injury
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 Corresponding author
person’s specific impairments results in widely differing costs of
care and levels of disability. Because conclusions are relatively Leighton Chan, MD, MPH, Chief, Rehabilitation Medicine
difficult to make about conditions such as spinal cord injury and Department, Clinical Center, National Institutes of Health, Bldg
amputation as an aggregate group, it is important for future 10, Rm 1-1469, 10 Center Dr, MSC 1604, Bethesda, MD 20892-
research to focus on the evaluation of, and creation of specific 1604. E-mail address: [email protected].
interventions for, thoughtfully delineated subsets of these
populations.
The high direct and indirect costs of disability are likely related References
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995.e1 V.Y. Ma et al

Supplemental Appendix S1 Search Strategy “traumatic brain injury”[Title] AND (cost[Title] OR disability
[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title]
and Results for Study Conditions OR burden[Title] OR epidemiology[Title] OR incidence[Title]
OR prevalence[Title])
Search Terms “multiple sclerosis”[Title] AND (cost[Title] OR disability
[Title] OR socioeconomic[Title] OR work[Title] OR impact[Title]
“back pain”[Title] AND (cost[Title] OR disability[Title] OR so- OR burden[Title] OR epidemiology[Title] OR incidence[Title]
cioeconomic[Title] OR work[Title] OR impact[Title] OR burden OR prevalence[Title])
[Title] OR epidemiology[Title] OR incidence[Title] OR preva- “spinal cord injury”[Title] AND (cost[Title] OR disability
lence[Title]) [Title] OR socioeconomic[Title] OR work[Title] OR impact[Title]
(“rheumatoid arthritis”[Title] OR rheumatism[Title] OR rheu- OR burden[Title] OR epidemiology[Title] OR incidence[Title]
matic[Title]) AND (cost[Title] OR disability[Title] OR socioeco- OR prevalence[Title])
nomic[Title] OR work[Title] OR impact[Title] OR burden[Title] Article Types
OR epidemiology[Title] OR incidence[Title] OR prevalence[Title]) Clinical trial
(amputation[Title] OR amputee[Title] OR limb loss[Title]) Journal article
AND (cost[Title] OR disability[Title] OR socioeconomic[Title] Meta-analysis
OR work[Title] OR impact[Title] OR burden[Title] OR epidemi- Randomized controlled trial
ology[Title] OR incidence[Title] OR prevalence[Title]) Review
(osteoarthritis[Title] OR arthritis [Title] not rheumatoid[Title]) Systematic reviews
AND (cost[Title] OR disability[Title] OR socioeconomic[Title] Text availability
OR work[Title] OR impact[Title] OR burden[Title] OR epidemi- Abstract available
ology[Title] OR incidence[Title] OR prevalence[Title]) Publication dates
stroke[Title] AND (cost[Title] OR disability[Title] OR socio- Within 5 years
economic[Title] OR work[Title] OR impact[Title] OR burden Species
[Title] OR epidemiology[Title] OR incidence[Title] OR preva- Humans
lence[Title])

Supplemental Table S1 Data Extraction

Identified Citations Additional Records Excluded Selected Studies for Studies Included
Condition Within 5y Identified Citations Detailed Review in Analysis
Back pain 443 24 433 34 13
Rheumatoid arthritis/rheumatism/ 607 13 594 26 8
rheumatic
Amputation/limb loss 57 24 50 31 10
Osteoarthritis/arthritis NOT 544 14 532 26 10
rheumatoid
Multiple sclerosis 547 8 537 18 9
Traumatic brain injury 230 6 221 15 14
Spinal cord injury 148 3 144 7 7
Stroke 1170 7 1161 16 11
Total 3746 99 3672 173 82

www.archives-pmr.org