Stay Invested. How to NOT freak out over flare ups

We have all been there.

Your patient has been doing SO well! Consistent with their home exercises, hardly any pain when they come into clinic, their stride is bouncy and effortless, they are nothing but rainbows and unicorns…

YAY Physical Therapy

YAY Physical Therapy!!

UNTIL that fateful day when you go to grab them in the waiting room:


BOO Physical Therapy!!

Your patient slouched down and barely shuffles back to the treatment area: 10 out of 10 pain, couldn’t sleep last night, exercises made it worse, meds don’t help. …. pretty sure it is the first day of spring and it is snowing outside, my dog ran away, AND nothing is right in the world.Oh, no my friends we are dealing with a flare up!

Your patient asks: “Am I back to square one?”


Even though I have seen a few people through the roller coaster of recovery. My initial response is still to freak out, just like my patients! I’m frustrated and worried…what did they do…what did I do !? Keep calm. Just breathe. Here in the Johns Hopkins Outpatient Center (JHOC), I’m surrounded by some amazing clinicians, they help keep me grounded in times of crisis. My coworker Mark recently shared an antidote:

“Physical therapy is like the stock market, it has it’s UPS and DOWNS, but you have to stay invested to see gains.”

This is so true. Often in recovery there are ups and downs, but the general trajectory of improvement is UP. When a patient has been doing well and all of the sudden they find themselves in one of the troughs OF COURSE they are upset. It is up to the clinician to stay grounded and reassure our patients that they are not back to square one. Remind them how far they have come and that this too will pass. If you are a new clinician like myself and still have mild panic attacks when this happens, I would HIGHLY recommend the books of David Butler & Lorimer Moseley:


Explain Pain” and “Graded Motor Imagery”

They speak to the nature of chronic pain, the physiology behind it, and how to guide your patients through the difficult process of managing their pain with a large emphasis on education. The authors take a delight spin on the old adage : “No pain, no gain”

“Know pain, or no gain.”

Remember, there will be setbacks. Almost no one goes from constant or frequent episodes of pain to absolutely no pain every again. Don’t get discouraged. We must encourage our patients (and ourselves) to stay the course, keep committed to their exercises, and help them see how far they have come. Remind your patients when they come through the other side of a flare up they have the tools to feel better, it is up to us to help them trust in the recuperative powers of their body.

Before you know it, it will be back to the unicorns and rainbows (perhaps some kittens too!)


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