Musculoskeletal pain and physical health status among confirmed COVID-19 patients of Bangladesh

Since December 2019, an outbreak of COVID19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began at Wuhan, China and is now a global threatening pandemic1. Since then, the spread of covid-19 has increased exponentially, with the World Health Organization has declared pandemic on 11 March 20202. As of 24 April 2021, more than 145 million cases and more than 3 million deaths had been reported worldwide3. COVID19 cases are also increasing day by day. According to the Directorate General of Health Services (DGHS) of Ministry of Health and Family Welfare of Government of Bangladesh more than seven hundred forty-two thousand patients with COVID-19 are identified as confirmed cases and more than five hundred deaths (as of 24 April, 2021) across the country4. Severe acute respiratory illness with fever and respiratory symptoms, such as cough and shortness of breath, comprise the Article Info Abstract

COVID-19 pandemic is now a great headache for the world population. Respiratory symptoms are the main presentation of COVID-19. However, musculoskeletal pain, headache, loss of taste and smell sense, and neurological manifestations may occur. Identification of patterns of musculoskeletal pain, fatigue and physical health status in COVID-19 is crucial. In this cross sectional study, a total 380 individuals with COVID-19 were recruited from the population following selection criteria. Pain varied widely in hip, neck, leg and calf muscles, back and spine, shoulder, arms and hand, and other parts of the body among the respondents. Inconstant, among respondents of younger age group (aged ≤50 year), 37.59% had moderate pain, 6.77% had severe pain, 13.91% had mild pain, and 41.17% had no pain. On the other hand, among older respondents (aged >50 year) 47.37% had moderate pain, 25.44% had severe pain, 13.15% had mild pain, and 14.03% had no pain. The differences between two groups was statistically significant (p<0.05). However, there was no difference in frequency of pain between males and females. Those respondents who had pain was reported having physical health worse than the average compared to that of those who had no pain.
working case definition, used to select people for viral testing. This strategy captures typical symptomatic presentation, but imperfectly identifies unusual manifestations, such as patients without respiratory symptoms or only very mild symptoms. One widely cited modeling study concluded that up to 86% of cases might have been missed in China 3 , and reports of patients with unusual presenting symptoms are rising worldwide. However, afebrile non-respiratory symptoms are also noted as important presenting features in patients with covid19 confirmed by real time polymerase chain reaction (RT-PCR).
According to Centre for disease control (CDC) of United States 5 headache, muscle ache, repeated shaking chills and loss of taste and smell may be presenting symptoms for COVID-19. Likewise, other viral fever, body ache is associated with COVID-19. But, we do not know which region or muscles group or joints are mostly involved in COVID-19. For example, bone breaking low back pain is associated in dengue. Although, muscle pain or body ache is prevailed in COVID-19, but which region of the body and or the limbs are predominantly affected is not well known. Patterns of involvement in the musculoskeletal system is yet to be unveiled. Moreover, untreated acute pain may turn into chronic pain -a complex and challenging condition 6 . The effectiveness of physical conditioning as part of a return to work strategy in reducing sick leave for workers with major illness compared to usual care 7 . Identification of patterns of musculoskeletal involvement in COVID-19 is crucial, because without knowing the scenario appropriate measures such as treatment and medical rehabilitation may not be taken in time and may be resulted with chronic pain and disability. There is no such data published available among Bangladeshi population, so far our knowledge. Keeping this gray area of knowledge, it is warranted to investigate the patterns of musculoskeletal pain and physical health status among Bangladeshi patients with COVID-19. Therefore, we plan to conduct a cross sectional study for assessment of pain and health status of COVID-19 patients across the country. The general objective of the study was to investigate patterns of musculoskeletal involvement among patients with COVID-19. The specific objectives of the study were (i) to investigate the pattern of musculoskeletal system involvement, and (ii) to assess pain and physical functioning among individuals infected with SARS-CoV-2.

Methodology
This cross sectional study was conducted in the Department of Physical Medicine and Rehabilitation at Bangabandhu Sheikh Mujib Medical University, funded by the Bangladesh Medical Research Council (BMRC) after approval from the national review committee of BMRC, bearing Ref No BMRC/Revenue-Grant/2019-2020/753(1-31) dated 26 June 2020. Participants were selected irrespective of age, sex, socioeconomic status, from those patients tested positive for SARS-CoV-2 in RT-PCR test across the country. We approached to 386 individuals with RT-PCR positive for SARS-CoV-2 for the telephonic interview for this study between October to December 2020. The response rate was 98.45% (380 out of 386 individuals). Any individual tested positive for COVID-19 having cognitive impairment and hearing problem; and the individual who were not able to communicate in Bengali were excluded from the study. Among the remain 6 individuals, 2 (0.5%) denied to be enrolled in this study and the rest of 4 (1.03%) was excluded from the study due to cognitive impairment. Finally, a total 380 individuals with COVID-19 were recruited from the population following selection criteria. Non-randomized sampling method was considered to recruit the participants considering all the available telephone numbers for the study population accessed from different RT-PCR lab of the government of the people's republic of Bangladesh. The survey was conducted using pre structured interviewer administered questionnaire. Cognitive ability of the responded was assessed by brief cognitive rating scale (BCRS) 8 . To assess musculoskeletal (MSK) pain intensity visual analogue scale (VAS, 0-10 cm) was considered 9 . Validated Bangla version of short form-12 V2 (SF-12v2) survey instrument 10 was used to assess physical global health. Telephonic interview was conducted for this survey which took about 20-25 minutes for each interview. Participants' phone numbers were collected from the RT-PCR tests result sheet of directorate general of health services. To assess the patterns of musculoskeletal involvement, data was collected by obtaining presenting symptoms, and meticulous history of pain. Pre-existence of any known rheumatic disorder was noted specifically and were excluded from the study. All the data was compiled and sorted properly and the numerical data were analyzed statistically by using Statistical Package for Social Scientists (SPSS-22.0). The results were expressed as percentage and mean±SD. Comparison of proportions was made with chi-square tests. Comparison of ordinal variables was made with Wilcoxon rank-sum tests. P <0.05 was considered as the level of significance.

Results
In this telephonic survey consisting 380 respondents, males were found more frequently (65.53%) infected with SARS-CoV-2. Majority (70%) of the participants were aged 50 years or younger, and respondents older than 50 was 30%. Majority (76.58%) of the respondents were married, 15.79% unmarried, and others (divorced/widowed) was 7.63%. Majority (66.05%) of the respondents had normal body weight, 30.53% were over-weight, 2.89% were obese, and 0.5% was under-weight. Among all respondents, 18.42% were homemaker, 16.84% retired personnel, 15% businessman, 13.95% healthcare workers, 12.37% students, 10.53% bankers, 5.26% administrative workers, 3.18% garments workers, 2.37% members of law-enforcing agencies, and others were 1.31%%. Majority of the respondents (50.26%) were from upper-middle income family, 26.84% from lower-middle income family, 17.37% from high income family, and only 5.53% were from low income family (Table I).  (Table II).   Pain varied widely in hip, neck, leg and calf muscles, back and spine, shoulder, arms and hand, and other parts of the body among confirmed COVID-19 study respondents. Among musculoskeletal system, the most frequent involved joint was hip joint (20.53%). Among all cases, 15.26% had moderate and 5% had severe hip pain. Neck pain was found in 9.21% of cases and moderate pain was reported in 6.84%, and severe pain 2.10% of cases. Moreover, 5.26% cases had leg and calf muscle pain, 5% back and spine pain, 1.58% shoulder, 1.05% arms and hands, and 5.78% had pain in others region. Among all respondents, 16.05% had headache of which majority had mild to moderate headache (7.63%, and 6.57% respectively, and 1.84% had severe headache. Additionally, 1.58% had pain in the eyes. The differences between the pain of various parts of the body were statistically significant (p<0.05) (Table III).
Physical health was measured by Validated Bangla version of short form-12 V2 (SF-12v2) survey instrument. About 49.21% respondents had both MSK pain, and physical health worse than the average, whereas, 19.21% had physical health worse than the average but had no pain. The difference between two variables was significant (P<0.05) (Table IV).
bp value was obtained from chi-square test.

Discussion
This study found older respondents suffered more from all severity (mild, moderate and severe) of pain compared to young age group. Another study found similar findings. They found clinical manifestations of muscle pain caused by COVID-19 were more likely to be experienced by adult patients rather than pediatric patients 11 . As older patients are commonly involved in osteoarthritis arthritis, polymiositis etc., they can have pain symptoms more compared to young people. With each passing year, human aging triggers a decline in cognitive abilities. Diet, exercise, lifestyle, and co-morbidities are factors that accelerate a person's biological age (hypertension, diabetes, obesity). Changes in the hematopoietic stem cell (HSC) pool lead to the loss of function in both the innate and adaptive immune systems as people age.
This study found among 380 participants, majority were males (65.53%) infected with COVID-19. The enhancing mortality rate from COVID-19 for males found (2.4 times) higher than females also found by another study 12 . The explanations for the sex differences in COVID-19 are perhaps multifaceted including variations in immune response, higher incidence of pre-existing disease, biological differences between the sexes such as high levels of androgens in men, differences in lifestyle such as smoking habits as well as differences in underlying comorbidities 13,14,15 .
Most frequent symptoms were found respiratory clusters symptoms including fever, cough, rhinorrhea and breathlessness (76.05%) followed by musculoskeletal pain (48.42%), headache (16.05%) and abdominal pain in 0.5% of a p value obtained from chi-square test. Physical health status was measured using SF-12v2.
cases. Another literature reported the clinical symptoms at the onset of illness in patients with COVID-19, in which fever was the most common symptom (98%), followed by cough (76%), dyspnea (55%), muscle pain or fatigue (44%), and headache (8%) 16 , which is similar to this study finding.
Among different types of pain, this study reveals that joint pain found among 22.63% males and 13.15% females. Rest complained of bone pain or pain in the muscles. Majority of the male and female respondents suffered from headache (22.89%) followed by hip pain (21.84%). According to another study 17 , patients with SARS Cov-2 also reported myalgia (49.3-60.9%), headache (35.4-55.8%), sore throat (12.5-23.2%), chest pain (10.4%), and abdominal pain (3.5%). Similar result found in a literature review 18 , the most common musculoskeletal manifestation found by them was myalgia (48 studies; 80%).
However, about 1 in every 2 confirmed COVID-19 individuals who had MSK pain was reported having physical health worse than the average. We didn't find any such data in the literature to compare with our findings.

Conclusion
This telemedicine based cross-sectional study was conducted among adults to assess the musculoskeletal pain within the context of COVID-19. Among the respondents, older age group suffered more with pain compared to younger age group. According to intensity of pain, participants from all age group suffered more from moderate pain. Across the marital status, all groups (unmarried, married and others) mentioned about moderate pain. Among musculoskeletal system, the reported involvement of hip joint was highest (one-fifth) and next category was neck. More than fifteen percent respondents complained about mild to moderate headache. To address this issue urgently pain rehabilitation intervention should be designed for COVID-19 infected patients. Additionally, post COVID follow up research is recommended.