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Musculoskeletal complaints in an industry annual complaint rate and diagnosis absenteeism and economic loss.

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Musculoskeletal Complaints in an Industry
Annual Complaint Rate and Diagnosis, Absenteeism
and Economic Loss
By ROBERTBROWNAND CLAIRE
LINGG
An industry, with a diversity of occupations and many different types of working conditions, was surveyed for the
incidence of rheumatic complaints
among its employees. The incidence
and site of complaint, as well as the
varieties of musculoskeletal disorders,
were correlated with age, sex and type
of work. Estimates were made of the
economic loss to the company owing
to rheumatic complaints in terms of
absenteeism and medical services required.
A
Un branca industrial, con diversissime
occupationes e multe differentias in le
conditiones de travalio, esseva studiate
con respecto a1 incidentia de gravamines
rheumatic inter le empleatos. Le incidentia e le sito del gravamines e etiam
le varietates de disordine musculoskeletic esseva correlationate con le etate
e le sex0 del subject- afficite e con le
typo de lor travalio. Estimationes esseva
facite concernente le perditas economic
resultante pro le firmas empleante ab le
gravamines rheumatic in consequentia
de absentismo e requirimento de servicio medical.
NUMBER OF SURVEYS of the incidence or prevalence of rheumatic
diseases in general population groups have been made, with estimates
ranging from 9 to 50 per
There is a considerable doubt as to whether
the data from different areas are comparable, but the more studies made,
provided attention is given to sound sampling methods and uniformity of
diagnostic criteria, the more complete will become our knowledge of this
complex problem.
Apart from sickness surveys of the general population, analyses of absenteeism in industrial populations have contributed substantially to the prevailing
opinion on the importance of rheumatic diseases as a cause of impaired health
in the community. Such studies have recently been ably reviewed and commented on by Mintz and Goldwater? As in population surveys, reported
studies of absenteeism in industries usually give little precise information regarding the different types of rheumatic disorders and their severity. Outstanding among investigations in occupational groups are those made in
England by Kellgren, Lawrence and Aitken-Swan,'-* in which it was possible
to examine individuals with rheumatic complaints.
From the Department of Medical Statlslics and the Rheumatic Diseases Study Group,
N e w York University-Be1levu.e Medical Center, Xew York.
This work was supported by Grant A-518 from the Public Health Seroict., National
Instiof Health.
The authors me indebted to iMks Hilrlegd hndsberger for her conscientious munagem i d of the collection of the data and secretarial n.sdstance; to Dr. Dormld M a i d a n d , Miss
Lee Herrera, Miss Elisabeth Street and Mtss Marion I . Sutcliffe for advice and help in
various phases of the work; and to Dr. Joseph J . Bunini for his interest and suggestionr,
which initiated this study.
283
284
BROWN AND LINGG
In a recent article, Bunimg listed the conditions that must prevail if the
records of the medical department of an industrial concern are “correctly to
reflect the prevalence or incidence of any or all diseases among the employees.”
After approaching several industrial organizations, one in particular-the
Consolidated Edison Company of New York-appeared to more or less fulfill the requirements. In 1952, therefore, a preliminary survey of the medical
records of this company, for the five years 1947 to 1951 was made.l0’’ This led
to a forward-going study which is the subject of this report. The aim of this
study was to determine in a particular industry, by age, sex and type of occupation, the annual prevalence of the various rheumatic disorders and to learn
how much disability and absenteeism resulted from such disorders. A further
purpose of this research was to ascertain the feasibility of making such
epidemiological studies in an industry.
THESOURCE
POPULATION
The Consolidated Edison Company of New York is engaged in the distribution and sale
of electrical energy and natural gas. It employs men and women trained in a wide
variety of skills and exposed to many types of working conditions. This population is
characterized by its exceptional stability. The average duration of employment in the year
1954 was 21 years.
With the exception of the personnel in the higher executive positions, all those
permanently employed are eligible for membership in the Mutual Aid Society, which
provides, among other benefits, medical care for any and all physical complaints. This
care incliides treatment in clinics maintained at the home office in Manhattan Borough and
at the branch offices in other boroughs, including a diagnostic clinic at the home office to
which patients with a diagnostic problem may be referred for a complete work-up;
house visits and visits to the offices of selected physicians in private practice in the districts in
which the employees live; hospitalization; outside consultation services and any laboratory
work deemed necessary. The care, all and any part of it, is provided by the Medical
Bureau of the Company, which utilizes the services of about 140 physicians. The cost
is paid by the Mutual Aid Society, which deducts a fixed sum from the wages of every
permanent employee. If an employee is absent from work two or more days, a visit to
the Medical Bureau is mandatory. Repeated single day absences will elicit a polite but
firm request to visit the Medical Bureau.
This system virtually insures that no major illness escapes the attention of the Medical
Bureau. Any minor illness involving absence from work is likewise entered in the medical
record. Since, after an absence of more than two days because of illness, approval for
return to duty must be obtained from the Medical Bureau, the majority of employees
seek care for all their illnesses through the Medical Bureau and the few who are treated
by outside physicians usually use the facilities of the Medical Department for laboratory
or x-ray studies, so that a record of outside care is also obtained. In view of the rigid
supervision of absences and the fact that with a few exceptions all employees pay for
medical care through a payroll deduction plan, it is unlikely that any illness sufficiently
severe to require medical care escapes recording.
The medical record system of the company consists of individual forms for each examination made, whether in one of the clinics or by il district physician. These forms, made out
in triplicate, are picked up by courier each day and brought to the home office, where
they are bound in individual patient folders. Each form contains the physician’s notes
as well as the diagnosis in code, Special forms are provided for x-ray and laboratory exami“This work was carried out under a research grant from the New York Arthritis and
Rheumatism Foundation.
285
MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY
nations. Reporb of outside consultations, hospitalization or private physicians not employed
by the company are also filed in the patient’s chart. The medical records were cmfully
examined and found to be comparable to those kept in a good hospital teaching clinic.
The physicians are alert, interested and well trained, and the work-up and follow-up are
of a distinctly high order.
In the year 1954, 24,157 individuals were employed by the company on a permanent
basis. In 1,332 of these, employment began sometime after the beginning or terminated
before the end of the year, with a mean duration of employment of six months. It is
estimated, therefore, that during the year there were 23,491 person-working-years. This
figure constitutes the source population for this study.
Table 1 shows the sex, age distribution and work classification of the population. It is
readily seen that 90 per cent of the population is male. The mean age was 48 years: 47
years for males and 41 years for females. The modal age for males was 50 to 59 years and
for females 40 to 49 years. About three-fourths of the employees were over age forty.
The mean duration of employment in 1954 was 21 years, with 52 per cent of the population employed 25 or more years.
The terms used in the table may be defined as follows: Light is assigned to clerical or
other work requiring no or only slight physical effort. Heauy is assigned to work requiring individuals to work in cramped quarters, in a position in which the spine is held
in flexion, or to lift weights of 30 or more pounds. Outdoor refers to work which requires
spending the greater part of the time out of doors, exposed to the elements. The majority
of the men (63 per cent) were engaged in heavy work involving bending and lifting. This
was so in most of the age groups. Less than half of the male population (32 per cent)
was engaged in outdoor work. This, too, seemed to be the case regardless of age. Of the
women, 98 per cent were clerical workers. The remaining 2 per oent were engaged in
heavy work, such as cleaning offices, etc. It is, of course, virtually impossible to determine
with any accuracy what stresses people encountered at home or when engaged in leisure
activities.
The list of job classification groups consisting of some 340 payroll titles was examined
with the aid of the payroll administrator of the company, who is thoroughly familiar
with the demands and responsibilities-including physical strains and stresses-of each of
the job titles. As a result, it was possible to break down the job categories into four
classes: Indoor Light, including such occupations as clerical and other office work, delinquent accounts investigator, machine operator, etc.; Outdoor Light, including meter reader,
delinquent accounts collector, crane operator, station guard patrolman, etc.; Indoor Heaoy.
including mechanic, production or boiler operator, engineer, subway workman, coal hoister,
janitor, stockmen, etc.; Outdoor Heuuy, including outside plant mechanic, production man,
meter tester and inspector, yard or coal foreman, pipeman, lineman, drillman, etc.
METHOD
OF STUDY
Because data pertaining to the entire population from which a stratified sample could
be drawn were not readily available when the study was begun, but especially because
Table 1.-Source
Population by Age, Sex and Occupation Group
Fenales
Yale3
Occnpation
Group.
Occupation Groups
Age
Groups
Under 30
30-39
40-49
50-59
60 and over
All ages
Indoor
light
Indoor
heavy
Outdoor
light
Outdoor
Employees
heavy
Employees
Indoor
light
Indoor
heavy
2,110
2,988
8,842
7,083
2,141
287
355
2,788
2,323
65 1
762
1,323
2,222
2,765
963
128
142
508
729
135
818
808
41
727
120
805
593
36
2
15
11
15
106
935
1,168
1,328
1,488
421
21,182
6,404
8,035
1,387
5,338
2,329
2,281
48
Total
,507
Total
5
286
BROWN AND LINCC
the rules and regulations of the company as well as the employee’s union would not permit
apparently healthy employees without symptoms to be released from work for a medical
examination, it was not possible to draw a random sample of the entire working population.
It became feasible instead to sample individuals who registered complaints referable to
the musculoskeletal system. This qtudy is, therefore, concerned with the frequency and
nature of rheumatic complaints. Patients with rheumatic disease were not included if
they were symptom-free or did not request medical advice during the year of the study.
The level of discomfort at which individuals seek medical care vanes from patient to
patient and is influenced by many factors--economic, emotional and physical. In this
study, therefore, the threshold of inclusion is the visit to the doctor. In short, we are
dealing here with an annual prevalence rate of rheumatic complaints, not necessarily with
the annual prevalence of rheumatic diseases.
In January 1954, a letter was sent to all physicians employed by the Edison Company
explaining the planned study and requesting their cooperation. It was acconipanied by a
copy of the most recent Primer on Rhenmatic Diseases, prepared by the American Rheumatism Association,ll which was to serve as a basis for a reasmiable degree of uniformity
in diagnosis. During the period of February 1, 1954 through January 31, 1955, all the
records of medical visits were examined each day and those were withdrawn which bore
a code number representing one of the following titles, appearing in the company’s diagnostic code system, that might conceivably include a rheumatic (musculoskeletal) disorder: arthritis, acute, infectious; arthritis, chronic, infectious (including deformans ) ;
gout; periarthritis; spinal osteoarthritis ( spondylitis ) ; traumatic arthritis; rheumatic fever;
hypertrophic arthritis; sacroiliac disease; sciatica; lumbago, niyositis or myofascitis; tenosynovitis; bursitis; Charcot joint; ruptured intervertebral disc; and neuritis (not due to
alcoholism). A card file was kept of all patients who reported rheumatic complaints from
day to day, and the daily list of patients with conlplaints was checked against this file
for the removal from the list of revisits,’ so that each individual with complaints had only
one chance of entering the sample. Each day, after the removal from the list of “revisit”
cases, the remaining were numbered chronologically and a random sample selected, using
the Random Number Tables of Kendall and Smith. From preliminary calculations it was
estimated that the total number of clinical examinations made each day would average
about 400, and that about one-tenth would present rheumatic complaints. It was expected
that with allowance made for repeat visits, an 8 per cent sample would yield about 1,OOO
cases with rheumatic complaints within the year. At the end of the first month, however,
it was found that the repeat visits were more frequent than had been anticipated. The
size of the sample to be selected was accordingly increased to one of 25 per cent. It follows that in making the final estimates, the observed cases had to be multiplied by 4
during the eleven months of 25 per cent sampling, and by 12 for the month when the
smaller sampling r a t i o - 8 per cent-was
used. A more complicated procedure. using
different sampling fractions in different subclasses (sex, age and occupation) was not
practicable under the conditions of this survey.
When a patient fell into the sample, his complete history (with the clinical findings
dating from about 1945, when new record forms were adopted by the Medical Bureau,
or, if employed since 1945, from the day of employment) was abstracted onto a specially
prepared form and the record of the current illness reviewed in detail. Essential features
of the plan included the following: ( 1) If laboratory or x-ray studies had not been ordered
by the examining physician and the clinical record seemed to warrant them, or if further
clinical examination seemed desirable, such procedures were to be instituted; and (2)
patients whose disorders were of a doubtful nature after adequate x-ray and laboratory
studies had been made were to be re-examined at the request of and in consultation
with the rheumatologist (Dr. Robert Brown, representing the Rheumatic Diseases Study
Group of the New York University-Bellevue Medical Center). The patient was then folODuring the year, 4,426 individuals registered rheumatic complaints. Together they
made 15,169 revisits.
287
MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY
lowed through his records until discharged, and the records were reviewed periodically
for further evidence of symptoms and signs of rheumatic disease, throughout the year
and for three years thereafter, when a final diagnosis was made in conformity with presentday concepts of rheumatic diseases.
Although the medical department had endorsed the plan and lent its wholehearted interest and cooperation, difllculties were, nevertheless, encountered. Of 314 x-rays ordered,
for example, the request was granted in only 41 per cent, and laboratory studies requested
(341)were carried out in 42 per cent. In cases with unquestionable rheumatic disease,
whether defined or undefined disorders, requests were granted in about 75 per cent, while
in those with questionable rheumatic disease, studies were obtained in only 10 per cent
( 105 x-rays and 341 laboratory studies were requested). In other instances where further
information was needed to clarify a case-such as a complete cardiac examination to
rule out anginal pair., or a neurologic examination for possible disc disorder-of five such
requests only one was granted. The reason generally given for not agreeing to further study
of a case, or for the re-examination of a patient in consultation with the rheumatologist,
was that since the patient’s symptoms had subsided siifficiently for him to be back on the
job, further loss of time from work for medical reasons was not warranted unless the recurrence or persistence of symptoms brought the patient back for medical adivce.
Throughout this study, when more than one diagnosis was made in a patient, the case
was listed under each diagnosis, and if more than one area of complaint was given, each
was assigned to the diagnosis presumably responsible for it. Similarly, days lost from work,
as well as medical visits made or received by an employee already in the sample, on account of rheumatic complaints, were assigned, as they occurred during the year, to the
particular type of disease or disorder which required the medical care or absence from work,
CRmIA
The cases were classified under the diagnostic terms recommended by the American
Rheumatism Association as defined in the Primer on Rheumatic Diseases.11 In addition,
three supplementary categories were included: ( 1 ) undefined rheumattc dlpenses--cornplaints and objective findings referable to the musculoskeletal system which failed to
clearly fit one of the diagnostic headings; ( 2 ) questbnuble rheumatic disease (minor coniplaintshthe symptom of pain referable to the musculoskeletal system without objective
findings and usually of less than seven days duration; (3) no diagnosis possible-symptoms
and/or objective findings in patients who, for one reason or another, failed to have necessary laboratory or x-ray studies made or on whom follow-up was inadequate.
RESULTS
It is estimated that during the year, IS per cent of all employees sought
medical advice because of rheumatic complaints (table 2). There was no
Table 2.-Estimated
Age
Groups
Incidence
Total
Employees
of
Rheumatic Complaints by Age and S e x
Males
Females
Employees with
Rheumatic Complaint8
Employees wlth
Rheumatic Complainta
Observed
Number
Toof Total
Estimated
Total
Employees
Observed
Number
Estimated
yoof total
12
9
17
17
15
11
17
15
729
135
816
608
41
864
1,465
2,329
16
6
35
26
0
22
61
83
9
18
18
21
0
10
19
16
~
Under 30
30-39
40-49
60 and over
2,110
2,986
8,842
7,083
2,141
Under 40
40 and over
AU ages
16,066
21,162
5059
5,096
54
85
255
274
74
119
803
722
288
BROWN AND LlNCC
I
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4
/
I
\
/'
/'
I
I
I
i
I
I
1
f
r'
I
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i
289
MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY
obvious difference in the over-all incidence between males and females. In
both sexes there appeared to be a gradually increasing rate of complaint with
advancing age.
There was no apparent relationship between rheumatic complaints and
work stress. Since all but 2 per cent of the females were engaged in light
(indoor clerical) work, this applies only to the male population. Among
males engaged in heavy labor or in non-physical work, whether indoor or
outdoor, there seemed to be no great difference in the estimated incidence of
rheumatic complaints. Among indoor light workers, the rate was the same for
males and females (table 3).
A tabulation of the mean daily patient-medical-visit per month for rheumatic complaints through the period of study showed a drop during the summer
months, reaching a low of 60 in August and a high (80 or more) during the
winter months (fig. 1). June to September are the months when a large
majority of the company employees were on vacation, usually not in the city,,
a fact that must be considered in any attempt to explain this falling off of
medical visits during the warm weather. There has been considerable speculation whether rheumatic subjects suffer more than usually during the cold
weather, and recommendations for sojourns in warm climates during the
winter months are not infrequent. The curve suggests that a carefully controlled study along this line might be illuminating.
Site of cornph.int. The most frequently reported site of complaint was the
lumbosacral, buttock, thigh area-roughly, the pelvic girdle ( designated in
the tables as lower region or L)-which, it is estimated, was reported, usually
as low back pain, by 50 per cent of all complainants. The neck, shoulder, upper a r m - o r roughly the shoulder girdle (designated as upper region or U)was the area of complaint in 35 per cent, and other sites, usually one or more
peripheral joints (designated as peripheral sites, or P), were reported as the
area of complaint in 29 per cent of the patients. It is of interest to note that
most studies of rheumatic complaints in industry have concentrated on the
problem of pain referable to the pelvic girdle, and that very little has been
said about pain referable to the shoulder girdle, which here involves a
considerably large percentage of the population at risk. More than one of
these three subdivisions of anatomic sites of complaint was reported by about
one-tenth of the observed patients.
Sex. There was an obvious difference in the estimated incidence of these
areas of complaint between the sexes. Men appeared to have predominantly
Table 3.-Rheumatic
Complaints and Work Stress
Employeen with Rheumatic Complaint%
Maim
Females
Occupation
Groups
ObeerVed
Number
Fgtimated
d/o of total
Observed
Number
Indoor light
Outdoor light
Indoor heavy
Outdoor heavy
228
62
259
173
16
19
14
15
84
-
Estimated
70 0ftot.l
16
-
290
BROWN AND LINGG
low back pain, while in women discomfort seemed to be most common in the
neck, shoulder, upper arm area (table 4 ) . This difference was not explained
by the fact that nearly two-thirds of the males worked at heavy labor. When
the incidence of the various complaint syndromes was compared in males and
females engaged in indoor light work, and under age 60 (retirement age for
women), the relative incidence was about the same.
History of complaint. The records revealed that an estimated 80 per cent
of the employees who applied for medical care owing to rheumatic complaints
in the year of this study had been treated by the Medical Bureau for such
complaints sometime within 10 previous years. It appears that in patients
with complaints referable to the pelvic girdle, as well as those involving the
shoulder girdle, over half (57 per cent) had had similarly localized complaints
in previous years.
DiQgn0d.s. Thirty-one per cent of the males and 40 per cent of the females
with musculoskeletal complaints revealed diagnosable rheumatic disease. Undefined rheumatic disease was found in 20 per cent of the males and in 11per
cent of the females; 42 per cent of the males and 47 per cent of the females
presented minor complaints of short duration, without objective signs of disease; while in 10 per cent of the cases, insufficient laboratory or x-ray studies
or none at all, or inadequate follow-up, made diagnosis impossible (table 5).
Defined rheumatic disease. The estimated incidence of defined rheumatic
disease was somewhat higher in females than in males. Bursitis and degenerative joint disease appeared to rank first and second in frequency, with fibrositis,
disc disorder, and gout in third, fourth and fifth places. Rheumatoid arthritis
appeared to be of infrequent occurrence.
Under “other” diagnosable disorders are included additional musculoskeletal conditions of too infrequent occurrence to be listed separately, such
as spondylolisthesis, psychogenic rheumatism, low back pain or lumbosacral
strain, calcaneal or olecranon spur, scleroderma, epicondylitis, ruptured meniscus, tendonitis or synovitis, etc. (table 5).
The estimated incidence of diagnosable rheumatic diseases, as a whole,
was found to be much higher after (63 per 1000) than before (19 per 1OOO)
age 40, and considerably higher after 40 in females (98 per 1000) than in males
(60 per 1000). Of all cases of defined rheumatic disease, it is estimated that
53 per cent presented articular and 47 per cent presented some form of nonarticular rheumatism, about the same proportion in males as in females.
The partial breakdown of the data up to this point-whether the differences
in incidence of rheumatic complsints, as a broad group, differed significantly
(in a statistical sense) from one category of subject to another-has, of course,
Table 4.-Areas
of Complaint
~~
Males
Area of
Comnhint
Females
-
Observed
Number
Estimated
% of total
Observed
Number
368
240
206
8
5
4
39.
28
23
Estimated
% of total
~
Lower Region
Upper Region
Peripheral Sites
3
8
4
291
MUSCULOSKELETAL COMPLAINTS IN A N INDUSTRY
Table S.--Rhsumtic Complaints
b y Diagnosis
Sample Cases
Diagnosis
Bursitis
Degenerative joint
disease
Fibrositis
Disc disorder
Gout
Rheumatoid arthritis
Other defined disorders
Total defined disorders
Undefined rheumatic
disease
Questionable rheumatic
disease (minor
complaints )
No diagnosis possible
Total with rheumatic
complaints
Total Employees
-
Number
Males
Females
61
13
54
5
6
4
Entimuted Cases
Per Cent
Males
Females
Per 1000 Employees
Males
Females
16
12
26
'
I
6
12
7
5
-
8
6
4
15
11
7
1
5
2
4
4
4
3
1
3
5
7
222,
33
31
40
50
67
144
9
20
11
29
19
306
39
73
7
42
10
47
8
62
15
67
15
722'
83t
100
100
21,162
2,329
27
28
20
9
23
1
8
2
-
"More than one diagnosis in 22 cases.
tMore than one diagnosis in 5 CdSeS.
little meaning. The following breakdown by diagnostic categories is more informative, and here the question of statistical significance will be considered.
Although a search for etiological or environniental relationships would be merely
speculative, the data were broken down into the most obvious subclasses: sex, age, and
general type of occupation."
Tests of statistical significance were applied merely as a help in deciding whether
separate incidence rates should be estimated for different subgroups. For example, in deciding whether to give separate bursitis rates for males doing light work and males
doing heavy work, the males were first divided by age ( 5 decades) and job location
(outdoor and indoor)-10 subgroups. Each subgroup was divided by work load (light versus
heavy) to give a fourfold table containing the observed bursitis cases, the marginal totals
being the total male employees in the appropriate category (occupation, decade and work
load). Such series of tables often showed that there was no consistent relationship between the frequency of a particular type of complaint and the attribute under test (e.g.,
type of occupation or age).
When the conclusion was in doubt, the weight of evidence presented by each fourfold
table was measured by calculating chi-square. The evidence from all the tables ia the
series was then combined by summating chi values (with appropriate plus or minus sign),
and the significance of the sum was tested by its standard deviation (the square root of
the number of component chi values). Unless the sum was more than twice its standard
deviation, indicating a probability (PI of less than 0.05, it was arbitrarily decided that
there was not sufficient evidence to justify keeping the attributes under test (e.g. heavy
"The observed or sample cases on which the statistical analysis is based numbered 805.
To provide material for further study, including comparison with other series, mimeographed
reproductions of tables may be obtained from the authors on request.
292
BROWN AND LINGC
and light work load) separate in estimating incidence rates. A more elaborate test of one
series of fourfold tables indicated that the summation of chi values was sufficiently reliable
for the purpose for which it was used in this survey.
DEGENERATIVE
JOINT DISEASE.It is estimated that of the total male employees,
12 per 1000 sought medical advice because of symptoms due to degenerative
joint disease. There were no cases under age 40. Over 40 the estimated rate
was 16 per 1O00, with an obvious increase in incidence with advancing age.
There was no suggestion of a difference in complaint rate by location or load
of work, outdoor or indoor, whether heavy or light. The ration of rates by regions of the body, L:U:P, was approximately 2:1:1, a difference not significant
at the 5 per cent level ( P = 0.10 - 0.05). Among females there was no
signi6cant difference from the rates in males, in a comparable group, engaged
in indoor-light work, between the ages of 40 and 59 (table 6).
DISCDISORDERS. Disc disorders, it is estimated, were present in 6 per 1000
employees (table 5). Most of the cases, 90 per cent, complained of symptoms
in the lumbosacral, buttock, thigh area, as would be expected. In the remaining 10 per cent, the upper spine was the seat of complaint. There was no
suggestion of a relationship between the incidence rates and age; location of
work, outdoor or indoor; or load of work, heavy or light.
Among females, the estimated over-all incidence was 7 per 1000, not significantly different from that in males, in a comparable group ( 5 per 1OOO). No
other differences were detected between the sexes.
GOUT.
There were no cases of gout under age forty. The estimated incidence
in males over forty was 5 per 1000 (table 5 ) . There was no relationship to
occupation. In this experience, there were no cases of gout in females. Gout
has long been known to be of rare occurrence in women, a subject which need
not be discussed here.
RHEUMATOID
ARTHRITIS. The estimated incidence of rheumatoid arthritis
among males as well as females was only 2 per 1000 (table 5 ) . No relationship to occupation was detectable (table 6). The small number of observed
cases, both male and female, may well have prevented the detection of possible associations and differences. An incidence rate of only 2 per 1000 is in
distinct contrast to the impression gained in arthritis clinics and in hospitals
where rheumatoid arthritis constitutes a large percentage of the patient load.
It was suggested that the low rate in this study might tre accounted for by
the possible exclusion from employment of applicants with this disease, or
the later separation from the company of rheumatoids because of physical
incapacity, but examination of the records of medical rejections of applicants,
as well as those of early disability retirement, failed to support this argument.
The likelihood that individuals with rheumatoid arthritis would not seek employment with a large industrial concern in the first place was also considered,
but ruled out in the light of the fact that, of the population at risk in the year
of the study, 54 per cent were under 25 years of age, 78 per cent under 30, and
91 per cent under 35 when first employed by the company. Available statistics
indicate that it is after the age of 35 that the rate for diagnosable rheumatoid
arthritis is highest.
MUSCULOSKELETAL COMPLAINTS IN AN
293
INDUSTRY
Table 6.-The Relationship of Age, Location, Load of Work and Site
to Males and Females in Different Diagnostic Groups
Diagnostic
Groups
Degenerative M
Joint
Dieease
F
DiscDisOrders
F
Arthritic
Bursitis
Obvious increase with age
Obvious increase with age
NSR
DNS
-
DNS
NSR
NSR
DNS
DNS
F
M
F
DNS
Undefined
M
Rheumatic
Disease
F
Significantlr
higher over 40
Significantly
higher over 40
DNS
DNS
-
NSR
DNS
-
-
Highly nignificant exceas in “upper“ redon
(U:L:P= 16:1:3)
Highly significant excess in “upper” region
(U:L:P = 13:O:O)
Significantly higher
Significant difference in
in OL group (OL: IL: ratio for body regions
OH:IH= 10:3:3:1)
(U:L:P=6:3:1)
NSR
-
Significantly higher in
IH group, 6th decade
(IH:IL=2.86:1)
Obvious difference in
ratio for body reeions
(U:L:P = 1:4:2)
Obvious difference in
ratio forb& d M
(U:L:P = 1:2:6)
Significantly higher
in “light” workers
(L:H = 1.27:l)
Significant difference In
ratio for U L regiona, in indoor outdoor workers
( 0 = U:L:P = 1.2:
3.66:l)
( I = U:L:P = 2.a:
a.s:i)
-
Significantly
higher over 40
Questionable M
Rheumatic
Disease
F
-
NSR
Signifieanthr
higher over 40
Significantly
higher over 40
Obvious relationship
to lower region
NSR
Significantly
higher over 40
~~~~~~
M
F
-
NSR
NSR
DNS
HighLrsignifi-
Fibmsitis
s i t e of
Complaint
Axe
DNS
M
F
Rheumatoid M
CompIaint
Location and
Load af Work
SaX
M
Gout
of
NSR
-
+
+
-
DNS = Difference not significant.
NSR = No auggestion of relationship.
Two possible explanations are offered for the low rate found in this study:
first, the uncertainty of diagnosis in atypical or early cases and secondly, and
more probably, the influence of the remittant nature of the disease on an
annual complaint rate.
BURSITIS.
The estimated over-all rate of complaints in patients with bursitis
in males was 12 per lo00 (table 5).* There was no significant difference in
complaint rate between men working outdoors or indoors, or between those
engaged in heavy or light work. A highly significant excess of complaints appeared in the upper body region, with a ratio of rates U:L:P approximately
16:1:2.7. This did not appear to be related to any special occupation or age
group (table 6 ) .
*There was a significantly higher rate above forty ( P
= 0.05 - 0.02) than below forty.
294
BROWN AND LINGG
The estimated number of females with bursitis was 60 (only 1 observed or
sample case under 40).The estimated rate for the over- 40 group was 37 per
1O00, compared with a rate of 18 per 1000 in a comparable group of males. The
higher incidence rate in females was highly sigdicant (P = 0.05 - 0.02).
Among females with bursitis, the shoulder, neck, upper arm area was the
only body region of complaint. All were cases of subdeltoid bursitis, or hicipital
tendinitis. Bursitis was the only one of the “defined rheumatic diseases in
which the incidence rate was significantly higher in females than in a comparable group of males (indoor light workers, under age 60).
In the study by Kellgren et al.,5 the incidence of bursitis and synovitis over
a five-year period was 1.4per cent in males and 1.0 in females. Although their
figure for males is approximately the same as the estimated figure in this
study, they found no appreciable difference between the sexes.
In our population, nonphysical indoor work engaged in by women comprises largely routine clerical jobs, such as typing, filing, operation of punch
card and tabulating machines, etc., whereas among males it includes largely
supervisory clerical work and other nonclerical types of indoor work.
Since there is some opinion that apart from trauma, infection, and other
factors, unusual repetitive use of a part may be associated with bursitis, it
was thought that the fact that nearly three-fourths of the females (71 per
cent) and less than one-half of the males (46per cent) were engaged in occupations requiring the constant use of the arms, might account for the
higher incidence of subdeltoid bursitis or bicipital tendinitis in women than in
men. Such occupations include the titles bookkeeper, accountant, draftsman,
stenographer, typist, file clerk, telephone operator, machine operator, tabulating
machine operator, accounting machine operator, addressograph operator and
key punch operator. When the incidence of bursitis was investigated in males
and females assigned to work in these occupations only, the difference in
incidence between the sexes was not significant. Nor was there a significant
difference in the incidence of bursitis between the sexes among employees
assigned to work in all other occupations. There was, on the other hand, a
significantly higher incidence of bursitis among employees, regardless of sex,
engaged in the above listed occupations than among those assigned to other
types of indoor light work (P = 0.01). In the opinion of the authors, the
higher incidence of bursitis in the occupation groups enumerated above is
directly attributable to the nature of the work involved. This is not to say
that the relationship is necessarily etiological. It may be that in individuals
w i t h - o r prone to--bursitis, the repetitive use of the arms and hands causes
exacerbation of symptoms.
FIBROSITIS.
The estimated over-all incidence of complaints due to fibrositis
was 8 per lo00 in males (table 5 ) . There was no significant relationship of complaint rate to age in any of the four occupation groups; nor did the combined
evidence from all four groups indicate an age relationship.
However, the occupation groups differed significantly in their rates (table 6).
There was a significantly higher rate of complaints among patients with
fibrosifis in the group engaged in outdoor light work, the ratio 0L:IL:OH:IH
being approximately 10:3:3:1. To attempt to assign a reason, such as exposure to dampness and cold, for the higher incidence in this group, would
MUSCULOSKELETAL COMPLAINTS I N A N INDUSTRY
295
be indulging in speculation. Too little is as yet known about the nature of
this rheumatic disorder. Furthermore, the small number of cases available
for statistical analysis in this as in some other of the defined rheumatic disease
groups may well have prevented the detection of other associations and differences that might have been piesent.
The ratio for body regions of complaint differed significantly from l : l : l ,
that of U:L:P being 5:3:1 ( P = 0.05 - 0.02). This inequality showed no
obvious difference with age or occupation.
In females with fibrositis, there was no significant difference from the rates
in a comparable group of males.
UNDEFINED
RHEUMATIC DISEASE. The estimated incidence of undefined rheumatic disease in males was 29 per loo0 employees, and there was a significantly
higher incidence from age 40 onward than below 40. This appeared to apply
to all occupation groups except the outdoor light group.
The only significant difference in the incidence in men engaged in heavy
versus light work was among indoor workers in the fifth decade. In this group
the H:L ratio was 2.85:l. Since this diagnostic group does not represent a
distinct disease entity, any attempt to explain this difference in incidence
would be meaningless.
Of all males with “single” sites of complaint, the neck, shoulder, upper arm
area was the body region of complaint in 14 per cent; the lumbosacral, buttock,
thigh area in 56 per cent; and peripheral areas in 30 per cent.
Among females there was no detectable relationship with age and no detectable difference from males engaged in indoor light occupations and under
age 60.The estimated incidence over age 40 was 26 per 1O00, compared with
24 per 1000 in males (tables 5 and 6 ) .
In 93 per cent of the cases classified as undefined rheumatic disease a
tentative diagnosis was suggested by the symptoms, signs and general course
of the episodes. These tentative diagnoses are as follows: fibrositis 27 per
cent; disc disorder 20 per cent; degenerative joint disease 18 per cent;
rheumatoid arthritis 10 per cent; gout 5 per cent; bursitis 5 per cent; other
disorders (psychogenic rheumatism, traumatic synovitis, ruptured meniscus,
etc.) 8 per cent.
Should these tentative diagnoses turn out to be definitive, degenerative
joint disease would head the list of the estimated frequency of occurrence
with 18 instead of 13 cases per 1000 employees. The incidence of fibrositis
would be doubled (from 8 to 16), as would that of disc disorder (from 6 to
12) and that of rheumatoid arthritis more than doubled (from 2 to 5 cases
per lo00 employees ) .
QUESTIONABLE RHEUMATIC DISEASE (MINOR COMPLAINTS). The estimated incidence of “minor complaints” among male employees was 62 per 1000. There
was no s i g d c a n t age relationship. This applied to each of the four occupation
groups.
There was a significantly higher incidence in men engaged in light than in
heavy work ( P = 0.05), the ratio of L:H being 1.27:l. This difference did not
vary significantly with age, with location of occupation (outdoor versus indoor), nor with body region of complaint.
There was little evidence of a difference in incidence in outdoor and indoor
296
BROWN AND LINGG
workers except in the group with complaints in the lumbosacral, buttock,
thigh area, and here it was confined to those engaged in light work, and under
age 40. In this group the ratio of incidence in outdoor workers to that of indoor
workers was 5:1.
The outdoor and indour workers differed significantly in the proportion of
complaints in the two body region classes U and L. Taking only “single” complaints, the figures were: outdoor-U’s, 21 per cent; L’s 62 per cent; P s 17 per
cent; and, indoor-U’s, 35 per cent; L‘s 50 per cent; P s 15 per cent. These differences did not vary markedly as between heavy and light workers.
Among females with “minor cclmplaints,” there was no suggestion of a difference in the estimated incidence with age, nor was there any suggestion of
a difference in the over-all incidence in females versus that in males. The
estimate was 69 per 1000 compared with 71 per 1000 in a comparable group
of males (tables 5 and 6 ) .
This large group is by far the most difficult with which to deal. Included in
it are probably cases which are frequently classified as fibrositis or psychogenic
rheumatism. The uncertainty which surrounds the nature of both these
syndromes, and the fact that the symptoms are often mild and of short duration, has tended to make them a catchall for cases that do not fit the description
of other more clearly defined rheumatic disorders. We have tried to avoid
such allocations in all cases that did not fit as unqualified as possible a description of either syndrome, such as the fairly consistent clinical pattern, with
negative laboratory findings, no pathological joint changes, and the exclusion
of possible early rheumatoid arthritis as well as mild osteoarthritis. By classifying them in a separate group, there is a greater likelihood of arousing
interest in and stimulating further study of these cases.
About three-fourths of these patients had been seen sometime within the
previous ten years by the medical bureau because of rheumatic complaints.
The charts of this group of patients, classified as having minor complaints,
were reviewed each year for three years after the year of study. At the end
of the period, 45 per cent had returned to the medical department owing to
further rheumatic complaints. Only 20 per cent had not reported any rheumatic
complaints except during the sampling year. The rate of appearance of any
diagnosable disease syndrome after three years was so small ( 1 per cent) as
to he without significance.
DISABILITY
AND ECONOMIC
Loss
In its plea for funds for the support of organized research in rheumatic
diseases, the Empire Rheumatism C ~ u n c i l ’reported
~
that 271/2-million days
were lost to industry from June 1953 to June 1954 through the rheumatic dis10 per cent of the total days lost through every form of illness.
ease.-nearly
In Denmark, according to Kalbak‘s3 estimate, rheumatism accounts for a loss
of approximately 7 million working days annually, and Bohman2 estimated
that in Sweden the loss is about 14 million working days per year. The U. S .
Public Health Service began as far back as 1990 to publish reports on sickness
absenteeism by cause, based on data submitted by industrial sick benefit
organizations. A review of absenteeism by cause in different industries and
MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY
297
occupations, in this country and abroad, emphasizes beyond a doubt the
importance of rheumatic disorders as an economic problem from the point of
view of loss of working time. Ten or 15 per cent or more of total working time
lost is attributed to some form of rheumatism. Lack of uniformity and precision
in nomenclature, diagnostic criteria and in methods of collecting data, however,
fails to permit direct evaluation of the economic effects of these diseases.
Estimates are frequently made of the monetary cost of illness to a community
or to an industry. Thus Kalbak3 estimates the annual cost of rheumatism in
Denmark as $25 million, and Bohman2 arrives at a figure of at least $14 million
in Sweden. Although such figures are impressive and probably do not overestimate the facts, means of arriving at them are so variable that they are
seldom comparable. In its Sickness Report for the year 1954,13the Consolidated
Edison Company of New York states that pay for time lost on account of sickness from all causes totaled $3,138,421 (Company Sick Pay Allowances and
Mutual Aid Sick Benefits) of which the cost for the Consolidated Edison
Company alone totaled $3,051,731. Obviously this figure does not represent
the total economic loss to the company on account of sickness. The value of an
individual employee to the company, which involves such imponderables as
his particular aptitudes, years of training and experience, is seldom reflected
in the amount of sick pay allowances or benefits paid. Insofar as the exact
value of a working day varies from individual to individual and from job to
job, it becomes meaningless to try to express economic loss in terms of dollars
and cents. Therefore, in attempting to estimate the cost of the rheumatic diseases to the Consolidated Edison Company. two types of determinations were
made: first, working days lust, and secondly, the medical cost expressed in
patient visits to the various service modalities provided by the company.
Working days tost. During the year, in the sample studied, rheumatic complaints accounted for the loss of 2,863 working days, which gives an estimate
of 15,040 total loss of working days for these complaints, or about 9 per cent
of the total days (161,920)" lost on account of sickness by the company's
employees in the occupational categories included in this study. The mean
days lost because of illness in general is staggering-7" days per employee in
the year 1954, of which, according to estimates from this study, one day was
lost on account of rheumatic complaints. Among sick employees, the mean
number of days lost during the year because of illness was 11," while among
those with rheumatic complaints, reported in this study, it was four days.
Of the total days lost on account of rheumatic complaints, leaving out those
cases in which no diagnosis was possible, definable rheumatic disorders claimed
more than half. with degenerative joint disease at the top of the list, and the
distribution among the various categories as shown in table 7.
Except in the case of gout, more than 40 per cent of the cases in each diagnostic category lost no time from work during the year. Seven of the ten cases
whose records led to the diagnosis of rheumatoid arthritis lost no time from
work on account of this disorder during the year of study, which may probably
be explained by the remittent nature of the disease. Ten days or more were
'Figures supplied by the company.13
298
BROWN AND LINGG
Table 7.-Time Lost from Work Owing to Rhatmutic Comphinints
Workine D s r s Lost Due to Rheumatic Complaints
No. of
Diagnosis
Barsitis
Degenerative joint disease
Fibrositis
Disc disorder
Gout
Rheumatoid arthritis
Other defined disorders
Total defined disorders
Undefined rheumatic
disease
Questionable rheumatic
disease (minor
comdaints 1
Percent
Cases in
of Total
Days Lost
74
Mean
per
None
4
4
4
10
10
27
255
10
13
5
10
5
3
7
53
45
55
43
44
15
70
6
46
19
15
0
7
15
153
34
6
53
16
18
13
345
13
1
66
25
9
0
Sample
59
33
32
u)
Patient
7
10
7
55
1-4
6-9
(Per Cent of Cases )
20
15
9
20
15
33
3
35
10
19
19
10+
15
15
15
34
35
20
19
20
lost by approximately one-third, each, of patients with gout and disc disorder,
and from five to nine days by one-third, each, of patients with gout and
fibrositis.
Of all the time lost owing to musculoskeletal complaints, one-third was lost
by patients with symptoms and objective signs of rheumatic disease which
failed to satisfy completely the definition of any of the definable diagnostic
groups. This time was lost by slightly less than half of these patients, an
average of six days each.
One-third of the patients with minor complaints of questionable rheumatic
disease lost more than one-tenth of the total working days lost because of
muscoloskeletal complaints.
Medical smuices. Among the cases in the sample, 3,821 medical visits (by
employee or physician) were made on account of rheumatic complaints during
the year of study, which gives an estimated total of 20,800 visits-approximately one visit per employee, or six visits per employee with rheumatic complaints. The distribution of these visits was as follows: 49 per cent to clinics
(40per cent to general medical clinics, 6 per cent to the diagnostic clinic, and
3 per cent to the office handling industrial compensation cases); 36 per cent
to the private offices of district doctors; 12 per cent house visits by district
doctors; and 3 per cent outside consultations. During the year, 1 per cent of
the.patients reguired hospitalization. Two per cent were known to have been
seen by a private physician some time during the year.
Of each of the various types of medical visits, the largest number were
made by patients with well-defined rheumatic disorders (table 8). Of visits
to general medical clinics and to the offices of the district doctors, the largest
proportion, considering only diagnosable rheumatic disease, was made by
patients with degenerative joint disease and with bursitis. Of visits to the
diagnostic clinic, the most frequent claimants were victims of rheumatoid
arthritis and disc disorders. It is not surprising that most of the visits to the
industrial compensation office were made: by patients suffering from disc dis-
299
MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY
Table b.--Medical Sewices Provided for Patients with Rheumtic
Complaints (Sample Cases)
Both Sexes
Per Cent of Total Visits Due to Rheumatic Complaints
Diwnosis
Bursitis
Degenerative joint disease
Fibrositis
Disc disorder
Gout
Rheumatoid arthritis
Other defined disorders
Total defined disorders
Undefined rheumatic
disease
Questionable rheumatic
disease (minor
complaints)
Total Visits
N0.M
General
Medical
Clinic
District
Doetorn’
Ofices
House
Visits
D.D.
74
59
33
32
20
10
27
10
13
4
5
3
2
4
14
18
8
5
9
6
6
9
11
2
3
255
41
59
153
30
29
Caeesin
Sample
345
Number
Percent
29
1526
100.
5
6
3
Indust.
Compens.
Office
Outside
Consult.
13
4
23
4
6
14
0
28
0
0
11
13
3
1
21
0
16
13
46
66
59
67
25
31
36
33
12
29
1393
100.
444
100.
Dingnostic
Clinic
6
9
7
3
216
100.
5
113
100.
0
129
100.
orders, nor that most of the visits to outside consultants were made by patients
with disc disorders and rheumatoid arthritis.
One-fourth or more of all visits to each of the service modalities were made
by patients with undefined rheumatic disease, about a third, each, to the
diagnostic clinic and to outside consultants, which is evidence that expense
was not spared in the effort to arrive at a definite diagnosis in these cases.
Of visits to general medical clinics and of house visits made by district
with minor
doctors, more than one-fourth were made b y - o r to-patients
complaints of questionable rheumatic disease. The usually mild and short
duration of symptoms in this group made further investigation appear unwarranted. Yet it is estimated that these symptoms were responsible for the loss,
during the year, of 1,608 working days, and for 1,988 visits to the medical
clinics, 764 visits to offices of district doctors and 520 house visits by district
doctors.
DISCUSSION
In the population under consideration, by far the greatest percentage of
individuals with rheumatic complaints, omitting those classified as “no diagnosis possible,” suffered from disorders of a noncrippling nature. In only 17
per cent were the symptoms definitely-and in an additional 9 per cent possibly-attributable to rheumatoid arthritis, degenerative joint disease, disc
disorders or gout. In the remaining 74 per cent, complaints were due to syndromes of a less severe and self-limiting nature. In the arthritis cIinics and on
the wards of the medical school teaching centers, we see primarily the 17 or 28
per cent with severe disease. Most of the remaining 74 per cent never reach
us.Yet it is these (three-fourths of the total) that pose an equally great problem
300
BROWN AND LINGG
in time lost from work, which in this study amounted to an estimated 6,368
working days lost annually and involved treatment requiring 9,064 medical
visits, as against 6,180 working days lost and 9,000 medical visits in the case
of the 26 per cent (one fourth of the total) with severe, possibly crippling
disease. Included in this large group are many syndromes, such as bursitis and
fibrositis, the nature of which is still little understood, tenosynovitis and
psychogenic rheumatism, and others that are as yet probably not even recognized. The largest proportion, as has already been noted, is the group with
apparently minor complaints.
In an industrial organization that usually offers medical care on the premises
and during working hours, through a payroll deduction plan, one would natorally expect to find a larger proportion of cases with minor complaints than
among patients who apply to hospital clinics or to the offices of private physicians for relief of symptoms. Rheumatologists are well aware of the fact that
the early stage of rheumatoid arthritis, for instance, has not only not been
studied, but has not even come under medical surveillance, since the symptoms complained of are usually considered unimportant. It has been suggested that persons who may be in the process of developing rheumatoid
years or
arthritis should be kept under observation for long periods-ten
more.14 The tendency is to dismiss cases without detectable objective signs as
unimportant, and consider the symptoms as probably due to hypersensitivity to
pain or other forms of discomfort, or to a general malingering attitude on the
part of some individuals. Although such inferences deserve consideration, especially in group health insurance, prepayment medical care and payroll
deduction plans, too much reliance should not be placed on them without
further investigation to rule out the possibility that the symptoms may be
prodromal of true rheumatic disease.
The reasons for selecting this particular industrial population for a study
of the incidence or prevalence of the different rheumatic diseases were
pointed out earlier in this report. They include the exceptional stability of the
population at risk, the fact that this population is under the close surveillance
of an active and competent medical department, and that there are available
on most patients detailed records of medical history and observation over a
period of 10 previous years (since 1945), thus obviating the disadvantage of
having to rely on the patient’s memory, a notoriously inaccurate instrument.
Although the medical department’of the company gave wholehearted interest
and cooperation to this project, difficulties are, nevertheless, met in conducting
such a study as this in an industry. As has been pointed out, it was not always
possible to have patients whose symptoms were episodic, or in whom the
diagnosis was doubtful, re-examined in consultation with the rheumatologist
or referred for further x-ray or laboratory studies, as had originally been
agreed to by the medical department. The reason for this was usually that since
the patient’s symptoms had subsided sufficiently for him to be back on the
job, further loss of time from work for medical reasons was not granted. From
the point of view of the industry, which is in business not to promote research
but to sell its services, and which maintains an efficient medical department
primarily for the purpose of reducing absenteeism due to illness, time off for
301
MUSCULOSKELETAL COMPLAINTS IN AN INDUSTRY
any reason, provided the employee is able to work, is an unnecessary loss to the
company.
Yet the need is great for more careful observation and follow-up of the
less well defined syndromes, and the development, if possible, of more and
better diagnostic tests and a more rational approach to therapy. Close observation over a period of years of a group of individuals with apparently minor
rheumatic complaints, including available diagnostic tests and psychiatric
examinations, may delineate syndromes now unrecognized. Clearly, it is in an
industrial population that these cases can best be studied. Neither the specialist
in private practice, nor the man in full time medicine, nor one who conducts
community studies, is in a position to make such observations. Industry alone
has the opportunity to undertake and help provide resources for such investigations, and it will be among the first to benefit from whatever knowledge may
grow out of them.
SUMMARY
A study of the incidence of the various types of rheumatic disorders in a
sample population with rheumatic complaints among the employees of the
Consolidated Edison Company of New York, within a period of one year
(January 1, 1954 to January 31, 1955), has been reported. The reasons for
selecting this particular industry, and some of the difficulties encountered in
making industrial surveys, are discussed.
A strictly random sample of 25 per cent was selected from daily medical
records in categories that would, or might, according to the company physicians’
coding, contain rheumatic disorders. The records of 805 cases which constituted the sample were studied.
It is estimated that 15 per cent of the employees requested medical care
because of rheumatic complaints. Thirty-two per cent of the sample cases
revealed diagnosable rheumatic disease. Undefined rheumatic disease was
found in 19 per cent, and 43 per cent presented symptoms, episodic in nature,
without objective signs of disease,
The relationship of age, sex, body region of complaint, and location or load
of work-whether indoor or outdoor, heavy or light-was
investigated in
each of the diagnostic groups. Differences found were tested for statistical
significance, and possible explanations for such differences were offered.
Rheumatic complaints accounted for an estimated loss of 15,040 days during
the year, which was 9 per cent of the total working days lost on account of
sickness by employees of the company, and an estimated 20,800 melical visits
were made by employee or physician because of rheumatic complaints. Twelve
per cent of the days lost and 18 per cent of the medical visits were attributed
to patients with minor though frequently recurring complaints, but without
objective signs of disease.
The need for more careful and prolonged observation of patients with the
less well defined syndromes is emphasized. A unique opportunity for industry!
REFERENCES
1. Woolsey, T. D.:Prevalence of arthritis
and rheumatism in the United States.
Pub. Health Rep. 87:505, 1952.
2. Bohman, F.: Social importance of rheumatic diseases in Sweden. Acta med.
scandinav. 132:150, 1948.
302
BROWN AND LINGG
3. Kalbak, K.: Rheumatic diseases in Denmark. Ann. Rheumat. Dis. 12:306,
1953.
4. de Bltcourt, J. J.: Investigation as to
the prevalence of rheumatic diseases
and to their dependence upon the
degree of dampness in dwellings.
Res. Inst. Health Engineering, T.N.
O., Rep. No. 20, December 1953.
5. Kellgren, J. H.,Lawrence, J. S. and
Aitken-Swan, J.: Rheumatic complaints in an urban population. Ann.
1953.
Rheumat. Dis. 12~5,
6. Mink, B. aud Goldwater, L. J.: Occupational aspects of rheumatic diseases-a review. Indust. hled. 83:
335, 1954.
7. Lawrence, J. S. and Aitken-Swan, J.:
Rheumatism in miners. Brit. J. Indust. Med. 9:1, 1952.
8. Kellgren, J. H. and Lawrence, J. S.:
Rheumatism in miners, part 11, x-ray
study. Brit. J. Indust. Med. 9:197,
1952.
9. Bunim, J. J.: The incidence of the
rheumatic diseases in industry. Indust. Med. 22:302, 1953.
10. Brown, R.: The incidence of various
rheumatic diseases in an industry.
Presented at the scientific session of
the Council on Industrial Health,
American Medical Association. Bethesda, Md., Jan. 24, 1955.
11. American Rheumatism Association.
Primer on the rheumatic diseases.
J.A.M.A. 152:323, 405, 522, 1953.
12. Empire Rheumatism Council. Industry
and rheumatism.
13. Sickness Analysis, 1954; Consolidated
Edison Company of New York, April
1, 1955.
14. Personal Communication, Sidney Cobb,
M.H., MP: H; Advisory Committee,
Pittsburg Arthritis Study, March 1953.
Robert Brown, M.D.,
Assistant Professor of C1,iriical Aledkinc:
and Member, Rheumatic Diseases Study Group, New York
University College of Medicine, New York, N . Y.
Claire Lingg, M.A., formerly with the Department of Medical
Statistics, at present with the Rheumatic Dkeases Study Group,
N . Y. University College of Medicine, New York, N . Y.
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