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 Preamble
The acronym COPCORD stands for ‘community oriented program for control of rheumatic diseases’. The key operative words are ‘community’ and ‘rheumatic diseases’. COPCORD is primarily an ILAR (International League of Associations for Rheumatology) initiative which was launched in collaboration with WHO in late 1980s to gather data on ‘pain and disability’ with a focus on grass root developing economies. The program was meant to measure and evaluate ‘pain and disability’ in rheumatic disorders.

COPCORD was to fill the void in the realm of data on rheumatic and allied musculoskeletal disorders (RMSK) in the developing World. In this regard, it has been an outstanding program for ‘community aches and pains’. Several COPCORD surveys all over the World have highlighted the RMSK burden and its impact and outcome. The active and enthusiastic participation of community and its health care providers to complete COPCORD surveys has been overwhelmingly satisfactory and endearing. Though the second ‘C’ in COPCORD represents ‘control’, COPCORD was not envisaged as a public health initiative. Control of rheumatic diseases is a major challenge for public health. Though COPCORD has imparted ‘health education’ in several communities, the thrust has rarely if ever been on control (or prevention). But there is sufficient data gathered by several COPCORD surveys to lay a foundation for prevention and control strategies.

COPCORD was born out of a simple need to measure RMSK ‘pain’ and ‘disability’ in a community. And the first item of the COPCORD agenda all over the World has been to complete a community survey with motivated grass root rheumatology oriented doctors using a low cost basic infrastructure model. Though an epidemiology program, COPCORD is not bound by conservative and rigid epidemiology tenets. It has been a program evolved in the field using clinical senses and practical knowledge. Most of the investigators have been clinicians with hardly any formal training in epidemiology and statistics. Largely, COPCORD has been a nongovernmental project using local resources and funds. Principle investigators have volunteered their time and expertise without any remuneration or compensation. The doctors have used a uniform protocol and design to complete the survey. Though several regional issues have dictated certain modifications and further validation, the core questionnaires have uniformly captured the data. Much of COPCORD surveys are published in peer reviewed literature.

Though a data acquisition exercise, COPCORD has also provided free of cost rheumatology services to the community in some sites. Though mostly a onetime survey, COPCORD has continued beyond survey in a planned manner in some sites to gather data on risk factors and incidence. The program site and its results have often been endorsed by the respective Government. Also, ‘The Bone and Joint Decade 2000-2010’ national action network in India adopted COPCORD to gather RMSK data.

Begun in Philippines under chaotic political conditions in late nineteen eighties, COPCORD has successfully overcome several hurdles in demonstrating MSK disorders in several countries in Asia and Latin America. Recently, it has completed survey in Egypt.


 History & Evolution
COPCORD was launched by WHO (World Health Organization) and ILAR (International League of Associations for Rheumatology) in 1980s. COPCORD was designed as a low cost - low infrastructure local resources based community program. The emphasis in population surveys was to record symptoms (in particular pain and disability) rather than diseases and syndromes. Clinical and field epidemiological skills rather than elaborate investigation was the basis of diagnostic approach.

In the parent COPCORD model , population data (Stage I) was collected through three successive phases- house to house survey by a local health worker to identify cases (Phase I), interview based questionnaires by paramedics to capture pain and disability (Phase II), and a standard medical evaluation by a doctor with some training in rheumatology(Phase III). A validated core questionnaire (CCQ), developed initially by ILAR could be modified to suit the local requirements as far as the principle questions on pain and disability were unchanged. Later, in the Bhigwan (India) COPCORD a fast track model was devised wherein all the three phases of Stage I were conducted in parallel and the CCQ contained a more comprehensive capture of pain and quality of life.

COPCORD also advocates education of the community and health care providers and identification of risk factors (Stage II). Based on community data, it also encourages investigators to plan, execute, and maintain improved health care through preventive and control strategies (Stage III). However, very few COPCORD were continued beyond the initial survey. The Chinese COPCORD has pursued several population studies on knee pains and osteoarthritis to identify risk factors. The Indonesian COPCORD survey findings of significant gout in the community led to several long term national initiatives in the nineties. Bangladesh COPCORD was continued further to evaluate low back ache and knee pains. The Bhigwan (India) follow up program (Stages II and III) has been the longest continuing COPCORD and is currently in its 15th year.

The earlier versions of COPCORD Core Questionnaire (CCQ) were based on ILAR experience [HA Valkenburg (The Netherland), Richard Wigley (New Zealand), KD Muirden (Australia), & others). The CCQ was later modified and developed [APLAR COPCORD Workshop Korea,1991, Prof S. van der Linden (The Netherlands), Late John Darmawan (Indonesia), and others). Maintaining basic framework, CCQ was modified and further developed by the fast track COPCORD Bhigwan (India) model and published (APLAR J Rheumatol 1997; 1: 145-154). The current proposed CCQ is based on the latter experience, review at the WHO-ILAR BJD Meeting Vienna, Austria 2005 (Clin Rheumatol 2007; 26: 1217-1227), inputs from several COPCORD investigators and experts, and discussions in the APLAR 2006 (Kuala Lumpur) COPCORD Session (Dr. Arvind Chopra, India, and others).

The WHO & UN supported ‘The Bone & Joint Decade (BJD) 2000 – 2010 has included ‘trauma’ along with arthritis & osteoporosis amongst the disease target conditions. The BJD program aims to create awareness and empower patients. It will measure the burden of rheumatic and other musculoskeletal disorders and reduce it in time through various community and medical programs. The new CCQ has incorporated a section to capture data on trauma.

The populations in COPCORD have generally been selected non-randomly. However, some randomized techniques were used in China (Shangai, Shantou), Peru , Brazil, Chile Mexico, Kuwait and Lebanon . Different personnel (doctors, nurses, health workers, volunteers, etc) have collected data. The earlier COPCORD used CCQ based on very early experience . Later, it was made less cumbersome. However, the survey screening Qs was generally meant to identify ‘pain/swelling/stiffness and limited range of motion in joints and/or musculoskeletal soft tissues in the last seven days (current) and/or anytime in the past’. Pain was predominantly captured. But methods of recording pain have differed. COPCORD surveys in India , Malaysia , Peru and Australian Aborigines used a human mannequin to record pain. Some of the earlier COPCORD surveys have published rates of joint pain/rheumatic disorders/ rheumatism (Beijing & Shantou ILAR China , Pakistan , Indonesia ). Patients with history of trauma prior to chronic MSK were excluded (China, Peru, Brazil , Iran, and Kuwait).Disability was recorded by asking specific individual items or using a validated modified Stanford Health Assessment Questionnaire (HAQ) as in India. Brazil COPCORD used a SF-36 quality of life instrument. Several countries have completed COPCORD surveys in both urban and rural regions. China, India and Mexico have completed COPCORD surveys in several sites.

The COPCORD sample size was not meant to measure uncommon disorders like lupus. Some earlier COPCORD surveys took long periods for completion. In Stage I, Phases I & II were sometimes combined . The response rate in various COPCORD surveys has exceeded 80%. However, very few surveys like Pune-Bhigwan(India) have published the diagnostic break up of all respondents . Some surveys have been more disorder centric rather than symptom centric .

Though it may not be appropriate to identify individuals, some have played a seminal role in envisaging and propagating COPCORD. Late Prof HA Valkenburg (The Netherlands), former Prof KD Muirden (Australia) and Dr RD Wigley (New Zealand) were the founding gurus and travelled the length and breadth of Asia to begin several COPCORD. Prof KD Muirden was the first COPCORD coordinator. He was succeeded by late Late Dr John Darmawan (Indonesia) who is credited for galvanizing COPCORD into an International movement and initiating several measures to standardize COPCORD surveys. Dr RD Wigley is the senior most mentor and champion of the World COPCORD movement and is actively involved in promoting its mission. Prof Shunle Chen (China) and Prof Q Zeng have been earlier crusaders to spread COPCORD in China and later in Asia. Dr N Khaltaev (WHO) was responsible for bringing the COPCORD data into the folds of BJD and other initiatives for assessing the global burden of MSK. Prof Hans Rasker ( The Netherlands) has been an ardent COPCORD supporter and played a critical role in taking COPCORD into Africa (Egypt). In recent times, Dr Arvind Chopra (India), Prof Atiqul Haq (Bangladesh) and Prof Davatchi (Iran) have played critical COPCORD roles. Prof Davatchi is the current APLAR COPCORD coordinator. Prof A Kutzbach (Guatemala) and Dr Mario Cardiel (Mexico) have recently completed challenging COPCORD in Latin America. Since 2005, Dr Arvind Chopra has been the COPCORD co-ordinator and responsible for the current COPCORD fast track model (with a service component) and the recently revised and proposed CCQ, and forging links with the BJD.


 Organization, Structure & Function
Though COPCORD has been around for over three decades, there was no formal organization and structure to administer and execute and handle budget. Though universally supported by ILAR, and APLAR in particular, COPCORD has survived through the efforts of individuals rather than international organizations. In the earlier ILAR organization, COPCORD as a subject was under the umbrella of its ‘epidemiology’ committee. Coordinators have been nominated in the past, both at ILAR and APLAR level (see above). Coordinators have directly dealt with investigators to provide expert guidance and assistance. Though COPCORD is extensively published, there is no central doctrine document containing guidelines and instruments. A core survey questionnaire was constructed by the ILAR at the launch of COPCORD. The latter has served as a template for future modifications and versions by the investigators (see above). The core contents of the questionnaire have remained unchanged in the approach towards RMSK in a community. However, in several instances, the investigators have taken recourse to their own clinical sense and expertise. As an example, investigators were not provided with a standard classification system of RMSK disorders for application. Also, there has been no standard ‘quality of life’ assessment in the earlier surveys. The investigators have had fair laxity to organize the COPCORD survey in the best possible manner consistent with the local scenario and situation.

The aim has been to obtain real life community data on RMSK using socioeconomically appealing methods and techniques. However, the overall methods and methodology used to collect data in different surveys has ensured fair amount of comparability between COPCORD surveys around the World.

The current ILAR committee is yet to decide on the mode of COPCORD functioning.
 
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