English version - Fit for Work Europe

Fit For Work? 

Musculoskeletal Disorders and 

the Japanese Labour Market 

Ksenia Zheltoukhova 

Stephen Bevan 

Hannah Waterson

Acknowledgements 

We would like to thank all those who participated in the expert interviews for this project for 

their valuable time and advice, as well as those who reviewed and provided helpful comments 

on earlier drafts of the report, and our partner – Department of Preventive Medicine and 

Community Health at the University of Occupational and Environmental Health – for valuable 

insight and inspiration. We would also like to thank our colleagues at The Work Foundation 

for their help in the preparation of this report, in particular, Ann Hyams and David Shoesmith. 

Additionally we would like to acknowledge the content contributions of Robin McGee, Tatiana 

Quadrello, Michelle Mahdon and Eleanor Passmore. 

This piece of work was supported by a grant from Abbott. 

Fit For Work? Musculoskeletal Disorders and the Japanese Labour Market 3

Contents 

4 

1. Executive summary 6 

2. Introduction 10 

2.1 The global burden of MSDs 10 

2.2 Evaluating the economic and social impact of MSDs 10 

2.3 International context 12 

2.4 Objectives of the study 12 

2.5 Structure of the report 14 

3. Work and MSDs in Japan 15 

3.1 Why is workforce health in Japan important? 15 

3.2 Definitions and available data 18 

3.3 The impact of MSDs on ability to work 20 

3.4 Summary 28 

4. MSDs and government 29 

4.1 Costs of MSDs to the wider economy and society 29 

4.2 MSDs: The policy context 30 

4.3 Recommendations for policy makers 35 

5. MSDs and health care professionals 38 

5.1 Costs of MSDs to the health care system 38 

5.2 Access to health care in Japan 42 

5.3 Condition-specific interventions 44 

5.4 Recommendations for health care professionals 47 

6. MSDs and employers 50 

6.1 Costs of MSDs to organisations 50 

6.2 The role of employers in reducing the impact of MSDs 52 

6.3 Recommendations for employers 63 

7. MSDs and individuals 66 

7.1 Impact of MSDs on individuals and households 66 

7.2 MSDs: Intrinsic factors and lifestyle choices 70 

7.3 Role of work in health outcomes 73 

7.4 Recommendations for individuals 77 

8. Conclusions and recommendations 79 

References 82 

Appendix 1: Interviews and consultation with experts 93 

Appendix 2: Fit Note Sample 94 

Appendix 3: Benchmarking grid 95 

Fit For Work? Musculoskeletal Disorders and the Japanese Labour Market

List of Boxes and Figures 

Box 1. Principles of managing non-specific MSDs 60 

Box 2. Case study: Health Initiatives in Mazda 62 

Box 3. Case study: Participatory approaches to workplace adjustment in Japan 75 

Figure 3.1. Unemployment rates in Japan 16 

Figure 3.2. Proportion of respondents reporting health issues that have affected work 

or productivity, by type 18 

Figure 3.3. Site of chronic pain and site of most persistent pain 21 

Figure 3.4. Number of RA patients in Japan 24 

Figure 4.1. Employment situation of persons with disabilities in the private sector 34 

Figure 5.1. Health care expenditure in Japan, by disease chapter 39 

Figure 5.2. Average number of days spent in hospital due to MSDs 40 

Figure 5.3. Breakdown of medical costs relating to RA 41 

Figure 5.4. Treatment choices of patients with chronic pain (including MSDs) 43 

Figure 6.1. Productivity losses by cause 51 

Figure 6.2. Productivity losses by length of time 52 

Figure 6.3. The number of work-related diseases requiring four or more days of absence 55 

Figure 6.4. Prevalence of MSDs, by occupation 56 

Figure 7.1. Timing, severity and duration of pain in Japan 68 

Figure 7.2. Productivity loss among informal carers 70 

Figure 7.3. Health concerns of outpatients aged 65 and over 71 

Figure 7.4. ICF model applied to work disability in RA 74 


1. Executive summary 

6 

The 

‘Fit for Work?’ 

project 

The Impact of 

MSDs on the 

Japanese 

workforce 

Japan is already facing the challenge of an older – and less healthy – working age population. 

The growing number of those out of work due to old age or disability is placing additional 

physical and emotional strain on working individuals. It is estimated that by 2035 over 30 per 

cent of the population will be consuming 70 per cent of total medical expenses. 

It is clear that the growing investment in the health care system cannot match the growing 

rate of dependency of the Japanese population. This is why Japan must prioritise prolonging 

individuals’ ability to remain in work and contribute to the society. 

While much is done to react to the impact of cardiovascular conditions and cancer, as well as to 

tackle the rapid rise in the prevalence of mental health issues, a vast burden of chronic diseases 

with low mortality rates remains unseen. The long-term impact of Musculoskeletal disorders 

(MSDs) receives little attention in Japan. 

This project has looked in some detail at the impact that MSDs have had on the working lives 

of millions of Japanese individuals. It has examined the adequacy of the treatment and support 

workers receive, their experiences at work, the effect of their condition on their family and 

colleagues, and the human and financial costs involved. Specifically, we have looked at back 

pain, work-related upper limb disorders (WRULDs) – two groups of conditions which are usually 

characterised by non-specific and short episodes of pain and incapacity – and rheumatoid 

arthritis (RA) and spondyloarthropathy (SpA), specific conditions that are often progressive and 

increasingly incapacitating. We conducted a review of the recent academic and practitioner 

research on the relationship between these MSDs and labour market participation, and 

conducted interviews with acknowledged experts in this field. 

MSDs have a significant impact on people’s ability to work; not only on an individual but an 

aggregate basis. Together, they affect the productivity and labour market participation of 

thousands of Japanese workers. Evidence suggests that: 

• Among a total of 87.9 million Japanese people aged 30 years or older in 2005, 21.4 

million (24.3 per cent), 3.2 million (3.7 per cent), and 9.1 million (10.4 per cent) were 

estimated to have low back, hip, and knee pains, respectively. The prevalence rates 

of low back, hip, and knee pains will gradually increase in subsequent years, reaching 

26.5 per cent, 4.4 per cent, and 12.9 per cent, respectively by 2055; 

• MSDs present the Japanese economy and society with a burden of up to JPY 2 trillion a 

year (7.5 per cent of national medical expenditure) just in the direct medical costs; 

• About JPY 231.2 billion each year are lost due to work incapacity resulting from pain. 


What can 

be done? 

Executive summary 

The effects of incapacity and pain from these and other MSDs can impact on several aspects 

of an individual’s performance at work, including stamina, cognitive capacity or concentration, 

rationality/mood, mobility and agility. 

It is becoming clearer that people with MSDs are also likely to have depression or anxiety 

problems related to their conditions. This can affect the severity of the condition, the ability of 

the individual to remain in work, the length of time they spend away from work and the ease with 

which they can be rehabilitated. Research suggests that a significant proportion of clinicians, 

employers and even individuals with MSDs do not fully appreciate the impact of ‘stress’ on 

the severity of physical incapacity. The biopsychosocial model of health emphasises the 

interplay between the biological (eg disease, strain, joint damage), the psychological (eg 

disposition, anxiety) and the social (eg work demands, family support) and represents a helpful 

way of assessing the causes of some MSDs, of planning treatment and management and of 

approaching rehabilitation into the workplace. It is not being adopted as widely as it should, 

however, because many clinicians and employers find it difficult to look beyond the immediate 

physical symptoms. 

Work can be both cause and cure. Whilst the physical conditions of work may cause or 

aggravate musculoskeletal symptoms, the impact or outcome on individuals (absence from work 

and disability) is strongly associated with psychosocial factors. Evidence suggests that work can 

help ameliorate the deterioration of many conditions and help recovery from MSDs. However, 

many health care professionals and employers mistakenly believe that workers with MSD must 

be 100 per cent well before any return to work can be contemplated. 

Looking to the future, with prospects for an ageing workforce, a growth in obesity, a reduction in 

exercise and physical activity and fitness in the general population, it is likely that the growing 

incidence and effects of MSDs will affect the quality of working life of many Japanese workers, 

and that the productive capacity of the Japanese workforce will be adversely affected at a time 

when we need it to be in top form. 

There are three main principles which Japanese clinicians, occupational physicians, employers, 

employees and the government should focus on if the working lives of people with MSDs are to 

be improved: 

• Collect reliable data on the prevalence of MSDs in Japan. The data on the incidence 

of occupational disease collected by employers, and the data on inpatients collected 

via the health care system are inconsistent because of the variability in methods of data 

collection. Furthermore, evidence and expert views gathered in his report suggest that 



8 

the data that is available does not reflect the true picture of the prevalence of MSDs in 

Japan. Lack of comprehensive data is one reason why many individuals in Japan do 

not receive appropriate interventions in time for the most efficient management of their 

conditions. A standardised and up-to-date method to collect data on the prevalence 

of MSDs in Japan should be introduced and used by occupational physicians 

and clinicians, so that the Japanese government and the employers can develop 

appropriate policies and practices to tackle the burden of this group of conditions. 

• Early diagnosis and intervention are essential. The overwhelming evidence is that 

long periods away from work are usually bad for MSD patients. Early diagnosis and 

intervention, as well as timely and appropriate rehabilitation, will help more people keep 

their jobs and will reduce the burden of chronic disease on the wider economy and 

society. Occupational physicians are ideally placed to identify the early presentation 

of many MSDs. They should strive to detect conditions as early as practicable, and 

refer individuals to specialist teams to enable a prompt start to managing the condition. 

Similarly, communication between the specialists in the Japanese health care 

system must be improved to ensure that individuals with MSDs access appropriate 

interventions in time. An integrated care team, involving the treating health care 

professionals, occupational physicians and the individual themselves should work 

together to establish an optimal plan of intervention and return to work. 

• Coordinate action. Five stakeholder groups – individuals, employers, occupational 

physicians, clinicians and policy makers – must embrace the principles of effective 

management of MSDs to reduce and prevent the impact of chronic conditions on 

individuals’ ability to remain at work and return to employment. Better communication 

and coordination must be put in place to ensure that those with MSDs receive 

appropriate support, and that the impact of their condition on the daily activities is 

minimised. 

The report calls upon each of the stakeholder groups to take action: 

• Policy makers have to acknowledge both the direct and indirect costs of MSDs. We 

need better measures to assess the social, economic and work impact of all MSDs, 

to allow the Japanese government to assess and monitor both the clinical and labour 

market impact of MSDs in a more ‘joined-up’ way. Considering the principal role of 

policy makers in advising employers on effective prevention of chronic conditions, the 

government should urgently review the guidelines for management of MSDs for both 

manual and white-collar workers. 

• Clinicians should prioritise staying in and returning to work as both a means and an 

outcome of patient treatment. For some MSD patients, early access to physiotherapy or 



drug therapies can reduce the severity, impact or progression of the condition; a delay 

in diagnosis or treatment can make recovery, job retention or rehabilitation much more 

difficult. Clinicians should work more closely with occupational physicians to ensure 

that clinical treatment is complemented by appropriate workplace interventions and 

vocational rehabilitation. 

• Occupational physicians should look beyond legal compliance in maintaining the 

health and well-being of employees and tailor vocational rehabilitation to individual 

worker needs. When reviewing the safety of workplaces, they should acknowledge not 

only the physical, but also the psychological impact of work on health in both manual 

and non-manual jobs. 

• Employers can change the way in which the work environment is organised (including 

simple changes to physical layout or to working time arrangements) to help prevent 

MSDs from getting worse and to help people with MSD to stay in, or return to, work. 

They need to do this in a way which preserves job quality, avoids excessive or 

damaging job demands and takes heed of ergonomic good practice. Employers must 

recognise that work environment and working conditions can impact the health of both 

manual and non-manual workers. Employers should explore successful examples of 

the participatory approach and gain from employees’ first-hand experience to improve 

working conditions and work environments. 

The evidence presented in this report illustrates that a large proportion of working age people 

in Japan are, or will be, directly affected by musculoskeletal conditions (MSDs) in the coming 

years. This can have very significant social and economic consequences for these individuals 

and their families, it can impede the productive capacity of the total workforce and parts of 

Japanese industry and it can draw heavily on the resources of both the health system and the 

benefits regime. 

We have found important clinical, epidemiological, psychological and economic evidence 

and expert opinion on the nature, extent and consequences of the MSD problem in Japan. 

However, there still seems to be a lack of coherence or ‘joined-up’ thinking and action which 

focuses on extending the working lives of MSD patients. While the number of advocates of 

the biopsychosocial model as it applies to all MSDs is growing, its principles are yet to be fully 

embraced. 


2. Introduction 

10 

2.1 

The global 

burden of 

MSDs 

2.2 

Evaluating the 

economic and 

social impact 

of MSDs 

At least one billion people in the world live with some form of disability; for 200 million of them 

the long-term health conditions significantly affect their ability to perform activities of daily life 

(World Health Organisation (WHO), 2011). Population ageing, as well as the increase in chronic 

health conditions such as diabetes, cardiovascular disease, cancer and mental health disorders 

contribute to the growing prevalence of disability. 

Musculoskeletal disorders (MSDs) such as low back pain, arthritis and other diseases of the 

joints are among the leading causes of disability (WHO, 2011). MSDs account for more than 

10 per cent of all years lost to disability globally (WHO, 2009). The conditions of this group, 

although not leading directly to mortality, impact the individuals’ ability to live independently and 

continue productive working lives. 

The impact of MSDs on individuals and their ability to work varies significantly from person to 

person. Work disability is usually estimated in relation to cessation of employment, reduced 

working hours or claiming of disability benefits. These estimates rarely take into consideration 

lost productivity whilst at work. The effects of pain from MSDs can impact on many aspects of 

one’s performance at work, such as stamina and resilience, cognitive capacity or concentration, 

rationality/mood, fatigue, mobility and agility. 

Reduced productivity of workers with MSDs and their premature withdrawal from the labour 

market have negative spillover effects on the economy and society. The variety of physical and 

psychological symptoms of MSDs and comorbidities means that the actual burden of MSDs on 

individuals, employers and the society may be significantly underestimated. Yet, work is still not 

considered to be a valued clinical outcome in treating individuals with MSDs. 

Calculating the exact costs of MSDs is not straightforward (Lundkvist, Kastäng and Kobelt, 

2008). Several factors need to be considered, and obtaining accurate, reliable and consistent 

figures is almost impossible. 

To calculate the cost of MSDs (or any illness) the following factors must be estimated: 

• Direct costs including medical expenditure, such as the cost of prevention, detection, 

treatment, rehabilitation, long-term care and ongoing medical and private expenditure. 

They are often further separated into medical costs occurring in the health care sector 

and non-medical costs occurring in other sectors (Lundkvist, Kastäng and Kobelt, 

2008); 


• Indirect costs including lost work output attributable to a reduced capacity for activity, 

such as lost productivity, lost earnings, lost opportunities for family members, lost 

earnings of family members and lost tax revenue; 

• Intangible costs including psychosocial burden resulting in reduced quality of life, such 

as job stress, economic stress, family stress and suffering (WHO, 2003). 

These costs vary considerably depending on the condition, on the severity of the symptoms, 

and whether these cause short or long-term absence or disability. Moreover, they vary 

depending on the particular methods used to calculate the costs. Some factors which affect the 

calculations include the following: 

• Severity of patient’s conditions; 

• Mix of patient demographics in a study; 

• Calculation method for productivity; 

• Definitions of work disability; 

• The treatment costs or outcomes due to treatments; 

• Change in health care financing systems; 

• Incidence or prevalence based estimates of costs. 

Introduction 

The biopsychosocial model (Waddell and Burton, 2006b) advocates taking into consideration 

the interplay between the biological (eg disease, joint damage), the psychological (eg 

disposition, anxiety) and the social (eg work demands, family support) factors, when assessing 

the overall impact of chronic health conditions. The psychological status and behaviour of 

a patient can be equally affected by a ‘physical’ injury (such as back pain), and should be 

addressed during treatment and rehabilitation. It is evident that the interaction of the biological, 

psychological and social dimensions defines the long-term impact of a musculoskeletal 

condition. 

While it is hardly possibly to quantify the exact burden of MSDs on individuals, employers and 

the wider society, it is clear that reduced workability contributes to the indirect and intangible 

costs of MSDs, which are eventually greater than the direct costs of treatment (Lundkvist, 

Kastäng and Kobelt, 2008). A number of stakeholders including policy makers, health care 

professionals, employers and individuals have to work together to anticipate the negative 

impact of MSDs in time for the most efficient prevention and management of the effects of those 

conditions. 


Introduction 

12 

2.3 

International 

context 

2.4 

Objectives 

of the study 

To raise awareness of the disability caused by MSDs the United Nations declared the years 

2000 to 2010 The Bone and Joint Decade. Many countries, including Japan, have since 

acknowledged the increasing prevalence of MSDs and the rising costs of those conditions. 

For example, over 107 million adults in the United States (US) reported MSDs in 2005 (United 

States Bone and Joint Decade, 2008). Similarly, chronic musculoskeletal pain is estimated to 

affect 100 million people in Europe (Veale, Woolf and Carr, 2008). 

Many of individuals living with MSDs are of working age. In the European Union (EU) MSDs 

affect more than 40 million workers and account for about half of all work-related disorders 

(European Trade Union Institute (ETUI), 2007), representing an estimated cost to society 

of between 0.5 and 2.0 per cent of gross domestic product (GDP) (Cammarota, 2005). The 

European Commission estimates that MSDs account for 49.9 per cent of all absences from 

work lasting three days or longer and for 60 per cent of permanent work incapacity (European 

Agency for Safety and Health at Work, 2007). 

Increasing awareness of the burden of MSDs on economies and societies has led to the 

proposal of the EU directive on MSDs, forthcoming in 2012. 1 Unlike other recent EU directives, 

this most recent one focuses primarily on MSD-related workplace risk, taking into account 

individual or psychological factors as well as the social milieu in which individuals live their lives, 

where work plays a large part. In particular, the directive prescribes that psychosocial factors 

(essentially stress) must be considered and assessed along with the ‘physical’ work-related ill 

health. Such recommendation signifies a welcome cultural shift towards viewing patients as 

workers and aiming at returning to work to become an ultimate outcome of treatment. 

This report looks at Japan in this wider global context and assesses where Japan is doing 

well and where it has challenges to confront. Appendix 3 compares Japan with other countries 

across a range of labour market, welfare and health care systems indicators. 

More specifically, this project has sought to address each of the following questions: 

1. What is the impact of MSDs on employment and economic performance in Japan? 

How is this likely to change in the context of future demographic, workforce and lifestyle 

changes? 

2. What is the relationship between work and MSDs? What impact do biological, 

psychological and social factors, including workplace factors, have on MSDs? 

1 See Health and Safety Executive http://www.hse.gov.uk/aboutus/europe/euronews/dossiers/msd.htm 


Introduction 

3. How well do employers, governmental bodies, clinicians and occupational health 

professionals understand and deal with MSDs as they relate to the workplace? How 

well equipped is the health sector to provide early intervention, rehabilitation and other 

support for people with these conditions? 

4. What early interventions can policy-makers and employers deliver to ensure that 

those with MSDs a) retain their jobs b) maximise their quality of working life and their 

contribution to society and c) maintain access to (and routes back into) employment? 

In addressing the objectives outlined above, we have used the following approaches: 

1. Desk research: Here we have drawn on existing published research from the medical, 

occupational health and health economics literature. This has enabled us to bring 

together the evidence on the nature, extent, impact and costs of MSDs to the Japanese 

economy, to employers and to individuals. We have examined a range of MSDs to 

assess the extent to which their impact varies and where policy and practice has been 

both strong and weak in preventing and intervening. 

2. Secondary data analysis: We have used data from domestic and regional studies and 

surveys to examine the prevalence and costs of MSDs in the working age population in 

Japan. 

3. Expert interviews: We have conducted interviews with sixteen Japanese experts across 

a number of disciplines (including occupational health, policy making, consulting, 

rheumatic disease, neck and back pain) to identify the main areas of policy and practice 

which need to be addressed by policy makers, health professionals and by employers. 

In addition to the wider picture, to focus the research, we have chosen to concentrate on four 

categories or groups of MSDs. These are: 

• Back pain; 

• Work-related upper-limb disorders such as regional pain and non-specific forearm pain 

(WRULDs); 

• Rheumatoid arthritis (RA); 

• Spondyloarthropathy (SpA). 

Back pain and the majority of WRULDs are categorised as non-specific and episodic conditions 

which may frequently be caused by, or be made worse by, work. They manifest themselves in 

disparate ways and may cause periods of intense discomfort and incapacity which may affect 

the ability of the individual worker to carry out their work. They may also abate for long periods. 

Many people with these conditions, such as back pain, never seek treatment and most recover 


Introduction 

14 

2.5 

Structure of 

the report 

on their own but the conditions can cause significant absence from work or lost productivity. 

Back pain and WRULDs are often included in the occupational health and safety guidelines and 

literature. Occupational health practitioners typically deal with these conditions. 

On the other hand, RA and SpA are specific and progressive rheumatic diseases which are 

not caused by work, but may be made worse by work and are often handled by general 

practitioners and specialists, not within the occupational health arena. They are clinically 

diagnosed conditions that, if untreated, progress in a broadly predictable way. They can have a 

significant impact on functional capacity at work and, in the long-term, participation in the labour 

market. Most people with these conditions require clinical interventions over a prolonged period 

of time and the management of these conditions for those of working age should involve the 

frequent and active participation of clinicians, employers and occupational health professionals. 

The analysis of the impact of MSDs in Japan is structured as follows: 

• Section Three examines the extent of MSDs in Japan and the implications of related 

poor health for the Japanese society. 

• Sections Four, Five, Six and Seven review the impact and costs of MSDs from the 

perspectives of the Japanese government, health care professionals, employers and 

employees, providing recommendations for each group of stakeholders on how to 

tackle the burden of chronic conditions in Japan. 

• Section Eight summarises the case for early intervention for MSDs and presents a Call 

to Action for the four stakeholder groups. 


3. Work and MSDs in Japan 

3.1 

Why is 

workforce 

health 

in Japan 

important? 

This section sets out what we know about the impact of MSDs on people of working age in 

Japan. It uses data, research and interview evidence from Japanese sources where this is 

available, and paints a picture of the challenges faced by both current and future Japanese 

workers, their families, their employers and, ultimately, state agencies. 

For many years Japan has been one of the strongest economies in the world, seeing a gradual 

slowdown since the 1990s. Historically, the Japanese economy relied on the manufacturing, 

construction, distribution, services, and agricultural sectors. However, following the downturn in 

Europe and the US, many Japanese companies have shifted production overseas, leading to an 

increase in unemployment rates. In addition, the tragic outcomes of the tsunami and earthquake 

in 2011 have affected many manufacturing companies based in North-East Japan, while 

radiation fears have negatively affected exports. 

From the post-war period until the end of the 1980s the Japanese employment system was 

characterised by the lifetime employment pattern, where promotion and wages were dependent 

on seniority. While aspects of this system remain, in recent years the employment structure 

has changed. The current economic climate means that Japanese companies are less likely to 

take on regular staff, as part-time and agency workers are not entitled to the same employment 

protection or benefits, and are easier to dismiss. The number of non-regular workers has 

increased from under 20 per cent in 1980 to over 34.4 per cent in 2010. Of these, 16.6 per cent 

were part-time jobs, 6.8 per cent – side jobs, 6.5 per cent – temporary positions, and 1.9 per 

cent – agency workers (Japan Institute for Labour Policy and Training (JILPT), 2012). 

The rise in non-regular workers has had severe consequences. Non-regular positions come with 

less financial security, making it difficult for individuals to make long-term plans. Consequently 

young people in these positions put off marriage and children, contributing further to the 

declining birth rate. More importantly, insecure jobs have a detrimental effect on individuals’ 

health, reducing the number of productive working years, as well as having a negative effect 

on the overall productivity (JILPT, 2012). Out of the fear of losing their jobs, many employees 

may be putting in unpaid overtime: for example, 20 per cent of 30-year-old males in Japan work 

over 60 hours per week – the degree of overtime which has been linked to physical and mental 

health problems (JILPT, 2012). 

Although the unemployment rate in Japan has been generally low for the past couple of 

decades, the proportion of long-term unemployed is relatively high: in 2010 at least 37.6 per 

cent of all unemployed people were without work for longer than a year. 2 

2 See Organisation for Economic Co-operation and Development (OECD) http://stats.oecd.org/ 


Work and MSDs in Japan 

16 

Figure 3.1 illustrates the changes in unemployment and long-term unemployment rates. 

Figure 3.1. Unemployment rates in Japan 

6.0 

5.0 

4.0 

3.0 

2.0 

1.0 

0.0 

2.3 2.2 

2.1 

2.4 

0.4 0.4 0.3 0.4 

3.0 

3.1 3.4 3.5 3.7 

0.5 0.6 0.7 0.7 0.8 

4.7 4.9 4.8 

1.1 

1.2 1.2 

5.4 5.3 

90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 06 07 08 09 10 

1.6 

1.7 1.7 

4.7 4.4 4.1 

Long-term unemployment Unemployment rate 

3.9 4.0 

1.4 1.4 1.2 1.3 1.4 

5.1 5.1 

Fit For Work? Musculoskeletal Disorders and the Japanese Labour Market 

1.8 

Source: JILPT (2012) 

Increasing long-term unemployment rates in Japan may be associated, among other reasons, 

with the difficulty for certain population groups to access equal opportunities in the labour 

market. The recession has affected many graduates competing for a smaller number of jobs, 

but equally those who are not able to perform to their full capacity due to ill health. 

While bad health may lead to unemployment, unemployment itself can negatively impact on 

health. Unemployment may exacerbate existing health conditions and lead to comorbidities, 

such as depression, further complicating the patients’ chances of competing in the labour 

market and placing an even higher burden on the Japanese health care system. 

Public expenditure on health in Japan has been growing year on year; however, it seems that it 

yet fails to match the challenges of ageing population (Nakamura, 2008). Although the overall 

population has been on the decline since 2005, the proportion of those aged 65 and over is 

higher that ever. In the next 50 years the proportion of senior citizens in Japan is predicted to 

grow, while there will be fewer people of working age to support the elderly.

There are serious concerns that the shrinking workforce will not be able to cope with social 

security demands of the ageing and ill population in future years (Nakamura, 2008). It is 

predicted that by 2017, the Japanese aged 65 years and over will account for 30 per cent of 

the population, that proportion rising to 40 per cent by 2050. This will place an an even greater 

burden on the nursing home services in Japan. 3 It is therefore essential that there are provisions 

to improve individuals’ health, so that people can continue to live and – where possible – work 

independently. 

At the same time, following the media focus on the high number of cases of death from 

conditions related to overwork (karōshi) and suicides related to work stress, new initiatives have 

been put in place aiming to improve workers’ mental health. However, much less is being done 

to prevent the impact of chronic conditions, such as MSDs, on the working age population. 

MSDs and chronic pain have significant impact on an individual’s productivity (Figure 3.2). 

A number of other indicators suggest that workforce health must become an important priority 

for policy makers and employers in the foreseeable future: 

• A comparison of MSD prevalence by occupation revealed higher prevalence among 

those doing professional work (20.5 per cent), office and technical work (18.1 per 

cent), and part-time work (16.9 per cent), whereas the lowest prevalence was found in 

students (7.0 per cent), followed by workers in agriculture, forestry, and fisheries (12 

per cent) and those with no occupation (13 per cent) (Nakamura, Nishiwaki, Ushida and 

Toyama, 2011). 

• 1.2 million individuals of working age are physically disabled (Ministry of Health, Labour 

and Welfare (MHLW), 2006). 

• Among a total of 87.9 million Japanese people aged 30 years or older in 2005, 21.4 

million (24.3 per cent), 3.2 million (3.7 per cent), and 9.1 million (10.4 per cent) were 

estimated to have low back, hip, and knee pain, respectively. The prevalence rates of low 

back, hip, and knee pains will gradually increase in subsequent years, reaching 26.5 per 

cent, 4.4 per cent, and 12.9 per cent, respectively by 2055 (Suka and Yoshida, 2009). 

Despite the growing evidence of the impact of MSDs on the health and productivity of the 

Japanese workforce, the early diagnosis and treatment of MSDs is only slowly becoming a 

priority among Japanese decision-makers. Lack of comprehensive data is one reason why 

many individuals in Japan do not receive appropriate interventions in time for the most efficient 

management of their conditions. 

3 Expert interview 




18 

3.2 

Definitions 

and available 

data 

Figure 3.2. Proportion of respondents reporting health issues that have affected work or 

productivity, by type 

Pain 

Including: Chronic back or neck 

shoulder pain 

Including: Arthritic pain 

Mental illness 

Physical injury or disability 

Non-infectious chronic disease 

Infectious disease 

15.3% 

14.7% 

23.7% 

23.7% 

27.1% 

31.6% 

0% 10% 20% 30% 40% 50% 60% 

The lack of standardisation and validation of the terminology and classification of MSDs is 

one of the reasons for the contradictory findings in the literature regarding the diagnosis, 

epidemiology, treatment and rehabilitation of these conditions (WHO, 2003). 

55.3% 

Source: American Chamber of Commerce Japan (ACCJ, 2011b) 

The list of occupational diseases in Japan, specified under the Ordinance for Enforcement of 

the Labour Standards Act of 1947, includes among others the following illnesses associated 

with jobs which involve extreme physical tension: 

a. Muscle, tendon, bone, or joint illness or prolapse of internal organs due to strenuous 

jobs; 

b. Low back pain resulting from work that involves handling heavy objects, work done in 

unnatural postures, or work which involves excessive tension to low back; 

c. Peripheral circulatory failure, peripheral nerve disorder, or motive organ disorder 

of fingers, forearms etc., associated with vibrations of the body due to the use of 

equipment or machinery, such as rock drills, rivetters, or chain saws; 


d. Cramping of fingers, inflammation of tendons, sheath of tendons or four parts around 

tendons of fingers, forearms etc., or shoulder-arm-neck syndromes resulting from work 

that involves punching, typing, telephone switchboard operation, or stenography, work 

which involves cash registers, work which involves the use of tools with triggers, or 

works which involves excessive tension to the upper limbs; 

e. In addition to the conditions listed in ‘a’ to ‘d’ and associated conditions, other illness 

which clearly results from work involving excessive tension to the body. 

While this list demonstrates an understanding of how conditions in the workplace are directly 

linked to diseases, it fails to reflect the likely changes in the epidemiology of disease associated 

with the structural changes in the labour market and overall population. The list above focuses 

mainly on disorders linked to heavy lifting and other physical factors associated with manual 

work, yet fails to address the workplace factors that may lead to MSDs among white-collar 

workers and those at the managerial level. 4 In addition, the list fails to address the fact that other 

conditions, such as RA, may affect work, although they are not directly caused by work. This 

suggests that the existing definition and categorisation of MSDs may be unhelpfully narrow as a 

reflection of MSD prevalence and impact specific to the Japanese population. 

Slow action in prioritising prevention of MSDs in workplaces may in part be explained by the 

poor quality of data used by the official agencies. The number of people with MSDs is estimated 

by the Health Statistics Office of the MHLW based on data supplied by the Patient Survey, 

which measures the number of people receiving treatment, and the Comprehensive Survey on 

Living Conditions, in which participants self-diagnose their symptoms. The effect of MSDs in the 

workplace, on the other hand, is measured by the Work-Related Diseases Survey carried out by 

the Labour Standards Bureau. Although MSDs feature predominantly in each of these surveys, 

there is little coordination between the ministerial departments in data collection and policy 

action. 5 

In addition, MHLW data on prevalence is based on the cases where employees take more 

than four days off work (MHLW, 2010b). Experts express concern that this method of collecting 

epidemiological data on work-related MSDs may mask the extent of the problem, where 

individuals may be experiencing MSD-related health issues without taking official sick leave. 

As a result, the data on the prevalence of MSDs in Japan is not consistent because of 

the variability in methods of data collection. For example, the MHLW Patient Survey uses 

international disease codes (ICD-10) to collect inpatient data on the incidence of MSDs, while 






20 

3.3 

The impact 

of MSDs on 

ability to 

work 

the data on work-related compensations is gathered according to the list of occupational 

diseases above. Such approach to epidemiological surveys may lead to misleading in-country 

and international comparisons. This is a troubling picture for a number of reasons: 

• Low awareness of the wider economic and societal costs of MSDs, their impact on 

productivity, workers and their families delay action necessary to be taken by Japanese 

employers and policy makers. For example, the guidelines on low back pain, issued in 

1994, are highly relevant for prevention of industrial accidents associated with manual 

work, yet are not applicable to prevent back pain among office workers. 

• If, as is likely, the prevalence of MSDs increases with the ageing of the Japanese 

workforce, the absence of good baseline data will complicate forecasting of the future 

impact of MSDs. 

• The benefits of clinical, labour market or workplace interventions are made all the more 

difficult to quantify (or justify) if there are no reliable or comprehensive data on the 

extent or impact of MSDs in the Japanese workforce. 

While the number of compensation claims for MSDs has been decreasing gradually in Japan 

(MHLW, 2010c), hinting at a decline in the incidence, this trend may in fact reflect the gaps in 

the system of classification of work-related diseases, which restricts the definition of MSDs to 

the occupational injuries caused by work. Exclusion of chronic diseases of the musculoskeletal 

system, with less obvious links to the work-related causes, may be misleading the reporting of 

the prevalence of MSDs. 

At the same time, Japanese National Livelihood survey on chronic pain (Nakamura et al., 2011) 

revealed that MSDs are the most common reason for individuals to be experiencing chronic 

pain in Japan (see Figure 3.3). 

This section reviews existing data on the prevalence of four MSDs common in Japan. 

3.3.1 Back pain 

Back pain, back problems and disc disorders are very common complaints in Japan. One 

large-scale study reports that of all the respondents experiencing chronic muscular pain, at 

least 65 per cent had pain in their low back (Nakamura et al., 2011). Another study reports that 

57.1 per cent of males and 51.1 per cent females experienced low back pain severe enough 

to seek treatment (Fukuhara, Suzukamo, Morita, Takahashi, Konno et al., 2003). At the same 

time, official data is much different from the self-reported prevalence. As the patient survey data 

collected by MHLW is based on absence data of four days and longer, the rates of back pain 

appear to be much lower: in 2009 only 81 cases of work-related low back pain were recorded, 


Figure 3.3. Site of chronic pain and site of most persistent pain 

Proportion of respondents 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Neck 

Shoulder 

Elbow & surrounding areas 

Hand 

Overall arm 


which is almost twice as many as the 45 cases in 2005 (MHLW, 2008a). In the vast majority of 

patients with back pain no specific diagnosis is given. 

Back pain is common, episodic, often recurrent and generally self-limiting. It is defined as 

recurrent if several episodes occur in one year for a duration of less than six months, acute if an 

episode lasts for less than six weeks, sub-acute (7-12 weeks) and chronic if it endures for over 

12 weeks. Back pain is a recurrent problem for many people, although this does not necessitate 

that symptoms will worsen. For the majority of people pain will disappear of its own accord 

within four to six weeks. In a European study of people visiting their family doctors because of 

back pain, 65 per cent were free of symptoms within 12 weeks (van der Hoogen et al., 1998 in 

Bekkering, Henriks, Koes, Oostendorp, Ostelo et al., 2003). 

In Japan 61.4 per cent of individuals reporting back pain are in employment (Fukuhara et al., 

2003). Recorded absence is greatest amongst the minority of individuals whose condition is 

chronic or recurrent. Most people who are affected by back pain either remain in work or return 

to work promptly. About 85 per cent of people with back pain take fewer than seven days off, 

yet this accounts for only half of the number of working days lost. The rest is accounted for by 

the 15 per cent who are absent for more than one month (Bekkering et al., 2003). In Japan, the 

Fit For Work? Musculoskeletal Disorders and the Japanese Labour Market 21 

Back 

Low back 

Hip & surrounding area 

Knee & surrounding area 

Site of chronic pain Site of most persistent pain 

Foot 

Overall leg 

Source: Nakamura et al. (2011)


22 

average time to return to work or household tasks after experiencing back pain was 11.3 days; 

the longest time taken off was two years (Fukuhara et al., 2003). 

The important question is therefore why, when so many people experience back pain, does 

it have such an adverse effect on some and not others? There is a growing consensus that 

psychological factors are the differentiating factor as they are strongly associated with the 

progression of back pain from an acute to a chronic condition that affects two to seven per cent 

of people (Burton, 2005), and to disability (Burton, 2005; Bekkering et al., 2003). For example, 

in Japan the prevalence of episodes of various musculoskeletal pain differed by gender, age, 

size of city lived in, income, job status, education, body mass index, and baseline quality of life 

(Tokuda, Ohde, Takahashi, Shakudo, Yanai et al., 2007). 

3.3.2 Work-related upper limb disorders 

WRULDs such as muscular pain in the neck, shoulders and upper limbs are second most 

common complaints relating to muscular pain in Japan. One survey found that of all the 

respondents experiencing chronic muscular pain, at least 55 per cent had pain in the neck, with 

just under 10 per cent complaining of pain in the arms or hands (Nakamura et al., 2011). At the 

same time, shoulder and neck were also highly ranked among sites of pain persisting for the 

longest periods of time (Nakamura et al., 2011). 

Katakori (neck and shoulder pain) is the most common complaint in Japanese females, and it is 

the second most common following lumbar pain in males, according to a comprehensive survey 

of living conditions (health and welfare) of the general population conducted in 2004. 6 On the 

other hand, Tada, Yoshida and Murase (2001) investigated the prevalence of industrial hygienerelated 

katakori, and showed that katakori was most commonly observed in office workers 

(63.2 per cent), followed by engineers (53.2 per cent) and skilled technicians (40.6 per cent). 

These results suggest that the prevalence of katakori differs according to occupation. MHLW 

recorded 726 cases of WRULDs in 2009, which is on decline from 986 the previous year 

(MHLW, 2010b). 

In an earlier study, reporting somewhat lower prevalence of neck and shoulder pain (at 20.3 per 

cent), Suka and Yoshida (2005) found that WRULDs interfere with individuals’ activities in 31 per 

cent of the cases for pain in neck and shoulder area, and 21.5 per cent of the cases for elbow, 

wrist, and hand area. 

6 See MHLW http://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa04/3-1.htm 


The difficulty in classifying WRULDs is also reflected by a considerable debate about the 

definition and diagnostic criteria for WRULDs, which are also commonly referred to as ‘sprains 

or strains’, ‘repetitive strain injuries or disorders’, or ‘cumulative trauma disorders’. Both specific 

and non-specific disorders and symptoms can be covered by this category. Van Eerd, Beaton, 

Cole, Lucas, Hogg-Johnson et al. (2003) identified 27 different classification systems for workrelated 

MSDs, of which no two were found to be alike. The fact that a single disorder is often 

described in different ways only amplifies the problem of the systematic monitoring of WRULDs. 

Critically, Van Eerd et al. (2003) found that the different classification systems did not agree on 

which disorders should be included. This definitional problem makes it difficult to calculate the 

number of people with WRULDs and to develop a common understanding of the associated risk 

factors. 

Whilst no agreed classification exists there is a common consensus that symptoms of WRULDs 

can present in the tendons, muscles, joints, blood vessels and/or the nerves and may include 

pain, discomfort, numbness, and tingling sensations in the affected area. WRULDs can be 

specific and non-specific conditions (Aptel, Aublet-Cuvelier and Cnockaert, 2002) and attempts 

at classification tend to focus either on the affected body area or on the cause. Examples of 

WRULDs by body part include the following: 

• Elbow: Epicondylitis (tennis or golfer’s elbow); 

• Hand, wrist and forearm: Carpal tunnel syndrome; repetitive strain injury, de Quervain’s 

syndrome; 

• Shoulder: Tendinitis of the shoulder; 

• Neck: Neck pain. 

Classification by occupational causes refers to actions such as vibration of the hand and arm, 

which can result in Raynaud’s Syndrome, for example. The breadth of the definition of WRULD 

means that almost all symptoms and impacts on work associated with MSDs are associated 

with WRULDs. Specific symptoms and impacts of MSDs are therefore discussed in more detail 

below with reference to back pain, RA and SpA conditions. 

3.3.3 Rheumatoid arthritis 


RA is estimated to affect 600,000 patients in Japan, or about 0.5 per cent of the population 

(Tanaka, 2011). This estimated prevalence is in line with the average world prevalence rate 

estimated by WHO at between 0.3 per cent and 1 per cent in most industrialised countries 

(WHO, 2003). 



24 

RA affects people of any age, although the peak incidence of RA is identified in the population 

aged 40-55 (Japan Rheumatoid Arthritis Friendship Association, 2010). In addition, females 

are more likely to be affected than males (see Figure 3.4). Epidemiological studies have shown 

that RA shortens life expectancy by around 6-10 years. The exact cause of RA is unknown. 

Evidence suggests that it is an immune reaction, presenting as an inflammation affecting joints 

and other tissues. Risk factors include gender, family history of RA and specific leukocyte 

antigen (HLA) (WHO, 2003). For Japan, the variation in the distribution of HLA in the population 

has to be taken into account when estimating the prevalence of RA (Tam, Leung and Li, 2009). 

Figure 3.4. Number of RA patients in Japan 

Thousands 

400 

350 

300 

250 

200 

150 

100 

50 

0 

1996 1999 2002 2005 2008 

Total RA patients 

Male 

Female 

Source: Japan Rheumatoid Arthritis Friendship Association (2010) 

Whilst at an individual level the clinical course of RA is extremely variable, its features include 

pain, stiffness in the joints and tiredness, particularly in the morning or after periods of inactivity, 

weight loss and fever or flu-like symptoms. It affects the synovial joints, producing pain and 

eventual deformity and disability. The disease can progress very rapidly, causing swelling and 

damaging cartilage and bone around the joints. It can affect any joint in the body, but it is often 

the hands, feet and wrists that are affected. RA can also affect the heart, eyes, lungs, blood and 

skin. 

The course of RA varies, meaning that it can go from a mild and even self-limiting form of the 

disease, to being severe and destructive within a short time (Young, Dixey, Cox, Davis, Devlin 


et al., 2000). RA is usually chronic (persistent) and people with the condition often have ‘flares’ 

of intense pain frequently associated with fatigue, although the reason for these symptoms is 

not known. In effect, ‘flares’ mean that one day someone will be able to perform their duties and 

the next they cannot. This can be difficult for colleagues and managers to comprehend, and can 

make planning workloads challenging. Managing these ‘flares’ in employment requires close 

communication and understanding between employees and employers. 

The effects of the disease can therefore make it difficult to complete every day tasks, often 

forcing many people to give up work or opt to work part-time. 7 Work capacity is restricted by 

two-thirds within one year and 40 per cent of those diagnosed with RA stop working after three 

years because of their RA (Bone and Joint Decade, 2005). People in more active roles are 

least likely to remain in work, however, those who work in more sedate, desk-bound jobs may 

not perform to their full capacity due to fatigue, pain or lack of concentration caused by these 

symptoms. As a result they may be more likely to make mistakes and are at greater risk of 

losing their jobs. In one survey of 8,307 RA patients, 25 per cent of respondents experienced 

suspension, resignation or withdrawal from work because of RA (Japan Rheumatoid Arthritis 

Friendship Association, 2010). 

Institute of Rheumatology, Rheumatoid Arthritis (IORRA) longitudinal study of individuals with 

RA in Japan, initiated in 2000, reports on the impact of the disease on individuals’ ability to 

continue working (Tanaka, 2011). Of the 5,201 respondents: 

• 32 per cent (1,666 people) continued the same job after diagnosis; 

• 9 per cent (469) have changed working hours or job; 

• 7.7 per cent (400) stopped working because of RA; 

• 40.3 per cent (1,097) work or help in the home; 

• 3.1 per cent (159) neither work, nor do housework. 

The impact of disease on patients’ quality of life may be underestimated when assessed with 

‘Western measures’ due to poorer communication with medical systems and lack of funds. 8 As 

well as the impact of the physical and cognitive symptoms of RA on an individual’s ability to 

work, psychological effects of the disease, such as depression, may also have an impact on 

a patient’s likelihood of returning to work or coping in the workplace; however, psychological 

support for patients with RA is not provided by the state and rheumatologists are yet to go 

beyond treating only the physical symptoms of the illness. 9 


8 Expert interviews 





26 

3.3.4 Spondyloarthropathies 

Spondyloarthropathies (SpA) represent a family of chronic inflammatory conditions which 

include: 

• Ankylosing spondylitis (AS); 

• Reactive arthritis (ReA)/Reiter syndrome (RS); 

• Psoriatic arthritis (PsA); 

• Spondyloarthropathy associated with inflammatory bowel disease (IBD); 

• Undifferentiated spondyloarthropathy (USpA). 

Prevalence of SpA in Japan is estimated at 0.95 per 100,000 population with incidence of 

0.48 per 100,000 person-years (Hukuda, Minami, Saito, Mitsui, Matsui et al., 2001). However, 

recent research on the frequency of SpAs across the European population concludes that the 

prevalence has long been underestimated, and SpAs may have a similar prevalence rate to RA 

(Akkoc, 2008). Similarly, a US study estimates that there are 2.4 million Americans with SpA 

compared to 1.3 million Americans with RA (Helmick et al., 2008; cited in Brown, 2009). 

Ankylosing spondylitis is a specific progressive and chronic rheumatic disorder that mainly 

affects the spine, but can also affect other joints, tendons and ligaments. Its prevalence in the 

general population is most commonly reported to be 0.1-0.2 per cent, with a 3:1 to 2:1 male: 

female ratio (Dagfinrud, Mengshoel, Hagen, Loge and Kvien, 2004). Prevalence of AS in Japan 

is estimated at 0.65 per 100,000 population with incidence of 0.33 per 100,000 person-years 

(Feldtkeller and Braun, 2002). First diagnosis is often made when people are in their teens 

and early twenties (the mean age of onset is 26). Research suggests that there is a strong 

genetic component to the cause of AS. Although anyone can get AS, it affects men, women and 

children in slightly different ways (Dagfinrud et al., 2004). In men, the pelvis and spine are more 

commonly affected, as well as the chest wall, hips, shoulders and feet. Women are supposed 

to have a later age of onset, milder disease course, longer asymptomatic periods but more 

extraspinal involvement. Accurate diagnosis can often be delayed since the early symptoms 

are frequently mistaken for sports or work injuries. 10 Sieper, Braun, Rudwaleit, Boonen and Zink 

(2002) suggest an average of seven years between disease onset and diagnosis. Typical AS 

symptoms include pain (particularly in the early morning); weight loss, particularly in the early 

stages; fatigue; fever and night sweats and improvement after exercise. Again, as with RA, the 

temporal aspects of the disease do not make work impossible, but require good management to 

ensure that individuals can perform their job. 

10 Information provided by an in-country expert 



Approximately half of people with SpA are severely affected whilst others report very few 

symptoms. AS is generally considered to be a disease in which many individuals can maintain 

relatively good functional capacity (Chorus, Boonen, Miedema and van der Linden, 2002), yet 

reported unemployment rates are three times higher among people with AS than in the general 

population (Boonen, Chorus. Miedema, van der Heijide, Landewé et al., 2001). 

Psoriatic arthritis is a form of joint inflammation affecting between 0.2 and 1 per cent of the 

general population (Wallenius, Skomsvoll, Koldingsnes, Rødevand, Mikkelsen et al., 2008) and 

between 10 and 20 per cent of individuals with psoriasis. In Japan, however, there is a 64- and 

180-fold lower incidence with prevalence of PsA at between 0.1 and 1 per 100,000 population, 

as compared with the median incidence and prevalence in other countries (Tam, Leung and Li, 

2009). 

When joints are inflamed they become tender, swollen and painful on movement. The joints 

are typically stiff after resting, early in the morning or while resting in the evening. Tissues 

such as ligaments, tendons around the joints may also be involved. Inflammation of tendons or 

muscles (such as tennis elbow and pain around the heel) is also a feature in those with psoriatic 

arthropathy. In approximately 80 per cent of cases the arthritis develops after the appearance of 

psoriasis. Men and women are considered to be equally affected, and comparative studies have 

showed that patients with PsA have a burden of illness which is comparable to that of patients 

with RA or AS (Wallenius et al., 2008). 

There are several features that distinguish PsA from other forms of arthritis: one pattern of 

inflammation is usually in the end of finger joints. Another pattern is involvement of the joints 

of the spine and sacroiliac joints which is called spondylitis (similar to ankylosing spondylitis). 

Neck pain and stiffness can occur or an entire toe or finger can become swollen or inflamed 

(dactylitis). There can also be a tendency for joints to stiffen up and sometimes to fuse together. 

Importantly the absence of rheumatoid factor in the blood helps distinguish psoriatic arthritis 

from rheumatoid arthritis. It is usual for the condition to develop in the teenage years. In women 

there may be an increased incidence following pregnancy or the menopause. 

As PsA affects both the skin and the joints, this has a negative impact on the quality of life of 

people with PsA; due to emotional problems, in fact, they may experience more pain and role 

limitations than patients with RA (Husted, Gladman, Farewell and Cook, 2001). A higher level of 

mortality compared to the general population has also been reported among people with PsA 

(Wallenius et al., 2008). 



28 

3.4 

Summary 

The impact of MSDs on the workforce is not commonly recognised in Japan, particularly, 

among non-manual worker groups. Some of the wider societal and economic impacts of 

these conditions are yet to be acknowledged and addressed. MSDs can affect not only the 

people living with them, but also their employers and the society as a whole. It is essential that 

individuals with MSDs receive diagnosis and treatment in time to be able to remain productive 

members of the workforce. 

Decision-makers in Japan should appreciate the fact that much of the burden of MSDs in Japan 

could be avoided if employers, employees and health care professionals were provided with a 

policy context conducive to a more effective collaboration. The following sections outline what 

can be done to tackle ill health in the Japanese workforce, providing specific recommendations 

for each stakeholder group. 


4. MSDs and government 

4.1 

Costs of MSDs 

to the wider 

economy and 

society 

Having a significant proportion of the working age population either temporarily or permanently 

unable to work because of chronic disease – even in a favourable economic climate – 

can reduce the aggregate level of labour productivity in an economy and damage the 

competitiveness and effectiveness of private and public sector employers. A significant burden 

of ill-health or disability can also have a number of damaging social consequences leading to 

marginalisation and social exclusion. 

It is imperative for Japan to optimise the supply of people that are fit for work in order to take full 

advantage of the country’s economic potential. Thus, it will be important to ensure that those 

with illness or long-term conditions are not disproportionately excluded from the labour market 

since such exclusion has a number of implications. 

First, in order to reduce the social security burden on younger generations it is vital that Japan 

maintains a healthy and productive workforce. Japan is the world’s third largest economy, built 

up as a result of rapid economic growth in the post-war period, during which time the country 

became technologically advanced. Economic growth has slowed significantly since the 1990s 

and the country has experienced several periods of recession which have changed working 

structures. The labour market gaps are exacerbated by the demographic changes in Japan and 

the growing dependency rate of the elderly population (JILPT, 2012). To minimise the impact of 

ill health, it is important to develop strategies to allow people with conditions such as MSDs to 

participate in working life for the longest possible time. 

Second, unemployment and job loss have serious financial and health consequences for 

individuals. Studies have shown widespread deterioration in aspects of physical and mental 

well-being among those who lose their jobs which can persist for many months (Armstrong, 

2006; Brinkley, Clayton, Coats, Hutton, and Overell, 2008). 

Third, it is essential that unemployment is not concentrated in the most vulnerable parts of the 

workforce, especially among those with disabilities or with long-term health conditions. Finding 

ways of improving job retention for these workers is vital, as we know that once they become 

detached from the labour market, their chances of finding meaningful work again are severely 

damaged. Latest available figures show that 58 per cent of people with disabilities of working 

age in Japan are not in employment (MHLW, 2006). 

The Japanese economy simply cannot afford for its development to be inhibited by a shortage 

of skilled, motivated and healthy workers. MSDs already present the Japanese economy and 

society with a burden of up to JPY 2 trillion a year (7.5 per cent of national medical expenditure) 

in the direct health care costs alone (MHLW, 2009). 


MSDs and government 

30 

4.2 

MSDs: 

Policy 

However, direct medical costs represent only a smaller portion of the total burden of the 

disease. Further societal burden is associated with the indirect cost of lost productivity resulting 

from ill-health. Although few surveys have considered the indirect societal costs of MSDs in 

Japan, a recent study estimates the indirect economic burden of disease in Japan (excluding 

medical costs) to be JPY 3.3 trillion a year, highlighting chronic pain (including neck, shoulder, 

back and joint pain) as a major contributor to that burden at JPY 372 billion per year (ACCJ, 

2011a). 

On the example of RA, Igarashi, Igarashi, Kikuta, Tanaka, Hoshi, Inoue et al. (2010) find that 

societal costs of disease increase progressively with worsening RA: 2,896,248 for those with 

higher score of disease severity EQ-5D score (>0.8) and 1,329,398 for those with the lower 

score (


must contract an occupational physician, while those with staff of 1,000 or more are obliged to 

provide such a specialist full-time. 

Occupational physicians are responsible for on-site safety inspections, education of employees 

and provision of annual health check-ups. In addition, under the Labour Standards Act 

employers are made responsible for financial damage caused by work-related accidents, 

covering medical costs and damages for lost wages and disability, or an annuity for bereaved 

families. Because back pain accounts for a significant proportion of industrial accident claims 

(85 per cent in 2010), a number of strategies have been developed to prevent its occurrence 

and progress has been made in blue-collar industries (Koda, 2006). 11 A number of preventative 

measures, such as the development of industry guidelines and ergonomic assistance have 

been put in place to prevent such accidents, and workers are able to claim Worker’s Accident 

Compensation Insurance which covers all medical costs should such an accident occur in the 

workplace. 

These regulations focus mainly on the prevention of industrial accidents and the provision of 

adequate compensation for employees injured in the workplace. Occupational health and safety 

standards are high and the annual accident rate across all industries is now 2.0 (per 1,000 

workers) compared to 5.0 in 1989. Some experts have challenged the validity of these statistics, 

drawing attention to the discrepancies between MHLW data and data recorded by the Japanese 

Industrial Safety and Health Association. 12 

However, this level of progress is not mirrored in white-collar industries where recognition of 

MSDs caused not by accidents, but by long-term working conditions, remains low (Inaoka, 

2006). 13 Non-injury related back pain and upper limb disorders account for only 2.4 per cent 

of total work related diseases (MHLW, 2010b). It is often difficult for the employee to prove 

the link between the workplace and the condition, and as such, applications for Workers 

Accident Compensation Insurance are uncommon, meaning these cases are absent from the 

official statistics on work-related diseases. A culture of presenteeism and a reluctance to use 

sick leave mean that the actual impact of MSDs on workplace productivity could be severely 

underestimated. 

In recent years occupational health and safety strategies in Japan have begun to recognise the 

interplay between physical, psychological and social factors and to emphasise the maintenance 

11 The Japan Industrial Safety and Health Association provides summaries of industrial accident statistics in English: 

www.jisha.or.jp/english/statistics/index.html 





32 

of good health. In the wake of a number of high profile cases of employee death by overwork 

(karōshi) and suicide as a result of work-related stress, the MHLW has introduced policies 

requiring greater attention to the general health of employees and the promotion of improved 

work-life balance (JILPT, 2012). As a result, not only the occupational physicians are now 

required to inspect working conditions, but they must also carry out annual health checks of 

employees and provide education on the maintenance of a healthy lifestyle. MSDs could be 

incorporated into this programme, providing an opportunity for the early detection of MSDs in 

the workplace and more widespread awareness of the effect of MSDs on productivity and the 

efficacy of preventative measures. Despite these potential benefits, the explicit links between 

work-related MSDs and psychosocial issues are yet to be reflected in occupational health and 

safety policy (Inaoka, 2006). 

The New Growth Strategy, passed by the cabinet in June 2010, aims for an economic growth 

rate of 3 per cent (2 per cent in real terms) and reduction of the unemployment rate to 3 per 

cent. In order to achieve this, the Employment and Personnel Strategy sets specific employment 

targets for four population groups – youth, women, older people and people with disabilities. 

The strategy calls for an increase in the employment rate of all sections of society to ensure that 

all Japanese people can participate in the labour market according to their wishes and abilities. 

Another key issue is raising awareness of effective ways of managing MSDs. Individuals are 

often not aware of the positive effect that work can have on reducing the impact of their MSDs. 

One of the most persistent (and pernicious) myths about back pain, for example, is that bed 

rest is the best solution. Health promotion campaigns have been shown to be effective at 

getting the message across that experiencing pain does not necessarily mean that the condition 

has worsened or that being active is bad for you (Buchbinder, Jolley and Wyatt, 2001). In 

Japan, there is conflicting advice concerning workers suffering from low back pain, but there 

is evidence to suggest that advice to stay active may be more beneficial than advice to rest 

(Matsudaira, Hara, Arisaka and Isomura, 2011). 

4.2.2 Social security interventions 

In response to the aging society and increasing social security burden, Japan has introduced a 

number of social security reforms. While these measures are not specific to MSDs, they could 

have a significant impact on the way MSDs are treated. For example, the latest round of reforms 

concerning the medical system, introduced in 2012, aims for faster discharges from hospital and 

a shift in focus to rehabilitation to ensure people can return to society as quickly as possible. 

The reforms also aim to speed up the availability of new drugs (Cabinet Secretariat, 2011). 



The Japanese welfare system provides two main sources of benefit for those unable to work 

because of sickness or disability. Those registered with a permanent disability can claim a 

monthly disability pension either through the national pension scheme or, for those who have 

previously been in employment, through the Employee Pension Insurance Scheme. In both 

cases, the amount received is dependent on the severity of the disability. National health 

insurance schemes, which cover all citizens, provide short-term sickness benefits at 60 per cent 

of monthly salary for those temporarily unable to work (up to 18 months). Although welfare and 

labour issues both fall under the remit of the MHLW, there is little cooperation between internal 

departments to move people off benefits and back into work. 14 As a result, disability benefits are 

a major contributor to the rising social security costs in Japan. 

In light of concerns over the ability of the workforce to meet the social security burden, specific 

measures to encourage and support people with disabilities to rejoin the workforce have been 

implemented. The Services and Support for Persons with Disabilities Act of 2006 provided 

extra support from the public employment bureau, ‘Hello Work,’ which liaises with employers to 

provide suitable employment opportunities for people with disabilities. 15 A mandatory quota for 

the employment of disabled people is set at 1.8 per cent for companies with over 50 employees, 

with financial rewards for those employers exceeding this quota and penalties for those who 

fail to meet it. The employment rate for people with disabilities has increased steadily since the 

introduction of the measures and currently stands at a peak of 1.68 per cent (see Figure 4.1). 

However, it should be noted that the mandatory quota is only currently met by 45.5 per cent 

of companies (Japan Organisation for Employment of the Elderly and Persons with Disability 

(JEED), 2011) and those who are employed report a range of concerns about the level of 

support provided to allow them to continue in their positions (MHLW, 2008b). In addition, the 

level of employment of people with disabilities in meaningful jobs remains very low. 16 

Similarly, the government has also taken steps to encourage continued participation of older 

people in the workforce, aiming for a labour force participation rate of 63 per cent for people 

aged 60-64 by 2020 (JILPT, 2012). As MSDs are more prevalent in older people, efforts will 

need to be made to ensure these people can remain in work. 


15 More information on support for disabled people can be found at http://www.mhlw.go.jp/english/wp/wp-hw4/dl/ 

honbun/2_2_9.pdf 




34 

Figure 4.1. Employment situation of persons with disabilities in the private sector 

400 

350 

300 

250 

200 

150 

100 

50 

0 

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 

Physically disabled 

Mentally disabled 

4.2.3 Health care interventions 

Individuals with learning disabilities 

Actual employment rate 

1.8 

1.75 

1.7 

1.65 

1.6 

1.55 

1.5 

1.45 

1.4 

1.35 

1.3 

Source: JEED (2011) 

The MHLW can also influence early intervention and treatment for patients with MSDs through 

the approval of new drugs and the pharmaceutical reimbursement cap. Japan has been slow to 

approve drugs shown to be effective overseas because the MHLW necessitates that extensive 

clinical trials are carried out with Japanese participants. For example, the RA treatment 

Methotrexate (MTX), widely used in the US and Europe, is only prescribed in low dosages 

in Japan (Miyasaka, 2011). The pharmaceutical reimbursement cap set by the MHLW also 

influences the type of treatment a physician will prescribe. 

Regarding prevention, some diagnostic techniques which would aid early diagnosis of RA 

are not currently covered by the reimbursement scheme (ACCJ, 2011a). However, the 

MHLW measures against rheumatism and allergic diseases focus on early diagnosis and 

the employment of new drugs, including biologics, to achieve remission (MHLW Intractable 

Diseases Department, 2011). It has been suggested that the MHLW could take similar 

measures to improve the management of patients with chronic pain through the inclusion of 

diagnostic techniques and treatments in the national health insurance reimbursement system 

(ACCJ, 2011a). 


4.3 

Recommendations 

for policy 

makers 

Recognising the prevalence of chronic pain (including back pain, MSDs and connective tissue 

diseases) and its potential effect on the economy, the MHLW established the Investigative 

Committee on Improving Measures for Chronic Pain in 2009. The Committee’s preliminary 

findings recognise that unclear disease indicators concerning the causes and symptoms of 

chronic pain lead to a lack of understanding both among medical professionals and the general 

public, severely impacting the quality of life of those living with pain. The committee aims to 

grasp the extent of the problem through a range of surveys, and has made several policy 

recommendations including: 

• The production of a standardised set of treatment guidelines to improve diagnosis; 

• A team medicine strategy with well-defined roles; 

• Better links between medical professionals, NGOs and patient groups; 

• Education and dissemination of information about chronic pain for both the general 

public and medical professionals; 

• Further scientific research into the causes and treatment of chronic pain (MHLW 

Chronic Pain Investigative Committee, 2010). 

The 2011 MHLW budget included funding of JPY 130 mln for research into chronic pain and its 

treatment. 

The existing evidence suggests that the proportion of the Japanese workforce with MSDs is 

likely to grow over the next few decades. While Japan is actively developing policies to tackle 

MSDs under worker compensation schemes, it is equally important to address MSDs such 

as arthritic conditions, which are not directly caused by work but have a severe impact on 

workforce participation. 

Calculations of the costs of treatment tend to evaluate the clinical costs and benefits of 

treatments. The wider impact of people with MSDs remaining in work or returning to work early 

extends to the biopsychosocial and economic effects to the individual of being in work. One 

assessment by MHLW suggested that promotion of a purposeful life through diverse jobs may 

create additional 1 million workers in three years, drawing on the pool of those aged 60-64. 17 

Taking a wider, more holistic approach to an analysis of costs of treatments for illness in general 

and MSDs in particular may provide a different and perhaps more realistic assessment of the 

costs and benefits of treatments. For example, the investment in early diagnosis is expected to 





36 

deliver better outcomes through investment, employment and innovation in the pathology sector, 

providing net savings on the long-term burden of chronic MSDs. 

One way to tackle the impact of MSDs on the working age population is an established national 

plan for the early diagnosis, treatment and rehabilitation of people with MSDs. Such plans 

outlines national standards of diagnosis and treatment, support coordinated effort between 

government departments and agencies and establish mechanisms which help health care 

professionals and employers to support job retention and return to work among people of 

working age with MSDs. 

Considering the evidence towards the wider benefits of early intervention that are currently 

taken into account in the cost-effectiveness models for treatment of MSDs, we recommend that 

Japanese policy-makers: 

• Acknowledge both the direct and indirect costs of ill health of the Japanese population. 

A vast burden of MSDs on the patients’ quality of life, caregivers’ employment 

opportunities and the welfare system should inform the government’s priorities in 

addressing the impact of ill health on the Japanese economy and society. 

• Develop a national system of monitoring and surveillance of MSDs. Building a 

comprehensive picture of the impact of MSDs on the Japanese population requires 

a more detailed differentiation between different types of musculoskeletal conditions, 

in particular between different types of arthritis. The inpatient data collected currently 

needs to be complemented by the information on sickness absence gathered by the 

employers and the outpatient clinics. 

• Improve coordination between different departments within the MHLW to develop a 

more coordinated approach in supporting people with MSDs moving off benefits and 

back into work. 

• Introduce early diagnosis and intervention strategies, such as improved access to 

diagnostic procedures, facilitated referral pathways, mandatory injury management 

programs and joined-up stakeholder consultations during case management. Ensure 

that the most up-to-date diagnostic and treatment measures are covered by the 

pharmaceutical reimbursement schedule and available to patients. 

• Support research into innovative programmes for managing and reducing the burden 

of work disability in Japanese workplaces and encourage workers compensation and 

rehabilitation authorities to do the same. 


• Conduct workforce planning in the medical profession to establish if it will have 

sufficient clinical staff (eg rheumatologists, physiotherapists) to accommodate the 

projected growth in MSDs as the population, and the workforce, ages. Medical training 

at all levels, from undergraduate to continuing professional development would benefit 

from inclusion of health and work issues, especially if the health of the working age 

population is set to deteriorate. 

• Raise employers’ awareness of the impact of MSDs on their employees both in 

blue-collar and white-collar occupations. Consider incentives that would stimulate a 

pro-active approach towards management of MSDs in the workplace. This could be 

integrated into the current occupational health check system. Incentivise employers to 

support MSD patients in returning to work. 

• Aim to raise employees’ awareness of the importance of the timely disclosure. 

National health campaigns and patient support programmes are tested mechanisms of 

improving awareness of workplace risks and norms of effective management of MSDs. 

• Promote education for physicians and nurses (undergraduate, postgraduate and 

specialist education) and for patients (in the areas of pain treatment and self-control 

of pain), based on the latest methods of diagnosis and treatment. In particular, require 

education on the proper medical use of controlled substances that are used to manage 

chronic pain. 

• Consider ways to optimise the health care system for managing MSDs, including 

revision of the national health insurance reimbursement system, such as additional 

reimbursement for MSDs and modification of the current reimbursement schedule. 

Develop a chronic pain control system across primary care (clinicians in general 

hospitals), secondary care (multidisciplinary pain care teams, including nurses at core 

hospitals), and tertiary care services (specialised pain centres). 

• Continue, and improve promotion of, the theme of purposeful life through diverse jobs, 

for example, as provided through the Silver Human Resource Centre programme. 18 

• Improve the quality of work of occupational physicians, establish a peer-review system 

of occupational physicians, where they could share and learn from best practice 

examples with a view to implement those in their own organisations. 

18 See http://longevity.ilcjapan.org/f_issues/0702.html 



5. MSDs and health care professionals 

38 

5.1 

Costs of 

MSDs to 

the health 

care system 

Job retention and return to work programmes are contingent on patients receiving appropriate 

medical care as quickly as possible. Ensuring that workers who have MSDs get access to the 

appropriate treatment and support in a timely manner must be a top priority for health care 

professionals. Early intervention for individuals with MSDs will help those people return to work 

more quickly, avoiding the high costs of treating the condition and its comorbidities at the later 

stages of disease progression. 

Direct costs, compared to indirect costs, usually represent a minority of the total costs 

(Dagenais, Caro and Haldeman, 2008; Kavanaugh, 2005; Kobelt, 2007; Lundkvist, Kastäng 

and Kobelt, 2008). However, for RA large cross-country variation in estimates of direct costs is 

found in the literature due to the different uptake of particular treatments in different countries 

(Lundkvist, Kastäng and Kobelt, 2008). 

Some specific evidence regarding direct costs to the health care system is associated with 

musculoskeletal conditions in general, and RA and low back pain in particular, as found in 

the literature, (Woolf, 2004 as cited in The Bone and Joint Decade, 2005; Kavanaugh, 2005; 

Dagenais, Caro and Haldeman, 2008) are: 

• Health professionals visits; 

• Outpatient surgery; 

• Emergency room services; 

• Rehabilitation service utilisation (physiotherapists, social workers); 

• Medications and alternative therapies; 

• Medical equipment; 

• Diagnostic / therapeutic procedures and tests: imaging and laboratory monitoring; 

• Devices and aids, environmental adaptations; 

• Acute and non-acute hospital facilities (with and without surgery); 

• Home health care services; 

• Mental health services. 

Cost-of-illness estimates therefore require input from a number of different factors, and great 

variation is found across different studies of the costs of MSDs. For low back pain, the most 

significant direct costs are related to physical therapy, inpatient services, drugs, and primary 

care (Dagenais, Caro and Haldeman, 2008). Nachemson, Waddell and Norlund (2000) 

calculated that some 80 per cent of health care costs are generated by the 10 per cent of 

patients with chronic back pain and disability. In Japan, for example, orthopaedic surgeons are 

the second largest group of medical professionals after paediatric physicians, constituting just 

under 9 per cent of all physicians in Japan (MHLW, 2008a). 


According to the MHLW Estimates of National Medical Expenditure Survey, MSDs account 

for 7.5 per cent of Japan’s total general medical costs, or nearly JPY 2 trillion in 2009 (MHLW, 

2009). Total expenditure on MSDs has risen throughout the last decade, from JPY 1.6 trillion in 

2003, although the proportion of medical expenditure allocated to these diseases has remained 

relatively stable. 

Figure 5.1. Health care expenditure in Japan, by disease chapter 

Circulatory diseases 

Neoplasms 

Respiratory diseases 

Musculoskeletal & 

connective tissue 

diseases 

Genitourinary 

diseases 

Yen (billion) 

0 2000 4000 6000 

2088.4 

1998.7 

1987 

MSDs and health care professionals 

3399.3 

5539.4 

Source: MHLW (2009) 

As Figure 5.1 shows, musculoskeletal and connective tissue diseases are the fourth largest 

disease category in terms of general medical expenditure (MHLW, 2009). The costs of RA 

alone add up to JPY 2.4 million per patient per year, of which JPY 760,000 are indirect costs 

associated with the productivity loss of patients and their careers (Tanaka, 2011). With an 

estimated 600,000 RA patients in Japan, this results in national expenditure of over JPY 1 trillion 

(Tanaka, 2011). 



40 

For RA, although direct health care costs have been relatively small in the past (Lundkvist, 

Kastäng and Kobelt, 2008), a number of studies indicate that direct costs increase as functional 

capacity decreases – making functional capacity a major cost driver (Huscher, Merkesdal, 

Thiele, Schneider and Zink, 2006; Kobelt, 2007; Leardini, Salaffi, Montanelli, Gerzeli and 

Canesi, 2002). Comparing those with lower EQ-5D score (0.8) the direct costs were 369,624 and 214,644 respectively; indirect costs were 300,766 and 

42,828 respectively (Igarashi et al., 2010). 

In Japan, inpatient care accounts for 41 per cent of MSD-related medical costs at JPY 816.4 

bn. The average length of hospital stay in Japan (for all diseases) is relatively long at 18.5 days, 

compared to an average of 7.2 days for OECD countries (OECD, 2011) and the subsidised, 

free-access medical system means that patients suffering from conditions such as RA tend to 

seek regular and intensive treatment (Tanaka, Inoue, Mannalithara, Bennet, Kamitsuji et al., 

2010). The 2008 MHLW Patient Survey (MHLW, 2008) estimates a rate of 54 patients per day 

(per 100,000 population) receiving care for MSDs in hospital, compared to 740 patients per day 

receiving outpatient care. The average length of hospital stay for MSDs has been falling rapidly 

over the past decade from 55.3 days in 1996 to 36 days in 2008. In a separate survey, Fukuhara 

et al. (2003) calculate that patients experiencing back pain spend on average 7 days a year 

receiving inpatient care and 19.7 days as outpatients. New social security policies described in 

the previous section aim to reduce the costs of inpatient care by reducing the length of hospital 

stays still further and focussing more strongly on the provision of rehabilitation. 

Figure 5.2. Average number of days spent in hospital due to MSDs 

60 

50 

40 

30 

20 

10 

0 

55.2 

44.2 

41.4 

37.8 

1996 1999 2002 2005 2008 


36 

Source: MHLW (2008)


According to Tanaka et al. (2010) the disability index for RA patients in Japan is lower than 

that of the US and as a result costs associated with hospitalisation are lower, with medication 

accounting for over half of the direct medical costs associated with RA. 

Figure 5.3. Breakdown of medical costs relating to RA 

Hospitalisation 

13.90% 

Laboratory 

examination 

and imaging 

22.50% 

Consultation 

7.70% 

Rehabilitation 

1% 

Medication 

55.40% 

Source: Tanaka et al. (2010) 

Medical costs associated with RA have continued to increase throughout the past decade as a 

result of the introduction of new treatments such as DMARDs and TNF. At least 67 per cent of 

RA patients in Japan are categorised as having moderate to severe RA and are subsequently 

receiving treatment under national health insurance schemes. 57 per cent of all RA patients are 

receiving DMARD treatment (Miyasaka, 2011). 



42 

5.2 

Access to 

health care 

in Japan 

Japan operates a free-access medical system, which means that patients are not registered 

with a specific doctor and are free to select and visit a physician of their choice, without referral 

from a GP. While there are a small number of family doctors in Japan who practice in a way 

similar to GPs, the majority of Japanese choose to attend a specialist clinic based on their 

symptoms. Even though this system provides access to a wide range of treatments and affords 

the patient a high level of choice in the treatment process, the doctor-patient relationship 

remains paternalistic. Patient empowerment in Japan is a developing concept, and while 

progress has been made in issues such as informed consent, many patients remain reluctant to 

question the expertise of their physician. 

All residents are enrolled in a universal statutory health insurance system either through their 

employer (kumiai hoken) or through the national citizens’ insurance programme run by the 

government (kokumin hoken), which covers around 40 per cent of the population (Tatara and 

Okamoto, 2009). Both systems cover a minimum of 70 per cent of the cost of the majority of 

treatment and prescription costs, with an income-dependent cap in place (currently between 

JPY 80,000 and JPY 287,000 per month) in the case of long-term treatment. Extra benefits are 

available for the elderly and those with disabilities or on low income. 

In the case of MSDs there are a range of treatment options for patients. Hattori (2006) found 

that of those seeking treatment for chronic pain (the majority of which was caused by MSDs), 

45 per cent attended an orthopaedic surgeon, 21.3 per cent – a general clinician, 15.1 per cent 

– a massage therapist or chiropractor, 12.4 per cent – an osteopath and only 0.8 per cent – a 

specialised pain clinic. A 2010 survey of patients suffering from chronic musculoskeletal pain 

showed that less than half (42 per cent) of those with symptoms sought medical treatment. 

Of those, only 19 per cent visited a hospital or clinic, while 20 per cent sought complementary 

therapy such as massage, or folk remedies (Nakamura et al., 2011). 

This apparent reluctance to seek treatment suggests a lack of awareness of treatment options 

for MSDs in the early stages, or a failure to recognise the serious impact of MSDs for everyday 

life and workplace productivity. 

It is important to recognise that for majority of those in employment occupational physicians 

are the first point of contact in case of illness. Occupational physicians should work together 

with other health care professionals to gain a better understanding of the physical, social and 

psychological risk factors for a range of work-related conditions. It is noted, however, that some 

delays in access to treatment occur due to the lack of communication between the occupational 

physicians and other health care professionals. 



Figure 5.4. Treatment choices of patients with chronic pain (including MSDs) 

Folk remedy 

20% 

Hospital/clinic 

19% 

Both 

3% 

No answer 

3% 

People with MSDs in Japan frequently access complementary or alternative medicines (CAM), 

either in place of or on top of medical care (Nakamura et al., 2011; Hattori, 2006; Kajiyama, 

Akama, Yamanaka, Shoji, Matsuda et al., 2006). At the same time, Kikuchi, Matsuura, 

Matsumoto, Inagaki and Ueda (2009) find that of 260 CAM products for osteoarthritis or RA 

available in Japan, only 41 CAM products had been tested in randomised controlled trials; 

there was no scientific evidence concerning the effectiveness of the remaining 219 CAM 

products. More research into the efficacy of such treatments and better communication between 

physicians and practitioners could aid patients in developing a comprehensive treatment 

strategy. 

The MHLW investigative committee into chronic pain found, there is little communication 

between physicians in this system and the need to develop a multifaceted team approach to 


None 

55% 

Source: Nakamura et al. (2011)


44 

5.3 

Condition- 

specific 

interventions 

treatment of MSDs involving specialists, nurses, psychologists etc. is recognised. A survey by 

the Rheumatoid Arthritis Friendship Association found that the establishment of better links 

between different physicians and institutions was the number one improvement that patients 

wish to make to their medical care (Japan Rheumatoid Arthritis Friendship Association, 2010). 

The committee also recommended the production of comprehensive set of guidelines for 

clinicians to assist with early diagnosis and effective treatment of chronic pain, including pain 

caused by MSDs (MHLW Chronic Pain Investigative Committee, 2010). 

Whilst it is widely acknowledged that early intervention is an essential part of addressing the 

onset of MSDs and work-related absence caused by these conditions, there is still some way to 

go before people with MSDs are given the best possible support to remain in work or return to 

work. Specific barriers which remain to be overcome include: 

• Failure to disclose health conditions in time to receive the most efficient treatment;, 

• Certain employers’ lack of capacity to deal with sickness; 

• Insufficient employee awareness about MSD conditions and their management; and 

• Inconsistency of messages regarding the effectiveness of various workplace 

interventions or return-to-work programmes. 

For those with specific musculoskeletal conditions, speedy referral to an appropriate 

specialist for diagnosis and treatment is generally vital. Those with MSDs may experience 

numerous problems associated with long-term care, including long waits, failure to undertake 

a multidisciplinary approach, poor advice on pain management, and a lack of clear pathways 

for an integrated treatment. Notwithstanding this, there are a number of condition-specific 

interventions which have been shown to be effective in improving job retention and return to 

work. 

5.3.1 Non-specific MSDs 

The primary focus of this report has been to examine the interventions and other factors which 

affect job retention, labour market participation and job quality among those with MSDs. As we 

have seen, there is evidence that physical impairment can represent a barrier to each of these 

aspects, but that many people – even those with serious and chronic incapacity – can and do 

lead full and fulfilling working lives. Since back pain and the majority of work-related upper limb 

disorders are not diseases to be cured, and there is very limited evidence that prevention is 

possible, it has been argued that the focus of treatment should be on returning to the highest 

or desired level of activity and participation, and the prevention of chronic complaints and 

recurrences (Burton, 2005; Bekkering et al., 2003) rather than on eradicating the cause of the 

problem or restoring the patient’s state of health to that before the onset of the condition. 



Whilst treatment to ease or relieve the symptoms of non-specific MSDs will always be a priority, 

medical intervention is not necessarily the only, or the best route to full recovery or sustainable 

management of the condition for the patients with non-specific MSDs. In fact, for non-specific 

conditions, an individual’s recovery and chances of returning to work can be adversely affected 

by ‘over-medicalising’ their condition. The limitations imposed by sick notes, statutory sick 

leave and formalised return to work programmes may serve to reinforce the ‘illness’ of the 

patient and can tie employers’ hands. Based on evidence that psychosocial factors are a 

determinant of chronicity and disability in those with back pain, there is a strong argument for reconceptualising 

this condition and its treatment, which has important lessons for other types of 

non-specific musculoskeletal pain (Burton, 2005). 

Waddell and Burton (2006b) summarise the challenge neatly in their work on vocational 

rehabilitation. They point out that, whilst many non-specific MSDs do not have clearly defined 

clinical features and have a high prevalence among the working age population, most episodes 

are resolved naturally, and most people with these conditions remain at work or return to work 

very quickly. According to Waddell and Burton, a focus on incapacity alone can be unhelpful: 

‘..the question is not what makes some people develop long-term incapacity, but why 

do some people with common health problems not recover as expected? It is 

now widely accepted that biopsychosocial factors contribute to the development and 

maintenance of chronic pain and disability. Crucially, they may also act as obstacles 

to recovery and return to work. The logic of rehabilitation then shifts from dealing with 

residual impairment to addressing the biopsychosocial obstacles that delay or 

prevent expected recovery.’ (Waddell and Burton, 2006b, p.7) (bold in original text) 

The biopsychosocial model is an explanatory framework that recognises the importance of 

psychological and social factors in determining how those with MSDs cope with their conditions. 

It is now widely accepted that ergonomic, psychological and occupational-psychosocial factors 

all contribute to the development of non-specific MSDs, such as WRULDs. In some cases 

the patient risks entering a self-reinforcing cycle of incapacity, delayed recovery and even 

depression if their dominant response to pain is to ‘catastrophise’ it. Of course there may be 

many factors which affect an individual’s disposition to ‘catastrophise’, including personality, 

previous medical history, levels of family support or job satisfaction (Sullivan and D’Eon, 1990). 

According to the biopsychosocial model of disease, an effective treatment for non-specific 

MSDs has to address all the causes rather than concentrate on the affected body part. In 

particular, it is crucial to identify and tackle the psychological syndromes associated with MSDs, 

such as anxiety or depression. 



46 

5.3.2 Rheumatoid arthritis 

The importance of effective and early treatment of RA in reducing joint damage and disability 

is now widely acknowledged (Pugner, Scott, Holmes and Hieke, 2000). Since there is currently 

no ‘cure’ for RA, the focus of treatment is on controlling signs and symptoms, enabling the 

patient to manage their condition and improving the quality of life. Medical treatments for RA are 

directed at suppressing one or other part of the joint-damaging processes, the effectiveness of 

which has improved in recent years. Since it is well documented that the functional capabilities 

of RA patients decline over time, it is critical that patients should be treated as quickly as 

possible with disease-modifying anti-rheumatic drugs (DMARDS) to control symptoms and 

disease progression. One study found that there is a 73 per cent risk of erosive damage in 

patients who wait over a year between symptom onset and referral to rheumatology clinics 

(Irvine, 1999 in Luqmani, Hennell, Estrach, Birrell, Bosworth et al., 2006). RA patients in Japan 

can be treated either by specialists in internal medicine, of whom 4,000 are currently registered 

as rheumatologists with the Japanese College of Rheumatology (JCR), or by orthopaedic 

surgeons. There are 5,000 JCR-registered orthopaedic rheumatologists. As the efficacy of 

pharmaceuticals improves, internal medicine specialists are playing an increasing role in 

the care of RA patients (Miyasaka, 2011), but there is little communication between the two 

specialities, often leading to patient confusion. 

The current schedule of RA treatment in Japan prioritises the target of clinical remission 

(Takeuchi, 2011). 19 However, considering the vast cost of disability and early retirement 

associated with this condition, the already enormous strain on the nursing care facilities 

in Japan, as well as the evidence for the positive effects of work on health, clinicians must 

consider workability as a realistic outcome for people with RA. Growing clinical evidence 

demonstrates that biologic drug therapies can have a more powerful effect on RA than 

DMARDs, especially in improving job retention and work participation (Halpern, Cifaldi and 

Kvien, 2008). In Japan, biological treatment has been approved for administration since 2003 

and usage has expanded rapidly since. The access to this new class of biological agents is 

restricted to patients with severe and progressive RA who are not responding to traditional 

DMARDs. This is mostly due to the high costs of treatment associated with the use of anti-TNF 

therapy. 

Medical interventions in the form of drug therapy to control inflammation and disease 

progression, and surgery to redress structural damage are only part of managing the care of 

RA patients. Other important elements include patient education and empowerment, practical 

self-management to help deal with symptoms and specialist support to help live with the disease 



5.4 


for health care 

professionals 


and its consequences. In one survey 50 per cent of individuals living with RA reported 

improvement in the rate of turnover and absence, given tight control of their condition (Japan 

Rheumatoid Arthritis Friendship Association, 2010). Effective management of RA has to involve 

not only the clinical team (including consultant rheumatologists, physiotherapists, chiropodists, 

podiatrists, pharmacists, primary care nurses and orthopaedic surgeons), but the participation of 

the patient and, ideally, their employers. Social workers also have a role to play. 

Rehabilitation accounts for just 1 per cent of medical costs of RA. A survey of 8,307 RA 

patients by the Rheumatoid Arthritis Friendship Association showed that only 27.7 per cent 

of patients were undergoing rehabilitation. At least 41.4 per cent said that they had not 

undertaken rehabilitation because it had never been suggested to them by their physician, 

while a further 14.7 per cent said a suitable rehabilitation specialist was not available (Japan 

Rheumatoid Arthritis Friendship Association, 2010). This again reinforces the need for increased 

communication between specialist physicians and other health care professionals, and the 

importance of a team medical system. 

5.3.3 Spondyloarthropathies 

Prompt referral to specialists for confirmation of diagnosis and the start of treatment is also 

essential for those with SpA and other rheumatic conditions. Since (similarly to RA) there is 

no cure for SpA, the aim of therapeutic intervention is to reduce inflammation, control pain 

and stiffness, alleviate systemic symptoms such as fatigue, and to slow or stop the long-term 

progression of the disease. Anti-TNF drug therapy is now commonly used in the treatment of 

SpAs in Japan. In addition, standard treatment also includes non-steroidal anti-inflammatory 

drugs as well as patient education, physical therapy, and self-management with exercise and 

relief of pain and stiffness (Stafford and Youssef, 2002). 

As SpA typically affects relatively young people, its potential to disrupt or even curtail an 

individual’s labour market participation may be significant. As discussed, there are important 

clinical, social and economic benefits to keeping these patients in work as long and as 

consistently as possible. Depending on the severity of their condition, AS patients may 

benefit from workplace adjustments, flexible working arrangements, exercise regimes and 

physiotherapy (Boonen et al., 2001). 

Prompt referral to the appropriate specialist, and a timely intervention are key to achieving the 

most effective outcomes of treatment of MSD patients. Individuals with MSDs can experience 

numerous problems associated with long-term care, including long waits, failure to undertake a 

multidisciplinary approach to treatment, poor advice on pain management, and a lack of clear 

integrated pathways. It is important that health care is planned in partnership with the employers 



48 

and patients’ themselves to ensure that the work capacity of individuals with MSDs is preserved 

for longer. 

In the long run early detection and treatment of MSDs will reduce demand for more expensive 

interventions, such as hospitalisation and advanced drug therapy. These treatment methods 

already represent two of the greatest direct costs of MSDs to the health care system in Japan. 

A combination of prompt medical intervention with other forms of therapy offers further savings 

in the treatment costs. It is hoped that the introduction of biologics early in the treatment process 

will reduce overall medical costs in the long term due to slower progression of the disease 

and a reduced need for surgery, but this trend has not yet transpired (Yasui, Nishino, Kadono, 

Matsui, Nakamura et al. 2010). At the same time, if work outcomes of the individuals with RA 

are considered, more patients in Japan could benefit from using anti-TNF therapies earlier in the 

course of their disease. While no Japanese studies have yet been published to demonstrate this 

link, a UK study found that rate of turnover and absence in the workplace improved by 50 per 

cent in patients using biologics, compared to those who were not (Bejarano, Quinn, Conaghan, 

Reece, Keenan et al., 2008). This would produce an estimated tax increase of JPY 17 trillion 

(ACCJ, 2011a). 

As it becomes clear that proactive management of MSDs reduces the prevalence of chronic 

conditions and disability in the long run, hinting at significant savings to the health care system, 

we recommend that the health care professionals in Japan: 

• Aim for early diagnosis and intervention. The evidence suggests that long periods 

away from work are usually detrimental to MSD patients. The longer they are away 

from work, the more difficult it is to return. Early detection of MSDs and referral to 

appropriate care, preferably in partnership with the patient and their employer, will 

help individuals to return to work as soon as possible and avoid work incapacity in the 

long term. Occupational physicians already employed at larger organisations could be 

trained to provide education and support to assist people with MSDs to continue their 

role, or return to the workplace. 

• Identify where job retention or early return to work is good for the patient. It is easy to 

assume that work is unambiguously bad for your patients, especially if you suspect 

that aspects of their job make symptoms worse. With some adjustments, staying at 

work with lighter duties or adjusted hours might still be a better option than a prolonged 

absence from work. 



• Think beyond the physical symptoms. Bring to bear your understanding of the 

biopsychosocial model and the limitations of the biomedical model in your diagnosis 

of the patient and – most importantly – your assessment of the role that the patient’s 

job might play in helping them stay active and avoid isolation. In the absence of a GP 

system, the development of an effectively linked, multifaceted medical care system is 

essential for the early assessment, diagnosis and treatment of patients with MSDs. 

Where appropriate, patients should be able to access specialist teams as early as 

practicable, to enable management of the condition to begin. 

• Avoid catastrophising. A patient can hold a very negative view of the impact and likely 

progression of their condition if the way that clinicians present it focuses on incapacity 

rather than capacity. Clinicians should consider what the individual can still do at work, 

taking into account the nature of the patient’s work capacity and pre-injury employment, 

demographic characteristics, physical and psychosocial demands of the job, and job 

quality. 


6. MSDs and employers 

50 

6.1 

Costs of 

MSDs to 

organisations 

It is also in employers’ best interests to act early if they are to minimise costs to the health of 

employees and to their business through absence. Japan is quite advanced compared to other 

countries in addressing ill health at work: government regulations require that occupational 

health physicians discuss and adjust work load and environment according to employee needs. 

If employees have concerns about their condition they may consult a health care professional 

and, following referral or diagnosis, advice and planned action, a review should be conducted 

within four weeks. 

Epidemiological studies of employees whose absence is caused by low back pain have shown 

that the longer the sick leave, the more difficult it is to get the employee to return to work and the 

higher the economic cost (Frank, Sinclair, Hogg-Johnson, Shannon, Bombardier et al., 1998; 

Meijer, Sluiter, Heyma, Sadiraj, and Frings-Dresen, 2006). Sick leave has also been shown to 

have a negative psychological impact on employees (Meijer, Sluiter, and Frings-Dresen, 2005). 

Early intervention is therefore crucial to individual recovery and self-management, and may 

contribute to reducing the number of working days lost and reduced productivity caused by 

MSDs. 

There are two main types of indirect costs most commonly measured in association with ill 

health in employees. These are absence from work and what is termed ‘presenteeism’, or loss 

of productivity in an employee while they are at work with an illness or incapacity. 

Sickness absence attributed to musculoskeletal disorders appears to be much less common in 

Japan than in the UK (Matsudaira et al., 2011). However, the fact that employees commonly use 

holiday entitlement rather than claiming sick leave means that the actual impact of MSDs in the 

workplace could be underestimated. 20 

Research shows that up to 30 per cent of workers with conditions such as rheumatoid arthritis 

(RA) are reluctant to disclose their condition to their colleagues and managers out of a fear 

of discrimination (Gignac, Cao, Lacaille, Anis and Badley, 2008) and 22 per cent of workers 

do not tell their employers about their condition (Gignac, Badley, Lacaille, Cott, Adam et al., 

2004). If workers continue to come to work when affected by the condition or associated pain, 

they are not performing to their full capacity, presenting additional safety hazard in high-risk 

work environments. It appears that in many cases in Japan pay is linked to attendance, which 

may cause some employees to refuse to take time off work due to their condition with further 

negative impact on employee productivity. 



MSDs and employers 

Attempts were made in Japan to estimate the level of presenteeism among employees. An 

ACCJ (2011b) survey of 5,000 people in Japan of 20 years of age and above reports high 

losses of productivity, particularly due to pain (see Figure 6.1). 

Figure 6.1. Productivity losses by cause 

Mental illness 

Non-infectious chronic 

disease 

Pain 

Infectious diseases or viral 

infections 

Physical injury or disability 

15.30% 

14.70% 

27.10% 

31.60% 

55.30% 

0% 10% 20% 30% 40% 50% 60% 

Source: ACCJ (2011a) 

For many employees their productivity was reduced for a significant proportion of their work 

time. On average employee productivity was affected for 11.8 hours per week in the previous 

month (see Figure 6.2). 

The same survey estimated the cost of absenteeism due to pain at over JPY 88 mln, the cost 

of pain-related presenteeism at JPY 52.6 mln (ACCJ, 2011b). Although there has been little 

further investigation into the cost of presenteeism in Japan, given that Japanese workers are 

traditionally reluctant to be absent from work, the burden of presenteeism may be even more 

significant than reported. 21 




52 

6.2 

The role of 

employers in 

reducing the 

impact of MSDs 

Figure 6.2. Productivity losses by length of time 

20% 

15% 

10% 

5% 

0% 

Almost comparable to usual productivity 

4-6h 

10-12h 

16-18h 

22-29h 

50-69h 

>90h 

Amount of productivity loss 

2-3h 

7-9h 

13-15h 

19-21h 

30-49h 

70-89h 


Efficient management of MSDs requires employers to think beyond their statutory duty to 

address health and safety risks, and to recognise that sickness absence management, effective 

return to work programmes and rehabilitation are the fundamental principles for effective 

management (Waddell and Burton, 2006b). Much is dependent on raising awareness about how 

to manage the symptoms of MSDs amongst employees and their managers, ensuring that the 

latter have the skills and confidence to support employees in work. 

Much of the attention that employers pay to the issue of MSDs and the impact of the workplace 

on the onset or deterioration of MSDs is driven by a concern to avoid or limit risk of litigation 

and ensure that they are fulfilling their legal duty of care. That is partially illustrated by the 

variation of the financial implications of employee absenteeism across different industry 

sectors in Japan. Because the workers’ compensation is proportional to their wages, in the 

mining industry, for example, where wages are relatively high, employers may be incentivised 

to invest in rehabilitation to return employees back to work sooner. On the other hand, 

rehabilitation opportunities may be delayed for the workers in the retail sector, where the costs 

of an individual being off work are not as high. Despite these paradoxes, there is a strong 

commitment to workplace-based rehabilitation in the workers’ compensation scheme legislation. 


Japanese employers must operate on the principle of ‘health consideration’, which requires that 

employers must assess health and safety for each worker, as it is deemed impossible to fully 

avoid risk conditions within the work environment. As a result of such assessment occupational 

physicians are required to issue ‘fit notes’ to formalize their awareness of the risk associated 

with a certain job, and to provide recommendations for the worker to minimise the impact of 

work on health. 

Tanaka, Hoshuyama, Takahashi, Ito and Okubo (1998) conducted a survey of occupational 

health physicians to evaluate the current situation and the application of systems for return to 

work and fitness for work in Japanese companies. Tanaka et al. found that most companies 

carried out assessments of return to work, and involved occupational health professionals 

and other related staff in the assessment process. In the majority of cases, the occupational 

physicians were in charge of the decision-making process on return to work and were 

authorized to make the final decision. In the companies with 3,000 or more employees, the 

cases of longer-term sick leave were assessed in a more comprehensive process than those 

of shorter-term sick leave. In the study 119 companies (88 per cent) conducted on additional 

health examination to assess the employee’s fitness for work. Sixty-four companies (47 per 

cent) had standardised criteria on fitness for work. 118 companies (83 per cent) had job training 

systems for employees’ return to work, and they mainly introduced restricting one’s job and/or 

reducing one’s work-load. It was suggested that complete systems for return to work and fitness 

for work were more available among companies with 3,000 or more employees than among 

companies with 2,999 or fewer employees. 

While the existence of the provision for fitness assessments is commendable, there is no official 

structure of the ‘fit note’. The University of Occupational and Environmental Health’s Department 

of Preventive Medicine and Community Health has identified22 the following types of the ‘fit 

notes’ issued by the occupational physicians: 

• Type 1: Work potentially affect worker’s health; 

• Type 2: Risk management and prevention of accident relating to disease; 

• Type 3: Referral; 

• Type 4: Communication to the head of department/supervisor; 

• Type 5: Fit for work with appropriate adjustments of work environment and/or/ 

conditions. 





54 

Occupational health physicians are in the front line of reducing staff absence, and are in a good 

position to spot early warning signs of a problem and to help rehabilitate employees after a 

period away from work. However, a standardised system of assessment of fitness for work and 

return to work is needed in order to take timely and appropriate measures to reduce the longterm 

costs of MSDs. 

6.2.1 Awareness of conditions and their management 

Many employers remain unaware of the nature of MSDs, both in terms of the immediate impact 

on functional capacity at work and, where relevant, the manifestations and progression of the 

conditions. For example, employees with RA or SpA may be susceptible to periodic ‘flares’ of 

inflammation and severe pain followed by fatigue and possible depressed mood. If employers 

are unaware that these symptoms are expected or ‘typical’, they be unhelpful or overly-cautious 

in facilitating the employee’s return to work. 

In terms of evidence and risk factors for the impact of work on MSDs, a distinction needs to be 

made between ‘work-related’ disorders and ‘occupational’ disorders (Punnett and Wegman, 

2004). As such, the fact that work can cause and contribute to MSDs is widely recognised in 

Japan, particularly in relation to physically-demanding jobs. 23 In Japan MSDs resulting from 

the exposure to the risks of the work environment are considered one of the eight national 

priority occupational diseases. In that respect much has been done both to improve working 

environments, as well as to eradicate unhealthy behaviours of staff. The number of work-related 

diseases may be lower than in the years before (see Figure, 6.3), however, due to the narrow 

official definition of what a ‘work-related’ disease is, these statistics may be misrepresenting the 

true extent of the impact of work environments on individuals’ health. 

At the same time, the development of knowledge-based sectors leads to emergence of new 

risks that exacerbate health conditions, for example, poor ergonomic design and unfavourable 

psychosocial environment. This is why occupational physicians in Japan have to focus on 

occupational health issues more than on occupational safety (Ikeda, Takezawa, Tsushimi 

and Sakurai, 2012). However, due to the lack of a comprehensive definition of a work-related 

disease, employers and employees themselves would only claim compensation for incidents 

directly preceding the exacerbation of their health status, disregarding the negative impact of 

cumulative exposure to risk factors at work. As a result, implemented measures of monitoring 

and prevention of work-related MSDs address only a portion of the hazards contributing to the 

development of work-related MSDs. 



Source: Japan Industrial Safety and Health Association 24 

The evidence linking other non-occupational MSDs and work is not conclusive and attributing 

cause and effect between specific aspects of work and particular ailments is difficult. It is 

clear that work is not the cause of rheumatic diseases such as RA and SpAs, though there 

is evidence that the demands of physical labour, lack of support, self-stigma and insufficient 

flexibility over working time can each make job retention or return to work more difficult (der 

Tempel and van der Linden, 2001; Gignac et al., 2004). For example, Nakata, Takahashi, Irie, 

Ray and Swanson (2011) find that poor job satisfaction was associated with sickness absence; 

another study confirms that job strain predicts MSD- and cardiovascular disease-related 

disability pension claims (Mäntyniemi, Oksanen, Salo, Virtanen, Sjösten et al., 2012). While 

many of the established risk factors that may contribute to the development of non-specific 

MSDs can be encountered at work, even if work does not cause a condition it may have an 

impact on it. Moreover, if we consider risk factors beyond the physical, then the impact of the 

workplace on MSDs is likely to be much greater. In a recent epidemiological study interpersonal 

stress in the workplace, frequent lifting and monotonous tasks predicted the onset of low back 

pain (Matsudaira, Konishi, Miyoshi, Kota, Isomura, Takeshita et al., 2012). 

24 See Japan Industrial Safety and Health Association www.jisha.or.jp/english/statistics/index.html 


Figure 6.3. The number of work-related diseases requiring four or more days of absence 

9,000 

8,500 

8,000 

7,500 

7,000 

6,500 

2000 2001 2002 2003 2004 2005 2003 2007 2008 2009 2010 



56 

The most frequently cited risk factors for MSDs encountered in the work place include the 

following: 

• Rapid work pace and repetitive motion patterns; 

• Heavy lifting and forceful manual exertions; 

• Non-neutral body postures (dynamic or static), frequent bending and twisting; 

• Mechanical pressure concentrations; 

• Segmental or whole body vibrations; 

• Local or whole-body exposure to cold; 

• Insufficient recovery time (Punnett and Wegman, 2004). 

MSDs affect employees in all kinds of industries and occupations, although some pf those are 

associated with a higher risk than others, and certain occupations are associated with strain 

on specific parts of the musculoskeletal system. Figure 6.4 below illustrated the comparative 

prevalence of MSDs among employees in four different industries. At the same time, due to the 

higher awareness of the risks, employers in labour-intensive industries are more likely to have 

improved the health and safety norms in their workplaces. 

Figure 6.4. Prevalence of MSDs, by occupation 

40% 

35% 

30% 

25% 

20% 

15% 

10% 

5% 

0% Low back 

pain 

Nurses 

Neck pain Shoulder 

pain 

Office workers 

Elbow pain Wrist/hand 

pain 

Disabling 

pain at any 

site 

Pain 

causing 

sickness 

absence, at 

any site 

Sales/marketing personnel Transportation operatives 



It is noted that large organisations are more likely to monitor health and safety of their workers 

consistently by performing workstation assessments and giving guidance on manual handling, 

for example (Tanaka et al., 1998). However, they are still likely to neglect the wider range 

of work-associated factors, including psychosocial aspects of the workplace, that can also 

contribute to MSDs. These aspects are often missed in the literature and advice dealing with 

health and safety. Even where ‘stress’ is mentioned, the connection between psychosocial 

factors and physical conditions is omitted, reinforcing the primary focus on safety. 

Lack of financial and human resources means that small and medium-sized enterprises (SMEs), 

especially those with fewer than 50 employees, are at risk of low compliance with occupational 

health and safety legislation. Small enterprises are not required to contract an occupational 

physician and may not see improving health and safety of the work environment as a benefit 

to performance and productivity. 25 Examining the organisations with clear occupational risks, 

Furuki, Hirata and Kage (2006) found that 51.9 per cent of enterprises with 1-4 employees, 

about 42 per cent of enterprises with 5-9 employees and 20 per cent of organisations with 10-49 

employees did not conduct special health examinations. At least 40.6 per cent of SMEs with 1-4 

employees, 26.8 per cent of SMEs with 5-9 employees, and 14.1 per cent of SMEs with 10-49 

employees failed to conduct regular periodic health examinations (Furuki, Hirata and Kage, 

2006). 

At the same time, the costs of ill health may be particularly significant for SMEs, as both 

presenteeism and absenteeism may have more severe effects on customer satisfaction, 

productivity and business performance. For example, occupational health specialists may at 

times be overly enthusiastic to return individuals to work immediately to ensure performance 

targets are met. 26 In some cases, 24 to 48 hours rest is advisable for people with certain MSDs. 

The importance of balancing support to return employees to work and the value of giving an 

employee the chance for respite is yet to be acknowledged by some Japanese employers. 

Generally there is an increased risk of injury when any of the physical risk factors mentioned 

above are combined, or when adverse psychosocial, personal or occupational factors 

are present (Devereux, Rydstedt, Kelly, Weston and Buckle, 2004). Psychological and 

organisational factors can also combine with physical factors to influence the probability of an 

individual leaving work prematurely. Research on low back pain shows that an employee’s 

belief that work itself produces pain precedes sickness behaviour, and is a risk factor for chronic 

work disability (Werner, Lærum, Wormgoor, Lindh and Indhal, 2007). Sokka and Pincus (2001) 

reviewed 15 studies and showed that physically demanding work, lack of autonomy, higher 

25 Reiterated in expert interviews 





58 

levels of pain, lower functional status and lower educational levels were predictors of someone 

with RA exiting work early. The evidence from Sokka and Pincus (2001) highlights that it is 

not only the physical elements of work that can influence someone’s functional work capacity 

and likelihood of staying in the labour market. We must also consider the psychosocial and 

organisational factors of work. 

Psychosocial and organisational factors associated with MSDs include: 

• Rapid work pace or intensified workload; 

• Perceived monotony at work; 

• Low job satisfaction; 

• Low decision latitude/ low job control; 

• Low social support; 

• Job stress. 

Job stress is a broad term and can result from a variety of sources such as high job demands 

or a mismatch between skills and job requirements. In addition stress can result from abuse or 

violence at work, as well as discrimination. 

Again, it is important to recognise the connection between the psychological and the physical. 

While job stress, including violence and discrimination at work, might lead to lost productivity 

due to stress or other common mental health problems, it may also lead to MSDs caused by 

tension or strain. An increased probability of experiencing a high level of pain has also been 

associated with low social support, low social anchorage or low social participation (Katz, 2002). 

‘Good work’ and the provision of high quality jobs is therefore crucial (Coats and Max, 2005; 

Coats and Lehki, 2008). 

6.2.2 Changing employer attitudes 

Whilst the message about manual handling and work design may have gotten through to many 

employers, the fact that absence or even reduced work requirements can be counter-productive 

is yet to gain wider understanding. Changing attitudes and raising awareness about the 

management of MSDs is an important part of reducing their burden to employers and society. 

Not only has evidence shown that work is good for you, but returning to modified work can help 

recovery (Feuerstein, Shaw, Lincoln, Miller and Wood, 2003; van Duijn and Burdorf, 2008). 

Among occupational health specialists, the use of vocational rehabilitation has long been an 

accepted mechanism for ensuring that individuals with illness, injury or incapacity return to 

work (even if with reduced duties) as soon as sustainably possible. There have been concerns 


that rehabilitation is not well-integrated into mainstream clinical practice and that return to work 

is not seen by a sufficient proportion of clinicians as a valued outcome for the patient (Frank 

and Chamberlain, 2006). It is also important to stress that vocational rehabilitation is not the 

preserve of professionals. In practice, effective management is as, if not more, important than 

formal rehabilitation. 

It appears that employers invariably consider only the physical job demands of employees 

with MSDs. The biopsychosocial model requires that the mental demands of work also be 

considered as part of the return-to-work process. There is a growing body of knowledge which 

shows that adjusting a variety of work demands can support successful return to work among 

those with a range of MSDs (Schultz, Stowell, Feuerstein and Gatchel, 2007; de Croon, Sluiter, 

Nijssen, Dijkmans, Lankhorst et al., 2004; Feuerstein, Shaw, Nicholas and Huang, 2004; 

Chorus, Miedema, Wevers and van der Linden, 2001). The success with which both employee 

and employer can manage the process of re-adjustment during the return to work can depend 

on the beliefs that both parties maintain about the extent to which the work itself is (at least in 

part) caused by or related to the incapacity. The optimal return-to-work hierarchy is: 

• Same employer, same duties; 

• Same employer, similar duties; 

• Same employer, new duties; 

• Alternative employer, same duties; 

• Alternative employer, similar duties, and 

• Alternative employer, new duties. 

At the same time, once people are at the mid-career point, it may be more difficult for them to 

return to the same job or find alternative work after a period of sickness absence. Because of 

the lifetime employment system in Japan, the recruitment in larger companies often focuses 

on attracting recent graduates. Under the New Growth Strategy public employment offices 

are encouraged to support the re-employment of middle-aged workers through guidance, job 

hunting support documents, financial incentives for enterprises employing middle-aged workers, 

and referrals through ‘Hello Work’. Many SMEs are already commonly recruiting mid-career 

workers. 

6.2.3 Intervention and adjustment of work demands 

Numerous types of work-based interventions can assist those with MSDs to stay in and return to 

work. Those include: 

• Ergonomic adjustments; 

• Physiotherapy; 




60 

• Modified work programmes; 

• Cognitive behavioural therapy; 

• Combinations of various strategies. 

Evidence on the success of these interventions at tackling non-specific MSDs is mixed (Meijer, 

Sluiter and Frings-Diesen, 2005). A systematic review of multidisciplinary treatment of patients 

with low back pain, for example, demonstrated that whilst the treatment improved function 

and decreased pain in individuals, it could not be demonstrated that these results were linked 

to employees returning to work more quickly, compared to those who had not received such 

treatment (Guzman, Esmail, Karjalainen, Malmivaara, Irvin et al., 2001). Whilst biomechanical 

or ergonomic factors may be related to the onset of back pain, evidence that interventions 

based on biomechanics or ergonomics will prevent re-occurrence or progression to chronicity 

is weak (Burton, 1997). In fact, it has been proven virtually impossible to determine whether 

one treatment is significantly more effective than another (Ekberg, 1995). Even for specific 

conditions such as RA, the evidence for the effectiveness of vocational rehabilitation is slim 

(Backman, 2004; de Buck, Schoones, Allaire and Vliet Vlieland, 2002). 

There is nonetheless broad agreement on the principles for managing non-specific MSDs, 

particularly back pain, that are outlined in Box 1. This includes advice and a number of simple 

measures for employees and employers to follow when dealing with back pain. 

Box 1. Principles of managing non-specific MSDs 

• Early treatment should be sought for back pain. 

• Most back pain is not due to a serious condition. 

• Simple back pain should be treated with basic pain killers and mobilisation. 

• It is important to keep active both to prevent and to treat back pain. 

• Getting back to work quickly helps prevent chronic back pain. 

• Adopt the correct posture while working. 

• All workplace equipment should be adjustable. 

• Take breaks from repetitive or prolonged tasks or postures. 

• Avoid manual handling and use lifting equipment where possible. 

• Clear information should be provided to employees about back care. 

• Health and safety policies should be implemented to cover all aspects of day-to-day 

work and should be reviewed regularly. 

Source: Health and Safety Executive, 2002 



Given that MSDs are one of the most common work-related health problem, and the importance 

of psychosocial factors in determining whether employees remain in employment or return to it 

as soon as possible, managers need to have the skills to deal with staff who have MSDs. 

The role of line managers in early intervention is crucial, both for work retention and 

rehabilitation. Yet many line managers feel ill-equipped to manage long-term absence and 

incapacity. They may find aspects of poor mental health or chronic incapacity awkward and 

embarrassing to talk about or confront, and are concerned about asking for more information 

on sick notes, making home visits or telephoning staff at home. Line managers may fail at these 

tasks for the fear of being accused of harassment or falling foul of the law, and thereby landing 

themselves and/or their organisation in a tribunal. They are also ignorant of, or uncomfortable 

with, the idea of rehabilitation. Most line managers, particularly in small-scale organisations, find 

job re-design difficult, irritating and disruptive. 

On the face of it, many of the return-to-work challenges faced by employees with MSDs could 

be improved if there was an improved level of mutual understanding between employers and 

clinicians. As highlighted above, clinical appreciation of most MSDs among the employers can 

be cursory. It is often argued that most clinicians, in turn, have little or no appreciation of the 

vocational or occupational dimension of many MSDs. Medical students in Japan generally 

spend a very small proportion of their course learning about occupational health. 

Quite often both employers and occupational physicians will focus on the aspects of the job 

which an MSD patient cannot currently perform, rather than on those which they can. Employers 

will only very rarely consider the value of an MSD patient’s return to work. Because of the 

mutual lack of understanding among employers and clinicians, and the resulting dearth of 

dialogue between them the MSD patient is left stranded, with no clear pathway back to work, 

and more importantly, no voice in their rehabilitation. An approach to vocational rehabilitation 

that is proactive, inclusive, multi-disciplinary, capability-focused,, and one that is informed by the 

biopsychosocial model and delivered through case management is widely regarded as the most 

effective for dealing with the majority of work-related MSD cases. 



62 

Box 2. Case study: Health Initiatives in Mazda 27 

In Japan Mazda employs around 20,000 workers, producing 1 mln vehicles a year. The age 

distribution of the workforce follows an M-peak with significantly more workers aged around 

30 and around 50 years. Most jobs are characterised by lifelong employment. Workers 

reaching the default retirement age of 60 can have a discussion with their manager regarding 

their willingness to continue working. Where their skills match the organisational demand, the 

occupational physician evaluates the older employee as ‘fit for work’, which enables them to 

continue working up to the age of 65 in part-time jobs. 

Mazda is promoting company-wide health improvement activities that emphasise enhanced 

mental health measures, lifestyle improvements, and measures to reduce health risks 

such as new strains of influenza. In addition to legally mandated health check-ups for all 

employees, Mazda carries out comprehensive medical check-ups covering a variety of areas 

for employees when they reach the ages of 30 and 35, and when they pass the age of 40. 

The company supports gradual return to work after a period of long-term absence: once a 

worker is found to be ‘fit for work’ they undergo a rehabilitation period of part-time work or 

reduced duties, before making a full return to work. 

Mazda runs a number of preventative health initiatives to help improve lifestyle choices that 

may compromise the well-being and productivity of employees: 

• Smoking cessation; 

• Prevention of obesity (metabolic syndrome); 

• Prevention of falling and tripping (particularly among employees aged 50 and over); 

• Programmes for physical exercise for workers of different ages; 

• Prevention of sickness resulting from overwork, as well as a No-Overtime Week system 

in which employees are prohibited from working overtime and from working on holidays; 

• Morning health checks conducted by supervisors: short questionnaires to assess 

physical and psychological well-being; 

• Stress-monitoring guidance and training for supervisors. 


Cont. 


6.3 


for employers 

Cont. 

In addition, Mazda’s ergonomic standard includes a consideration of health and safety in 

process design: for example, details in car manufacturing never exceed the weight that can 

safely be handled by an individual worker. Since 1992, Mazda has conducted risk assessments 

of work stations, using an international system of risk classification: 

• Assessment Classification 3 (‘red’): improvement necessary (improve to Classification 

2 or 1); 

• Assessment Classification 2 (‘yellow’): needs attention (work toward reaching 

Classification 1); 

• Assessment Classification 1 (‘green’): good condition (maintain current state). 

Best practice at Mazda: 

1. Phased return to work; 

2. Preventative and comprehensive approach to health and well-being; 

3. Considering health and safety of both manual and non-manual jobs; 

4. Considering both physical and psychosocial aspects of health at work; 

5. Involvement of managers and supervisors in well-being initiatives. 


One of the attractions of the biopsychosocial model is that it ‘joins up’ the three core strands of 

the MSD patient’s experience, and management of, their condition. It offers a comprehensive 

framework with which to approach the diagnosis and treatment of a range of MSDs. This 

framework is essential when an important outcome for the individual is to stay engaged in, or to 

return swiftly to, work. 

The importance for a successful return to work of maintaining the worker’s connection to the 

workplace and the employer’s connection to the worker is well recognised. Managers and 

occupational health specialists in organisations are best placed to detect the early signs of 

MSDs and plan appropriate interventions and rehabilitation. They must take into account the 

physical, psychological and social dimensions of MSDs to prevent work-related causes of MSDs 

and fully embrace the benefits of workplace rehabilitation. 

Encouraging workers to return to work will help organisations save directly through reduced 

recruitment costs, training costs and incapacity payments, and indirectly through future premium 

calculation. Conversely, a lack of suitable employment and an unsupportive workplace can 



64 

lower the morale and self-esteem of injured workers, leading to low engagement, social and 

family problems and secondary psychological injuries. 

To maximise employees’ capacity when supporting their return to work, we recommend that 

employers: 

• Intervene early. Employers should always take action sooner rather than later because 

caution and delay can only make matters worse. As long as employers behave 

compassionately and make decisions based on evidence and expert opinion, early 

intervention cannot be construed as harassment and can often hasten recovery or 

rehabilitation. Reporting of early signs of illness will help prevent long-term incapacity. 

• Implement imaginative job design that will assist rehabilitation. Managers can change 

the ways work is organised (including simple changes to working time arrangements) 

to help prevent MSDs from getting worse and to help people with MSDs return to work. 

Managers need to do this in a way which preserves job quality, avoids excessive job 

demands and takes heed of ergonomic good practice. Occupational physicians should 

carefully evaluate all aspects – physical and psychosocial – of employee working 

environments, taking into consideration both occupational safety and occupational 

health aspects. 

• Communicate with clinicians. If medical statements are not providing a clear enough 

indication of the nature of an employee’s health problem, or its impact on their 

capacity to work, occupational physicians should challenge and clarify the clinician’s 

assessment, if only to help understand which tasks the employee can still perform, 

or what support they might require to return to work. Occupational physicians should 

start co-operating with the treating physician immediately after the appearance of the 

disability, and begin exchanging medical and occupational health information with each 

other. 

• Include a health and well-being component in managerial awareness-raising and 

training. Vocational rehabilitation carefully organised and tailored to the individual 

can make a real difference to return to work, productivity, morale and performance 

sustainability. Involve occupational health professionals as early as possible. 

• Go beyond legal compliance. A ‘risk management’ mentality when dealing with 

an employee with an MSD can often lead to delay, ambiguity and negative health 

outcomes. In almost all cases, the employee is better off at work. 



• Occupational physicians need to plan for changes in the workforce: changes in 

retirement age and increasing incidence of disease, as well as a rise in the number of 

non-regular employees will define the needs of the future, higher-age workforce. It is 

essential that organisational design and innovative working environments take account 

of those changing needs. 

• Standardise the format of the ‘fit note’. An example from the UK is presented in 

Appendix 2. 


7. MSDs and individuals 

66 

7.1 

Impact of MSDs 

on individuals 

and households 

Evidence on the burden of MSDs on the economy, society and organisations still 

underestimates the true cost of these conditions in Japan. Because of the impact on their quality 

of life and the experience of chronic pain, individuals are often the bearers of the largest costs 

associated with arthritis and musculoskeletal conditions. 28 

A survey investigating chronic musculoskeletal pain found that the out-of-pocket expenses on 

medical treatment for most patients suffering with MSDs amount to between JPY 3,000 and JPY 

5,000 each month, with some patients spending as much as JPY 10,000-15,000. Patients meet 

a maximum of 30 per cent of their own medical expenses, the rest being covered by health 

insurance, and treatment is often prolonged (70 per cent of treatment in this survey lasted over 

a year), indicating that MSDs can have a large effect on household budgets (Nakamura et al., 

2011). 

Another study (Igarashi et al., 2010) finds that for individuals the annual costs of RA were: 

• JPY 132,000 (out of pocket to hospital); 

• JPY 84,000 (out of pocket to pharmacy); 

• JPY 146,000 (CAM); 

• JPY 105,000 (caregiving); 

• JPY 22,000 (transportation); 

• JPY 30,000 (self-help devices); 

• JPY 188,000 (house modification). 

Considering utilisation rates, these costs add up to JPY 262,000 and JPY 61,000 for severe and 

mild forms of RA respectively. 

At the same time, intangible costs are rarely included in cost calculations as it is almost 

impossible to quantify the intangible costs of pain in monetary terms (Sieper et al., 2002). The 

ACCJ (2011b) reports that back and neck/shoulder pain is one of the most prevalent concerns 

among the Japanese, reported by 27.8 per cent of population and second only to cancer. More 

than 20 per cent of individuals in the survey had a pain level of 5 (out of 10) or higher in the past 

month, with women reporting higher levels of pain than men. Of those individuals in moderate to 

severe pain, 21 per cent said they could not perform to their full ability at work (ACCJ, 2011b). 

The evaluation of intangible costs gives useful information regarding the price paid by people 

with MSDs in terms of quality of life (QoL), and QoL measures should be used as further 



MSDs and individuals 

indicators to measure the effectiveness of interventions (Leardini et al., 2002). Presently, two 

widely used QoL measures are: 

1. Disability adjusted life years (DALYs). This is a measure of the disease burden which 

tallies the complete burden that a particular disease exacts. Key elements include age 

at which the disease or disability occurs, how long its effects linger, and its impact on 

quality of life. One DALY is equal to one year of healthy life lost. 

2. Quality adjusted life years (QALYs). The QALY is also a measure of disease burden, 

including both the quality and the quantity of life lived. It is used in assessing the 

value for money of medical interventions and is based on the number of years of life 

that would be added by these interventions. A QALY gives a measure of how many 

extra months or years of life of reasonable quality a person might gain as a result of 

treatment, helping in the assessment of the cost-utility of treatment options. 

Both measures are the subject of debate, but have become accepted as helpful in making 

comparative judgements across different countries and medical conditions. WHO (2009) 

estimates that in Japan up to 10,170 DALYs were lost due to MSD per 100,000 population in 

2004 (almost 8 per cent of all DALYs lost in Japan), including 583 DALYs attributed to RA. 

Suka and Yoshida (2005) find that the loss of QALYs due to low back pain in the Japanese adult 

population was estimated at 9.18 per 1,000 population. While low back pain has not received 

the same level of attention from health professionals in Japan as cancer and cardiovascular 

disease, it is suggested that low back pain substantially deprives the Japanese adult population 

of their quality of life. It is predicted that with the population ageing, the losses of QALYs 

associated with low back, hip, and knee pains per 1,000 population will increase from 17.2, 3.8, 

and 8.9, respectively in 2005 to 18.8, 4.5, and 11.2, respectively by 2055 (Suka and Yoshida, 

2009). 

The most common symptom affecting quality of life among individuals with arthritis and other 

MSDs is chronic or recurrent musculoskeletal pain. While the Japanese report less chronic pain 

than Europeans (13 per cent compared to 19 per cent), 58 per cent of these people report being 

in constant pain, compared to only 35 per cent in Europe (Hattori, 2006). 

In the National Livelihood Survey of 11,507 individuals Nakamura et al. (2011) find that 15.4 per 

cent of the Japanese population experience chronic pain. The majority of chronic pain is due to 

MSDs (see Figure 3.4 above). For many the pain is severe and long-term (see Figure 7.1). 



68 

Figure 7.1. Timing, severity and duration of pain in Japan 

Number of respondents 


3,000 

2,500 

2,000 

1,500 

1,000 

500 

0 

2,000 

1,800 

1,600 

1,400 

1,200 

1,000 

800 

600 

400 

200 

0 

Today Within 1 

week 

Most recent time of pain 

Within 1 

wk to 1 mo 

1-3 mo 

ago 

Severity of pain 

4-6 mo 

ago 

> 6 mo 

ago 

Unclear 

No pain 2 3 4 5 6 7 8 9 Worst 

pain 



2,500 

2,000 

1,500 

1,000 

500 

0 


70 

7.2 

MSDs: 

Intrinsic 

factors and 

lifestyle 

choices 

Figure 7.2. Productivity loss among informal carers 

20% 

18% 

16% 

14% 

12% 

10% 

8% 

6% 

4% 

2% 

0% 

Almost comparable to usual productivity 

4-6h 

10-12h 

16-18h 

22-29h 

50-69h 

>90h 

Amount of productivity loss 

Mean = 11.3 hours lost 

MSD progression may be influenced by an array of factors. Some studies, for example, have 

noted that a higher prevalence of musculoskeletal pain among working women may be linked to 

the fact that such women are still responsible for doing the majority of housework (Punnett and 

Wegman, 2004). Intrinsic risk factors also have a part to play in both the onset and progression 

of MSDs. Some intrinsic factors can be altered; others, such as genetic predisposition, cannot. 

WHO (2003) suggests several intrinsic risk factors for non-specific MSDs, including: 

• Obesity, height; 

• Spinal abnormalities; 

• Genetic predisposition; 

• Pregnancy; 

• Psychosocial stress: self-perception; 

• Health beliefs: locus of control, self-efficacy, perception of disability and expectations; 

• Family stress; 

• Psychological stress: somatisation, anxiety and depression; 

• Ageing. 

2-3h 

7-9h 

13-15h 

19-21h 

30-49h 

70-89h 

Source: ACCJ (2011b) 


Japan has an older population compared with many other countries: the proportion of the 

population aged 65 years and over has risen from 17.4 per cent in 2000 to 23.1 per cent in 

2010, and is predicted to reach 40 per cent by 2050. 29 Between 2000 and 2010, the proportion 

of those 80 years old and over increased from 2.7 per cent to 6.5 per cent. 30 Evidence suggests 

that there is a greater chance of deteriorating health – particularly higher rates of MSD 

prevalence – among the older cohorts of the workforce (see Figure 7.3). Prevalence of muscular 

pain was highest in people in their 40s (18.6 per cent), followed by those in their 30s (18.3 per 

cent) and 50s (17 per cent) (Nakamura et al., 2011). 

Figure 7.3. Health concerns of outpatients aged 65 and over 

Age 75 and over 

31 

Age 65-75 

22.1% 24.30% 

18.8% 17.80% 16.40% 

6.60% 

0.90% 

7.90% 

7% 30.30% 

7.50% 31.5% 

0% 20% 40% 60% 80% 100% 

Individuals with lower socioeconomic status are found to be more likely to have arthritis and 

musculoskeletal conditions, which have a further detrimental impact on their quality of life. It 

is suggested that arthritis-related disabilities reduce opportunities for employment and higher 

education, which in turn decreases the likelihood of effective self-management of arthritis 

29 See OECD http://stats.oecd.org/ 


31 See MHLW Health Statistics http://www.mhlw.go.jp/english/database/db-hss/hs2007.html 


Diseases of the musculoskeletal 

system and connective tissue 

Diseases of the circulatory system 

Diseases of the digestive system 

Factors influencing health status 

and contact with health services 

Endocrine, nutritional and 

metabolic diseases 

Others 

Source: MHLW Health Statistics 31 



72 

and other health conditions. In addition, lower socioeconomic status is linked to inactivity and 

obesity, both of which are risk factors for certain types of arthritis. 

Recently, awareness of the effects of diet on health has been increasing in Japan. Although still 

low, the rate of obesity – a risk factor not only for bone and joint conditions but cardiovascular 

disease and diabetes as well – is on the rise in Japan, currently at 5.5 per cent among men and 

3.5 per cent among women (WHO, 2009). Although prevalence is lower than in other countries, 

increasing rates of childhood obesity over the last decade are of great concern (Matsushita, 

Yoshiike, Kaneda, Yoshita and Takimoto, 2004; Munakata, Sei, Ewis, Umeno, Sato et al., 2010; 

ACCJ, 2011b). Obesity in childhood has been found to be a predictor of obesity in adults, thus 

reducing the age at which obesity-related diseases, such as MSDs, may manifest themselves. 

In addition, sedentary lifestyle may contribute to obesity and MSDs: in one survey 40 per cent 

of adults admitted they did not engage in any moderate or strenuous exercise in the previous 

week, and only 30 per cent performed an hour or more (ACCJ, 2011b). Notably the intensity of 

exercise increased with age, with individuals aged 60 and above being more likely to exercise 

regularly (ACCJ, 2011b). 

Having acknowledged the effects of changing diet coupled with lack of physical activity, 

particularly among older people, the MHLW have been promoting healthy lifestyles via 

‘Shokuiku (Food and Nutrition Education)’, as well as via publications such as the ‘Exercise and 

Physical Activity Guide for Health Promotion 2006’ (MHLW, n.d.). 

Finally, smoking has been found to have an impact on the progress of RA disease (Bone and 

Joint Decade, 2005). A worryingly large proportion of Japanese aged 15 years and over are 

regular smokers: 36.6 per cent of males and 12.1 per cent of females, although the rate of 

smoking has been declining gradually. 32 More adults are exposed to the harmful effects of 

second-hand smoke (MHLW, n.d.). 

It is important to recognise that individual personality differences and behaviours moderate 

the relationship between MSD symptoms and productivity loss/disability, associated with those 

symptoms (Burton, 2005). In other words, whilst individuals may experience musculoskeletal 

pain (in their back, for example), it is not possible to predict: 

a. Their strategies for dealing with illness or injury (seeking medical attention for example); 

b. How the ailment will affect their work performance or whether they will take time off 

work, or 



7.3 

Role of work 

in health 

outcomes 


c. Whether, ultimately, they will become one of the very small minority who become 

permanently disabled by their condition. 

For example, back pain may be caused both by ergonomic and psychosocial factors 

(Matsudaira et al., 2012). Some people experience a high level of disability but only mild 

amounts of pain. These individuals tend to be older, more stressed, working more overtime, 

more depressed, and less satisfied with their job content, income, working conditions and 

relationships with co-workers. Conversely, people with little disability despite severe pain have 

lower scores on the above indicators (Takahashi, Kikuchi, Konno, Morito, Suzukamo et al., 

2006). 

A growing body of evidence confirms the close connection between quality of work and the 

health status of individuals (Waddell and Burton, 2006a). A recent survey of more than 7,000 

respondents in Australia has confirmed that poor-quality jobs, characterised by excessive 

demands, low autonomy, high job insecurity and significant effort-reward imbalance – were 

more detrimental to employees’ mental health than joblessness (Butterworth, Leach, Strazdins, 

Olesen, Rodgers et al., 2011). 

Research conducted among individuals with RA (Chorus, Miedema, Boonen and van der 

Linden, 2003) and AS (Gordeev, Maksymowych, Evers, Ament, Schachna et al., 2009) 

confirmed that physical health-related quality of life of individuals with those conditions was 

positively influenced by work. Chorus et al. (2003) conclude that work ’might be an important 

factor in positively influencing patients’ perception of their physical performance‘. This finding 

concurs with Waddell and Burton (2006a) that, overall, good quality work has health and 

recuperative benefits for workers. 

On the other hand, poor experiences at work may negatively affect individuals’ health. De Croon 

et al. (2004) looked at the research on work disability among people with RA and concluded that 

psychosocial factors were often a better predictor of work disability than standard bio-medical 

factors. Since it was first proposed in the late 1970s, a growing body of evidence has developed 

in support of the biopsychosocial model. For example, research has demonstrated that job 

dissatisfaction can be an important predictor of speedy and successful return to work (Bigos, 

Battie and Spengler, 1992). In Figure 7.4 below, the authors highlight how wider environmental 

and personal factors enhance the explanatory power of the International Classification of 

Functioning, Disability and Health (ICF) in the case of work disability and RA. 



74 

Figure 7.4. ICF model applied to work disability in RA 

(Impaired) body 

functions and 

structures 

Environmental 

factors 

Rheumatoid 

arthritis 

Activity 

(limitations) 

Personal 

factors 

Participation 

(restrictions); 

work (dis)ability 

Source: de Croon et al., (2004) 

Some critics of the biopsychosocial model have focused on this last point, highlighting concerns 

that this approach may encourage or ‘permit’ helplessness in some patients or that, in other 

circumstances, it may alienate patients who feel they are being told that their condition is ‘all in 

the mind’. Clearly, clinicians and others must take care in how they mitigate these risks, but the 

balance of the literature – and of the expert opinion offered during the course of our interviews – 

strongly supports the biopsychosocial model and its role in informing the management of MSDs 

in both clinical and occupational settings. 

An example of reducing sickness absence by using successful intervention based on the 

biopsychosocial model is provided by Ektor-Andersen, Ingvarsson, Kullendorff and Ørbæk 

(2008). In their study, Ektor-Andersen et al. (2008) developed a tool based on the CBT method 

of functional behaviour analysis, according to which risk factors for long-term sick leave due 

to musculoskeletal symptoms were identified in four different domains: the community, the 

workplace, the family/spare time and the health care system. Care-seekers were examined 

by each member of the interdisciplinary team and risk factors were identified and classified 

as stable or dynamic. Dynamic factors were the ones which the care-seekers and the team 

agreed to intervene on. Some of these interventions involved CBT or physiotherapy sessions, 



which were administered for a year. Results from the study show that this type of intervention is 

effective in reducing sick leave and social security expenditure four months after the intervention 

began. Although the cost-benefit analysis presented by Ektor-Andersen et al. (2008) 

underestimates the total savings by taking into account social security costs alone, the costs of 

this type of intervention are balanced out by reduced costs in sickness allowance during the first 

year. 

Box 3. Case study: Participatory approaches to workplace adjustment in Japan 

Participatory approaches to improvement of the workplace have evolved since the mid- 

1980s. They have developed in the form of ‘action-oriented training of local people who plan 

and implement immediate improvements in their own workplaces’ (Kogi, 2006, p.548). People 

thus develop the capacity to control a significant amount of their activities at work and power 

to influence both processes and outcomes in order to achieve desirable goals (Kogi, 2006). 

Studies suggest that a participatory approach carries benefits for both employer and employee. 

By facilitating workers’ initiative, it could create good communication among workers and a 

healthy climate within the workplace. It could also lead to the rise of work engagement and 

to the improvement of work performance. Nagami, Tsutsumi, Tsuchiya and Marimoto (2010) 

have surveyed 777 full-time employees at a manufacturing company in Japan to show that 

job control was positively related to job performance. 

The example of the WIND training programme presented below creates preconditions for a 

healthier, safer and better informed workforce (Ikeda et al., 2012). WIND also demonstrates 

features of the kaizen method of workplace improvement. 

‘Kaizen is the Japanese word for improvement, carrying the connotation in industry of 

all the uncontracted and partially contracted activities which take place in the Japanese 

workplace to enhance the operations and the environment. Kaizen epitomises the 

mobilisation of the workforce, providing the main channel for employees to contribute to 

their company’s development. In isolation, the concept seems simple: with every pair of 

hands, you get a free brain’ (Brunet and New, 2003, p. 1427) 

The principle of kaizen is characterised by generality and simplicity. The importance of 

kaizen in Japanese management has been widely recognised. It is often described as 

one of the underlying principles of lean production and total quality management (TQM). 

In the management literature it has often been credited as the key element in Japanese 

manufacturing success. 

Cont. 



76 

Cont. 

Kaizen has often been described as ‘continuous’, ‘incremental in nature’ and ‘participative’. 

It is closely associated to the notions of quality circles (QCs) and TQM, but is not identical to 

them. In the 1950s, the concept of TQC (total quality control) substituted the earlier concept of 

statistical quality control (SQC) in Japan. TQC included company-wide activities and education 

in quality control (QC), QC circles and audits, and promotion of quality management principles. 

By 1968 the elements of TQC management had been outlined by one of the fathers of TQC 

in Japan – Kaoru Ishikawa. These include: 

• Quality comes first, not short-term profits; 

• The customer comes first, not the producer; 

• Customers are the next process with no organisational barriers; 

• Decisions are based on facts and data; 

• Management is participatory and respectful of all employees; and 

• Management is driven by cross-functional committees covering product planning, 

product design, production planning, purchasing, manufacturing, sales, and distribution. 

(Pecht and BSoulton, 1995) 

Participatory training programmes are being increasingly implemented in Asia to support 

grassroots initiatives in informal economy workplaces. These are devised to improve safety, 

health and working conditions and are usually based on a set of simple principles: ease 

of application and use of low-cost, locally available materials. Common actions taken in 

informal economy workplaces include clear transport routes, improved workstations for better 

work posture, machine guards, safer handling of hazardous substances, and basic welfare 

needs such as safe drinking water and sanitary toilets. Easy-to-apply training tools are used 

throughout the programmes (Kawakami, 2007). 

An example of such a training programme is WIND (Work Improvement in Neighbourhood 

Development), designed to improve the health and safety of farmers. It was developed by 

the International Labour Organisation (ILO) and was based on the successful example of 

the WISE (Work Improvement in Small Enterprises) training programme, which assisted 

participating small enterprises in improving productivity and working conditions. The WISE 

methods rely fully on self-help of owners and workers in local small-scale enterprises rather 

than on a classroom-style lectures, and enable the participants to improve their working 

conditions immediately. WISE trainers should serve as facilitators to provide concrete support 

for existing self-help efforts towards workplace improvement. 

Cont. 


7.4 


for individuals 

Cont. 

The main functions of the trainers are to: 

• Collect good local examples; 

• Encourage visible achievements; 

• Convince managers that improvement of working conditions is important; 

• Facilitate learning-by-doing experiences; 

• Stimulate exchange of practical experience; 

• Promote workers’ active involvement. 


The WIND programme was born out of the active participation of farmers in the Mekong Delta 

area of Vietnam in 1995. The programme’s inspiring achievements in Vietnam allowed it to 

spread into neighbouring counties like Cambodia and Thailand, and later to Central Asia, 

Africa, Eastern Europe and Latin America. The programme is based on participatory training 

methods executed in a systematic manner. Methods include: farm visits, checklist exercise, 

group discussions by farmers, best practice picture examples, etc. 

The programme is usually run in the form of a short-term workshop (1-2 days) or a series of 

mini-workshops, and allows farmers to understand health and safety risks, as well as practical, 

low-cost solutions. Equal participation of women and men is actively promoted (Kawakami, 

Khai and Kogi, 2009). 

As Waddell and Burton (2006b) have argued, the goal of the biomedical model is to relieve 

symptoms, whereas the goals of clinical management informed by the biopsychosocial model 

– especially in occupational settings – should be to control symptoms and restore function. This 

suggests that employers play a role in the ‘social’ aspect of the biopsychosocial model, and that 

employers’ actions can make a difference in the health outcomes of individuals with MSDs. 

Individuals must play an active part in the management of their condition. Many people feel that 

their health condition is controlling their lives at home and at work. However, there are many 

ways to learn about your condition, learn how to recognise patterns in pain or fatigue and how to 

minimise the condition’s impact on functioning and well-being. 

It has been found that people with who actively manage their condition recover earlier than 

those who catastrophise their disease. For example, RA patients receiving anti-TNF therapy 

report higher employability after treatment. Overall, the use of TNF inhibitors improves self- 



78 

reported work ability, quality of life and fatigue in first-year RA patients (Herenius, Hoving, 

Sluiter, Raterman, Lems et al., 2010), and sleep quality among those with AS (Rudwaleit, 

Gooch, Michel, Herold, Thörner et al., 2011). With the right support from return-to-work 

programmes, TNF inhibitors could support employment opportunities (Herenius et al., 2010). 

Ohkusa (2003) reported that the Japanese may be willing to pay JPY 1 mln to improve 1 

QALY. Therefore, the improvement of quality of life in for the Japanese with low back pain may 

be worth a total investment of JPY 947 bn (equivalent to 0.2 per cent of the gross domestic 

product). 

Given that health outcomes for Japanese patients with MSDs may be significantly improved if 

the individuals themselves take a proactive approach to self-management of their condition, we 

recommend that those with MSDs: 

• Speak up early. If your MSD is causing you difficulty, or you anticipate having a period 

when you will need to adjust your working time, talk to your manager so that you can 

both plan what to do about it. The earlier the better, as managers don’t like last minute 

surprises, and they can usually find a solution to most problems if they have some 

notice. You might also find it useful to talk to your union representative, HR manager or 

someone in occupational health. Delay could compromise recovery. 

• Focus on capacity, not incapacity. It is natural to feel anxious or even guilty about 

the parts of your job that are difficult to perform because of your MSD. But you still 

have much to contribute – so play to your strengths. Your specialist knowledge and 

experience doesn’t disappear just because you have pain, discomfort or mobility 

problems; you can still contribute in many ways. Work with your managers and your 

colleagues to find out how you can maximise your impact at work within the constraints 

of your condition. Be open with them and they should respond better. 

• Know your rights. As both a patient and as a worker you should know what support and 

advice you are entitled to. If you are a trade union member, your union should be able 

to guide you in exercising your rights. 

• Get family involved in job retention and rehabilitation. Your family and friends are 

important sources of support. They may not realise that staying in or returning to work 

is both possible and desirable. You need to help them help you by getting them involved 

in your rehabilitation at work. Even small adjustments to working time or commuting 

arrangements can make an immense difference. 


8. Conclusions and recommendations 

In general, work is good for health. It provides income, generates social capital and gives us 

purpose and meaning. Even when unwell or injured, remaining in work – even in a reduced 

capacity – is often better for recovery than long periods away from work. If the Japanese 

workforce is to be productive and competitive in the global economy, and if the quality of their 

working lives is to be enhanced, it is important that a large proportion of the workforce is, as 

much as possible, fit for work. 

The evidence presented in this report illustrates that a high percentage of working age people in 

Japan are, or will be, directly affected by MSDs. This can have significant social and economic 

consequences for these individuals, their families, their employers and the Japanese society as 

a whole: MSDs can impede the productive capacity of the overall workforce and the Japanese 

economy; In addition, they can lead to heavy draws on the resources of both the health service 

and the social benefits regime. 

There are three main principles on which clinicians, occupational physicians, employers, 

employees and the Japanese government should focus if the working lives of workers with 

MSDs are to be improved. 

• Collect reliable data on the prevalence of MSDs in Japan. The data on the incidence 

of occupational disease collected by employers, and the data on inpatients collected 

via the health care system are inconsistent because of the variability in methods of data 

collection. Furthermore, evidence and expert views gathered in his report suggest that 

the data that is available does not reflect the true picture of the prevalence of MSDs in 

Japan. Lack of comprehensive data is one reason why many individuals in Japan do 

not receive appropriate interventions in time for the most efficient management of their 

conditions. A standardised and up-to-date method to collect data on the prevalence 

of MSDs in Japan should be introduced and used by occupational physicians 

and clinicians, so that the Japanese government and the employers can develop 

appropriate policies and practices to tackle the burden of this group of conditions. 

• Early diagnosis and intervention are essential. The overwhelming evidence is that 

long periods away from work are usually bad for MSD patients. Early diagnosis and 

intervention, as well as timely and appropriate rehabilitation, will help more people keep 

their jobs and will reduce the burden of chronic disease on the wider economy and 

society. Occupational physicians are ideally placed to identify the early presentation 

of many MSDs. They should strive to detect conditions as early as practicable, and 

refer individuals to specialist teams to enable a prompt start to managing the condition. 

Similarly, communication between the specialists in the Japanese health care 

system must be improved to ensure that individuals with MSDs access appropriate 


Conclusions and recommendations 

80 

interventions in time. An integrated care team, involving the treating health care 

professionals, occupational physicians and the individual themselves should work 

together to establish an optimal plan of intervention and return to work. 

• Coordinate action. Five stakeholder groups – individuals, employers, occupational 

physicians, clinicians and policy makers – must embrace the principles of effective 

management of MSDs to reduce and prevent the impact of chronic conditions on 

individuals’ ability to remain at work and return to employment. Better communication and 

coordination must be put in place to ensure that those with MSDs receive appropriate 

support, and that the impact of their condition on the daily activities is minimised. 

The report calls upon each of the stakeholder groups to take action: 

• Policy makers have to acknowledge both the direct and indirect costs of MSDs. We 

need better measures to assess the social, economic and work impact of all MSDs, 

to allow the Japanese government to assess and monitor both the clinical and labour 

market impact of MSDs in a more ‘joined-up’ way. Considering the principal role of 

policy makers in advising employers on effective prevention of chronic conditions, the 

government should urgently review the guidelines for management of MSDs for both 

manual and white-collar workers. 

• Clinicians should prioritise staying in and returning to work as both a means and an 

outcome of patient treatment. For some MSD patients, early access to physiotherapy or 

drug therapies can reduce the severity, impact or progression of the condition; a delay 

in diagnosis or treatment can make recovery, job retention or rehabilitation much more 

difficult. Clinicians should work more closely with occupational physicians to ensure 

that clinical treatment is complemented by appropriate workplace interventions and 

vocational rehabilitation. 

• Occupational physicians should look beyond legal compliance in maintaining the 

health and well-being of employees and tailor vocational rehabilitation to individual 

worker needs. When reviewing the safety of workplaces, they should acknowledge not 

only the physical, but also the psychological impact of work on health in both manual 

and non-manual jobs. 

• Employers can change the way in which the work environment is organised (including 

simple changes to physical layout or to working time arrangements) to help prevent 

MSDs from getting worse and to help people with MSD to stay in, or return to, work. 

They need to do this in a way which preserves job quality, avoids excessive or 

damaging job demands and takes heed of ergonomic good practice. Employers must 

recognise that work environment and working conditions can impact the health of both 

manual and non-manual workers. Employers should explore successful examples of 


Conclusions and recommendations 

the participatory approach and gain from employees’ first-hand experience to improve 

working conditions and work environments. 

• Individuals should play an active part in the management of their condition. There are 

multiple ways of learning more about chronic health conditions how to minimise their 

impact on work performance and psychological well-being. It is crucial to tell your doctor 

and occupational physicians about worsening health status, so that it can be addressed 

in time for appropriate intervention: early diagnosis is crucial for the prevention of longterm 

incapacity at work. 

Although the problem of MSDs and their impact on work is much higher on Japan’s official 

agenda than it is in Europe, there is still a paucity of clinical, epidemiological, psychological and 

economic evidence on the precise nature, extent and consequences of the MSDs in Japan. 

Nevertheless, we know enough to conclude that MSDs will affect a growing proportion of the 

working age population in the coming years, and while acceptance for a more holistic approach 

to MSD treatment is growing, the principles of biopsychosocial model are yet to be fully 

embraced. There is a need for more coherent, ‘joined-up’ action by government, clinicians and 

employers which would focus on extending the working lives of MSD patients. 


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WHO. (2011). World Report on Disability. Geneva: WHO. Retrieved on 4 August 2011 from 

http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf 

Yasui, T., Nishino, J., Kadono, Y., Matsui, T., Nakamura, K. et al. (2010). Impact of Biologics on 

the prevalence of orthopaedic surgery in the National Database of Rheumatic Diseases 

in Japan. Modern Rheumatology, 20, 233-237 


References 

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Young, A., Dixey, J., Cox, N., Davis, P., Devlin, J. et al. (2000). How does functional disability 

in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of 

follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology, 39, 603-611. 


Appendix 1: Interviews and consultation with experts 

The following people shared their views and information with us during the course of our 

research and we are very grateful for the time each spent. We have taken their views into 

account in writing this report, though their participation in the study does not in any way imply 

endorsement of the report’s conclusions. 

Dr Atsushi Funahashi 

Dr Takashi Kawagowe 

Mazda Motor Corporation 

Prof Hiroshi Udo Hiroshima Bunkyo Women’s University 

Prof Masaharu Kumashiro 

Prof Seichi Horie 

Prof Shinya Matsuda 

Dr Yoshihisa Fujino 

Dr Tadayuki Mizutani 

Kenji Takagi 

Hirofumi Ogura 

Toshiyuki Kawasaki 

University of Occupational and Environmental Health 

Ministry of Health, Labour and Welfare, 

Department of Health and Welfare for persons with Disabilities 

Dr Shigeki Shiiba Ministry of Health, Labour and Welfare, 

Industrial Health Division 

Prof Hiroshi Jonai Nihon University 

Mieko Hasegawa The Japan Rheumatism Friendship Association 

Prof Hisashi Yamanaka Tokyo Women’s Medical University 

Dr Ippei Mouri The Institute for Science of Labour 


Appendix 2: Fit Note Sample 

94 

Source: Department for Work and Pensions (2010). 


Appendix 3: Benchmarking grid 

The Fit for Work study has looked across a range of European countries, Australia, New 

Zealand, Canada and Japan. This approach allows us to explore how far early intervention is 

implemented across the world. It also enables us to see how far we may identify both enablers 

and barriers to early intervention given the different approaches to policies that affect the labour 

market, the welfare system and the health care system. To explore this we have looked widely 

at a number of indicators covering the: 

• Labour market; 

• Welfare system ; 

• Health care system. 

The data presented below come from various international data sources. Where possible we 

used 2009 data to allow for comparisons across countries for a number of different indicators. 

The data mainly come from the OECD. We present a selection of indicators below. 



96 

Sources: OECD (n.d.), *Eurostat (n.d.), OECD (2010) 

OECD-Europe -- -- -- -- -- -- -- -- -- 103.6 106.9 

OECD $33,080 66.8 14.6 8.5 7.7 24.2 -- 62.3 63.5 102.9 106.7 

US $45,674 67.0 12.9 10.3 8.1 16.3 11.9 63.9 64.4 101.8 108.8 

EU-27 $31,257 67.2* 17.2* 9.0* 8.9* 3.0* -- 61.9* 60.5* -- -- 

New Zealand $28.885 66.5 12.8 6.1 6.2 6.3 -- 63.9 66.5 97.8 116.1 

UK $35,159 66.5 15.8 8.8 6.5 24.6 17.6 61.9 63.2 103.7 107.6 

Canada $37,808 69.5 13.9 9.4 7.0 7.8 12.1 61.9 63.3 101.2 110.4 

Japan $32,062 63.9 22.7 5.3 4.8 28.5 -- 69.5 66.5 95.0 101.1 

2006 data 2006 data 

Australia $39, 660 67.6 13.3 5.7 5.4 14.7 12.0 62.2 64.4 101.2 104.9 

Brazil $10,453 67.3 6.8 6.5 9.9 -- -- -- -- -- -- 

in PPP, 

2009 

GDP per 

capita 

Percentage 

of the 

population 

of working 

age 

Percentage 

of the 

population 

aged 65 

and over 

rate, % of all 

unemployed 

Unemployment 

rate (%) 

Long term 

unemployment 

Disability 

prevalence, 

as a 

percentage 

of 20-64 

population 

Average age 

of withdrawal 

from the 

labour 

market 

Labour 

productivity 

per unit labour 

input, relative 

to base year 

2005 (=100) 

Unit 

labour 

cost, 

relative 

to base 

year 2005 

(=100) 


Male Female Male Female

Sources: OECD (n.d.), Osterkamp and Rohn (2007) 

OECD $33,139 -- -- -- -- -- 

US $46,337 16.0 7.2 1.3 0.3 2.70 

EU-27 $30,769 -- -- -- -- -- 

New Zealand $28,567 18.4 7.1 2.5 0.2 -- 

UK $35,719 20.3 6.8 2.4 0.2 3.87 

Canada $38,353 16.9 7.0 0.9 0.6 3.52 

Japan $33,635 18.7 8.1 0.8 0.3 -- 

Australia $39,002 16.0 5.7 2.2 0.4 4.10 

Brazil $9,900 -- 3.7 -- -- -- 

system 

(0/7 scale) 

GDP per inhabitant 

in PPS, 2007 

Social 

expenditure 

(% GDP) 

Public expenditure on (% of GDP) Generosity of 

the welfare 


Health Incapacity related Unemployment 

Appendix 3: Benchmarking grid


98 

Sources: OECD (2009); OECD (n.d.); WHO (2006; 2007); Lundkvist, Kastäng and Kobelt (2008); OECD (n.d.) 

*-practicing physicians 

OECD 3.4 4.2 4.4 -- -- -- -- -- -- 

Europe -- -- -- -- -- -- 660 45,263 -- 

2004 data 2008 

Australia 1.3 2.6 2.9 32.7 4.49 0.76 136 2,164 1.49 

Brazil -- -- -- -- 2.46 0.63 -- -- -- 

Canada 2007 

1.5 -- -- 19.9 4.72 0.88 215 2,249 1.09 

Japan -- -- -- -- 5.73 0.92 -- -- 2.15* 

2008 

New Zealand -- -- -- 13.0 4.24 0.72 -- -- 0.85 

UK 2005 

3.2 6.7 6.3 14.1 4.11 0.81 399 6,577 0.77 

US 2008 

3.6 4.7 4.6 26.0 3.76 0.71 1,976 41,631 0.3 

Male Female 

% of working 

days lost 

% of working 

age population 

inactive due to 

sickness and 

disability 

Total) 

MSD-related 

disability 

claims 

DALYs 

MSDs 

(% of 

DALYs 

RA 

(% of 

total) 

Number 

of RA 

Patients 

general 

population 

(‘000) 

Total annual 

cost of RA, 


mln euros 

Practising 

general 

practitioners 

(GPs), density 

per 1,000 

population

Unit labour cost, relative to 

base year 2005 (=100) 2009 

Unit labour costs measure the average cost of labour per unit of output. They are 

calculated as the ratio of total labour costs to real output. Output per hour. If the index of a 

country is higher than 100, this country’s value is higher than the OECD average and vice 

versa. 

OECD (n.d.) 

Labour productivity per unit 

2009 

Output per hour. If the index of a country is higher than 100, this country’s value is higher 

than the OECD average and vice versa. 

OECD (n.d.) 

Average age of withdrawal 

from the labour market 2009 

The indicator gives the average age at which active persons definitely withdraw from 

the labour market. It is based on a probability model considering the relative changes 

of activity rates from one year to another at a specific age. The activity rate represents 

the labour force (employed and unemployed population) as a percentage of the total 

population for a given age. 

OECD (n.d.), 

Eurostat (n.d.) 

Disability prevalence, as 

a percentage of 20-64 

population 

Self-assessed disability prevalence, as a percentage of 20-64 population OECD (2010) 

Long-term unemployment, % 

of total unemployed 2009 

Unemployed for one year and above. Data refer to the shorter of the following two periods: 

the duration of search for work, or the length of time since last employment. 

OECD (n.d.), 


Unemployment rate by 

gender 2009 

Data refer to persons who are without a job, want a job, have actively sought work in the 

last four weeks and are available to start work in the next two weeks or are out of work, 

have found a job and are waiting to start it in the next two weeks. 

OECD (n.d.), 


Percentage population aged 

65 and over 2009 

Share of total population of age 65 and above. OECD (n.d.), 



Percentage of the population 

of working age 2009 

Share of total population of age 15 to 64.. OECD (n.d.), 


Gross domestic product in US 

dollars per capita 

At current prices and current 

PPPs 2009 

Gross domestic product is an aggregate measure of production equal to the sum of the 

gross values added of all resident institutional units engaged in production (plus any taxes, 

and minus any subsidies, on products not included in the value of their outputs). The 

sum of the final uses of goods and services (all uses except intermediate consumption) 

measured in purchasers’ prices, less the value of imports of goods and services, or the 

sum of primary incomes distributed by resident producer units. 


OECD (n.d.) 

Labour indicators 

Variable Definition – Provided by source Source


100 

O&R generosity index Seven different measures of generosity were combined to construct a single measure 

of generosity that ranges from between 0 and 7, where 7 indicates the highest level of 

generosity. The seven variables include waiting period, self-certification, total maximum 

duration of payment, employer maximum duration of payment, employer amount of 

payment, sickness fund amount of payment and external proof. 

Osterkamp and 

Rohn (2007) 

Unemployment – Social 

benefits by function – % of 

total benefits 2008 

Unemployment compensation, early retirement for labour market reasons. 

OECD (n.d.) 

Disability – Social benefits by 

function – % of total benefits 

2008 

Care services, disability benefits, benefits accruing from occupational injury and accident 

legislation, employee sickness payments. 

OECD (n.d.) 

Sickness/health care benefits 

– % of total benefits 2007 

Spending on in- and out-patient care, medical goods, prevention. OECD (n.d.) 

Social benefits (% of GDP) 

2007 

Social benefits are current transfers received by households intended to provide for 

the needs that arise from certain events or circumstances, for example, sickness, 

unemployment, retirement, housing, education or family circumstances. 

GDP per inhabitant in PPS 

2007 

Gross domestic product is an aggregate measure of production equal to the sum of the 

gross values added of all resident institutional units engaged in production (plus any taxes, 

and minus any subsidies, on products not included in the value of their outputs). The 

sum of the final uses of goods and services (all uses except intermediate consumption) 

measured in purchasers’ prices, less the value of imports of goods and services, or the 

sum of primary incomes distributed by resident producer units. 


OECD (n.d.) 

OECD (n.d.) 

Welfare indicators 

Variable Definition – Provided by Source Source

Practising general 

practitioners (GPs), density 

per 1,000 population 

2008 

Number of practising GPs per 1,000 population. OECD (n.d.) 

Total annual cost of RA, mln 

euros 

Estimated direct and indirect costs of RA. The percentage is calculated from the 

number of people with RA and estimated cost per individual. 

Lundkvist, Kastäng 

and Kobelt (2008) 

Number of people with RA Estimated number of people with RA. The percentage is calculated from the number 

of people with RA divided by the population numbers listed in the article. 



DALYs – RA DALYs are frequently used to assess the burden of disease. The WHO’s definition of 

DALY ‘combines in one measure the time lived with disability and the time lost owing 

to premature mortality. One DALY can be thought of as one lost year of healthy life. 




DALYs – MSDs, male and 

female 

Disability-adjusted life years (DALYs) are frequently used to assess the burden of 

disease. The WHO’s definition of DALY ‘combines in one measure the time lived with 

disability and the time lost owing to premature mortality. One DALY can be thought of 

as one lost year of healthy life. 

% of working age population 

inactive due to sickness and 

disability 2009 

All persons who are not classified as employed or unemployed, of population aged 

between 15 and 64. 


WHO (2006; 2007) 

MSD-related disability claims Number of claims associated with musculoskeletal disorders. OECD (2009) 

OECD (2009) 

% of working days lost The median number of days absent because of health. OECD (2009) 

Health outcomes 

Variable Definition – Provided by Source Source


References 

102 

Eurostat Statistical Database. (n.d.). Data retrieved on 20 July 2011 from http://ec.europa.eu/ 

eurostat 

Lundkvist, J., Kastäng, F. & Kobelt, G. (2008). The burden of rheumatoid arthritis and access 

to treatment: health burden and costs. European Journal of Health Economics, 

8(Supple 2), 49-60 

OECD. (2009). Sickness, Disability and Work. High-Level Forum, Stockholm, 14-15 May. 

OECD Factbook. (2010). Economic, Environmental and Social Statistics. Retrieved on 20 

July 2011 from www.oecd-ilibrary.org 

OECD Statistics. (n.d.). Data retrieved on 20 July 2011 from http://www.oecd.org/statsportal 

Osterkamp, R. & Rohn, O. (2007). Being on sick leave: Possible explanations for differences of 

sick-leave days across countries. CESifo Economic Studies, 53, 91-114 

WHO. (2006/7). Highlights on health. Geneva: WHO 


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