Pain usually leads to changes in activity levels. You may give up activities as a way to avoid pain. You may find that you push harder, determined the pain won’t beat you. Pushing harder can mean you get pain flares1, and avoiding activity can also lead to more pain and disability2. Using a 'paced' approach gives you a way to break everyday activities and exercise into smaller bits; it means doing little bits often or finding the middle road between not overdoing and not under doing. Pacing is important in pain management because it helps you to stay active, doing the things you care about and want or need to do, and helps you to avoid pain flares3,4. Pacing helps you to:
- do more of what is important to you
- experience less pain flares
- reduce pain in the future
- feel more in control of your life
About pacing and pain
Activity pacing is 'the regulation of activity level and/or rate in the service of an adaptive goal or goals'5.
The main purpose of activity pacing is to help you achieve your adaptive goals, rather than pacing to avoid activity.
Activity pacing has 2 parts to it:
- conserving energy for activities you value (for example, playing with your kids; undertaking a pleasurable recreational activity)5
- setting graduated activity quotas to help you to increase your ability to do activities (tolerance) and reduce your disability5
Pacing is designed to be a tool you use not to 'react to pain', but a tool used in a pre-planned way.
Just like you plan for a trip away and plan what to pack, pacing should be used as a pre-planned strategy in combination with a graded activity program to increase your activity levels5. Grading your activity has benefits for conditions such as low back pain and chronic fatigue syndrome, but more studies are needed as small or no effects have also been found6.
Pacing uses a 'time-contingent' approach to activity rather than a 'pain-contingent' approach. This means activity that is based on a measurement (such as an amount of time, a distance, number of repetitions) rather than pain. This measure gives you a target and a limit for the activity - for example 15 minutes of walking or 20 minutes of light housework. It gives you a basis from which to build 'activity tolerance', which is important to allow you to do everyday tasks.
The disadvantage of using a pain-contingent approach is that you get pain, without necessarily being able to increase your activities. This often leads to the highs and lows of 'overdo and underdo' cycles or 'boom and bust' cycles1,2.
Give yourself a break from pain and use a 'time-contingent' approach to activity now. Current best research indicates that both avoidance of activity and over activity are associated with poorer patient outcomes2.
Pacing is a practical approach you can do to get less pain flares, whilst slowly increasing your activities.
How do I pace?
Decide what your goals are first: what do you value most? (see below for guidance on goal setting). Try and think about the two parts of activity pacing mentioned above.
1. Set the baseline
The key is to work out how long you can do a task without a pain flare. Here it is important to remember that it is normal to expect some pain increase after an activity. This may last for 20 to 30 minutes and this is not a pain flare.
- write the time, distance or number of times that you can do the activity or task without a pain flare
- set your baseline based on the most limiting symptom for that activity (e.g.pain, fatigue)
- taking 3 measures over 3 days often gives the best guide
- take an average of these measures: add the 3 numbers together, then divide by 3. You should then reduce this number by 20% (or multiple by 0.8) to give yourself a buffer. This is your first week baseline for activity "one". Repeat for other activities.
- you can calculate this number on your phone, calculator or computer
2. Repeat the task daily
Using your baseline number, do this activity daily for the first week using this baseline time (e.g. standing, doing dishes), distance (e.g. walk), or number (e.g. number of shirts ironed, number of book pages read, number of repetitions of a particular exercise).
3. Increase by 10% per week
Slowly increase the time, distance, or number of repetitions each week by 10% (or multiply the baseline number by 1.1). This becomes your baseline for the second week. Download our pacing activity template to help you calculate and manage your paced activities.
4. Build up your activity levels using SMART goals
SMART goals stand for: Sustainable, Meaningful, Achievable, Realistic, and Timed. Write your goals down to help you to stay on track and remind you of those things that are important to you.
5. Small bits often
Do small bits often - break activities into smaller chunks - this helps to maintain the range of your activities and your tolerance to activity. Make sure you alternate your position or posture regularly, e.g. sitting, standing, and walking. Your body will benefit in many ways from movement. Calculating and recognising your baselines (or "tolerance") means you avoid pain flares.
6. Take regular planned relaxation periods
Take regular planned relaxation periods - regular planned rests and relaxation breaks, even on days when you feel pretty good, are essential. Make sure you plan short rests before and after particularly stressful or demanding tasks. Practising relaxation, stretching and daily walks, even on not so good days also helps control the pain. Download our pacing activity examples to see some examples of pacing and how you can apply it in your pain management schedule.
- pain flares sensitise your nervous system resulting in more pain for less activity
- when pain gets in the way it is a mistake to push through it or to stop doing things completely
- using pacing to find the middle road is best
Helpful tips for pacing
- on a good day, do not do more than the pacing schedule allows
- have a plan and aim to change only one or two things at a time
- keep a record of what you're doing and how much you are doing - write it down
- alternate heavier tasks with lighter or less stressful ones:
- do little bits often
- use one kind of task as a break from another
- change your body position/posture regularly
- build up time on a task gradually - start low and increase slowly
- set your baseline
- start doing the task at about 20% less when you start paced activities
- increase the time by up to 10% each week
- on a bad day try to do some activities, but remember to be kind to yourself
- if you have had a flare-up, go back to a level that you can cope with and start pacing it up again
What about goal setting?
1. Set your goals - Plan and prioritise
It is easy to lose sight of your priorities when dealing with a difficult problem such as managing chronic pain. Pain often drives a wedge between the things that you care about and what you actually do. Give attention to those things that deserve it, the truly important things for you. Do activities every day that reflect these values. So for example, if your relationship with your partner is highly valued to you, you may plan to spend time talking with them over dinner, or arranging an activity together; if caring for your children is something you value highly you might include activities with them such as listening to them read or cook them a nutritious meal; if your health is a high priority to you, include some gentle exercise each day, eat some healthy food, make that appointment you have been meaning to do. Think ahead and plan activities so that you don’t overstretch yourself.
2. Write down the things you have to do
Once they are in front of you, arrange them into order of priority. Ask yourself if each task really needs to get done, and then cross off those that are not necessary. If there is one really important thing you need to do, arrange your day around this task.
3. Do little and often
For example, breaking down tasks such as cleaning or gardening into smaller amounts; carrying the groceries from the car in small amounts. This may seem more complicated at first, but it is a very helpful way to conserve energy and reduce pain flares. In this way, many activities that you might have given up (like gardening), become possible again. This means a change of emphasis and not expecting yourself to do things like you used to.
4. Alternate tasks
Plan to alternate heavier tasks with lighter or less stressful ones. Plan to incorporate relaxation periods every day. Writing down a weekly plan can help you to balance out tasks and to focus on your goals.
- Andrews NE, Strong J, Meredith PJ, Gordon K, Bagraith KS. "It's very hard to change yourself": an exploration of overactivity in people with chronic pain using interpretative phenomenological analysis. Pain 2015; 156(7): 1215-31. [PubMed]
- Andrews NE, Strong J, Meredith PJ. Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis. Archives of physical medicine and rehabilitation 2012; 93(11): 2109-21 e7. [PubMed]
- Nicholas MK. On adherence to self-management strategies. European journal of pain 2009; 13(2): 113-4. [PubMed]
- Nielson WR, Jensen MP, Karsdorp PA, Vlaeyen JW. Activity pacing in chronic pain: concepts, evidence, and future directions. The Clinical journal of pain 2013; 29(5): 461-8. [PubMed]
- Nielson WR, Jensen MP, Karsdorp PA, Vlaeyen JW. A content analysis of activity pacing in chronic pain: what are we measuring and why? The Clinical journal of pain 2014; 30(7): 639-45. [PubMed]
- Gatzounis R, Schrooten MG, Crombez G, Vlaeyen JW. Operant learning theory in pain and chronic pain rehabilitation. Current pain and headache reports 2012; 16(2): 117-26. [PubMed]