Published March 26, 2021
Editor’s note: In this article, pediatric pain researcher Wendy Gaultney, PhD, a postdoctoral fellow at Oregon Health & Science University, recounts her discussion with Dr. Harriet Kemp, MD, PhD. Kemp, a pain researcher at Imperial College London, UK, and an anesthetist, recently co-authored an editorial on the management of chronic pain in those who recover from the coronavirus.
The long-term effects of COVID-19 infection for survivors are coming into better view. Many pain researchers and health care providers are working to develop supports early on to prevent persistent pain in these individuals.
As the world watched survivors of COVID-19 first begin to walk out of the intensive care unit early last spring, we all felt the same surge of relief that they were “out of the woods.” However, researchers are concerned that we may be underestimating the long-term threat of persistent pain facing those who survive COVID-19 illness.
Dr. Harriet Kemp of the Pain Research Group at Imperial College London, along with co-authors Dr. Eve Corner and Dr. Lesley Colvin, wrote an editorial in the British Journal of Anesthesia on this topic last year, early in the pandemic. Their aim was to raise awareness that a large number of patients are likely at risk for persistent pain following COVID-19 illness. They also offered considerations about what should be done to prepare for pain treatment in COVID-19 illness survivors.
I had the opportunity recently to speak with Dr. Kemp to ask her about the editorial and her perspective on what healthcare providers are seeing now, a year into the pandemic.
A potential “pain pandemic” after COVID-19?
Dr. Kemp told me that the editorial was in part an exercise in “extrapolating from what is already known about pain after critical illness” early in the pandemic to prepare for what patients may face next.
Previous research with other critical illness populations suggests that some critical care survivors experience post-intensive care syndrome (PICS), which is a complex set of cognitive, physical and psychological symptoms, including pain. The editorial noted that “estimates of chronic pain prevalence after [intensive care] vary from 14% to 77%,” although little is known beyond those broad estimates.
Similar to other critical illnesses, many patients who require critical care treatment for COVID-19 endure pain at various points during their illness and treatment. Some pain is associated with tissue damage resulting from the illness itself. Pain can also occur in the context of life-saving medical procedures and passive injury from weeks of immobilization.
Further, after what can be weeks of hospitalization muscles weaken, which can put nerves on high alert to protect the body from additional injury, leading to pain. Equally important, there is an enormous emotional toll of illness and recovery from COVID-19, which can exacerbate pain.
Because of this, Dr. Kemp and her colleagues note that healthcare providers have been on the lookout for signs that survivors of COVID-19 may experience symptoms of PICS, including chronic pain, after critical illness.
Monitoring pain in COVID-19 patients
The editorial pointed to what we can learn about the potential risk of pain after critical illness from research on past viral illnesses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), each of which has featured pain as a long term effect.
The editorial also reminded healthcare providers about the importance of adequately assessing the patient’s pain during COVID-19 illness and during recovery; one theme of the editorial and my conversation with Dr. Kemp was around the challenges and importance of doing so.
In the context of critical care, basic medical support to keep patients alive is of utmost importance. During those times, pain assessment is challenging and often is not the priority.
But after recovery from critical illness, patients may visit various medical specialty providers for follow-up of their COVID-19 illness. One concern is that a patient’s pain may not be assessed in those appointments consistently. Dr. Kemp told me that her medical colleagues have told her that sometimes pain is not assessed because “we don’t know what to do about it.”
But she and her co-authors are calling for providers to assess pain even if there is not an immediate solution, hoping that their editorial encourages providers who may be following patients post-COVID-19 to do so.
A “rehabilitation pandemic”
In addition to encouraging ongoing pain assessment, Dr. Kemp and her colleagues also noted the importance of getting rehabilitation programs ready to treat an influx of pain patients post-critical COVID-19 illness. Here there a host of challenging issues, including minimal available evidence about rehabilitation best practices with COVID-19 patients as well as the diversity in existing models for care after critical illness.
So, the editorial also aimed to engage those in the rehabilitation community in preparing for the treatment of post-COVID-19 patients. The editorial also noted a lack of lead time to gather evidence and evaluate the effectiveness of specific programs and care models for COVID-19 survivors.
Above all, Dr. Kemp and her co-authors urged the healthcare community to recognize that “flexibility and changes to health and social care delivery are required” to meet the rehabilitation needs of these patients.
Treating pain in patients after COVID-19 illness
Although we have yet to see much data on the prevalence and other features of persistent pain in COVID-19 survivors, it is likely that there will be diversity in patient complexity and treatment needs.
For example, patients may be followed by renal (kidney), respiratory and mental health providers in addition to their primary care provider, while others may be followed only by their primary care physician post-COVID-19. So, early assessment of pain problems, communication among health care providers, and effective triaging based on patient complexity and treatment needs will likely be key to effective treatment of pain after COVID-19, according to the editorial.
The authors also noted that existing pain services are commonly multidisciplinary, including medical, psychological, and rehabilitation specialists, all of who contribute to the patient’s treatment. It is likely that similar models will be beneficial for COVID-19 survivors.
“Although the acute challenges of managing COVID-19 have been significant,” the authors wrote in their editorial, “it may be the long-term effects, including pain, that will have the greatest impact on survivors and society.”
They concluded by encouraging the healthcare community to monitor patients’ pain, and to develop and evaluate rehabilitation services along the way to ensure that survivors of COVID-19 walk out of the ICU feeling confident that if they have pain, they’ll receive the right services and be on the road to recovery.
Wendy Gaultney, PhD, is a postdoctoral fellow at Oregon Health & Science University, US.