What about patients with pain during and after the COVID-19 pandemic?

Dear editor,

What a start to this 2020! The pandemic situation has brought uncountable challenges for public health, politics, economy, and interpersonal relationships around the world. COVID-19 has made huge impacts¹ A focus has been driven to the care for patients who were infected by the virus, particularly those who developed severe respiratory dysfunction. On the other hand, many patients with chronic diseases have been devoid of routine, safe and easy access to health care.

Pain is the most prevalent health complaint all over the world, and unrelieved pain remains a global health problem. However, a systematic review showed that the prevalence of patients with chronic pain in the general population of developing countries was 18%, Brazilian-based population studies identified a proportion of 28 to 40% of the population suffering from chronic pain, with a higher prevalence of women, elderly and lower human development index^2,3. During the global pandemic situation, risks for pain morbidity and even mortality can be largely amplified. According to the World Health Organization, previous pandemics led to a higher number of patients with diagnoses of chronic musculoskeletal pain associated with a post-traumatic stress disorder⁴.

What does happen to those patients during the quarantine period? This scenario is not promising to patients with chronic pain, especially in developing countries. There is no doubt that what could be done to manage pain is distinct from what has been done to it in developing countries. Some factors have contributed to this situation such as limited education of health professionals, lack of facilities for pain management and poor access to treatments for pain relief. In developing countries, excitement for pain education and exceptional clinical training has increased, whereas several barriers to practice changes in developing countries have been imposed by governments and health administrations⁵.

Firstly patients who were being assisted had their health care disrupted. Although telemedicine/telerehabilitation have been used in many cases with success for many outcomes⁶, this cannot be faced as normal life overnight. Additionally, we should highlight that the situation in developing countries such as Brazil is very precarious if we take into account the scarcity of appropriate equipment and connectivity and the acculturation for this more recent technological practice in the health scope.

Additionally, telehealth is probably going to be incorporated by some services after this forced usage of technological tools and experience with patients, as it was considered in the recent PAIN publication this month⁷. However, health professionals must be careful later when this humanitarian crisis is solved once we will need to have clear criteria to indicate what kind of patient/disease/dysfunction or what phase of pain management can be addressed using telehealth. There is no guarantee this is going to work widely in any case. Chronic pain is multidimensional, and patients in pain usually require personal contact and assistance. In a recently letter published in BrJP⁸ described the main factors that must be considered for this implementation in Brazil.

Moreover, all individuals have biopsychosocial characteristics that affect pain. Besides, biological components, psychoemotional and social aspects are relevant to the patient with pain⁹. Still considering the biological context, social isolation has highly interfered with the physical-based strategies for pain management. Exercise has been a gold standard to treat the most chronic painful conditions.

However, many patients with pain need adequate professional supervision and appropriate space to adhere to and carry out the exercise program. Now, patients are at home. Are they moving enough? Do they have enough desire to move? Do they have access to health professionals to virtually help and follow them? Do they have access to this new technology? Are they motivated (by themselves or by family/friends) to do this? Unfortunately, most of them have indeed stopped moving.

Furthermore, several psychoemotional aspects strongly correlate with many states of pain, such as anxiety, depression, catastrophizing, fear, low self-efficacy, hypervigilance. Conditions about humor, energy for activities, appetite, and sleep also interfere with emotions. All those factors contribute to initiate, maintain and/or exacerbate pain conditions.

Lastly, socio-economic status, culture, relationships can influence health. Many social aspects can affect and increase pain such as bad home conditions, lack of food and hygienic supplies, worries about job, accumulation of debts, concern with family/friends, lack of privacy, absence of family/friend support, uncertainty about the future.

Definitively, we are going to be different from before. So will our patients. They will be transformed. Their pain characteristics will probably be changed. Are we going to have different patients with pain after the pandemic? Who were they before the pandemic? How was their pain? What did each one go through during the quarantine? How did they do it? Are you mentally prepared enough to consider all this possible transformation?

Despite the pessimism put hitherto and considering science is changeable, is more pain the only clinical context we may expect? Maybe, serious situations of social misery, uncontrolled panic about the disease or the survival, increase of domestic violence, grave daily sensation of home as prison can play a role of brain distractor and change pain manifestations as we do not know yet how those extreme experiences can modulate pain status.

Attention is needed. Both health professionals and researchers who conduct observational studies or clinical trials must be conscious of many of those factors that could have affected the pain status of patients after the pandemic period is over, and life tends to the new normality.

Frequently, negative events are followed by a kind of positive transformation. We know we are already witnessing behavior changes in some persons who have learned the value of small things, and the importance of people, outdoor living, socialization, daily routine, and stability.

Indeed, what a restart!

REFERENCES

• ¹
  Tay MZ, Poh CM, Rénia L, MacAry PA, Ng LFP. The trinity of COVID-19: immunity, inflammation, and intervention. Nat Rev Immunol. 2020;20(6):363-74.
• ²
  Souza JB, Grossmann E, Perissinotti DMN, Oliveira Junior JO, Fonseca PRB, Posso IP. prevalence of chronic pain, treatments, perception, and interference on life activities: Brazilian population-based survey. Pain Res Manag. 2017;2017:4643830.
• ³
  Ferreira KASL, Bastos TRPD, Andrade DC, Silva AM, Appolinario JC, Teixeira MJ, et al. Prevalence of chronic pain in a metropolitan area of a developing country: a population-based study. Arq. Neuropsiquiatr. 2016;74(12):990-8.
• ⁴
  World Health Organization et al. Integrating palliative care and symptom relief into responses to humanitarian and crises: a WHO guide. 2018.
• ⁵
  Bond M. Pain education issues in developing countries and responses to them by the International Association for the Study of Pain. Pain Res Manage 2011;16(6):404-6.
• ⁶
  Adamse C, Dekker-Van Weering MG, van Etten-Jamaludin FS, Stuiver MM. The effectiveness of exercise-based telemedicine on pain, physical activity, and quality of life in the treatment of chronic pain: a systematic review. J Telemed Telecare. 2018;24(8):511-26.
• ⁷
  Eccleston C, Blyth FM, Dear BF, Fisher EA, Keefe FJ, Lynch ME, et al. Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161(5):889-93.
• ⁸
  Fioratti I, Reis Felipe JJ, Fernandes LG, Saragiotto BT. The COVID-19 pandemic and the regulations of remote attendance in Brazil: new opportunities for people dealing with chronic pain. BrJP. 2020;3(2):193-94.
• ⁹
  Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-36.

Publication Dates

• Publication in this collection
  21 Aug 2020
• Date of issue
  Jul-Sep 2020