The year 2020 has been the year of the SARS Covid-19 pandemic. It has been and still is an unprecedented situation that has transformed the lives of people all over the world. Besides the physical suffering it has inflicted, it has also affected the emotional, social, financial, and spiritual lives of people. The prolonged lockdown and the new norms which includes social distancing, has changed the very lifestyle and social behaviour of people. People, especially, the aged ones are wary of visiting their healthcare provider for health issues unless it is an emergency or a life-threatening situation.
One segment of the population that has been affected by the pandemics’ do’s and don’ts is the patient suffering with chronic pain. During the lockdown and subsequent unlock period, all routine pain consultations and interventional procedures for pain were cancelled. Besides, patients also felt that it was better to bear pain than visit a hospital and contract the dreaded virus. Moreover, the treatment of pain, be it opioids for cancer or steroids for chronic pain, has the potential for adversely affecting the health of the patient by causing suppression of the immune response and predisposing them to the risk of contracting the virus.
Untreated pain can be disastrous and can cause not only physical suffering but could also cause anxiety and depression and affect the very quality of life in these people. Delaying treatment can worsen the underlying pain condition and, therefore, it is very important that they consult a pain specialist if not physically, at least virtually. Although treatment of pain is a fundamental human right, yet, unfortunately during the pandemic, it has been considered a non-urgent treatment and it had to take a backseat. This is because all routine consultations and procedures for pain management were cancelled as healthcare resources were diverted to management of Covid patients either in the wards or in the ICUs. Moreover, factors such as social isolation, fear and anxiety related to the pandemic, new habits cultivated to prevent contracting the virus etc has adversely affected the mental health of many people. Since pain can affect the mind and vice versa, all these new norms have only played havoc with the physical and emotional health of these people.
The elderly population are particularly vulnerable to the effects of chronic pain during the pandemic. Many of them have age-related degenerative disease of the spine which includes both cervical as well as low back problems, osteoarthritis of the joints especially the knees, as well as pain due to other neurological disorders like Parkinson’s disease, neuralgias, post-stroke pain etc. Nearly 88% of the elderly have comorbidities like heart disease, diabetes, kidney related problems, depression and even cancer which makes them particularly vulnerable to contracting the Covid-19 virus. They also tend to get anxious and worried because of the pandemic. This, in turn, makes them hesitant to step out of the house to visit a hospital and, often have to bear their pain and disability out of sheer helplessness.
It is not just the elderly who are victims of pain during the pandemic. The young and middle-aged officegoer who is now working from home are also susceptible. Since they work long hours on their computers and laptops, often in makeshift conditions and positions, they land up with myofascial pain involving the neck, shoulders, arms and back. This is because their work ergonomics is not right. Added to this is the stress of doing household tasks, taking care of their children’s online classes, and minding them when they are free and avoiding other distractions while working from home. Many a time, they find all this difficult to cope with and this can further compound the pain and make it worse. Lack of exercise and restricted physical activity often adds to the problem. Sleep is often disturbed, and the sufferer tends to get irritable and short-tempered. Myofascial pain, as seen in these patients, can be quite incapacitating sometimes and often does not easily get relieved by taking analgesics. The number of such patients consulting orthopaedic doctors for their aches and pains have considerably increased during the pandemic.
So, what is the solution for these patients?
In the light of the restrictions imposed by the pandemic, telemedicine and video consultations for health problems have gained popularity as it safe for both the patient as well as the healthcare provider. Telemedicine is the practice of caring for patients remotely using telecommunication technology, where both the healthcare provider and the patient are not physically present with each other. However, there is a two-way interaction between the doctor and patient and is a valuable tool to provide healthcare services. Psychiatrists and clinical psychologists were already using it even before the pandemic began. This platform is now being increasingly used by other medical specialists as well.
Since pain is a biopsychosocial phenomenon, a holistic management of chronic pain needs to involve other specialities also like the physiotherapist and clinical psychologist as well besides the pain physician. Nowadays, both clinical psychologists and physiotherapists are resorting to telemedicine to provide consultations, psychological therapy like counselling and even physical therapy (telerehabilitation).
Can the pain physician also provide services through telemedicine?
Telemedicine can be useful for obtaining the history of the patient and this can be got in great detail by just talking to the patient. We can view the patient, the site of pain, movement of the affected area etc. We can also review all the old records as well as the investigations. The main drawback of a video-consultation is that physical examination for tenderness, spasm and certain tests that need to be done are not possible. It is often the physical examination that helps in clinching the diagnosis and unless the right diagnosis is made, the right treatment cannot be administered.
However, most of the time, pain consultations can be done virtually using telemedicine. This is especially so with cancer pain where a lot of information regarding the cause of pain can be gleaned by talking to the patient. Also, in cancer pain, the sheet anchor of pain management is the WHO pain ladder in which most of the medications can be administered orally based on the type and severity of pain and this can be explained in detail by teleconsultation. An online prescription can also be uploaded which the patient can immediately receive.
Many types of acute pain too, such as a strained back or a pulled ligament or muscle, can also be addressed through video-consultation and these are also very amenable to oral analgesics and other non-drug therapies like ice, immobilization, rest etc.
But while treating certain types of chronic pain like shoulder pain, pain due to spine disease or nerve diseases, a physical/neurological examination is necessary to clinch the diagnosis and administer the right treatment. In such cases, a pure teleconsultation may not be the best practice to reach the correct diagnosis. So, while a vast majority of patients with pain can be treated online during this pandemic which may suit the patient as well as the healthcare provider, there is a segment of patients with chronic pain in whom a physical consultation and examination may be necessary to provide relief from pain and suffering. In such a situation, the patient, the pain specialist, and the healthcare facility must take all due precautions so that safety to all the stakeholders is ensured and the patient is benefited by the treatment. Since the last couple of months, it has been observed that more and more patients are visiting clinics and hospitals for pain management.