Pain, And Mental Health Features Before and During COVID-19 Pandemic Social Isolation in Brazil

Background: The COVID-19 pandemic and social isolation measure has influenced the behavior and health of worldwide populations. The goal of this study was to investi-gate features related to pain, and mental health impact due to COVID-19 social isolation before and during the outbreak in Brazil and its mains macro-regions, which have cli-mates, cultures, and economic differences. Methods: This is an observational cross-sectional study through an online, validated, self-administered questionnaire (PEF-COVID19). The Brazilian general population, age ≥ 18 years was invited to participate from 21th April until May 3rd 2020. T-test for independent samples and Chi-square tests were used to compare Brazil and different macro-regions (S, southern; SE southeastern; and NE, northeastern regions), before and during the pandemic, p˂0.05. Results: A total of 1,977 participants filled the survey and 1,848 were includ -ed. Eighty percent of the included participants were in social isolation. In general, the self-related pain before and during the COVID-19 pandemic, mainly in the head and neck area increased in the SE region during the pandemic and the highest levels of self-related anxiety and stress (8-10) increased significantly in a similar way between the 3 mains macro-regions (~10% to 34% and ~14 to 30%, respectively). Conclusions: The COVID-19 pandemic strongly influenced the levels of anxiety and stress increased in Brazil and its main macro-regions. The increase in pain mainly influenced the inhabitants of SE region. These results can be used to create measures, as home-based exercise programs, to avoid the harm of sedentary behaviors and mental health impact during and after the pandemic.


Introduction
The necessity of being confined at home as a consequence of the outbreak of COVID-19 caused great involvement and concerns worldwide, changing drastically people daily life and quality of life [1], the economy and the nations' health systems, especially during the first wave of the pandemic. As a consequence of the Social Isolation (SI), a negative impact in the general health due to sedentary behaviors [2][3][4][5][6], pain [6,7] and lead to psychological conditions, such as anxiety and stress [6,8,9] would be possibly expected. The study of SI impact has been investigated on pain conditions and mental health. A longitudinal study about SI in people seeking treatment for pain management investigated the SI interference on pain and provided evidence that individuals with higher levels of SI status presented greater impact on pain levels and decreased physical function [10]. Another study investigated whether SI predicts the clinical outcomes of disability, anxiety, depression and pain in people with low back pain [11].
Emotional support, to participate in social activities, and satisfaction are inherent to human beings [10] and negative social experiences can induce profound effect on our emotional wellbeing [12]; loneliness on a daily basis, shows an up regulation of pro-inflammatory response genes, which may contribute to the risk of inflammatory diseases in individuals who experience chronically high levels of subjective SI [13]. The degree of SI can induce a higher or lower prevalence of physical or mental health problems [12]. Considering that the first wave of COVID-19 caused great public concern, because the population experienced the fear of the unknown, the fear of death and the amount of daily information about the pandemic "numbers", the aim of this study was to use the validated questionnaire "Physical exercise level before and during social isolation" (PEF-COVID19) [14], to identify in Brazil and its mains macro-regions, the changes in the level of pain and psychological impact as stress and anxiety during the first wave of COVID-19 outbreak. Our hypothesis was that COVID-19 lockdown will result in major levels of self-related pain, anxiety and stress.

Materials And Methods
A self-administered questionnaire delivered through the e-mail and social media was conducted in this observational cross-

Sample
Brazilian population over 18 years old was invited to participate of this study. The responders who agreed to participate, after an explanation of the consent form in the beginning of the survey, with ≥18 years old, were included. At any time, the responder could give up concluding the survey without any penalty or constraints.
Brazilians were divided according to the macro-region where they lived during the survey application. Survey. The questionnaire PEF-COVID19 was created to assess the levels of physical exercise and psychological impact of general population before and during the social isolation due to the COVID-19 pandemic. The psychometric properties of this instrument were previously described [14], and it reports the validity indexes and the test-retest reliability and feasibility, being considered a valid and reliable instrument.
The PEF-COVID19 was divided into four sections, (I) Subject's characterization with demographic, anthropometric and health status questions; (II) Physical exercise performed or not, pain, anxiety and stress before COVID-19; (III) Confinement situation update; (IV) Physical exercise performed or not, pain, anxiety and stress during COVID-19 [14].

Data Collection
The questionnaire was distributed using social and network

Results
A total of 1,977 participants filled the survey. Prior to data analysis, 129 answers were excluded (6.5%) of the initial respondents because they were from other countries than Brazil or with age below 18 years-old, leaving a total of 1,848 questionnaires to be considered in the current study. Brazil has five different macroregions. Table 1
Comparing Brazil with the mains macro-regions, the age distribution

Social Isolation Status
Most of the individuals were in social isolation (~80%) at the time of the survey application and the ones that were not in social isolation (~15%) were not released from their jobs. Few respondents (1.5%) do not believe in the importance of social isolation.

Pain and Psychological Impact
The level of pain and psychological impact of the sample before and during the COVID-19 pandemic are presented on Table 2.
Considering the pain before and during the COVID-19 pandemic for the Brazilian general population, the independent chi-square test showed that the COVID-19 pandemic influenced the pain

Discussion
To the best of our knowledge, this is the first study to evaluate the level of pain and psychological impact as stress and anxiety together in Brazilian mains macro-regions during the COVID-19 outbreak. Our hypotheses were confirmed, and COVID-19 lockdown contributed negatively to increase the levels of selfrelated pain, anxiety and stress. It was observed that the majority of the respondents were following the social isolation during the first wave of the pandemic and government restrictions (about 80%) considering that in February 3rd the epidemic was declared a Public Health Emergency of National Concern [15] following the notifications of the disease spread and deaths in all continents [16]. The decrease of exercise and physical activity during the pandemic and SI can also generate mental health impacts, as stress or anxiety [17] that many will experience in the face of the feeling of fear [18] (fear of being sick or dying, possible loss of family and friends, economic impact) and isolation from common social life [19,20]. Moreover, this survey shows alarming results considering the level increase of anxiety and stress, which the highest levels (8-

10) in a scale with a maximum of 10 points increased significantly
comparing before and during the pandemic for Brazil.
A recent study [21] investigated the fear of COVID-19, stress and anxiety in undergraduate students from Ecuador; they observed the complex relationships between fear, stress, and anxiety in the development of depression symptoms and how they can be taken into account in programs aimed to prevent and alleviate the mental health disorders. Two other studies presented also the effects of the pandemic on mental health for general Brazilian population [6,22] and in both studies anxiety, depression and stress scores were higher during the pandemic, and mainly the ones that were not physically active [22]. Also, the self-related pain level increased significantly mainly in the head and neck regions for Brazilians in general and SE macro-region inhabitants. Inappropriate posture watching television, using computers [23,24] and smartphones [25] or psychosocial stressors [20,26] might be the reason for the pain increase in such body regions. Furthermore, in a review [27], the authors verified strong consistent evidence for the relationship between both psychological distress, and time spent using screens for leisure and depressive symptomatology.
Moderate evidence supported the relationship between low self-esteem and screen use. Poorer mental health status was found among adolescents using screen time more than 2-3h per day, and gender differences exist. Corroborating with our findings, considering that SI can favor chronic stress and pain, Majumdar et al, 2020 [28] reported that the chronic stress of living through a pandemic led to a host of physical symptoms, like headaches, insomnia, digestive problems, hormonal imbalances, and fatigue. and in specific regions, due to the COVID-19 period post-pandemic.
As a limitation, the number of respondents was different in the various regions that were investigated. Moreover, in two regions, North and Midwest, the number of respondents was reduced.
Due to the unknown home-quarantine in each region of the country, a specific adaptation of the questionnaire was not possible to be done. In general, the Brazilian regions have specific characteristics, as nutrition, political approaches, and local costumes. Also, self-reported instruments can induce bias. The findings obtained with the PEF-COVID19 showed, in general, that the Brazilian general population was affected by the pandemic considering the increased levels of self-related pain, stress and anxiety. SE macro-region is the economic center of Brazil presented a significant increase in the levels of self-related pain compared to the others mains macro-regions; the higher levels (8-10) of stress and anxiety increased significantly in all studied macroregions, with similar results. These results will be valuable to the establishment of actions to aid the population of Brazil to minimize, with different approaches, the undesirable commitment due the social distancing related to the COVID-19.