II. Definition: Chronic Pain Flare

  1. Flares are same pain type and same location with an increase in intensity

III. Protocol

  1. Rule out serious new or progressive underlying condition
    1. Flares are an increase in the same pain type at the same location
      1. Recognize obvious triggers (e.g. overuse, stress, acute medical illness)
    2. Tolerance to medication therapy occurs early in course
      1. After first few months of pain management baseline dose should be stable
    3. Evaluate new pain or red flags (e.g. neurologic deficit, fever or other systemic symptoms)
  2. Help the patient manage the flare and cope with the crisis
    1. Reassure patient that flares are increase in same pain and not a new serious condition
    2. Manage contributing factors
      1. Specific exacerbating factors (e.g. cough exacerbating thoracic pain)
      2. Manage comorbid Insomnia, Anxiety Disorder, and Major Depression
    3. Eliminate barriers to flare improvement
      1. Chemical Dependency needs to be treated
      2. Develop coping skills and reduce stressors
    4. Reset reasonable expectations for pain management
      1. Flares have clearly defined endpoints and limited duration (days to a couple of weeks)
      2. Pain management returns to baseline after flare
      3. Flare management is the patient's responsibility and they need to develop a toolkit
    5. Medication dose increase protocol
      1. See below
  3. Patient establishes management strategy for next pain flare
    1. See management below
    2. Patient is in control of their flare management (maximize the toolkit - see below)
      1. Active self management is critical
      2. Practicing techniques with each flare is important to longterm management
    3. Mnemonic: BUMS
      1. Behavioral (e.g. breathing techniques, relaxation, pacing activity)
      2. Unloading (e.g. Chiropracter, Splinting and Assistive Devices)
      3. Movement (e.g. Tai Chi, Pool Exercises)
      4. Stimulation (e.g. Heat therapy or Ice Therapy, TENS unit, Massage, Acupressure)

IV. Management: Relaxation Techniques

  1. Breathing techniques
    1. Imagine body as hollow
    2. Imagine breathing-in fills a hollow body and breathing-out empties the hollow body
  2. Muscle Relaxation Techniques (e.g. Shoulder shrugs, head circles, Shoulder rolls)
    1. See Progressive Relaxation in Hypnosis (can be adapted for general relaxation)
  3. Music therapy

V. Management: Local pain management

  1. See Chronic Pain Management with Physical Therapy (also covers energy conservation)
  2. Local Cold Therapy
  3. Local Heat Therapy
  4. Contrast Baths
  5. TENS Unit
  6. Acupressure
  7. Ball Therapy

VI. Management: Pharmacologic Therapy

  1. See Acute Pain Control
  2. No more than 30 doses per month
  3. Additional Opioid to <2 week duration
  4. Maximize non-Opioid medications that are specific for flare type
    1. Muscle relaxants
    2. Antiinflammatory medications (e.g. NSAIDs)
    3. Neuropathic pain agents (e.g. Gabapentin)
    4. Consider Antidepressants and possibly a short course of Anxiolytic

VII. References

  1. Belgrade (2009) UMN Internal Medicine Review, Minneapolis

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