Pain Flare-Up Plan
A worksheet for building a written plan for pain flare-ups before they happen: recognising the early signs, the thoughts that turn a flare into a crisis, what to do and not do, and how to get back to baseline afterwards.
About this resource
Flare-ups are part of living with chronic pain. Even with good pacing, pain will rise sharply from time to time, sometimes for an identifiable reason and sometimes not. What distinguishes people who manage flares well from those who are derailed by them is less the intensity of the pain than the response to it. Catastrophic appraisal ('this is the damage getting worse', 'I'll never get back to where I was', 'I can't cope with this') drives fear, muscle tension and a rapid retreat into rest and avoidance, which Vlaeyen and Linton's fear-avoidance model identifies as the route to greater disability. The flare then lasts longer, confidence collapses, and each flare leaves the person doing a little less than before.
A flare-up plan applies problem-solving in advance. Decisions about what to do are made when the person is calm and thinking clearly, and written down so that they do not have to be made in the middle of the flare. The plan draws on CBT for chronic pain (Otis) and on ACT (Dahl and Lundgren): it identifies early warning signs, the catastrophic thoughts and a more accurate alternative, practical coping steps including reduced rather than abandoned activity, willingness to have the pain without fighting it, and a specific route back to the usual baseline. It also addresses the two common errors: pushing through and making the flare worse, or stopping everything and making recovery slower.
The professional version notes that the plan should be built when the client has already learned pacing and some cognitive skills, that medication use during flares should be discussed with the prescriber rather than in therapy, and that new or markedly different pain needs medical review rather than a self-management plan.
How to use it
- Build the plan in session, when the client is not in a flare. Use their last two or three flares as the raw material: what happened, what they thought, what they did, and how long it took to recover.
- Work through the catastrophic thoughts carefully and help the client write a believable alternative in their own words. A plan that says 'stay calm' is useless; a plan that says 'this is a flare, I have had them before, they pass' is usable.
- Be concrete about activity: what a reduced version of their usual routine looks like, so that the choice is not between full activity and bed.
- Include willingness explicitly. Fighting the pain with tension and anger adds a second layer; the plan should give the client a way to acknowledge the pain and make room for it.
- Ask the client to keep the plan somewhere accessible, and review it after the next flare. Adjust what did not work.
References
- Otis, J. D. (2007). Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach, Therapist Guide. Oxford University Press.
- Dahl, J., & Lundgren, T. (2006). Living Beyond Your Pain: Using Acceptance and Commitment Therapy to Ease Chronic Pain. New Harbinger.
- Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85(3), 317-332.
- Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation. Psychological Assessment, 7(4), 524-532.
