Athena Knight, who served nearly 20 years in the Army, has undergone multiple surgeries for injuries related to her military service. As a result, she has had to cope with chronic pain for many years. She also struggles with debilitating migraines, and suffers from post-traumatic stress disorder, having been inside the Pentagon during the 9/11 terrorist attack.

Until the pandemic hit, she had been able to manage her pain with physical therapy, acupuncture, meditation, electro-stimulation, non-opioid medications and — for PTSD — in-person counseling. The coronavirus disrupted those strategies for her and many others.

“My pain got worse,” says Knight, 44, who lives in Silver Spring, Md., and who left active duty for the National Guard in 2005 before retiring in 2016. “It got worse every day.”

First, surgery scheduled on her shoulder was postponed. Then, one by one, her other appointments were canceled. She couldn’t get physical therapy or acupuncture, and — because many providers initially didn’t do telemedicine — her trauma therapist halted their sessions.

“I really went backwards in my recovery,” she says. “It was also mentally draining, since I also was trying to deal with my PTSD and couldn’t see my therapist. It’s been a very painful year.”

About 50 million American adults suffer from chronic pain, which is among the most frequent conditions prompting people to seek medical help, according to the Centers for Disease Control and Prevention and other research. It often results from injury, surgery or long-term diseases such as arthritis or autoimmune disorders, among others. Chronic pain can seriously impair someone’s ability to work, sleep and manage other routine functions of daily life, such as getting dressed, cooking, driving and shopping. Many also suffer from depression and anxiety.

“Chronic pain can be incredibly burdensome,” says Linda Porter, director of the Office of Pain Policy at the National Institute of Neurological Disorders and Stroke. “It seems to have become a bigger problem during covid than before covid. Isolation makes your pain worse. People couldn’t get where they needed to go for care. Also, the pain cycle often includes depression and anxiety and all of this taken together has really, really affected peoples’ lives.”

Research conducted before the pandemic has found that social isolation exacerbates chronic pain for many people.

“It is an underappreciated aspect of chronic pain,” says Sean Mackey, professor of anesthesiology, perioperative and pain medicine at the Stanford University Medical Center and one of the study authors. “We lose sight of the fact that we are social creatures by nature. We want to make medicine so much about the structure and function of the person. But all of it is influenced by our social connectedness.

“Historically, [my] field has been driven by a biological model: find the source of pain and eliminate it. That hasn’t worked well. We tend to think all we need to do is figure out where the problem is — the back, spine or leg — and treat it, but it’s so much more complicated than that.”

A voluntary online survey conducted by the American Chronic Pain Association, an international and peer support organization, among more than 1,000 of its members found that nearly half of the respondents reported that both their pain and stress had increased during the past year. More than one-third said they felt depressed. Many also described feeling isolated, and said they have been exercising less.

“All of these emotions are normal for people with chronic pain, but [the pandemic] only increased those feelings, making it even harder to cope,” says Penney Cowan, founder and chief executive of the group. “Everything has been shut down and people have had to stay at home, which only increases stress.”

Many people, for example, find swimming helpful but “with the pandemic, swimming — as well as acupuncture, biofeedback and massage — were suddenly gone from their tool-bag of pain management,” she says. “Once you break that routine, it’s so hard to get back into it. People just sit there and think about their pain — and the more they think about it, the more pain they feel.”

Gone, too, were such incentives as social occasions.

“It’s easy to just get down in the chair or bed, and not want to move because it hurts,” says Jacqueline Winfield Fincher, immediate past president of the American College of Physicians. “But it’s basic human psychology that when you have something to look forward to, you have a goal that motivates you to want to get better. But it’s been very hard this year because there have been no goals, no motivation.”

Fincher, an internist and primary care physician who practices in Thomson, Ga., near Augusta, says that in her small rural town, social structure revolves around civic organizations and churches. For her patients, the loss of those activities “has been really tough and made all their medical problems worse, including pain,” she says.

“We have a wonderful YMCA that holds classes that cater to our older population, the only place where they can work out, and it’s been closed. Everything has been shut down for a year, and we’ve seen people deteriorate in physical function as a result.”

This hasn’t been true for everyone. For certain patients, pandemic effects have underscored their resilience. Mackey has found some of his patients have been doing better — sleeping more and feeling less fatigued — probably because they are spending more time at home. Also, many are married and living with family, thus escaping the debilitating impact of social isolation, he says.

“I think it has to do with social buffering,” he says. “The vast majority of our patients are married, and have family members around them. The people living by themselves and disconnected from others, who don’t have a social pod or group, are having a worse time of it than before. The pandemic brings out extremes. We’ve seen both.”

Probably the single most important action a pain patient can take right now is to get a vaccination to protect against covid-19, the disease caused by the coronavirus. “Vaccination is key because it’s going to help them re-engage with other people, friends and society sooner,” Mackey says.

The ACPA has a guide to managing chronic pain, and will put patients in touch with a chronic pain support group, many of them meeting via videoconferencing.

Knight is now fully vaccinated. She underwent the long delayed surgery on her shoulder last summer, and has resumed in-person therapies. Her pain is under control again.

“Not having treatments for more than a year really hurt my body,” she says. “I am feeling much better now. But I definitely don’t want to go through anything like that again. Ever.”