Flare-ups, breakthrough pain or set-backs: self managing exacerbations of pain

ResearchBlogging.orgA couple of days ago I wrote about medication and managing flare-ups, and out of that post there was a bit of discussion about what exactly I meant by flare-up, and whether it might be better defined as break-through pain.  I’ve found that there is not a lot of agreement in the literature – nor with clinicians! – in terms of distinctions between flare-up or breakthrough, so I’ve decided to redefine the problem completely. Not that I’m the first to do so, as you’ll see from the paper I’ve referred to today.  I have to admit that I like Turk’s approach to chronic pain, as it’s the way I have been trained to approach pain management.  Turk is also the author of a self-help book for chronic pain management that I still think is one of the best – The Pain Survival Guide. I intend to consider both as a form of set-back.  And I’ll refer to exacerbations of pain as flare-ups for want of a better term.

How do both flare-ups or breakthroughs affect people?

The first thing is that both represent exacerbations of pain.  Whether the exacerbation is very brief, or somewhat longer, the fundamental problem is that pain has increased from a baseline.  This is a very common situation – it’s also one of the main features of having a chronic health condition. So we can expect chronic pain to change in intensity from time to time, and learning to manage that is one of the key aspects of maintaining self management.

Flare-ups are one of the main reasons people with chronic pain who have been through pain management return to their health care providers. Some models of self management see this ongoing relationship with a clinician as an integral part of how to live with the condition.  I think it can be somewhat fraught with the potential for self management to be inadvertently undermined as I’ll discuss in a moment.

Using a cognitive behavioural approach for managing pain means recognising that how a person appraises, or evaluates a situation (including pain) influences both the emotional response, and the behavioural response.  Appraisal is also influenced by past experiences, anticipated future outcomes, underlying mood, longer term tendencies (such as negative affectivity, anxiety sensitivity and so on), and social context.

Because a flare-up is a change in the intensity of pain, a very common tendency is to catastrophise, or think the worst.  It’s a difficult situation often, because we are almost hard-wired to take notice of novel stimuli, and especially those that are particularly salient.  In other words, changes in our situation that our brains consider to be important are brought to our attention pretty rapidly.  For a nice discussion of this tendency, a recent paper by Iannetti and Mourax (2010) is a good read.  As a result, any change in pain, particularly any increase in pain, tends to catch the attention – and then a number of cognitive habits come into play.

Once a person evaluates pain intensity in a catastrophic way, emotional distress starts to increase.  People respond to emotional distress differently, depending on emotion regulation tendencies (to externalise, to suppress, to seek action and so on), and this leads to a range of often unhelpful coping strategies.

During flare-ups, escape and avoidance strategies often come into play – and this makes sense initially because it may mean a reduction in pain.  It also either means a reduction in getting involved in activities that are valued or important, and – often not recognised – it doesn’t necessarily change the pain intensity very much at all.  It may instead reduce distress.  Now that’s not always a bad thing, because heightened distress brings with it many undesirable outcomes such as additional attention from others, negative judgements about self, and a reduction in the range of options to help manage the situation (see my posts on the ‘broaden and build’ theory).  But it does mean that life can become rather less satisfying, especially over time.

Self management can be undermined

When encountering a person who is distressed it’s relatively easy for a treatment provider to address reducing the immediate distress, while omitting to look at the longer term effects of doing so.  This is especially important when a person is developing self management.

Confidence to manage pain, or self efficacy, involves successfully using active coping strategies even during difficult times

If a clinician can show the person with pain that he or she can manage with active coping, this will support self efficacy for managing pain.  If a clinician instead suggests a method that reduces distress but doesn’t support the use of self management (such as prn medication or passive treatments), this reinforces to the person with pain that the coping strategies they have to hand are insufficient.  By doing this, it effectively reinforces to the person that they shouldn’t have confidence in self managing pain.

What to do, what to do…

If I’m suggesting here that clinicians should avoid undermining self management by thinking carefully about how to respond to distress, what exactly will be useful?

Well, one thing to remember is that we, as clinicians, are susceptible to responding to distress.  It’s probably one of the reasons we choose to work in health care!  We need to be empathetic, rather than sympathetic.  By this I mean we need to come alongside the person, and acknowledge their distress, but not allow this to influence our reasoning process.

Distress often arises from catastrophic thinking – thinking things like ‘I can’t cope’, ‘This pain will never end’, ‘I shouldn’t have this pain’, ‘It’s horrible’ and so on.  When someone’s highly distressed, it’s not easy to work through a reasoning process to challenge these thoughts.  It’s helpful in the first instance to work on reducing their negative emotions through down-regulating their arousal level – and because the aim is to help the person manage by themselves, it’s useful to remind them to use diaphragmatic breathing, calming self statements, and by doing so, interrupt the distressing chain of thoughts.

Once they’re somewhat calmer, I think it’s helpful to reconceptualise a flare-up as a set-back from their usual pain management plan.  A couple of days ago I described the main components of a pain management plan – along with this plan, I think that recognising that set-backs will occur, and pre-planning for this eventuality does a couple of good things:

  • The shock value of a set-back is somewhat diminished
  • By developing a plan when emotions are neutral or even positive, creative options for coping are much more readily generated than when a person is distressed (see Broaden and Build theory again)
  • It gives everyone a set of options to support the person to get through the experience (including family, friends and health care providers)
  • It recognises that set-backs can come in many forms, and plans can counter this in many different ways

More on this tomorrow – it’s a very important area of pain management to work through.

Turk, D.C., Swanson, K.S., & Tunks, E.R. (2008). Psychological approaches in the treatment of chronic pain patients–When pills, scalpels, and needles are not enough The Canadian Journal of Psychiatry, 53 (4), 213-223

Iannetti, G., Mourax, A., (2010). From the neuromatrix to the pain matrix (and back). Exp Brain Res  205:1–12


  1. Huh. I guess that’s why people who don’t know me well think my problems can’t be that bad. I react to pain flares by telling myself things like, “This can’t last long… I’ll be back to normal soon enough,” “The more I can do, the better I’ll feel about myself,” and “I can manage.” I told my classmates in my dance class about my fibromyalgia and asthma, so they’d understand if I scaled back some days, and instead, I work harder than these kids half my age and one of them thought I was ‘the healthiest person in the room’.

    Hate the conditions; love the coping skills.

    1. That’s a good point Samantha – there seems to be a sort of social contract that applies in chronic pain. If you’re in pain you’re either meant to say nothing and look healthy, or say something – and act as though you have problems. And in the latter case, you may find other people start to get fed up with hearing and seeing your situation, and their responses may be less than supportive!
      I guess my stance is that if I can help people decide what they want, then they can determine how much to reveal to other people. It sounds to me as if you’re doing really well to live ‘well’ despite pain!

  2. Great article! Not your usual back pain piece.
    Where can one find the state-of-the-art pain management pieces? books, blogs, articles besides those you’ve cited above?
    thanks! Charles

  3. My Rheumy old me that I was the only patient that he has seen with a constant flare-up. Every day I take many meds and they did nothing for the pain.

  4. There are flare ups and there are flare ups. Sometimes you can’t move so a flare up occurs on a scale from not being able to move to a milder exacerbation of the norm. Sometimes I think people regard chronic pain as something stable thus easily managed.

    1. Flare-ups vary as widely as chronic pain varies! And they can knock your feet off the ground, but happily they DO improve, things DO return to normal, even though normal isn’t “completely pain free”!!

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