What is commonly referred to as a flare-up in pain?

An increase in pain or fatigue that significantly disrupts your daily function and/or sleep for a few days or more is commonly referred to as a flare-up, some people use other terminology, for example a set-back.  Some things commonly go along with this including increased self-criticism, frustration, low mood, and loss of tolerance for some activities.

What is a compassionate flare-up plan:

A flexible plan, developed and implemented through a compassionate lens, of what you can do to self-manage what is happening, to calm things down and build things back up again.  It draws on previous experience of managing your pain and what is helpful for your wellbeing.

Why is compassion important?

Compassion is important in a flare-up plan as often people blame themselves, self-criticism and frustration commonly increase, which in turn turns up the pain volume and has other draw-backs like the impact on your mood.  Having a compassionate focus also encourages kindness, gentleness, courage and strength.  Compassion helps you support yourself and do what’s wise for you at that time, for example, asking for a little more help and support for a few days or weeks (there is both strength & vulnerability in asking for help).  Compassion has also been shown to help in many ways including decreasing self-criticism, rumination and stress, along with improving resilience & overall wellbeing.

Compassion encourages you to step back rather than pushing on regardless or stopping everything (neither of which are recommended) and ask yourself questions like ‘what can I do for myself out of kindness today’ (this is a question I love that I heard on a course with Dr Mary Welford).

‘Our compassionate self brings wisdom that illuminates the available choices & the possibilities flowing alongside them, along with what could be most helpful right now.’

What causes a flare-up?  There are many reasons and commonly it is a combination of things, including:

• Doing too much (this could be the boom-bust cycle if it happens regularly)
• Working to build tolerance and fitness levels up
• Choosing to do an activity outside of tolerance levels (some activities are worth this)
• A virus
• Increased stress
• Decreased sleep

It isn’t always easy to work out what has caused a flare-up, sometimes it helps to explore what had led up to it and other times it isn’t.  If you find you are having repeated flare-ups without any obvious contributors the best thing to do is usually to focus on actioning your compassionate plan.

Why do we need a flare-up plan?  Here are a few reasons:

• It helps you stay in control and feel confident with self-management.
• There are always flare-ups when living with pain and sometimes these are really difficult to deal with and sometimes feels like a million steps backwards have just happened at great speed.  A compassionate flare-up plan helps us remember the things that are helpful, what we can do to manage things, calm things down and build tolerance back up.  It’s not always easy when pain increases to think clearly, having a plan helps us take action away from getting caught up in things like self-criticism, rumination and anxiety.
• If we don’t have a plan we can end up getting stuck n a cycle of doing less and less, as a result we end up maintaining a new lower level as systems adapt to this and we lose fitness and tolerance for the activities we need and want to do.  This also affects confidence for doing daily activities amongst other things.
• Flare-ups can make people withdraw further from others, themselves and the world around them.  Retreat is a natural protection mechanism, this may be a helpful short-term strategy, however it is not helpful when it is repeated regularly in the long-term.  Retreat and disconnection are also things that turn up the pain volume and sensitivity, connection to others and ourselves is an important part of managing pain and overall wellbeing.
• Some things are worth the flare-up, these are the things that matter most to us.  You can make a mindful choice to do an activity, even though pain is likely to increase, because you feel the activity is worth it and knowing you have a compassionate plan to help you over the following days to find some ease can be reassuring.  So, a compassionate flare-up plan can help you take steps forwards towards your values and what matters most to you.

What to put in a compassionate flare-up plan?

This is individual to you and requires some exploration and reflection.  Grab a notebook and make some notes, if you are having a flare-up now use this experience and previous ones as you read to make notes, otherwise remember the last time or times you had a pain or fatigue flare-up that affected your function and sleep for a few days or more.

• Consider what may have contributed to the flare-up, if this is helpful (sometimes it’s not, notice if you get stuck in a look of self-criticism and guilt).  Compassionately acknowledge (a gentle tone, a helpful acknowledgement without criticism) this and what could be done differently next time, if anything.
• What helped you calm things down and build things up before?  What didn’t help before?
• Set yourself some easy short-term goals based on meaningful activities (what’s important to you, what do you most enjoy doing).
• Plan to gradually build things up to rebuild tolerance and fitness.  Align this with your goals and allow yourself flexibility to adjust things if needed along the way.
•  Moving little and often is usually helpful.  Remember to include movement in your plan.
• Prioritise what needs to be done and leave the rest or ask for help (it’s not a weakness to ask for help it’s a strength).  It can be frustrating leaving things, there are strategies that can help you manage this.
• Having flexibility & support from your employer is important, having open and honest discussions with them about what support could be helpful during a flare-up (for example, frequent short breaks) to helps things settle down again.
• Remember to change how you usually pace things for a short-time, you will have lower tolerance as the need for protection has be deemed to have increased (things are on high alert), pacing differently can help calm things down.  It is important to have a flexible plan for building things back up as you will otherwise adapt to the new lower level.
• Don’t stop everything and rest for more than a few hours at a time, it is usually better to do a small amount regularly with short rests.
• Notice self-criticism with self-compassion and unhook from unhelpful thoughts.  One way to do this is to say, for example, ‘I notice that I am thinking the thought that…’  Another is to write a compassionate letter to yourself to acknowledge how things are and that it’s not your fault, it is understandable & part of being human and living with pain.  There was a post on this on Unity Physiotherapy & Wellbeing’s Facebook page in September 2019 as part of Pain Awareness Month.  There is also guidance in The Compassionate Mind Workbook & Compassion Focused Therapy for dummies.  If you are unsure, or struggle with this, please get help from a suitably trained therapist.
• Practice self-compassion.  There is guidance in both books mentioned above, The Compassionate Mind by Professor Paul Gilbert and on Kristien Neffs website https://www.self-compassion.org
• Increase relaxation based activities, for example meditation, gentle stretching or anything you find calming.

• Integrate more things that stimulate the soothing system (this is part of the 3 circles model in compassionate mind training/compassion focused therapy).  I go through this in clinic with people, there is also guidance in the above books and this video by Chris Winson https://m.youtube.com/watch?v=peC-bB4DqXQ&fbclid=IwAR3b10RyukjKxkukeByQB4XQVeo0bMkVfjo1uvwggpamb09iTc0r-vpc07M
• Consider if you need medication in a bad flare-up or can you manage things effectively with other strategies.  If you need medication discuss this with your Doctor, Pharmacist or Non-Medical Prescriber, such as a Physiotherapist who has done additional training, how to optimize this.
• Focus on the present moment and the small steps rather than the set back and where you were.

Need further help?

Ask your physiotherapist or other healthcare provider for help if you are unsure of how to create your flare-up plan.  Creating individual compassionate flare-up plans is something I help people with at Unity Physiotherapy & Wellbeing.

‘A compassionate flare-up plan helps you keep returning to a life full of meaning & purpose with pain in the background’