Flare-Ups 101—Prevention, Planning, and Troubleshooting: November 5, 2016



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    About Krista:
    Krista is a highly-qualified yoga and Pilates teacher with more than 2000 hours of training and nearly 5 years of experience working with people who live with chronic pain. Additionally, she holds a Master’s degree in Psychology, with an emphasis on cognitive neuropsychology, and a post-graduate Certificate in Chronic Pain Management from the University of Alberta.

    Krista began working at The myo Clinic, a small pain clinic in Victoria BC, in September 2011 after being referred there for assessment and treatment of her own chronic pain. In 2013 she moved to Vancouver to join CHANGEpain, where she currently works as the Manager of Group Programs. She continues to teach movement, sleep, and pain education classes there regularly.

    In addition to her work with movement, Krista has been interested in sleep and insomnia, as well as the importance of language and communication in chronic pain. She studies and uses cognitive behavioural therapy techniques, motivational interviewing, non-violent communication, and coaching strategies in her work with people in pain. She also runs a small and busy private practice for one-to-one movement and/or coaching sessions.

    Having lived with chronic back pain for nearly 20 years, Krista controls her pain through her own practice of movement and relaxation, along with healthy diet and sleep routines. She is passionate about learning about pain, and sharing her knowledge to help others manage their own chronic pain. However, even with a lot of knowledge, set-backs and flare-ups can happen. Learning to prevent flare-ups is a critical tool for anyone living with pain, but in the event that flare-ups happen, what can we do? This session is an opportunity to ask questions about flare-ups, the importance of stopping the “boom-bust” cycle, and how to prepare yourself for those “bad days” in advance.

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  • @kristafriesen
    That's great. Thanks!



  • Thanks so much for having me!!

    @Forum_Moderator said:

    That ends today's chat! Thank you, Krista, for your thoughts and advice. This chat will live here on Live Plan Be so you can go back to it at anytime if you want to re-read Krista's responses.

    Thanks again, Krista!



  • That ends today's chat! Thank you, Krista, for your thoughts and advice. This chat will live here on Live Plan Be so you can go back to it at anytime if you want to re-read Krista's responses.

    Thanks again, Krista!



  • Also, if you sign up for notifications from this post, and I find any more specific papers, I will post links here.

    @Criptastic said:

    @kristafriesen
    Interesting. Do you have any links to articles about the nervous system "learning" like this? I don't quite understand how signals of safety or signals of persisting despite the "alarm bell ringing" actually set the nervous system to respond with more or less vigour. I think reading the science would help me connect with the reality of being able to modify with system of response.



  • There are definitely some articles on this, though I would have to dig them up. Some of this comes from Lorimer Mosely/David Butler's Protectometer work, which you can read about here: https://noijam.com/2015/03/12/dim-sims/

    Basically the concept is that there are certain nervous system responses to danger (like gripping muscles and holding breath) that are associated with threat (imagine a bear stepping in front of you while you are hiking). Only in chronic pain the bear doesn't leave and the nervous system continues to receive threat signals and perpetuates that cycle. By creating safety signals (slow deep breaths, relaxing the grip of your muscles) your nervous system says "oh, we usually only take slow deep breaths when we are safe, hmm. maybe there isn't as much danger as I thought". and this can sometimes be enough to create a decrease in the immediate severity of pain.

    Does that help?

    @Criptastic said:

    @kristafriesen
    Interesting. Do you have any links to articles about the nervous system "learning" like this? I don't quite understand how signals of safety or signals of persisting despite the "alarm bell ringing" actually set the nervous system to respond with more or less vigour. I think reading the science would help me connect with the reality of being able to modify with system of response.



  • Sure! CHANGEpain is an integrated clinic with physicians of varying specialties, other clinicians (physio, chiro) and a team of pain-focused teachers offering classes specifically for people living with chronic pain. My role there is both in managing the patient education programs and in teaching them. My personal focus is in general pain management classes, as well as movement and sleep classes.

    We offer a number of different movement classes in which I spend a lot more time expanding the idea of moving without flaring and setting realistic goals. we also offer yoga and pilates practice classes for people with pain.

    In addition to movement, we have a skilled teacher team providing courses on nutrition for chronic pain, and the nervous system and relaxation for chronic pain (including breath and meditation classes), and a sleep program.

    Recently, we also started offering a program with two pain-focused psychologists, who will be teaching groups on depression/anxiety and pain, as well as work/relationships and chronic pain.

    We're really excited about what we have been able to put together because, as we all know, there are so few options out there for people who live with pain.
    There is a lot more info on our programs at the changepain website (changepain.ca).

    @Forum_Moderator said:

    Thanks, Krista! We have about 10 minutes left. Can you tell us about what you do/offer at CHANGEPain clinic? You also have some workshops too, right?



  • @kristafriesen
    Interesting. Do you have any links to articles about the nervous system "learning" like this? I don't quite understand how signals of safety or signals of persisting despite the "alarm bell ringing" actually set the nervous system to respond with more or less vigour. I think reading the science would help me connect with the reality of being able to modify with system of response.



  • Thanks, Krista! We have about 10 minutes left. Can you tell us about what you do/offer at CHANGEPain clinic? You also have some workshops too, right?



  • Thanks for your comment Criptastic. Absolutely. I would say that acceptance without resignation is absolutely one of the hardest pieces to find in a chronic pain journey, but I think many times, once you even start to find some acceptance (even a little!), there is a lot of freedom in it, and some of the pressure to "not let anything stop you" can drop away, while you prioritize taking care of yourself.

    @Criptastic said:

    @kristafriesen
    Very well said. The shoulds and striving for normalcy create much more physical and psychological pain. It's a tough thing to manifest, the level of acceptance required, especially because we want more, there are tasks that need to be done and society pushes the don't let anything stop you attitude on everyone.



  • Great question. we often see flares after something like exertion and even there, I would argue that in many cases, it is still an example of increased nervous system sensitivity. when we have chronic pain, there is definitely a mechanical change in the muscles, but one of the things that also happens, is that our alarm bell (pain) rings well before damage occurs. this is NOT to say that you should just push through that pain. Not at all. In fact, if we push through that pain, the nervous system responds by saying something like
    "I tried to tell you that this was dangerous, and you didn't seem to hear me. So, now I'm going to yell a lot louder".

    When we push through a lot of pain, the nervous system learns that it is not being vigilant enough (even though it was trying, it still didn't prevent a flare) and so next time, the alarm bell rings earlier.

    By taking regular rests, you offer the nervous system a signal of safety - you can essentially "hack" your nervous system by reducing your muscle tension and slowing down your breath, and the system responds by saying "oh, okay, I guess this wasn't as dangerous as I thought".

    The key to safe exertion is to figure out how much you can do (even if there is some pain) without triggering a flare, and offering plenty of safety signals to your body, like relaxed muscles and breath.

    @Forum_Moderator said:

    And here is a question from Facebook:

    Earlier you wrote that flares are not a new danger and are unrelated to a new problem - I get that - but when you write about flares after exertion, there does seem to be a mechanical issue going on like muscle strain etc. It seems like there is more going on than increased sensitivity and that's why rest or changing position actually helps, right?



  • @kristafriesen
    Very well said. The shoulds and striving for normalcy create much more physical and psychological pain. It's a tough thing to manifest, the level of acceptance required, especially because we want more, there are tasks that need to be done and society pushes the don't let anything stop you attitude on everyone.



  • Honestly, the most common thing that I hear from is that they sometimes know that they should do a little less, or they can feel that their pain is increasing as they are making their way through the aisles of a grocery store, but they feel like they "should" be able to do these things. "Should" is one of the hardest things that we say to ourselves. "I should be able to cook this meal" or "I should be able to sit at my desk for longer than 20 minutes" and so people push through, trying to maintain whatever sense of "normalcy" that they can. Letting go of these "shoulds" is one of the hardest things that I see for people. and I understand it completely.

    There are two responses to this: one comes from how pacing really works - that if a person can figure out those baselines and stick to them, there is a good chance that you will end up with MORE usable hours in a day, and not less.

    The other response is that in order to make progress, we have to be able to see ourselves where we really are. If we get stuck trying to cling to the things we used to be able to do, it is very challenging to see a clear path to move forward - because we are not accepting where we are at. This accepting is pivotal in reducing flares. But note that acceptance is not the same thing as resignation. you can still make progress and take steps forward, even while accepting where you are now.

    @Forum_Moderator said:

    That is good to hear, Krista. At Pain BC, we often hear about the difficulties that people have with managing their pain. They talk about that vicious cycle you referred to earlier. Thinking about the "troubleshooting" part of this talk, what problems do you hear the most often from your clients?



  • And here is a question from Facebook:

    Earlier you wrote that flares are not a new danger and are unrelated to a new problem - I get that - but when you write about flares after exertion, there does seem to be a mechanical issue going on like muscle strain etc. It seems like there is more going on than increased sensitivity and that's why rest or changing position actually helps, right?



  • That is good to hear, Krista. At Pain BC, we often hear about the difficulties that people have with managing their pain. They talk about that vicious cycle you referred to earlier. Thinking about the "troubleshooting" part of this talk, what problems do you hear the most often from your clients?



  • I have had chronic back pain since I was quite young and to be honest, I always just assumed it was normal, especially as it worsened when I was in university. During my graduate degree, I spent almost as much time lying on the floor of my office as I did in my chair at my desk!

    My pain is quite well controlled now, through a lot of movement, relaxation, and definitely pacing. However, I still find that if my stress levels increase, so does my pain - and of course, when my stress levels increase, it is usually related to increased work load and that makes it less likely that I take time to do the things I need to do to manage things!! It is a vicious cycle.

    Now when my pain starts to flare, I take a lot of time out to focus on getting good sleep, and working on relaxing - given that my pain is stress-related, it helps to get my stress under control! Having worked pretty hard over the years a figuring out what helps prevent flares, I have changed my work station so that I have a sit/stand desk with multiple chair options for when I am seated (allowing frequent posture changes), and I sign up for registered yoga/pilates classes (so I am less likely to skip them, even when I am busy at work!).

    But the fact is that even with a lot of tools and practice, flares will still happen and then I just curl up in an epsom bath and try to get to bed early :)

    @Forum_Moderator said:

    Those are good tips. You said that you live with chronic back pain. How have you managed to prevent flare-ups? Can you tell us about a particular time?



  • Those are good tips. You said that you live with chronic back pain. How have you managed to prevent flare-ups? Can you tell us about a particular time?



  • Prevention can be a tricky little piece of work, that is true. Oftentimes, flares are related to overdoing activities (and sometimes even underdoing - like sitting for too long) and people may have an indication like a slight increase in pain... and indication they ignore in order to get something done. For example, perhaps you start to sweep your house and about halfway though, you back pain starts to feel like it's getting a little worse. But you ignore it because... well... you want to finish what you started.

    The first key to preventing a flare is listening to that signal. Just because you started a task, does not mean it needs to be finished without a rest.

    What I generally recommend for flares is learning what your baselines are. If you know that you can only stand for 10 minutes before your pain gets worse, and you can only sit for 15 minutes before your pain gets worse, then maybe you sweep for 10 minutes, then sit at your computer for 10-15 minutes, then take a short rest in a lying down position for 5 minutes, and then maybe you can go back to the floors.

    The other key is for those times where you really have no idea why your body decided to flare up. Flares can occur after a few days of doing just a little bit too much, again - this is a pacing principle. Many people with pain fall into the trap of doing a LOT more on their good days, and then paying for it. I always recommend not doing more than 10-15% of anything above normal amounts on your good days. That way it is less likely that the next day is a flare day.

    Pacing or activity journals can help, if you are having trouble figuring out what your baselines are.

    @Forum_Moderator said:

    We never would have thought to have a "flare-up box" ready! Great idea! So we've talked about the "Planning" part of the talk today...what about "Prevention"? It seems difficult/impossible to prevent a pain flare-up, no?



  • We never would have thought to have a "flare-up box" ready! Great idea! So we've talked about the "Planning" part of the talk today...what about "Prevention"? It seems difficult/impossible to prevent a pain flare-up, no?



  • Definitely. I always recommend having at least 2 different flare-ups plans, one for milder flares, and one for more severe flares. I often hear comments from people with pain that when their more serious pain flares hit, they don't even think about all the things that they would normally use to help them feel better, so I suggest actually creating a box with a list of anything you might need to do:
    eg: remember to cancel appointments if you have them.

    • remember to call someone to pick up the kids from school
      etc. These are the things that can go in the list, that is in the kit.

    Then you can put actual items in kit including a heating pad, the phone number for your favourite take out place, a movie you like to watch, a recording of a guided meditation that you like, medications that you might use (if you use them), your favourite tea. maybe even the phone number of a friend you can call to come and help you.

    @Forum_Moderator said:

    Interesting... we have heard that you should have a "flare-up plan" ready to go in the event of a flare-up. Can you tell us a few things to have in this "plan"?



  • Interesting... we have heard that you should have a "flare-up plan" ready to go in the event of a flare-up. Can you tell us a few things to have in this "plan"?


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