pacing

Interrupted by Pain


If there’s one thing I loathe, it’s being interrupted when I’m in the middle of something. There I am, working away at something, in the flow, knowing where I’m going and what I’m doing then BANG! something gets in the way!

I wasn’t aware, but there is a science of interruptions – mainly studied within ergonomics or human factors research (the study of work and humans) – and this science has begun to unravel some of the issues associated with interruptions. Interruptions are not only annoying, they’re also a good way to provoke mistakes!

Pain is, as Geert Crombez and others have shown, a stimulus we find difficult to ignore. It interrupts what we have planned, and orients us towards finding ways to escape the stimulus. Of course, when pain doesn’t stop, as in chronic pain, people learn to deal with the interruptive effect of pain so they can get on and do things that are important – but at the same time, because part of our brains must deal with the pain in some way, our performance can be degraded.  Essentially, to continue doing something important when pain is also present requires us to deal with goal conflict. 

What happens when a person becomes aware of his or her pain while working on another goal?

Well, initially, the goal pursuit remains strong – our brains are very good at prioritising what we want to do, except when the new stimulus is salient (relevant), novel (new) and intense. Pain is (usually) relevant (it’s a threat!), is experienced as something new or different about our bodily status, and varies in intensity. So in the context of a task, people may remain focused on the task until the pain is intense enough, or meaningful enough, or new for it to capture the attention.

So, pain gets in the way, and we attend to the threat and the threat reduces.

After some time, we return to what we were doing – but the time that it takes to get back to what we were doing differs depending on a bunch of things.

Those things include

  • the threat value of the pain,
  • how readily it resolved,
  • how close to the end of the original activity we were,
  • how quickly we oriented towards the pain (the more quickly we do, the less easily we return to doing what we were originally doing, perhaps because we don’t have time to code the need to return to it into our memory before we move on to address the pain),
  • whether there are cues in the environment that help us remember to get back to the original activity

and a bunch of other things as well.

Some interesting facts have emerged about interruptions – if we have many interruptions, it’s easier to adapt to them and get back to the original task (which is possibly why mothers are known to be good at multi-tasking!); unpredictible interruptions are more difficult to recover from, they’re more disruptive; interruptions that last a long time make it more difficult to return to the original task.

In the case of chronic pain, pain is usually present to at least a certain degree all the time. It’s when it is intense, or the character changes, or it is particularly salient, or perhaps our overall coping is less, that pain interrupts more. So, for some people, it’s possible to delay being taken off task to attend to pain because these people might have learned that it’s “nothing unusual”, it isn’t a threat, it will subside of its own accord, or it’s just less important than the goal they’re working on.

For those of us who do deal with chronic pain, the aspect that may still trip us up is getting back to the activity we were working on before we needed to take a break because of our pain. If we need to take a long break, if we stop the original activity without having clearly planned to stop, if we don’t give ourselves cues to return to the activity, we might find it more difficult to remember (a) where we were in the activity, and (b) that we actually were working on something!

The relevance of interruptions becomes very important when, as therapists, we suggest to people that they consider using activity pacing.

While the definitions of pacing are not clear and still being debates, essentially it means interrupting what a person is doing to take a break, regain energy or maintain pain at a reasonable level. I’m sure many of you will remember the old-fashioned programmes on the computer that used to flash up a screen telling you to STOP! and do a break or stretch. You could “ignore” it a few times, but eventually it would lock your computer so you couldn’t use it until you’d taken the predetermined break. I LOATHED it! I’d be halfway through writing something and it would stop me and get in the way. So I deleted the programme.

That’s one of the problems of these kinds of approaches to activity management – they may stop you “overdoing” something, but they often stop you from completing a task, and completely disrupt your thinking!

My preferred way of helping people to use “pacing” was to suggest “activity chunking” where, at the completion of some chunk of an activity, the person could take a quick break to do a body scan or stretch or something. I found that people used this strategy more often, complained less often, and consequently relaxed a lot more!

After reading about pain and interruptions, I can now understand why this strategy was a little more effective – because at the end of a chunk of activity there are cues established in the memory to remind us that we’ve got a task to complete. These breaks were planned and expected, so they were easier to anticipate, and therefore accommodate.  Eventually, as people got good at them, they become habitual and no longer seem to get in the way of doing the original task.

Pacing, interruptions and pain. People with chronic pain are chronic multi-taskers. We know multi-tasking isn’t good for cognitive efficiency, accuracy or even energy (see the references below), so quite apart from the added burdens we as clinicians might give to people with chronic pain by suggesting “pacing”, people who have chronic pain are chronically stretched cognitively.

My suggestion for managing the demands of pacing and pain is to use planned breaks, preferably using chunks – or, as I’ve been doing recently, using Pomodoro technique to plan and schedule my activities and breaks. I also use mindfulness when my pain begins to get noticeable. By doing this I can remain “on task” rather than distracted.

Conard, M.A., & Marsh, R.F. (2014). Interest level improves learning but does not moderate the effects of interruptions: An experiment using simultaneous multitasking. Learning and Individual Differences, 30, 112-117.
Finley, J.R., Benjamin, A.S., & McCarley, J.S. (2014). Metacognition of multitasking: How well do we predict the costs of divided attention? Journal of Experimental Psychology: Applied, 20(2), 158-165.
Gatzounis, R., Schrooten, M. G. S., Crombez, G., & Vlaeyen, J. W. S. (2014). Interrupted by pain: An anatomy of pain-contingent activity interruptions. PAIN®, 155(7), 1192-1195. doi: http://dx.doi.org/10.1016/j.pain.2014.03.017

Katidioti, I., & Taatgen, N.A. (2014). Choice in multitasking: How delays in the primary task turn a rational into an irrational multitasker. Human Factors, 56(4), 728-736.
Munneke, J., Fait, E., & Mazza, V. (2013). Attentional processing of multiple targets and distractors. Psychophysiology, 50(11), 1104-1108.
Sanjram, P.K. (2013). Attention and intended action in multitasking: An understanding of cognitive workload. Displays, 34(4), 283-291.

 

Pacing: What’s the evidence for it?


ResearchBlogging.org
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. (more…)

Quick plead — and a plug for my survey


As you’ll know, research of any kind is a challenge.  That’s why I’ve resorted to using an on-line survey to find out some things that I’ve been wondering about for a while.

Sooooo, as I said I would, I’m nagging again to ask you to please consider clicking on this link to my brief survey about pain management strategies.  What YOU think matters! It takes about 5 – 10 minutes to complete, and it’s simple to do, just answer 10 questions on your thoughts on some common pain management strategies.  I’d like to get 100 responses – so keep ’em coming!

Thanks to those of you who have filled the survey out, I’m really grateful.  And to anyone else? Think about clicking, at least to see what I’m raving on about!

This is the link – thanks!

Friday Funny!


If you’ve got someone you’re working with that just needs to learn how to SLOW DOWN, this website is for you!

Did you know that multitasking is a moral weakness?
Although if you’re a woman, this is slightly less of a problem…

Some great posts here – including this one on the benefits of a Good Night’s Sleep
and this one on the horror of work – I suggest this one for you when you have your next performance review….

And what you really need on a Friday afternoon….A beginner’s guide to slowing down.

Can I suggest you start with a cup of tea and a moment or two reading this blog? It’s a good start! Don’t forget the cup of tea…

Change


This is just a quick ponder on the words we use in pain management.  Quite often we talk about ‘goals’ and ‘prioritising’ and ‘planning’ and ‘skills’ – as if it’s an event that will come to an end.

‘Oh I’ve done my planning, and achieved my goals’.

The team I work with has started to consider whether an overarching theme in our programme should be around the process of changing – a process that never stops.  In the programme maybe there will be three elements throughout the three weeks – one that focuses on skills for managing pain; another that helps develop skills for managing change; and still another that provides opportunity to consider change itself.

One of my long-term concerns about pain management programmes, and in fact any intensive programme of change, is that it’s all fine and dandy while the programme is running.  Lots of skills, lots of new things that generate energy, and lots of new plans to put in place.

But after six months, what will have actually changed?  What will remain of those skills, that energy and those plans?

When I asked people who had ‘graduated’ from a three week pain management programme what was different about their lives since they completed the programme, it was sad to hear that so little had changed.  Yes, attitudes towards pain had changed, and most talked about ‘pacing’, ‘exercise’, ‘relaxation’ – but their day to day lives didn’t look at lot different.  Their outlook and ideas for the future hadn’t changed much.

They gave lots of reasons for not implementing their skills.  Things like ‘you can’t do pacing at work’, ‘you can’t go away and do a relaxation at work’, ‘my case manager wanted me to do something else’, ‘I look stupid doing exercises’, ‘I don’t have any time to do my relaxation/exercises/social stuff/look for work’… And these comments were from people who were motivated to see me about returning to work!

Something wasn’t gelling – it’s almost like ‘lead a horse to water and watch them walk away’… Or is it?

At the time I was naive to the Prochaska and DiClemente model of stages of change – perhaps some of these people were simply not yet ready to integrate their pain management into a ‘new life’.  And some had very complex psychosocial situations with mental health problems, family problems, as well as (often) medical influences.

But as I reflect today, I wonder whether we talked about specifically planning, over time, to implement each piece of the pain management puzzle until it formed a ‘new’ life.  And I know we didn’t talk about the process of acceptance…

So, here are 10 thoughts to help people weave new habits into their lives…

1. Begin by making small changes.  Pick one or two skills to begin with each fortnight.  Get used to these before adding in some more.

2. Mentally link changes to daily routines you already do. This can make changes like taking on a new habit happen much more smoothly. For example, if you want to begin using relaxation at home, try adding it in to your bedtime routine.

3. When a change feels most stressful, it’s probably about something really important. Achieve in this area, and others will feel much easier.

4. A timetable or checklist to record progress helps maintain your motivation.  And you can show it to others to keep yourself honest!

5. Remember that all change involves a degree of learning. You don’t expect to be skillful until after you’ve practiced.

6. Remember that upheaval and confusion are often natural parts of change. Both you and other people may find it difficult to feel comfortable with new ways of doing things.  It won’t always feel great.  It will probably be ‘odd’ until you no longer have to think about it to do it.

7. Don’t feel like you have to cope with changing circumstances or the stress of making a change on your own. Talk about what’s going on for you with a friend or write about it in a journal. Sharing your feelings can give you a sense of relief while helping you find the strength to carry on.

8. No matter how large or difficult a change is, you will eventually adapt to these new circumstances. Remember that regardless of how great the change, all the new that it brings will eventually settle into the right places in your life.

9. When you feel ambivalent about ‘doing it’ pick something, anything, to do and do it right away! Don’t stop to think about it! Completing something provides impetus to keep doing.

10. If you’re trying to change a pattern of behavior or navigate your way through a life change, don’t assume that it has to be easy. Wanting to cry or being moody during a period of change is natural. Then again, don’t assume that making a change needs to be hard. Sometimes, changes are meant to be that easy.

 It takes about six to eight weeks for a new behaviour to start to feel automatic.  Some things help make it easier, I’ll be posting about these shortly!