Overdoing or Underdoing: Activity levels in chronic pain

By a strange coincidence, after writing about regulating activity levels yesterday, I came across a pre-print editorial in the European Journal of Pain discussing exactly this: avoidance or persistence.

We’ve become quite familiar with the avoidance idea – avoidance leading to deactivation, leading to disability, loss of roles, depression and so on. There have been several models to explain this, most recently Vlaeyen’s pain-related anxiety and avoidance model which implicates an underlying negative affectivity, health anxiety and catastrophising, and ultimately leading to kinesiophobia, or fear of movement. Treatments arising from this model include graded exposure, along with reduced physiological arousal and cognitive restructuring around catastrophising.

What has been discussed much less often is the ‘boom and bust’ pattern I described yesterday, and the even less frequently discussed ‘overdoing’ group of people. In the ‘boom and bust’ group, people seem to pursue activity to a high level, then stop to ‘recover’, returning to a high level of activity only to need to stop to recover again. This pattern can lead to a gradual decline in activity as the high level of activity gradually reduces over time – notably when pain is used as a guide for how much and how long activities are carried out.

In the overdoing group, the pattern seems to be one of consistently pushing to complete activities throughout the day, only to become exhausted at night, sleep poorly and begin the busy-ness the next day. Sometimes this continues for a long time, only to subside in deactivation when the person reaches exhaustion, becomes depressed, or sustains another illness.

The problem with both of these activity patterns is that there is to date little research describing this pattern. We simply don’t know a lot about this type of behaviour. There have been several theoretical models trying to describe this subgroup, but as Karsdorp & Vlaeyen point out in this editorial, there is very little evidence to support any of them. The model discussed in this editorial is the avoidance-endurance model developed by Hasenbring et al (2009), which includes affective, cognitive and behavioural responses – the fear-avoidance group is ‘characterised by fear of pain, catastrophising thoughts about pain and avoidance behaviour patterns. The endurance group … displays suppression of pain-related thoughts and reports positive affect and persistence behaviour despite the pain’. As noted in the editorial, the endurance group doesn’t appear to demonstrate the same disability levels as the avoidance group – the rationale being that they ‘may withstand the interruptions of pain during daily activities and therefore may show less disability’.

In my experience, this may hold true at the beginning of a pain episode. Over time, however, I think the area that becomes strained is the emotional resilience. People I’ve observed may use internal cognitive rules about the need to complete activity (such as ‘I must be a good mother and clean the house’, or ‘I should be a good worker and finish this job’), and use this to persist in behaviour. Without adequate recovery time, however, fatigue (particularly emotional fatigue) becomes evident, and eventually with the advent of perhaps another stressor such as personal illness, job change, family demands, the person begins to use either a ‘boom and bust’ pattern, or turns to an avoidance pattern.

I suspect several things are missing in our current models of activity pattern in chronic pain – one is the trajectory over time. This is mentioned in Karsdorp & Vlaeyen’s editorial, where they suggest that ‘a more process-oriented approach’ is required in research on endurance and avoidance because we don’t know whether these behaviours are stable over time.

The second is the role of external events such as a secondary stressor or behavioural reinforcement. The pain-related anxiety and avoidance model doesn’t include contextual factors such as compensation, social cognitive factors such as other people’s behaviour, it simply describes the individual’s own cycle. There are huge social reinforcements in being a ‘workaholic’. Not simply rewards as in remaining in employment, but also rewards by avoiding guilt, especially if the ‘work’ is that of being a parent caring for children.
Secondary stressors may erode resilience over time and create an environment where coping falls away, leading to longer periods of recovery – this is the ‘boom and bust’ pattern, which as I suggested earlier can lead to gradually lower and lower levels of activity over time.

I’m not sure that there needs to be One Grand Model describing all pain-related disability. Perhaps the pain-related anxiety and avoidance model explains one aspect of pain-related disability. Perhaps another set of factors interacts with these to create the persistence behaviour – and contributes to the ‘boom and bust’ pattern.

At this stage, I think once again we’ll be left with questions – ahhh! the bliss of working in a field where there is so much to be discovered!

Karsdorp, P., & Vlaeyen, J. (2009). Chronic pain: Avoidance or endurance? European Journal of Pain DOI: 10.1016/j.ejpain.2009.02.001



  1. I think what I’m looking for in this is “this is the way you should do things” and instead it looks like none of the models (avoidance, boom and bust or persistance) are the best choice to maintain and maximize ability.

    I lean towards the persistance model. I set the bar of what I “must” complete each day feeling that “if you don’t use it, you wil loose it”. It is almost like being persued—chased by disbility. And yes, by the end of the day or sooner, I am exhausted. It makes no difference that I am only asking myself to do what I used to be able to do. I don’t get myself more into shape. I get cranky, I get mentally and physically less able, and it can be discouraging.
    Rest helps, and then I get up and push off and get going again. I try to remember to count it victory to do the thing I wanted to do.
    Sometimes I do think to save some energy for something special that is coming up. But it is hard to let something go—it waits for me!
    I do have a friend who has chosen the avoidance model. She has become less and less able as her body looses physical condition from inactivity to compound her disability from pain. And it is very hard to get back what has been lost.
    The thing about chronic pain is that there is plenty of time to try something new…..

    1. Hi kmom
      Yes, I think these models probably show what not to do rather than what to do…! I’m guessing that what’s needed is a good deal of flexibility in terms of setting out a plan for what you want to achieve each day, allowing for your baseline pain level, setting a time or ‘chunk’ quota based on this, then working to this almost like a budget. Of course, there are always days when things go wrong, or you have emergencies, that you may need to change your plans for, and times when your pain is in the middle of a flare-up that might make you want to stop a little earlier – but provided you can keep to that consistent time-based activity level, and gradually increase towards your goal, this seems to be the most successful way to both get things done and not blow the energy or pain levels out.
      At least, that’s what I’ve learned with my own pain, and what I generally advise. The hard part is in the mind chatter that can get the better of you at times. Now that bit I still haven’t always managed!

  2. I have traveled both routes in dealing with my disability. I think that I have an advantage in also being an alcoholic in recovery because I live the lifestyle of Alcoholics Anonymous which gives me a skill set and support system which helps me live in the present moment which helps me continually evaluate how I am feeling in the moment. It also helps me evaluate my basic needs of HALT (Hungry, Angry, Lonely or Tired). Boy if I don’t pay attention to these my pain levels go through the roof as well as the depression and pity. Finally, by believing in a higher power and the concept of their will I am unburdened of guilt and that overwhelming feeling of defeat because I am doing the best I can for that day. I am not trying to preach AA but have tried many things to deal with my high levels of chronic pain and the nerve disease RSD. By living using the above skill and Lyrica and a couple different anti depressants I am able to be the most functional I have been in 6 years. Not sure this would work for everyone but it works for me. Just wanted share in case this helps anyone out there suffering.

    1. I’m sure that your experiences with getting in touch with your feelings, and being able to ‘sit with’ negative emotions and thoughts has given you a lot of strength to face the challenges of both pain and your alcohol abuse. Do you think that in managing your situation it’s about keeping an appropriate level of activity for the long-term rather than reacting to here and now or the short-term?
      Thanks for taking the time to comment, it’s great to hear about people’s experiences.

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