Last week I talked about making the choice to do some activities that are not my usual thing. And as predicted, I had a flare of my pain! And then I decided to do some gardening this weekend and my already ouchy body has got even more uncomfortable as a result. I’m definitely in the middle of a flare-up.
It’s time to dig into pain flares as they’re investigated in research papers to see if my experience lines up with what’s been published.
One of the most prominent names in flare research (for people with low back pain) is Nathalia Costa from University of Queensland. Today I’ll be drawing a lot on research carried out by Costa and colleagues – so be aware that this means there are biases in what I write about, because any single researcher or research group will be approaching their work from a particular perspective. This tendency to be biased is why I mainly use literature selected from different research groups, but in this instance it’s not easy to locate works by other groups. For some weird reason, flares haven’t been investigated as much as you’d hope.
What is a flare? Well Costa and colleagues conducted a systematic review of the literature, published in 2018, on how flares are defined in musculoskeletal conditions (Costa et al., 2018). After searching the databases and using fairly strict (and replicable) criteria for inclusion and exclusion, 51 studies were included in a qualitative synthesis, with 28 studies reports derivations of flare definitions, and 23 reporting validations of flare definitions. It’s interesting to note that many of the musculoskeletal conditions included in this study were inflammatory conditions such as rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis and gout where measurable changes in inflammatory markers can be identified. Conditions such as low back pain, osteoarthritis, fibromyalgia – not so easily ‘validated’.
13 ‘themes’ were developed from the analysis (see above, p. 313). Themes were used because there isn’t consistency either in what is included as a ‘flare’ symptom, and as a result measuring them is also inconsistent. It’s not possible (yet) to do statistical analysis on these experiences.
What Costa and colleagues found was that while most definitions started with ‘symptom worsening’, most extended to include multiple dimensions of ‘flare’ such as pain intensity, functional impact, and emotional impact. They also found that definitions varied, and for conditions that don’t have ‘biomarkers’ (eg inflammatory markers), there’s limited consensus on how to define a flare. The final paragraph is an important one: “the concept of flare differs from other definitions commonly used to describe fluctuations of symptoms (e.g., episode and recurrence), as those are commonly defined only taking into consideration duration, intensity of symptoms, and when the period of symptoms is preceded by a period without symptoms (e.g., LBP recurrence). It is likely that risk factors for flares will be different to those associated with a new episode of a condition, and these need to be studied separately.” [italics my own].
In the next piece of work about flares, Costa and colleagues asked people with low back pain to contribute. Now low back pain is often ongoing, but also can include periods without pain (intermittent), and periods with lower levels of pain that may kick off into higher levels of pain (recurrent). In this mixed methods study, people with low back pain were asked to respond to a survey and their responses used to draft a pain flare definition. This definition was then presenting to experts (ie pain researchers and clinicians) who added their views, and then the resultant definition was put to a delphi process. After two rounds in which 50 people contributed their votes, a definition was accepted for the final round where people with low back pain were asked for their response to what was proposed. A long process – but a solid one for when agreement is needed, especially for the beginning of studying this phenomenon.
The finalised definition? “A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions.”
The third study I want to include today won the International Society for the Study of the Lumbar Spine prize in clinical science in 2021 – a very prestigious award! This study investigated risk factors for low back pain flares – and raised an important point. That point is: how we define a flare influences how we investigate them, and the factors associated with risk for flares. Words really do matter.
In this study, participants with low back pain of at least 3 months duration were recruited for an intensive longitudinal study of their pain fluctuations. Participants responded to questions each day for 28 days, three times a day. Using the usual complex statistical analyses required for this kind of study, the data were analysed to find out predictors for flares, and agreement between self-identified flare and other data (from their responses).
Pain flares for people with low back pain in this study were predicted by poor sleep quality, fatigue, leisure time physical activity, and fear of physical activity. Risk factors differed depending on the way flare was defined – a narrow definition using just pain intensity alone found pain intensity in the morning, afternoon and/or evening increased the risk of a flare up to three days later. The researchers called this ‘a transient pain increase’ and interestingly, participants didn’t necessarily think these were ‘flares.’ When a broader definition was used, only pain in the preceding morning predicted increased flare, and high afternoon or evening pain did not. Costa et al (2021) suggest that self reported flare (the broader definition) might reflect the influence of poor sleep and in turn that this might be associated with increased immune response as this modulates nociception and therefore pain. I kind of wonder if poor sleep also means poorer ability to recruit/draw on cognitive coping strategies, while also increasing negative affect (mood). These in turn will affect how much we’re willing to do and how much attention pain grabs.
It seems that poor sleep really has a profound impact on how much pain interferes with life and in self reported flares. Good sleep reduced the risk of flares of both pain intensity alone AND self reported flares.
Interestingly, in this study, leisure activities (like my gardening and high wire escapades!) didn’t increase the odds of self reported flares. Costa and colleagues suggest that maybe this is because leisure activities have an effect on mood, and also that ‘acceptance’ (willingness to do the thing even though it might increase pain) might be a contributing factor.
Where does this leave me?
I’m definitely sore, and I’d agree that my experience today meets the definition ‘a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions.’ I’m a little more irritable, I have to think harder to do normal movements like getting up off the chair, or putting my clothes on. My sleep is fine – and I’m confident that I can still do the things I need to do, but perhaps not all the things I want to do (this is not uncommon!).
Having fluctuations in pain is pretty common when living with any long-term painful condition, and especially nociplastic pains like most low back pain and of course, fibromyalgia. I find that when I’m flared like this, it will take less to increase my pain even more – and it’s likely to last longer than my ‘typical’ fluctuations. If I’d been ‘sensible’ perhaps I wouldn’t have pruned the wisteria and plum tree this weekend, and maybe my flare would have settled. BUT the weather was good, the pruning needed to be done now because plants carry on growing, and I know I can handle the flare. Sorry to those around me who will hear me whinging!
Do I think we need more discussions on flares? You bet! Flares are not something we can completely avoid, and a life without fluctuations and variations in daily doing is not something many of us can achieve. Having a flare isn’t a sign of ‘poor management’ – and I don’t think we should be using pain flares (or the absence of) as a marker of success in a pain management programme. The best way to avoid a flare is to sleep well, and make no changes to daily routines. And that’s not possible for many of us!
I think a more useful approach is to recognise that flares happen, and lean in to ways to flex with the flares – to build confidence that people can manage fluctuations. Why? Because people seek treatment when they feel they can’t cope. And many of those treatments are both not very helpful (ie they don’t reduce pain very much, and only have short-term effects), they’re costly (adding to the economic burden of living with pain, while also adding to the cost of publicly funded healthcare here in NZ), and they have risks of harm both physically and psychologically. How confident can you feel about your own coping strategies if you feel you must ‘get treatment’ from someone when you have a flare? How does that help you move from being a ‘patient’ to being a ‘person’? Given how common flares are, shouldn’t we aim for ways to help people live their own lives without needing to ‘get treated’?
Costa, N., Ferreira, M. L., Cross, M., Makovey, J., & Hodges, P. W. (2018). How is symptom flare defined in musculoskeletal conditions: A systematic review. Seminars in Arthritis & Rheumatism, 48(2), 302-317. https://doi.org/10.1016/j.semarthrit.2018.01.012
Costa, N., Ferreira, M. L., Setchell, J., Makovey, J., Dekroo, T., Downie, A., Diwan, A., Koes, B., Natvig, B., Vicenzino, B., Hunter, D., Roseen, E. J., Rasmussen-Barr, E., Guillemin, F., Hartvigsen, J., Bennell, K., Costa, L., Macedo, L., Pinheiro, M.,…Hodges, P. W. (2019). A Definition of “Flare” in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus. J Pain, 20(11), 1267-1275. https://doi.org/10.1016/j.jpain.2019.03.009
Costa, N., Smits, E., Kasza, J., Salomoni, S., Ferreira, M., Sullivan, M., & Hodges, P. W. (2021). ISSLS PRIZE IN CLINICAL SCIENCE 2021: What are the risk factors for low back pain flares and does this depend on how flare is defined? Eur Spine J, 30(5), 1089-1097. https://doi.org/10.1007/s00586-021-06730-6