What is the therapeutic management for myalgia (muscle pain) and neuropathy (nerve damage) post COVID-19 (coronavirus disease 2019)?

Therapeutic Management for Myalgia and Neuropathy Post COVID-19

For post-COVID myalgia and neuropathy, a multimodal approach combining NSAIDs as first-line therapy, careful use of steroids, and telemedicine-based rehabilitation with pacing strategies is recommended to reduce symptoms and improve quality of life. 1, 2

Pharmacological Management

First-Line Therapy

• NSAIDs are recommended as first-line treatment for post-COVID myalgia and should be continued with regular monitoring for adverse effects 1, 2
• Patients should report any mild fever or new myalgia promptly while using NSAIDs 1

Second-Line Therapy

• Steroids should be used with caution due to their potential for immune suppression and increased risk of viral infections 1, 2
• When steroids are necessary, use the lowest effective dose with preference for dexamethasone or betamethasone over other corticosteroids 1, 2
• Evaluate the risk-benefit ratio carefully before administering steroid injections for localized pain 1

Neuropathic Pain Management

• For patients with confirmed neuropathic component (approximately 19% of post-COVID musculoskeletal pain cases), consider specific neuropathic pain medications 3
• Patients with history of hospitalization and pulmonary involvement during acute COVID-19 have higher risk of developing neuropathic pain and may require more aggressive management 3

Non-Pharmacological Approaches

Physical Activity Management

• Implement carefully structured physical activity programs with pacing strategies to avoid post-exertional symptom exacerbation 2
• Avoid aggressive exercise programs as they may worsen symptoms in 75% of long COVID patients 2
• Consider online self-management programs that integrate components of exercise, sleep hygiene, pacing, and healthy lifestyle 1

Telemedicine Support

• Use telemedicine as the first approach for most cases to evaluate, triage, and manage pain 1, 2
• Virtual consultations provide continuity of care while minimizing infection risk 1
• Telemedicine platforms can facilitate multidisciplinary interactions for comprehensive pain management 1

Traditional Chinese Medicine Approaches (Optional)

• For patients interested in complementary approaches, consider breathing relaxation training, mindfulness training, or Tai Chi, which have shown benefit for post-COVID symptoms 1

Special Considerations

Indications for In-Person Evaluation

• Consider in-person evaluation for cases with significant functional decline, intractable pain unresponsive to initial management, or signs of complex regional pain syndrome 2
• Screen patients for COVID-19 symptoms before in-person visits 1

High-Risk Patients

• Patients with history of hospitalization and longer hospital stays during acute COVID-19 infection have higher risk of developing neuropathic pain 3
• The prevalence of peripheral neuropathy and myopathy in post-COVID patients is approximately 56.3%, with higher rates among those who had severe respiratory symptoms 4

Monitoring and Follow-up

• Monitor for development of small-fiber neuropathy, which may underlie autonomic dysfunction and paresthesia in some long COVID patients 5
• Regularly assess pain severity using standardized tools like Visual Analog Scale (VAS) 3
• Screen for neuropathic component using tools such as Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) in patients with persistent pain 3

Pitfalls and Caveats

• Avoid hydroxychloroquine for treating any stage of SARS-CoV-2 infection as it provides no additional benefit and may worsen prognosis 1
• Be aware that fatigue is the most common musculoskeletal complication of long COVID, often accompanied by myalgia and arthralgia 6
• Steroid injections may increase the risk of viral infections and should be used with caution 1, 2
• Aggressive exercise programs should be avoided as they may worsen symptoms in patients with post-exertional malaise 2