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