Treatment of Chronic Pain from Covid-19
By MOACIR SCHNAPP, MD
By now, we are all too familiar with the fatal devastation COVID-19 has wrought on this country, with hundreds of thousands dead. We view those who recovered from the virus as lucky, and most are. However, what we are learning and seeing now is that those patients' stories don't end when their obvious symptoms go away, or they walk out of the hospital on their own. Instead, many "recovered" COVID patients who have gotten back to their normal lives are finding themselves plagued by something unexpected: chronic pain.
Chronic pain can develop after many viral infections, not just COVID-19. An example is mononucleosis, caused by the Epstein-Barr virus, which can cause long term pain and fatigue. Another, is the common flu virus; while most of us "get over" the flu, some affected individuals never recover completely. In general, there is a connection between the severity of a viral illness and the development of long-term symptoms such as pain.
Neurological damage from direct brain involvement caused by the coronavirus or by the body misdirecting its defenses towards the brain are often blamed for chronic pain and fatigue. The so called "long Covid" may belong to that category, with tiredness, loss of concentration, sleep disturbances and a myriad of other problems. While the virus is gone, some of the sequelae or aftereffects persist. Even people with moderate illness - the kind that does not require medical care - can go on to develop chronic symptoms.
A special neuropsychological condition called "central sensitization" can occur after viral infections such as COVID-19. Due to certain chemical and cell alterations in the central nervous system, a person's body may become hypersensitive to pain, to the point that even touching the skin may hurt.
While COVID-19 itself is responsible for many of the ongoing effects patients will experience, the treatment itself may similarly contribute to long lasting pain. Of those severely ill patients requiring hospitalization, many landed in the ICU, where prolonged bedrest can cause stiffness of the joints and severe loss of muscle mass (up to 10 percent in 10 days). Long stays in ICU may also cause peripheral neuropathy, a painful damage to the nerves in the legs and arms that can also lead to weakness and numbness. Invasive procedures such as chest tubes inserted between the ribs to expand the lungs and all sorts of procedures including IVs and catheters (common among the treatments required for COVID-19 patients) add to the problem.
Being in an ICU is very stressful, but it can be terrifying when you cannot count on the presence of family and friends due to infection precautions. Pain and suffering go hand in hand. Our mental health can deteriorate when we are sick or preoccupied with family members and isolated from friends and the community. The ensuing psychological changes may actually intensify chronic pain and vice versa.
The treatment of any severe, chronic pain begins with a proper diagnosis. The rehabilitation of these individuals requires a multidisciplinary team of dedicated specialists including doctors, nurses, physical and occupational therapists, psychologists, and others. Such a team is responsible for the diagnosis of the specific needs of each individual and tailoring his or her treatment accordingly.
Doctors commonly subdivide the pain into three categories: mechanical (bones, joints and ligaments), neuralgic (nerves and central nervous system), and visceral (lungs, gut etc.).
This helps us choose the most effective treatment. For example, pain medication such as ibuprofen or codeine don't do much for nerve pain but can help the bones and joints, while some drugs used for epilepsy, like gabapentin, are commonly prescribed for the treatment of neuralgias (nerve pain). Early intensive intervention with daily exercises, respiratory rehabilitation, psychological support and preparations to resume home and work activities are the mainstay of such a program.
Despite the recent controversies regarding the use of strong pain medication, such as opiates, they remain an invaluable tool for the treatment of pain, and it can mean the difference between a person being independent or ending up confined to a wheelchair. It is worth remembering that the vast majority of deaths and overdoses from opiates in this country are due to the illegal use of these substances.
One of the most effective therapies for chronic pain consists of injections around the affected nerves, known as nerve blocks. The purpose is to temporarily stop the pain, without causing damage to the nerve. We compare this to rebooting a computer that crashed, allowing the nerves and the central nervous system to "reset itself." The vicious cycle of the pain may be so interrupted, facilitating the rehabilitation process. By reducing the pain from neuralgias, nerve blocks also improve the quality of sleep and allows for the reduction in pain medications. Typical of this type of treatment are epidural blocks, often used in the treatment of sciatica.
In the past, mental health issues were labeled as "psychological" or "neurological." Today, this distinction mostly disappeared and the treatment of depression, anxiety, and PTSD, among others, is best accomplished by combining counseling and medications. We understand now that both the severe stress from an illness and the brain impairment from a viral infection can lead to similar behavioral and personality changes.
Hope can, however, be the greatest healer, but it hinges in great part on the support from family and friends and the encouragement from doctors, nurses, and therapists who are focused on reducing a patient's pain and restoring function. The rehabilitation process can be arduous, tiresome and sometimes boring. Hope helps.
Moacir Schnapp, MD, is a neurologist and Medical Director of Mays & Schnapp, Neurospine and Pain, the only CARF-accredited outpatient pain clinic in the Mid-South. Visit https://www.maysandschnapp.com