Unlike most of my posts, this one doesn’t have specific research to back it up. I guess this reflects the lack of research in the area of applied pain management! After discussing activity levels, especially over-doing activity, I thought it might be helpful to review some of the ways I’ve worked with people to develop an optimal level of activity that works for them.
My first metaphor is about developing a ‘budget’ of activity. Other words to use might be template or framework, or even timetable! I like the idea of a budget because it suggests that there is a fairly set amount of energy to work with, and while it’s possible to over-spend - usually you have to make that deficit up at some point! Having said this, you can top-up your fund by doing things that can expand your energy level and gradually ‘grow’ your budget over time.
I think the first thing I do is work out what the person’s activity pattern is like.
How do they organise their day (do they organise it at all?!).
Are they typically over-doers, avoiders or a combination of both?
Then I’m keen to draw on a model such as the pain-related anxiety and avoidance model of Vlaeyen’s to establish some of the factors that may be influencing their activity level. The problem with over-doers and ‘boom and bust’ patterns is that there isn’t a very clear model to use, so it’s much more a case of working through an individualised formulation to determine what the various factors might be influencing their activity pattern. To do this I use a generalised cognitive behavioural model such as Tim Sharp’s CBT model
As you can see, it’s complex and covers almost all of the psychosocial factors involved in the pain experience! Back to activity…
Then I ask the person what they need to achieve in each time period (depending on what we’re working on - days, weeks, hours?). This is where the person’s own sense of what is important to him or her is critical. I may at this point ask why certain activities are so important, especially if there is a deficit of energy available for them to complete everything that they want to.
Every day we make choices about what we can achieve. It’s no different for a person with chronic pain then for someone without chronic pain -except perhaps the expectations and constraints might be a bit different. I’m someone who habitually has ‘things to do’, so I’m inclined to overload myself and expect more from myself than I can actually do. It’s an ongoing learning curve for me to rein myself in to be a little more realistic, to use words like ‘I could do…’, ‘it would be nice to do …’, rather than ‘I must do…’, or ‘I should do…’.
So with a person who has chronic pain, I also work through their underlying thoughts, beliefs and attitudes about how much they have on their ‘to do list’.
The next step is to establish a lower limit of activity to be done in a day - if the person is a habitual under-doer, this is set just a little higher than what they expect to do on a ‘bad day’. If the person is typically an over-doer, setting a realistic activity level is a real challenge - so I might start with scheduling brief rest breaks. The challenge from here in is working with their thoughts, emotions and behaviours to develop a regular and reasonably consistent level of activity each day.
Now you might see I’ve left out the ‘boom and bust’ pattern from the section above. This is because one of the first things to work out is whether there is any ‘boom’ in that pattern at all!! It may be that the person believes they have a boom and bust pattern, but over time the over-activity cycle is actually not very high at all, and instead they’re really deactivated and avoidant. If they really are over-active then under-active, I think the process is about working out the factors that lead to over-activity and scheduling a quote-based level that is above the ‘recovery’ level of activity but below the higher level.
Most people hate this process! I do myself! I’d much rather not have to acknowledge that I’m not super-human (I’m not really!!), that I do have limits, that I have interest and motivation in lots of things but I simply can’t do them all. The factors that lead me to do this include getting a bit of a ‘high’ from being productive, that I’m curious about lots of things and get interested in them which can lead me astray from recognising my fatigue/pain levels and curbing my activity. I’m also not especially good at saying no to others, or myself. And I’m sure I get lots of rewards for being busy. Perhaps at times I feel uncomfortable ‘doing nothing’ - being ‘lazy’.
I don’t think regulating activity levels is at all easy - after all time management courses are one of the more popular ’self help’ courses in work life! So carefully working through not just the allocation of activities through the day, but also the underlying beliefs and attitudes - and rewards - is a critical part of the process. Having a ‘budget’ of activity means that it’s possible to ‘borrow’ from another time period (the next hour, the next day) on the odd occasion, provided that the loan is repaid. Taken to the extreme this can lead straight to that boom and bust pattern, and if that’s continued it’s not an especially great way to live. A bit like living off a credit card! So some sort of prioritising process needs to happen - I think identifying values is one way of doing this. Why is this activity important? What is important over time in the person’s life? Over a week, how much of what they do is aligned with what they really value?
And finally, I really like Steven Covey’s ‘four quadrant’ approach to prioritising. This takes into account the ‘urgent’ and ‘important’ things that happen in life, but encourages a much less stressful ‘important’ but ‘not urgent’ - and very planned - approach to every day.