A couple of days ago I wrote about activity patterns, and a study from Maastricht University that looked at the variable levels of activity that people with chronic pain can engage in. The study was designed to look at the pattern of activity from day to day, and found ‘… that for most of the participants, their activity levels varied from day to day, with high activity levels interspersed with low activity level days.’
Huijnen, Verbunt, and colleagues suggested that ‘for patients with chronic pain this could represent an activity pattern characterised by interfering involuntary rest stops due to pain. The high level of fluctuations could be a representation of the sawtooth pattern in their activities. Patients go on with their activities till the activity is finished and afterwards they have to take rest to recover.’ (2009) While the overall (mean) activity level may be fairly ‘normal’ and not directly associated with their reported disability level, the higher their disability level the higher the peaks and troughs of activity. The conclusion was that ‘patients who have a disabling fluctuating pattern in their activities, [may] benefit more from learning strategies to fine tune their activities during the day instead of increasing their activity level.’
Many self-help books and resources developed for professionals to use contain the concept of activity ‘pacing’ - this is typically about setting a baseline level of activity, and gradually building up activity tolerance until the desired level is achieved. The problem with this concept is that when you ask a person what pacing is, they invariably say something like ‘break the activity up into smaller chunks’ or ‘take breaks in the middle of an activity’ - which can actually lead to pain being the guide and overall lower levels of activity. I wrote about this some time ago when I discussed the lack of evidence for pacing, and a paper by McCracken and Samuels found that it loaded on to a set of ‘passive coping strategies’ used by patients, rather than being an ‘active’ coping strategy (2007).
Perhaps the problem is, as Huijnen & Verbunt et al suggest, one of ‘fine tuning’ activity levels. And maybe the term ‘pacing’ needs to be banished! I suggest calling it either a ‘quota’ system, where a pre-determined amount (either time or portion of an activity) is used, or calling it ‘activity regulation’ - where the amount of activity is regulated just as we regulate emotions, physiological arousal and exercise.
I’m keen to get some sort of definition around this term because while the name itself isn’t important, the pervasive view from both therapists and patients is that pacing involves slowing down how much should be done at one time - and it almost always leads to pain being used as the guide.
In practical terms I think what can happen is this: a person starts on a certain amount of activity, say 10 minutes vacuuming, then 5 minutes dusting, back to vacuuming for 10 minutes, and so on. On a good day, this is manageable - or maybe a little too easy, so the person decides to do a little more - 15 minutes vacuuming. By the end of that day, pain intensity has risen, the person sleeps badly ( I’ve written about the relationship between pain intensity and poor sleep - poor sleep leads to increased pain intensity which leads to poor sleep and so on). So the next day, instead of doing 10 minutes of vacuuming, the person does 5 minutes, and sits down to rest in between.
Or perhaps all goes well for a day or two, then a ‘high risk’ situation arises - someone is coming to visit! The person decides to go all out and vacuum furiously and do the whole house, collapsing by the time the visitor arrives. Next day, the person is too sore to do anything.
Or maybe even the person carries on with the paced level of activity, and after a week increases the amount of vacuuming as instructed, but this immediately increases pain intensity (which is expected), but the person forgets this - and adjusts the vacuuming level back to the original amount on the day following.
The key things that may help are these:
Never ever let pain be your guide in setting activity levels!
Do no more on a good day, no less on a bad
Work through cognitions that may trip you up ‘I must’, ‘I should’
Especially work through ‘I can’t do this because my pain is too bad’
Develop coping strategies for when the pain levels do increase (and they will!)
Remind the person that an increase in pain is to be expected when increasing activity level - but that it will pass and the body will habituate to it
When planning increases in activity level in a graded way, work through at least one increase successfully with the person before you stop your support - this way the person might just see that it’s possible to successfully increase activity without the world falling apart, even though pain levels do increase
Developing activity regulation is as much about thoughts and emotions as it is about planning, fitness, and physical ability. It’s my belief that any therapist who is helping someone change their activity level either through exercise or daily activities (ie physiotherapists, occupational therapists, nurses, social workers, psychologists) need to actively help the person develop awareness of, and ability to challenge, their thoughts about fluctuations in pain.
HUIJNEN, I., VERBUNT, J., ROELOFS, J., GOOSSENS, M., & PETERS, M. (2009). The disabling role of fluctuations in physical activity in patients with chronic low back pain European Journal of Pain DOI: 10.1016/j.ejpain.2008.12.008
McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity patterns in chronic pain. Pain 2007;130(1–2):119–25.