How To Manage Pain Flare Ups

Nature Helps Calm Stress

Pain flare ups are a common occurrence with both acute injury or chronic pain. Knowing how to manage them well can be the difference between being able to maintain a high quality of life or not.

Pain flare ups, simply put, are a normal part of being a human in pain. Sometimes, they are related to something you have or haven’t done, but many times, there is no discernable cause for a pain flare up.

Most pain flare ups are short term – be it a few days or weeks – which can, at the time, seem like they will never end, leading you to pursue options for relief that are ineffective, costly and possibly even dangerous.

Instead, with this article, I hope to show you some strategies you can use immediately, or store away for reference in the (unfortunate) event of a pain flare up.

Why do pain flare ups occur?

Biological systems are non-linear, complex systems. Whilst it is easy to think of recovery as a straight line from injury to repair, in reality, things are a lot more up and down. (2)

In fact, I wrote about this in the last newsletter (you can subscribe at the end of this post, so you won’t miss any future issues).

This fact alone means pain flare ups are an expected, yet unpredictable phenomenon, but beyond saying that flare ups are inevitable, there are more issues at play.


Sensitisation is the increased sensitivity of the nervous system to stimuli, whether it is at a peripheral level (nerve endings throughout the body), a spinal level or in the brain itself (3).

Because of this process, what was once a pain free task can become painful over time.

Biologically this is designed to protect us from further harming an injured area, which works well in acute injuries, but with chronic conditions, where pain and tissue damage become poorly correlated, it’s not so useful.

Lowered tissue tolerance

Whilst similar to sensitisation, lowered tissue tolerance occurs when you do not use/load body tissues appropriately over time and they decondition.

Whereas sensitisation is purely neurological, tissue tolerance is related to structural changes as well as a heightened sensitivity. The two often go hand in hand.

An easy way to understand this is with the example of muscle wasting caused by immobilisation. There is a reduced tolerance for load, and exceeding this can cause pain.

With both acute injuries and chronic pain, often the loading on the affected area is decreased, either consciously or unconciously, which leads to decreased tolerance of the tissues to loading.


Often people with pain, whether acute or chronic, expect certain things to hurt them.

I was wearing heels all day yesterday because I had a wedding, so I knew I’d be sore today.

What’s interesting about expectation, is that is a self-fulfilling prophecy.

If you think something will hurt, it probably will, thus confirming your thoughts.

That’s not to downplay the involvement of the activity in question, but there are studies that show simply priming  (3) someone with “old” words and thoughts causes them to walk more slowly, without even realising it.

With this in mind, if you are expecting the worst, then chances are you’ll get it. (4, 5, 6)

What to do about pain flare ups

Every strategy to manage pain needs to be individualised to the individual – no one thing works for everyone, nor does anything work the same from person to person.


Acceptance and Commitment Therapy (ACT) is becoming more and more popular in treating/managing pain, because it is so effective (7).

What is so powerful about ACT, is that accepting flare ups will happen, and that you will be in pain, takes away their biggest weapon – frustration and disappointment.

In ACT, thoughts and feelings are not considered to be “helpful” or “unhelpful”. This is important during pain flare ups, because pain can cause us to think negatively, painting situations into worse than they are within our minds.

In essence, ACT is a form of mindfulness.

This is probably the most challenging thing to master, but when you do, the results are profound, both in the context of pain, but also in the greater context of your life.

Modify your activities

Whilst in the long term, avoidance strategies aren’t very successful, because they simply reduce what you are capable of, in the short term, as a management strategy, modifying or even ceasing activities that hurt is a viable option.

Ideally, you will continue as best you can, with what you want/have to do, but it is completely reasonable to put things off.

This makes intuitive sense: if you have low back pain and it hurts to bend, then you will likely avoid bending when it hurts.

However, as mentioned, simply avoiding bending forever is not a solution, and actually makes things worse.

A better approach is to see if you can modify how you bend, and how much you are bending in the short term, whilst working to restore the ability to bend freely in the long term, using a graded approach.

Use pain relieving techniques that work for you

When in pain, it’s natural to want to get rid of it as soon as possible, no matter the cost.

Unfortunately, there is no one medication/therapy/product that can effectively eliminate pain in everybody, all the time.

So, instead of chasing a magic bullet that drains all your time, money and energy, it makes sense to stick with proven strategies.

Once you have found your “recipe” for relieving pain, you can seek to optimise it, with less conventional methods, if they are safe.

Things you can try, which do have effectiveness to varying degrees are:

Focus on what you can do

It’s really hard to stay positive during pain, the whole point of pain, from a biological perspective, is to over-ride our consciousness to take alternative/evasive action from our current situation.

This means a stress response, and a stress response, physiologically, is designed for action, black/white thinking.

What this can do, is cause you to focus on negative thoughts and emotions, setting of a vicious cycle making things worse over time.

If you focus on what you can do – with both a macro and micro perspective – then you completely shift the way you are living.

After all, if you can’t control whether you experience a pain flare up, wouldn’t you at least want to control your thoughts and activities?

BONUS TIP: Spend time in nature to calm stress

Just as I was editing this, I realised it was hard to find pictures of “pain flare ups”, so instead I went for a calming picture of nature, because spending time in nature is quite beneficial for a multitude of reasons, but simply put, time in nature calms our bodies and our minds, which is a massive key for anyone in pain.


Pain flare ups are a massive challenge for patients and practitioners alike, for many reasons.

As with most things, there is no quick fix, but you can definitely improve your experience of pain flare ups in the short term, whilst in the long term, a tailored pain management strategy can help reduce or even eliminate them.


This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1) Complex systems theory

(2) Neurobiology of pain

(3) Priming

(4) How expectations shape pain

(5) The subjective experience of pain

(6) Expectation of pain enhances response to non-painful stimuli

(7) ACT

Why Mobility Exercises Don’t Work, And What To Do Instead

Man with great mobility doing yoga with laptop

You don’t wake up one day suddenly stiff, it only feels like that.

Mobility, like most skills, exists on a “use it or lose” basis.

Unfortunately, for most of us adults, our daily lives don’t incorporate much “using it”, so we end up “losing it”.

The best way to maintain mobility if your life doesn’t have you climbing trees and crawling around on a daily basis is through exercise, but, if you have already lost a large amount of mobility, then you’ll have to work specifically to regain it, exercise alone is often not enough.

If you ask google “how to increase mobility”, the top 5 results say roughly the same thing: stretch, foam roll, perform dynamic “joint mobility” and “activation” exercises.

These are valid, but incomplete strategies.

The reason being, lack of mobility is usually not a true range of motion issue – I could lie you down on a treatment table and passively move your joints through a much greater range of motion than you can demonstrate – but rather, a stability issue.

Instability is perceived as a threat by the central nervous system, so protectively, it shuts down range of motion so you can’t cause yourself any harm.

Thus, the underlying cause of limited mobility is neurological.

So, in order to improve mobility in the real world, you must go deeper than foam rolling and targeted stretching/joint exercises and “release the brakes”.

If you don’t, you will just end up spinning your wheels, because when improperly applied, mobility exercises don’t work.

This is because you can’t force the body to do anything, it will resist in an effort to maintain equilibrium.

Now, there are definitely cases where there are physical changes to soft tissues and joint structures that limit mobility, but, outside of diseases and trauma, these physical changes usually occur as a result of the limited mobility caused by the nervous system (use or lose it principle).

So, if you have lost mobility over time, how do you get it back? There are many ways, this is the process I’ve found effective and use with my patients:

Osteopathic Manual Therapy

Being an osteopath, I like to start with manual therapy, but not for the reasons you might think.

Manual therapy doesn’t change tissue length, nor does it “put you back into place” or “re-align” you.

What manual can do, and in the hands of a skilled practitioner, does very well, is provide the body with a chance to change.

Movement, or motor output, is the result of complex co-ordination that takes place in the brain, based in part, on sensory information provided by the peripheral nervous system.

Nociception, the transmission of “danger” signals to the brain and spinal cord from nerves located throughout the body can inhibit motor output.

Nociception is related to, but not the same as, pain. You probably know that if something hurts, it usually doesn’t work well. This can also happen when that something doesn’t necessarily hurt, but the nerves are hyper-active anyway.

Because the body functions as a whole, when one area isn’t moving properly as a result of this increased nociception, then there is a chain reaction throughout the rest of the body.

By using manual therapy, we can inhibit nociception, change motor output and affect a change throughout the rest of the body – often decreasing pain and increasing mobility.

Often manual therapy alone is enough, especially if the issue is relatively new or minor, and new, dysfunctional patterns have not had time to become ingrained. If the problem has been around longer, or is not responding to manual therapy alone, we can move to the next step.

Restore Reflexive Stability

Reflexive stability is the term physiologists give to the near instantaneous adjustments that take place when we move.

This allows us to move safely and effectively, and usually efficiently.

With disuse and pain, this response is dulled, and one of the results is an increase in stiffness, which is designed to protect us in the absence of true stability.

To restore this, you have to go back to fundamental movement patterns, progressing to the next only when you have reached mastery each position/stage.

As mentioned earlier, most stiffness is the result of instability, rather than a true range of motion issue. With this in mind, regaining lost reflexive stability is an effective way to improve mobility by addressing the underlying cause.

Reflexive stability exercises are by nature, whole body movements, performed in progressively more challenging positions/postures.

For the vast majority of people, a combination of manual therapy and reflexive stability exercises will improve most mobility deficits.

For an example of reflexive stability in action, try this simple test:

Perform a squat, noting your depth and the amount of tension involved in achieving it.

Now, get down on your hands and knees and perform 60 seconds of quadruped rocking (below):

After 60 seconds, get up and retest your squat.

If you notice an improvement, then you just witnessed the benefits of reflexive stability. If it was the same for you, then either you don’t have a deficit, or your deficit is elsewhere.

Maintaining Reflexive Stability

After you have gone through the progressions, moving from ground based to upright, the easiest way to maintain your reflexive stability and build your health is by walking properly and walking regularly.

Walking is largely reflexive – a lot of the control occurs at a spinal, not brain level – which means that once you have restored your reflexes, maintaining them simply requires using them.

Now, any old shuffle won’t do, what you want in order to reap the benefits, is to walk with a contra-lateral arm swing, looking up. Ambling down the street with your phone in your hand and your eyes on your phone isn’t going to help you, it’s only going to re-inforce the issues the caused you stiffness in the first place.

For most people, especially those of you who don’t exercise, these two steps alone are enough to restore the mobility you need to go about your daily living.

If you are exercising and/or you want to take things even further, then we can add a few more steps.

Active Stretching and Functional Movement

If you have addressed potential issues with manual therapy and general (reflexive) stability work, but you’re still not getting the specific mobility improvements you want, it is time to begin more targeted work.

One form of targeted mobility work I like to use is “active stretching”.

Active stretching is probably just another name for PNF (Proprioceptive Neuromuscular Facilitation) stretching, but it’s simpler for my patients to understand, so I prefer that.

Active stretching is where you are stretching a muscle group whilst simultaneously activating opposing or synergistic muscle groups – essentially adding stability to the newly explored range of motion.

I’ve found this to be far more effective than passive static stretching, and it really helps people “get” what a joint position is supposed to feel like.

If you then use this increased joint range of motion in more demanding, functional tasks, then you “teach” the body that this range is okay to use, because you are adding strength/stability to a previously weak/unstable position.

This results in an increase in mobility.

In the following example I shared on Instagram, I’m using an active hip flexor stretch, followed by an isolated glute activation exercise before reinforcing the new pattern under load with a barbell squat:

If the problem was at the ankle instead/as well as at the hips, another sequence might involve an active calf stretch (demonstrated below), followed by a dynamic mobilisation of the ankle joint before squatting.

Again, these exercises are not only addressing range/length of a joint/tissue, but improving stability, which, as we discussed, is often the real driver of joint mobility.

The functional exercise then reinforces the pattern, and once repeated enough times, in correct fashion, it is usually enough on its own to maintain the improvements in mobility.

Whilst I demonstrated the example with a barbell squat, this isn’t necessary, you might simply perform a full squat position, as millions of people around the world do on a daily basis, in order to maintain mobility.

As always, the execution will depend on your needs and wants, but the underlying principles remain the same.

An Aside On Exercise Technique

In the examples above, the active stretching is then reinforced by the high demands imposed by the squat.

However, if you are squatting with poor form, then you are undoing the effects of the active stretching.

Good form is easy to spot – it is controlled, stable and smooth. Whilst everyone has different body shapes and sizes, thus the execution of movements will look different, the ability to perform controlled movement should be universal.

It’s also important to understand that if you skip straight to exercise, without addressing the stability issues first, then your body will simply “survive” the exercise by using whatever movement pattern is strongest, optimal or not.

Once you have addressed these issues, using optimal exercise technique reduces the need for continuing mobility work – once you’ve got it, maintaining it is easy – this is why in countries where people continue to squat throughout their life, mobility deficits are less common.

Maintaining Mobility

Maintaining mobility is relatively simple: use what you have got.

If you are coming to this article with restrictions, then it is still simple: regain what you’ve lost, then use it to keep it.

If you go to all the effort and expense of getting treatment and performing the work to regain mobility, only to continue with the lifestyle that got you needing treatment in the first place, then chances are, you’ll end up back where you started, given a long enough time frame.

Because we don’t have many (any) physical demands to survive anymore, we have to deliberately perform tasks that challenge us physically, including our range of motion.

This goes against human nature, which is to conserve as much of our energy as possible – it’s wired into our brains to do this – so, what I recommend is to build mobility maintaining activities into your day.

Examples of mobility maintaining activities are:

  • Walking properly (as discussed earlier) instead of driving short distances
  • Sitting on the floor to watch TV instead of on a couch
  • Squatting instead of bending to pick things up from the ground

Whilst these activities are not going to prepare you for a Cirque de Soleil audition, they will help with your activities of daily living (ADL) and your quality of life.

Beyond this, exercise, particularly full range of motion strength training, in all its forms, is the best way to maintain, and even improve mobility.


Mobility exercises need to be used in context. If you use them when you have an underlying stability issue, either at the stiff segment or elsewhere in the body, they will not be effective.

Used in a sensible, principle based approach, like the one I outlined above, they can play a valuable role in regaining mobility.

Once you have restored lost mobility, it’s much easier to maintain. This can be done by incorporating activities into your day that require you to use extra mobility.

Walking is one of the best general exercises, if you do it well, and can help maintain good health, including mobility.

For more focused efforts, full range of motion strength training is probably the best way to maintain and even improve joint mobility, once you are moving correctly.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




Nociception and motor function

Cutaneous afferent regulation of motor control

Feed forward control and movement stability

Physiological basis of functional joint stability

Training the Core

Lower motor function, Lederman, E., The Science and Practice of Manual Therapy, pp 99-100

Osteopathy for Headaches and Migraines

Woman with headache

Chronic headache is the most common neurological complaint presenting to GPs in Australia. (1)

This means it’s likely to be even more widespread than statistics suggest, as many people simply don’t seek medical treatment for chronic pain conditions.

So it’s safe to say, headaches and migraines are kind of a big deal.

Most people experience headache at some point in their life. If it is simply a one off, or infrequent, then most of the time, the best management involves either putting up with it, taking simple over the counter analgaesics or getting treatment from an osteopath (or similar).

However, when headaches are persistent, more targeted management is needed, and the first step is identifying the type of headache you have, which will influence the type of treatment accordingly.

Types of Headache

When it comes to headaches and migraines, there are two broad categories:

  1. Primary headaches, which the headache is the problem itself. These include migraine, tension type headache, cluster headache and other (less common) primary headaches.
  2. Secondary headaches, where the headache is a symptom of an underlying condition, including meningitis, brain tumours, aneurysms and brain bleeds. (2)

Because of the serious nature of the underlying conditions that cause secondary headaches, new headaches, particularly very intense or persistent ones, and those with other neurological symptoms like nausea, dizziness, visual changes and loss of balance should be examined by a medical professional.

This post will look at primary headaches and migraines, to give an understanding of the physiology involved as well as treatment options and self-management strategies.

The Headache Continuum

Primary headaches account for 90% of headaches, and are a common cause of visits to health professionals, including osteopaths.

The two most common form of primary headache are migraines and the tension type headache.

Understanding the difference between the two will help identify appropriate management strategies, so an accurate diagnosis is imperative (this means seeking out someone who went to university and studied medicine, not someone who watched an episode of House and wrote in an online forum).

A helpful way to understand the differences between tension type headaches and migraines is by the use of a continuum (3).

Health professionals love a good continuum, and I’m no exception. In the case of headaches, we have migraines on the far left and tension type headaches on the far right.

Headache-Migraine Continuum

In terms of the continuum, we have neuro-vascular involvement (migraines) at one end, and psycho-neuro-muscular involvement at the other (tension type headaches).

Though not officially recognised by the International Headache Society (IHS), there tends to be an agreeance amongst many clinicians and academics of the existence of mixed type headaches as well, which would exist about halfway along the continuum.

Finally, for this post, we will consider cervicogenic headaches, as commonly diagnosed by osteopaths and physical therapists, as well as GPs, to be similar to tension type headaches, in that the clinical features and physiology underpinning them is quite similar.


Migraines are typically intense headaches that can last up to 3 days, often accompanied by other neurological symptoms such as photophobia (sensitivity to light) and dizziness. There are two main types of migraine – those with an aura and those without.

Migraines involve the activation of, or the perception of, the activation of the pain-producing innvervation (nerve supply) of the cranial blood vessels. (4)

Diagnosing migraines comes down to a careful history.

As migraines involve a heightened sensitivity to change in stimulus, with a careful history, often triggers can be identified and managed.

Although this is a tedius process, for those sufferers who can identify specific triggers through a process of elimination, managing migraines with lifestyle changes becomes a whole lot more viable.

In addition to lifestyle changes, there are medications which are effective in both the management of acute migraine and in the prevention/reduction of chronic migraine.

For acute migraines, one of the most effective interventions is to take 900 mg of aspirin along with 1000 mg paracetamol. (5)

In some people, NSAIDs (Naproxen, Ibuprofen etc) will have a better effect.

In many cases, there are more specific medications that will work better than those listed, though the list is long-ish, so it might take some trial and error to find out the specific medication and dosage that works for you. Again, work with your doctor, not a blog, to figure out the best approach for you.

Please understand, all medications (in fact, all interventions) have potential side effects, so before you go taking any medications, get medical advice.

Tension Type Headaches

Tension type headaches are mostly diagnosed on an exclusion basis – that is, they don’t have particular features that would classify them as another type of headache. They are the most prevalent form of headache, but often go untreated, as people don’t seek out assistance for them.

The specific patho-physiology of tension-type headaches isn’t clearly understood, but the name implies some form of mental or physical tension involvement, which is agreed upon by headache researchers.

The reason they exist at the opposite end of the continuum to migraines is the absence of vascular involvement. (6)

It is most important to get an accurate diagnosis, as these headaches, are quite a clinical challenge to treat. So if you actually suffer from migraines, but get diagnosed as suffering from tension type headaches, you are potentially missing out on efficacious treatments.

Many people with tension type headaches experience exacerbation in times of psychological or physical stress.

If this is you, pro-actively managing your stress is one of the best preventative treatments available.

Additionally, tension type headaches often have a muscular component – that is, physical tension produced by overactive muscles, usually across the face, head and neck.

Osteopathy For Headaches and Migraines

What is interesting about headaches, is that, in terms of nerve supply, facial and cranial areas are all supplied by the trigeminal nucleus.

So although the cause may differ between a migraine and a tension type headache, the origin, may be the same.

This is clinically significant, because the trigeminal nucleus blends with the nerves from C1, C2 and C3 (the upper part of the neck).

This means that treatment to influence these nerves, can, theoretically, influence all kinds of headache.

Unfortunately, theory doesn’t always translate to practice, but many osteopathic techniques to treat this area relatively safe and risk free, with the big exception being techniques that involve end range rotation of the neck, thus it may be worth exploring.

Additionally, for most people, osteopathic treatment can help relieve some of the systemic effects of headache, including an increased stress response and muscular tension.

Some of these systemic effects include:

            • Sympathetic inhibition via rib raising. The sympathetic nervous system is involved in the stress response, including blood vessel dilation/constriction, which can potentially affect migraines. (7)
            • Parasympathetic stimulation via manual therapy and breathing exercises (see the image below). The parasympathetic nervous system counteracts the sympathetic nervous system, and stimulation is involved relaxation and recovery from many stress mediated conditions. (8,9)

Take a deep breath.Chances are you’re not aware how breathing can improve your health and wellbeing (beyond keeping…

Posted by Integrative Osteopathy on Monday, 8 February 2016

These manual techniques can be quite effective, however, as previously mentioned, it is important to “treat the person, not the headache” and consider psycho-social variables as well.

An osteopath can help you recognise and deal with particular triggers of migraines or your response to stressors that might be contributing to your tension type headache and if there is further management required, an osteopath will work alongside your “health team” which may include your GP, neurologist and possibly a psychologist to optimise your management.

What Can You Do For A Headache?

Best practice for the treatment of painful conditions involves what is term an “active approach“, that is, an approach where you are engaged in you care and actively participating to achieve a result.

i.e. “doing something”, as opposed to merely showing up and receiving treatment passively, or having something “done to you”.

This means, if you are suffering from headaches you can definitely do a few things that may help relieve or reduce the incidence:

                          • Educate yourself. Understanding a problem can help you deal with it better. Understanding alone doesn’t seem to improve pain outcomes, but when combined with other active therapies (as listed below) and incorporated into your medical management, it makes a big difference.
                          • Increase your physical activity. If you don’t meet the guidelines (>30 mins daily of moderate activity), then increasing your activity by walking more will have general health benefits that may improve your headaches.
                          • Practice mindfulness. Mindfulness helps you deal with stressful situations better. It also “strengthens” your brain, building neural links that are often negatively impacted with pain.
                          • Sleep better. Improve your sleep hygiene – take electronic devices out of your room, use black out curtains and keep the room slightly cooler than the rest of the house. Additionally, build a bed time routine so that you fall asleep more easily. Fatigue can increase neural sensitivity, and the only way to combat fatigue is with adequate high quality sleep.
                          • Talk to people. Chronic pain, including headaches, can be quite debilitating, as well as isolating. Talking to others who suffer from headaches/migraines in support groups, or a professional counsellor can help with some of the negative thoughts and feelings that develop around pain and often times make it worse.

The best thing about all of these things, are that they are either free, easy to do or both.


Headaches are debilitating, yet with a proper diagnosis, treatment and management is possible.

This treatment must incorporate biological (physical) as well as psycho-social factors.

Looking at the research on osteopathy/manual therapy and headaches, it can seem that often times “nothing much can be done about them”.

However, when you look at physiological plausible mechanisms of treatment, and apply these to both the causes and origins of headaches, the picture seems more promising.

As always, there is no holy grail, and getting on top of things takes a team effort between yourself and your practitioner(s).

Additionally, there is much you can do for yourself, which, while it may not be “headache specific” can greatly improve your health, wellbeing and potentially your headaches.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1,2, 3) RACGP – Management of Chronic Headache

(4,5,6) Wall and Melzack’s Textbook of Pain

(7) Rib raising and autonomic activity –

(8) Osteopathic Manipulative Therapy and HRV – unpublished research from London School of Osteopathy

(9) Deep breathing, pain and autonomic activity –

(10) Relationship between rcpm and dura –