Over the last two weeks I’ve written here and here about painful flare-ups and the little we know about them. This week I’m turning to how to manage them.
Firstly, it’s difficult to avoid flare-ups. They happen for so many reasons, can be quite unpredictable in terms of duration and intensity, and there are times when people quite literally choose to Do The Thing knowing a flare-up is likely, because The Thing is worth it. My latest flare is a case in point. And it’s still hanging around – flared again this weekend when I went clambering over rocks to get to a particularly delicious trout fishing spot! Attempting to control or avoid flare-ups is unlikely to enhance living the spontaneous and free life most of us aspire to.
If you’re a clinician you may be worried that the person you’re working with will have a flare and blame you. I’ve seen a lot of pain management plans where ‘avoid having a flare’ is one of the stated outcomes. This is both a hiding to nothing AND can lead to the person living a life of monotony as all the potential ‘triggers’ for a flare are eliminated. I’m not even sure it works.
My approach? Check in with the person: are they aware of the potential influences on their flares? Are they able to make the choice – is it worth it to Do The Thing? If it’s not worth it, is it possible to avoid the trigger or at least minimise the impact? In either case, what is the effect of having a flare on this person?
The effects of a flare will likely differ from person to person, and over time. When I first developed my pain, flares were pretty scary and I’d be worried I’d done something awful to myself. Over time I’ve approached flares with more equanimity. They still annoy me and yet I know they’ll settle with time. They’re the price of doing things I love (no trout were caught this weekend but oh how I had fun trying!).
The main effect of a flare for me now is that I move more slowly. Some of the things I need to do (bending down to pick something up off the floor, standing on one leg to get my foot through a pair of knickers, reaching to make the bed) take more time, more thought and yes I’ll admit to thinking hard about whether I need to make that movement. I am wearing knickers. Thanks for asking.
But according to a study by Tan and colleagues (2019) for people with low back pain, flares can mean a sense of disablement, change in mood, using coping strategies and lack of understanding from others. This study was an online qualitative one of 130 participants with ages ranging from 22 years to 72 years, 75% female, and mainly living in Australia. Most had pain for between 1 – 9 years, but some had pain for much longer (11 participants had pain for between 30 – 40 years).
When we dig into the sense of disablement theme, aspects of social life, frustration, work and concentration, daily life activities, and the need to depend on others to do things were featured. In terms of mood, participants reported feeling low in spirit, lacking ‘drive’ and motivation, and frustration and irritability were identified.
People described using ‘passive’ coping strategies such as medication (and indicated they ‘need’ or ‘have to’ use medications) but at the same time, reported negative side effects of the same. Ice packs, heat packs, and hot showers along with seeing health professionals were also described. Active strategies were also used by a small number of people: modifying life/work/training activities, being a bit more careful with stretches and moving more at work were mentioned.
I’m curious about these responses. As an aside, I’m not fussed about calling them ‘active’ or ‘passive’ strategies – because these labels can imply a kind of dichotomous ‘good’ = ‘active’ and ‘bad’ = ‘passive’, when I’m not sure this kind of light/dark, black/white is helpful. But back to being curious: I note nothing was mentioned about strategies such as distraction, positive coping statements, noticing, mindfulness, relaxation, music and even <gasp!> hands on therapy like massage.
My questions are about the way people recall or remember what they do in the middle of a flare-up. How easily recalled are these latter strategies? My go-to strategy is first to notice and then to remind myself that it will pass. This is a time thing – I’ve gone through flares before, and they’ve always settled down in time (even if not quite as quickly as I’d like!).
The way questions are asked can influence how they are answered. Most qualitative research is carried out using interviews where the researchers can probe the answers more deeply, and where meaning is constructed between the interviewer and respondent. This study used an online survey format with lots of room for free text, and free text can be analysed using inductive thematic analysis, as these authors indicate. In their paper, however, they don’t provide the whole survey, so it’s not possible to see how the questions were framed – what context the questions were asked in. The actual question is given as ‘What changes in your life when your low back pain flares up?’ but this doesn’t ask a direct question about how people went about managing the situation. The other papers published from this survey don’t answer the question of how people dealt with their flares as they were more focused on defining flares, and the explanations or reasons people gave for their flare-ups occurring in the first place.
People in the community often hold outdated beliefs about their pain, often referring to biomechanical ideas (these are the conclusions from one of the studies by this same research group – 1) due to the body being like a ‘broken machine’, 2) permanent/immutable, 3) complex, and 4) very negative. Most participants indicated that they learnt these beliefs from health professionals (116, 89%) Setchell et al., 2017). I suppose it’s unsurprising that people experiencing a flare-up will tend to echo the fears they hold based on these unhelpful narratives.
What might help?
For clinicians, express your confidence that the person will come out of this flare in time and can get through; that flares are part of living with an ongoing pain problem and probably more about overall nervous system twitchiness than ‘issues in the tissues.’
For people living with pain, making temporary adjustments to what you do and how you do it – and nudging into those painful movements – along with giving your nervous system things that soothe it can be pretty helpful. For what it’s worth, I’m moving into the painful zone (my current one is down my left flank, so this means some quite weird twisty bendy movements that I’m doing while sitting and when lying on the floor), I’m taking more frequent breaks to get out of my chair and walk around, I’m adjusting how I get things off the floor (using my toes to pick things up!), sitting down to put things on my lower body, and I’m doing my usual noticing so I can be ready to relax into a movement rather than bracing myself (which is what I found I was doing without really noticing when I woke up this morning). I’m not using medication because I’ve never found them helpful, and while I love a good shower I don’t find heat lasts all that long. If I’m especially cranky tonight I might fire up my TENS and give that a go.
These strategies are intended to help me keep doing the things I want and need to do. I guess some of them could be called ‘passive’, but to me, the reason I’m using them is to help me do the things I want to. There are lots of ways I can go about getting dressed, making the bed, bending to pick things up – the key thing is that I get those things done. And I expect this pain will settle, just as the pain I’ve had the past two weeks has also settled – until I go climbing to get to my fishing spot!
Setchell, J., Costa, N., Ferreira, M., Makovey, J., Nielsen, M., & Hodges, P. W. (2017). Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord, 18(1), 466. https://doi.org/10.1186/s12891-017-1831-7
Tan, D., Hodges, P. W., Costa, N., Ferreira, M., & Setchell, J. (2019). Impact of flare-ups on the lives of individuals with low back pain: A qualitative investigation. Musculoskelet Sci Pract, 43, 52-57. https://doi.org/10.1016/j.msksp.2019.06.003