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Pacing is one of the more divisive terms among clinicians and people living with pain. It’s either the best thing since sliced bread – or the worst thing in the world.
Let’s define it, because some of the problems might start here.
Pacing may be defined as a strategy to modify over- and under-activity, and to work at a steady and consistent level. It can include a quota-based approach where time (or quantity/distance/activity ‘chunk’) is set ahead of time, and individuals essentially work to rule . It can be used to temporarily moderate how much a person does, with the idea of gradually increasing the quota over time as part of rehabilitation. See Antcliff et al., 2022 for a new study exploring the acceptability of this approach. It can also, and possibly more commonly, be used as a long-term approach to daily life.
The idea is to keep activities at a generally consistent level for a couple of reasons: (1) To avoid over-doing and exacerbating pain in a nervous system that is already sensitive. Over-doing it is likely to lead to a flare-up, and consequently people don’t want to do things during that flare-up period. This reluctance to do when you’re sore leads to not doing as much, so activity looks like a ‘saw tooth’ pattern. Boom and then bust. By avoiding over-doing it, symptoms are moderated. The focus is on the effect on symptoms in this first approach. (2) To disentangle the ‘doing’ from ‘pain’ – in other words, to draw on an operant conditioning model. In this approach the idea is to avoid using pain as a guide, set a quota that is consistent and do this pretty much regardless of pain ups and downs (more on this shortly!). The focus is on how much is done, so that eventually the relationship between activity and pain is less powerful. Doing is the focus and pain has less influence on how much is done.
In a rehabilitation setting, particularly where people have been deactivated, or not doing as much as they’d like to, pacing can be used to very gradually nudge how much is done in each quota. The idea behind this is to almost fool the nervous system into habituating to the higher level of activity, so that pain (or other symptoms) are less sensitive to activity. Hopefully, clinicians using this approach, begin by establishing a baseline level of activity, then nudge into a consistent quota that can be a little push on a bad day, but pretty easy on a good one. Over time the quota gets increased and voila! The person returns to a normal level of activity. This is possibly the way pacing is done in a sports and conditioning context for people without a grumpy nervous system (see Pomarensky & Macedo, 2022; Grunberg et al., 2022).
In a long-term context, pacing is probably done a little differently. For people living with fluctuating pain (common!), pacing is one way to do what needs doing but without over-doing it. It’s more like a rationing of what gets done and when. This approach often involves the person making decisions about when certain activities get done in a week, breaking tasks down into smaller chunks and interspersing these activity chunks with alternative activities – perhaps those using different body parts, or more relaxing/calming and less demanding.
There have been problems with pacing in pain management. One study found that pacing used in the first, symptom-focused approach was associated with more distress and disability (McCracken & Samuel, 2007). It’s important to note that this study was in a group of people referred for pain management at a major tertiary centre, and didn’t explore pacing over time in a longitudinal intensively measured approach. It didn’t investigate the contexts or how pacing was used by people – and remember these people were seeking help for their pain.
Clinical takeaways: Introducing a person with pain to activity management requires tact and care. You’re asking people to change the way they live their life – at least temporarily. For some, this is for the rest of their life. The least you can do is understand the person’s life contexts and what matters to them before you suggest they make changes to what gets done and when. And you probably should listen to people if they say pacing isn’t working in particular situations: there are places where pacing cannot be done (like retail sales or the killing chain at the freezing works!).
Pacing is not easy! If you use a quota approach, you’re essentially asking someone to delay gratification for a pay-off that might not arrive for a while. In the short-term the is challenge things won’t get done – and this isn’t great. Life does not work on a quota (or a timetable) for most of us. It requires supports in context for pacing to be achievable.
At the beginning, work with the person to establish what their goals are: is it consistency and reliability? Is it so they have enough get up and go at the end of the day or the week? Can they do the things that really matter to them? Do they value certain activities and contexts over others? I like to get an idea of a person’s usual daily routine – so a diary can be useful, as can a step counter. I like to work out times when people feel more energised, and times when they feel less so. Planning activities around these natural habits and routines helps use resources the person already has.
Pain intensity is not always the most important thing, but values are. We do things that might flare pain up because contexts and practicalities matter: like pushing to finish the grocery shopping because no, it’s not possible to leave your shopping cart and go do a pacing break! Decisions about activity management need to incorporate values, so rigid rules about quota can flex a little depending on context.
I think about ‘energy’ rather than pain as the ‘measure’ for quota: this is the mix of cognitive demands, emotional regulation (frustration tolerance often!), and pain and fatigue. Energy isn’t static (so no, I don’t use the ‘spoons’ metaphor), but we work best with a certain amount of reserve. Quota can then be about the effect of activities on this sense of ‘energy’ rather than other so-called objective measures like steps or METs or even time.
In general the aim is for a consistent and reasonably reliable level of activity so the person can trust how much they can demand from their body. This means scanning across the week to see what needs doing and when, and planning activities so that each day has around the same amount of demand. Some days might be higher demand, but need to be balanced by days with less demand. Within each day, putting some high demand activities and some low demand activities in place, so that there’s a recovery period available. The balance of high and low demand activities is individual – some seemingly low demand activities like socialising might feel high demand to some, while high demand activities like gardening could feel low demand to others. In other words, it’s how these activities are experienced that matters.
Then I work with them to experiment with scheduling the things they do and how they do it, so they’re in charge of working out how it feels. I let people know why we’ve set on this plan and how it fits with their values so they can use those values to dig deep when it gets hard.
Pacing or activity management needs to be flexible, responsive to context, and be a living approach. Sometimes pacing needs to change, and knowing what pacing is intended to achieve will probably help modify the way it’s implemented.
Antcliff, D., Keenan, A. M., Keeley, P., Woby, S., & McGowan, L. (2022). “Pacing does help you get your life back”: The acceptability of a newly developed activity pacing framework for chronic pain/fatigue. Musculoskeletal Care, 20(1), 99-110. https://doi.org/10.1002/msc.1557
Grunberg, V. A., Greenberg, J., Mace, R. A., Bakhshaie, J., Choi, K. W., & Vranceanu, A. M. (2022). Fitbit Activity, Quota-Based Pacing, and Physical and Emotional Functioning Among Adults With Chronic Pain. J Pain, 23(11), 1933-1944. https://doi.org/10.1016/j.jpain.2022.07.003
McCracken, L. M., & Samuel, V. M. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain, 130(1-2), 119-125. https://doi.org/10.1016/j.pain.2006.11.016
Pomarensky, M., Macedo, L., & Carlesso, L. C. (2022). Management of Chronic Musculoskeletal Pain Through a Biopsychosocial Lens. Journal of Athletic Training, 57(4), 312-318. https://doi.org/10.4085/1062-6050-0521.20
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