By: Joshua Swart, Dipl. Ac.
The dreaded flare-up! The patient comes in to see you to get better, and yet you managed to flare them up. Their pain got worse. They lost confidence in you and don’t want to get any more treatment. You lost a patient.
It’s happened to us all, and while it seems inevitable, the truth is it happens far too often. Flare-ups should be a very rare occurrence, if ever.
When it does happen though, the practitioner is left wondering, “Why? I did this treatment before on other patients and had success. I really thought it would work for the same problem on this patient”.
Let’s look at some reasons why flare-ups happen and how to avoid them.
First, you are not treating just a “problem” or complaint. You’re treating the patient. And what was done before on other patients that worked cannot be applied to just any patient. This isn’t paint by numbers.
Patients have histories as varied as there are numbers of people on the planet. And while it may seem like it’s just a game of chance that a flare-up may occur, it really isn’t. There is a simple way to avoid flare-ups: Properly classifying the patient as Mechanical or Chronic Systemic. When you do this, you will know which treatment approach to take and avoid any chance of flare-ups.
Mechanical vs. Chronic Systemic
Mechanical patients have straight forward conditions that can be easily neuromodulated and treated, regardless of how long the problem has occurred (days, weeks, months, or years). Muscle inhibitions can be reversed, and they test stronger in subsequent visits. Underlying causes of the pain can be treated using motor points, electro-acupuncture, and soft tissue work. The EXSTORE assessment can be carried out, and the results of that along with the patient history and intake provide everything you need for a straight-forward treatment plan.
In chronic systemic patients, we are working with patients who have conditions and diseases that are pre-existing or underlying which prevents the body from healing properly. Chronic systemic patients’ nervous systems are not able to properly process, nor control, pain.
Important to note though is with chronic systemic patients, we’re NOT talking about how long the patient’s MSK or pain complaint has been going on (e.g., chronic low back pain). Instead, chronic systemic means a long-term chronic condition that is systemic and affects the entire system, including the autonomic nervous system. This in turn makes it much more difficult to neuromodulate their pain, reduce their noxious stimuli, and promote healing.
If the proper classification is not recognized, at best your treatments will not work. At worst, you will flare up the patient’s pain and make their condition much worse than it was. In either event, this would lead you to question why, revisit the history, and make changes in your treatments. However, after a flare-up you may not get that chance.
Here are some common questions practitioners have regarding flare-ups in their patients:
Why do patients flare up?
As briefly noted above, a chronic systemic patient is unable to take a lot of stimulation, and when you treat them it is quite easy to provide way too much input into their nervous system. The patient’s body considers your treatment as noxious stimuli, and the cascade effect results in flaring up the pain cycle. Because the chronic systemic patient cannot modulate pain well, the mechanisms that control pain do not work properly and the pain becomes worse over time.
One technique that causes too much stimulation for a chronic systemic patient is using motor points. When treating motor points, we needle into the muscle. In the muscle are specific nerve fibers (Type 2 muscle spindles) that when stimulated, create a stimulus that the body considers very noxious. Superficial needling is recommended for these patients, along with other techniques.
Why did the patient feel better after treatment but got worse later in the evening or the next day?
Why did the treatments work one visit, and then after the next visit the patient flared up?
Chronic systemic patients are unpredictable. They already live with bouts of pain, fatigue, and many other signs and symptoms associated with their underlying condition(s). This is what makes it so difficult to find a causative/aggravating factor to their pain. Often the patient will report the pain is everywhere and all the time, or that it flares up for seemingly no reason. So, it is not surprising that adding in more stimulation in the form of treatment could also cause flare ups, particularly when combined with other factors that already exist, in an unpredictable way.
Stress, poor sleep, certain foods, or anything that flares their underlying condition can all vary depending on the day. Therefore, there is seemingly no rhyme or reason to what happens after a treatment. You cannot expect a reliable pattern. When this happens, don’t dwell on it. Just go back to the history and you’ll likely find chronic systemic signs and symptoms. And if you’re not sure, the patient should get blood work.
I have colleagues who tell me they had patients with fibromaylgia who responded well to motor points and electro-acupuncture
Fibromyalgia is a catch all diagnosis of exclusion. Primary care physicians (MDs) diagnose the patient with fibromyalgia when all other conditions/illnesses are ruled out. It is not an exact science. And “ruled out” means they have ruled out what they are looking for.
Primary care doctors also diagnose fibromyalgia when they give up and have no answers for the patient. This includes those patients who have a mechanical problem.
In any event, you can never trust anyone else’s diagnosis. Keep the information in consideration, but do not rely on it. Those who treated the patient before you do not take into account what you are looking for. And if a patient responded very well and claims to have had fibro, then chances are they didn’t actually have fibro. Again, go back in their history and see what you find.
The above classification system should be the gold standard for acupuncturists treating musculoskeletal problems and pain. Determining mechanical vs. chronic systemic is a very reliable way to avoid flare-ups – and drastically improve treatment outcomes. Of course, there will always be exceptions, and these are picked up more easily as you get more experience. If you ever have questions on a particular patient, you can always find help on Dr. Anthony Lombardi’s mentorship community, dranthonylombardi.locals.com.
You can also learn more about treating chronic systemic patients, including hypersensitive patients, in Dr. Anthony Lombardi’s various webinars and live seminars at aseseminarsllc.com.
Note: This article discusses post-treatment pain that is different than just normal soreness following treatment. When treating chronically inhibited muscles or tight muscles, patients may go through a period of soreness, followed by feeling much looser and less pain with increased function. This is typically normal and seen in patients with mechanical conditions.
*The above is a summary of chronic systemic and mechanical patients based on my experience and the work of Dr. Anthony Lombardi. For more information on this classification system, please refer to the source.