Outpatient burden of neurological disorders: A prospective evaluation of 1500 patients
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.263249
Source of Support: None, Conflict of Interest: None
Keywords: Headache, outpatient, neurology
Neurologists spend a significant amount of time in providing outpatient services. Newly joined residents are least trained to manage most of the common neurological disorders as little importance is given to diagnosing and managing these disorders efficiently in the undergraduate and postgraduate training programs. As a result, most of the common disorders are not given their due importance, resulting in a vicious cycle of poor patient care and follow-up. The commonest of neurological complaints like headache and backache are the most neglected. Most of the residents are familiar with the criteria for motor neuron disease (MND), but none of them will know the criteria for migraine, which is much more common in the population and causes significant disability. No comprehensive studies from India have looked into the real burden of these common disorders in the outpatient population. We embarked on this study so that we get a clear data on the burden of these disorders that may help in redesigning the curriculum of undergraduate and postgraduate residents in medicine and neurology.
The aim of this study was to determine the incidence of various neurological disorders in the outpatient department and to identify those which needed maximum emphasis during the training program of undergraduate and postgraduate residents in medicine and neurology.
The study was conducted in a tertiary care medical center with a large outpatient load. Four consultants and eight residents were involved in the clinical assessment and entry of the data. The clinical data of 1500 consecutive outpatients who attended the outpatient services were collected over a period of 2 months from December 2014 to January 2015. All patients were evaluated by a resident trainee and a senior consultant. Routine hemogram and biochemical investigations were done in all patients. Magnetic resonance imaging, electroencephalography and electroneuromyography were done wherever applicable. The most probable clinical diagnosis was made after a detailed history and a thorough neurological evaluation. Age, sex, and the diagnosis were recorded and entered in an Excel sheet. Appropriate statistical methods were used for descriptive analysis.
During the study period of 2 months, data were collected from 1500 patients. Out of the 1500 patients, 766 were male and 734 were female. In the 0–20 age group, 68 were male and 80 were female. In the 21–40 age group, 286 were male and 308 were female. In the 41–60 age group, 262 were male and 251 were female. In the 61–80 age group, 147 were male and 90 were female. Over the age of 80, there were 3 male and 8 female patients [Figure 1].
The most common complaints with which patients came to the outpatient services were headaches, muscular and radicular pains, seizures and hemiparesis/monoparesis. Movement disorders, neuropathies, and nerves palsies were also present in a significant number of patients [Figure 2].
Primary headache disorders
Headaches accounted for the majority, presenting in up to 28.6% (429/1500) of all the cases. Of these, migraine was the most common diagnosis, accounting for 46% (198/429) of all the headaches. The mean age of the migraineurs was 33.6 years (standard deviation [SD] ± 1.31), with the condition being 1.5 times more common in female than in male patients. About 18.7% of the migraineurs had concurrent fibromyalgia. Only three cases were identified as having migraine with aura.
Tension-type headaches (TTH) accounted for 25.6% (110/429) of all the headaches and were equally prevalent in both male and female patients. The mean age of these patients was 40 years (SD ± 1.37). Trigeminal autonomic cephalalgias (TAC) accounted for 2.8% (12/429). Majority of the TACs were hemicranias continuas (7), followed by paroxysmal hemicranias (2), cluster headaches (2), and a single case of Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing (SUNCT) syndrome. The mean age of these patients was 47 years (SD ± 1.89) and the disease was equally prevalent in both sexes.
Secondary headache disorders
Cortical venous thrombosis was diagnosed in 4.4% (19/429) of patients and was more prevalent in females. The mean age of these patients was 33.8 years (SD ± 8.73). Meningitis accounted for 4.2% and was more prevalent in males. Most of the cases of meningitis were those of TB meningitis, with only two each of bacterial and cryptococcal meningitis. Both the cases of cryptococcal meningitis were positive for human retro-virus.
Cervicogenic headaches, posttraumatic headaches, temporal arteritis (TA), brain tumors, incidental granulomas, and unclassifiable headaches accounted for 16.9% (72/429) of all the headaches. Brain tumors were present in 2.3% of all the headaches (10/429) and included gliomas, meningiomas, and metastasis. Cervicogenic headaches were present in 2.1% (9/429), granulomas in 2.1% (9/429), posttraumatic headaches in 1.9% (8/429), chronic daily headache in 1.9% (8/429), and TA in 0.9% (4/429). Two cases of Arnold– Chiari malformation More Details were also seen. The rest of the cases of headaches were unclassified and either did not fit under any description of the various types of headaches or were lost to follow-up, because of which a definitive diagnosis could not be made [Figure 3].
Musculoskeletal and radicular pains
Neck pain, backache, musculoskeletal pain, fibromyalgia, and hemipain syndromes accounted for 24.7% (371/1500) of all the cases. About 30.2% (112/371) were diagnosed with lumbosacral and cervical radiculopathies. The mean age of these patients was 45 years (SD ± 1.2) and this manifestation was equally prevalent in both sexes. Musculoskeletal pain was present in 22.6% (84/371) patients. This diagnosis was given in patients with shoulder periarthritis, tendinitis, ligament tears, tennis elbow, golfer's elbow, and isolated muscle pains/sprains. The mean age of these patients was 41.6 years (SD ± 1.31) and this type of pain was equally prevalent in both sexes. Fibromyalgia was diagnosed in 17.2% (64/371) of these cases and was almost twice as common in females as compared to males. The mean age of these patients was 44.5 years (SD ± 1.23). Almost 58% (37/64) of the patients with fibromyalgia were given a diagnosis of fibromyalgia with migraine. Joint pains accounted for 8.3% (31/371) and included rheumatoid arthritis, osteoarthritis, and postviral arthralgias. Neuralgic pain was seen in 6.2% (23/371) of these cases and more than half had trigeminal neuralgia. The mean age of patients with neuralgic pain was 50.5 years (SD ± 1.3). Hemipain was seen in 4% (15/371) of these cases, with a mean age of 40 years (SD ± 1.27). Both hemipain and joint pains were slightly more common in females, whereas neuralgic pain was equally prevalent in both sexes [Figure 4].
Seizures accounted for 12.7% (190/1500) of all the cases. Partial seizures were more common, being present in 52.6% (100/190) of these cases. The mean age of these patients was 27 years (SD ± 1.7). Generalized seizures were diagnosed in 26.8% (51/190). The mean age of these patients was 29.7 years (SD ± 1.48). Both partial and generalized seizures were equally prevalent in both sexes. Most common of the generalized seizures was juvenile myoclonic epilepsy (JME).
Secondary causes of seizures included cysticercal granulomas, tuberculomas, hyponatremia, hyperglycemia, hypocalcaemia, posterior reversible encephalopathy syndrome, and febrile illness-related epilepsy syndrome.
Strokes/transient ischemic attacks accounted for 11.9% (178/1500) of all the cases and were 1.5 times more common in males than in females. The mean age of these patients was 67 years (SD ± 1.39). More than 90% of these cases had ischemic strokes. Among these, 10 cases were stroke in young patients, 8 patients had post stroke seizures, and 7 cases were classified as recurrent strokes. Stroke with vascular Parkinsonism More Details accounted for five cases and stroke with vascular dementia accounted for four cases.
Nerve palsies and neuropathies
Nerve palsies and neuropathies were present in 7.7% (115/1500) of all the cases. About 27.8% (32/115) of these patients had carpal tunnel syndrome (CTS). CTS was almost twice as common in females and had a mean age of 46.8 years (SD ± 1.45). Diabetic neuropathy was present in 15.6% (18/115) patients and had a mean age of 50 years (SD ± 1.3). Bell's palsy was seen in 13.9% (16/115) patients and had a mean age of 39 years (SD ± 1.5). Other causes of neuropathy such as B12 deficiency, human immunodeficiency virus (HIV) and drug-induced neuropathy accounted for 13% (15/115) of cases, and had a mean age of 43 years (SD ± 1.8). Isolated nerve palsies were seen in 9.6% (11/115) of the cases with a mean age of 45.9 years. Other cases of neuropathy that were seen included trigeminal neuropathy, auditory neuropathy, vasculitic neuropathy, alcoholic neuropathy, meralgia paresthetica, two cases of Guillain–Barre syndrome, and a case of numb chin syndrome.
Movement disorders accounted for 5.9% (89/1500) of all the cases. Parkinson's disease was the most common movement disorder presenting in 28.1% (25/89) cases. Their mean age was 67 years (SD ± 9.4) with almost equal prevalence in both sexes. Secondary parkinsonism was seen in 12.3% (11/89) cases. Vascular etiology was the dominant cause of secondary parkinsonism. Other causes of parkinsonism included drug-induced and postencephalitic parkinsonism (n = 1). Parkinson-plus syndromes were present in 10% (9/89) cases with a mean age of 70 years (SD ± 7.01) and included multisystem atrophy, progressive supranuclear palsy, and a case of Lewy body dementia More Details. Essential tremors accounted for 13.5% (12/89) cases with a mean age of 49 years and were 1.5 times more common in males. Restless leg syndrome accounted for 11.2% (10/89) cases with a mean age of 44 years and an equal prevalence in both sexes.
Vertigo accounted for 2.8% (42/1500) of all the cases. These patients had a mean age of 50 years with an equal prevalence in both sexes. Benign paroxysmal positional vertigo was diagnosed in 75% (32/42) of these cases with a mean age of 48 years (SD ± 9.35). Other causes of vertigo included vestibular paroxysmia, Meniere's disease, and a case of cerebellopontine angle tumor.
Functional and/or psychiatric disorders were seen in 2.2% (33/1500). The mean age of these patients was 38 years (SD ± 1.57), with no gender predilection. Psychogenic vertigo was diagnosed in 51.5% (17/33) of these patients. Other diagnoses included dissociative attacks, pseudo seizures, anxiety, and panic attacks.
Demyelinating disorders of the central nervous system (CNS) accounted for 2% (30/1500) of all the cases with a mean age of 39 years. Multiple sclerosis was present in 70% of these patients, with a mean age of 32.8 years and an equal prevalence occurred in both sexes. Other diagnoses included neuromyelitis optica, a case of central pontine myelinosis, and a case of progressive multifocal leukoencephalopathy.
Syncope accounted for less than 2% (22/1500) of all the cases, with a mean age of 35.5 years (SD ± 1.9), and was almost equally prevalent in both sexes. Almost every case of syncope seen was postural, along with two cases each of micturition syncope and cough syncope.
Dementia accounted for less than 2% (20/1500) of all cases. Alzheimer's dementia (AD) accounted for 45% (9/20) of all cases of dementia and was three times more common in males, with a mean age of 70 years (SD ± 7.5). Other causes of dementia included vascular dementia and fronto-temporal dementia (n = 1).
Myasthenia gravis (MG) was seen in less than 2% (16/1500) of cases. Of them, two were ocular and others were generalized myasthenia. One case of congenital myasthenia was also seen. MG was 3 times more common in males with a mean age of 56 years (SD ± 1.7).
Ataxic disorders, such as spinocerebellar ataxia, sensory ataxic neuropathy, and postviral cerebellitis, along with muscular dystrophy and myopathies each accounted for less than 1% of all the cases.
Some of rare disorders seen during the 2-month period were two cases of MND, a case of Hirayama disease and a case of suspected Harlequin syndrome.
Around 1.1% of the total patients were non-neurological cases. Most of these had vascular disorders such as varicose veins, peripheral vascular disease (PVD), and cellulitis.
This study was the first of its kind done in India to analyze the burden of various neurological disorders in outpatient services. There have been numerous studies done to determine the prevalence, incidence, and/or pattern of specific types of neurological disorders but not as a whole.
A study in Eastern India, similar to ours, was done to determine the prevalence of neurological disorders in a rural population through a community-based survey. The study was done in two phases; a door-to-door screening in the first phase and a detailed evaluation in temporary clinics in the second phase. The study identified a total of 606 patients and classified them according to the standard diagnostic criteria. The commonest disorders per 100,000 population were headache (870), vertebral disease with neurological involvement (540), seizure disorders (360), vertigo (240), stroke (147), movement disorders (140), and peripheral neuropathy (80). Another neuroepidemology study conducted by National Institute of Mental Health and Neurosciences from urban and rural population of Bangalore district studied the prevalence rates (PRs) per 100,000 population of the most frequent disorders in the descending order of frequency. They were headache (1119), epilepsy (883), febrile convulsions (330), cerebrovascular disorder (150), and mental retardation (142). Similar neuroepidemiological survey carried out at Malda district also examined the crude PR of neurological disorders per 100,000 population. These included epilepsy (305), vertigo (24.45), mental retardation (42.90), paralytic poliomyelitis (53.63), movement disorders (26.81), spinal cord disorders (21), and MND (2.7). [Table 1] shows the comparison between various neuroepidemiological studies carried across different parts of India.
In our study also, headache was the most common disorder seen in the outpatient clinic, followed by muscular/radicular pain, seizure disorders, stroke, nerve palsies and neuropathies, movement disorders, and vertigo. Muscular/radicular pain included neck pain, backache, radiculopathies, fibromyalgia, hemipain syndrome, and joint pains. These disorders were second in prevalence, thus highlighting their importance. Another study similar to ours was done in Bangladesh, studying the outpatient burden of neurological disorders in a specialized neurology clinic at a tertiary care level. This study evaluated a total of 3173 patients over a 1-year period. Data were collected through a predesigned questionnaire. The study identified 88.7% of the patients who presented to the clinic as having a neurological disorder. Stroke and headache were the two most common diseases encountered, followed by epilepsy, peripheral neuropathy, Parkinson's disease, and pseudovertigo. The diagnosis in patients with non-neurological disorders who presented to the clinic mainly included peptic ulcer and anxiety neurosis. In a similar study from rural northwest India, based on a neurology registry from a tertiary care center, a total of 2431 patient were analyzed. This study revealed that six major neurological disorders such as epilepsy and seizures, headache, spondylosis with neurological manifestations, cerebrovascular disease, parkinsonism, and neuropathies accounted for more than two-thirds of the patients. Of these neurological disorders, epilepsy, seizures, and headache together constituted more than one-third of the disorders seen. In our study, headache was the most common, and stroke was placed fourth in presentation. The commonest non-neurological problems in our study were varicose veins and PVD. [Table 2] shows the comparison between the hospital-based studies.
Most of studies from India have been on specific diseases like stroke, epilepsy, Parkinson's disease, and dementia, which are associated with high rates of mortality and morbidity, given their obvious grave prognosis. Among the most neglected and poorly studied neurological disorders is ironically the most common, that is, headache. A study was done in 2002 to determine the prevalence and pattern of headaches at a tertiary headache clinic in Mumbai. In a sample of 3000 patients, 91.4% were identified as having a primary headache and only 1.7% were identified as having a secondary headache. Among the primary headaches, migraine was the dominant cause, at 77.9%. TTH were seen in 19.5%, cluster headaches in 2%, and miscellaneous headaches in less than 1%. Among the migraineurs, only 2.7% were identified as having migraine with aura.
Another study was done in 2013, at a tertiary care center in Varanasi, India, to study the etiological and clinical profile of various headaches using the second edition of International Classification of Headache Disorders (ICHD-2) and to identify the associated triggers. The study analyzed a total of 2043 patients. Among the primary headaches, migraine was the most common at 46%, followed by TTH at 31.7%. Among the migraineurs, 10.5% were classified as migraine with aura. Cluster headaches were seen in 0.5% and hemicrania continua was seen in 0.4%. Among the secondary headaches, intracranial neoplasms were seen in 4%, posttraumatic headaches in 2.8%, cervicogenic headaches in 1.8%, and meningitis in 0.7% patients. Trigeminal neuralgia was seen in 1.6% patients. The study also concluded that migraine and TTH were more common in females, whereas cluster headaches and trigeminal neuralgia were common in males. In yet another community-based study done from eastern India to assess the prevalence, burden, and risk factors of migraine, it was shown that 342 (14.1%) subjects had migraine out of 2421 subjects who were screened for the study. In the present study also, of the 1500 subjects screened, 198 (13.2%) subjects had migraine and 110 (7.3%) had tension headache.
In our study, an important association was observed between migraine and fibromyalgia. Among the 64 patients who were diagnosed with fibromyalgia, more than half of them had concurrent migraine, highlighting an important association between these two conditions. A study conducted in an Israeli headache clinic evaluated a total of 92 consecutive patients with migraine and found that 22.2% of the female patients (and none of the male patients) were also diagnosed with fibromyalgia syndrome.
A study done in 1998 showed the prevalence of various epilepsies and epileptic syndromes in an epileptic population presenting at a university hospital in South India. Out of 2531 cases, 48% were classified as cryptogenic, without unequivocal generalized or focal seizures, or situation-related seizures. Localization-related epilepsies and epileptic syndromes were seen in 62.9% of the patients. Similar to our study, juvnile myoclonic epilepsy (JME) was the most common idiopathic generalized epilepsy, accounting for 4.9% of the study population. Childhood and juvenile absence epilepsies were seen in less than 1% of the study population.
A study was done in Kolkata, India, to determine the incidence, prevalence, and mortality rate of Parkinson's disease in an urban area, on a stratified random sample using a door-to-door survey. A total of 100,802 patients were screened in this study over a period of 4 years. The age-adjusted PR and average annual incidence rate for Parkinson's disease were 52.85/100,000 and 5.71/100,000 per year, respectively.
A study was done in Mumbai, India, to determine the prevalence of dementia in an urban population. A total of 24,488 people were analyzed, of which 105 were identified to have dementia. Alzheimer disease (AD) was the most common cause of dementia at 65% followed by vascular dementia at 22%. The overall PR for AD in the population was 0.25%, and 1.5% for those aged 65 years and above. The study concluded that the prevalence of AD and other dementias was less compared to that seen in developed countries and was more in women than in men. In another study from a teaching hospital in North India, it was shown that vascular dementia was more common than AD. However, a community-based survey of subjects from western India revealed that AD was a common form of dementia among the people aged above 65 years. In the present study also, AD was the common form of dementia encountered; this was followed by vascular dementia.
The most common neurological disorders in the outpatient services are headache, neck pain, backache, fibromyalgia, stroke, epilepsy, and neuropathies. Of these disorders, paramount importance should be given to primary headache disorders like migraine and TTH. There is a strong association present between migraine and fibromyalgia, which needs assessment by further studies. Newly joined residents should be well trained to efficiently manage these common out-patient disorders such as migraine, TTH, and muscular/radicular pain including fibromyalgia.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]