“It’s important that you pace your activity, this is to minimize the risk of your pain increasing. Once you identify how long you can spend at a task before your pain increases, you will eventually be able to increase your time doing the task.”
Pacing
Activity pacing (AP) is a term widely used to describe a common rehabilitation strategy within pain management programs, but it has been recognized as a poorly defined construct, leading to confusion amongst patients and clinicians (Andrews & Deen, 2016).
Bill Fordyce is well known for developing the AP strategy of graded activity. Using an operant learning approach, shaping of healthy behaviours was positively reinforced through completion of time contingent activity quotas. It was a chap called Richard Sternbach that adapted the approach by emphasizing the idea that quotas should be set below tolerance levels because if a patient engages in an activity reaching pain tolerance levels, their efforts will be more likely followed by an increase in pain, effectively punishing healthy behavior. Sternbach also emphasized that “not overdoing but gradually increasing endurance” meant that there would be greater satisfaction towards established goals (Nielson, Jensen, Karsdorp, & Vlaeyen, 2013). This approach to AP appears to be the most commonly understood method. Identifying what the person can manage from a time contingent perspective on a good day and then from a time contingent perspective on a bad day. Then applying some simple math’s to set a target time. For example:
On a good day I can do 20 minutes of walking. On a bad day I can do 5 minutes of walking. If I add 20 and 5 I get 25 minutes. I then divide by 2 to give 12.5 minutes. This would be my start point with respect to the time spent walking. Over time I would then gradually build up. This also means that you stay well within your tolerance zone but build endurance through walking.
Another way would be to chunk the activity to minimise the risk of flare up. Let’s say you did 20 minutes of gardening on Monday and had a flare up for 2-3 days afterwards (which is an example of booming and busting). This 20 minutes of activity essentially has lead to reduced activity for the following 3 days.
An alternative approach would be to split the 20 minutes up over the same 4 days, giving you 5 minutes of activity over each of the 4 days. 5 x 4 = 20. So, you would still have done 20 minutes of gardening but the idea being that because you didn’t push to a full 20 minutes in one day there is less chance of you hitting the dreaded flare up zone. Same amount of time over the same period but with leas chance of having a flare up. Once again over time we would build endurance and gradually build up the time.
Interestingly, evidence has suggested that pacing was found to have a positive relationship with disability. However, this appeared to be dependent on whether pacing was used for pain reduction or if pacing was done in a way that reduces pain’s influence. For example “I do my tasks more slowly so that I can get them done with less pain” instead of “If I do my tasks slowly, pain won’t bother me” (Luthi, Vuistiner, Favre, Hilfiker, & Léger, 2018; McCracken & Samuel, 2007). This suggests that the valence* we place upon the strategy may well have an impact on the outcome. In addition, pacing may also reflect some “hidden form” of avoidance, which is more pain contingent and oriented on symptom reduction rather than on activity achievement (Kindermans et al., 2011; Luthi et al., 2018).
Goals and Values
This leads me onto another commonly used concept in pain management, goal setting or to be more specific SMART goals. SMART (Specific, Measurable, Achievable, Reliable, Timely) goals have received very little attention with respect to their effectiveness in pain management. In actual fact, there is very little evidence for SMART in healthcare. It is surprisingly weak – except for maybe specific, and SMART goals do not necessarily create the context for sustained engagement nor build capacity for future health and well-being (McPherson, Kayes, & Kersten, 2014).
A paper by Dekker et al., (2020) highlighted that clients have hopes and aspirations and often set goals around this. Such as, “I want to return to work” or “I just want my life back”. The barrier clients face is that often health professionals consider these goals as “unrealistic” and prefer to set more “realistic” short term goals also known as SMART goals!
Furthermore, it appears that clients do not always appreciate these goals referring to them as “prescriptive”and “Inflexible” with minimal respect to client’s needs or aspirations.
So here’s my thought, It seems to me that common AP strategies appear to run parallel to SMART goals. I don’t think this is coincidental, it’s just how things have always been done. There are some similarities between the two, for example like pacing, SMART goals work towards an achievement of an activity with a set time contingent quota. Like pacing, SMART goals are future orientated. Like pacing, SMART goals may have limited wiggle room. Like pacing, SMART goals may result in failure and poor coping if experiencing a flare up after activity.
So how can we overcome the dominance of something that is overly SMART. Bennett and Oliver (2019) in their book point out that it can be easy to become fused with the pursuit of a goal at the expense of the value that pointed you towards the goal in the first place. People living with pain can find it difficult to pursue activities they once enjoyed. It is common for people to become fixated on going back to doing things they used to do, fusing with the belief that if they cannot then they are not the person they once were. Undoubtedly, this can be upsetting, the point with values is it’s moving in a direction that is important rather than the actual activity itself, which is often where SMART goals are directed, see figure.1. Furthermore, whilst SMART goals do have something to offer if a simple and straightforward task is the goal, in pain management and in fact healthcare rarely is getting one’s life back whilst living with pain a simple, straightforward task. Pain management programs are as much about self-management as they are about receiving input from healthcare professionals. A collaborative approach to care is required and so the person living with pain needs to be an active participant rather than a passive recipient in pain self-management. What healthcare professionals need to do is consider the broader picture particularly when someone has lived with pain for a prolonged period. Through understanding who or what is important, what matters to the person, goes beyond the simple, straightforward perspective of a SMART goal.
So, what about persisting flexibly?
Persisting flexibly is not a new term, it has also been labelled endurance, overdoing or confronting and is described as doing (activity) despite pain. More recently it has been linked with the model of psychological flexibility (McCracken & Morley, 2014), whereby the individual engaging in activity remains connected to the present moment in order to continue engagement with the overarching value. This may mean that the activity changes somewhat but the overarching value or meaning remains. Consider the goal of ‘In 3 months I will play cricket with my children for 60 minutes 3 times a week. This SMART goal has a strict and clear set of parameters that can make it prescriptive and inflexible. There are a whole host of factors that may infringe or inhibit the achievement of this goal, such as the weather, the tide coming in, children become sick, a flare up of symptoms. Yet if we consider the overall value or meaning of the activity, which could be that the individual wants to be a good parent, then there could be lots of various ways this value could be fulfilled and if we want to specifically look at movement, many activities share many different movements.
A values based approach to activity works like a compass, it can help to guide in a direction that intends to fulfil what is meaningful or matters most to the person, see figure.1. Having flexible persistence is about finding ways or using ‘creativity’ to guide towards fulfilment but using anything and everything to help you get there. This may well mean prioritising what or who is important over things that are of less value to you. Such as you may want to work on your car, but then you also don’t wash the deck or do the gardening. How are these things of value you ask? Working on the car may be important to someone because it brings fulfilment and enjoyment, it may mean that the person feels they have a place in their family as the handyperson, that the car is fixed meaning that money is saved for the all-important family outing.
McPherson, Kayes, & Kersten, (2014) discuss something called the theory of intentional action control, which refers simply, to a type of action-coping plan. The use of an If-then or when-then plan intends to accommodate for things that get in the way of doing goal related activities. Consider the value of staying healthy. Most healthcare professionals would encourage exercise. A SMART goal might be:
“In 3 months time, I will walk on the beach for 60 minutes, twice a week.”
An if(when)-then plan embraces more flexibility and is less rigid. It accommodates the challenges that people face when working with a SMART goal. For example, using the same value of being healthy and using exercise/activity, we might write an if(when)-then plan such as:
“When it is 10 am, then I will walk on the beach”
Here’s where the flexibility bit comes in. We can develop a series of if(when)-then plans to accommodate the challenges. Let’s say it’s raining and you just don’t fancy getting soaked, the if(when)-then plan might be:
“If it is raining at 10 am when I planned to do my walk on the beach, then I will go to the local shopping mall for my walk.”
or
“If it raining at 10 am when I planned to do my walk on the beach, then I will schedule the walk in my diary for 2pm instead.”
or
“If I get anxious about going for my walk on the beach, then I will remind myself that in the past a walk has made me feel good.”
You may recall earlier, I spoke about the outcome of pacing in relation to the valence* placed upon the activity. Persisting flexibly takes this one step further in that we remain in the present moment and make room for difficult sensations, emotions so that we can continue to take steps to what’s important or what matters most. Let’s look at health again and exercise/activity. If there is an activity that I am particularly keen to complete then I may be prepared to face the consequences. The if(when)-then plan might read something like:
“When I work in the garden and want to finish a section off, then I am aware and prepared that I may experience a flare up.”
The point is, flexible persistence embraces the principles of psychological flexibility. That the person is willing to experience unpleasant sensations, thoughts, emotions in the pursuit of what matters most or what is important.
A word on Acceptance
The word acceptance has likely been used inappropriately and misrepresented. Nobody, should just have to “accept their pain.” Acceptance is not “just accepting it” or about giving up. Acceptance is not the same as approval. Acceptance means that you may well accept that you have pain or experience a flare up but in no way does that mean you approve of having it or living with it. Every person I speak to doesn’t want to have long term pain.
Acceptance is a deliberate act or choice, it embodies a sense of willingness to make room and space for difficult experiences or sensations or emotions so that you can take steps towards what matters most (Bennett & Oliver, 2019).
Thanks you If you have read this far, I hope this blog has encouraged some deeper thought for clinicians and alternative strategies and opportunities for people living with pain.
Thanks for having a read.
TNP
*Valence, is the affective quality referring to the intrinsic attractiveness/”good”-ness (positive valence) or averseness/”bad”-ness (negative valence) of an event, object, or situation
References
Andrews, N., & Deen, M. (2016). Defining Activity Pacing: Is It Time to Jump Off the Merry-Go-Round? Journal of Pain, 17(12), 1359–1362. https://doi.org/10.1016/j.jpain.2016.05.001
Bennett, R., & Oliver, J. E. (2019). Acceptance and Commitment Therapy: 100 Key Points and Techniques. Abingdon, Oxon OX14 4RN: Routledge.
Dekker, J., de Groot, V., ter Steeg, A. M., Vloothuis, J., Holla, J., Collette, E., … Littooij, E. (2020). Setting meaningful goals in rehabilitation: rationale and practical tool. Clinical Rehabilitation, 34(1), 3–12. https://doi.org/10.1177/0269215519876299
Kindermans, H. P. J., Roelofs, J., Goossens, M. E. J. B., Huijnen, I. P. J., Verbunt, J. A., & Vlaeyen, J. W. S. (2011). Activity patterns in chronic pain: Underlying dimensions and associations with disability and depressed mood. Journal of Pain, 12(10), 1049–1058. https://doi.org/10.1016/j.jpain.2011.04.009
Luthi, F., Vuistiner, P., Favre, C., Hilfiker, R., & Léger, B. (2018). Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses. PLoS ONE, 13(9), 1–22. https://doi.org/10.1371/journal.pone.0203329
McCracken, L. M., & Morley, S. (2014). The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management. Journal of Pain, 15(3), 221–234. https://doi.org/10.1016/j.jpain.2013.10.014
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
McPherson, K. M., Kayes, N. M., & Kersten, P. (2014). MEANING as a smarter approach to goals in rehabilitation. In R. J. Siegert & W. M. M. Levack (Eds.), Rehabilitation Goal Setting: Theory, Practice and Evidence.
Nielson, W. R., Jensen, M. P., Karsdorp, P. A., & Vlaeyen, J. W. S. (2013). Activity pacing in chronic pain: Concepts, evidence, and future directions. Clinical Journal of Pain, 29(5), 461–468. https://doi.org/10.1097/AJP.0b013e3182608561
The Naked Physio / The curiouser 
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