Managing musculoskeletal conditions at work (Part 1) — breaking the boom and bust cycle

Lauren Finestone

A musculoskeletal physiotherapist talks about what pain is, ‘boom and bust behaviour’, activity pacing, making a flare-up plan and other useful self-management tips.

In an online event hosted by Musculoskeletal Australia, experts offered some tips, strategies and resources for people who are working and dealing with back pain or other musculoskeletal conditions. 

In a 3-part article, we look at their advice for how people can manage symptoms, go about changing jobs — if that’s the best self-management option for them —and understand their legal rights and responsibilities at work.

In this first article, Professor Anne Daly, a senior musculoskeletal physiotherapist, shares her tips about what people can do to manage their pain so they can be in the best shape to keep working and living as fully as they can. 
Understand your pain

One of the most important things is to understand that there are different types of pain. 

  • Nociceptive pain — is the ‘garden variety pain’ that begins in tissues, bones, joints, muscles or ligaments. Pretty much all of us experience it at some time. It's the pain when you sprain your ankle or 
    break a bone. We usually understand how this pain behaves and what we can and can't do to help it.
  • Nociplastic pain — this pain doesn't seem to have a clear cause. It's often seen in conditions like fibromyalgia and irritable bowel syndrome. This type of pain happens when there's a change in the nervous system, which can make it more sensitive and increase the person's response to pain.
  • Neuropathic pain — is pain caused by damage or disease in the nervous system, like from diabetes, a stroke, spinal cord injury or surgery. 

When you have complex pain or pain for a long time, usually more than one of these types of pain exist at the same time. Pain (like musculoskeletal pain) always involves the spinal cord and brain, even if they aren’t the cause of the pain.

And different types of pain respond to different treatments. Opioids may help with some types of pain, but not neuropathic pain. Massage or other techniques that work for some types of pain might not work or could even make neuropathic pain worse. 

Balloon about to be popped with a pin

Bust the ‘boom and bust’ cycle

This is where a person overdoes it at home or at work because they’re feeling pretty good that day. They often feel guilty about all the things they haven’t been able to do and so decide to do it all at once. Their pain then gets worse, so they rest up, feel better, and the cycle starts again. 

When this ‘boom and bust’ behaviour pattern becomes entrenched, the nervous system becomes more sensitive to pain signals. It starts to expect pain whenever we’re active. So It's important to notice this behaviour and think about how to change it. Taking breaks, trying different positions and being mindful of your habits can help.

Activity pacing

This is probably the most useful strategy Professor Daley has in her repertoire of things to help patients with complex pain and are stuck in that boom and bust cycle.
It helps you to predict pain and know how much you can do before you have a flare up of your symptoms. 

The first step is to choose 2 tasks — one that’s pleasant (doing something for yourself that would make your life a bit richer and enjoyable) and one that’s practical (something that would make your life or your work easier if you could do more of it) — and break them down into smaller parts to understand what each aspect of the activity involves. 

For example, say you wanted to attend a work meeting. Start with one task, like walking (or driving, standing, sitting or talking). For 5 days, measure how far you feel comfortable doing that task and keep track of it.

Then set a baseline at 80% of this average. (If there are big differences in the trial measurements, you may reduce the average by 50%). For the next week, practice the baseline activity level and then slowly increase it by about 10% each week. So if your baseline for walking is 10 minutes, in week 2, you’ll walk for 11 minutes 

That sounds like nothing. But heres’ the thing: it’s important to stick to the baseline activity level on good days and tough days. If you go over the baseline on good days this can lead to a boom bust cycle.  

The good news is on a good day you can just enjoy yourself and not feel like you've got to go out and flog yourself with exercise. But on one of your tough days, you've still got to stick with the baseline. You’ll know it's safe because you've been doing it through your trials, and you’ve reduced it by 20%. 

The goal is to gradually increase what you can do in a slow and steady way. And it works.

Make a flare up plan 

Professor Daley knows how easy it is to ‘flip over into sort of a catastrophic oh-my-god-what-am-I going-to-do-now-nothing's-working psyche’. She suggests that before a flare-up happens, it's important to think about what things you usually do that help settle the pain. 

Then write these down on a card the size of business-card. Keep it somewhere accessible (like in a wallet or on the fridge) and follow it when a flare-up happens. Often that can be enough to just settle the pain down over a few days.

An example of her own flare-up plan for knee pain includes taking medication, sitting down and relaxing, doing deep breathing and knee exercises and giving herself permission to take a break. 

It’s also good to have a flare-up plan for work. It could be using a sit-stand desk, taking the lift rather than the stairs, having virtual meetings and asking for help from others. Or saying ‘I'll do what I can today. It's great I'm doing some work’.

Spend your energy wisely

There are lots of ways to think about how much energy you have.

Professor Daley uses the analogy of having only $100 of energy to use in a day and it’s up to you how to spend it. Activities like taking care of family, getting to and from work, work tasks, household chores and personal worries all consume our physical and mental energy. Visualizing our energy as a pool of $100 helps us work out how to allocate it wisely.

Some things we can’t get rid of — like our caring roles or our work. And often we can’t imply stop worrying about things. So — what can we change on that day? Maybe it’s catching an Uber rather than the train. Or working from home for a few days. Can the dishes and washing wait until tomorrow? Can someone else walk the dog?

Get some sleep!

Sleep is closely connected to pain, mood, thoughts and energy. Change in one area will affect the others, but it can take at least 6 weeks for sleep habits to improve. 
It's normal to wake up 4 to 5 times during the night. We only know we’ve woken a lot if we're uncomfortable, worrying or if we've got something biologically wrong with our sleep such as sleep apnea or depression. 

We need to be able to get ourselves back to sleep. To improve sleep we can:

  • establish a bedtime routine
  • turn off screens
  • reduce light and caffeine
  • regulate room temperature so it’s not too warm
  • keep a notebook by the bed so you can write down worrying thoughts or that amazing idea or you think of that important thing you've forgotten. 

If you do wake practice relaxation techniques like deep breathing, listening to relaxing music, a sleep App, visualization or progressive muscle relaxation. 

Exposure to morning light by just getting outside for 20 minutes and avoiding caffeine in coffee, green tea and chocolate in the afternoon can also help improve sleep.

Check your thoughts, beliefs and mood

Our thoughts and beliefs about also have a huge impact on our pain (as well as our mental health and general well-being). They can be helpful or unhelpful. Asking ourselves if they are true or just a passing thought that we can let go is a useful strategy. 

Our mood, emotions and personal experience can also shape our thoughts, especially if we are dealing with depression. Depression can lead to rumination and negative thinking patterns and can be difficult to change. 

Beliefs about pain can be about what is causing the pain to what the future may hold. For example, someone may believe that bending over is dangerous for their back because it was how they first hurt it. But this may not always be true and it’s important to challenge these beliefs with facts about back pain.

Cognitive behavioural therapy can help us to challenge and reframe our thoughts in a more helpful way.

Where’s your attention?

Where we place our attention and how much we focus on our pain or the affected area can also have a big impact on our experience of pain. 

Our brain isn’t usually interested in our back, knees or shoulders until something happens there. It’s more focused on our hands, toes and mouth area. But when we experience (nociceptive) pain in other parts of our bodies, the brain can start to constantly scan that area a lot more that if we didn’t have pain there. 

This can lead us to direct our attention there. To manage this, it is important to shift our focus away from the affected area and stop constantly checking or touching it.

In Part 2 we’ll look at what advice another expert has for people who are reconsidering their work and career options because of their pain condition.




Published 09 February, 2023 | Updated 14 February, 2023