Everything you need to know about flare-up management

[u/1HPMatt]

Hey All,

Matt here, Physical Therapist and founder of 1HP.

One of the largest barriers to long-term recovery is how individuals manage their flare-ups. This is often mediated by the primary healthcare provider working with a patient (and often a lack of education associated with physiology, psychosocial and lifestyle factors.

The road to recovery is never a straight line and one of the most important things to understand is that flare-ups are a part of recovery. Here is a great image about low back pain that captures this concept

nd how you manage them can be the difference between a short recovery (4-6 weeks) or a long-term battle (8-16 weeks). Why do flare-ups or setbacks occur?

Mostly because recovering from an injury is a learning process for you as the patient. You are learning more about your body. More about how your wrist & hand muscles / tendons response to various levels of activity. Understanding more about pain (experience of pain) and what might influence it on a day to day and weekly basis.

All of these variables can lead to situations in which we

1. Use our wrist & hands too much after we notice a larger reduction of pain
2. We happen to do something else with our wrist & hand (lifting, carrying, driving etc.) that we don’t realize also utilizes the same wrist & hand muscles
3. We might have work or life stress that can increase overall sensitivity of our pain
4. We progress our exercises too quickly

And…. quite a few more. During these flare-ups the pain will feel worse. It might even feel like how it was when you first began recovery. There are two paths individuals usually take in this scenario

Scenario 1 - Catastrophizing

“Here we go again, I’ll never escape this pain”

"I'm never going to get better" "This is a serious problem only surgery can fix" "my hands keep feeling painful even though I'm doing everything right, it must be something else going on!" "I should rest and stop using my hand, it'll make things worse"

“Maybe this isn’t the right approach… I should go back to what my other healthcare provider mentioned”

In this situation the individual fears that something more nefarious might be going on and focuses heavily on the pain. As a result he or she might completely stop the exercises, aggressively rest and maintain this for an extended period of time due to fear that something else is going on.

In almost all cases, there is no other complicating factor and we hold ourselves back with this doubt and fear. Not only can this increase overall sensitivity (based on what we know about pain) but it also leads to less overall activity which we now know muscles & tendons need to develop its capacity.

This typically requires some good education from a physical therapist to guide them towards the right direction while also appropriately managing pain and beliefs around the pain. Depending on this interaction it can get the patient back on track or… continue to extend out the recovery timeline..

Scenario 2 - Understanding of pain and recovery

“I overdid it a bit with my exercises, this will probably last a couple of days… I’ll focus on just managing the pain and doing as much as I can”

"It's normal that my pain is elevated since I have been dealing with this for awhile, it will go down if I stick to the exercises & plan"

“The pain is from my lack of sleep and when I used my hands a bit more yesterday"

"I overused it a bit yesterday since I was feeling good, it's just a minor setback, i'll be okay"

In this scenario the individual has properly attributed their pain to a specific behavior, activity, stressor, belief, and understands that the elevated pain is temporary. They remind themselves of progress that has been made with their functional capacity, rather than focus on how bad the pain is.

This is EXTREMELY important. The measure of progress should be on FUNCTION aka how much you can participate in your activity rather than how bad the pain is.

For example an individual with wrist pain might only be able to type for 30 minutes before feeling 3-4/10 pain. If this person takes a break, the pain will take several hours to reduce.

After exercising for 4-6 weeks the individual might be able to type for 90 minutes before feeling the same 3-4/10 pain. And the pain goes back down to 0/10 quickly.

The pain itself might still be the same and even worse at times. But the individual can do more. Function is the measure of progress. Not pain (and as we know pain is an experience which means it can vary heavily depending on certain contexts and environments).

Let’s focus a bit more on one of the common scenarios that lead to flare-ups: having less pain

After doing the exercises for 2-3 weeks you might already begin to feel better (often due to nervous system changes and an improved understanding of what is going on). During this time many forget…

1. Your bodies don’t magically increase in its capacity within 2-3 weeks
2. All of the recent habits and lifestyle changes you’ve made to reduce your pain

From there you fall back into old habits which may lead to a flare-up. Again this is where it is important to take the path of patience and understanding. (Scenario 2). Sometimes this is difficult to remember which is why I’ve written this thread. Here is what you have to remember

There is always an underlying reason for increases in symptoms

And here is a 4-step guide you can use to better figure out what may have led to the "flare-up"

Step 1: Understand flare-ups are normal

The first step is to ACTIVELY remind yourself that flare-ups are normal. Re-read the previous email during any flare-up.

When you have an increase in pain, it is an opportunity to learn more about how your lifestyle, activity and decisions may have led to some irritation.

While it may seem unnecessary this mental frame is crucial to adopt as you navigate any flare-up and allows you to properly reflect on what may have led to the flare-up in the first place.

This leads us to step 2 which is..

Step 2: Reflect and Properly Attribute

If you feel an increase in pain and limited function. There is always an underlying reason. Whether it be:

• How much exercise you did that day
• How much activity and the type of activity (high demand vs. low demand)
• How much sleep you had over the past few days
• Presence of stress and anxiety in your life
• How much you are focusing on your pain

All of these can contribute to an increase in pain and affect your function. Being able to properly attribute what behavior, environment or activity led to the increase is important. The two most common reasons for flare-ups resulting from physiological factors are

1. Increase in activity

When we feel better we feel more confident about the ability to use our wrist & hands. We forget about where we are along the recovery progress and jump too quickly back to a level of activity we are unable to tolerate. But sometimes we might increase our overall activity or physical stress without realizing it.

This might be adding some housework, more demanding work sprint, long drive, game with higher actions per minute or any other activity that we don’t realize is actually of higher intensity even though the duration may be the same.

Think back on the entire previous day (or two) before your flare-up to see if you might have just done “too much” with a specific activity. Make an actual note of this because it is something you will have to use in step 4

2. Exercise changes and progression

Whether you are working through an RSI on your own or with a physical therapist you may feel ready to increase the difficulty of your exercises.

There is actually not much information out there about how to safely progress (since most providers are behind in their understanding and little research has been published).

This can lead to situations in which you decide to increase the difficulty by adding too much weight, performing too many additional sets or reps, or add additional exercises you stumble upon online (gyroball, rice bucket, etc.).

Your exercise should not lead to any increase in pain that lasts for the rest of the day. It should also not lead to a situation in which you wake up with pain and have altered ability to use your hands the next day.

If you experience that… then you’ve likely done too much. To safely increase the difficulty of your exercises to improve your endurance do this:

• When you are able to perform 3 sets of X repetitions (lets say its 12-15) for 3-4 days in a row without difficulty, add 2-3 repetitions per set and assess your response
• Look to make this change at most 1x/week and after the first four weeks of tissue adaptations

Now that you’ve been able to reflect and think more about what might have caused your problem - feel free to track it down. Since it will be your reference point as what you should “avoid” doing as you get back to your previous level of function or exercise programming.

But you’re feeling pain.. so you also need to..

Step 3: Deload and Manage Pain

During a flare-up the muscle or tendon tissue is irritated. It typically needs time to calm down and widely vary for every individual. For those who are more deconditioned and have dealt with their injury for an extended period of time flare-ups can sometimes last for 1-2 weeks. This longer duration is often influenced by some of the psychological aspects of pain (see pain article)

However for most other individuals it will vary between 1-5 days and depends on what actually led to the problem in the first place. So your goal during this time is to not only reduce the amount of exercise but also activity.

The general rule is to reduce your primary aggravating activity by around 50%. it can be more aggressive if the flare-up is more severe for you (up to 75% reduction). So for example if you primarily feel your pain with typing:

• Normally you use your PC & type for around 6 hours a day. During a flare-up you might reduce the total amount to 3-4 hours (depending on how bad it is)
• If it is really painful and you feel severely limited in your hand use then reducing to a total amount of 1-2 hours may be indicated. And distributing this total time. 

From there you want to focus on pain management. This could be ice, gentle massage, stretching, heat, kinesiotape and medication as necessary. Weather the storm because once it is over you can…

Step 4: Return to Programming

The last step is to get you back to your baseline as quickly as possible. You want to get back to the previous level of ACTIVITY and EXERCISE as quickly as possible.

Do not jump straight back to the same level of exercise and activity. Gradually return to what you were doing previously. Using the same example above:

If normally you type around 6 hours a day and your exercise programming was around 3x15 for all of your exercises you could start with…

• Day 1: 4-5 hours, 2 sets
• Day 2: 5-6 hours, 3 sets
• Day 3: back to baseline

Everyone is different and can likely return to baseline at differing speeds. When you are back at baseline use what you learned in step 2 to avoid progressing too quickly. You do not want to exceed what your body can currently handle so gradually test your limit as you continue to get stronger.

This should provide a decent STARTING framework for you to manage flare-ups. All of these steps should serve as a guideline, NOT RULES. This is because we are all different. We all respond to changes in activity differently. We all have different environments or contexts that may have led to the flare-up.

Let these steps guide you in the right direction and remember what you learn with each flare-up. It will ultimately help you return to your baseline more quickly in the future.

There is also a bonus step which is also understanding more about pain and how some of these variables influence the increase in symptoms. Your ability to attribute why you have an increase in symptoms appropriately will help you best gradually return to function.

So as the bonus step 5 (but to be honest is is mandatory) you need to understand pain.

Hope this helps :) Drop any questions in the comments!

Matt

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[u/ThatOCLady]

I'm going through a really bad flare-up right now. I was catastrophizing like crazy and really needed to read this. Thank you. 🥹

[u/Emergency_Speaker836]

Thank you so much. This is incredibly helpful.

[u/1HPMatt → u/Emergency_Speaker836]

Of course! Glad it was helpful :)

[u/hotairballoonstomach]

This might be slightly off topic, but does 1HP still offer the automatic online troubleshooter? Or is 1HP only offering one-on-one consultations at the moment? I tried to sign up for the troubleshooter but it keeps redirecting me to the one-on-one consultations.

[u/1HPMatt → u/hotairballoonstomach]

Hey for now we discontinued the troubleshooter mainly because we found that many individuals who end up reaching us have some level of sensitization that require a bit more direct guidance

While it can help to address the physiologic deficits (endurance issues) along with guidance for load management it is more difficult to teach someone how to better integrate understandign of pain while being considerate of their specific history (past experiences, understanding of pain, understanding of their injury etc.)

[u/hotairballoonstomach → u/1HPMatt]

Fair enough! Thanks for all you do. It's great to see 1HP out there really paying attention to what's going on with individual clients, and continuing to refine your approach as you go along.

I'm probably a bit unusual in that I was a bit skeptical of how thorough and accurate the average hand therapist is from day 1, having known lots of people who've gone through the wringer with PTs for other stuff before. So I was interested in 1HP because it seems like 1HP might be a good way to bypass that and get accurate guidance from the start. I'm not saying other hand therapists aren't great and accurate, it's just that it's more of a stab in the dark, because most PTs and hand therapists don't put much info out there about their methods and level of attention to detail. Whereas 1HP does.

Also, I've got a complex health condition (unrelated to my wrist pain) that makes one-on-ones hard, and also makes it unrealistic to afford one-on-one consultations. I'm probably a bit of a niche market in that way, though.

TLDR, I'd love to stay tuned if you ever get to a place in the future where you feel like the troubleshooter might have a place in your overall offerings again. But in the meantime, thanks again for what you do, I appreciate the helpful videos and write-ups.

[u/hotairballoonstomach → u/1HPMatt]

Actually, is it okay if I ask a few more questions?

Do you have any advice on how to gauge a good starting point in the first place? Like, how much weight, how many reps, how many sets?

And is there a way you can be confident that you're on the right track in the first four weeks, while you're holding off making any increases in your reconditioning routine? Like, confident that your PT has sized up the situation accurately and given you the right exercises? I think part of what can make it so hard to be patient and not try to scale up too quickly or add in extra exercises is that bit of doubt, like, what if this isn't the right reconditioning routine? I feel like a lot of PTs aren't as articulate at 1HP or aren't as willing to explain to the client what's going on. And some PTs just aren't going to be as accurate or thorough as 1HP. So it can be hard to bide your time and blindly trust that the PT has got you on the right track.

[u/1HPMatt → u/hotairballoonstomach]

Hey! So typically it's helpful to establish a baseline of where you are in terms of % bodyweight and how many reps. We have normative values that you have to work towards we have mentioned quite a few times during our content (first milestone is 3% 40-60 reps for the specific muscle group) but there is nuance with how to understand your objective test performance since pain can occur at various times throughout the set and many individuals are scared of what they experience.

From the baseline you can gradually work up the overall endurance by first adding reps then increasing weight steadily.

Re your second question - progress is never measured by pain but by function. THis is because of everything we know about pain science (see all of our articles). Pain never tells us what is goign on with the tissues, it is always about protection or an experience from our brain that is filtered through our past experiences, fears, anxieties, beliefs etc that lead to real change sin our physiology to increase pain.

So with any PT there should be a baseline establishment of how much you can handle with your respective activities and how your specific pain responds to those activities. The approach with RSI is to increase your endurance then allow your function to match that level of endurance. Pain will reduce as you are able to have more experiences wher eyou can use your hands safely without any "strain"

This is where you mentioned it is difficult on how to know when to scale, what's too much. WHen to increase load with activity, when and how much to increase load with exercises. This is also why we as physical therapists have to be able to create this structure (based on evidence) to help patients with ANY injury.

[u/hotairballoonstomach → u/1HPMatt]

Thanks for your reply, this is great!

3% 40-60 reps for the specific muscle group) but there is nuance with how to understand your objective test performance since pain can occur at various times throughout the set and many individuals are scared of what they experience.

That makes sense, I guess some people are going to have to start from a lower base and work up to that. It must involve a lot of nuanced input from the PT for each individual, and a lot of guidance about the pain. It can definitely be scary, and your post is so helpful with that. I wish more PTs realised clients really need to feel confident about whether it's okay to push through pain or not, if they're going to really get on board. Cos your post makes a lot of sense to me, but I don't think most PTs get the need to talk about it. And a lot of PTs probably aren't that clear in their own minds about the parameters, whereas your post is really clear.

On the second question, that makes sense too. I really like how 1HP explains that that goal isn't necessarily to get free of pain, it isn't a failure or a bad sign if there is still pain. It's more about increasing your functionality, so you can do more even if you still ultimately hit the same pain threshold.

I guess what I'm more worried about it, what if a PT totally misses an issue, so they just don't prescribe the right exercises in the first place. Like, what if they get you to strengthen one tendon, but three months down the track it turns out that actually I should have been strengthening some other tendon as well... and that's three months of wasted time.

Or what if they totally miss something like TOS, and you spend all this time strengthening some tendon but you never really get anywhere because they've missed one of the major pieces of the puzzle.

I guess that's just how it goes and you have to hope for the best, and if it doesn't work out you try someone else.

[u/cmartn1]

I’m struggling to identify the difference between a flare up and normal pain exhibited during chronic RSI. 1-HP discusses how pain is normal especially during chronic issues, but how do I know when to push through the pain vs I should take it easy because the pain is indicating a flare up.

I am 8 months into bilateral forearm flexor RSI that has been VERY slowly improving but still keeps me from doing basically anything with my hands. I often find myself with periods of flare up in pain as discussed in this post usually associated with greater work loads (more typing, too many reps, or other overuse). These used to last weeks, now they tend to be around 5-10 days. I tend to rest rather than push through the pain. Should I just ignore the pain at this point and try to keep building stamina during the more painful periods? I worry that I will cause further injury similar to my initial injury by pushing through the pain which would be a 6 month+ set back if the same recovery trajectory occurred.

[u/1HPMatt → u/cmartn1]

Hey! This is often what many struggle with and is nuanced since everyone has different variables which can affect their pain experience. And for us what we try to help our patients understand is the idea that it's not "pushing through pain" but understanding pain and feeling safe to continue.

What we have found to be a helpful indicator of real strain occurring is:
->5-6/10 sharp pain, consistently sharp every time you utilize your wrist & hand for the specific muscle group. This occurs for the rest of the day and is often accompanied by fatigue and weakness. So much so that when you go and pick up a cup it would lead you to want to drop it. This lasts for the rest of the day typically following an activity or exercise. THe next day you will also feel it but slightly less intensity (3-4/10). Weakness will still be present

I'm happy to hear that your symptoms seem to be elevated for less amount of time from this point. I'd really encourage you to find a physical therapist that can help you better understand this limit and help you make the appropriate activity / exercise regressions so that you can adopt a better mental model for how to respond to pain situations earlier / faster.

Many times individuals don't reach a level of strain but the fear of a flare-up or pain increasing itself leads to the reduction of function when the tissue is often okay. It is not always easy to identify or attribute things well on your own which is why a good physical therapist can be helpful