pain management in covid

Pain in Covid & Post Covid Patients

Management of Pain in Covid 19 patients

How common is the pain in covid patients?

Covid 19 illness presents with a variety of symptoms, most common being fever (98%), followed by cough (76%) and dyspnoea (55%). Different types of pain or fatigue (44%) come next. The common pain symptoms are myalgia or arthralgia (14.9%), and headache (13.6%). Many of these pain symptoms continue long even after recovery from acute covid. This condition is called Long Covid.

Due to the high incidence of pain, it is often used as a symptom Covid-19 for its diagnosis and used to follow up this disease.

What do we mean by musculoskeletal pain?

Muscle pain or myalgia & joint pain or arthralgia are together called musculoskeletal pain. Myalgia is very commonly caused by systemic or local infection. It’s usually diffuse instead of localized. Arthralgia is defined as joint pain or stiffness that leads to poor quality of life, emotional changes, reduced compliance, and even interruption of treatment.

Joint and muscle pain are common in the general population and include pain in the shoulder, neck, back, knee, and small joints of hands & feet. Many of us will have had these at some point in their life. Most of those problems aren’t serious and improve or recover quickly except for those who are suffering from rheumatoid arthritis, spondyloarthritis, or fibromyalgia.

What causes joint and muscle pain in covid and long covid?

There are multiple reasons behind the muscle and joint pain. These are:

  1. Damage of muscle because of viral infection of immunological injury: Myalgia during virus infection is typically mediated by interleukin-6, which are upregulated and cause myalgia or arthralgia. Creatine kinase (CK) and Lactate Dehydrogenase (LDH) can be associated with striated muscle damage. Mao et al found that patients with Covid-19 having muscle symptoms had higher levels of CK and LDH than those without muscle symptoms. Myalgia could be caused by striated muscle injury. ACE2 is additionally present in striated muscle, and SARS-CoV-2 may bind with ACE2 to infect striated muscle.
  2. Damage and changes of nerves and nociceptors: There is evidence of stroke and micro-damage of the brain and peripheral nerves which may cause sensitization and pain. Changes in peripheral nociceptors can also cause amplification of pain. All these can cause burning sensations and electric shock-like nerve pain.
  3. Deconditioning of muscle and joints: There are other simpler causes also behind muscle and joint pain. Many people will have had some aches and pains before getting ill with Covid. Being unwell may have made these problems come or worsen. This is often because joints and muscles are better once we regularly move. When unwell with Covid people are less active than usual. This will cause deconditioning of muscles and joints and cause aches and pains, stiffness, and muscle weakness. Muscle weakness can cause difficulties with activities like standing, climbing stairs, gripping objects together with your hands, or lifting your arms above your head.
  4. Pain associated with the treatment of Covid illness: A number of the treatments that were needed during your Covid illness may have put extra stresses and strains on a number of your joints and muscles. These may have caused new or increased joint and muscle problems.
  5. Psychological issues like anxiety and depression: It is well known that anxiety and depression increase the feeling of pain. Small tissue damage or no tissue damage can cause severe pain in presence of anxiety and depression which is very common in Covid and Long Covid patients.
  6. Preexisting patients of chronic pain: Many patients who are already suffering from different chronic painful diseases like fibromyalgia, rheumatoid arthritis, spondyloarthritis, etc may suffer from increased pain because of stress, deconditioning, or treatment of Covid. Steroids are very often used in Covid treatment which keep the pain of these problems under control, but when steroids are withdrawn, the pain of these inflammatory conditions may increase.
  7. Focal myalgia and rhabdomyolysis: General myalgia is extremely common in patients with Covid-19. Focal myalgia is less common should alert the doctor that the patient may have a rare condition called rhabdomyolysis. Rhabdomyolysis may be a potentially fatal syndrome, and its important indices are the concentration of serum CK or the appearance of myoglobinuria. The CK level may indicate the severity of rhabdomyolysis.

Which types of pain are most often seen?

The most common types of pain are shoulder and back pain, but small joint and muscle pain can occur in any part of the body.

Some people experience severe shoulder and arm pain after Covid, especially those that were admitted to the hospital. These problems are often a mixture of pain, stiffness, burning and tingling sensations, numbness of the arms, and weakness in some muscles. Many of those problems improve with time, but if the problem is severe and persists longer one must contact a doctor.

Some people have widespread pain, burning sensations, and pin & needles sensations all over the body which is also gradually recovered.

What should be done in muscle and joint pain?

Most joint and muscle pain after Covid improves quite quickly. You can take care of your muscles and joints with simple activities and exercises. Never get panicked and take the help of doctors whenever it is more than mild or persist longer.

You should gradually return to your usual activities, gradually increase the quantity of movement and activities. Joints, muscles, and bones are wasted and deconditioned with rest and become stronger with movements. So, do movement, walking and gradually increase the activities.

It is safe to do exercises after Covid unless advised by a doctor. Aim for a balance between activity and rest. Initially, you’ll need to rest more frequently than general physical activities and no exercises. With time and improvements gradually increase general physical activities and later add exercises. Never overdo for rapid recovery.

General physical activity means all the activities that we normally do like washing and dressing, going to the dining table to take breakfast or lunch, housework like cleaning, gardening, etc.

There are different types of exercises like strengthening exercises, flexibility exercises, stretching exercises, etc. The simple exercise to start with can be walking on a plane surface. Other forms of exercises should be done with the advice of a physiotherapist in a setup for post covid rehabilitation

Yoga, pranayama, or meditations can also be started with the advice of a physiotherapist.

When and what medicines can be started at home?

Painkillers medicines can be dangerous and must be taken with the advice of doctors only. Apart from its side effects, many a time these pain medicines may hide the danger signal and one can report to a doctor later.

Most commonly doctors prescribe paracetamol and muscle relaxants for pain. But many patients need additional nerve medicines and antidepressant medicines. Some time doctors advise interventions like joint injections if it is needed. Application of heat or cold sometimes gives good pain relief and can be done at home.

When should one contact a doctor?

Ideally, all patients should consult a doctor at least once for a check-up even after recovery, but a doctor must be consulted in the following situations:

  • More than mild pain
  • Persistent pain even it is mild
  • Presence of numbness, tingling sensations
  • Presence of weakness of a part of the body
  • If there difficulties in passing urine or stool
  • If there is persistent chest pain, abdominal pain, or headache
  • History of unconsciousness or convulsions
  • Swelling of joints
  • Red or hot joints
  • Difficulties in sleep because of pain

Most types of pain are recovered quickly and one must not be anxious or panicked. But it is always advised to take a doctor’s opinion at least once.

References:

  1. https://www.dovepress.com/pain-symptoms-in-patients-with-coronavirus-disease-covid-19-a-literatu-peer-reviewed-fulltext-article-JPR#f0001
  2. https://www.nejm.org/doi/full/10.1056/nejmoa2002032
  3. https://www.yourcovidrecovery.nhs.uk/managing-the-effects/effects-on-your-body/musculoskeletal-shoulder-and-back-pain/
  4. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html

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