Q&A Time! How to Handle a Flare-Up (You Caused) | Modern Manual Therapy Blog

Q&A Time! How to Handle a Flare-Up (You Caused)

This edition of Q&A Time comes from a comment on last Thursday's post, No Pain, No Pain. Apparently, many of my facebook page's followers do not regularly read my blog - you can see that thread here. The question is below.

"I've found that using this approach greatly helps with rapidly assisting most patients to gain function quickly, however I'd like to get you're thoughts on decreasing threat that has inadvertently been introduced during the examination Dr. E.

I've had several patients on my caseload who have definitely had ramped up sensitivity to movement. Sometimes simple movements or motions will set them off in the treatment room such that it's very difficult to continue with any thing manual, active, or passive movement wise without setting off alarm bells. Do you have any techniques or methods for helping to "hit the reset button" so to speak and allow treatment to continue?"

First let's talk about things you can do to minimize the above scenario
  • perform no provocative special tests or repeated motions
  • once you listen to the patient, and realize flexion or unloading based repetition or prolonged positions worsen or reproduce their complaints, avoid testing those and just look for the directional preference
  • explain the stop light rule (review here)
    • make sure to point out that any red light is a temporary flare-up
    • make sure they know the difference between a red and yellow light - discomfort they can walk off
  • most patients also need a moderate to heavy dose of Pain Science Education to minimize threat and make them realize pain does not equal harm

The above may take even 10-20 minutes or more, but laying down that groundwork makes for less fear avoidance if anything sets off that alarm in their CNS.

If that alarm goes off and they become intolerant to any movement, position or technique, these are the steps that I follow
  • apologize for temporarily irritating their complaints
    • be sure to use "irritation" and "complaints" lest they think "damage" their "insert tissue/structure here"
  • switch gears and say there is normally a position of ease which if held for a period of time, will calm down this irritation
    • this position of ease should be hopefully different enough from what you were doing to make it novel and not associated with whatever flared them up
    • use heat/ice/stim or any passive modality you have at your disposal to ease their comfort
  • if they have their phone/earbuds, have them listen to their favorite song
  • during the position of ease, have them picture their baby's face, child/ or pet, which should release some oxytocin
  • work on diaphragmatic breathing to calm their facilitated system down

In the end, it's also about keeping your cool, presenting it as useful information (we know you're not quite ready for that yet), and moving on to a position/motion/activity that calm it down. This normally happens with spine patients more than extremitiy, so having a table that can easily position them in the directional preference, that you can ease into over 20-30 minutes over heat/ice really helps.

Any thoughts as to you handle an iatrogenic flareup? Comment below or on the Facebook page!

Keeping it Eclectic...


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