Discussion:
This study has been carried out to identify the clinical and demographic
characteristics of the patients who were admitted to the PM&R
outpatients’ clinics during the COVID-19 pandemic in Turkey. The
patients from all age groups with disability and pain are the main
population of the PM&R clinics. This study showed that the number of
female patients was higher than that of male patients and the main
reason for admission to the PM&R outpatient clinic was pain. Pain is a
major health problem which may be intense enough to impair the patients’
daily routines and social activities and to reduce quality of life. It
is a subjective and individual experience and patients’ attitudes
towards pain might vary from person to person. It has been demonstrated
that demographic factors including age, gender and ethnic group as well
as genetic and psychosocial factors contribute to these individual
variations in pain 11. Females are at greater risk of
conditions related to chronic pain 12. In this study,
female patients were more than male patients and the age of patients
ranges from 0 to 88 with a mean of 47.2 and 43.1 for women and men,
respectively. In a recent study in which demographic characteristics of
the patients referred to the PM&R outpatient clinics in Turkey have
been examined, the mean age was reported as 53.3 for women and 48.9 for
men 3. It is not surprising that this study examined a
relatively younger population because the elderly patients generally
avoided to visit hospitals due to high risk of fatality when they
infected with SARS-CoV-2.
Regarding the analysis of pain characteristics, the number of patients
with acute pain was prominently higher than those with chronic pain for
each disorder in both hospitals. This result is also understandable as
patients experiencing acute pain usually face considerable uncertainty
and more inclined to seek an explanation about the source and meaning of
their pain. They want to learn the prognosis and management of this
pain. In contrast, the patients with chronic pain are more likely to be
aware of the causes and prognosis of their pain and perform better
self-management of their pain. Apart from follow-up and prescription,
the most common reasons for admission of the patients to the outpatient
clinic were low back pain, shoulder pain, neck pain, knee pain and
neuropathic pain respectively. Previously, low back, knee, neck, and
shoulder have been demonstrated to be the most affected areas for
admission to the PM&R outpatient clinic based on the review of the
medical records of 46,729 patients in Turkey 3. Low
back pain is the most common reason for admission to outpatient clinics
in both studies. This result is reasonable since low back pain has a
high rate of prevalence and it has been reported as the most frequent
form of pain in different populations 13-15. In this
study, it has also been demonstrated that the number of patients who
suffered from low back and neck pain with radicular pain were higher
than those without radicular pain. Radicular pain, a common type of
neuropathic pain, arises from the inflammation of the affected nerve and
is typically associated with paresthesia, numbness, weakness and burning
and sharp pain 16. On the other hand, among the
patients who were admitted for prescription and follow-up, neuropathic
pain and fibromyalgia were the most common disorders and pregabalin,
duloxetine and gabapentin were usually prescribed drugs. In this
respect, it can be concluded that the number of patients who had
neuropathic pain was much higher than it was assumed. Neuropathic pain
tends to be more severe and bothersome than nociceptive pain due to
strange and unpleasant signs and symptoms. Besides it causes greater
impairment and complexities in patients’ daily living activities,
quality of life and sleeping pattern. Patients with neuropathic pain
have higher anxiety and depression levels compared to those without it17,18. In a previous study, it has been demonstrated
that neuropathic pain was one of the most two frequent reasons for using
the help of a pain clinic 19. The percentages of
patients admitted with neuropathic pain became more pronounced with age
in the current study. It has been already known that some pain related
conditions (e.g. osteoarthritis, neuropathic pain) deteriorate with age
although some disorders such as migraine, back pain, temporomandibular
disorders tend to decrease after the peak prevalence between the 30s and
50s. Fibromyalgia is also characterized by chronic widespread pain,
fatigue, sleep disturbances, cognitive difficulties and mood
disturbances. It has a complex pathogenesis and central sensitization
which is one of the responsible mechanisms of the fibromyalgia. The
patients with fibromyalgia generally have neuropathic sensations and
neuropathic pain and catastrophizing of the pain is not uncommon20. In view of the above, it is not surprising that
among the admitted patients the number of those with radicular pain was
greater than those without it and that neuropathic pain and fibromyalgia
were the most common diagnoses among the patients who visited PM&R
outpatient clinics for prescription and follow-up.
Although some previous studies reported that shoulder was less
frequently affected area than knee and neck 3,21,22,
the number of patients with shoulder pain was higher than those with
neck or knee pain in the current study. Patients aged between 18-60
years were mostly presented with shoulder pain. Moreover, contrary to
expectations, even in patients over the age of 60, shoulder and knee
were found to be affected similarly. This discrepancy of the results can
be explained with strong association of shoulder disorders with sleep
disturbance such as inability to sleep on the involvement side and
insomnia. It has been concluded in several studies that patients with
shoulder pathologies suffer from sleeping disorders due to nocturnal
pain and that inevitably affects patients’ daily living activities and
consequently quality of life 23-25. Based on the
results of this study it may be concluded that shoulder pain is tended
to be more intolerable when compared to knee pain. And patients usually
look for ways to prevent or manage this pain as quickly as possible.
The number of patients with neurological disorders such as stroke,
spinal cord injuries, spina bifida and cerebral palsy have been
perceptibly reduced in this period. This can be explained with the
patients’ comorbidities which may be the result or cause of these
neurological disorders. Therefore, patients or caregivers might have
preferred to postpone their medical checks due to fear of infection at
the hospitals or have chosen a non-pandemic hospital which may explain
why less patients visited these two PM&R outpatient clinics.
The number of patients with osteoporosis and rheumatological conditions
also decreased dramatically. This was an expected result since the
patients over the age of 65 forms a good portion of the osteoporosis
population and the patients with rheumatological conditions generally
use immunosuppressive drugs as well as their increasing comorbidities.
In addition, they did not need prescription to buy their drugs from
pharmacy as the Ministry of Health made necessary arrangements to reduce
the number of visits to the hospitals during the pandemic.
Although the use of telemedicine has grown in the world throughout
COVID-19 pandemic, it is not yet used in both of centers26-28. Telemedicine is mainly utilized for follow-up
visits in PM&R practice which was one of the most common reason for
admission according to a recent study 26. Promoting
the use of telemedicine may reduce the number of admissions due to
follow-up and chronic pain.
Although this is a sound study to demonstrate the patient
characteristics who visited the PM&R outpatient clinics despite the
risk of infection, it has some limitations which should be stated as
well. Retrospective design of this study is the main limitation. The
patients’ sociodemographic characteristics which may affect the results
could have been reported if the study was designed prospectively.
Moreover, the admission reasons could have been detailed to show
patients’ specific complaints such as nocturnal pain, unbearable pain,
significant difficulty in daily living activities and desire to know the
source of symptoms.
In conclusion, based on the results of this study, acute pain can be
considered as the most outstanding reason for admission of patients to
the PM&R outpatient clinics. Regardless of its source, pain has a
negative impact on people’s lives and causes ongoing hospital admissions
despite the risk of infection. This situation is even more valid for the
patients with fibromyalgia and neuropathic pain. Therefore, causes of
pain and effective pain management strategies form an important part of
the PM&R practices. Patients should be able to access information about
their complaints online and telemedicine should be provided by the PM&R
specialists in order to decrease hospital visits and thereby protect
patients against disabilities and infection risks.
Data availability: Data available on request from the authors
Declaration of interest: The authors report no conflicts of interest
Funding: There is no funding to report for this submission.
Acknowledgments: None