Pain Flare Management Plan: Suggestions to Offer Patients

“A Pain Flare Management Plan: Suggestions to Offer Patients” is part of a series of six tools designed to assist clinicians who want to enhance Veteran’s chronic pain self-management skills.  For additional information, refer to the other materials in Self-Management of Chronic Pain.

Below are examples of what clinicians can offer patients to assist them with self-management of pain.  Note, however, that the VA has specific requirements regarding materials that are directly given to patients, including that materials must be kept at a certain reading level.  Clinicians are invited to offer some of these suggestions as part of what they discuss in a clinic session, but this material is not formally approved to be used as a patient handout.

Flare-ups are a very real problem for many with chronic pain, even when they are taking pain medications. A flare-up is an increase from normal, or more baseline, levels of pain. Unfortunately, pain flares can lead to many other problems including decreased mood, lower activity levels, and a feeling of being out of control.

There is a lot a person can do before calling a practitioner’s office or going to the Emergency Department or Urgent Care.  The more an individual can independently manage a pain flare, the better.  Lacking confidence in managing pain flares can cause people to live in fear of pain, and this can lead to limiting important activities.

This clinical tool is divided into two sections. Section 1 contains ideas for managing flare-ups.  Section 2 offers a framework patients can use to write their own flare-up plans.

Section 1.  Some Ideas to Consider

Plan ahead

When a pain flare occurs, it is often difficult to think clearly, focus, concentrate, or problem-solve. Often, a person may go into survival mode just by trying to endure the increased pain level.  It is better for people to plan ahead, when they are not having pain, so that they will be ready for flares.

Hurt versus harm

It is important to be clear about whether pain is just related to “hurt” (very unpleasant sensations), or if there is actual “harm” (tissue damage) being done.  In the vast majority of times, pain hurts but does not indicate actual harm being done to the body. This is important, because most people feel like there must be something really wrong if their pain flares.

Be a detective

Try to understand what can create a flare-up, e.g. bending or lifting something, not getting enough sleep, experiencing an emotionally stressful conversation, or another event.  Knowing what triggers flare-ups can allow a person to approach those situations in a different way in the future.  Sometimes, if a person tries to get too much done on a “good” day, it might lead to several “bad” days. Patients can determine what the patterns are and respond accordingly, remembering that sometimes pain flares even when a person is “doing everything right.”

Keep a pain diary

A pain log or diary can sometimes be helpful with recognizing the connection between increased pain and whatever may have triggered it. Patients can share their diaries with their health care team to help them understand the pain more fully.  A diary should include the positive things that a person is doing to actively manage their pain as well.

Work with acceptance

Acceptance does not mean a person likes the pain or is no longer going to do anything about it.  It means that the person accepts it is a problem that has to be managed now, and day-by-day.  When the problem of chronic pain is accepted, the constant conflict that can occur inside a person about having the pain can settle down.  This can decrease physical and emotional stress and give a person more energy for coping with the pain and using other strategies to manage it.

Section 2.  Personal Flare-Up Plans

Focusing on the following areas can help with self-management of pain flares.  Patients should keep their plans close, so that when a pain flare occurs, they will be prepared. As people develop more skills or become more aware of what helps, they might want to go back and update the plan.  It can help to write down ideas for each of the areas listed below.

Distraction

Have a patient look for ways to divert attention to other things to minimize over focusing on the pain, especially when pain is high. Ask, “What are the things that help to distract you?” Everyone is different. Distractions could include music, movies, conversation, games, etc.

Relaxation

Relaxation is a very useful skill to practice with chronic pain because physical tension and emotional distress can make things worse.  What relaxation skills is the person already using?  Clinicians can assist patients with learning new skills. There are many types of relaxation skills including breathing techniques, autogenics, progressive muscle relaxation, imagery, hypnosis, meditation, and biofeedback.  (Refer to the “Power of the Mind” overview for more details about these and other tools.)  Relaxation might not take the pain completely away, but it can assist with coping better and recovering quicker.  People who already use relaxation should use it even more during a pain flare.

Activity level

It is important not to give up on physical activity completely during a flare.  It may be necessary to cut back on normal activity, but it should not cut it out completely.  Encourage patients to ask for help. This can be difficult, but it is important that support teams know how they can help. Have patients slowly get back to more activity again as the flare quiets.  For example, try increasing activity by 20% (or some other percentage) each day.

Refer to the “Working the Body in Chronic Pain: What Clinicians Need to Know” tool for more suggestions.

Soothing the pain

This can include applying heat or cold, taking a warm bath or shower, resting, taking a nap, self-massage, applying an ointment, etc. All of these can be added to a flare-up plan.

“Catastrophizing” thoughts

Negative thoughts can arise during a flare-up, creating more tension, distress, and pain.  It’s easy to begin imagining the worst, such as, “It will always be this bad”, or “I will never recover from this flare.” These sorts of thoughts are actually associated with poorer function and more disability. Try having patients replace such statements with more positive ones, such as “This will pass,” or “I have had flare-ups before and I will get back to normal with time.”

Medications

New medications or additional medications may not be needed to manage pain flares if a person engages in some of the helpful behaviors above.  However, if a person uses more pain medications during a pain flare, they should discuss it with their prescribing providers.

Author(s)

“A Pain Flare Management Plan: Suggestions to Offer Patients” was written by Shilagh A. Mirgain, PhD, and by Janice Singles, PsyD (2014, updated 2016).

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.


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