Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Chapter 17. Dealing With Flare-Ups and Set-Backs

Most people with chronic pain report their pain varies in intensity through the day, often depending on what they’ve been doing. If you have been using the ADAPT approach regularly you should have fewer flare-ups than previously, but they will still happen.

At times, your pain may get quite intense and difficult to bear, but it will often settle within a few hours. However, from time to time your pain may flare-up for a few days or even longer. No matter how long the increased pain lasts, you may have trouble keeping up your activities and exercises.

How long such flare-ups or set-backs last and how much trouble they cause will strongly influenced by the ways in which you deal with them.

You could simply wait till it happens, then stop everything, start taking pain killers or tranquillisers again, tell yourself the ADAPT approach hasn’t worked, call the doctor out, and retire to bed for as long as it lasts. But what would be the likely result of that approach?

You probably don’t need to think about it very long at this stage, but it is hard to see how that approach would really help, especially if it keeps being repeated.

On the other hand, if you accept that such temporary set-backs or flare-ups are bound to happen sooner or later, you could work out a plan well in advance and then put it into practice as soon as you become concerned about it.

There probably isn’t a “best way” of dealing with set-backs or flare-ups that will work for everyone. But, by trying out different ways of dealing with set-backs you will eventually work out a plan that works best for you. Some basic strategies could help you to get started.

We have found it helpful to take this in stages. When your pain flares-up initially you won’t really know how long the flare-up will last (even though you may start to think it could last forever). In most cases the flare-up will not last more than a day or so. In these cases that is all you need to get through. So, your initial strategies should be based on dealing with that period.

In other cases, the flare-up may go on for several days. That will mean you have to plan to deal with it over that time.

On the next page is an outline of a basic plan for dealing with the initial flare-up stage.

When your pain flares-up – a brief checklist

1) STOP AND THINK – What’s happening? (clarify the problem)

– Have I been overdoing something?

– What can I do now – what are my options?

– Work out a plan.

2) IF POSSIBLE, TAKE YOUR TIME BEFORE REACTING

– Reacting without thinking (panic) could make things worse.

– Identify any negative, unhelpful thoughts and instead think of other, more helpful ways of looking at the situation

3) THINGS YOU COULD TRY

– Stop what you have been doing – have a short break. Look for something else to do for a while (eg: lie down briefly, go for a walk, do some stretch exercises).

– Relaxation – calm yourself – spend a couple of minutes (or more) practising your relaxation technique.

– Use your desensitising technique – calmly focus your mind on the pain. Let it be there, don’t try to push it away or block it. Remember, it’s just activity in your nerves, and you are OK – it’s not harming you.

– Identify any negative thoughts – be realistic. Thinking the worst never helps, instead you can remind yourself of more realistic and helpful thoughts. “I know I can’t make my pain go away completely, but I can cope with it”. “I’ve coped with this pain before, I can do it again”. “Even when it gets really bad I know it won’t stay like that”.

– You might have to change some of your plans for the day. You may have to pace things more for the rest of the day. What are your priorities – what can be left?

4) THINGS TO AVOID

– Carrying on without thinking (“I’ll just get this finished, then I’ll stop”).

– Over-reacting (catastrophising) – you’ll only get more upset.

– Stopping everything and retiring to bed for the day – this might seem a good idea at the time, but is a long rest the answer?

– Taking pain killers – an occasional one is OK, but they usually don’t work as well as you’d like. There are drawbacks too – side effects and the risk of getting into a habit of using them to enable you to overdo things – not a sustainable option.

– Calling the doctor out – you know by now that unless you have a new problem, there’s not much he/she can do at these times (except give you more medication).

5) WHEN THE PAIN STARTS TO EASE review how you coped this time.

– What can you learn from this episode?

– What do you like about what you did?

– Recognise your achievements – praise yourself for coping as well as you did

– What could you do better next time?

– Check how well you have been pacing activities – could you do better?

If your pain flare-up continues for more than a day or so, then in addition to following the checklist on the last page you may need to take more comprehensive action. The points mentioned here could also be helpful if you have simply stopped doing the program due to something else, like an illness.

When things start going wrong for more than a day or so we call that a set-back because your daily activities may be significantly disrupted.

1) GET IN EARLY

The earlier you identify a set-back, the easier it will be for you to deal with it. Keeping some sort of record of your exercise practise or weekly activity goals could help you to pick up early signs of a set-back (such as starting to miss sessions or avoiding certain activities). On the other hand, you or those around you may start to notice you are wanting to rest more or to avoid going out. Use signs like these to put your set-back plan into operation (don’t wait till you are having real trouble before acting).

You may also notice that set-backs tend to happen at certain times or in certain (high risk) situations, such as shopping in the week before Christmas or when the family visit you for the weekend. If you can see one of these times coming up, it could help to work out a plan to deal with it (e.g. spread out your tasks, get others to help, leave out unimportant tasks for the time being, explain to those around you that from time to time you will need to take short rest breaks to help you get through the day, etc.).

2) REASSURE YOURSELF

Periods of increased pain happen to most people with chronic pain every now and then. Sometimes they last only a few hours, but at other times it may be a matter of days or even weeks. They may happen for no clear reason or they may be due to something you have overdone. One reason you could overlook may be after you have stopped your activity and exercise programme for a while (like during a holiday or while you have been in bed with the flu’). One thing you can be pretty sure of, though, is that depending on your condition, unless you’ve done something fairly dramatic (like fall down the stairs) the increased pain will not be due to some extra damage you’ve done to yourself.

3) IF POSSIBLE, WORK OUT WHY

Review what may have led up to the set-back (or flare-up of pain). This could give you a guide to the best way to deal with the situation.

If you have been overdoing something and you are still doing it, you have a choice to make. Either carry on (and just accept that you will have to try to cope with the consequences later) or cut-back (stop what you’re doing – try something else in a different position, do some relaxing, do some stretch exercises, etc. – then go back to what you were doing, but at a slower pace or with more breaks, if possible).

If you think the set-back (or flare-up) is due to what you have been doing over the last week, you could try to learn from it (and next time pace yourself more or do it differently). At the same time, you should pace your activities more today as well or do fewer things – and if you find some exercise is making things worse, do less of them for a day or two – then gradually pace them up again. But don’t stop everything!

If you can’t identify the cause of your flare-up, you will still face a choice – either carry on as if nothing has happened (but be ready to change if things continue getting worse) or cut back on your exercises and other activities for two or three days till the flare-up eases, then gradually pace them up again [this may take more than a week or two in some cases]. We recommend that you cut back your exercises by a reasonable amount – say, 50% on all exercises.

If the flare-up continues for more than a week or so, you may need to have a close look at how you’ve been doing things (overdoing repeatedly? not watching your posture?) or what you’ve been doing (too much of one activity, such as sitting?). You may also need to cut back on most of your exercises and activities (re-set your baselines for them) – then gradually pace them up again over a few weeks. This will take time and patience, but remember you did it just like this when you started the ADAPT programme. Remind yourself you are not back at square one, because now you know how to get out of it.

4) REMEMBER YOUR COPING STRATEGIES

Check if you are catastrophising about the set-back. Are you thinking or reacting in a positive, realistic, helpful way? It is alright to be concerned and careful, but worry and desperation don’t help. Consider what you can do, what you did the last time you felt like this or were in this position. What seemed to help? What didn’t help? What options are there? It might help to re-read some sections of this handbook to refresh your memory on ways of coping.

Are you getting tense or wound up? Remember your relaxation and desensitisation techniques.

5) BE FLEXIBLE BUT REALISTIC

Depending on how things are going, you may need to change your plans as the set-back persists, such as stop one exercise completely for a few days or put off a planned outing. But remember, most of the things you try to deal with the set-back will not work 100% (very few things are 100% successful). But that doesn’t mean you should stop doing them completely. At these difficult times it is especially important to try to keep a balanced view on things. So, if the relaxation technique doesn’t seem to help as much, don’t stop doing it – at least by doing it you are doing what you can and it will be a lot better than getting into a panic over the set-back. You may need to remind yourself that you’ve survived difficult times before and, if you can hang on now, you will get through the present trouble.

6) HELP FROM OTHERS

Normally, you will want the people around you (at home, work, etc.) to stand back and let you get on with things, unless you specifically ask for their help. However, when you’re having a set-back, it can help to explain to your family or friends (or co-workers, etc.) what is happening (trying not to sound alarmist) – what you will be trying to do to deal with the problem – and, most importantly, what you would like them to do (or not to do). By making these points as clearly as possible (but not in a demanding way), you will help the people around you to help you rather than hinder you. At the same time they will be reassured and will find it easier to understand what you’re going through (remember no one can read minds, no matter how well they know you).

If you’re finding it hard to cope by yourself, even with helpful friends or family, you could always try going to see your doctor to discuss the situation with him or her. Sometimes, they might think of something you’ve overlooked. Maybe it is time that you were referred to a multidisciplinary pain clinic for assessment and help with your pain?

7) WHEN IT’S OVER

It’s natural that you would just want to forget about it, but we recommend that you spend a bit of time reviewing how you dealt with each set-back or flare-up. This can help you to learn ways of coping better next time and, perhaps, ways of preventing some future set-backs.

Reinforce your achievements – what did you like about the way you coped? Did you deal with the set-back better than last time? What could you do better next time?