On 11th March 2020 the WHO declared COVID-19 outbreak as a global pandemic and 1 year on we are still haunted by the mysteries of this virus. Much has changed in the world of medicine in the last 1 year including how we look at COVID-19 as more evidence accumulates supporting COVID-19 as a complex multisystem disease rather than just being restricted to the lungs.
The widespread perception is that if one gets COVID infection the possible outcomes include recovery in two to three weeks or hospital admission or death in severe cases. Contrary to this, for some people COVID 19 infection is not a discrete episode lasting a few weeks, but marks the start of a long-term illness with ongoing and often debilitating symptoms. This is addressed as Long COVID and may perhaps be the first illness name to be coined by patients themselves through social media. This diagnosis challenges the clinical and governmental assumptions about COVID and brings more uncertainty into the picture.
Persisting pain and fatigue is one of the symptoms seen in Long COVID. This writeup explores the relationship between COVID-19 infection and pain, including the pains related to acute COVID-19 infection and those persisting after the infection as a part of Long COVID-19.
PAINS ASSOCIATED WITH ACUTE COVID-19 INFECTION
In the list of COVID -19 infection symptoms, muscle pain and fatigue (44%) are not far behind other symptoms such as fever (98%), cough (76%) and dyspnoea (55%). Even the so called mild COVID-19 cases can be troubled by miserable symptoms such as debilitating headaches, body aches and extreme fatigue. Commonly observed pain issues during an acute infection with incidence range as found in different studies are as follows
• Muscle & Joint pain 1.5 – 61 %
• Headaches1.7 – 33.9%
• Sore throat0.7 – 47.1%
• Chest pain1.6 – 17.7%
• Abdominal pain1.9 – 14.5%
Generalised soreness, pain and fatigue are commonly seen with viral infections such as seasonal flu. In COVID-19 pain is described by most as diffuse ache or soreness sensation similar to that one experienced after exercise. These pains are however not localised to one part of body and take longer to resolve. Some studies have observed more involvement of muscles as compared to joints in the early stages.
Multiple mechanisms are postulated to be possibly contributing to these pains such as virus triggered inflammation, direct muscle damage and blockage of blood vessels by clots leading to poor blood supply to the muscles, etc. The relative contribution of these factors remains unknown. Besides these, other factors such as stress and low mood may play a role in modulating the pain perceived by an individual.
PERSISTING PAIN AFTER COVID-19 INFECTION
A study conducted in Italy evaluated 143 patients for persisting symptoms, 60 days after the initial onset of COVID-19 symptoms. 87.4% of patients reported persistence of at least 1 symptom with 55% having 3 or more symptoms. Symptoms included fatigue (53.1%), dyspnoea (43.4%), joint pains (27.3%) and chest pains (21.7%). Worsened quality of life was observed among 44.1% of patients.
Another study from China, involving 1733 patients, found that six months after discharge 76% of patients had at least one of the these symptoms- fatigue/weakness (63%), difficulty sleeping (26%), hair loss (22%), altered smell and taste (11 and 9%), and mobility issues (7%).
These studies highlight the impact of COVID even after the resolution of the acute phase. Other commonly observed symptoms include inability to concentrate, impaired memory, anxiety, depression and sleep disturbances. Persistence of these problems are termed as post-acute-COVID-19 syndrome or “Long COVID-19” with incidence varying between 10- 70% in different studies. There is uncertainty regarding the underlying mechanisms responsible for Long COVID. Some of the possible causes include a reduced or lack of immune response, relapse or reinfection of the virus, inflammatory and long lasting changes to the immune system, post-traumatic stress and injury to multiple organs.
Joint pains or arthritis after viral infections is not a new phenomenon with viral arthritis responsible for 1% of acute arthritis cases worldwide. In India joint pains after viral infections such as dengue and chikungunya are common. Diagnosis of viral arthritis can be challenging, with early onset within the first weeks of infection and a self-limiting pointing towards the possibility of viral arthritis.
Concerns have been expressed regarding increase in severity of certain types of arthritis with COVID-19 infection, and how this unfolds in the future remains to be seen. Currently there are many published case reports with arthritic symptoms in lower limb and small joint of hand developing after COVID-!9 infection. Some of these patients have benefited from the use of anti-inflammatory medications and local joint injections.
LONG COVID MANAGEMENT
Currently there is limited available evidence no specific treatments that can be offered as a cure. As the number of patients recovering from COVID-19 grows and research evidence accumulates, we may be able to answer this question better. Many patients, however, recover spontaneously with holistic support, rest, symptomatic treatment and gradual increase in activity. As there can be huge variations in the symptoms, individualized rehabilitation plans may have a role.
One can make sensible lifestyle changes such as balancing rest and activity, following a healthy diet with weight management , not smoking, limiting alcohol and coffee, getting quality sleep, managing depression, anxiety and stress. Protective role of supplements such as vitamins, if any remains unclear although maintaining normal levels is sensible.
—The writer is Senior Consultant & Head, Pain Management Services, Max Hospital, Saket, New Delhi