When dealing with chronic pain conditions, flare-ups in pain come part-and-parcel with the condition. While minimising the chance of them occurring is obviously the first priority, what’s JUST as important is managing them appropriately when they do occur!
Psycho-social components – such as an individual’s perception of their pain condition, their beliefs around their capabilities, and the level of support around them – are all significant contributing factors to the pain that they experience. So we, as exercise physiologists, have a huge role to play in ensuring that our interactions with our clients don’t reinforce the fear that they (likely already have!) around their condition.
Here are the three key factors we consider, to manage flare-ups and minimise client ‘scare-ups’…
First, we ask the questions…
Our first thought is to get to the root cause of the flare-up.
- Why? Is there a possible cause for the flare-up? When exactly did the pain start to worsen? Is there a clear link to an activity they were doing prior?
We may look at their program progression…
- Have we increased the volume of exercise, or the intensity too soon? Did we make any big jumps in exercises?
- And sometimes – Have they pushed the limits in one of their independent sessions?
It is also important to look at what they have been doing outside of their exercise sessions.
- Have they been more active around the house or garden?
- Did they stand for hours at an event over the weekend?
- Conversely, did they spend hours sitting slouched on the couch watching Netflix?!
- How many beers did they have at the Friday night work drinkies?
Once again, the influence of psycho-social factors on the pain experience cannot be ignored…
- Have they had a stressful week at work?
- Did they have a fight with their spouse or best friend?
- Have they been struggling with their anxiety lately?
As you can see, pain flare-ups are by no means a simple equation. They can be related to a complex, messy, interconnected web of variables, and sometimes you may not be able to find any clear explanation at all! But that is why looking at the bigger picture is so important. And it’s also why managing flare-ups appropriately is so important for the success of the program.
Don’t stop, just modify
A well-intentioned clinician may think that they are being supportive or empathetic by postponing a session in the instance of a pain flare-up…
“Go home and rest up”, they may say… “Have a relaxing night and we will pick things back up next week when you are feeling better”.
Here’s where the tricky part is… Yes – it is important to listen to your client, to show them kindness and support. You can’t blame them for wanting to go into hibernation mode until they are feeling better!
But hiding from the pain is exactly the wrong thing to be doing if they want to overcome the shackles that hold them back. We call these behaviours fear avoidance behaviours – and they subtly, but insidiously, reinforce the pain condition.
They send the message that movement is something to be feared. This creates hypervigilance around the pain, and around movement in general (I liken this to the jitters you may feel walking around a dark graveyard after watching a horror movie… Any noise will make you jump – or any movement will trigger pain!).
So instead of reinforcing the fear-avoidance behaviours, we recommend that our clients come to the session regardless of their pain, as much as is possible. We modify the exercises accordingly, substituting the more physically challenging exercises with stretches or gentle cardio.
The most important thing is to keep them moving! Smoothing out the booms and busts of activity are important to combat the fear-avoidance behaviours and pain hypervigilance. The ‘softer approach’ only reinforces them further.
Our final point, and this can’t be stressed enough, is the importance of managing client expectations. There will almost always be flare-ups – this is the rule and not the exception! Knowing that this is a normal and expected part of recovery means that you can plan ahead with your client and create strategies for managing them when they arise.
This reduces the fear response when they do occur. Pain flare-ups come and go, but the knowledge that it is simply ‘part of the process’ means that the pain doesn’t have to be surrounded with anxiety, hopelessness and overwhelm.
We know… Pain is complex! But taking some time to consider its complexities and act accordingly when flare-ups occur, goes a long way with long-term outcomes in mind.
Author: Yolanda van Vugt
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