What exactly do we mean by this word? And how does it work, exactly?
I don’t use the word pacing, to be honest. I use ‘activity management’ because there are times when people might want to increase their overall pattern of activity, and times when they might want to reduce it, and plenty of times when people want to be judicious about when and why they employ this approach.
Activity management is, depending on your definition, about deciding when and how to undertake the things you need or want to do, and it’s been a part of pain management for a very long time. I think the earliest description of pacing comes from Fordyce, in his work using the principles of operant conditioning to help people with chronic pain engage in fewer ‘illness behaviours’ and more ‘well behaviours’ (Fordyce, Fowler & Delateur (1968); Fordyce, Fowler, Lehmann, Delateur, Sand & Trieschmann (1973); and detailed in the republished book Fordyce’s behavioural methods for chronic pain and illness).
In this approach to activity management, Fordyce’s argument was that pain contingent activity (ie let your pain be your guide) was associated with greater disability and pain interference. He found that by altering the decision rules a person used to decide what and how much activity to do, they could do more in each day and learn to disentangle pain from the decisions about what to do. Pain, in other words, lost the power to directly influence action.
The decision rules were about using time or a quote of activity as the guide to ‘how much’ or ‘how long’ to engage in an activity rather than using the then-common (and still now!) pain intensity guide. The important part of this strategy is that it’s not about altering pain intensity, but about ‘rewards’ that come from doing what matters, while keeping a lid on the temptation to over-do on days when pain is lower, and avoid on days when pain is higher. In contrast, ACT tends to focus less on pain and much more on the satisfaction that comes from meeting important values – similar concept, but instead of focusing on rules about how much to do, ACT focuses on how well the overall actions in a day help the person do what matters.
The alternative model, if you like, of activity management is based on energy conservation techniques, and is quite popular in occupational therapy because occupational therapists were involved for decades in helping people recover from long-term illnesses like tuberculosis (treated in the early days with lots of rest). This approach looks at energy expenditure and tries to help people plan their day/week in ways to engage in what matters and incorporate resting to reduce pain and fatigue. A popular interpretation of this approach refers to ‘spoons’ and the number of spoons (energy) a person has that can be allocated over the day, interspersed with breaks. The focus of this strategy is not only on what the person prioritises but also how they plan their rest, with the aim to help people avoid the worst parts of ‘boom and bust’ while still getting some things done.
Measuring daily activity patterns, and understanding the goals of strategies people use for allocating their energy or engaging in activity, has been hampered by difficulty measuring what it is people are actually doing and why. I suspect intensive longitudinal approaches such as ecological momentary assessment, daily diary studies, and integrated ‘smart watch’ devices might help us with the actual recording process. That is, eliminating the need for a person to interrupt their activities to record details of what they’re doing, might shed light on more information than diaries and so on. BUT if these devices aren’t measuring anything important they’re not a lot of use.
Smart watches can measure patterns of ‘up time’ based on step counts, heart rate, and geolocation, but on their own can’t measure the goal or purpose of this activity so on their own are, I think, inadequate.
Self-report measures, like pen and paper diaries listing various coping strategies and their frequency (or their electronic equivalent) do exist. These typically ask the person to recall the number of times they’ve used a strategy over the past seven days or so. Examples include the Brief Pain Response Inventory (McCracken et al., 2010) and the Coping Strategies Questionnaire (originally by Rosenstiel & Keefe, 1983). Of course there are always problems when we ask people to remember what happened days ago, particularly when people are already sore! These problems include remembering what you did, remembering how often you did them, and remembering to fill the questionnaire out!
But none of these take into account the ‘why’ a person might employ a particular strategy at a time. Although these measures have theoretical models underpinning their development, most of them haven’t asked people with pain about their rationale for using a particular approach at a particular time.
If we adopt a functional contextual perspective on engaging in daily doing among people with pain, the separation between context and the person and the actions they take disappear. For those reading Vaz and colleagues ideas of an affordance-effectivity approach to understanding people with pain (Vaz et al., 2023), and occupational therapists using the PEO model or any of the occupational therapy models to be fair, this will be somewhat familiar. A functional contextual perspective means we look at how this action works (or functions in terms of pre-defined purposes) for this person in this context. This philosophical approach to understanding human actions states that the outcomes of any action (provided they’re aligned with what the person set out to achieve and in ACT, related to long-term values or life directions) is more useful to understand than the form of that action. In other words, how we get somewhere is less important than that we get there.
For pain management, where we are going is the critical thing, IMHO. And our measures, to date, haven’t incorporated the ‘why’ a person has chosen a specific strategy. Or they’ve assumed it: eg ‘passive’ and ‘active’ coping strategies; emotion-focused vs problem-focused; avoidance or approach.
I can now say there IS a measure that includes both the ‘why’ and the ‘what’ in pain coping. This is a newly developed measure called the AMI-P (Activity Management Inventory for Pain), developed by Racine, Jensen, Cane, Moulin, Vlaeyen, and Nielson (2024). It’s a 20-item measure that divides into three subscales: (1) rest; (2) alternating activity and (3) planned activity; and four goal scales: (1) feel less pain; (2) get more done; (3) complete the task; and (4) save energy.
Now this measure is not designed for daily use. It’s a recall measure, asking people to indicate how often they’ve used a strategy over the past week (number of days), and their reason for using it. The 20 items were rigorously developed (although I note, not including people living with pain), along with the four goals for using these strategies. They were then tested in two groups of people with chronic pain attending tertiary pain management services, and the results compared and contrasted with other measures used in these kinds of programmes. The final result is a 20-item questionnaire with two questions for each item: frequency and goal.
The authors note that this questionnaire has marginal internal consistency and reliability, and that there needs to be more work to investigate the psychometric properties of the instrument. They acknowledge the length of the questionnaire and that this may get in the way of it being useful clinically.
I agree it’s too long. This is too long for the kind of naturalist, intensive daily measurement that I think will shed insights into the complexity of making decisions about how to go about life with pain. However, it does step us a little way forward by considering the reasons a person might use a strategy. What it doesn’t incorporate is a measure of the value of perhaps focusing less on pain intensity and more on completing a task, or of choosing to do relatively less because of fewer ‘spoons’ available in a day. But that a team of researchers has started this work means there is a jumping-off point – and perhaps this might help clinicians and people with pain consider how important it is to include the end goal of a strategy alongside the use of it. This might then form a springboard for developing a range of strategies to meet the end goals the person wants.
If you can access the full paper, do! If you can’t, you can obtain the final version of the AMI-P questionnaire and a downloadable version including scoring instructions from the following website: http://research.melanieracine. com/activitymanagement/
Fordyce, W. E., Fowler, R. S., & Delateur, B. (1968). An Application of Behavior Modification Technique to a Problem of Chronic Pain. Behaviour Research and Therapy, 6(1), 105-107.
Fordyce, W., Fowler, R., Lehmann, J., Delateur, B., Sand, P., & Trieschmann, R. (1973). Operant conditioning in the treatment of chronic pain. Archives of Physical Medicine and Rehabilitation, 54(9), 399-408.
Main, C. J., Keefe, F. J., Jensen, M. P., Vlaeyen, J. W. S., Vowles, K. E., Fordyce, W. E., & International Association for the Study of Pain, i. b. (2015). Fordyce’s behavioral methods for chronic pain and illness : republished with invited commentaries. Wolters Kluwer.
McCracken, L. M., Vowles, K. E., & Zhao-O’Brien, J. (2010). Further development of an instrument to assess psychological flexibility in people with chronic pain. Journal of Behavioral Medicine, 33(5), 346-354. https://doi.org/http://dx.doi.org/10.1007/s10865-010-9264-x
Racine, M., Jensen, M. P., Cane, D., Moulin, D. E., Vlaeyen, J. W. S., & Nielson, W. R. (2024). The Activity Management Inventory for Pain (AMI-P): Initial Development and Validation of a Questionnaire Based on Operant Learning and Energy Conservation Models of Activity Management. Clin J Pain, 40(4), 200-211. https://doi.org/10.1097/AJP.0000000000001198
Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain, 17(1), 33-44.
Vaz, D. V., Stilwell, P., Coninx, S., Low, M., & Liebenson, C. (2023). Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management. Brazilian journal of physical therapy. https://doi.org/10.1016/j.bjpt.2023.100554
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