Pacing – aka working to quota, activity scheduling, chunking, time contingent activity, timetabling

This skill has to be one of the all time favourites for therapists in pain management.
What is it?
Well, that’s a wee problem actually.

The term ‘pacing’ can be used rather loosely – and although we may know what we mean, we do need to make sure the people we work with interpret our definition in the same way we do. There are three definitions that spring to mind immediately: (any more – let me know)

1. Scheduling activities throughout a period of time to ration energy (energy conservation)
2. Doing no more on a good day, no less on a bad day and therefore reducing the learning relationship between pain and activity (time contingent activity)
3. Planning activity to ensure a balance of pleasurable and less pleasurable tasks

Similar – but with very different results in the long-term when we are thinking of pain management

Scheduling activities to ration energy is helpful when the health condition is acute (eg during inflammatory periods in rheumatoid arthritis), when the prognosis is gradual deterioration of function (eg multiple sclerosis), or fatigue is the predominant symptom (eg traumatic brain injury).

The purpose of scheduling in this case is to help the person maintain activity throughout the day.
It reduces the risk of ‘boom and bust’ where energy available is expended before the end of the day.

It can be used in chronic pain management at the beginning of developing time contingent activity, but needs to be paired with gradual increase of activity. Otherwise it can lead to using ‘pain as the guide’ with gradual reduction of activity level over time, and confirming anxiety about (and subsequent avoidance of) activities when pain fluctuates.

Planning activity to ensure a balance of pleasurable and less pleasurable tasks is helpful when low mood is a feature, and the person is finding motivation to do activities difficult.

The purpose of activity planning is to ensure the person ‘rewards’ completion of difficult/challenging activities with pleasurable ones. It helps encourage increased activity level, and can be used to help people experiencing chronic pain to engage in activities they find difficult especially at the beginning of a ‘reactivation’ programme. Again, it is important that activities planned in this way use time or activity completion as the guide rather than pain.

The risk is that difficult activities are stopped prematurely, or avoided altogether, reinforcing pain avoidance, and that the activity level is not gradually increased.

When working to quota is used to disrupt the learned relationship between activity and pain levels, an opportunity to (1) reduce inadvertent learned associations and (2) begin to use skills to help confront fear of pain and take control can begin.

The purpose of working to quota is to ensure a pre-set level of activity occurs irrespective of pain intensity, and then gradually increased over time as the body ‘habituates’ to the experience of pain.

Setting the initial quota is an art rather than a science, but if activity intensity (task and duration) are scheduled using a hierarchy from ‘least problematic’ to ‘most problematic’ in collaboration with the individual, a working baseline can be developed. From this initial baseline (which I establish using ‘what can you do on a bad day’ as my guide), increments are graded depending on the model being used in therapy. If a graded exposure model is being used, increases will depend upon the beliefs being challenged; if a cardiovascular fitness model is used, heart rate and respiration will be used as a guide; and if an instrumental learning model is used, increases will depend on modeling, rewards and techniques learned (eg manual handling techniques).

Steps for developing a quota

1. Establish your clinical rationale for using this approach – what is your goal and why
2. Working with your client/patient, establish his/her important activities and eventual goal. Ensure your reasoning for using this approach is made clear to the person (and yourself!), as it will shape your plan.
3. Establish a hierarchy of activities from least concerning to most concerning. Identify exactly what the concerns are – do they need to be addressed with information, or do they need to learn from experiencing (testing) what happens ‘in vivo’
4. Establish your baseline, and develop a ‘timetable’ for a week (or any period of time) in collaboration with the person.
   Ensure they have skills to manage fluctuations of pain intensity, and both a recording system and a reward in place for when they successfully adhere to the plan
5. Establish your review date
6. Review and reset the activity schedule – maintain or increase activity level at this time, do not reduce demands. It is important that activity level is not reduced because the effect of this is to reinforce that pain is a threat, to be avoided, and that you do not trust that this person can cope

Pacing, or working to quota (my preference) is a strategy that can provide excellent results for people experiencing pain. It is important that you, as a clinician, are very clear about why you might employ it – and what some of the unintended consequences may be. My preference is to use it as both a behavioural experiment (to test beliefs about consequences of actions), and to titrate or grade activity intensity as the person becomes habituated to varying levels of pain.

Date last modified: 1 March 2008