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\begin{document}

\title{Why did Patients Admit to Physical Medicine and Rehabilitation
Outpatient Clinic Despite the Risk of COVID-19?}



\author[1]{CANAN SANAL-TOPRAK}%
\author[2]{Tugba Ozsoy-Unubol}%
\author[1]{Osman Hakan Gunduz}%
\affil[1]{Marmara University School of Medicine}%
\affil[2]{Sultan Abdulhamid Han Egitim ve Arastirma Hastanesi}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: The aim of this study was to investigate the characteristics
of patients who applied to physical medicine and rehabilitation (PM\&R)
outpatient clinics of two pandemic hospitals despite the risk of
COVID-19 infection. Methods: Patients who were admitted to PM\&R
outpatient clinics of two pandemic hospitals in April and May 2020 were
retrospectively scanned from hospital records. Age, number of
admissions, the reason of admission, diagnosis and the prescribed
medications were recorded. The descriptive statistical methods were
employed. For the comparison of means student-t test was used. Results:
A total of 1078 patients (female 606, male 472) admitted to two tertiary
referral hospitals' PM\&R outpatient clinics. The ages of patients
ranged from 0 to 88 years with a mean age of 45.4\selectlanguage{ngerman}±14.9 years. The most
common reasons for admission were acute peripheral joint pain (290),
follow-up and prescription (244) and acute low back pain (140),
respectively. The most commonly affected joint was the shoulder and
followed by the knee. Most frequent causes for follow-up and
prescription were fibromyalgia and neuropathic pain, and pregabalin and
duloxetine were mostly prescribed medications for these patients.
Conclusion: Acute pain may be considered as the most important condition
for admission of patients to PM\&R outpatient clinics. Regardless of its
source, pain has a negative impact on patients' lives and causes
hospital admissions despite the risk of infection. This effect is more
prominent in patients with fibromyalgia and neuropathic pain.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Introduction}

Physical medicine and rehabilitation (PM\&R) is an area of medical
specialty that aims to improve the functionality and quality of life of
the patients with a wide range of diseases related with disability and
pain through prevention, medical diagnosis, treatment and rehabilitation
management \textsuperscript{1}. Therefore, patients should be checked by
the PM\&R physicians in any situation that may cause pain and functional
impairment. These diseases are classified as traumatic musculoskeletal
diseases, myofascial pain syndrome, peripheral and/or central nervous
system-related neurological diseases, degenerative joint and spine
disorders, rheumatic, cardiopulmonary, genitourinary, genetic and
congenital diseases, lymphatic system-related disorders, endocrine and
metabolic diseases and cancer-related complications \textsuperscript{2}.
Among these, degenerative joint and spine diseases are the most common
cases, while the low back, knee, neck and shoulder are the most affected
areas \textsuperscript{2,3}. Pharmacological or/and non-pharmacological
treatment methods are frequently used in the treatment of these
diseases, usually for long-term periods. Therefore, most of the patients
with such disease needs regular follow-ups. Moreover, with the recovery
rate of patients increasing thanks to the advancing treatment methods,
the population aging and subsequently chronic diseases are surging more
and more patients have been admitted to the PM\&R outpatient clinics
with the expectation of reducing their pain, and improving their bodily
functions and quality of life \textsuperscript{4}.

The~coronavirus disease 2019 (COVID-19) that caused by~severe acute
respiratory syndrome coronavirus 2~(SARS-CoV-2) was first identified in
Wuhan, China, in December 2019 \textsuperscript{5}. To date, more than
91,5 million confirmed cases and about 2,000,000 deaths have been
reported in 196 countries. COVID-19 has been declared a pandemic by the
WHO, on March 11, 2020. The first case in Turkey was reported on March
10, 2020. Since then, the number of infected patients and deaths has
been increasing gradually. It prompted the government and the private
sector to introduce several restrictions similar to ones applied
worldwide to contain the spread of COVID-19. In this respect, people
were prohibited from travelling abroad and urged to stay at home to the
extent possible. In addition, a curfew was declared on March 21 for the
people above the age of 65 and after a while a weekend curfew has been
introduced for all citizens in 31 cities until early July.

The SARS-CoV-2 primarily spread among people through small aerosolized
droplets produced during breathing, coughing, sneezing, and talking to
others within a close distance. People can also be infected, albeit less
commonly, through contacting contaminated surfaces and then touching
their faces. Therefore, social distancing and washing hands frequently
are the basic recommendations to prevent the spread of this disease. The
older people and those with chronic diseases such as diabetes mellitus,
hypertension, cardiovascular diseases are considered as higher risk
group for severe COVID-19 infection \textsuperscript{6,7}. There exists
no vaccine to boost immunity against this virus yet. Although several
studies have been carried out hastily to identify the potential
treatments for COVID-19, effectiveness of the treatments suggested by
randomized controlled trials has yet to be demonstrated and confirmed
clearly \textsuperscript{8,9}. Under these circumstances, increasingly
less patients have been admitted to outpatient clinics especially to
those in the pandemic hospitals as a measure to prevent them from
infection. Yagci et al. recently showed that the number of patients
visiting the PM\&R outpatient clinics has dramatically decreased
following the first month of the COVID-19 pandemic in
Turkey\textsuperscript{10}.

This study is aimed to investigate the characteristics of the patients
who applied to the PM\&R outpatient clinics of two pandemic hospitals,
in Istanbul, despite the risk of COVID-19 infection.

\textbf{Patients and Methods:}

The patients who were admitted to PM\&R outpatient clinics of xxxxxx
Hospital (Center A) and xxxxxxxxxxxxx Hospital (Center B) in April and
May 2020 were retrospectively scanned from the hospital records. The
approval for this study was obtained from xxxxxxxx University Ethics
Committee (protocol number: 09.2020.716).

The variables like age, gender, number of admissions, the reason for
admission, diagnosis and the prescribed medication were recorded. The
reasons for admission were classified as follow up and prescription,
acute and chronic neck and low back pain acute and chronic peripheral
arthralgia, neuropathic pain, cramp and admission for physical therapy
and rehabilitation. The diagnosis of patients who admitted for follow-up
and prescription was noted. Records of patients with neck or low back
pain were assessed whether they had radicular pain or not. In patients
with arthralgia, the region of affected joint was also saved. If there
is a patient with more than one application, only the first application
was taken into consideration.

The Statistical Package for Social Sciences (SPSS) 22.0 was used for the
statistical analysis. Shapiro-Wilk test was applied to evaluate the
normality of distribution. The descriptive statistical methods
(frequency, percentage, mean, standard deviation, minimum, and maximum)
were employed. For the comparison of means student-t test was used.
P\textless{}0.05 was set as statistical significance at 95\% confidence
interval.

\textbf{Results:}

The hospital records show that 1078 patients were admitted to the two
tertiary hospitals' PM\&R outpatient clinics in April and May 2020. Of
these, 541 (50.2 \%) of them were admitted to center A and 537 (49.8\%)
were admitted to center B. Of the patients who applied to center A, 115
were admitted twice and 18 were three times. The remaining 408 patients
applied only once. In Center B, 106 patients applied twice, 25 patients
three times, and four patients four times. The remaining 402 patients
applied only once (Table 1).

In April, a total of 401 (188 and 213, respectively) and in May 677 (353
and 324, respectively) patients applied (Figure 1 and 2). The age of
patients ranges from 0 to 88 with a mean age of 45.4\selectlanguage{ngerman}±14.9 (0-88) years
(47.2 and 43.1 for women and men, respectively) and there is no
statistically significant difference between the two centers in terms of
the age of the patients (p=0.863). While most of the admitted patients
were between the ages of 40 and 60 years, the number of patients
aged\emph{\textless{}} 18 years was the least. Among 1078 patients 606
(56\%) were female. In both centers, the number of female patients was
higher than that of male patients (Table 1).

The most common reasons for admission were acute peripheral joint pain,
follow-up and prescription, acute low back pain, respectively (Table 2).
When stratified patients by age, the most common reason of admission was
peripheral arthralgia in all ages except \emph{\textless{}} 18 years. In
this group, patients were admitted predominantly for follow-up. The most
frequent causes of follow-up and prescription were fibromyalgia and
neuropathic pain. When the distribution of the affected joints was
evaluated, although the most frequently affected joint was shoulder in
total, the number of patients with knee and shoulder pain were similar
over the age of 60 years (Table 3).

In addition, neuropathic pain was the cause of admission in 54 patients.
These patients had a diagnosis of carpal tunnel syndrome (n=14), ulnar
nerve entrapment or injury (n=3), other peripheral nerve injury (n=10),
polyneuropathy (n=9), zona zoster (n=2), lumbar disc herniation or
spinal stenosis (n=14), and cervical disc herniation (n=2). 112 out of
199 patients with low back pain and 56 out of 98 patients with neck pain
also had radicular pain.

Of the 1078 patients 893 had a prescription. The most prescribed
medication was non-steroid anti-inflammatory drugs (NSAIDs) which were
prescribed to a total of 569 patients. This medication is followed by
pregabalin (Table 4). As far as the patients who were admitted for
prescription and follow-up are concerned, pregabalin and duloxetine were
prescribed the most.

\textbf{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 \textsuperscript{11}. Females are at greater risk of
conditions related to chronic pain \textsuperscript{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 \textsuperscript{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 \textsuperscript{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 \textsuperscript{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 \textsuperscript{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
it\textsuperscript{17,18}. 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 \textsuperscript{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
uncommon\textsuperscript{20}. 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 \textsuperscript{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 \textsuperscript{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
centers\textsuperscript{26-28}. 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 \textsuperscript{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

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Table 1: Patient characteristics and distribution of admissions\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Center A\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Center B\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Total\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Gender (F/M)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Gender (F/M)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
277/264\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
329/208\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
606/472\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age (mean\selectlanguage{ngerman}±SD) (years) \emph{\textless{}}18 years (n)\\
19-40 years (n)\\
41-59 years (n)\\
\emph{\textgreater{}} 60 years (n)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age (mean\selectlanguage{ngerman}±SD) (years) \emph{\textless{}}18 years (n)\\
19-40 years (n)\\
41-59 years (n)\\
\emph{\textgreater{}} 60 years (n)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45.5\selectlanguage{ngerman}±14.3 8 193 255 85\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45.4\selectlanguage{ngerman}±15.6 22 170 255 90\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45.4\selectlanguage{ngerman}±14.9 30 363 510 175\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Number of patients April 2020\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Number of patients April 2020\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
188\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
213\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
401\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Number of patients May 2020\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Number of patients May 2020\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
353\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
324\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
677\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Number of admissions\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1 2 3 4\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
408 115 18 0\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
402 106 25 4\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
810 221 43 4\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

F: Female, M: Male

Table 2. The reasons for admissions\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Center A (n=541) & Center B (n=537) & Total (n=1078)\tabularnewline
Follow-up and prescription & 71 & 176 & 247\tabularnewline
Acute neck pain & 43 & 30 & 73\tabularnewline
Chronic neck pain & 6 & 19 & 25\tabularnewline
Acute back pain & 24 & 9 & 33\tabularnewline
Chronic back pain & 2 & 6 & 8\tabularnewline
Acute low back pain & 93 & 47 & 140\tabularnewline
Chronic low back pain & 27 & 32 & 59\tabularnewline
Acute peripheral arthralgia & 185 & 105 & 290\tabularnewline
Chronic peripheral arthralgia & 30 & 64 & 94\tabularnewline
Neuropathic pain & 32 & 22 & 54\tabularnewline
Cramp & 6 & 3 & 9\tabularnewline
Physical therapy and rehabilitation & 22 & 24 & 46\tabularnewline
\bottomrule
\end{longtable}

Table 3. Admission causes of the patients stratified by age\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& \emph{\textless{}} 18 (n=30) & 18-40 (n=363) & 40-60 (n=510) &
\emph{\textgreater{}}60 (n=175)\tabularnewline
\vtop{\hbox{\strut Follow-up and prescription
Fibromyalgia}\hbox{\strut Neuropathic
pain}\hbox{\strut Osteoporosis}\hbox{\strut Rheumatic
diseases}\hbox{\strut Other disorders}} & 25 (83.3\%) 0 0 0 0 25 & 56
(15.4\%) 16 11 1 19 9 & 109 (21.4\%) 41 29 8 18 13 & 58 (33.2\%) 12 23
11 8 4\tabularnewline
Low back pain & 1 (3.3\%) & 86 (23.7\%) & 94 (18.4\%) & 17
(9.7\%)\tabularnewline
\vtop{\hbox{\strut Peripheral arthralgia \textgreater{} 5
joints}\hbox{\strut \textgreater{}1
joint}\hbox{\strut Hip}\hbox{\strut Knee}\hbox{\strut Ankle /
Foot}\hbox{\strut Shoulder}\hbox{\strut Elbow}\hbox{\strut Wrist /
Hand}} & 4 (13.4\%) 1 0 0 2 0 0 0 1 & 129 (35.5\%) 17 6 15 23 5 41 3 18
& 177 (34.7\%) 12 1 16 25 12 74 16 10 & 64 (36.5\%) 5 1 2 27 2 24 1
2\tabularnewline
Neck Pain & 0 (0\%) & 36 (9.9\%) & 58 (11.4\%) & 4
(2.3\%)\tabularnewline
Neuropathic Pain & 0 (0\%) & 14 (3.9\%) & 22 (4.3\%) & 18
(10.3\%)\tabularnewline
Other & 0 (0\%) & 42 (11.6\%) & 46 (9\%) & 14 (8\%)\tabularnewline
\bottomrule
\end{longtable}

Table 4. Distribution of medications prescribed\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Center A (n=481) & Center B (n=412) & Total (n=893)\tabularnewline
NSAID & 366 & 203 & 569\tabularnewline
Analgesics other than NSAIDs & 12 & 27 & 39\tabularnewline
Steroids & 0 & 6 & 6\tabularnewline
Pregabalin & 43 & 71 & 114\tabularnewline
Gabapentin & 4 & 19 & 23\tabularnewline
Duloxetine & 20 & 30 & 50\tabularnewline
DMARDs & 3 & 16 & 19\tabularnewline
Anti-TNF & 4 & 7 & 11\tabularnewline
Magnesium & 4 & 1 & 5\tabularnewline
Vitamin D & 6 & 12 & 18\tabularnewline
Vitamin B12 & 6 & 12 & 18\tabularnewline
Osteoporosis medication & 13 & 8 & 21\tabularnewline
\bottomrule
\end{longtable}

Figure 1- Number of patients admitted to the centers by month

Figure 2-Number of patients admitted to the centers by day\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure--1/Figure--1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure-2/figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

