Effects of the COVID-19 pandemic on chronic pain in Spain: a scoping review

Pandemic impact and adaptation to telehealth in chronic pain treatment providers across two COVID-19 pandemic years

OBJECTIVES

The COVID-19 pandemic has had substantial impacts for both people using pain services and healthcare professionals delivering them. While the effects on service users have been studied, less is known about the effects for service providers. This study aimed to assess the impact of the pandemic on providers and the evolving role of telemedicine in treatment.

DESIGN & METHODS

An electronic survey was distributed to the professional membership of the European Pain Federation (EFIC). The survey evaluated impact and adjustment to the COVID-19 pandemic separately across two pandemic years (March 2020-February 2021 and March 2021 to February 2022) and assessed worry about COVID-19, disruption and adjustment of pain services, and use of telehealth services. The change between the first and second pandemic years and the degree to which telehealth services were adopted was evaluated.

RESULTS

From 149 respondents, 131 (88%) participants provided sufficient data to be included in the analysis. Both providers worry about the pandemic and service disruption decreased significantly from the first to the second year of the pandemic. Prior to the pandemic, only 30% of providers offered telehealth appointments but this increased to 64% and 83%, respectively, in the first and second years of the pandemic.

CONCLUSIONS

Although provider worry and disruption to delivery of pain services decreased during the second year of COVID-19 pandemic, waiting times for appointments continued to lengthen. The pandemic has hastened the adoption of telemedicine in pain services and plans to continue telehealth services seem common.

Cost-utility of a multicomponent intervention for fibromyalgia versus usual care: a pragmatic randomised controlled trial

OBJECTIVE

To perform an economic evaluation on a multicomponent intervention programme for patients with fibromyalgia syndrome compared with usual clinical practice in primary care.

DESIGN

A cost-utility analysis was conducted alongside a pragmatic randomised controlled trial (ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/record/NCT04049006) from a societal perspective, a human capital approach, and a 1-year time horizon.

PATIENTS

Patients diagnosed with fibromyalgia  syndrome from the public health system in south Catalonia, Spain.

METHODS

Crude and adjusted incremental cost- utility ratios were estimated to compare the treatment strategies based on cost estimations (direct medical costs and productivity losses) and quality-adjusted life years. One-way and 2-way deterministic sensitivity analyses were performed.

RESULTS

The final analysed sample comprised 297 individuals, 161 in the intervention group and 136 in the control group. A crude incremental cost-utility ratio of € 1,780.75 and an adjusted ratio of € 851.67 were obtained, indicating that the programme  significantly improved patients' quality of life with a cost-increasing outcome that fell below the cost-effectiveness threshold. The sensitivity analysis  confirmed these findings when  varying large cost components, and showed dominance when increasing session attendance.

CONCLUSION

The proposed multicomponent intervention programme was cost-effective compared with usual care for fibromyalgia, which supports its addition to standard practice in the regional  primary care service.

A network analysis on biopsychosocial factors and pain-related outcomes assessed during a COVID-19 lockdown

Psychological stress, social isolation, physical inactivity, and reduced access to care during lockdowns throughout a pandemic negatively impact pain and function. In the context of the first COVID-19 lockdown in Spain, we aimed to investigate how different biopsychosocial factors influence chiropractic patients' pain-related outcomes and vice-versa. A total of 648 chiropractic patients completed online questionnaires including variables from the following categories: demographics, pain outcomes, pain beliefs, impact of the COVID-19 pandemic, stress/anxiety and self-efficacy. Twenty-eight variables were considered in a cross-sectional network analysis to examine bidirectional associations between biopsychosocial factors and pain outcomes. Subgroup analyses were conducted to estimate differences according to gender and symptom duration. The greatest associations were observed between pain duration and pain evolution during lockdown. Participants' age, pain symptoms' evolution during lockdown, and generalized anxiety were the variables with the strongest influence over the whole network. Negative emotions evoked by the pandemic were indirectly associated with pain outcomes, possibly via pain catastrophizing. The network structure of patients reporting acute pain showed important differences when compared to patients with chronic pain. These findings will contribute to identify which factors explain the deleterious effects of both the pandemic and the restrictions on patients living with pain.

The impact of the COVID-19 pandemic on pain and psychological functioning in young adults with chronic pain

ABSTRACT

Data are equivocal on the consequences of COVID-19 pandemic on pain and well-being for individuals with chronic pain. Furthermore, little is known regarding its impact on the health of young adults with chronic pain. We conducted a longitudinal study to compare pain, psychological functioning, and substance use before and during the pandemic of 196 young adults with chronic pain. Participants aged 18 to 24 years (M = 21.1 years; 79.6% females) reported on pain, anxiety, depression, and substance use before (October 2018-August 2019) and during the pandemic (October 2020-November 2020), in addition to the assessment of COVID-19 exposure and its impact. Before the pandemic, young adults experienced mild-to-moderate pain intensity (M = 3.75, SD = 2.33) and pain interference (M = 3.44, SD = 2.69). Findings were that pain intensity, pain interference, and depression symptoms remained stable during the pandemic. In contrast, anxiety symptoms increased significantly (M = 8.21, SD = 5.84 vs M = 8.89, SD = 5.95, P = 0.04). Tobacco, alcohol, and cannabis use were unchanged. Mixed linear models revealed that COVID-19 exposure and impact were not associated with changes in pain intensity or interference, with female sex associated with increased pain intensity (β = 0.86, P = 0.02) and pain interference (β = 0.87, P = 0.02). Our findings indicated relative stability of pain symptoms experienced by young adults with chronic pain. However, the increases in anxiety highlight the need to facilitate treatment access for mental health services to mitigate downstream impact.

Neuroticism and Conscientiousness Moderate the Effect of Oral Medication Beliefs on Adherence of People with Mental Illness during the Pandemic

Background. After the declaration of the pandemic status in several countries, the continuity of face-to-face visits in psychiatric facilities has been delayed or even interrupted to reduce viral spread. Little is known about the personality factors associated with medication beliefs and adherence amongst individuals with mental illness during the COVID-19 pandemic. This brief report describes a preliminary naturalistic longitudinal study that explored whether the Big Five personality traits prospectively moderate the effects of medication beliefs on changes in adherence during the pandemic for a group of outpatients with psychosis or bipolar disorder. Methods. Thirteen outpatients undergoing routine face-to-face follow-up assessments during the pandemic were included (41 observations overall) and completed the Revised Italian Version of the Ten-Item Personality Inventory, the Beliefs about Medicines Questionnaire, the Morisky Medication Adherence Scale—8-item and the Beck Depression Inventory—II. Results. Participants had stronger concerns about their psychiatric medications rather than beliefs about their necessity, and adherence to medications was generally low. Participants who had more necessity beliefs than concerns had better adherence to medications. People scoring higher in Conscientiousness and Neuroticism traits and more concerned about the medication side effects had poorer adherence. Conclusions. These preliminary data suggest the importance of a careful assessment of the adherence to medications amongst people with psychosis/bipolar disorder during the pandemic. Interventions aimed to improve adherence might focus on patients’ medication beliefs and their Conscientiousness and Neuroticism personality traits.

Interaction Matters: The Effect of Touching the Social Robot PARO on Pain and Stress is Stronger When Turned ON vs. OFF

Social touch between humans, as well as between humans and animals, was previously found to reduce pain and stress. We previously reported that touching a social robot can also induce a reduction in pain ratings. However, it is unclear if the effect that touching a robot has on pain perception is due to its appearance and its pleasant touch, or due to its ability to socially interact with humans. In the current experiment, we aimed to assess the contribution of the interactive quality to pain perception. We assessed the effect of touching the social robot PARO on mild and strong pain ratings and on stress perception, on a total of 60 healthy young participants. The robot either interacted with participants (ON group, n = 30) or was turned off (OFF group, n = 30). Touching the robot induced a decrease in mild pain ratings (compared to baseline) only in the ON group while strong pain ratings decreased similarly in both the ON and the OFF groups. The decrease in mild pain ratings in the ON group was significantly greater in participants with a higher positive perception of the interaction with PARO. We conclude that part of the effect that touching the robot has on pain stems from its interactive features.

Challenges in Utilizing Telehealth for Chronic Pain

Purpose of Review

Chronic pain in the USA has presented with higher prevalence rates among women, older adults, those unemployed, living in poverty, living in rural environments, and adults with public health insurance. The COVID-19 pandemic has heavily played into the biopsychosocial model of pain. Consequently, greater impacts have affected patients with mood disorders, opioid abuse, and chronic pain. Concurrently, telemedicine has become a popular vehicle during the COVID-19 pandemic in continuing to provide quality patient care. The purpose of this article is to review the benefits and challenges related to the delivery of telemedicine for patients with chronic pain.

Recent Findings

The benefits of telemedicine have been examined from patient psychosocial and convenience factors as well in relation to medical practice efficiency. Within chronic pain management, one of telemedicine’s most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions. Challenges also exist in this framework, from lack of physical examination and convenient close therapeutic monitoring and drug screening, to technological and resource cost capabilities of older and disadvantaged chronic pain patients, to barriers in establishing patient-provider rapport. During the COVID-19 pandemic, telehealth services were covered at rates comparable to in-person visits. Health insurance coverage and payment were major barriers for implementation of telemedicine prior to the pandemic. It is difficult to predict ongoing coverage and payment of telehealth services, although the benefits in terms of access and patient satisfaction have clearly been demonstrated.

Summary

While telemedicine has proven to be a very useful tool with a wealth of advantages, the delivery of virtual healthcare for chronic pain poses a set of challenges that will need to be met to ensure the quality and standard of care continue to be upheld.

Home-Based EEG Neurofeedback Intervention for the Management of Chronic Pain

Background

Chronic pain and associated symptoms often cause significant disability and reduced quality of life (QoL). Neurofeedback (NFB) as part of a Brain Computer Interface can help some patients manage chronic pain by normalising maladaptive brain activity measured with electroencephalography (EEG).

Objectives

This study was designed to assess the efficacy and safety of a novel home-based NFB device for managing chronic pain by modifying specific EEG activity.

Methods

A prospective, single-arm, proof-of-concept study was conducted between June 2020 and March 2021 among adults with chronic pain (registered with ClinicalTrials.gov NCT04418362). Axon EEG NFB systems for home use were provided to each, and 32–48 NFB training sessions were completed by the participants over 8-weeks. The primary outcome was self-reported pain. Assessment of central sensitisation, sleep quality, affective symptoms, change in QoL, adverse events during use and EEG correlations with symptoms were secondary outcomes.

Results

Sixteen participants were enrolled. Eleven reported pain relief following NFB training, eight reporting clinically significant improvements. Central sensitisation symptoms improved by a third (p < 0.0001), sleep quality by almost 50% (p < 0.001), anxiety reduced by 40% (p = 0.015), and QoL improved at final follow-up for 13 participants. The majority (69%) of participants who upregulated relative alpha reported improved pain, and those who downregulated relative hi-beta reported improved pain, reduced anxiety and depression scores. There were no adverse events during the trial.

Conclusions

Home-based NFB training is well-tolerated and may provide relief for sufferers of chronic pain and its associated symptoms.

Summary

Axon, a home-based NFB training device, can positively influence pain and associated symptoms in a proportion of people with chronic pain.

From hands-on to remote: Moderators of response to a novel self-management telehealth programme during the COVID-19 pandemic

BACKGROUND

In March 2020, state-wide lockdowns were declared in many countries, including Spain. Citizens were confined to their homes and remotely supported activities were prioritized as an alternative to in-person interactions. Previous data suggest that remote and self-management interventions may be successful at reducing pain and related psychological variables. However, individual factors influencing the effectiveness of these interventions remain to be identified. We aimed to investigate the psychological and motivational factors moderating changes in pain observed in chiropractic patients undertaking a novel telehealth self-management programme.

METHODS

A cohort of 208 patients from a chiropractic teaching clinic was recruited to participate in the study. Patients received telehealth consultations and individualized self-management strategies tailored for their current complaint. They were encouraged to make use of these strategies daily for 2-4 weeks, whilst rating their pain intensity, motivation and adherence. Validated questionnaires were completed online to assess catastrophizing, kinesiophobia and anxiety.

RESULTS

A total of 168 patients completed the first 2 weeks of the programme, experiencing significant reductions in all variables. Kinesiophobia emerged as a key factor influencing pain reduction and moderating the association between motivation and pain relief. In turn, adherence to the programme was associated with lower pain intensity, although moderated by the degree of motivation.

CONCLUSIONS

In the context of COVID-19, when introducing remote and self-management strategies, pain cognitions and motivational factors should be taken into consideration to foster adherence and yield better pain outcomes.

Impact of the COVID-19 pandemic on patients with chronic pain in Germany: associations with expectations and control beliefs

Background

While the COVID‐19 pandemic is affecting people's well‐being worldwide, it may place a particularly high burden on people with chronic pain, as pain is known to be influenced by societal and psychological conditions.

Methods

In this observational study, we conducted telephone interviews with 196 patients with chronic pain to assess the impact of the pandemic on various aspects of their pain and everyday life. The initial interviews were conducted between April and May 2020 and were followed up by a second interview between August and December 2020.

Results

A substantial percentage of patients (39% at the first and 32% at the second interview) reported an increase in pain intensity due to the pandemic. Exploratory analyses revealed that patients who already suffered from greater pain and who experienced greater restrictions due to the pandemic were more likely to express pain worsening. Psychological factors such as negative expectations about the development of their pain and pain treatment and a high external locus of control were also associated with increases in pain.

Conclusions

These findings illustrate the complexity of chronic pain, suggesting that not only the impact of the pandemic on various areas of life but also the severity of the pain‐symptoms themselves and psychological factors influence the course of patients' symptoms during the pandemic.

Significance

This study underlines the importance of psychosocial factors in chronic pain and demonstrates that the societal and psychological impact of the COVID‐19 pandemic can affect patients' pain and their ability to cope with it. The extent to which patients experience pain aggravation seems to interact with other psychological factors such as pain expectations and control beliefs.

OUP accepted manuscript

Objectives

Societal and health system pressures associated with the coronavirus disease 2019 (COVID-19) pandemic exacerbated the burden of chronic pain and limited access to pain management services for many. Online multidisciplinary pain programs offer an effective and scalable treatment option, but have not been evaluated within the context of COVID-19. This study aimed to investigate the uptake and effectiveness of the Reboot Online chronic pain program before and during the first year of the COVID-19 pandemic.

Methods

Retrospective cohort analyses were conducted on routine service users of the Reboot Online program, comparing those who commenced the program during the COVID-19 pandemic (March 2020–March 2021), to those prior to the pandemic (April 2017–March 2020). Outcomes included the number of course registrations; commencements; completion rates; and measures of pain severity, interference, self-efficacy, pain-related disability, and distress.

Results

Data from 2,585 course users were included (n = 1138 pre-COVID-19 and n = 1,447 during-COVID-19). There was a 287% increase in monthly course registrations during COVID-19, relative to previously. Users were younger, and more likely to reside in a metropolitan area during COVID-19, but initial symptom severity was comparable. Course adherence and effectiveness were similar before and during COVID-19, with moderate effect size improvements in clinical outcomes post-treatment (g = 0.23–0.55).

Discussion

Uptake of an online chronic pain management program substantially increased during the COVID-19 pandemic. Program adherence and effectiveness were similar pre- and during-COVID. These findings support the effectiveness and scalability of online chronic pain management programs to meet increasing demand.

[Impact of the COVID-19 pandemic on patient-reported patient safety in Primary Care]

OBJECTIVE

To evaluate the impact of the changes introduced in response to the pandemic on patient-reported patient safety in Primary Care.

DESIGN

Prospective observational panel study (health center) based on two cross-sectional surveys.

SETTING

29 Primary Health Care centers from three Spanish health regions (Mallorca, Catalunya Central and Camp de Tarragona).

PARTICIPANTS

Random sample of patients visiting their centers before (n=2199 patients) and during the pandemic (n=1955 patients) MAIN MEASUREMENTS: We used the PREOS-PC questionnaire, a validated instrument which assesses patient-reported patient safety in Primary Care. We compared mean scores of the "experiences of errors" and "harm" scales in both periods, and built multilevel regression analyzes to study the variations in patient and center characteristics associated with worse levels of safety. A qualitative (content) analysis of patients' experiences during the pandemic was also performed.

RESULTS

The "experiences of errors" and "harm" scales scores significantly worsened during the COVID-19 period (92.65 to 88.81 (Cohen's d=0.27); and 96.92 to 79.97 (d=0.70), respectively). Patient and center characteristics associated to worsened scores were: women, people with a lower educational level, worse health status, more years assigned to the center, and health region.

CONCLUSIONS

During the pandemic, a perceptible worsening in patient safety perceived by patients treated in Primary Care has been observed, which has differentially affected patients according to their sociodemographic characteristics or health center profiles.

Effects of COVID-19 Social Distancing Measures in Individuals with Chronic Pain Living in Spain in the Late Stages of the Lockdown

Social distancing measures during the lockdown have had a negative impact on chronic pain patients' function. Research, however, has only focused on the early stages of the first lockdowns. The aim of this study was to improve the understanding of the effects of COVID-19 social distancing measures on individuals with chronic pain living in Spain during the late stages of the lockdown. A group of 361 adults with pain participated in this study. They responded to an online survey and provided information on sociodemographic issues, pain, fatigue, perceived health, and quality of life. The data showed that most participants suffered moderate to severe pain and interferences with pain treatment and an increase in pain intensity during the lockdown. Most participants also informed us that fatigue had worsened during the lockdown (62%). Importantly, females with lower monthly family income and lower education have been found to be associated with greater levels of pain and fatigue. Despite this, participants perceived themselves as having good health and good quality of life. The findings from this study can be used to inform policy and specific responses for future COVID-19 waves and future pandemics where social distancing measures must be implemented.

Pain catastrophizing mediates rapid benefits of accessing in-person chiropractic care during the COVID-19 lockdown

Background

In March 2020, the COVID‐19 pandemic forced the Spanish government to declare a state of emergency. A stringent lockdown was enforced, restricting access to healthcare services, including chiropractic. Reduced access to care provision in combination with psychological stress, social isolation and physical inactivity during the lockdown were shown to negatively influence pain conditions. However, data on strategies to mitigate the impact of the pandemic on these conditions are lacking.

Methods

Upon easing of restrictions in May 2020, 51 chiropractic clinics throughout Spain pseudo‐randomly invited patients, recruiting a total of 385 participants. During a 14‐day period, participants were exposed to in‐person chiropractic care in either one (n = 177) or multiple encounters (n = 109) or to no care (n = 99). The effects of access to chiropractic care on patients’ pain‐related and psychological outcomes were assessed online through validated self‐reported questionnaires before and after the period of care. Coprimary outcomes included pain intensity, pain interference and pain cognitions.

Results

When comparing to participants without access to care, pain intensity and interference were significantly decreased at follow‐up, irrespective of the number of encounters. Kinesiophobia was also significantly reduced at follow‐up, though only after multiple encounters. The relationship between fear of movement, changes in pain intensity and interference was mediated by catastrophizing.

Conclusion

Access to in‐person chiropractic care may provide pain relief, associated with reductions in interference and pain cognitions. Prioritizing in‐person care for patients with maladaptive pain cognitions may help dampen the detrimental consequences of the pandemic on physical and psychological well‐being.

European knowledge alliance for innovative measures in prevention of work-related musculoskeletal pain disorders (Prevent4Work Project): protocol for an international mixed-methods longitudinal study

INTRODUCTION

Work-related musculoskeletal (MSK) pain is a highly prevalent condition and one of the main contributors to disability and loss of work capacity. Current approaches to the management and prevention of work-related MSK pain do not consistently integrate current evidence-based knowledge and seem to be outdated. The Prevent4Work (P4W) Project aims to collect and spread evidence-based information to improve the management and prevention of work-related MSK pain. P4W will longitudinally investigate (1) risk factors associated with the prevalence of work-related MSK pain, (2) predictive factors for new events of work-related MSK pain in the short term and (3) the modification of pain beliefs after participating in evidence-based e-learning courses.

METHODS AND ANALYSIS

This project employs a mixed-methods design with international cohorts of workers from Spain, Italy and Denmark. All participants will be assessed using self-reported variables at baseline (ie, cross-sectional design) with follow-up after 3 and 6 months (ie, prospective-predictive design). Throughout the first phase (0-3 months), all participants will be offered to self-enrol in e-learning courses on work-related MSK pain. Changes in pain beliefs (if any) will be assessed. The dataset will include sociodemographic characteristics, physical and psychological job demands, lifestyle-related factors, MSK pain history and pain beliefs. At baseline, all participants will additionally complete the P4W questionnaire developed to detect populations at high risk of suffering work-related MSK pain.Descriptive statistics, binary logistic regression, and analysis of variance will be used to identify the significant factors that influence the history of work-related MSK pain, evaluate the short-term prediction capacity of the P4W questionnaire, and investigate whether workers' participation in e-learning courses will modify their pain beliefs.

ETHICS AND DISSEMINATION

The study received ethical approval from the Ethical Committee of San Jorge University (USJ011-19/20). The results will be made available via peer-reviewed publications, international conferences and P4W official channels.