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Treating pain in recovered COVID-19 patients poses unique challenges, a pain expert said at the American Academy of Pain Medicine virtual meeting.

"A lot of these patients are going to need rehabilitation" or physical therapy, noted Natalie Strand, MD, of the Mayo Clinic in Scottsdale, Arizona, at the meeting. "There can be quite a bit of deconditioning that occurs, especially after a prolonged ICU stay. Neuropathic pain is also quite common."

Post-COVID neuropathy can be viral or may be related to positioning, including prone positioning in patients who need to improve oxygenation. Some patients "may need short-term opioids or gabapentinoids and they may experience aggravation of prior underlying pain, either due to direct physical causes or to the increase in anxiety and depression that can accompany a COVID infection," Strand said.

A study that followed 143 patients 2 months after acute COVID-19 showed a high proportion reported -- including fatigue (53%), joint pain, (27%) and chest pain (22%) -- that often bring patients to a pain clinic for further evaluation and management, she noted.

After any ICU admission the prevalence of persistent pain is high, ranging from 28% to 77%, Strand said. In COVID-19 patients, chronic neuropathic pain after an ICU stay may include muscle pain related to or muscle atrophy, and pain due to critical illness myopathy or polyneuropathy. Peripheral nerve injuries also have been for COVID-19-related acute respiratory distress syndrome, she added. Other potential causes of neuropathic pain include complications from traumatic procedures like placement of chest tubes or tracheotomy.

Long-term followup of hospitalized COVID-19 patients indicate that pain can persist, Strand said. Three-quarters of patients previously hospitalized with COVID-19 in China continued to report at least one symptom 6 months later, with fatigue or muscle weakness by far the most common symptoms (63%). "Compared with 2-month follow up, 6 months later we see the same trends," she pointed out.

In that study, "13% of the patients who did not develop an acute renal injury during their hospital stay and presented with normal renal function exhibited a decline in GFR at follow up," Strand noted. This may signal caution about using NSAIDS to manage pain in some patients, she said: "Normal renal function at discharge does not necessarily mean it will remain this way 6 months afterwards."

Chronic neuropathic pain may be related to the SARS-CoV-2 virus, Strand observed. In a recent article in , "the authors concluded it could be direct or indirect effects of the virus on the nervous system that can cause neuropathic pain," she noted. "We know that there are neuropathic symptoms involved with the famous loss of taste and loss of smell with presentation," she continued. "But also in the acute phase, we commonly see headache, dizziness, muscle pain, ataxia, and in hospitalized patients we see stroke, meningitis, encephalitis, and autoimmune disorders like Guillain-Barré syndrome and acute disseminated encephalomyelitis."

Chronic pain also can emerge in relation to psychological stressors, Strand added. "Anxiety and depression often follows COVID-19 infection," she said. "It may be wise to screen our patients for anxiety and depression after infection to see if we can further control these components to help manage their pain overall."

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