Pacing: What’s the evidence for it?
Pacing is one of those words: almost every person who has been through a pain management programme of any sort will roll their eyes and groan ‘pacing’ when asked about one of their least favourite strategies.
I have long disliked the word because of the mixed ways in which therapists (and patients) interpret what it actually means, not to mention my own challenges to actually DO it when I’ve needed to!
The term can mean anything from taking a break ‘before it hurts’, ‘breaking a task down into achievable chunks’, starting at ‘what you can do on a bad day, and increasing by 10%’, ‘working at 80%’ – well, you can see my point huh?!
I was delighted to read some time ago, a paper by Birkholtz, Aylwin and Harman (2004) in which they discuss the concept of pacing – apart from the fact that it is one of the few occupational therapy research papers on the topic, it highlighted the problems we have in defining it.
In 2007, McCracken and Samuels identified that pacing grouped with avoidance and other ‘passive’ coping strategies when activity patterns were analysed (McCracken & Samuels, 2007). Despite this, self help books I’ve reviewed before (see here, here, here, here and here) all include activity pacing as a strategy, and I’ll bet that a quick survey of pain management providers would show that the majority consider it a key strategy.
Gill and Brown, in a paper in press, describe a structured literature review carried out on the terms chronic pain, pain treatment, pain management, chronic disease, quota, activity rest cycling, pacing, pace, and activity pacing.
There were no outcome studies on the effect of pacing on chronic pain.
None. Nothing. Zero. Zilch.
They say ‘Although there is research that has been conducted on pacing, the focus of these studies relates to pacing as a component of a self-management program and the outcome of interest is patient engagement in self-management’. What this means is there is no evidence for the use of this strategy – however it is defined. And therein lies a big part of the problem: the definitions, as I said above, are not clear.
What’s the history of pacing?
Well, according to Gill and Brown, pacing as a term originated in the rehabilitation literature in the middle of the 20th century. It appears to have been based on the idea of energy conservation as then used for conditions like rheumatoid arthritis (Planning, Position and Pacing). It then grew to be considered a part of ‘problem solving’ (Hagedorn, 2000), which included consideration of cognitive demands as well as physiological. Others, such as Strong (2002) and Butler (2006) describe it as ‘‘introducing tasks in a graded manner, in order for the client to build skills, confidence and tolerance for the activity, so that activity levels can be increased”
I’ve always considered pacing to related more to Fordyce’s (1976) operant conditioning approach. This is where the relationship between pain and activity level is no longer linked through the use of a ‘quota’ or set amount of activity that is carried out irrespective of pain intensity. This also allows for scheduling activity and more restful periods throughout the day, to counter the ‘boom and bust’ pattern of some people – it is also similar to the scheduling strategy used in mood management, where pleasurable activities are scheduled through the day.
So… given that there is little agreement on what pacing is, and even less specific research supporting it, what to do, what to do?
I’m ambivalent. If pacing is associated with avoidance and passive coping, is it a helpful approach?
If it’s popular, perhaps it’s because it’s like the occupational therapy myth that ‘activity is good’ – perhaps we think if we do it enough, it’s GOT to be good. That’s what they said about blood-letting!
It may be popular because it is a passive approach – I don’t know how many times I’ve heard a patient justify gradually reducing their activity level, and using a pain contingent approach to decide how much activity is’enough’ on the basis of ‘but you told me to pace myself’.
And there are times when ‘pacing’ or, working to a quota does not work: think about it, how on earth would you get through a wedding or funeral or school parent/teacher meeting if you had to pace all the way through it? Or evacuate the house in case of fire ‘oh stop the fire, I need to do my pacing’!! Or tell an employer ‘oh sorry about your deadline, but I’m pacing right now’.
OK, that last one is perhaps arguable.
But you get my point: there are times when pacing cuts across values, or things that are important in life. Too often however, patients throw out the pacing AND the rest of pain management because ‘you can’t do pacing here, here, and here’.
I look forward to ongoing debate and research into this coping strategy. Let’s make sure it is well-defined – perhaps renamed? I quite like the idea of ‘activity regulation’ which has a similar ring to ‘self regulation’ – the idea of determining the right distribution of activity to achieve important goals. What are your thoughts?
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J GILL, C BROWN (2008). A structured review of the evidence for pacing as a chronic pain intervention European Journal of Pain DOI: 10.1016/j.ejpain.2008.03.011
Birkholtz M, Aylwin L, Harman RM. Activity pacing in chronic pain management:
one aim, but which method? part one: introduction and literature review. Brit J
Occup Ther 2004;67(10):447–52.
Hagedorn R. Tools for practice in occupational therapy: a structured approach to
core skills and processes. London: Churchill Livingstone; 2000.
McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity
patterns in chronic pain. Pain 2007;130(1–2):119–25.
Strong J, Unruh AM, Baxter GD. Pain: a textbook for therapists. Toronto: Churchill