Osteomuscular and connective tissue diseases are a group of disorders with a diverse demographic, genetic and clinical profile. Although they usually affect the locomotor apparatus, sometimes are accompanied by multiorgan systemic commitment derived from generalized autoimmune phenomena.1 They are characterized by pain, chronic and persistent inflammation, alteration of functional ability and deterioration in quality of life. Several of these diseases are linked with a significant decrease in life expectancy.2

In the past 40 years, it has been documented a 2–4-fold progressive increase in the prevalence of musculoskeletal symptoms3; phenomenon to which the Latin American countries have not been oblivious.4 This increase has represented a significant rise of the costs derived from their medical care.5 Several strategies have been designed to try to impact the public health problem that these disorders represent. One of the most significant was the declaration, by the World Health Organization, of the Bone and Joint Decade for the period comprised between the years 2000 and 2010, which sought to join efforts of governmental and non-governmental organizations in the search for integral solutions to the public health problem that these entities represent.6

The World Health Organization and the International League of Associations of Rheumatology (ILAR) developed the Community Oriented Program for Control of Rheumatic Diseases (COPCORD) as an epidemiologic strategy designed for the identification, prevention and control of the rheumatic diseases in developing countries.7 The strategy consists of 3 stages, the first one identifies the patients with osteomusculoarticular symptoms of non-traumatic origin through a direct interview, classifies the symptoms by pain or limitation with the use of questionnaires and, finally, with the participation of a trained physician, the rheumatologic diagnosis is established. Stages 2 and 3 are addressed to the design of strategies that allow the integral care of patients with these diseases.8

Its use allows to identify the frequency of these diseases, their distribution and potential intervention factors as public health strategies.9 The COPCORD strategy has been implemented in several Latin American countries: Argentina,10 Mexico,11 Guatemala,12 Cuba,13 Peru,14 Venezuela,15 Brazil16 and Ecuador.17 Studies have also been conducted in indigenous populations from Venezuela (Warao, Kariña and Chaima), Mexico (Mixteco, Maya-Yucateco and Rarámuri) and Argentina (Qom).18 In these countries it has been reported a prevalence between 17 and 50%. Osteoarthritis (OA) has been the most frequent disease, and rheumatoid arthritis (RA) ranges between 0.9 and 1.6%.

Epidemiological studies are the base for the determination of the economic impact of the diseases through the estimation of the number of affected individuals. The combination of the prevalence with factors related with the quality of life, the functional limitation and the costs allows to establish the attributable economic impact and burden of these conditions on the macroeconomic variables of the State.5 In developed countries, the costs of the rheumatic diseases can represent between 1 and 3% of the gross domestic product, which constitutes them in a public health problem of high impact.19 In Latin America and Colombia there is little information related to the prevalence, costs and economic impact of these diseases.

The objective of this study is to estimate the prevalence of musculoskeletal manifestations and of the main rheumatic diseases in Colombian population through the implementation of the stage i of the COPCORD strategy.

The study conducted in Mexico during the years 2012–2014 was taken as reference for the development of this study. It was performed the transcultural adaptation and validation of the methodology and screening questionnaire (COPCORD) Mexican version 220 to identify musculoskeletal discomforts and rheumatic diseases, following the guidelines proposed by Beaton et al.21 The population studied consisted of adults over 18 years of age, who had been living in the household surveyed for more than 2 years and who were mentally able to answer the survey and fill out the forms that were included in it. Persons residing in hospitals, military institutions or prisons, as well as individuals unable to answer the interviews or questionnaires were excluded.

Recruiting

Trained interviewers applied questionnaires structured and validated for the Colombian population, face to face, in the homes of the participants. Different variables were collected: sociodemographic (age, gender, race, educational level, marital status), socioeconomic (family income, current professional status, health insurance, health care opportunity, medication coverage, percentage of the family income dedicated to health, among other econometric variables). The quality of life was measured using the EQ-5D-3L questionnaire, a generic and multidimensional instrument, which evaluates 5 dimensions (mobility, self-care, activities of daily living, pain/discomfort, and anxiety/depression), in 3 levels of response (1=without problems, 2=moderate problems, 3=extreme problems), and a scale to measure the health state in the present day (EQ-5D-VAS) (from 0=the best imaginable health state to 100=the worst imaginable health state)22,23; the physical function was measured using the Health Assessment Questionnaire (HAQ-DI), which is an instrument that contains 20 items organized into 8 categories which are qualified from 0 to 3.24 The latter 2 forms were previously validated for the Spanish language and the Colombian population. Information related with the antecedents of self-reported non-communicable chronic diseases (chronic high blood pressure, diabetes mellitus, cardiopathy, cancer, tuberculosis, mental disorders, obesity, venous insufficiency of the lower limbs, cerebrovascular disease, epilepsy and headache) was also collected.

The COPCORD questionnaire identifies individuals with rheumatic symptoms through an interview with trained surveyors. It includes questions related to the symptoms (pain and stiffness), disability, treatment and adaptation to the problem. This instrument includes a section on help-seeking behavior and a list of unconventional remedies.9 Individuals who manifested: pain, inflammation or stiffness during the past 7 days, at any time during their life and not associated with trauma, were classified as positive COPCORD. They were evaluated by a physician resident in Rheumatology of the programs of the Nueva Granada Military University or of the University of La Sabana, who completed a medical history and a physical examination using the Mexican strategy previously adapted and validated. Those subjects with possible rheumatic disease were assessed by a specialist in Rheumatology. The general performance of the previously validated screening procedure reported a sensitivity of 71% and a specificity of 35% for rheumatic disease. The definitive diagnosis was established based on the classification criteria of the American College of Rheumatology for OA, fibromyalgia (FM), RA, systemic lupus erythematosus (SLE), gout, Sjögren's syndrome, dermatomyositis, and systemic sclerosis; and based on the criteria proposed by the European Spondyloarthropathies Study Group (ESSG) for the spondyloarthritis (SpA).

For the classification of soft-tissue rheumatism, was used the definition of regional appendicular pain syndrome (RRPS), proposed by Álvarez-Nemegyei, which groups the tendinopathies, bursopathies, entrapment neuropathies and enthesopathies non-associated with systemic disease.25,26 For the manifestations of pain, inflammation or stiffness of some osteomusculoarticular structure that are non-classifiable within the previous categories, it was used the denomination non-specific musculoskeletal discomfort and non-rheumatic diseases were classified according with the CIE-10 registry.

A specific questionnaire for OA, FM, RA, gout, SpA and SLE was conducted (Fig. 1).

Fig. 1.

General scheme of the study. DANE: National Administrative Department of Statistics.

aAdditional surveys n=165.

bNot interested: 614; Did not attend the evaluation after 7 contacts: 1123; Wrong contact information provided: 497; Deaths: 1; Dangerous area: 4. Discrimination by city: Bogota 806 (36%), Cali 628 (28%), Medellin 457 (20%), Cucuta 131 (6%), Barranquilla 125 (6%), Bucaramanga 92 (4%).

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During the fieldwork of the study there was an epidemic of chikungunya fever which compromised 80% of the territory of the country and 5 of the 6 cities selected for the survey. An instrument for data collection of the patients suspected of chikungunya fever was designed according to the criteria of the World Health Organization. Serologic determination of IgG and IgM was performed for the confirmation of the cases with rheumatic commitment secondary to the infection. The specific data of this measurement will be reported in another publication.

6693 individuals from 6 cities of Colombia were evaluated. The average age was 46.40±18.35 years and 4283 (64%) were women. In Fig. 2 is shown the population of each city with positive response to the COPCORD form.

Fig. 2.

Scheme of positive COPCORD surveyed cities. COPCORD: Community Oriented Program for Control of Rheumatic Diseases.

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The majority of patients belonged to the low socioeconomic stratum with middle educational level and 50.5% of people were occupationally active. The sociodemographic characteristics of the population are shown in Table 1.

Musculoskeletal discomfort given by pain, inflammation or stiffness was reported by 4947 (74%) individuals. Its manifestation in the past 7 days was present in 3493 (48%), with a pain intensity of 6.67 (SD: 2.79) according to the visual analogue pain scale (from 0 to 10cm). Of the respondents, 4947 (73%) referred osteomuscular symptoms at some time in their life, with an average of 6.81 (SD: 3.99) (visual analogue pain scale of 0–10cm).

The main location of pain was in the knees for both forms of presentation of the musculoskeletal discomfort; in the past 7 days it was of 31% and at some time in life of 35%. It was followed by the hands (25 vs. 26%) and the lumbar spine (18 vs. 20%), respectively.

Table 2 shows the distribution by ages of the general population and the positive COPCORD population. The age range in which osteomusculoarticular symptoms were most frequent in women was between 50 and 70 years (35.9%), while in men the symptoms were most frequent between 18 and 29 years (24.2%).

The prevalence of rheumatic diseases in Colombia is shown in Table 3. The majority of osteomusculoarticular symptoms manifested by the population correspond to non-specific muscle discomforts with a prevalence of 16.09% (95% CI: 14.72–17.58%).

The most prevalent rheumatic disease in Colombia is OA (10.81%; 95% CI: 9.68–12.06%). RRPS is a group of entities frequent in the population (9.73%; 95% CI: 8.48–11.14%). Mechanical low back pain represented the third leading cause of rheumatic disease (7.24%; 95% CI: 6.28–8.34%), being slightly more prevalent in men than in women (8.58 vs. 8.19%).

Of the inflammatory rheumatic diseases, RA was the most prevalent in the adult population (1.49%; 95% CI: 1.12–1.98%); followed by FM (0.72%; 95% CI: 0.47–1.11%). Gout, the SpAs, Sjögren's syndrome and SLE are less prevalent diseases. The distribution of the prevalence by cities is presented with detail in Table 4 and the distribution of the prevalence by age group of the most common diseases is shown in Fig. 3.

Fig. 3.

Distribution of prevalence by age groups of the most common diseases.

NSMD: non-specific musculoskeletal discomfort; OA: osteoarthritis; RRPS: regional appendicular pain syndrome; MLBP: Mechanical low back pain; CHIK F: Chikungunya Fever; RA: rheumatoid arthritis; FMG: fibromyalgia; ILBP: inflammatory low back pain.

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69% of the Colombian rheumatic patients reported having some comorbidity. The most frequent were chronic high blood pressure in 330 (20.95%), migraine in 300 (19.11%), venous insufficiency in 278 (17.69%) and mental disorders in 273 (17.3%) (Fig. 4).

Fig. 4.

Most frequent comorbidities in rheumatic patients. Population: 1571 patients.

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When comparing the biomechanical load measured by a standardized instrument, significant differences were observed between the group of individuals with musculoskeletal pain and those who do no report it, and in the limitation of the participants to perform a work or daily living activities.

The patients with inflammatory rheumatic diseases (RA, SpA and SLE) had a greater alteration in the quality of life assessed by the EQ-5D-3L generic instrument. The patients with FM presented results very similar to those of RA in pain and discomfort, in the difficulty for the development of daily living activities and in the levels of anxiety and depression. In the same way, the patients with RA and SLE had the biggest functional limitation measured by HAQ-DI, followed by FM and OA (Fig. 5).

Fig. 5.

Quality of life and functional limitation assessed by EQ-5D-3L and HAQ-DI.

Panel A: Functional ability assessed by HAQ, the dots represent the mean of the instrument. Panel B: The lines represent the percentage of patients without pain of discomfort, anxiety or depression, or without mobility problems to perform daily living activities or personal care. RA: rheumatoid arthritis; CHIKV: chikungunya fever; FM: fibromyalgia; SLE: systemic lupus erythematosus; MLBP: mechanical low back pain; OA: osteoarthritis; OTHER: other non-rheumatic diseases; RRPS: regional appendicular pain syndrome; HEALTHY: healthy individuals; SpA: spondyloarthritis.

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This is the first study conducted to estimate the prevalence of the most frequent rheumatic diseases in Colombia: OA, mechanical low back pain, RA, FM, systemic autoimmune diseases, gout, Sjögren's syndrome, SLE, dermatomyositis and systemic sclerosis. To the best of our knowledge there is no previous report in our population based on a direct assessment of the patients in a representative sample of 80% of the population of the country. Likewise, there does not seem to exist any information that is directly derived from a detailed evaluation of the prevalence of these diseases such as the data related to the burden of the disease and the economic impact on our setting.

Another aspect that is worth highlighting in the realization and the results obtained in this research is related with the application of the instrument that measures the mechanical stress to which the joints and the soft tissues of the osteomuscular apparatus are subjected. Although there are reports in specific population groups, this appears to be the first study in open population with a broad sample, in which this information is recorded (Table 5).

The prevalence of pain and musculoskeletal discomfort excluding trauma, in the past 7 days, in the present study, was 48%, a figure that significantly increased up to 73% when their presence at some time in life was considered. This percentage of population resulted high when compared with other results obtained in Latin American countries with similar cultural and sociodemographic conditions. In these countries, the prevalence of these symptoms varies from 11.86% reported in Guatemala12 to 53.7% in Argentina.10 This could be explained by the development of the epidemics of chikungunya fever between the years 2014 and 2015 in the country, which coincided with the fieldwork related to the direct population survey, and could have generated a global increase in the prevalence of rheumatic manifestations, especially in the category qualified as non-specific musculoskeletal discomfort, which involved 16.09% of the population, in comparison with the results obtained in Cuba (6.4%),13 Ecuador (7.0%)17 and Mexico (2.3%).25 This figure resulted similar to that reported in population of Portugal where the frequency was 15.8%.27 These results could be explained in part by the similarity in the distribution of the age groups in these 2 studies.

OA has a behavior similar to that reported in the majority of populations, with a value very similar to that reported in Mexican and North American populations.In neighboring countries such as Venezuela and Cuba it was between 15% and 20.4% of the population, respectively. The increase in the prevalence from 40 years (2.43%), until affecting one of every 3 individuals (33.9%) after 70 years of age is striking. This situation poses a challenge for all the agents involved in the solution of health problems, in the implementation of primary prevention programs where obesity plays an important etiologic role. All these problems of mechanical origin will continue to grow directly proportionally to the increase in survival and the secondary aging of the population.28

The low back pain (lumbago) of mechanic characteristics turned out to be a frequent manifestation in the young population, especially in men younger than 50 years of age. It calls the attention that, in Medellin and Bucaramanga, the prevalence was lower when compared with the other cities. It could be related to the type of work and the body mass index. As in OA our data were similar to those reported in the majority of Latin American countries except Cuba. In Portugal the prevalence was 26.4%. The figures of low back pain and OA in Cuba and Portugal had a similar behavior with figures significantly higher in comparison with the other countries.

The RRPS was more prevalent than what was reported in other studies such as in Mexico in 2011, where the global prevalence was 5% (95% CI: 4.7–5.4), with an important variation according with the studied region, being lower in the state of Yucatán 2.3% (95% CI: 1.8–2.8), and higher in Mexico City 6.9% (95% CI: 6.2–7.7). However, the term RRPS in other cohorts is superimposed to the concept of non-specific musculoskeletal discomfort. It is important to highlight the non-inflammatory etiology of the majority of components of this syndrome, for which a mechanic origin has been proposed, as a probable consequence of the use, overuse or misuse of the osteomuscular apparatus.

The foregoing could be related to the significant difference found between the patients who resulted positive in the screening of the COPCORD form and those who did not. The positive patients reported that they have been working in activities that involve frequent exposure to biomechanical stress, either static or dynamic, as described in Table 5. This relationship has been reported in the studies conducted in Mexican indigenous populations: Maya-Yucateca29 and Raramuri in the State of Chihuahua, in the north of the country.30

It is important to highlight the prevalence of RA found in our work, which was estimated in 1.49 (95% CI: 1.1–1.92), being similar to the reported in Mexico,25 higher to that of Venezuela15 and Brazil,31 and lower to that found in some Mexican indigenous groups of the Yucatan Peninsula (2.8%)26 and in Argentina (2.4%) in the Qom group (Toba) located in the Province of Rosario, in the Northwest of the country.10 The distribution of the prevalence of RA by cities was higher in Bogota, Cali and Barranquilla.

In Colombia, it has been reported a lower prevalence equivalent to 0.01% (95% CI: 0.008–0.02) in the African Colombian population of the municipality of Quibdó, located in the Pacific region in the West of the country.32 Due to logistic difficulties, this population is not represented in the sample of this study. The ethnic diversity and the miscegenation patterns in the regions involved in this study could explain in part this difference. In the city of Medellin (capital of Antioquia), the European ancestral pattern represents 96.7% of the population, situation that contrasts with the population of Cali (department of Valle del Cauca) where this pattern is of 21%.33

Another study recently reported a global prevalence of RA of 0.9%, which was obtained by an approximation based on the review of administrative reports from the National Department of Statistics.34 The data may be influenced by multiple factors that can turn into confounders or biases depending on the solidity of the sources from which the data are obtained.

The prevalence of FM in the Colombian population resulted similar to that previously reported in Mexico (0.7%), a figure comparative lower than the prevalence in Brazil, Portugal and Ecuador. However, it is necessary to recognize the impact of the disease on an individual level. In Colombia the patients with FM have been qualified as with the worst quality of life, below patients with inflammatory diseases such as RA, systemic autoimmune diseases, SLE and other conditions of generalized chronic pain. This deterioration has been related with the compromise of the functional ability due to pain, poor sleep pattern, less productivity, more comorbidities, greater chronic use of analgesics and increased costs.31 Thus, it has been proposed to consider FM as a complex dimensional disorder, beyond the simple representation of chronic pain, to consider the impact on the quality of life of these patients, especially in the aspects related with the physical function, the fatigue and the associated mental disorders such as depression and anxiety.32

Another information that this study provides is the impact of living in environments of high physical demand that lead to have chronic musculoskeletal pain; besides conditioning a limitation to work or perform the daily living activities.29 This is an important element for the design of population interventions for the management of working conditions with high physical demand that will reduce the disability secondary to living with chronic musculoskeletal pain and the socioeconomic impact that it conditions.

The rheumatic diseases in Colombia, like in the majority of countries of the Western hemisphere, represent frequent ailments. In the country, one of every 4 adults suffers from any of these pathologies. The problems derived from the use, overuse, misuse or overload due to overweight of the musculo-articular apparatus, justifies the majority of the ailments in the population younger than 50 years of age, being more prevalent in occupationally active men. The diseases caused by wear of the structures of the locomotor system are the most frequent in adults over 50 years of age. OA is the most important disease, with an exponential growth that causes that at the age of 80 years it affects one of every 3 individuals. Autoimmune diseases, especially RA, were more prevalent in Colombia than in the majority of Latin American countries, with the implication that this represents at the individual level secondary to the impact on the functional ability and the quality of life, and at the collective level, on the health expenditure derived from their treatment.

This study had the unrestricted economic support of the Colombian Association of Rheumatology and the University of la Sabana which guaranteed the full realization of the project.

The authors declare that they do not have any conflict of interest.