The difference between Chronic and Acute Pain in HMS

[Rosie]

Thread split by site admin as subject very interesting and deserves its own place!! Thankyou peeps


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Naama wrote the following in reply to buprenorphine thread link

These have just been suggested to me for something to keep in reserve for really bad flare ups. I'm reading that they aren't good for acute pain though. I'm a bit confused. I guess I need to work out the difference between a flare up of chronic pain and actual acute pain. Hmm, I think I need a pain management programme!!

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Rosie wrote:-
Hi Naama
The pain management course did nothin to help me sort out which pain is chronic and which is acute. They asked us 'Do you have pain?' answer 'yes' question 'have you had pain for more than 6 months' answer 'yes' and we were told ' you have chronic pain' but no one asked me if it was the same pain I had over that time.
The pain management course was for chronic pain, and they didn't seem to know what to do with someone who has both chronic and acute pain.
As far as the meds go, I use oramorph for flare ups, couldn't tell you whether this pain is chronic or acute (it doesn't last for 6 months, but it is not caused by an injury/trauma/etc) but I do know that the oramorph helps with it, and is probably worth a try.
Is it you who has been offered a place on the pain management course for HMS? If it is, then they should be able to sort out the chronic/actue pain. Knowing us, what we have doesn't fit people's boxes very well, so the HMS course would be great.



Rosie

[nonyanomemory]

what is pain

Am giving this link (subject to copyright)not to endorse the private hospital simply because the descriptions are short and to the point (although the writing is a little small).
Descriptions are given of the following:

Acute pain
Chronic pain
Neuropathic Pain
Mechanical pain
Inflammatory and chemical pain
Somatic pain
Visceral pain
Ischaemic pain

Regarding breakthrough pain my understanding is this is unanticipated / aggravation or worsening of pre-existing chronic pain. A 'flare-up' I suppose? To improve breakthrough pain possibly re-adjusting meds, looking again at pacing and multi-disciplinary approaches to pain management through the many aspects already discussed all over the site could assist in its management. This is different to Acute Pain. The pharmicist on the pain management course I attended did say it doesn't mean it doesn't hurt as much as Acute Pain though!

I guess all this is the reason why its difficult to assimilate information on pain but that is how it was explained to me. Acute pain therefore is usually a response to an injury - in its simplest form I suppose pricking ones finger with a needle could be described as Acute and the pain following an operation can be Acute but Acute pain does go away. So in us as Rosie alludes in her post above Acute pain could be the pain felt immediately after a bad dislocation/sublux? A muscle spasm could be described as breakthrough pain as the result of ongoing chronic pain exacerbated by lack of use or conversly over-use due to pain and poor muscle tone due to de-conditioned muscles??? Our stretchy collagen letting us know whats what I suppose!

action-on-pain.co.uk (charity) This site gives helpful assessment tools, describes the pain gate theory well and has general tips on managing flare ups etc.

Another here (copyright protected) hence the link - is a dictionary of pain terminology.
painclinic.org

Hope the links are at least a little helpful.

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Now the next bit is me waffling on as ever and you may have guessed my opinion on pain at the minute!! Lets hope that nickb's recent talk at the national rheumatologists conference helps somewhat in the understanding of the complexity of pain in the hmser. I am most thankful to her.

To be honest I am an hmser who is a little fed up at the minute of well intentioned gp's saying to me - the thing is with your condition is something that would be nothing to a normal person seems immense to you (pain wise). I am sure this means they have read a little on the condition and are trying to be helpful but it just gets my goat!! Perhaps if they lived with the intractable pain of hms with its different manifestations they would understand it is a pretty patronising thing to say! Well meant but maddening.

I found the pharmacist the most helpful at the pain management course I attended in his understanding of the 'impact' of pain and whilst he did believe in pacing, distraction alternative therapy etc. he also firmly believed in appropriate medication something which the psychotherpist did not. Which is all fine and dandy but I will put my hand on my heart and say I am sorry but with the best will in the world I cannot manage my pain without medication! I try my hardest and I mean my hardest to distract, relax, understand my pain gates and shut them off, meditate, cognitively talk myself out of it all but at the end of the day - pain does hurt! I know this because of the lengthy explanations I received on it and all about my spine, messages down it from my brain etc...

As Professor Grahame says on the home pages of the site - more research is needed as to 'why' the hms patient seems to suffer with more pain than the average and why medication is often innefective. We are not nuts but we do need understanding on the pain front. I entirely agree with Rosie when she describes pain management and hms - its not that we are extra special in any way but some days the pain is intolerable but we are a brave and stubborn lot who refuse to give in.

If you have got this far - I am amazed frankly but do feel free to disagree, put me right when I am wrong, as I have only put my understanding of pain and generally discuss.

Although I would say this thread is not intended as one where it turns into oh my hip,leg, knee,back, neck, ankle, shoulder etc hurts today more of an information exchange for current concepts, theories etc.. to assist peeps to understand pain and therefore help each other to manage our pain

nonya x

nonya

[naama]

OK, so on that basis, most of my pain is acute pain. It's just that I have several acute pain sources at the same time. My SI joint hurts because various things over the weekend led to it going wandering. The fact that it immediately (within six weeks) follows a previous episode doesn't make it chronic even though my SI joint has niggled in the meantime. My shoulder, which is generally uncomfortable even with painkillers is chronic pain. Agghhh. I wish I could get my brain around this. You can bet your bottom dollar that when I go for my TENS appointment they will just tell me which settings to use for chronic and which to use for acute and won't actually tell me which is which!!

[hannah]

Hmm. This is an interesting one. I got fairly close to a 'foot stamping strop' on my pmc because I was certain my pain wasn't all chronic and they were being patronisingly slow to understand.

How do you tell if it is chronic if you injure something far too often? I mean, for example a joint that comes out regularly. In me, I would say it is mainly acute pain, although I also think there might be a low level chronic. I mean my SI pain continues for longer than 3 months - as in about 2 years so far, but it goes up and down in direct relation to injury. If I manage a few weeks with no SI slips (yes, I did manage that once ) then it can go down to almost zero!! Does this mean that actually it isn't chronic pain?

I wonder if pacing works for HMS, not because we don't aggravate old chronic pain, but because we don't push our bodies into self destruct? - Meaning, e.g. I have found my SI pain helped no end by pacing, but reading this thread I honestly think it is acute, and the main effect of combined pacing and physio is that I don't slip joints as much = less acute injury = less acute pain.

Would Chronic Pain be constant? I don't mean always at the same level, but more does it disappear completely, to reappear when you are naughty? or is it always there, with certain things that will aggravate it?

and confession time, I don't use the phrase 'flare-up' cos, um, I don't actually know what it means - unless it means 'inexplicably bad patch'?

Oh and also, what would the pain increase due to e.g. damp weather be?

[naama]

Hannah,
Totally! I mean, I totally agree with you - I don't know the answers either. Maybe that's why the bendy pmc is good - because we need to be taught about pain as it occurs in bendy people. We will wait (for a long time) and see.
I'm also not sure about the difference between flare-ups and acute problems. I know that sometimes people ask 'what did you do' and I don't know. That may be because it's a chronic problem that is usually controlled by painkillers but rears its ugly head for no apparent reason or it could be that I did do something but I haven't immediately linked cause and effect. Like my SI joint at the moment. I'm almost sure that it hurts like stink because I went shopping on Saturday. My hip subluxed. My knee gave way as I walked up a step. Neither of them manifested into pain but my SI joint has been horrible since Sunday. Now it cracks and pops every time I stand for a length of time after I've sat for a length of time. In the meantime it is just mindblowingly painful. I didn't directly hurt my SI joint at the time but now it is hurting in a way that it only hurts when I've done it an injury.
Confused!!

[hannah]

Yup. the whole thing infinitely complicated by a propensity to injure without noticing and with no impact

[Kayzee]

The way I understand it, and of course I may be wrong is that chronic pain, is long term pain, and acute pain is intense pain that will get better. We have chronic pain, that is there constantly, but when we injure ourselves, or have a flare up, it becomes acute, until it reduces back to chronic pain again.

I might be totally wrong, but this is my interpretation of it

Kay x

[lucienh]

I've been totally confused by the question of which pain is what, and it was great to read this thread and realize that there isn't one clear answer. We're the real experts, so it's no wonder that doctors who don't know as much as we do have no idea of how to help us. In a sense, we're on our own and have to take responsibility for our individual needs for pain control and management. It helps to read everyone's thoughts and strategies, not to mention the emotional support we get on this forum.

[nonyanomemory]

Complex area indeed. At the pmc I was on a great deal of time was spent explaining that often chronic pain patients spend time investigating the reason for their pain to little avail. That time spent pacing etc and general strategies on pain management to improve the quality of life of one's life was more effective long term. I did take this on board and understood the general ethos. To an extent I get really cross now if I am on the merry go round of investigations etc to find the specific cause of a particular pain as after years of living with hms it is frustrating when in the end I know that its the hms that is the root of the problem. When I was struggling with this concept I found myself becoming quite angry and emotional which is something that happens I believe quite often and is a natural part of some pmprogrammes. Coming to terms with my lot did help me to let go of a lot of the pent up anger and frustration and concentrate more on good old pacing etc etc.

A particularly helpful OT dealing with my hands - spent a fair few sessions, explaining that my main goal should be 'prevention' of acute injury as in my hms acute injury left untreated as yet another bad episode could in turn lead to ongoing chronic pain. Does that make sense.

So I suppose - really concentrating on core stabilising exercise, teaching myself to try really hard not to hyperextend my thumb and dislocate it many many times a day eventually helps in the pain management side of it. Just using my thumb as one example here-to help me with this she made me wear a rigid cast on my thumb for a whole week which was incredibly frustrating but it did teach me that I continually overuse and ask to much of it. Thinking before tasks helps and more often than not know my thumb pain is chronic rather than acute!! I still get so mad with myself when I do ordinary things without 'thinking' and start the whole pain cycle off again.

I spent ages with my physio, practising (probably due to poor propciprocipection (that word I just cannot spell ) instead of turning right or left when changing direction, taking steps to walk in small circles, mad but true, this helps me to not dislocate my knees nearly so often! Again that thinking thing! I may look odd doing it but I discussed with the psychotherapist also my worries about possibly drawing attention to my condition by doing things like this. The conversations were helpful if a little revealing that I have spent some 25 years or so of my adult life, sort of pretending that I am fine!! We did some role play as did others in the group, which ended in tears and laughter - acting out scenario's that were actually 'us' managing 'our' pain in our own different ways. It doesn't have to be obvious always but the funniest was a lovely man who loved to go fishing with his mates but had the worst worst back pain - he described how its wasn't good for his ' street cred' to get up from his chair - night fishing - disturb all the other fishers and walk around for ten minutes or so. This refusal had led to him drinking Jack Daniels all night to deal with the pain. He loved his fishing and was not prepared to give it up. The psychotherapist and he devised a cunning plan, whereby he didn't feel self conscious about it, he got to socialise and fish and he just stopped worrying away about his perceived embarrassement about pacing. I can't remember their specific strategy but on his return from a Saturday night's fishing - he announced that his mates actually preferred his pacing to his sullen drunkedness created by his embarassment about not being able to get up and move every ten minutes to stop his muscle spasms.His pain management improved his pain, his mood, his relationships with other people and his life. At the end of the six week course this gentle giant 'a real bloke' hugged us all and the professionals involved and said that he wished he had got his head round the 'pain stuff' years ago.

I haven't yet learnt by any means to avoid 'acute pain' but I am learning that asking for help, pacing, relaxation, etc. and being able to say 'no' I can't do that I am afraid today or tomorrow but I would love to pencil it in for next week all being well, helps me to cope just a little better.

SI issues are a big thing for me at the minute also and 'planning' how I am going to approach a task does help with this, sudden movements are a no no and watching my daughter go for a driving lesson makes me live in hope that I have managed to pass on a little. She puts on proper shoes, she takes her special cushion and she asks to do manouvere's with gaps in between - driving - manouvere - driving - manouvere - Simple things like thinking about how we exit our cars, so that I at least don't put out my SI, twist my knees and fall flat on my face, is one way I avoid Acute Injury which can lead to ongoing chronic pain.

I also try hard to get prompt physio for acute injury after a suitable period of rest to try to avoid an ongoing chronic problem.

In saying that I do suffer intractable chronic pain but my main aim is avoiding and prevention of acute pain it sort of helps me feel more in control of my pain rather than my pain controlling me.

I have enough ongoing chronic pain which needs, me to concentrate on my general fitness with appropriate core stabilising, pacing and planning to be getting put back by acute pain which is the worst for me to cope with.

In saying that, fell flat down on both very dodgy knees last week on pavement and all that pacing, planning and strategic pain mangement stuff, went out the window - the joys of HMS eh.

Time I went on holiday - as I have truly waffled enough now.

nonya

[Rosie]

Hi all

I have been thinking about types of pain a lot since this thread started. Even with all the definitions of the different types of pain, I still have problems saying what pain I have. With the chronic pain definition of having had pain for longer than a set period, something like pain caused by an arthritic knee is clssfified as chronic. But with chronic pain defined as pain without a specific underlying cause, where does that leave the arthritis? In that case the cause of the pain is known, but the body cannot heal itself so the pain continues.

I find it really difficult to sort out which pain I have is chronis, and which is acute. I think a lot of my pain is of the 'muscle overuse' type, and in turn this can turn into muscle spasms, trapping nerves and causing more pain. This varies from day to day, each morning I wake up and think my way around my body to see what is painful. As well as this I have joint pain, which tends to go in phases, and every now and then something new will join in, my SI joints are the most recent. Most of the time I can't point at a specific reason for joint pain, my ankle hurts but I haven't twisted it recently, but I know that most of, if not all of, my pain is due to my EDSIII! So I am still confused. BUT

Does it matter? What difference does it make to me whether my pain is chronic, acute, or doesn't really fit either of these boxes? I know my condition causes the pain, so it is not as if I have pain that I don't know what is causing it. I know that different types of medication act better on some type of pain than on others, but I can try different meds to see what helps. I understand about the perception of pain, and I try relaxation, gate theory, distraction, or anything else I come across to help to relieve my pain. I am working on my core stability as I know that is poor (can't balance on 1 leg if my life depended on it), and I am leaving physio for specific joints until my core stability improves as much as it can.

I would love to know what is causing each pain in my body, but I don't want to spend my entire life chasing answers. If I do find an answer for a specific pain, most times there is not a lot that can be done anyway. Having said that, there are times when I seek further investigation into a certain pain, for example I know my knees are arthritic, and I will probably need a knee replacement, but it doesn't change the fact that I have knee pain. I do like to know what causes pain, but it is enough for me to know that this pain is my SI joints, or that pain is my shoulders where the muscles are tense. I will do what I can to lesson the pain e.g wear SI belt, use lower arm supports, but I think that I try to deal with my pain holistically as well. So that brings me to .....

PACING. Like Nonya, I found the pacing information the most useful part of the PMC. Understanding how to set physical targets and baselining activities is fairly simple stuff, carrying it out without wiping yourself out completely is another thing. I think that this is where the 'taking control of your life' comes into place. I know I have to be quite selfish to get my pacing to be effective. I have to say no to some things, and I have to decide what I want to do, as well as what I have to do. It can take time to give yourself permission to behave in this way, putting yourself first at times, and I have to thank my keyworker for talking me through this. I am lucky that my husband is retired so he home all day, and my children are at an age where they are fairly independent (the youngest is nearly 9). I think this must be even harder when you have young children, or anyone else for that matter, depending on you for physical needs.

OK, I think I have rambled on enough. Writing this out has helped to clarify a few things in my own mind, so if you have got this far with reading this, thank you for your patience, and I hope that maybe something I have written will help you too.



Rosie

[Shadowlady]

What a fascinating read this thread makes!

I don't like to try and fit my pain into categories called 'acute' and 'chronic'. They just don't fit well. This is something I've pondered on a few times as I try to deal with my tendency to 'under-do', and my pain seems to fit into the following categories;

1. Injury pain - *something* has moved out of line causing damage, that one part (not my whole body) needs rest with only gentle, considered movement to keep it working right until it has healed. It will probably need careful treatment and exercise to help it settle so it doesn't come out again too soon.

2. General overuse pain - mainly muscular, as described so well by Rosie above. Requires plenty of gentle stretching to reduce and balance muscle tension and ease the strain on joints, plenty of consideration to pacing, and not 'rest' as such, just ... not over-doing it straight away again!

3. Overuse irritable inflammatory pain (feels hot in the joint(s), often accompanied by 'sparkles' and sharp 'pin-pushing-in' pains in muscles nearby) - when I've really over-done it 'vulnerable' joints, especially in my back, become inflamed (not usually noticably swollen), unlike 'general' overuse pain, this does need more rest, still need to keep moving though to stop things 'setting', but too much activity makes it flare right up. I beleive this upsets my body's 'chemical balance' and leads to...

4. Utterly pointless pain - not related to injury or overuse, this pain is NOT a warning of potential further damage, and needs to be ignored by hook or by crook. I typically get this in my hands initially, they puff up, and everything I do with them hurts, especially things like opening jars. Nothing has moved out of line though, there has been no injury to my hands, they hurt because my body is 'irritable' because it's not happy about my approach to looking after myself in general. It was this 'chronic' pointless pain that overtook me back when I was ill. No one reason for it, just my bodies reaction to my lifestyle, which seriously needed changing. This was the pain that made Doctors question whether I was somehow dreaming up the pain inside my own head - which is of course very insulting b******s. I stopped moving so much because of this pain - a foolish but completely understandable mistake - this pain does not need rest, it does not need any consideration or attention, paying too much attention to it, trying to figure out the cause, changing how I did things and used my body (which led to actual damage and injury pain), and curbing activity ... all foolish (with crystal clear hindsight!). I needed to carry on like normal, change my diet, and carefully balance exercise, activity and rest to make my body as healthy and resilliant as possible. Meditation and relaxation helped a lot, especially spending time focussing on anything and everything in my body that did not hurt - it was like turning down the volume and it helped a lot.

5. Osteoarthritis pain - masquerades as general overuse pain, needs to be ignored, carry on as normal. The 'inflammatory' nature of it does not 'spread' and make me feel generally ill like number 3 pain, and rest only makes it stiff and 'set'.

So really, the first three would probably be classed as 'acute' and the last two as 'chronic' but these terms are confusing, because my acute pains can last longer than my chronic pains! I had that 'pointless pain' in my hands from Sunday to Tuesday of this week after shopping on Saturday - I had done nothing to them for them to hurt, but they did for a few days regardless and I did my bestest to ignore em. However the 'acute' pain in my back from over-doing it is still here - making the terms 'acute' and 'chronic' pretty inaccurate in my book.

How does this compare to your pain and strategies for dealing with it?

Best wishes,
S

[hannah]

Great points made there shady!

I was reading a Terry Pratchet book the other day. It was talking about rules, and how humans have this ability to discount anything that falls into a category of 'b****y stupid'. I get pain that falls into this category - like shady described so well. It is irrational and foolish pain and I ignore it (although possibly make sure I'm pacing, exercising etc. enough). I would far rather call this b****y stupid rather than chronic - I mean it isn't necessarily long standing.

Rosie and Nonya - I agree that in a way it doesn't matter which it is provided you manage it in the right way.

Hoever, trying to communicate with medics who seem to be programed into chronic vs acute is when I run into problems.

Perhaps I should stop trying to couch my explanations/descriptions in terms that fit their professional dictionary, and just say "this hurts cos I subluxed it, that hurts cos I did too much yesterday and that hurts cos its being annoying." That approach will take a lot of courage.

Warning!!!!: ignoring pain might not always be a good idea and should be done with caution and preferably in consultation with sensible Dr/physio - The hand pain I've been ignoring for months the RR thinks might be carpal tunnel !!!

[gila]

great thread!

I also got very annoyed at pmc motto "we dont talk about your pain" (seems from what I heard that's the same on HMS specific pmc...)

this 'idiotic' motto meant it took me ages to realise that a lot of my pain wasnt just due to 'nerves going haywire' chronic pain, but due to lots of subluxes, overtight muscles, snapping tendons, 'wrong' movements, 'end of range' ligament overstretches...chronic frequent injury pain...

so it of course also took ages till I found ways to minimize, in case of my toes even totally eliminate!, pain...that although pacing etc is really helpful, there is a lot more that we can do to help ourselves...

that the pmc idea to 'help us to help ourselves' is good but that the way they go about it is still woefully inadequate...

WE NEED TO TALK ABOUT THE PAIN!

cause if you dont know which pain is what, how are you supposed to deal with it properly????

[kezzykat]

Hi people,

Well, my perspective with regards to pain is one of a mixed vantage point...LOL...What I mean is that as a Registered Nurse who did courses on palliative pain, acute pain and chronic pain Etiology...I thought that I had a pretty good grasp on pain.

How wrong was I..

The thing is I never realized that the day to day pain which I have had since I can remember , was not normal..I seemed to overlook it in myself, yet I sought diagnoses and treatment for my clients..odd huh?

Also when my pain seemed to branch off into the Pain Condition ~ like a chronic fatigue/pain syndrome ( diagnosed now as being a component of my mixed eitiology EDS) ..THAT was when I came to realize that *I* had/have a very complex pain situation.

Thing is, like many I suppose, If I am asked to rate my pain using the Verbal Description Scale ( VSD) which uses 0-5 to describe pain, or the Numerical Rating Scale ( NRS) 0-10 I have hard problems becuase I typically only am able to quantify my acute pain from the numerous daily dislocation.

My situation is complecated by my Neuropathies which have left me with a Nerve/neurological pain..This pain is neither the same as an injury pain (acute), or my Chronic long term EDS 'syndrome' pain ( even though that has electricy type pains) but instead it is another creature. Even usng the McGill pain questionnaire, which is more Qualitative doesn't help me articulate this facet of my pain.

mind you the McGill's questionnaire is a butache really...Many of us are perhaps familiar with it if they ever went to a pain clinic, especially a Chronic one..

The one true Gem which I was taughtt as a Student Nurse, and one which has been my mantra when I was treating Patients, is that "pain is what the person says it is"..It is quite fascinating how one person may cut their finger nearly off and hardly bat and eye lid and the same person has a headache and they are 'dying'...Pain recpetors are a very complex thing and that is why one treatment can not blanket treat all pain...and why a multisystem approach needs to be taken.

To complicate still further, there are also chemical factors involved. This means that individuals have more than the "physical" causes of their pain ( such as dislocations, fractures, a cut, bang or fall etc) to deal with.

The theory is that one facet of chronic pain ( and it IS only one small part of the puzzle is an oversensitization of part of or allo0f the body, long after physical trauma/causes would likely be 'healed'. Of course this is something which is present in NON hms/EDS individuals as well as being thought to effect us bendys, but it is another thing to consider.

Basically the theory is that the messages which go back and forth to the brain to tell of pain get to a situation whereby they are unable to 'switch' off the message of "pain being present". This often happens in atheletes following a substantial debilitating injury etc. This type is thought to be linked to Kinesiphobia (whereby the person gets into a cycle of pain avoidance by avoiding movement at all of affected area. Although the theroy above is not directly linked to EDS, the Kinesophobia is thought to be at times and in some people, and is a complication of Chronic Pain.

Also the joint overuse type pain mentioned by others in this thread..there is also the Bursitis etc which happens to many of us who have daily multiple dislocations/subluxations of single/multiple joints..

I have tried lots of things ( pain relief pills to self hypnosis, to meditation etc) to help sort my pain. For me the neurological pain is the worst as it is both Chronic and yet "acute" and is completely unresponsive to many pain medications. It took me a long time to come to sort of acceptance that I was probably always going to have high levels of complex pain...Afterall, I was taught that all pain could be treated with the right approach!...Thing is, the more I go on I see that it can..But not how I trhought.

For example, the pain is pretty much never eliviated, yet I am able to cope much more effectively with the chronic elements by the coping stratedgies which I have adopted which although are not great, allow me to get through the hour, half day, day etc.. The major step has been to actually admit to myself that I haven't failed by not being able to cure myself, nor have my drs..But I have infect claimed my life back..not by ridding myself of pain and the level of disability I have, but Inspite of it.


I am sure many here can relate

Great , thought provoking thread..

Peace,

KK

[lucienh]

Thanks, everyone. This is a thread that I'm printing out so that I can study it. So much good information.