key: cord-0890308-u24c7wto
authors: Korkut, Sevda; Ülker, Türkan
title: The Effect of Pain Experienced during the COVID-19 Infection on the Fear of Pain and Quality of Life
date: 2021-08-20
journal: Pain Manag Nurs
DOI: 10.1016/j.pmn.2021.08.007
sha: a8dc71a48fb9dd557e00330fc4884ecfe05dc5a2
doc_id: 890308
cord_uid: u24c7wto

PURPOSE: This study was conducted to determine the effect of pain experienced during the COVID-19 infection on the fear of pain and quality of life of individuals. DESIGN: The study was carried out as descriptive, comparative and correlational design. METHODS: Snowball sampling method was used in the research and the data were collected online. A total of 404 individuals participated in the study. The data were collected using the Descriptive Characteristics Questionnaire, Numeric Rating Scale, Fear of Pain Questionnaire-III and The 36-Item Short Form Health Survey Questionnaire. RESULTS: It was determined that 87.1% of the individuals experienced pain during the COVID-19 and the mean intensity of this pain was 6.16±2.75. In addition, 37.1% of the individuals experienced pain for a while after the COVID-19 and the mean intensity of this pain was 3.81±3.00. The individuals who experienced pain during COVID-19 had higher fear of pain and lower quality of life than those who did not experience pain. There was a significant correlation between the severity of pain experienced during COVID-19 with the fear of pain and the quality of life. CONCLUSIONS: According to the results of the study, it can be said that individuals who experienced intense pain during COVID-19 infection have higher fear of pain and lower quality of life. In addition, as the fear of pain increases, the quality of life of individuals decreases. CLINICAL IMPLICATIONS: Negative pain experiences may lead to fear of pain, and this fear of pain may negatively affect the quality of life.

Pain is one of the important symptoms experienced in viral diseases (Widyadharma, Dewi, Wijayanti, & Utami, 2020) . As with many infections, pain has been a common symptom in COVID-19 infection. The virus not only invades the respiratory system, but also causes individuals to experience many pain symptoms such as headache, dizziness, abdominal pain, chest pain, muscle-joint pain by invading different tissues of the body (Weng, Su, & Wang, 2021) .

Pain can develop for many reasons in viral diseases, and many mechanisms are mentioned about this condition. It has been reported that pain develops due to reasons such as skeletal muscle injury in viral diseases or penetration of the virus into the central nervous system. This clinical feature is also believed to be caused by tissue inflammation which will cause the release of inflammatory mediators which will stimulate nociceptors (Widyadharma, Dewi, Wijayanti, & Utami, 2020) . Unfortunately, in some cases, pain is not only seen during the infection process, it may cause the individual to complain of pain after the infection. As a matter of fact, it is reported that the pain symptoms of individuals continue after some infectious diseases (Clauw, Häuser, Cohen, & Fitzcharles, 2020; Moldofsky & Patcai, 2011; Hickie et al., 2006) .

The experience of pain is affected by many factors (Lautenbacher, Peters, Heesen, Scheel, & Kunz, 2017; Potter, Perry, Stockert, & Hall, 2017) . According to the theory in the neurophysiology of pain, the individual's psychological state, anxiety, stress, and fears can activate pain stimuli and lead to the perception of pain (Cimpean & David, 2019) . In other words, negative pain experiences in the past can also open the gate and pain impulses pass through when the gate is open and cause intense pain (Markfelder & Pauli, 2020) . Fear of pain is related to the past painful experiences of the individual, and especially recurrent and unmanageable pain experiences may lead to the development of pain fear (Cimpean & David, 2019) . Accordingly, it can be said that pain and fear are inseparable and pain may lead to fear, and fear may lead to pain by increasing sensitivity to pain. Increase in the level of fear and anxiety may lead to further increase in the level of pain (Olango & Finn, 2014; Kristiansen, 2013) . Moreover, fear of pain is assumed to significantly contribute to the development of chronic pain. A metanalysis has revealed a small but strong association that fear of pain contributes to increased pain perception and this may encourage pain to become chronic (Markfelder & Pauli, 2020) .

Individuals have high levels of fear and stress due to the COVID-19 outbreak (Pakpour & Griffiths, 2020; Polizzi, Lynn, & Perry, 2020; Taylor, et al., 2020) . Although there are studies showing that individuals with COVID-19 experience pain Chow et al., 2020; Guan et al., 2020; Huang et al., 2020; Pan et al., 2020; Zhu et al., 2020; Xu et al., 2020) , there are no studies that evaluate the relationship between fear of pain and quality of life of people after COVID-19 infection. Pain, which is a subjective experience, may negatively affect individuals' the quality of life and cause fear of pain (Potter, Perry, Stockert, & Hall, 2017) . Therefore, this study was conducted to determine the effect of pain experienced during the COVID-19 infection on the fear of pain and quality of life of individuals. The study sought answers to the following questions:

 Is there a difference between those who experienced pain during COVID-19 infection and those who did not in their fear of pain and quality of life?  For persons who experienced pain during COVID-19 infection, is there a correlation between intensity of pain and fear of pain and quality of life?

The study was performed as descriptive, comparative and correlational design.

The research was conducted using an online survey, in April 2021, in Turkey. The research sample was reached by using the snowball sampling method. The country in which the study was conducted consists of seven regions. Therefore, seven participants who had experienced COVID-19 infection were selected initially. The first selected participants were known to the researchers. Each of these participants represented different regions of the country. Each one of them was asked to send the web link of the survey to other people who have had the COVID-19 infection.

Sampling was calculated with Post hoc power analysis. It was applied through G*Power 3.1.9.2 program (Franz, Universitat Kiel, Germany) with 5% type I error with reference to fear of pain scores. Because the power = 0.99 was determined in this analysis, it was decided that the sample size was sufficient and the study was completed with 404 people. Individuals over the age of 18, who had experienced COVID-19 infection and volunteered to participate in the study were included in the scope of the study. Participants with chronic pain before COVID-19 infection were excluded from the study.

The data of the research were collected through the Google Forms. The Google Forms is a cloud-based data management tool used for designing and developing web-based questionnaires. In this method, an automatic Web URL is generated for the survey (Raju & Harinarayana, 2016) . Data were collected by sending this web link to the participants. The request for participating in the web survey was sent via online forums, social networking sites or e-mail. The Google Forms records the respondent data in its spreadsheet. This answers given by the participants to the questionnaires were recorded online to the researchers' account through the site where the form was created.

The data were collected using the Descriptive Characteristics Questionnaire, Numeric Rating Scale, Fear of Pain Questionnaire-III and The 36-Item Short Form Health Survey Questionnaire.

In the form created by the researchers, there were questions about some sociodemographic characteristics of the participants such as age, gender, education level and chronic disease status and the state of experiencing pain during COVID-19 infection.

Scale was developed by Duncan et al in 1989 , Paice et al in 1997 , and Seymour in 1982 its validity and reliability were verified (Wang & Keck, 2004) . It has been used in studies to assess the intensity of pain perceived subjectively and has been found to be reliable and valid.

It is a 10-centimeter scale in which 0 represents no pain and 10 severe pain.

The scale was developed by McNeil and Rainwater to measure the fear and/or anxiety experienced for pain (McNeil & Rainwater, 1998) . The Turkish validity and reliability study of the scale was conducted by Ünver and Turan in 2018. In the validity and reliability study, the Cronbach's alpha reliability coefficient of the scale was 0.93. In this study, the Cronbach's alpha of the scale was found to be 0.95. The scale consists of severe pain, minor pain, and medical pain subscales. There are 10 items in each sub-dimension. The scale is five-point Likert type. The lowest score of the scale is 30 and the highest score is 150. The higher the score obtained from the scale indicates that the fear of pain is also high (Ünver & Turan, 2018) .

The SF-36 questionnaire has been developed to be used in examining the health conditions and quality of life of individuals. It consists of 36 items, which are used to calculate eight subscales: (1) physical functioning, (2) role limitations due to physical problems, (3) the role limitations due to emotional problems, (4) energy/vitality, (5) mental health, (6) social functioning, (7) physical pain, (8) general health. Scores for the SF-36 scales range between 0 and 100, with higher scores indicating a better quality of life (Ware & Gandek, 1998; Ware, 1994) . The Turkish validity and reliability study of SF-36 was conducted in different samples (Bilir Kaya & İçağasıoğlu, 2018; Koçyiğit, Aydemir, Fişek, Ölmez, & Memiş, 1999; Pınar, 1996) . In the current study, the Cronbach's alpha of subscales of SF-36 ranged from 0.70 to 0.92.

Statistical analysis was performed using IBM SPSS Statistics 21.0 (IBM Corp, Armonk, NY, USA). Descriptive statistics were used to introduce the participants' baseline characteristics. The data were presented as as number (n), percentages (%), and mean ± standard deviation values. The Shapiro Wilk's test and Q-Q graphs were used for normality testing. The Mann Whitney U test was employed to examine the distribution of the scores obtained from the scales according to the pain experienced by the participants during COVID-19 infection. Spearman's correlation was performed to test the correlation among continuous variables and scales. p < 0.05 was accepted as significant.

First of all, the study was approved by the Ministry of Health Scientific Research Platform (2021-03-10T21_16_21) and the Ethics Committee of the University (2021/172). In the research link sent to the participants, the purpose of the research was explained firstly and the participants were informed about the research. Participants who wanted to participate in the study were asked to continue the study by selecting the option "I agree to participate in the study".

Of the 404 participants, the majority were not hospitalized (83.7%) and reported pain (87.1%) during COVID-19 infection. The vast majority have experienced multiple sources of pain, including joint, muscle, headache, and back during COVID-19 infection. The severity of this pain was on average 6.16 ± 2.75. In addition, the majority of the participants reported no pain after COVID-19 infection (62.9%) ( 37.1% of the individuals reported pain for a while after the COVID-19 infection and the average intensity of this pain was 3.81 ± 3.00. 76.5% of individuals said they were afraid of getting COVID-19 infection again, and 74.5% were afraid of reliving the pain during COVID-19 (Table 3) .

Individuals' fears of pain and quality of life were compared according to their pain and hospitalization experience during COVID-19 infection. It was determined that individuals who experienced pain during COVID-19 infection had higher fear of pain and lower quality of life than those who did not experience pain. Individuals hospitalized during COVID-19 infection had a lower quality of life (Table 4 ). In addition, the Spearman test showed significant correlation between the intensity of pain experienced during COVID-19 infection with the fear of pain and the quality of life (Table 5 ).

Pain is one of the most common symptoms experienced by a large number of people for a variety of reasons (Meulders & Bennett, 2018; Chou et al., 2016) . As with many infectious diseases, pain has been one of the common symptoms in individuals with COVID-19 infection (Carfi et al., 2020; Weng, Su, & Wang, 2021) . Patients with COVID-19 infection may experince various symptoms, such as fever, dyspnea, cough, headache, muscle pain, sore throat, abdominal pain, and chest pain Chow et al., 2020; Guan et al., 2020; Huang et al., 2020; Pan et al., 2020; Zhu et al., 2020; Xu et al., 2020) . The virus not only invades the respiratory system but also effects other systems in individuals and results in corresponding symptoms, including nervous system (eg, headache), digestive system (eg, abdominal pain), and cardiovascular system (eg, chest pain) Huang et al., 2020 ). An observational study in Wuhan noted that 36.4% of COVID-19 patients with neurological symptoms were dizziness and headache (Mao, 2020) . Guan et al. (2020) found that the common pain symptoms include myalgia or arthralgia (14.9%), sore throat (13.9%), and headache (13.6%). In a systematic analysis, it is specified that the incidence rate is 1.5-61.0% for myalgia/arthralgia, 0.7-47.1% for sore throat, 1.7-33.9% for headache, 1.6-17.7% for chest pain, and 1.9-14.5% for abdominal pain. Different pain reflects the damage of different body systems (Weng, Su, & Wang, 2021) . In present study, it was determined that 87.1% of the individuals experienced pain during the COVID-19 experience, the average intensity of this pain was 6.16 ± 2.75, and they mostly experienced joint, muscle, headache and back pain (Table 3 ). Studies have shown that individuals experience pain in different anatomical regions. This shows that the virus affects many parts of the body. In addition, the pain is a subjective symptom, the individuals have different perceptions of stress, and the pain is affected by the past pain experiences of the people.

Acute viral illnesses often present with organ-specific symptoms in addition to myalgia and fatigue, as noted in outbreaks such as H1N1 and SARS. Results with these infections almost always focus on the immediate response to acute illness and little attention is paid to long-term effects (Clauw, Häuser, Cohen, & Fitzcharles, 2020) . In a study conducted with 22 individuals infected during the SARS epidemic, it was stated that chronic post-SARS syndrome consisting of fatigue, widespread myalgia, depression and non-restorative sleep persists for almost 2 years (Clauw, Häuser, Cohen, & Fitzcharles, 2020; Moldofsky & Patcai, 2011 ). In addition, it was observed that 12% of patients infected with 3 different pathogens such as Ross River virus, Coxiella burnetii and Epstein -Barr virus experienced a postviral pain syndrome up to 12 months after infection (Clauw, Häuser, Cohen, & Fitzcharles, 2020; Hickie et al., 2006) . The presence and severity of somatic symptoms during acute infection is closely related to the subsequent development of chronic fatigue and pain (Clauw, Häuser, Cohen, & Fitzcharles, 2020) . As a matter of fact, in this study, it was determined that 37.1% of the individuals continued to have pain for a while after COVID-19 infection (Table 3) . Subjective experiences as pain are heavily influenced by individual experiences in the previous period of life (Michaelides & Zis, 2019) . Unfortunately, actions and situations related to pain may create fear of pain over time (Meulders & Bennett, 2018; Racine et al., 2012) . Fear of pain may result from an extremely negative interpretation of pain and moreover cause more damage than pain itself (Wang et al., 2018) . In our study, the fear of pain of individuals who experienced pain during COVID-19 infection were found to be significantly higher than those who did not experience pain. In addition, the fear of pain of hospitalized and non-hospitalized individuals were similar (Table 4 ). The intense anxiety and uncertainty experienced during COVID-19 may have caused individuals to feel high levels of pain. These severe pains may have caused the individual to be afraid of this experience and develop fear of pain. Multiple and persistent stressors can aggravate pain even in the absence of viral illnesses.

Fear of pain may affect most activities of daily living with pain avoidance behaviors and cause a misperception of pain intensity (Wang et al., 2018) . Fear of pain has the risk of causing many problems such as chronic pain, depression, and injury (Maeda, Kan, Fujino, & Shibata, 2018) . Increasing anxiety, fear and stress leads to an increase in perceived pain intensity and a decrease in pain tolerance (Michaelides & Zis, 2019) . In this study, 76.5% of individuals said they were afraid of getting COVID-19 infection again, and 74.5% were afraid of feeling pain during COVID-19 (Table 3) . Associative learning about pain can be adapted initially, individuals can prevent pain and potential harm. However, avoiding permanent routines and experiences can negatively affect physical performance, mood, and sense of selfperception (Meulders & Bennett, 2018) . Since fear of pain has a wide scope, it should be taken into account that there are also various biopsychosocial (e.g. genetic, psychological, anthropological, social) components that can lead to pain-related fear (Randall et al., 2017) . In addition, pain has a negative impact on patients' quality of life because it may significantly affect daily living activities and lead to mood disorders (Michaelides & Zis, 2019) . Studies have shown that the quality of life of individuals experiencing pain is negatively affected (Fagerström, Elmståhl, & Wranker, 2020; Luque-Suarez, Martinez-Calderon, & Falla, 2019 ).

In the current study, the individuals who experienced pain during the COVID-19 experience had lower quality of life than those who did not experience pain (Table 4) . Moreover, a negative correlation was found between the fear of pain and the quality of life of the individuals (Table 5 ). In this case, it is estimated that as the fear of pain increases, the quality of life of the individuals decreases and the quality of life in all areas decreases due to the emotional effects of the individuals. In addition, it was determined that the quality of life of individuals who were treated in hospital during COVID-19 infection was generally low.

However, it is difficult to give a definite explanation for this situation. Because both the quality of life and hospitalization are affected by many factors (Soares, Mattos, & Raposo, 2020; Fayers & Machin, 2016) .

Pain can have negative affects on both physical activity and psychological state of patients. While this may seem like a simple process, it is actually very complex. Therefore, relief of pain is the basic requirement of individuals (Meulders & Bennett, 2018; Chou et al., 2016) . The nurse, who has an important role in the care of the patient with pain, should be able to describe the pain behaviors of the individuals in order to provide an effective approach in the control and relief of pain (Potter, Perry, Stockert, & Hall, 2017) .

In stressful diseases such as epidemics, the severity of the pain experienced by individuals may increase. Negative pain experiences may lead to fear of pain, and this fear of pain may negatively affect the quality of life. While explaining pain and management of pain in nursing education, pain due to viral infections and its short and long effects on the individual should be explained. Because nurses should know the effects of pain on the fear of pain and quality of life, and take a role in preventing chronic pain in individuals with appropriate interventions by evaluating the individual well while providing care to the patient. Nurses should be aware that pain itself may affect quality of life and increase fears of pain and suffering in the future.

In future nursing research, it should be investigated with long follow-up studies how long the pain due to viral diseases continues in which anatomical parts of the body, how it affects individuals, and whether it causes chronic pain. In addition, there is a need for future studies on quality of life and it's impact on the individual experiencing chronic pain.

In the sample where the study was carried out, it can be said that individuals who experienced intense pain during COVID-19 infection have higher fear of pain and lower quality of life. In addition, as the fear of pain increases, the quality of life of individuals decreases.

Although individuals from all regions of the country participated in the study, the fact that it was conducted in a single country may limit generalizability. Conducting the study with an online survey is other limitation of our study.

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 1(0.2) * More than one answer is given ** Renal failure, ulcerative colitis, cirrhosis, prostate, autoimmune disease 

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