Case of the Month #24: Long Covid by Dr Angeline Lee

Self-management
Advice about self-management of common symptoms is available on the Your Covid Recovery (https://www.yourcovidrecovery.nhs.uk) and NHSinform (https://www.nhsinform.scot/long-term-effects-of-covid-19-long-covid) websites, both of which provide patient information leaflets developed with patient and public involvement and multiple organisations in England and Wales and Scotland. 

There are no pain specific sections on these sites, and advice on pain management is listed under joint and muscle problems or headaches and is mainly focused on keeping moving and pacing. Both sites do not specifically advise any analgesic agent or therapy and advise patients to contact primary care or pharmacy services for further advice if this is insufficient.

Pharmacological agents
NICE does not recommend any specific pharmacological intervention for long Covid.
There is insufficient information to conclude whether over-the-counter vitamins and supplements are effective for long Covid.

A 48-patient observational cohort study demonstrated potential benefit of amitriptyline for use in headache after long Covid, [10] fitting with the nociplastic/neuropathic pattern theorised to cause headache in long Covid. 

Multidisciplinary rehabilitation
NICE recommends a multidisciplinary approach to guide rehabilitation including biopsychosocial aspects of management. This is similar to many pain management programmes and this is an area where pain clinicians can provide particular expertise to support development of these programmes at a community level. Many applications and platforms have been developed to encourage people to monitor their progress with rehabilitation, including the Your Covid recovery app mentioned in an earlier section.

Pain interventions
There is no guidance or recommendation for any specific pain intervention to manage pain arising from long Covid. Longitudinal studies such as PHOSP-Covid [11] are collecting information about long Covid patients for further investigation into possible treatment targets and more information about the natural history of the condition.

The International Association for the Study of Pain (IASP) have developed a resource for long Covid on their website (https://www.iasp-pain.org/resources/topics/covid-19-and-pain/) which presents research related to long Covid and a virtual educational series for long Covid.

Other considerations
Many patients with long Covid have serious difficulties accessing care and support for their illness. [12] It may be worthwhile for pain clinicians to have an awareness of their local long Covid pathways to rehabilitation and recovery to support patients in navigating these complex systems.

As specialist clinicians we play an important role in listening to patients and validating their condition, acknowledging uncertainties and offering continuity of care. Many long Covid patients have waited many months to access primary care level long Covid services and perhaps longer to attend pain clinic, all the while suffering with their symptoms and experiencing rejection from the healthcare system. [12] Even if we may not be able to directly treat long Covid, a little kindness can go a long way.