In prior blog posts (here) I’ve stated that I do not use the traditional pain scale. And, I’ve given an overview of how I instead focus on tolerance during sessions. Additionally, I reframe a person’s experience as baseline versus flare-up. Today I will develop this topic further. I believe it is an important change in perspective on the quest for neuroplastic change away from a dominant pattern of pain/danger.
I have not found in the literature any consensus definition of what baseline and flare-up mean . Here is how I define it. Baseline is the set of symptoms that a person experiences most consistently whether or not they are able to manage some activity level. I define flare-up as any negatively perceived change from the baseline set of symptoms. The domains of flare-ups that I address are frequency, duration, addition of symptoms, percent increase from baseline, and if they are aware of anything that may have an impact on this in either direction. I sometimes add other features as they pertain to the individual. This may include medication use, healthcare utilization, speed of onset, missed days of work, missed life roles, and days of isolation. Tracking these also offers opportunities for goal setting related to self management. It’s the flare’s interference with the person’s ability to function the way they want to that is particularly relevant.
It is imperative that people feel hopeful, not hopeless. It is common, in my experience, for individuals to have a sense of both constancy and randomness of their symptoms. This can leave individuals feeling helpless to impact their suffering. The idea that symptoms vary, can imply that something is influencing the change. If we can track symptom changes better, then we have an opportunity to decipher what may be contributing to that fluctuation. Importantly, this emphasizes that the pain is not random. Patients may learn to predict flare-ups through this process. I reinforce this idea every session to strengthen their sense of control over their pain as we determine what impacts how they feel and what they can do about it. To those with persistent pain, this guided discovery can be an empowering experience.
When I initiate this conversation, a common response regarding flare-ups is "I'm always flared", "my pain is constant", "my pain never changes," or "I have a flare up every hour lasting for an hour." If patients don't have a clear picture of this for themselves, that’s okay and to be expected. I educate them to think about it over the next week and we'll continue to revisit it.
Here is how I do it:
After they've conveyed their narrative I ask specifically about baseline and flare up:
-What symptoms do you experience constantly that rarely if ever change?
-Tell me about times that this elevates or changes, or symptoms that you experience sometimes but not always, I want to understand that more.
-What do you do when you experience a flare-up?
It is okay if people need some prompting with any of these questions. By all means give them examples if they need them.
It has been my experience that this typically takes patients a few sessions to begin to better define this for themselves. I reinforce the concepts at the start of every session by asking the following:
How many flares up have you had each day over the last few days?
About how long did they last?
What if anything did you notice that led up to it?
Was there anything you did that helped to alleviate it, or tried but wasn’t helpful?
And examples of how I document it:
First Visit:
Objective:
flare ups: Patient notes that flares feel like increased intensity, sometimes notes “stabbing” in neck, tension under tongue, burning in arms and legs as well. They last about 45-60 minutes.
strategies for self management: Patient tried to ignore flare up and sometimes it quieted down.
strategies for self management: patient identified that they really like dogs and flowers. Google images were searched for images they like the most and were printed out for them. They were instructed to look at them 5x/day and when a flare up begins
Subsequent Visit:
Objective:
flare ups: Patient noted that they experienced flares at 4 hours of work regardless if they took a break. They felt their feet start to bother them followed by low back, and LUE.
Strategies for self management: Patient reports that they are having a difficult time remembering to look at images and only reviewed them a few times.
Subsequent Visit::
Objective:
flare ups:flare-ups are lasting approximately 45 minutes.
what precipitates flare-ups: identified that feeling "unease" leads to a flare up.(instructed to explore this with her counselor)
Strategies for self management: Patient reported that she remembered to regularly look at images and that she likes them a lot and they make her happy.
Parry, E., Thomas, M., & Peat, G. (2018). Defining acute flares in knee osteoarthritis: a systematic review. BMJ Open, 8(7), e019804. doi: 10.1136/bmjopen-2017-019804
Parry, E., Ogollah, R., & Peat, G. (2017). Significant pain variability in persons with, or at high risk of, knee osteoarthritis: Preliminary investigation based on secondary analysis of cohort data. BMC Musculoskeletal Disorders,18(1). doi:10.1186/s12891-017-1434-3
Setchell, J., Costa, N., Ferreira, M., Makovey, J., Nielsen, M., & Hodges, P. W. (2017). What constitutes back pain flare? A cross sectional survey of individuals with low back pain. Scandinavian Journal of Pain,17(1), 294-301.
Von Korff, M., & Dunn, K. (2008). Chronic pain reconsidered. Pain, 138(2), 267-276. doi: 10.1016/j.pain.2007.12.010
Von Korff, M., Ormel, J., Keefe, F., & Dworkin, S. (1992). Grading the severity of chronic pain. Pain, 50(2), 133-149. doi: 10.1016/0304-3959(92)90154-4
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