Remote Interventions for Pain Amid COVID-19

I am the first to admit that I find treating patients with chronic pain to be SO HARD. Thanks to a few helpful tips from friends and some continuing education, I can just barely touch my toe to the water. But, like many, I have been wondering how COVID-19 and lockdowns and masks and all of those things that have so drastically changed our way of life are changing the pain experience of my patients. Instead of making gross exclamations like so many new stories, I’m looking to the evidence.

Researchers in neuroscience, pain management, and psychology came together recently to write an article on this exact thing. How ARE patients who have chronic pain experiencing this pandemic lifestyle? How is it effecting their perceptions of pain? Is their life changing because of this? And what are the recommendations for what we do about it?

Over 500 people took part in the survey which asked them questions about their pain experience at different points during the pandemic (in the UK). Questions were asked pre- and post-lockdown and comparisons were made for pain behaviors, pain catastrophizing, and pain ratings. Psychological health conditions were also monitored.

The participants in the study were varied across ages and gender descriptions (including “other”), and the time period observed was about a month. It was amazing to me how much could change for the patients in only a months time with the onset of lockdown restrictions. Pain diagnoses were also varied with the highest number of participants demonstrating the diagnoses of “chronic widespread pain” and “chronic primary/secondary musculoskeletal pain”. However, some other more familiar categories were also present such as CRPS, chronic headache, and neuropathic pain.

Among other scales and tests, patients were asked to identify their pain on a 100 point VAS. The pre-COVID to post-COVID scores were significantly different, with a change of about 33 points in perceived pain on average across participants. That is a HUGE increase. Hoping all other factors were equal as much as they could have been, simply the presence of lockdown restrictions increased perceived pain by one third in patients who already had chronic pain. Now, I say perceived pain intentionally, as patients were also assessed in other ways to determine physical pain, which did not actually change throughout the time frame. The authors are clear that this demonstrates a psychological distress effect of lockdown restrictions on the perception of pain, not actual physical pain.

Patients with chronic pain were also eight times more likely to self-isolate and four times more likely to have a confounding illness during this time than their matched peers who did not have chronic pain.

Patients with chronic pain also experienced tiredness and loneliness twice as often, experienced pain catastrophizing twice as often, anxiety five and a half times as often, and depression nine times as often. They were also ten times more likely to reduce their physical activity.

“As pain catastrophizing was also the strongest predictor of self-perceived increases in pain in the full chronic pain cohort, this points to the need to make this a principle clinical outcome and
target for telemedicine pain management.”

Fallon, et al., 2020

The article has some recommendations for what we can provide remotely to help these patients. COVID-19 has opened the door to telerehab, telehealth, telemedicine, remote services, or whatever you have to call it to be able to bill for it. The reimbursement may not be awesome, but this method of providing care for rehab clinicians is here to stay. Do you know how I know that? Because Seema Verma said so. And if she is committing CMS to stick with it, most everyone else will follow suit. I have some information about telerehab on the resources page if you need more information about how to bring this in to your practice.

So, we know that opioids are NOT the answer to pain. But sometimes it feel like ONLY rehab clinicians actually know that because we still see them prescribed so often. However, this particular articles has some better options:

• Now, like I said above, I’m no expert in chronic pain. But, I do know that education can be very effective in modulating and mitigating pain in certain populations and can be especially effective for patients who experience pain catastrophizing. This education can very easily be delivered through a remote platform.
• Cognitive behavioral therapeutic techniques can also successfully be delivered remotely and are effective in the management of pain catastrophizing.
• And the big one: physical exercise needs to be implemented. Not just to reorient fear-avoidance behaviors and provide neuromuscular re-education, but also to return patients with chronic pain to their prior level of function. Remember, we was above that they were significantly more likely to self-isolate and reduce their physical activity.

Now, obviously we don’t know if these interventions are AS effective when delivered remotely as they are in person, but that sounds like a really great research opportunity for some of my friends out there who primarily manage chronic pain! There is some preliminary evidence that telerehab interventions may be just as effective but we need more evidence.

We highlight the pivotal role of pain catastrophizing and reduced physical activity on the experience of people who live with chronic pain during lockdown conditions. This is significant because it points to potential clinical targets for therapeutic and behavioural interventions during the current, and future, crises.

Fallon, et al., 2020

If you aren’t treating patients remotely, yet, you need to start. Telerehab is the answer for chronic pain, now and in the future. Be ready to move with the rest of us.

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What interventions are you providing remotely for your patients with chronic pain? Tell me about it in the comments!

References

Ambrose KR, Golightly YM. Physical exercise as non-pharmacological treatment of chronic pain: Why and when. BEST PRACT RES CL RH 2015;29(1):120-130.

Fallon, N., Brown, C., Twiddy, H., Brian, E., Fank, B., Nurmikko, T., Stancak, A. (2020). Adverse effects of COVID-19 related lockdown on pain, physical activity, and psychological well-bring in people with chronic pain. medRxiv [made available pre-review]. Retrieved from https://www.medrxiv.org/content/10.1101/2020.06.04.20122564v1.full.pdf

Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017(4).

Piga M, Cangemi I, Mathieu A, Cauli A. Telemedicine for patients with rheumatic diseases: Systematic review and proposal for research agenda. Seminars in Arthritis and Rheumatism 2017;47(1):121-128.

Schütze R, Rees C, Smith A, Slater H, Campbell JM, O’Sullivan P. How Can We Best Reduce Pain Catastrophizing in Adults With Chronic Noncancer Pain? A Systematic Review and MetaAnalysis. J Pain 2018;19(3):233-256.

Westman AE, Boersma K, Leppert J, Linton SJ. Fear-avoidance beliefs, catastrophizing, and distress: a longitudinal subgroup analysis on patients with musculoskeletal pain. Clin J Pain 2011;27(7):567-577.

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