Epidemiology of Musculoskeletal Impairments and Associated Disability
LINDA S. CUNNINGHAM, PHD, AND JENNIFER L. KELSEY, MPH, PHD
Abstract. Data from the US Health and Nutrition Examination
Survey (HANES I) of 1971-1975 confirm the high prevalence of
musculoskeletal impairments among United States adults. Musculo-
skeletal impairments tend to be more prevalent among older per-
sons, and persons with less education and with lower annual family
incomes. Prevalence rates are slightly higher in females than in
males, while Whites and non-Whites are affected with almost equal
frequency. Among persons reporting a history of musculoskeletal
symptoms, those who have some disability tend to be older, non-
Introduction
Musculoskeletal impairments are among the most com-
mon and disabling of medical disorders. Among those with
musculoskeletal impairments, some persons are disabled by
their condition while others are not. Thus, prevention of
disability can be approached either by preventing the impair-
ment itself, or by preventing the impairment from becoming
a disability. Since relatively little is known of the epidemiol-
ogy of musculoskeletal impairments or of the circumstances
under which they are associated with disability, basic de-
scriptive information on both their frequency of occurrence
and their impact on those affected is needed.
This report describes the overall prevalence of musculo-
skeletal impairments among noninstitutionalized United
States adults aged 25-74 years, as indicated by the preva-
lence of certain signs and symptoms of musculoskeletal
disorders and certain specific physician-diagnosed musculo-
skeletal conditions. Certain demographic and medical char-
acteristics associated with disability among persons with
self-reported musculoskeletal impairments are described.
The data source is the US Health and Nutrition Examination
Survey, 1971-1975 (HANES I), which is based on a proba-
bility sample of the noninstitutionalized population of the
United States during the years 1971-1975.
Methods
HANES I is a multistage, stratified probability sample
of loose clusters of persons in land-based segments of the
United States.' The detailed examination component of
HANES I on which the present analysis is based, consisted
of a medical examination and extensive medical history,
supplemented with questions regarding nutrition, psycholog-
ical characteristics, and use of medical care. The detailed
examination sample included 6,913 adults aged 25-74 years.
All persons in the detailed examination sample were
given a thorough musculoskeletal evaluation. For the pre-
sent analysis, physician-observed musculoskeletal abnor-
malities include joint tenderness, joint swelling, limitation of
motion, and pain on motion. Specific musculoskeletal diag-
From the Department of Epidemiology and Public Health, Yale Universi-
ty. Address reprint requests to Jennifer L. Kelsey, Columbia University,
School of Public Health, Division of Epidemiology, 600 W 168th St., NY, NY
10032. This paper, submitted to the Journal July 11, 1983, was revised and
accepted for publication December 22, 1983.
01984 American Journal of Public Health 0090-0036/84 $1.50
574
White, of lower education and income, and widowed, separated, or
divorced. Persons with multiple parts of the body involved, or
reporting that their symptoms are due to accident or injury are also
especially likely to report disability. Taken as a whole, the data
suggest that medical, social, and economic factors all play a role in
determining whether a person with musculoskeletal impairment
goes on to develop disability related to his or her impairment. (Am J
Public Health 1984; 74:574-579.)
nostic groups are defined by using the diagnoses assigned by
the examining physician.
In the medical history interview, examinees were asked
if they had ever experienced certain symptoms possibly
related to arthritis.* Persons who reported symptoms were
administered the Arthritis Supplement, which asked further
about joint pain, aching, swelling, and morning stiffness, as
well as about any associated disability. The present analysis
includes symptoms which occurred in the past, as well as
current symptoms. It should be noted, however, that 80 to 90
per cent of persons reporting that they had ever experienced
a specific musculoskeletal symptom reported that they had
experienced it in the past year.2
Three indicators of musculoskeletal disability, based on
responses to items on the Arthritis Supplement, are used in
this analysis. Persons who reported having their physical
activity restricted quite a bit or a whole lot, having had to
change theirjob status, or having lost five or more days from
work in the past year because of their joint condition are
considered to be disabled.
The sample weights provided by the National Center for
Health Statistics are used in estimating the total numbers of
persons affected in the United States, while for comparisons
within the HANES I Sample, where no explicit extrapola-
tion to the US general population is intended, the unweight-
ed data are presented. This approach makes the bivariate
analyses directly comparable to the multivariate analyses,
where a weighted analysis was not analytically feasible.
Results
Two thousand four hundred ninety-four persons in the
sample had joint swelling, tenderness, limitation of motion,
or pain on motion which was observed by the physician at
the time of the examination. Extrapolated to the United
States, an estimated 34,741,000 persons aged 25-74 years
(32.6 per cent) are so affected. In the Arthritis Supplement,
2,112 persons reported having had musculoskeletal symp-
toms such as pain, swelling, or morning stiffness, extrapolat-
ing to 31,612,000 persons (29.7 per cent).
Table 1 gives the prevalence and percentage distribution
of both self-reported history of musculoskeletal symptoms
and physician-observed musculoskeletal abnormalities ac-
cording to the specific part of the body involved. Using
either criterion, back trouble is the most frequent problem
*Pain in back, neck, hip, knee, or otherjoints on most days lasting at least
a month; joint swelling and pain or morning stiffness lasting at least a month.
AJPH June 1984, Vol. 74, No. 6
 MUSCULOSKELETAL IMPAIRMENTS AND DISABILITY

TABLE 1-Estimated Prevalence among US Aduits of Self-Reported TABLE 3-Percentage of HANES I Examinees with History of Musculo-
Musculoskeletal Symptoms and Physician-Observed Muscu- skeletal Symptoms and Percentage of HANES I Examinees
loskeletal Abnormalities by Part of Body Involved with Physician-Observed Musculoskeletal Abnormalities by
Seiected Demographic Variables
Physician-Observed
Self-Reported Symptoms Abnormalities Per Cent with Per Cent with
Variable Number Symptoms Abnormalities
Estimated Prevalence Estimated Prevalence
among US Adults among US Adults Age (yrs)
Part of Number Number 25-34 1563 16.Oa 14.3b
Body (1,000s) Per Cent (1000s) Per Cent 35-44 1216 26.3 22.9
45-54 1613 34.2 35.2
Back 18,388 17.2 16,121 15.2 55-64 1288 39.1 47.5
Shoulder 7,100 6.7 3,218 3.0 65-74 1233 39.6 60.3
Elbow 6,596 4.2 1,268 1.2 Sex
Wrist 3,286 3.1 1,006 0.9 Male 3171 28.6c 34.1
Fingers 7,223 6.8 4,739 4.4 Female 3742 32.2 35.9
Hip 8,776 8.2 3,416 3.2 Race
Knee 14,153 13.3 12,803 12.1 White 5968 30.8 35.0
Ankle 4,613 4.3 840 0.8 Non-White 945 29.0 35.8
Foot 3,369 3.2 297 0.3 Education (yrs)
Less than 12 2809 36.7d 46.6e
12 2334 27.6 28.8
More than 12 1737 24.6 24.6
Annual Family Income
(15-17 per cent), followed by knee trouble (12-15 per cent). Less than $5,000 1864 39.1f 48.49
Hip, finger, and shoulder problems are somewhat less fre- $5,000$9,999 1867 30.3 36.7
quent than knee trouble, while ankle, wrist, and foot impair- $10,000-$14,999 1519 27.5 29.4
$15,000 and above 1663 24.1 23.4
ments are less common still. Although not shown, over 85 Marital Status
per cent of persons with musculoskeletal impairments have Married 5314 30.1h 32.9
more than one joint affected, and over 40 per cent of those Widowed 598 41.0 57.5
Never married 451 22.6 32.6
with musculoskeletal impairments have involvement of the Separated/divorced 544 30.9 33.5
back or neck as well as at least one other joint.
Table 2 gives the estimated population prevalences of a) Test for Trend z = 15.33, p = .001
the musculoskeletal diagnoses most often made by the b) Test for Trend z = 27.72, p = .001
C) X2 = 10.82, p = .001
examining physician. Osteoarthrosis is by far the most d) Test for Trend z = 9.38, p = .001
commonly diagnosed musculoskeletal disorder, with an esti- e) Test for Trend z = 21.42, p= .001
mated 13 million adults in the United States affected. How- f) Test for Trend z = 41.47, p = .001
g) Test for Trend z = 15.96, p = .001
ever, the majority of abnormalities identified by the physi- h) X = 44.60, p = .001
cians were not given a specific diagnosis. i) Xi = 145.55, p = .001
Table 3 gives percentages of examinees with self-report-
ed musculoskeletal symptoms and physician-observed mus-
culoskeletal abnormalities by selected demographic varia- with specific musculoskeletal diagnoses. All of the disorders
bles. Both musculoskeletal symptoms and musculoskeletal considered except the back disorders increase in prevalence
abnormalities increase in prevalence with increasing age. with advancing age. The peak prevalence of back disorders
They are also more prevalent among those of lower income tends to be in middle age. Osteoarthrosis and rheumatoid
and a lower level of education, and among widowed persons. arthritis are more prevalent among females than among
Females are more likely than males to report musculoskele- males. With respect to race, there is an excess of other
tal symptoms, but physician-observed abnormalities are arthritis and rheumatism and, to a lesser extent, of synovitis,
approximately equally common among males and females. bursitis, and tenosynovitis among Whites compared to non-
Table 4 shows the demographic variables associated Whites. Lower educational achievement and lower annual
family income are characteristic of people with arthritic
disorders. Disc disorders do not appear to be associated with
TABLE 2-Estimated Prevalence among US Adults of Physician's Specif- either education or income, but there is a tendency for
ic Musculoskeletal Diagnoses vertebrogenic pain syndrome to be associated with higher
education and income. Persons with arthritic disorders are
Estimated Prevalence more likely to be widowed, whereas the two back disorders
among US Adults
are more common among married persons.
Number It is apparent from these data that the same set of
Diagnosis (1,000s) Per Cent demographic variables is associated with musculoskeletal
symptoms, physician-observed musculoskeletal abnormali-
Osteoarthrosis (ICD 713) 12,926 12.1 ties, and physician-diagnosed arthritic disorders, and that
Other Arthritis and Rheumatism many of these characteristics tend to be associated with each
(ICD 714,715,717) 3,348 3.2 other. Linear logistic regression analyses were therefore
Synovitis, Bursitis, and
Tenosynovitis (ICD 731,733) 1,312 1.2 performed with musculoskeletal symptoms, physician-ob-
Vertebrogenic Pain Syndrome served musculoskeletal abnormalities, and osteoarthrosis as
(ICD 728) 1,197 1.1 the dependent variables.**
Disc Disorder (ICD 725) 1,138 1.1
Rheumatoid Arthritis (ICD 712) 802 0.8 **Osteoarthrosis was the only specific diagnosis included in the multivar-
iate analysis because it is the only diagnosis with sufficiently large numbers.

AJPH June 1984, Vol. 74, No. 6 575

CUNNINGHAM AND KELSEY

TABLE 4-Percentage of HANES I Examinees with Physician's Specific Musculoskeletal Diagnoses by

Selected Demographic Variables
Other Synovitis Vertebrogenic
Arthritis and Bursitis, Pain Disc Rheumatoid
Osteoarthrosis Rheumatism etc. Syndrome Disorder Arthritis
Variable (n=987) (n=255) (n=103) (n=86) (n=75) (n=55)
Age (yrs)
25-34 1.2 2.3 0.6 1.1 0.6 0.1
35-44 4.0 3.4 1.3 1.8 1.1 0.5
45-54 12.8 4.2 1.7 1.4 1.5 0.9
55-64 23.7 4.0 1.8 1.2 1.4 1.1
65-74 33.2 5.0 2.2 0.7 0.8 1.5
Sex
Male 11.9 3.8 1.7 1.1 1.4 0.5
Female 16.3 3.7 1.3 1.4 0.9 1.0
Race
White 14.2 4.1 1.6 1.3 1.2 0.9
Non-White 14.5 1.6 0.6 0.6 0.6 0.4
Education (yrs)
Less than 12 21.2 4.2 2.1 1.1 1.2 1.1
12 10.8 3.3 1.2 1.2 0.9 0.5
More than 12 7.7 3.6 1.1 1.6 1.2 0.8
Annual Family Income
Less than $5,000 22.6 4.1 1.2 0.9 1.1 1.0
$5,000-$9,999 15.3 4.0 1.9 0.9 0.9 0.8
$10,000414,999 10.3 3.1 1.7 1.9 1.3 0.8
$15,000 and above 7.4 3.7 1.1 1.5 1.1 0.5
Marital Status
Married 13.0 3.5 1.6 1.4 1.2 0.7
Widowed 32.8 5.2 1.5 0.3 1.0 1.3
Never married 10.6 3.6 0.9 0.4 0.9 0.9
Separated/divorced 9.7 4.4 1.3 1.1 0.4 1.3

Table 5 shows the odds ratios for the associations of
each of the demographic variables with history of musculo-
skeletal symptoms, with physician-observed musculoskele-
tal abnormalities, and with osteoarthrosis, adjusted for all
the other demographic variables in the Table. It may be seen
that even when other demographic variables are taken into
account, persons with musculoskeletal impairments tend to
be female, older, poorer, and less educated than persons
without musculoskeletal impairments. In addition, two vari-
ables not associated with musculoskeletal impairment in the
bivariate analyses-White race and ever married-are asso-
ciated with self-reported musculoskeletal symptoms in the
multivariate analysis. Widowhood, on the other hand, is not
associated with any of the measures of musculoskeletal
impairment once the other variables are taken into account.
Turning to the question of indicators of disability among
the 2,112 persons who reported a history of musculoskeletal
symptoms, Table 6 shows that about 21 per cent of the
HANES I examinees who gave a history of musculoskeletal
symptoms reported moderate to severe activity restriction,
18 per cent reported a change in job status, and 11 per cent
reported having lost five or more days from work in the past
year because of their joint condition. Among persons of
usual working age (<65), 11.4 per cent reported having lost
five or more days from work. Older age, non-White race, a
lower level of education and income, and widowhood,

TABLE 5-Adjusteda Odds Ratios for the Associations of Self-Reported Musculoskeletal Symptoms,
Physician-Observed Musculoskeletal Abnormalities, and Physician-Diagnosed Osteoarthrosls
with Selected Demographic Variables

Adjusteda Odds Ratio (95% Confidence Limits)

Variable Unit Symptoms Abnormalities Osteoarthrosis

Age 10-year increase 1.31 (1.25-1.36) 1.63 (1.56-1.71) 2.09 (1.95-2.25)

Sex Female/male 1.26 (1.13-1.41) 1.14 (1.02-1.28) 1.67 (1.42-1.96)
Race White/Non-White 1.20 (1.03-1.43) 1.18 (0.99-1.37) 1.14 (0.91-1.43)
Education Less than 12 years/
12 years or more 1.85 (1.75-2.00) 1.16 (1.10-1.23) 1.16 (1.08-1.27)
Marital Status Widowed/married 0.99 (0.84-1.16) 1.03 (0.88-1.21) 1.07 (0.88-1.29)
Separated or divorced/
married 1.14 (0.96-1.34) 0.95 (0.81-1.12) 0.84 (0.66-1.08)
Never married/married 0.79 (0.65-0.95) 1.09 (0.91-1.30) 1.01 (0.78-1.32)
Annual Family
Income $5,000 decrease 1.11(1.06-1.16) 1.15 (1.10-1.20) 1.11(1.04-1.19)

aAdjusted for all other variables in table by linear logistic regression.

576 AJPH June 1984, Vol. 74, No. 6

 MUSCULOSKELETAL IMPAIRMENTS AND DISABILITY

TABLE 6-Percentage of Respondents with History of Musculoskeletal Symptoms Reporting Specific

Disabilities by Selected Demographic Variables

Percentage Reporting

Moderate/Severe Change in Five or More Days

Variable Number Activity Restriction Job Status Lost from Work

Total 2112 21.3 18.0 11.0

Age (yrs)
25-34 250 10.98 13.7b 8.9
35-44 320 15.4 16.9
45-54 551 20.8 16.3 11.2
55-64 503 23.9 20.4 12.8
65-74 488 28.8 20.5 9.2
Sex
Male 906 20.9 18.7 11.1
Female 1206 21.6 17.5 10.2
Race
White 1838 19.9c 17.5 10.2d
Non-White 274 31.4 21.4 17.9
Education (yrs)
Less than 12 1030 28.7e 22.1' 13.79
12 645 15.6 15.3 10.6
More than 12 427 13.1 12.3 6.2
Annual Family Income
Less than $5,000 626 29.9h 22.6i 13.0
$5,000-$9,999 565 20.1 17.4 10.0
$10,000-$14,999 418 19.4 17.0 11.6
$15,000 and above 400 11.9 12.9 8.8
Marital Status
Married 1597 1 9.0k 17.11 11.0
Widowed 245 31.8 21.0 12.0
Never married 102 21.7 11.3 7.2
Separated/divorced 168 28.4 25.8 13.6

a) Test for Trend z = 5.89, p = .001
b) Test for Trend z = 2.69, p = .007
c) X2 = 18.66, p = .001
d) XI = 13.04, p = .001
e) Test for Trend z = 7.56, p = .001
f) Test for Trend z = 4.87, p = .001
g) Test for Trend z = 8.26, p = .001
h) Test for Trend z = 2.56, p = .01
i) Test for Trend z = 3.84, p = .002
j) Test for Trend z = 1.83, p = .07
k) Xi = 26.97, p = .001
I) X23= 1 1.87, p =.001

separation, or divorce were associated with one or more of
these disability indicators.
Table 7 shows the adjusted odds ratios for the associa-
tions of the demographic variables with each of the disability
outcomes.
Table 8 gives the percentage distribution of specific
indicators of disability by the area of the body involved.
Persons who reported involvement of all areas (back or neck
and the upper and lower extremities) were most likely to
report each disability outcome; persons with lower extrem-
ity and back or neck involvement only were the next most
likely to report a disability outcome. Upper extremity in-
volvement alone was associated with the least disability,
although almost 12 per cent of the persons who reported
upper extremity involvement alone said that they had had to
change jobs because of their joint condition.

TABLE 7-Adjusteda Odds Ratios for the Associations of Selected Indicators of Disability with Selected
Demographic Variables

Adjusteda Odds Ratio (95% Confidence Limits)

Moderate/Severe Change in Five or More

Activity Job Days Lost
Variable Unit Restriction Status from Work

Age 10-year increase 1.15 (1.04-1.27) 1.04 (0.94-1.15) 0.87 (0.77-0.99)

Sex Female/male 0.97 (0.77-1.23) 0.90 (0.70-1.15) 0.79 (0.58-1.06)
Race Non-White/White 1.31 (0.96-1.78) 1.04 (0.74-1.46) 1.67 (1.13-2.44)
Education Less than 12 years/ 1.26 (1.11-1.43) 1.19 (1.04-1.37) 1.20 (1.02-1.43)
12 years or more
Marital Status Widowed/married 1.06 (0.80-1.41) 1.09 (0.78-1.50) 1.34 (0.90-2.02)
Separated or divorced/
married 1.18 (0.86-1.60) 1.52 (1.10-2.12) 1.12 (0.74-1.70)
Never married/married 1.02 (0.69-1.51) 0.64 (0.39-1.05) 0.66 (0.36-1.21)
Annual Family
Income $5,000 decrease 1.12 (1.01-1.25) 0.95 (0.86-1.05) 1.01 (0.88-1.15)

aAdjusted for all other variables in table by linear logistic regression.

AJPH June 1984, Vol. 74, No. 6 577

 CUNNINGHAM AND KELSEY

TABLE 8-Percentag of R"pondents with History of Musculoskeletal Symptoms Reporting Specific

DisabIlifties by Area of Body Involved
Percentage Reporting

Area of Body Moderate/Severe Change in Five or More Days

Involved Number Activity Restricfion Job Status Lost from Work

Upper Extremity
Lower Extremity,
and Back/Neck 348 37.8 27.4 18.4
Upper and Lower
Extremities 206 19.1 12.6 8.0
Upper Extremity
and Back/Neck 123 20.0 16.5 7.4
Lower Extremity
and Back/Neck 367 31.0 26.5 17.2
Upper Extremity
Only 208 7.8 11.6 2.9
Lower Extremity
Only 441 13.6 12.4 5.5
Back/Neck Only 389 17.8 16.3 14.2

Table 9 shows that persons who reported that their
musculoskeletal symptoms were due to an accident or injury
were much more likely to report each of the disability
outcomes than were persons who did not attribute their
symptoms to an accident or injury.
Discussion
One problem with using HANES I to study musculo-
skeletal disorders is that, even with the relatively large
sample size for the detailed examination component (6,913
persons), the number of persons with any one specific
musculoskeletal diagnosis other than osteoarthrosis tends to
be low. A second problem is that the examining physicians
made their diagnoses only on the basis of clinical evidence.
HANES I is, therefore, of limited use in examining the
disability associated with specific medically diagnosed mus-
culoskeletal disorders. In addition, the HANES I design
specified that only persons who answered certain screening
questions related to musculoskeletal symptoms positively
were asked in detail about their musculoskeletal symptoms
and any related disability. This undoubtedly resulted in
underreporting of both musculoskeletal symptoms and dis-
ability associated with musculoskeletal symptoms.
The present results are partly consistent with the Health
Interview Survey, which also found that musculoskeletal
impairments are more prevalent among older persons, and
among persons with lower incomes and lower educational
achievement.4-6However,theHealthInterviewSurveyfounda
greater tendency for musculoskeletal impairments to be
associated with the White race, and did not show any
consistent relationship between the prevalence of musculo-
skeletal impairments and the female sex. The Health Inter-
view Survey data may be less reliable, since no special
emphasis was placed on the musculoskeletal system, and
since the design of the Health Interview Survey permits
proxy respondents. On the other hand, the HANES I data
are based on a survey with a lower response rate and with a
smaller sample size.
Among specific diagnoses, the data on osteoarthrosis
are of particular interest, as they are based on a substantial
number of persons. The strongest known risk factors for
osteoarthrosis are age, and, beyond that, localized "wear
and tear," and previous joint disorders.7 In these data,
osteoarthrosis is associated with increasing age, the female
sex, lower education, and lower annual family income.
Knowing the demographic characteristics of persons
with musculoskeletal impairments is useful in assessing
future health care needs and in suggesting and evaluating
etiologic hypotheses. The demographic data alone are not
particularly useful in suggesting ways that the prevalence of
musculoskeletal impairment in the population might be re-
duced, other than by general improvement in the conditions
of life. The demographic data do suggest why some persons
with musculoskeletal impairments are disabled by their
conditions, while other persons with impairments are not so
affected.
Data from both Great Britain and the United States8'9
indicate that in terms of absolute numbers there are more
women disabled by musculoskeletal impairments than there
are men. The present results suggest that this observed
female preponderance is attributable to higher rates of

TABLE 9-Percentagof Respondents with History of Musculoskeletal Symptoms Reporting SpecIfic

Disabilities by Whether or Not Symptoms Believed Du to Trauma
Percentage Reporting

Symptoms Believed Moderate/Severe Change in Five or More Days

Due to Trauma Number Activity Restriction Job Status Lost from Work

Yes 506 28.2 25.8 33.5

No 1606 13.4 15.4 13.4

578 AJPH June 1984, Vol. 74, No. 6

 MUSCULOSKELETAL IMPAIRMENTS AND DISABILITY

musculoskeletal symptoms among females rather than to
higher rates of disability among females with symptoms than
among males with symptoms.
The findings that the non-White race and lower educa-
tion and income are associated with at least some measures
of disability suggest an effect of social disadvantage on
disability rates. These effects might be explained by a lack of
financial and/or social resources with which to deal with the
impairment. Race is a particularly interesting variable in this
context, because the prevalence of musculoskeletal impair-
ment is, if anything, slightly higher in the White race,
whereas, among the impaired, disability is associated with
the non-White race.
Having less than a high school education is associated
with having had to change jobs because of a musculoskeletal
condition and with having lost five or more days from work
in the past year. This is consistent with the work of Yelin, et
al, '0 who found that rheumatoid arthritics who had unskilled
jobs with strict work schedules were more likely to become
unemployed than were rheumatoid arthritics who had white
collar or professional occupations. Yelin, et al,'0 suggested
that this may reflect the tendency of low-paying nonskilled
jobs to be difficult or impossible to perform in the presence
of chronic musculoskeletal symptoms, either because of the
physical requirements of the job, or because of inflexible
work schedules.
The finding that separated or divorced persons with
musculoskeletal symptoms are more likely to have had to
change jobs because of their impairment may indicate the
importance of social support in preventing disability.
Persons who believe that their symptoms are due to
trauma are more likely to report being disabled by their
impairment than persons who did not believe that their
symptoms are the result of accident or injury. Several
explanations of this association seem plausible. Disorders
attributed to injury tend to be perceived as more severe, and
thus might be expected to result in greater disability. Al-
though not shown, 21 per cent of the persons who rated their
symptoms "mild" believed that their symptoms were due to
trauma, compared to 27 per cent of those who rated their
symptoms "moderate," and to 30 per cent of those who
rated their symptoms "severe." A second reasonable expla-
nation is that injuries are less likely to allow for a period of
gradual adjustment to impairment than are musculoskeletal
impairments of more insidious onset. Finally, the amount of
reported disability related to injuries probably reflects insur-
ance and workers' compensation policies to some extent.
REFERENCES
1. Miller HW: Plan and operation of the Health and Nutrition Examination
Survey: United States 1971-1973. Vital Hith Stat Series 1 1973; 10a.
2. Cunningham LS: Epidemiology of chronic musculoskeletal disorders with
special attention to psychological factors and medical care utilization.
PhD Thesis: Yale University, 1982.
3. Wilder CS: Limitation of activity due to chronic conditions: United
States, 1969 and 1970. Vital Hlth Stat Series 10 1973; 80.
4. Wilder CS: Limitation of activity due to chronic conditions: United States
1974. Vital Hlth Stat Series 10 1977; 111.
5. Feller BA: Prevalence of selected impairments: United States 1977. Vital
Hlth Stat Series 2 1981; 73.
6. Kelsey JL: Epidemiology of Musculoskeletal Disorders. New York:
Oxford Ltiiversity Press, 1982.
7. Acheson RM, Kelsey JL, Ginsburg GN: New Haven Survey of joint
disease: XVI. impairment, disability, and arthritis. Br J Prev Soc Med
1973; 27:168-176.
8. Wood PHN, Badley EM: An epidemiological appraisal of disablement.
In: Bennett AE (ed): Recent Advances in Community Medicine No. 1.
Edinburgh: Livingstone, 1978.
9. Yelin E, Nevitt M, Epstein W: Toward an epidemiology of work
disability. Milbank Mem Fund Q 1980; 58:386-415.
10. Kelsey JL, Cunningham L: Epidemiological Aspects of Disability from
Rheumatic Diseases. In: Lawrence RC and Schulman ME, eds. Epidemi-
ology of the Rheumatic Diseases. New York: Gower Medical Publishing
Ltd, 1984; 302-311.

I Healthcare Education and Training Society to Hold Annual Meeting

The American Society for Healthcare Education and Training (ASHET) of the American Hospital
Association will hold its 14th Annual Meeting and Conference on "Innovation and Excellence in
Healthcare Education" at the Detroit Plaza Hotel-Renaissance Center in Detroit, MI, June 10-14,
1984.
Plenary sessions will emphasize innovative approaches to staff education, human resources
development, health promotion, patient education systems, wellness and adult education. In addition,
more than 20 workshop sessions led by national experts will address a wide range of timely topics, from
financing patient education, to on-site telecommunications coordination, to conducting research in the
workplace. The conference will feature an experience exchange that will provide participants an
opportunity to share experiences, ideas, resources and professional practices. Papers selected from
ASHET's annual "Call for Papers" will be presented by society members.
For more information, contact Emmett Kennedy, American Society for Healthcare Education and
Training, American Hospital Association, 840 North Lake Shore Drive, Chicago, IL 60611, 312/280-
6428.

AJPH June 1984, Vol. 74, No. 6 579