Chronic Primary Pain in the COVID-19 Pandemic

How Uncertainty and Stress Impact on Functioning and Suffering

Ann Meulders; Johan W.S. Vlaeyen; Andrea W.M. Evers; Albère J.A. Köke; Rob J.E.M. Smeets; Jan H.M. Van Zundert; Jeanine M.C.F. Verbunt; Dimitri M.L. Van Ryckeghem


Pain. 2022;163(4):604-609. 

In This Article

Abstract and Introduction


COVID-19 is a highly infectious disease caused by the severe acute respiratory syndrome (SARS)-CoV-2.[40] Owing to the virus' rapid spread across the globe, the World Health Organization (WHO) declared it a pandemic in March 2020. As such, COVID-19 has become a major societal concern, not least because of the large number of infections, the potential severity of the disease, and the mounting death toll worldwide. The COVID-19 pandemic has affected many people's lives and health, with potential long-term consequences. Notably, the detrimental impact of this pandemic is not limited to physical health. For some, the uncertainty and lack of control imposed by this pandemic may lead to increased stress levels, (health) anxiety, and worry, which may further negatively affect mental health and general well-being of both infected and noninfected people.[118] In addition, the restrictions enforced to contain the virus (eg, physical distancing) and to minimize the burden on the healthcare system further disrupt our social lives and prevent people from connecting with each other, causing loneliness, and in turn negatively affecting health and well-being.[6,53]

People suffering from persistent pain represent a vulnerable group at risk to be disproportionately affected by the COVID-19 pandemic and its measures. First, the reduced access to health care and suspension of routine pain management can exacerbate chronic pain disability.[25] Second, uncertainty may prime increased attention to bodily sensations and pain,[29] increasing health anxiety, and catastrophic worry, especially in those who are intolerant of uncertainty or those lacking effective coping strategies (eg, seeking support), some of which are unavailable because of the safety measures.[84] Third, to avoid contamination, physical distancing often boils down to complete self-isolation in individuals with chronic illness; isolation inevitably leads to reduced participation in daily activities and thus increases disability,[75] as well as it decreases health behaviors and reduces physical activity worsening health outcomes.[28] Finally, high-stress situations increase suffering and psychological distress in individuals with chronic pain, eg, in the aftermath of terrorist attacks,[72] as well as reducing self-rated mental health after the first lockdown.[28]

In this review, we propose a conceptual framework describing how COVID-19 may affect modifiable factors resulting in worsened health outcomes and disability in people with chronic pain. We cautiously suggest strategies targeting these modifiable factors and how these can help to guide treatment and reduce the negative impact of the current pandemic. We present a model (Figure 1) outlining how the impact of known risk factors in the development and maintenance of chronic pain may become more pronounced during a pandemic because of increased uncertainty, perceived uncontrollability, COVID-related stress, and paradoxically by contagion-reducing safety behaviors. Furthermore, other precautions to contain the spread of COVID-19 (eg, physical distancing) may compromise resilience factors (eg, positive affect, optimism, and social support), which may hamper daily functioning and participation of people with chronic pain. Finally, this model aims to inspire future research aimed at a better understanding of how to reduce negative long-term effects of the COVID-19 pandemic in people with chronic pain and prevent patients who are still functioning from becoming severely disabled.[51,113]

Figure 1.

Theoretical model showing how risk factors for the development and maintenance of chronic pain disability in daily life and work may be triggered or amplified by uncertainty, uncontrollability, and intensity of COVID-related stress, and these COVID-related factors and safety measures may compromise resilience factors affecting long-term health outcomes such as pain intensity, emotional distress (including, but not limited to, fear, anxiety, sleep disturbance or insomnia, depression, and helplessness), and disability in daily life and work (including domains such as family/home responsibilities, recreation, social activity, occupation, sexual behavior, and self-care).