Cite as: Le T, Xiang N. Post-COVID pain treatment and management. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra020122.009.

The COVID-19 pandemic has changed the medical landscape that we all practice in. The novel SARS-CoV-2 virus’s effects on the human body extend beyond the respiratory complications commonly associated with the coronaviridae family. Acute COVID-19 infection can also result in multisystem insults and injury, including neurologic, cardiovascular, renal, and hematologic complications, and an increasing number of patients experience a heterogenous constellation of pain symptomatology. Termed “post-COVID pain,” it presents a new challenge for pain management providers globally, with the potential to affect any of the 323 million documented cases of COVID-19 infection as of January 16, 2022.¹ This article provides a brief summary of our current understanding of post-COVID pain symptomology and describes various healthcare providers’ approaches to treatment and management.

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Given its heterogeneous and multisystem nature, management should be personalized for each patient and include multimodal therapies and interventions that address each of the proposed etiologies. 

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Chronic pain after acute COVID-19 infection presents with several different symptoms that may vary significantly among patients. Most commonly, patients report myalgias, arthralgias, and atypical chest pain; less-common symptoms include neuralgias, headaches, and abdominal pain.^2,3 Other types of symptoms also persist after acute COVID-19 infection, but those fall under a broader diagnosis of post-COVID syndrome or “long COVID.”

The available literature on the prevalence of post-COVID pain symptoms is thus far largely limited because most studies and analyses focus either on the broader post-COVID syndrome, a specific body system (eg, only musculoskeletal symptoms), or pain symptomatology during acute COVID-19 infection. One meta-analysis suggested that the overall prevalence of post-COVID myalgia, joint pain, and chest pain ranged, respectively, from 5.7%–18.2%, 4.6%–12.1%, and 7.8%–23.6%. The ranging prevalence is the result of different follow-up intervals in each study (from 30–180 or more days).² Another study of 143 patients at a mean follow-up time of 60 days reported a 27% prevalence for arthralgia, 21% for chest pain, 10% for headache, and 5% for myalgia.³ 

Given the paucity of information surrounding post-COVID pain, the exact pathogenesis is still poorly understood, though it is likely multifactorial given acute COVID-19 infection’s systemic presentation. The exact pathophysiology of COVID-19 infection is beyond the scope of this article. However, in brief, studies have suggested that prolonged proinflammatory states associated with acute disease may be a driving factor in post-COVID syndrome’s pathogenesis,⁴  which is consistent with current understanding of chronic inflammation and central sensitization and its role in chronic pain.⁵ Similarly, other proposed mechanisms of pathogenesis are immune-mediated vascular dysfunction, thromboembolism, and nervous system dysfunction.⁴

Kemp et al. discussed several domains and features of acute COVID-19 infection that could potentially predispose patients to chronic pain, including positional injury, procedural pain, critical illness polyneuropathy, and myopathy, as well as mental health effects such as post-traumatic stress disorder or social isolation.⁶ To further complicate the picture, post-COVID fatigue can contribute to ongoing pain issues, similar to presentations with central sensitivity such as fibromyalgia.⁷

No guidelines or consensus statements are available to guide the management of patients with post-COVID pain. Given its heterogeneous and multisystem nature, management should be personalized for each patient and include multimodal therapies and interventions that address each of the proposed etiologies. Post-COVID pain management likely will involve various combinations of physical and occupational rehabilitation, mental health support and therapy, selective serotonin-norepinephrine reuptake inhibitors, antineuropathics, anti-inflammatory agents, and interventions such as targeted sympathetic blocks (eg, for postischemic limb pain).^8,9

We have followed these principles in our practice to evaluate new patients with post-COVID pain. In addition, our clinic has begun using low-dose naltrexone (LDN) (with typical initial dosing at 1.5–6 mg daily). Emerging evidence for its use in chronic inflammatory states and chronic pain supports LDN’s utility as part of a multimodal, non-opioid approach to treating post-COVID pain,^10–12 and our understanding that post-COVID syndrome and pain may be a result of the proinflammatory state from acute infection further supports its use.

The pandemic will continue to challenge current and future pain providers. The extent to which COVID-19 infection can lead to chronic pain as well as the pathogenesis of the wide array of symptoms require further research and evidence. Until we have a better understanding and develop standardized guidelines, our best strategy to manage post-COVID pain should be tailoring treatments and interventions to each individual's presentation.

Thien T. Le, MD, is the chief anesthesia resident at the Emory University School of Medicine in Atlanta, GA.

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Nan Xiang, MD, is an assistant professor at the Emory University School of Medicine in Atlanta, GA

References

1. World Health Organization. Weekly epidemiological update on COVID-19- 18 January 2022. https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19---18-january-2022. Updated January 18, 2022. Accessed January 21, 2022.
2. Fernández-de-Las-Peñas C, Navarro-Santana M, Plaza-Manzano G, Palacios-Ceña D, Arendt-Nielsen L. Time course prevalence of post-COVID pain symptoms of musculoskeletal origin in patients who had survived to severe acute respiratory syndrome coronavirus 2 infection: a systematic review and meta-analysis. Pain. 2021;10.1097/j.pain.0000000000002496. https://doi.org/10.1097/j.pain.0000000000002496 
3. Carfì A, Bernabei R, Landi F, for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603–5. https://doi.org/10.1001/jama.2020.12603
4. Maltezou HC, Pavli A, Tsakris A. Post-COVID syndrome: an insight on its pathogenesis. Vaccines (Basel). 2021;9(5):497. https://doi.org/10.3390/vaccines9050497 
5. Ji RR, Nackley A, Huh Y, Terrando N, Maixner W. Neuroinflammation and central sensitization in chronic and widespread pain. Anesthesiology. 2018;129(2):343–66. https://doi.org/10.1097/ALN.0000000000002130
6. Kemp HI, Corner E, Colvin LA. Chronic pain after COVID-19: implications for rehabilitation. Br J Anaesth. 2020;125(4):436–40. https://doi.org/10.1016/j.bja.2020.05.021
7. Sharma P, Bharti S, and Garg I. Post COVID fatigue: can we really ignore it? Indian J Tuberc. 2021;23. https://doi.org/10.1016/j.ijtb.2021.06.012
8. Barreto Junior EPS, Nascimento JDS, de Castro APCR. Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior [Neurolitic block of the lumbar sympathetic chain improves chronic pain in a patient with critical lower limb ischemia]. Braz J Anesthesiol. 2018;68(1):100–3. https://doi.org/10.1016/j.bjan.2015.03.007
9. Mahli A, Coskun D, Cosarcan K. Peripheral sympathetic block with therapeutic local anesthesia for the management of upper limb digital ischemia. Hippokratia. 2018;22(3):141–3. https://pubmed.ncbi.nlm.nih.gov/31641336
10. Ekelem C, Juhasz M, Khera P, Mesinkovska NA. Utility of naltrexone treatment for chronic inflammatory dermatologic conditions: a systematic review. JAMA Dermatol. 2019;155(2):229–36. https://doi.org/10.1001/jamadermatol.2018.4093
11. Parker CE, Nguyen TM, Segal D, MacDonald JK, Chande N. Low dose naltrexone for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2018;4(4):CD010410. https://doi.org/10.1002/14651858.CD010410.pub3
12. Younger J, Parkitny L, McLain D. The use of low-dose naltrexone (LDN) as a novel anti-inflammatory treatment for chronic pain. Clin Rheumatol. 2014;33(4):451–9. https://doi.org/10.1007/s10067-014-2517-2