Fibromyalgia and Chronic Fatigue Syndrome in the Age of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which leads to the condition known as coronavirus disease 2019 (COVID-19), is unlike anything that we, as a society, have seen in our lifetime. The COVID-19 pandemic will forever serve as a historical marker. With more than 10.5 million documented infected cases globally and more than 500,000 deaths in a short period of time, SARS-CoV-2 has left a lasting impact on our global society in unprecedented ways.

It has been demonstrated that clinical outcomes of COVID-19 are significantly worse in persons with advanced age and those with “traditional” medical comorbidities (cardiovascular disease, pulmonary disease, diabetes, malignancy, and immunosuppression). But what about the ever-increasing group of people in our society, many of whom do not have “traditional” medical comorbidities, who suffer chronically from pain, fatigue, and functional decline? We are referring to patients with fibromyalgia (FM) and chronic fatigue syndrome (CFS): 2 conditions that, although medically distinct, share a common pathophysiological etiology: central sensitization (CS).3, 4, 5, 6

Fibromyalgia is a chronic centralized pain-sensitivity disorder characterized by diffuse, migratory, waxing, and waning pain; fatigue; sleep disturbance; mood symptoms; and many other somatic complaints. At present, the estimated prevalence of FM ranges from 2% to 8% of the US population. Statistically, approximately 1 of every 12 people whom you encounter has FM. Stated yet another way, based on current US census data, estimating a US population of 330,000,000 people, 8% (the upper estimate of FM prevalence) of the US population would equal 26,400,000 people: more than the entire population of the state of Florida.

Chronic fatigue syndrome is a condition characterized by chronic fatigue, lasting at least 6 months, that impairs one’s ability to perform daily activities; demonstrates postexertional malaise and unrefreshed sleep; and exhibits either cognitive impairment or orthostatic intolerance. According to the Institute of Medicine (IOM), although approximately 2.5 million Americans (just under the entire population of the city of Chicago) are diagnosed with CFS, it is estimated that 84% to 91% of persons suffering from CFS are currently undiagnosed.

Based on our clinical experience, we suspect this cohort (patients with FM or CFS) to be an extremely vulnerable population in the setting of COVID-19. First, this cohort is by no means exempt from SARS-CoV-2 infection, sharing the same concerns we all have living through these uncertain times.

Second, it is increasingly acknowledged that stressors (whether physical, mental, emotional, or financial) directly and negatively affect the underlying process of CS, which, in turn, worsens symptoms. As a review, CS is the pathophysiological process underlying many different conditions in which structural, functional, and chemical changes in the central nervous system lead to alterations in how the brain and spinal cord process pain and other sensory stimuli.,, These maladaptive processing changes—in conjunction with neuroplastic changes in the central and peripheral nervous systems, hypothalamic-pituitary-adrenal axis changes, sympathetic nervous system hyperactivity, and endogenous opioid system hyperactivity—collectively cascade into developing chronic symptoms and conditions. The additional COVID-19–associated stressors are likely to affect the underlying CS negatively, leading to worsening symptoms in persons with FM and CFS. This potential impact should be further investigated in well-designed prospective studies.

Third, given the highly comorbid nature of mood disorders in patients with FM or CFS, we fear that this pandemic will have detrimental impact on mood. Further limbic-system dysregulation in centrally sensitized patients can intensify symptoms of depression and anxiety acutely. Furthermore, for many of these patients, who already experience significant psychosocial difficulties, further mood dysregulation—as a result of pandemic-associated stressors—could lead to increased suicidal ideations, a trend that is already being seen during the COVID-19 pandemic in the general population, with an exponential rise in national suicide hotline calls.

Fourth, it is widely known that the financial and societal impact associated with conditions such as FM and CFS are staggering. With predicted worsening of symptoms, we foresee greater health care utilization, direct medical expenses, indirect societal costs, and further loss of productivity. In the age of COVID-19, in which layoffs, furloughs, and financial uncertainties are all around us, the majority of these patients are not in a position to “weather this storm.”

This brings us to the ultimate question: What can we offer to help stave off these predicted outcomes? Patients with chronic medical conditions need routine checkins; patients with FM or CFS should be treated no differently. We recommend routine follow-up visits, whether done virtually (telehealth options) or in person. These visits can be performed by any member of the health care team and should be time-limited, focused, and scheduled regularly. These encounters will allow for assessing current symptoms, adherence to medication regimens, and the presence of any red-flag concerns. Furthermore, these encounters will help to foster a supportive and healing environment, given that patients routinely tell us that “being heard” and “acknowledged” are extremely therapeutic. As such, for patients with FM or CFS, we recommend simply reaching out, offering support, and not allowing isolation during these uncertain times.

In addition, health care professionals should take the opportunity to further reinforce the utility of effective nonpharmacologic treatment options.3, 4, 5, 6, Nonpharmacologic treatment recommendations should include graded exercise, healthy lifestyle, meditation and meditative movement activities (tai chi and yoga), mindfulness activities, paced diaphragmatic breathing, supportive counseling, cognitive behavioral therapy, biofeedback therapy, sleep hygiene, and ongoing patient education. Given the physical distancing challenges during the pandemic, it should be noted that many of these therapeutic modalities are available digitially (online and app-based offerings). Patients should be made aware of these convenient options, encouraged to participate, and appropriate clinical referrals should be facilitated.

In summary, we are in the midst of an unprecedented pandemic. We can only speculate on the long-term effects and implications of COVID-19. Among persons with FM and CFS, we anticipate the consequences of pandemic-associated stressors, isolation, and uncertainties to further dysregulate the underlying CS. Consequently, the health of these people could be profoundly and negatively affected. In the midst of everything, please do not overlook this vulnerable group.