Pacing is a crucial skill to help patients break out of the ‘boom and bust cycle’ of behaviour and adopt balanced levels of activity. It is a number one skill for becoming more active despite the pain.
Your role is to help your patient understand the concept and techniques of pacing. This is important for retaining their trust as they start to consider changing their activity levels.
It is common for people with chronic pain to do as much as possible at times when their pain levels are lower. You might hear things like, “I try to catch up on all my jobs before the pain gets me”. They then find the following day they are exhausted, often overwhelmed with pain and unable to do anything. This becomes a vicious and demoralising, self perpetuating cycle.
The alternative is to do nothing and lose fitness. In this case the patient might think, ‘I used to be able to run 10km and I should be able to, but I can’t so it isn’t worth doing any exercise at all.’
Pacing is taking a break before pain or tiredness become overwhelming and forces an activity to stop. It is a skill that needs patience and practice. It requires the patient to be aware of the effort that an activity involves and balance this with rest breaks or a change in the task. Ultimately, this can mean that the total amount of activity achieved over a number of days will be greater. This will help the patient to build up stamina, confidence and self-efficacy.
You can help your patient to learn about pacing by working through the action points below:
Action to take
Identify tasks that need to be paced
This is any task that is difficult because of pain or can increase pain.
Discuss how much effort the patient can put in without causing their pain to become worse
This will take some trial and error and involves considering:
- Distance of activities
- Speed of activities
- Duration of activities
Once they have identified at what point pain tends to increase, the idea is to put in a break before they reach that point, usually at the half way point.
Encourage the patient to be flexible in their response to pain and activity. Plans may need to be adjusted to take account of day to day variations in pain and energy levels. This means the ‘listen to your body’ message is very unhelpful for people with chronic pain as their pain is present all the time.
Emphasise the importance of planning in breaks
For instance, your patient could:
Use a timer as a reminder of when to take breaks.
Plan a set rest activity such as having a drink, sitting down and listening to music, doing some breathing exercises.
Offer strategies to avoid ‘all or nothing’ thinking
For instance, your patient could:
- Avoid words like ‘should’ or ‘must’, and replace them with ‘could’
- Involve friends and family, let them know about pacing and invite support
- Prioritise – accept it is OK if not everything gets done today
- Use different approaches to planning activity. They could divide tasks into different levels of effort, for example:
– Doing all of the ironing, digging the garden for two hours – very high effort levels so not to do now – vacuuming the downstairs carpets, going for a short bike ride – moderate effort so might do over next 7-14 days (planning and pacing the activity well) – getting medications, seeing sick family member – some effort and essential to do in next 48 hours
Resources for your patient
Pacing leaflet for patients
Next time you are talking to your patient about increasing their activity levels, add in the concept of pacing. Give them this pacing leaflet to take home with them, and ask for feedback when you next review them.
Summary of key points
- Pacing is a very important skill that will help the patient to avoid ‘boom and bust’ overactivity and underactivity
- It is worthwhile spending a consultation on this and sharing resources
- It is important to discuss pacing before setting goals about becoming more active