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Indian Journal of Community Medicine

A Cross Sectional Study of Rheumatic Muskuloskeletal Disorders (RMSD) in an Urban Slum Population

Author(s): A.S. Pingle, D. D. Pandit

Vol. 31, No. 4 (2006-10 - 2006-12)

A.S. Pingle(1), D. D. Pandit(2)

Introduction

Musculoskeletal disorders are the most common cause of severe long term pain and physical disability affecting hundreds of millions of people around the world. Joint diseases, account for more than half of all chronic conditions in persons aged 60 years and over; and back pain is the second leading cause of sick leave. Despite their enormous impact worldwide they do not receive the attention they deserve by the medical profession, policy makers and the media due to the perception that musculoskeletal diseases are less serious. Unlike cardiovascular disease, AIDS and cancer, these are largely chronic, non fatal conditions and tend to be seen as an inevitable consequence of ageing. As the worlds population ages, the extent of the problem will increase, placing huge burdens on societies and health care systems.

To help redress the balance on an international level, a group of health professionals, decided to start a global campaign declaring the fi rst 10 years of the 21st century the “Bone and Joint Decade” (BJD). The purpose of the decade is to improve the health related quality of life of people with bone and joint diseases and injuries worldwide by raising awareness and understanding of the importance of these severe conditions and increasing the amount of research funding.1

The “Community Oriented Programme for the Control of Rheumatic Diseases” (COPCORD) was launched by the World Health Organization (WHO) – International League of Associations for Rheumatology (ILAR) in 1981. Its primary objective is to acquire data on the prevalence of Rheumatic Musculoskeletal Symptoms/ Disorders (RMSD) and their related disability in rural communities in developing countries. The COPCORD epidemiological model, which is socioeconomically designed, targets the community RMSD rather than specific diseases. The COPCORD model advocates a low cost structure utilizing available local resources with minimal use of investigations (for diagnosis).3

This community based study was therefore undertaken to find the magnitude of the problem related to rheumatic musculoskeletal disorders in urban slum population. This study can be used as a baseline for further studies related to rheumatic musculoskeletal disorders.

Material and Methods

MultistageThis study was carried out in an urban field practice area of L.T.M. Medical College and Hospital, Sion, Mumbai. It was an epidemiological study of Rheumatic Musculoskeletal symptoms/disorders (RMSD). Respondents with age more than 15 years were included in the study as was done in all WHO-ILAR COPCORD studies2,6,7. A sample size of 460 was selected for study taking prevalence as 18%3. The study population was distributed in 8 sections. Each section was considered as one strata. Stratified systematic sampling study was from August 2002 to July 2003. Actual survey was carried out by visiting households with pretested proforma. All persons above age 15 in the house were interviewed and examined for the presence or absence of Rheumatic Musculoskeletal symptoms/disorders. Data was collected using a pretested interview schedule by personal interview. A semi structured interview schedule was devised for interviewing the respondents.

The survey instrument was the COPCORD (Community Oriented Programme for Control of Rheumatic Diseases) Core Questionnaire, which has already been used and validated in earlier surveys in the Asia-Pacific regions5. Some modifications were made in the questionnaire by taking the expert opinion of a Rheumatologist of a teaching hospital. All the subjects were clinically examined in their houses. The diagnosis of rheumatic musculoskeletal disorders was done as per standard criteria.12

Results

The prevalence of RMSD found in our study was 18%.

Table I. Association between Prevalence of RMSD and Age Group of Study Population.

Age Group
in yrs.
No. of
Respondents
No. of persons
with RMSD
No. %
15-24 113 01 0.9
25-34 136 15 11.0
35-44 87 23 26.4
45-54 56 23 41.1
55-64 41 12 29.3
> 65 27 09 33.3
Total 460 83 18

r = 0.83 p< 0.05, significant

The prevalence of RMSD was 0.9% in 15-24 years and 11% among 25-34 years as compared to 41.1% in 45-54 years which was significant. Also the prevalence in the age group above 55 years was in the range of 29-33 percent which is more than that in the younger age group below age 35 (Table I).

28.2% of total females had a RMSD, which was significantly high as compared to 8.1% in male population. Family history of RMSD was present in only 2.4% of the subjects in our study. The findings of the study showed that there was no significant difference in the prevalence of RMSD among Hindus (18.4%), Muslims (19.4%) and other castes (11.8%).

The prevalence of RMSD was found to be more in the illiterate subjects (31.1%) as compared to only 5.9% in those with higher secondary education and graduates combined. It was found that heavy work led to a higher prevalence of RMSD (31.3%) as compared to 21.5% in moderate and 16.3% in those performing light work. Among subjects with Upper Lower and Lower class socioeconomic status, the prevalence of RMSD was 17.5% and it was 20.5% in Lower Middle class which was more as compared to 9.4% among Upper and Upper Middle class but the difference was not statistically significant11. The findings reveal that as the body weight increases the percentage of RMSD also increases.

Table II. Relation Between RMSD and Different Variables.

Age Group
in yrs.
No. of
Respondents
No. of persons
with RMSD
No. %
Sex
Male 233 19 8.1
Female 227 64 28.2
Total 460 83 18
χ2 = 31.22 df = 1 p< 0.001, highly significant
Religion
Hindu 354 65 18.4
Muslim 72 14 19.4
Others 34 04 11.8
Total 460 83 18
χ2 = 1.02 df= 2 p> 0.05, not significant
Education Status
Illiterate 119 37 31.1
Primary 168 25 14.9
Secondary 89 16 18
Higher Secondary 53 03 5.7
Graduate 31 02 6.4
Total 460 83 18
χ2 = 23.14 df = 3 p< 0.001, highly significant
Type of Work
Light 258 42 16.3
Moderate 93 20 21.5
Heavy 67 21 31.3
Not applicable 42 -
Total 460 83 18
χ2 = 7.79 df = 2 p< 0.05, significant
Socio-economic status
Class I 27 01 3.7
Class II 48 06 12.5
Class III 288 59 20.5
Class IV 86 14 16.3
Class V 11 03 27.3
Total 460 83 18
χ2 = 5.03 df = 2 p> 0.05, not significant
Body Mass Index
< 18.5 83 09 10.8
18.5-24.99 259 40 15.4
25-29.99 108 28 25.9
> 30 10 06 60
Total 460 83 18

r = 0.69 p< 0.05, significant

28.8% of the subjects had BMI ≥ 25 as compared to 15.4% with BMI between 18.5-24.99 and 10.8% in those with BMI <18.5. This shows a positive relation between body weight and prevalence of RMSD and it was found to be statistically significant. (Table II)

Majority of the subjects were suffering from Osteoarthritis (OA) i.e. 36.2% followed by 31.4% with Symptom Related Diagnosis (SRD). Soft Tissue Rheumatism (STR) was present in 26.5% and Unclassifi able Inflammatory Arthritis (IA-U) was present in 6.0% of the subjects. It was found that OA and IA-U was more common in males while STR was found more in females. (Table III)

Table III. Profile of Diagnosis in RMSD.

Diagnosis Male Female Total
No. % No. % No. %
Soft Tissue
Rheumatism
2 10.5 20 31.2 22 26.5
Infectious arthritis/
Gout
Nil - Nil - Nil -
Osteo arthritis 8 42.1 22 34.4 30 36.2
Inflammatory
Arthritis-
3 15.8 2 3.2 5 6.0
Unclassifiable
SLE Nil - Nil - Nil -
Rheumatoid
Arthritis
Nil - Nil - Nil -
Symptom Related
Diagnosis
6 31.6 20 31.2 26 31.4
Total 19 100 64 100 83 100

It was observed that 47% of the subjects were not taking any sort of treatment as they did not perceive the symptom as an illness. Most of the subjects took Allopathic treatment i.e. 47% for relief of symptoms while 6% subjects took Ayurvedic treatment. Of the subjects who took treatment for their ailments (53%), majority i.e. 68.2% consulted a private practitioner while only 25% subjects approached Tertiary Care Hospital. (Table IV)

Table IV. Distribution of Study Subjects as per the Type and Place of Treatment.

Treatment taken No. of subjects with RMSD %
Type (n=83)
Allopathy 39 47
Ayurvedic 05 6
No treatment 39 47
Total 83 100
Place (n=44)
Tertiary Care Hospital 11 25
Urban Health Centre NIL -
Private Practitioner 30 68.2
Others 3 6.8
Total 44 100

The findings of the study show that history of trauma was present in 8.4% of the subjects with RMSD. Of those with history of trauma, 71.4% had a motor vehicle accident and 28.6% had suffered a fall. 39.7% of the subjects with RMSD reported some disturbance of sleep. Moderate disturbance of sleep was reported by 28.9% and severe disturbance by 4.8% of the subjects with RMSD. 32.5% of the subjects with RMSD reported seasonal variation in pain and the intensity of pain was more in winter season. (Table V)

Table V. Distribution of Study Subjects as per History of Trauma, Sleep Disturbance and Seasonal Variation.

  No. of subjects with RMSD %
History of Trauma
Present 7 8.4
Absent 76 91.6
Total 83 100
Sleep disturbance
Present 33 39.7
Absent 50 60.3
Total 83 100
Seasonal variation
Present 27 32.5
Absent 56 67.5
Total 83 100

Discussion

The prevalence of RMSD found in our study was 18%. A study by Chopra et al2 found the prevalence to be 18.2% which is very close to our study. A study by Farooqi and Gibson5 found the prevalence to be 16.5%, while a study by Lawrence et al showed the prevalence of RMSD to be 15% in Americans.7

In this study the prevalence increased gradually upto age group 45-54 but later on there was a slight fall in the prevalence which could not be explained. Similar findings were seen in a study by Chopra et al2 where the prevalence of RMSD increased gradually upto age 45-54 but later on there was a slight fall in the prevalence. A study by Woolf and Pfleger revealed that prevalence of RMSD increased markedly with age.6

Females were affected more than males. RMSD was seen to be dominant in females in a study conducted by Chopra et al2. The study by Woolf and Pfl eger also showed that females had a high prevalence of RMSD than males6. The prevalence of RMSD was found to decrease as the level of education increased. In a study in United States the prevalence of musculoskeletal disorders was higher for women who had less than or equal to 11 years of education (30%).10

RMSD was seen more in the subjects with heavy work as compared to moderate and light work. A study by Coggon et al showed that OA is more common in people who had performed heavy physical work, and particularly in those whose jobs had involved kneeling or squatting.9 The prevalence of RMSD was more in the lower socio economic status. In a study done in United States, the prevalence of self reported arthritis was found more in those females who resided in households with lower economic status (29.9%).10

Body Mass Index (BMI) showed a positive correlation with prevalence of RMSD. Obesity (high body mass index) is a risk factor for the development of osteoarthritis as seen in a study by Woolf et al.6

Majority of the subjects were diagnosed as suffering from Osteoarthritis (36.2%). Symptom related diagnosis (SRD) was seen in 31.4%. 26.5% had Soft tissue Rheumatism (STR) and Unclassifiable Inflammatory Arthritis (IA-U) was seen in 6.0% of the subjects. OA and IA-U were more common in males while STR was more in females. A study by Chopra et al showed that in almost one-third of the patients, a Symptom Related Diagnosis (34%) could be offered while OA (29%) and Soft tissue Rheumatism disorders (20%) were commonly seen. Infl ammatory arthritis was seen in 11% of the subjects.4 A study by Woolf et al showed that in case of OA, men are affected more often than women.6

Allopathic treatment was taken by 47% of subjects for relief of symptoms while 6% subjects took Ayurvedic treatment. 47% subjects did not take any sort of treatment. A study by Chopra et al showed that of the urban subjects with RMSD, 68% consulted a complementary or alternative system (Ayurvedic/herbal medicine being the most popular) for relief and 35% of the patients used both systems concurrently. Only 32% of the urban subjects with RMSD strictly adhered to the modern medicine system. It also showed that less than 5% of the subjects with RMSD in rural area used the alternative medicine.3 Of the subjects who took treatment for their ailments, majority i.e. 68.2% consulted a private practitioner while only 25% subjects approached Tertiary Care Hospital.

History of trauma was present in 8.4% of the subjects with RMSD and they related it to be a contributory factor for their current ailment. In a study by Chopra et al, history of trauma was recorded in 23% of the subjects with RMSD, and they believed it to be the cause for their musculoskeletal disorders.3

39.7% of the subjects with RMSD reported some disturbance of sleep. In a study by Chopra et al, some disturbance of sleep was reported by 52% of respondents.3

Seasonal variation of pain was seen in 32.5% of the subjects with RMSD and the intensity of pain was reported to be more in winter season. A study by Chopra et al shows that 58.7% of the subjects found an association with weather. 2.7%, 15.5% and 28.2% reported an association of RMSD pain with summer, monsoon and winter seasons respectively.3

Conclusion

The findings of the study revealed that there is a substantial burden of RMSD as 18% of the subjects were suffering from RMSD and it had a moderate effect on daily living in most of the subjects. Despite the enormous impact worldwide, RMSD does not receive the attention they deserve. This study brings out the need for action for control of RMSD.

References

  1. Lidgren L. The Bone and Joint Decade 2000-2010; Bull of WHO 2003; 81(9):629.
  2. Chopra A, Patil J, Billempelly V, Relwani J and Tandale H.S. Prevalence of Rheumatic diseases in a rural population in Western India: A WHO-ILAR COPCORD study. J Assoc Physicians India 2001; 49: 240-246.
  3. Chopra A, Saluja M, Patil J and Tandale H.S. Pain and Disability Perceptions and Beliefs of a Rural Indian population: A WHO ILAR COPCORD study. J Rheumatol 2002; 29: 614-621.
  4. Chopra A, Patil J, Billampelly V, Relwani J and Tandale H.S. The Bhigwan (India) COPCORD: Methodology and First Information Report. APLAR J Rheumatol 1997;1:145-151.
  5. Farooqi A and Gibson T. Prevalence of Major Rheumatic Disorders in the adult population of North Pakistan. Br J Rheumatol 1998; 37: 491-495.
  6. Woolf A.D. and Pfl eger B. Burden of major musculoskeletal conditions. Bull of WHO 2003; 81(9): 646-656.
  7. Lawrence R.C., Helmick C.G., Arnett F.C., Deyo R.A., Felson D.T., Giannini H.E. et al. Estimates of the prevalence of Arthritis and selected Musculoskeletal Disorders in the United States; Arthritis Rheum 1998; 41: 778-799.
  8. Sharma L, Lou C, Cahue S and Dunlop D.D. The mechanism of the effect of obesity in knee osteoarthritis. Arthritis Rheum 2000; 43: 568-575.
  9. Coggon D, Croft P, Kellingray S, Barret D, McLaren M, Cooper C. Occupational physical activities and osteoarthritis of the knee. Arthritis Rheum 2000; 43: 1443-1449.
  10. CDC. Prevalence and impact of Arthritis among women - United States, 1989-1991. MMWR 1995; 44: 329-334.
  11. Mahajan B K and Gupta M C. Textbook of Preventive and Social Medicine; 2nd edition; Jaypee Brothers, New Delhi, 1995; Chapter 11; Social Environment: 135.
  12. John J Cush, Peter E Lipsky; Harrison’s Principles of Internal Medicine; 14th edition; 1998; Volume 2; Part 12; Section 3; Chapter 321; Approach to Articular and Musculoskeletal disorders; Fig. 321-1; P 1930.

(1) Bombay City Eye Institute and Research Centre, Mumabi
E-mail: [email protected]
(2) Deptt. of Preventive and Social Medicine, L.T.M Medical College
and General Hospital, Sion, Mumbai- 400022.
Received: 8.12.04

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