Potentially More Chronic Pain after COVID

Considering the potential for an increase in chronic pain after the COVID-19 pandemic: PAIN – August 2020

I’m immediately skeptical after noticing that the first 2 of the 4 authors specialize in various forms of mental illness: Psychiatry, Psychosomatic Medicine, and Psychotherapy.

• Clauw, Daniel J. – Departments of Anesthesiology, Medicine (Rheumatology), and U Chronic Pain and Fatigue Research Center, the University of Michigan Medical School, Ann Arbor, MI, United States
• Häuser, Winfriedb, – Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, München, Germany and Department Internal Medicine I, Klinikum Saarbrücken, Saarbrücken, Germany. 

The toll of this pandemic extends beyond physical illness, with important psychosocial stressors that include prolonged periods of limited interpersonal contact, isolation, fear of illness, future uncertainty, and financial strain.  

Uncertainty is fuelled by the constant media coverage, often with conflicting information, differing recommendations by public health authorities in different jurisdictions, and the unknown duration and likelihood of resurgence of this pandemic.

In this context, we will examine the potential health consequences of COVID-19 germane to CP, which might be

• nociplastic,
• neuropathic, or
• nociceptive.

Specific possibilities might include:

1. CP as part of a postviral syndrome or the result of viral-associated organ damage;
2. worsening of CP due to exacerbation of preexisting pain physical or mental complaints; and
3. CP newly triggered in individuals not infected with COVID by exacerbation of risk factors (poor sleep, inactivity, fear, anxiety, and depression).

Chronic pain conditions can be triggered by psychosocial stressors or organ-specific biological factors, which may preferentially occur in individuals with a fragile stress response system.

2. Infections as a trigger for chronic pain

Acute viral illnesses often present with myalgia and fatigue,

Outcomes related to these infections are almost always focused on the immediate response to the acute illness, with little attention to long-term outcomes.

Although some infections cause specific postinfectious syndromes, there is also a common stereotypical response to any type of infection that is often observed.

For example, up to 12% of patients infected with 3 different pathogens, ie, Ross River virus (the cause of epidemic polyarthritis), Coxiella burnetii (cause of Q fever), and Epstein–Barr virus, experienced a postviral syndrome of pain, fatigue, and memory difficulties for up to 12 months after infection.

The presence and severity of somatic symptoms during acute infection was closely correlated with the subsequent development of chronic fatigue and pain.

Current estimates are that

• 80% of laboratory-confirmed COVID-19 patients have mild to moderate disease, including both pneumonia and nonpneumonia cases,
• 13.8% have severe disease, and
• 6.1% develop critical illness requiring intensive care unit (ICU) admission

This makes no sense when we hear that up to 40% of coronavirus cases don’t even show any symptoms, which is exactly what is making this virus spread so easily.

We can avoid obviously sick people, but healthy-seeming infected folks are impossible to identify and avoid (unless you have a COVID detection dog (Dogs can identify COVID in humans)

3. Potential health-related consequences of COVID-19

3.1. Chronic pain as a consequence of COVID-19 disease

Most patients experience symptoms for 1 to 2 weeks with complete resolution, although some require hospitalization.

Many individuals with COVID need ICU care, and individuals surviving an illness requiring ICU admission are at increased risk of long-lasting severe functional limitations, psychological distress, and CP.

Surveys have reported persistent CP in 38% to 56% of ICU survivors when evaluated 2 to 4 years after ICU admission.

Mental health is also frequently affected by severe illness. Between 41% and 65% of SARS survivors have experienced persistent psychological symptoms.

3.2. Exacerbation of chronic pain in the absence of actual infection

Reduced clinical encounters with interdisciplinary healthcare team members (eg, physiotherapists, psychologists, and self-help groups) can have adverse consequences.

Access to medications may be reduced due to logistical factors or true drug shortages when analgesic medications are diverted to emergency care

Another factor to consider is reduced health-related physical activities, which are a vital management strategy for CP, that result from social distancing and isolation, and closure of group activity programs such as gyms and pools

Limited social support will also contribute to poor psychological health

3.3. New onset of chronic pain related to psychological stressors

It is not currently known whether COVID-19 will cause an increase in new-onset CP for the population at large.

Although CP conditions are thought by some to be highly related to stress and distress, studies have consistently shown that high baseline levels of psychological distress are only modestly related to the development of chronic regional or widespread pain

What?

“High levels of stress are only modestly related to the development of chronic pain.” This goes completely against the catastrophizing theory, which posits that psychological distress leads to chronic pain.

Nearly everyone is exposed to relentless media coverage and conflicting messages, and concerns about contracting SARS-CoV2, routine medical care, family, jobs, and economic issues are pervasive.

Further stressors relate to social distancing, isolation and quarantine, and in some, grieving a death without the usual social support system. Persistent and extreme stress can lead to severe mental health consequences including an increased suicide rate.

There is preliminary evidence that

• anxiety and depression (16%-28%),
• self-reported stress (8%), and
• sleep disturbances

are common reactions to this pandemic.

Immediate consequences of COVID-19 and strategies to mitigate these effects

Routine medical care will resume for most patients, and healthcare professionals should be flexible and willing to adapt to new methods of healthcare delivery, especially with regard to telemedicine.

Conclusion

The impact of the COVID-19 pandemic on health will likely be manifested in both infected individuals and in people spared infection, but are nevertheless adversely affected by disruptions in normal life and experience a wide array of physical, psychological, and social stressors.

Amidst many uncertainties, the research community is urged to study, devise, and implement strategies aimed at mitigating the pain-related health consequences of this pandemic.