Possibilities of the nurse’s action in front of the effects of social isolation on the patient with chronic pain: integrative review

Carvalho, Fracielle Rozendo de; Silva, Silvia Sidnéia da; Melo, Alexandra de Souza; Medeiros, Priscila de; Pereira do-Carmo, Lilian Sheila de Melo; Silveira, Belisa Vieira da

doi:10.5935/2595-0118.20230073-en

Brasil

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REVIEW ARTICLE • BrJP 6 (3) • Jul-Sep 2023 • https://doi.org/10.5935/2595-0118.20230073-en linkcopy

Possibilities of the nurse’s action in front of the effects of social isolation on the patient with chronic pain: integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

HIGHLIGHTS

• This study reinforced the impact of isolation on patients with chronic pain, which affected functionality and quality of life.
• The role of nurses as an integral part of caring for these patients with telehealth was also reinforced.
• This research opted for an integrative review in order to get to know the current panorama of nurses’ scientific production on the care of patients with CP.

ABSTRACT

BACKGROUND AND OBJECTIVES: Social isolation, as experienced in the context of the COVID-19 pandemic, has triggered psychological and neuropsychiatric problems; these conditions can aggravate chronic pain crises. It is also known that social relationships play an important role in pain and emotions. Chronic pain (CP) is a challenging disease, especially in terms of its multifaceted mechanisms and treatment. Thus, the aim of this study was to provide a better understanding of nurses’ work with patients with CP and the impact of social isolation resulting from the COVID-19 pandemic.

CONTENTS: This is an integrative review, carried out in the Virtual Health Library (Biblioteca Virtual em Saúde - BVS) and Medline via Pubmed databases of the National Library of Medicine. To select the articles, the following descriptors in health sciences and Medical Subject Headings (DeCS/MeSh) were considered: “Social isolation”, “Chronic pain”, “COVID-19”, “Nursing care” and “Patient care planning”, with their synonyms/alternative terms. A total of 45,703 articles were found; based on the inclusion and exclusion criteria, 27 articles were selected. This study hoped to answer the following guiding questions: “how do nurses work with individuals with CP during the social isolation caused by COVID-19?”, and “what are the consequences of social isolation for this population due to the COVID-19 pandemic?”. Of the 27 articles, most were published in North America and Europe, and three in Brazil. The population most affected by CP are seniors, women and people on low incomes. In terms of profession, only three of the 27 articles were published by nurses. The data was discussed considering the work of nurses with individuals with CP, especially through telehealth, as well as the impacts that people with CP have suffered from social isolation during the coronavirus pandemic.

CONCLUSION: There is a significant gap in the literature regarding the role of nurses with individuals with CP in social isolation, suggesting the need for further studies in this area, mainly at the national level. From the studies found, it was evidenced that individuals who live with CP have the multiple dimensions of the human being affected, but that in this moment of social isolation due to the COVID-19 pandemic, the worst commitment was the emotional one. Thus, with the continued rise of telehealth and the possibility of future pandemics, it is recommended to move the existing guidelines for the formal development of telehealth competencies towards relevant curricular content and clinical experience for all nursing programs.

Keywords Chronic pain; COVID-19; Nursing care; Patient care planning; Social isolation

Database (DeCS/MeSh)	No. of articles found
Medline	5,103
LILACS	744
BDENF- Nursing	39
APA PsycINFO	2
Pubmed	39,815
Total	45,703

Descriptors	Definition
Social isolation	The separation of individuals or groups resulting in the lack of or minimizing of social contact and/or communication. This separation may be accomplished by physical separation, by social barriers and by psychological mechanisms. In the latter, there may be interaction but no real communication.
Chronic pain	Aching sensation that persists for more than a few months. It may or may not be associated with trauma or disease, and may persist after the initial injury has healed. Its localization, character, and timing are more vague than with acute pain.
COVID-19	A viral disorder generally characterized by high fever; cough; dyspnea; chills; persistent tremor; muscle pain; headache; sore throat; a new loss of taste and/or smell (ageusia and anosmia) and other symptoms of a viral pneumonia. In severe cases, a myriad of coagulopathy associated symptoms often correlating with COVID-19 severity is seen (e.g., blood coagulation; thrombosis; acute respiratory distress syndrome; seizures; heart attack; stroke; multiple cerebral infarctions; kidney failure; catastrophic antiphospholipid antibody syndrome and/or disseminated intravascular coagulation). In younger patients, rare inflammatory syndromes are sometimes associated with COVID-19 (e.g., atypical Kawasaki syndrome; toxic shock syndrome; pediatric multisystem inflammatory disease; and cytokine storm syndrome). A coronavirus, SARS-CoV-2, in the genus betacoronavirus is the causative agent.
Nursing care	Care given to patients by nursing service personnel.
Patient care planning	Usually a written medical and nursing care program designed for a particular patient.

Authors	Country	Profession
Dassieu et al.¹²	Canada	Doctors, Sociologist, Psychologist, Pharmacoepidemiologist, Mathematician and Engineers
Hruschak et al.¹⁸	United States	Doctors and Psychologists
Serrano-Ibáñez et al.¹⁹	Spain	Psychologists
Rau et al.²⁰	Germany	Doctors
de Moraes et al.²²	Brazil	Nurses, Doctor and Computer scientist
Puntillo et al.²³	Italy	Doctors, Physiotherapists and Dentists
Karos et al.²⁴	United States	Psychologists
Amja et al.²⁵	Canada	Psychologist and Dentists
Consonni et al.²⁶	Italy	Psychologist and Doctors
Eccleston et al.²⁷	United States	Psychologists, Doctors and Nurse
Bannon et al.²⁸	United States	Psychologists and Senior Biostatistician
Yamada et al.²⁹	Japan	Doctor
Richardson and Kundu³⁰	United States	Professor of pediatric psychology and doctor
Miró et al.³¹	Spain	Psychologists and Doctor
Cankurtaran et al.³²	Turkey	Doctors
Murphy and Latif ³³	United States	Doctors
Shanthanna et al.³⁴	North America and Europe	Doctors and psychologists
Iglesias-López, García-Isidoro and Castellanos-Sánchez³⁵	Spain	Physiotherapists and pharmacobiologist chemist
Sowicz et al.³⁶	United States	Nurses
Mun et al.³⁷	United States	Doctor and Psychologists
Marinangeli, Giarratano and Petrini³⁸	Italy	Doctors
Schwab et al.³⁹	Germany	Doctors
Jiang et al.⁴⁰	China	Doctors
Alonso-Matielo et al.⁴¹	Brazil	Biomedical, Biochemical Pharmacist, Biologist and Software Developer
Smyrnioti et al.⁴²	Greece	Doctors and Dentist
Antunes et al.⁴³	Brazil	Nurses
Yu, Kioskli and McCracken⁴⁴	Europe	Psychologists

References	Objectives	Methodological outline	Main results	Level of evidence
12.	To comprehend the experiences and challenges of people living with CP during the COVID-19 pandemic in Canada.	Expert opinion. Scenario: end of the first wave of COVID-19 and the beginning of the reopening of the workplaces in Canada. Participants: 22 individuals living with CP across the country.	The COVID-19 pandemic has revealed and intensified pre-existing disparities and challenges among people living with CP, in terms of material resources, psychosocial status, social support and access to care.	VII (weak)
18.	To examine the severity and interference of pain among individuals with CPduring an initial phase of social distancing mandates and to identify characteristics of the individuals who were most affected.	Cross-sectional research study. Setting: academic medical center in Boston, Massachusetts, between April 28, 2020 and May 22, 2020. Participants: 150 patients with fibromyalgia, chronic back and post-surgical pain.	Social distancing was associated with greater pain severity and interference and demographic, socioeconomic and psychosocial factors were associated with greater pain severity and interference during social distancing.	IV (moderate)
19.	To investigate the contribution of life changes due to coronavirus to emotional distress in individuals diagnosed with CP due to central sensitization (CS) and to test whether the associations between pain level and sensitization were independent or mediated by emotional disturbances.	Cross-sectional study. Setting: Online survey with Spanish CD associations. Participants: 477 people aged between 18 and 65; only 363 had chronic primary pain related to CS: fibromyalgia (78%), generalized CP (15%) and low back pain (7%).	The study identified an association between the psychological effects in patients with central sensitivity syndrome and changes in lifestyle due to confinement.	IV (moderate)
20.	To examine how CP changed in schoolchildren before and during the COVID-19 pandemic, and how changes in CP were related to changes in psychological well-being and experiences related to COVID-19.	Longitudinal observational. Scenario: German schools Participants: 777 German schoolchildren (aged 9 to 17).	The study showed that during the COVID-19 pandemic, the prevalence of CP in school-age children decreased overall. However, stressful situations and pre-existing vulnerabilities in psychological well-being can promote the development of CP during the pandemic.	II (strong)
25.	To identify participants’ experiences of living with CP during the COVID-19 pandemic.	Prognostic study/qualitative research. Scenario: Semi-structured interview with Quebec residents living with CP during the COVID-19 pandemic. Participants: 22 patients with chronic low back pain (10 men and 12 women).	The results showed that feeling socially isolated made the patients feel as if they had lost their purpose in life, and with this they experienced high levels of stress which, more often than not, aggravated their CP.	VI (weak)
26.	To investigate the impact of COVID-19-related suffering on CP patients, highlighting the effects of changes in individual habits and the reconfiguration of public health on physical and psychological health.	Cross-sectional observational study. Scenario: COVID-19 pandemic Participants: A total of 80 adults, 25 patients with small fiber neuropathy, 42 patients with migraine and 13 healthy patients’ family members.	Patients with small fiber neuropathy and chronic migraine had a lower quality of life, poorer physical and mental health and a more catastrophizing attitude towards pain than the patients’ healthy relatives.	IV (moderate)
27.	To guide those trying to make the rapid transition to remote service with technology.	Narrative review. Scenario: COVID-19 pandemic Participants: not described.	With drastic changes in the provision of pain treatment services to minimize the risks of exposure to the virus, for example elective medical procedures, face-to-face care and multidisciplinary services are being limited, while telehealth, digital treatment and virtual reality are expanding.	VII (weak)
28.	To assess the improvement in social isolation during treatment and whether these improvements were responsible for improvements in emotional and physical functioning.	Randomized clinical trial. Scenario: Outpatient clinic for 10-week mind-body physical activity program. Participants: 82 patients with heterogeneous chronic musculoskeletal pain.	The study found that interventions for social isolation resulted in significant improvements in self-reported pain intensity and emotional and physical function.	II (strong)
29.	To detect changes in biopsychosocial and socioeconomic factors before and after the COVID-19 outbreak.	Cross-sectional study. Scenario: COVID-19 pandemic Participants: 25,482 people aged between 15 and 79 (12,809 women and 12,673 men).	The study shows an increase in the frequency and intensity of pain and the prevalence of CP in the Japanese population. With increased social isolation due to the pandemic, pain may be more common in depressed patients.	IV (moderate)
30.	To analyze the impact of the pandemic on the treatment of CP and address the types of strategies that can be implemented to overcome the limitations imposed on the provision of care.	Type of study: narrative review. Scenario: COVID-19 pandemic Participants: Children, adolescents and caregivers (parents).	Providing health care through telehealth has allowed pediatric CP clinics to increase patient and staff safety and ensure continuity of care.	VII (weak)
31.	To improve understanding of the effects of COVID-19 social distancing measures on individuals with CP living in Spain during the final stages of lockdown.	Cross-sectional study. Scenario: COVID-19 pandemic and the social distancing measures tolerated in Spain. Participants: 361 adults with CP.	The study found increased pain intensity during the final stages of the blockade among individuals with CP in Spain, and women with lower monthly household incomes and lower levels of education were associated with higher levels of pain and fatigue.	Nível IV (moderate)
32.	To assess the level of fear and anxiety by COVID-19 and examine its effect on disease severity, sleep quality and mood in Fibromyalgia patients compared to the control group.	Cross-sectional study. Scenario: Physical medicine and rehabilitation outpatient clinic Participants: 62, 31 patients with FM and 31 in the control group.	The study showed that COVID-19 anxiety and fear scores were higher in fibromyalgia patients than in healthy patients. In fibromyalgia patients, COVID-19 fear and anxiety were associated with symptom severity, sleep quality and anxiety level.	IV (moderate)
33.	Analyze existing literature to develop consensus recommendations for pain management during the current COVID-19 pandemic.	Narrative review. Scenario: pain management during the COVID-19 pandemic. Participants: Not described.	The Study presents options to mitigate the spread of the pandemic by limiting the adverse impact of pain and suffering in patients with CP.	VII (weak)
34.	Highlighting potentially significant for consideration clinical and empirical research in the months and years to come.	Narrative review. Scenario: North America and Europe Participants: 10 pain specialists, psychologists and researchers.	The study showed that telemedicine is a good way of preventing “missed appointments”, helping to classify an individual case as urgent or emergent and to treat emotional disorders related to the pandemic.	VII (weak)
35.	To determine the impact of confinement on the pain, quality of life and public health of the Spanish population due to the COVID-19 pandemic.	Observational study. Scenario: Follow-up in April and May 2020 during the peak of the first wave of the coronavirus. Participants: 225 participants with CP.	The presence of pain in individuals subjected to confinement was persistent, with intensity and frequency varying based on age, gender, physical activity and work situation. In any of these conditions, the quality of life of the subjects in lockdown was severely affected.	IV (moderate)
36.	Explore the changing role among pain management pain management nurses who provided care during the the COVID-19.	Descriptive qualitative. Scenario: various practice settings. Participants: 18 registered nurses who speak English.	The study showed the many different experiences of pain management nurses and how their roles have been affected by the pandemic.	V (weak)
37.	Examine the initial impact of COVID-19 on pain severity, pain interference and control of CP; and variables associated changes perceived in pain intensity and pain interference.	Observational cross-sectional study. Scenario: United States via Amazon’s Mechanical Turk platform. Participants: 1,453 adults with CP.	The study showed that the impacts of the pandemic on CP vary according to the social disadvantage/advantage, often exacerbating underlying health inequality in disadvantaged populations.	IV (moderate)
38.	Appeal not to neglect the continuity of care of patients who have chronic diseases, including those who use opioids.	Narrative review. Scenario: Pandemic of COVID-19. Participants: not described.	The authors particularly highlighted the danger of neglecting the treatment of CP. Inadequate analgesic treatment can lead to self-medication, adverse events and even treatment discontinuation.	Nível VII (weak)
39.	To evaluate changes in the perception of pain and disability and changes in the emotional and social aspects of pain in patients with endometriosis during social isolation or quarantine due to the pandemic.	Observational and cross-sectional study. Scenario: COVID-19 pandemic in Germany, April 2020. Participants: 285 women over the age of 18 years old with a confirmed diagnosis of endometriosis.	The study showed that physical pain and disability, on the one hand, and the experience of emotional and social pain, on the other, were differentially affected by the emerging emotional, social and health restrictions related to the SARS-CoV-2 pandemic.	IV (moderate)
41.	To provide an overview of the implications of COVID-19 in acute and CP states.	Type of study: Narrative Review. Scenario: The COVID-19 pandemic. Participants: not described.	Results recognizing that COVID-19 induces CP and exacerbates pre-existing CP are of utmost importance for a better understanding of the disease. In addition, immediate targeted treatment, as well as strategies to reduce the potential impact of CP, should be strongly encouraged.	Nível VII (weak)
42.	To assess the perceived impact of the first wave of the pandemic on pain, quality of life and access to care during the first strict lockdown in Greece.	Type of study: cross-sectional study. Scenario: Pain Management Unit of Attikon University Hospital - Greece - during the period of the first 42-day austere lockdown due to the COVID-19 pandemic. Participants: 101 patients with CP.	The impact of the initial lockdown on social and professional life was apparently more severe for pain patients than the pandemic itself.	IV (moderate)
43.	To describe the implementation of the Integrator Program for patients with chronic postoperative pain.	A descriptive study, in the form of an experience report. Scenario: Pain clinic at the National Institute of Traumatology and Orthopedics in Rio de Janeiro Participants: orthopedic post-surgical patients who are experiencing CP after 3 to 12 months.	The study described the four phases of the program, with interprofessional supervision focused on improving the quality of life, anxiety, depression and catastrophic thinking of patients with CP.	V (weak)
44.	To investigate psychological functioning in the context of COVID-19, including fear and avoidance, specifically its association with daily functioning and the role of psychological flexibility in people with CP.	Cross-sectional study. Scenario: social media and online platforms designed to support people with pain, such as Pain Support. Participants: 555 adults with CP.	The study shows that pandemic stressors (fear, avoidance, anxiety, depression) impact the quality of life and increase the sensation of pain in patients with CP.	IV (moderate)

Identification No.	Thematic focus	Articles	Main findings
1º	Impacts that people with CP have suffered from social isolation during the COVID-19 pandemic.	A¹²_, A¹⁸_, A¹⁹_, A²⁰_, A²²_, A²³_, A²⁴_, A²⁵_, A²⁶_, A²⁷_, A²⁸_, A²⁹_, A³⁰_, A³¹_, A³²_, A³³_, A³⁴_, A³⁵_, A³⁶_, A³⁷_, A³⁸_, A³⁹_.	Disconnection and feelings of loneliness, change in routine such as physiotherapy, acupuncture, physical activities, stress, uncertainty or worry about the future, sleep problems, feelings of insecurity, negative thoughts, fear of being infected with coronavirus, anxiety, mood swings, depression, excessive opioid use.
2º	Chronic pain as a consequence of COVID-19.	A²³_, A²⁷_, A³⁶_, A⁴⁰_, A⁴¹_, A⁴²_.	The physiology of the disease, along with pain, can be neglected because it is considered a low priority compared to other complications. The presence of pain can affect recovery from COVID-19.
3º	Telehealth as a possibility for nurses and other professions to work with patients with chronic pain.	A²²_, A²³_, A²⁷_, A³³_, A³⁴_, A⁴³_, A⁴⁴_.	Online resources can disseminate pain education and can develop online training programs on pain self-management for professionals, pain patients and relevant staff.

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