Pain's Rollercoaster: Coping with Flare-Ups
During Physical Therapy school, I spent the last year doing three 12-week rotations at three different clinics. Over these 36 weeks, you gain an abundance of clinical knowledge and experience, and you get to treat all the different pathologies you spent the last two years learning about in a textbook.
Over the last year of clinical rotations, I had one patient case that resonated with me the most. Not only was this patient case valuable for me as a learning opportunity at the time, but years later I am still constantly reminded of the important lessons I learned while working with this patient.
During my last rotation, I had the most brilliant clinical instructor. He was sharp, experienced, and charismatic. Most importantly, because of his clinical expertise, I trusted him, and so did his patients.
The patient was a lady in her late 60’s. She presented to physical therapy with a primary diagnosis of biceps tendinitis from her referring physician. Easy peasy. From all my schooling and training I knew exactly what to do. I knew the most efficient way to evaluate her, the proper treatment interventions to provide, and what to expect for a timeline of expected progression.
Wouldn’t you know it, four visits later she returned to therapy reporting she was 95% better and felt that she could be done with therapy because of her improved symptoms. We had agreed that at the end of that 4th session, we would have her come into therapy one more session and if she was still 95%+ better we would discharge at that time.
What happened when she showed up for that 5th appointment would change the way I treated moving forward. She came in, sat down, started to tear up, and said, “My pain is back. I feel I am back to where I started.”
I still can feel my body when I think of those words she said. I became flush in the face, my heart started pounding, and my mind began to race. I asked her some general questions to get a better understanding. After questioning her, I realized I had absolutely no clue what was wrong. I had no explanation for her and began to question myself if it was because I was providing treatment that was insufficient. The textbooks didn’t cover what happened in these situations.
My clinical supervisor was nearby and heard the conversation. He could sense that I was thrown off and came over to ask the lady a few more questions. After he questioned her, he said calmly and confidently to the lady, “What you are experiencing is normal. This sounds like a flare-up.” He would then go into greater detail explaining to the lady that she was unlikely to go back to where she started and gave her the proper education to explain what was likely going on and what we were going to do about it.
To summarize, the lady ended up coming back to therapy the very next session stating she was back to 95% and couldn’t believe how quickly her symptoms had resolved.
The lesson here was invaluable. I learned what a “flare-up” looks, sounds, and smells like, but most importantly, I learned how to handle these situations emotionally and educationally.
The story is a precursor to first letting you understand you are not alone, and many people deal with setbacks or flare-ups. It also sets the stage for the importance of being surrounded by a healthcare provider that you can trust and that will correctly educate you on what is going on and what steps need to be taken. Movement specialists happen to be the perfect resource.
First question: What is a flare-up?
When talking about flare-ups, I first want to clarify we are talking about an increase in symptoms in a musculoskeletal structure, such as a tendon. Flare-ups that occur with autoimmune diseases such as Rheumatoid arthritis is a separate topic.
Simply put, a flare-up is a situation where your pain has improved or been completely resolved and then returns. When the pain returns, it will likely occur in the same body area that was previously injured and will feel like it is causing the same amount of disability that it was prior to you feeling better.
The big question: Why do flare-ups happen?
The most likely cause of a flare-up is overexertion or physical strain on the already injured body area. Physical activities that put stress on muscles, joints, or other body tissues can lead to pain and discomfort if the demands of the task exceed the demands of what the soft tissue can handle. Overexertion, improper form during exercise, or repetitive heavy lifting can cause acute pain or exacerbate existing conditions. This is very easy to tease out with a few questions, and likely you know exactly what you did yesterday that caused it. (Yes, raking leaves for four hours yesterday likely did this).
However, things get a little trickier when we cannot recall a recent instance where we applied a higher level of demand to our body or did something obvious or silly that could have caused this. This is where we stop and look at the entire pie. Physical exertion is one slice of the pie. Other slices of this pie include factors such as sleep, nutrition, and stress, among other things. If your body is not getting the proper fuel or is not getting adequate recovery, this can likely be a cause. Again, with a healthcare provider facilitating the right questions, it will lead to a strong understanding of what likely has changed in your daily routine and the actionable steps you can implement immediately.
Another explanation of what could have caused your flare-up is the trickiest and may even be influenced by a potential cause listed above. It usually involves individuals who have been dealing with pain for months to years, rather than weeks to months. This is called central sensitization. Central sensitization is a neurological process in which the central nervous system (the brain and spinal cord) becomes more sensitive to pain signals, leading to an amplified perception of pain. This phenomenon can increase the pain that individuals feel in response to various stimuli. The simple analogy I often give is to think of a house alarm. A house alarm does not need to go off simply because someone is in your yard, but the second they bust your door open the alarm should sound. Central sensitization is the idea that the house alarm goes off as soon as someone steps into your driveway, or maybe even a leaf blowing through your yard.
The solution of how to resolve central sensitization is a whole separate topic. By decreasing our stressors and learning strategies on how to manage our stress we can begin to communicate to our nervous system telling it to dial the level of sensitivity down. A great place to start is learning how to breathe, meditate, and/or get adequate sleep. For questions on how to breathe, click this link. I understand the idea of breathing to help your pain may seem obscure and abstract but if this is you and you are reading this, I really challenge you to try. Learning how to breathe properly provides so many benefits and for the sake of this topic, it will help you through a flare-up.
Flare-ups happen, and they happen often. There are many strategies that a physical therapist can use to help you manage these increases in pain we go through. It starts and ends with proper education. Often my first or second time with a patient I will already begin educating what a flare-up is and the action steps we can immediately implement so we can get ahead. With the correct questions and proper assessment, an experienced physical therapist will know how to properly manage your recent increase in symptoms. The good news, if addressed right away, these flare-ups will often only last a couple of days.
I always tell patients: Imagine your physical therapy journey is like a marathon. The goal is 26 miles. You come out of the gates doing great and the next thing you know you are at mile 20. At mile 20, something happens such as your shoe falls off or you need a rest. After lacing your shoe back up or taking a short rest, you take off again at mile 20 with only 6 miles left. You don’t go back to the starting line. A flare-up works the same way. Don’t give up, trust the process, and surround yourself with a provider that has your best interests in mind!
Cheers!
Dr. Ryan