Pain Flare-Ups Don’t Mean You’re Getting Worse

Written by Dr. Amy Mackinnon, Chiropractor | Vital Performance Care | Calgary, AB

One of the most frustrating moments in chronic pain recovery is the flare-up.

You've been doing well. You've been consistent with your treatment, you've been moving more, things have felt manageable, and then, seemingly out of nowhere, the pain spikes. It might be worse than it's been in weeks. You go back to where you started, or at least it feels that way. And the thought that follows is almost always the same: something must have gone wrong. I must have re-injured it. I'm not getting better after all.

This interpretation is understandable. It's also, in the vast majority of cases, incorrect, and believing it can set your recovery back more than the flare-up itself.

What a Flare-Up Can Be

A flare-up in chronic or persistent pain isn’t necessarily the same as an acute injury. It can be a temporary increase in pain that occurs within the context of an already-sensitized nervous system, and that sensitization is the key word.

When pain has been present for weeks or months, the nervous system adapts. The spinal cord becomes more responsive to incoming signals. The brain becomes more vigilant about threats coming from the affected area. The threshold for producing pain drops. This is called central sensitization, and it is a normal, if uncomfortable, feature of how the pain system works in persistent conditions.

A sensitized nervous system is an excitable one. It responds to things it wouldn't normally respond to, and it responds more intensely than the input warrants. Which means that a flare-up can be triggered by things that have nothing to do with tissue damage:

• A poor night's sleep
• A stressful week at work
• Dehydration or illness
• A change in activity level, doing more or doing less than usual
• Weather changes
• An emotionally difficult experience 
• Sitting in an unusual position for longer than normal

None of these are injuries. None of them cause new structural damage. But in a sensitized system, any of them can be enough to tip the nervous system into a higher pain state.

Why Flare-Ups Can Happen During Recovery

This is the part that surprises most people: flare-ups are a normal feature of recovery from persistent pain. Not a sign that recovery isn't working, often, a sign that it is.

Here's why. In recovery from persistent pain, one of the things that has to happen is that the nervous system has to be gradually re-exposed to movement, load, and activity. The goal is to shift the brain's assessment from "this movement is dangerous" to "this movement is safe." That process is not linear. It involves periods of progress, periods of plateau, and yes, temporary increases in pain.

Think of it like building fitness after a long break. The first few weeks involve more soreness, more fatigue, more discomfort than your baseline, not because training is damaging you, but because the system is adapting and increasing it’s capacity. Recovery from chronic pain follows a similar arc, but the "soreness" is pain.

The flare-up is not the body telling you to stop. It is the nervous system recalibrating.

The Fear-Avoidance Cycle

The danger of misinterpreting a flare-up as damage is that it feeds a cycle.

Pain spikes → the person stops moving, out of fear of re-injury → reduced movement leads to deconditioning and increased sensitivity → the next movement or stimulus triggers more pain → more fear → more avoidance.

This is called the fear-avoidance cycle, and it is one of the most well-documented pathways through which acute pain becomes chronic pain, and chronic pain becomes permanent disability. The cycle is maintained not by tissue damage but by the belief that movement is dangerous, a belief that flare-ups, when misunderstood, reliably reinforce.

Research on pain outcomes consistently shows that catastrophizing, the tendency to interpret pain as more serious than it is, to ruminate on it, to feel helpless in the face of it, is one of the strongest predictors of poor recovery. Not injury severity. Not imaging findings. Catastrophizing.

Understanding what a flare-up actually is takes some of the catastrophizing fuel away.

What to Do During a Flare-Up

The instinct is to stop. To rest, to protect, to wait until it passes before resuming anything. For most people dealing with persistent pain, we may want to consider the following.

Stay as active as you comfortably can. This does not mean push through severe pain or ignore red flags. It means that within a tolerable range, continuing to move is generally better than stopping entirely. Movement sends safety signals to the nervous system. Stopping can send threat signals.

Don't make permanent decisions during a flare. A flare-up is a temporary state. It is not representative of your trajectory. Decisions like "I need to stop treatment," "I need to rest for a month," or "this is never going to get better" are made during flares and regretted after them. Wait. Breath. Be patient. Yes, this takes a little will power, I know… 

Notice what preceded it. Flares often follow patterns, a particularly poor sleep week, a high-stress period, a significant change in activity. Identifying the trigger doesn't always prevent the next one, but it gives the flare context and makes it feel less random and less threatening.

Talk to your practitioner. A good clinical response to a flare-up is not "rest and come back when it settles." It's an adjustment to the treatment approach, a conversation about what changed, and a re-establishment of the plan.

Recovery Is Not Linear - But It Is a Direction

Chronic pain recovery is a trajectory, not a straight path. It moves generally forward, but with oscillations. The mistake might be using any single data point, a good day, a bad day, a flare, as the measure of progress.

The measure of progress is the trend. And flare-ups, when navigated with understanding rather than fear, do not interrupt that trend. They are part of it.

If you're dealing with persistent pain and struggling to separate flare-ups from actual setbacks, or if your current treatment approach doesn't include a clear plan for managing flares, that's a conversation worth having.

Book a complimentary 15-min consult with Dr. Amy →

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References

Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317–332.

Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7(4):524–532.

Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807–813.

Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15.