MUSCULOSKELETAL DISORDERS IN FEMALE VETERANS: A SURVEY W. Anthony Allison, MD, and Rita Roque, RNC Philadelphia, PA
This study discusses age distribution, outpatient clinic visits, and diagnoses of female veterans with trauma-related musculoskeletal conditions. From 1981 to 1988, data were collected of female veterans seen for treatment or examination of compensation awards. Their prevalent musculoskeletal disorders were of the back, feet, and knees. This study served as a means of preparation for the anticipated changing needs of these patients when ambulatory. Key words * female veterans * musculoskeletal disorders * trauma-related Approximately 1.2 million civilian women today were on active duty in the United States armed forces. Today, women comprise about 4% of the veteran population.' As the female veteran population increases, we anticipate there will be greater demands for medical care under the Veterans Affairs (VA) medical system. The impetus for this study developed from: 1) the observation of a steady increase in the number of clinic visits from women with musculoskeletal conditions; 2) a desire to take a closer look at the musculoskeletal disorders in female veterans; and 3) a From the VA Ambulatory Care Clinic, Philadelphia, PA. Requests for reprints should be addressed to Dr W. Anthony Allison, VA Ambulatory Care Clinic, 1421 Cherry St, Philadelphia, PA 19102. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
need to prepare for the anticipated increase in female patients in an ambulatory setting. This report discusses age distribution, visit characteristics, and diagnoses of female veterans with musculoskeletal disorders.
GEOGRAPHIC DISTRIBUTION OF PATIENTS Veteran patients treated at the Philadelphia VA Ambulatory Care Clinic are from Philadelphia, areas of eastern Pennsylvania, and New Jersey. Eighteen percent of veteran patients seen in the Orthopedic Unit are from New Jersey (unpublished survey).
METHODS The study population consisted of female veterans with trauma-related musculoskeletal conditions seen in the Orthopedic Unit for treatment or examination of compensation awards (compensation and pension examinations). Data were collected from January 1981 to the end of December 1988. A daily log of each patient's visits, listing their name, age, social security number, musculoskeletal diagnoses, and comments, was maintained. Since 1984, the data were also maintained in a computerized database. Internal diagnoses are coded using the VA code,2 and cross-tabulated with the International Classifications of Diseases, (ICD-9-CM)3 and the International Classification of Health Problems in Primary Care (ICHPPC2).4 Diagnosis categorization is based on the work of Schneeweiss et al,5 and modified in the style described in their paper. For example, the category of knee 65
MUSCLOSKELETAL DISORDERS IN FEMALE VETERANS
TABLE 1. AGE DISTRIBUTION OF FEMALE VETERANS WITH MUSCULOSKELETAL DISORDERS
(N Age (years) 18-29 30-39 40-49 50-59 60-69 70 and older
=
207)
Number Percent Distribution 120 58.0 53 25.6 8 3.9 6 2.9 14 6.8 6 2.9
disorder includes all impairments of the knee such as meniscus injury, ligament injury, or joint dysfunction. Rank analysis is based on the principal diagnoses, similar to the National Ambulatory Medical Care Survey.6
RESULTS Two hundred and seven female veteran patients with musculoskeletal disorders were seen in the Orthopedic Unit. One hundred seventy-three (83.6%) were 18 to 39 years of age (Table 1), and 20 (9.7%) were over 60 years old. One hundred sixty patients (77.3%) were examined for compensation and pension awards, and 47 were seen for treatment and follow-up visits. Nine were referred to other services. Back and neck conditions comprised 55.1% of the musculoskeletal disorders. Seventy (33.8%) suffered from knee problems, 51 from foot disorders (24.6%), 11.1% from shoulder impairment, and 10.1% from hip disorders. Of the total 207 women, 81 (39.1 %) had either foot or ankle conditions, or combinations of both. Sixteen women (7.7%) who were examined for treatment and 58 (28%) who were seen for compensation and pension awards, had two or more musculoskeletal disorders. Table 2 shows the frequency of musculoskeletal disorders among the 10 principal diagnoses. Comparison of frequency and percent of musculoskeletal disorders in female and male veteran patients are shown in Table 3. Of the female patients seen in the Orthopedic Unit during this study, six were pregnant and three were under psychiatric care.
DISCUSSION This study permitted the clinic to review the important musculoskeletal conditions in female veteran patients. We did not include in this study an evaluation of patients' health outcomes. 66
TABLE 2. RANK ANALYSIS OF MUSCULOSKELETAL DISORDERS IN FEMALE VETERANS BY THE TEN PRINCIPAL DIAGNOSES
(N Rank 1 2 3 4 5 6 7 8 9 10
Diagnosis (Disorder) Lumbosacral
=
207)
Number 72 Foot 51 Bilateral knee 31 Cervical 26 Right knee 23 Left knee 16 Hip 15 Left ankle 11 Thoracolumbosacral 9 Right shoulder 8
Frequency (Percent) 34.8 24.6 15.0 12.6 11.1 7.7 7.2 5.3 4.3 3.9
The prevalent musculoskeletal disorders related to trauma involved the back. Of particular note was the frequency of foot disorders in women compared to men. Foot disorders ranked third (24.6%) as problems in female patients. When an analysis was made of the 10 principal diagnoses, foot disorders ranked second. In male veterans, foot disorders ranked fifth, comprising 4.5% of visits for musculoskeletal conditions. Although knee disorders were expected to be high, an unexpected discovery was the high percentage of patients having disorders in both knees (15%). Analysis of raw data revealed that approximately 16% of female veteran patients seen in the Orthopedic Unit were receiving treatment for non-musculoskeletal
conditions.7 The causes of trauma-related musculoskeletal conditions in female veterans were, in general, different from those of male veterans. Injuries sustained by men were mostly attributed to shrapnel and gun shot wounds, parachute jumps, explosions, falls, heavy lifting, crushing, thermal, and sports injuries, as well as helicopter jumping. Most injuries in female veterans were attributed to lifting, long marches, contusions, falls, and sports. Currently, 4% of patients visiting the clinic are women. Analysis of raw data indicates there will be a steady increase in women in the Orthopedic Unit. Within 5 to 6 years, approximately 6% of visits will be from female patients. Veterans with musculoskeletal disorders are followed for years in the Veterans Affairs medical system. The Orthopedic Unit expects to follow and manage these veterans with chronic musculoskeletal conditions. The aims of the Unit are to: 1) relieve patients' pain; 2) JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
MUSCLOSKELETAL DISORDERS IN FEMALE VETERANS
TABLE 3. COMPARISON OF RANK AND PERCENT (FREQUENCY) OF MUSCULOSKELETAL DISORDERS OF FEMALE AND MALE VETERAN PATIENTS Female Veterans Male Veterans* Musculoskeletal Disorder Percent Percent Rank Rank (Problem Category) (frequency) (frequency) Back and neck 1 1 55.1 41.3 2 Knee 33.8 2 29.8 Foot 3 24.6 5 4.8 Ankle 4 4 14.5 5.9 Shoulder 11.1 5 3 8.7 Hip 6 10.1 4.7 6 7 Wrist 3.4 8 1.9 Elbow 8 1.9 9 1.3 Limb amputation 9 0.5 7 2.0 Total patient visits 207 3039
*Male veteran patient visits in 1986.
increase functional ability; 3) decrease morbidity and risk factors; and 4) provide the best patient care possible. This study indicates that using various statistical tools to analyze and infer possible risks and outcomes from collected raw data from patients with chronic musculoskeletal conditions is effective. This approach, along with the formulation of theoretical and biological models of musculoskeletal disorders, will permit closer association between basic researchers and those carrying out the treatment.8 The staffs orientation should not only be toward the psychosocial approach, but also toward new technology and new devices. It is expected that these will offer patients with musculoskeletal disorders a greater chance for relief of symptoms. Literature Cited 1. Russell M. The Female Veteran Population: Reports and Statistics. Office of Reports and Statistics, Statistical Policy and Research Division (711), monograph RSM 70-84-1. Washington, DC; 1983:1-5. 2. Veteran Administration: Schedule for Rating Disabili-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
ties- Under the Authority of Title 38, United States Code. 3. International Classification of Diseases, 9th revision. Clinical Modification, vol. 1-3 DHHS Publication No. (PHS) 80-1260;: US Department of Health and Human Services, September 1980. 4. ICHPPC-2: Intemational Classification of Health Problems in Primary Care. 2nd ed. Report of the Classification Committee of the World Organization of National Colleges and Academic Association of General Practitioners/Family Physicians. New York, NY: Oxford University Press; 1979. 5. Schneeweiss R, Rosenblatt RA, Cherkin DC, Kirkwood CR, Hart G. Diagnosis clusters: A new tool for analyzing the content of ambulatory medical care. Med Care. 1983;21:105122. 6. The National Ambulatory Medical Care Survey: 1975 Summary. U.S. Department of Health, Education and Welfare Vital & Health Statistics Series 13-No 33. DHEW Publication No. (PHS) 1978;78-1784. 7. Allison WA. Nonorthopedic conditions in veterans with musculoskeletal disorders: A survey. J Natl Med Assoc. 1987; 79:217-219. 8. Finkelstein SN, Hutton J, Person J. Assessing technology for rehabilitation. International Journal of Technology Assessment in Health Care. 1987;3:376-379.
67
This study discusses age distribution, outpatient clinic visits, and diagnoses of female veterans with trauma-related musculoskeletal conditions. From 1981 to 1988, data were collected of female veterans seen for treatment or examination of compensation awards. Their prevalent musculoskeletal disorders were of the back, feet, and knees. This study served as a means of preparation for the anticipated changing needs of these patients when ambulatory. Key words * female veterans * musculoskeletal disorders * trauma-related Approximately 1.2 million civilian women today were on active duty in the United States armed forces. Today, women comprise about 4% of the veteran population.' As the female veteran population increases, we anticipate there will be greater demands for medical care under the Veterans Affairs (VA) medical system. The impetus for this study developed from: 1) the observation of a steady increase in the number of clinic visits from women with musculoskeletal conditions; 2) a desire to take a closer look at the musculoskeletal disorders in female veterans; and 3) a From the VA Ambulatory Care Clinic, Philadelphia, PA. Requests for reprints should be addressed to Dr W. Anthony Allison, VA Ambulatory Care Clinic, 1421 Cherry St, Philadelphia, PA 19102. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
need to prepare for the anticipated increase in female patients in an ambulatory setting. This report discusses age distribution, visit characteristics, and diagnoses of female veterans with musculoskeletal disorders.
GEOGRAPHIC DISTRIBUTION OF PATIENTS Veteran patients treated at the Philadelphia VA Ambulatory Care Clinic are from Philadelphia, areas of eastern Pennsylvania, and New Jersey. Eighteen percent of veteran patients seen in the Orthopedic Unit are from New Jersey (unpublished survey).
METHODS The study population consisted of female veterans with trauma-related musculoskeletal conditions seen in the Orthopedic Unit for treatment or examination of compensation awards (compensation and pension examinations). Data were collected from January 1981 to the end of December 1988. A daily log of each patient's visits, listing their name, age, social security number, musculoskeletal diagnoses, and comments, was maintained. Since 1984, the data were also maintained in a computerized database. Internal diagnoses are coded using the VA code,2 and cross-tabulated with the International Classifications of Diseases, (ICD-9-CM)3 and the International Classification of Health Problems in Primary Care (ICHPPC2).4 Diagnosis categorization is based on the work of Schneeweiss et al,5 and modified in the style described in their paper. For example, the category of knee 65
MUSCLOSKELETAL DISORDERS IN FEMALE VETERANS
TABLE 1. AGE DISTRIBUTION OF FEMALE VETERANS WITH MUSCULOSKELETAL DISORDERS
(N Age (years) 18-29 30-39 40-49 50-59 60-69 70 and older
=
207)
Number Percent Distribution 120 58.0 53 25.6 8 3.9 6 2.9 14 6.8 6 2.9
disorder includes all impairments of the knee such as meniscus injury, ligament injury, or joint dysfunction. Rank analysis is based on the principal diagnoses, similar to the National Ambulatory Medical Care Survey.6
RESULTS Two hundred and seven female veteran patients with musculoskeletal disorders were seen in the Orthopedic Unit. One hundred seventy-three (83.6%) were 18 to 39 years of age (Table 1), and 20 (9.7%) were over 60 years old. One hundred sixty patients (77.3%) were examined for compensation and pension awards, and 47 were seen for treatment and follow-up visits. Nine were referred to other services. Back and neck conditions comprised 55.1% of the musculoskeletal disorders. Seventy (33.8%) suffered from knee problems, 51 from foot disorders (24.6%), 11.1% from shoulder impairment, and 10.1% from hip disorders. Of the total 207 women, 81 (39.1 %) had either foot or ankle conditions, or combinations of both. Sixteen women (7.7%) who were examined for treatment and 58 (28%) who were seen for compensation and pension awards, had two or more musculoskeletal disorders. Table 2 shows the frequency of musculoskeletal disorders among the 10 principal diagnoses. Comparison of frequency and percent of musculoskeletal disorders in female and male veteran patients are shown in Table 3. Of the female patients seen in the Orthopedic Unit during this study, six were pregnant and three were under psychiatric care.
DISCUSSION This study permitted the clinic to review the important musculoskeletal conditions in female veteran patients. We did not include in this study an evaluation of patients' health outcomes. 66
TABLE 2. RANK ANALYSIS OF MUSCULOSKELETAL DISORDERS IN FEMALE VETERANS BY THE TEN PRINCIPAL DIAGNOSES
(N Rank 1 2 3 4 5 6 7 8 9 10
Diagnosis (Disorder) Lumbosacral
=
207)
Number 72 Foot 51 Bilateral knee 31 Cervical 26 Right knee 23 Left knee 16 Hip 15 Left ankle 11 Thoracolumbosacral 9 Right shoulder 8
Frequency (Percent) 34.8 24.6 15.0 12.6 11.1 7.7 7.2 5.3 4.3 3.9
The prevalent musculoskeletal disorders related to trauma involved the back. Of particular note was the frequency of foot disorders in women compared to men. Foot disorders ranked third (24.6%) as problems in female patients. When an analysis was made of the 10 principal diagnoses, foot disorders ranked second. In male veterans, foot disorders ranked fifth, comprising 4.5% of visits for musculoskeletal conditions. Although knee disorders were expected to be high, an unexpected discovery was the high percentage of patients having disorders in both knees (15%). Analysis of raw data revealed that approximately 16% of female veteran patients seen in the Orthopedic Unit were receiving treatment for non-musculoskeletal
conditions.7 The causes of trauma-related musculoskeletal conditions in female veterans were, in general, different from those of male veterans. Injuries sustained by men were mostly attributed to shrapnel and gun shot wounds, parachute jumps, explosions, falls, heavy lifting, crushing, thermal, and sports injuries, as well as helicopter jumping. Most injuries in female veterans were attributed to lifting, long marches, contusions, falls, and sports. Currently, 4% of patients visiting the clinic are women. Analysis of raw data indicates there will be a steady increase in women in the Orthopedic Unit. Within 5 to 6 years, approximately 6% of visits will be from female patients. Veterans with musculoskeletal disorders are followed for years in the Veterans Affairs medical system. The Orthopedic Unit expects to follow and manage these veterans with chronic musculoskeletal conditions. The aims of the Unit are to: 1) relieve patients' pain; 2) JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
MUSCLOSKELETAL DISORDERS IN FEMALE VETERANS
TABLE 3. COMPARISON OF RANK AND PERCENT (FREQUENCY) OF MUSCULOSKELETAL DISORDERS OF FEMALE AND MALE VETERAN PATIENTS Female Veterans Male Veterans* Musculoskeletal Disorder Percent Percent Rank Rank (Problem Category) (frequency) (frequency) Back and neck 1 1 55.1 41.3 2 Knee 33.8 2 29.8 Foot 3 24.6 5 4.8 Ankle 4 4 14.5 5.9 Shoulder 11.1 5 3 8.7 Hip 6 10.1 4.7 6 7 Wrist 3.4 8 1.9 Elbow 8 1.9 9 1.3 Limb amputation 9 0.5 7 2.0 Total patient visits 207 3039
*Male veteran patient visits in 1986.
increase functional ability; 3) decrease morbidity and risk factors; and 4) provide the best patient care possible. This study indicates that using various statistical tools to analyze and infer possible risks and outcomes from collected raw data from patients with chronic musculoskeletal conditions is effective. This approach, along with the formulation of theoretical and biological models of musculoskeletal disorders, will permit closer association between basic researchers and those carrying out the treatment.8 The staffs orientation should not only be toward the psychosocial approach, but also toward new technology and new devices. It is expected that these will offer patients with musculoskeletal disorders a greater chance for relief of symptoms. Literature Cited 1. Russell M. The Female Veteran Population: Reports and Statistics. Office of Reports and Statistics, Statistical Policy and Research Division (711), monograph RSM 70-84-1. Washington, DC; 1983:1-5. 2. Veteran Administration: Schedule for Rating Disabili-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
ties- Under the Authority of Title 38, United States Code. 3. International Classification of Diseases, 9th revision. Clinical Modification, vol. 1-3 DHHS Publication No. (PHS) 80-1260;: US Department of Health and Human Services, September 1980. 4. ICHPPC-2: Intemational Classification of Health Problems in Primary Care. 2nd ed. Report of the Classification Committee of the World Organization of National Colleges and Academic Association of General Practitioners/Family Physicians. New York, NY: Oxford University Press; 1979. 5. Schneeweiss R, Rosenblatt RA, Cherkin DC, Kirkwood CR, Hart G. Diagnosis clusters: A new tool for analyzing the content of ambulatory medical care. Med Care. 1983;21:105122. 6. The National Ambulatory Medical Care Survey: 1975 Summary. U.S. Department of Health, Education and Welfare Vital & Health Statistics Series 13-No 33. DHEW Publication No. (PHS) 1978;78-1784. 7. Allison WA. Nonorthopedic conditions in veterans with musculoskeletal disorders: A survey. J Natl Med Assoc. 1987; 79:217-219. 8. Finkelstein SN, Hutton J, Person J. Assessing technology for rehabilitation. International Journal of Technology Assessment in Health Care. 1987;3:376-379.
67
