How to manage myofascial pain in patients with COVID-19 (Coronavirus disease 2019)?

Management of Myofascial Pain in COVID-19 Patients

NSAIDs should be used as first-line pharmacological treatment for myofascial pain in COVID-19 patients, with careful monitoring and avoidance of aggressive exercise programs that can worsen symptoms in the majority of patients. 1, 2

Pharmacological Management

First-Line Treatment

• Initiate NSAIDs as the primary pharmacological intervention for COVID-19-related myofascial pain, with regular monitoring for adverse effects 1, 2
• Instruct patients to report any new fever or worsening myalgia promptly while on NSAIDs 1
• For acute symptom management during active COVID-19 infection, paracetamol is preferred over NSAIDs when treating fever and associated symptoms 3

Steroid Considerations

• Exercise extreme caution with corticosteroids due to immune suppression risks and potential for worsening viral infections 1, 2
• If steroids are deemed necessary, use the lowest effective dose with preference for dexamethasone or betamethasone over methylprednisolone 1, 2
• Carefully evaluate the risk-benefit ratio before administering steroid injections for localized pain, as they may increase viral infection risk 1, 2

Opioid Use (End-Stage/Severe Cases)

• For severe, distressing symptoms in end-of-life care, consider morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as needed, with concomitant antiemetic and stimulant laxative 3

Non-Pharmacological Approaches

Physical Activity Management

• Implement carefully structured, paced physical activity programs rather than aggressive exercise regimens 1, 2
• Avoid aggressive exercise programs entirely, as they worsen symptoms in 75% of long COVID patients with post-exertional malaise 1, 2
• Use pacing strategies to prevent post-exertional symptom exacerbation 1, 2

Telemedicine-First Approach

• Utilize telemedicine as the primary method for evaluation, triage, and ongoing management 1, 2, 4
• Virtual consultations provide continuity of care while minimizing infection transmission risk 1, 2
• Telemedicine platforms facilitate multidisciplinary pain management interactions 1

Complementary Therapies

• Consider breathing relaxation training, mindfulness training, or Tai Chi for patients interested in complementary approaches 1
• Online self-management programs integrating exercise, sleep hygiene, pacing, and healthy lifestyle modifications can be beneficial 1

Interventional Techniques

• Both dry needling and wet needling (trigger point injections with lidocaine) can be effective for myofascial pain in long COVID patients, providing both short- and long-term therapeutic benefits 5

When to Transition to In-Person Care

Reserve in-person evaluation for specific high-risk scenarios: 1, 2

• Significant functional decline unresponsive to remote management
• Intractable pain not responding to initial pharmacological interventions
• Signs suggesting complex regional pain syndrome development
• Always screen patients for active COVID-19 symptoms before any in-person visit 1, 2

Critical Pitfalls to Avoid

• Never use hydroxychloroquine for any stage of SARS-CoV-2 infection or post-COVID myofascial pain, as it provides no benefit and may worsen prognosis 1
• Do not recommend aggressive exercise or rehabilitation programs without careful pacing strategies 1, 2
• Avoid using antipyretics solely to reduce body temperature during acute infection 3
• Do not overlook the potential for neuropathic pain components, which occur in approximately 42% of post-COVID pain patients 6

Monitoring and Follow-Up

• Recognize that myofascial pain often worsens in patients with pre-existing arthralgia or myalgia after COVID-19 infection 6
• Monitor for anxiety and depression, which commonly increase during social isolation and can aggravate pain conditions 4
• Assess quality of life regularly, as musculoskeletal symptoms significantly impact physical function, social function, and general health perception 6