Take control of your pain with activity pacing

Special thanks to guest writer Jo Rankin for this article. Jo is a Melbourne based physiotherapist with a masters in Pain Management. She is currently the Rehabilitation Coordinator at Metro Pain Group and Director of Hydrotherapy Solutions.

Tom injured his back in a work injury six months ago. He is worried any activity that hurts is further damaging his disc, so he stops and sits down whenever he feels pain. He seems to be doing less and less.

Gita was diagnosed at age 40 with axial spondyloarthritis. She prides herself on her parenting, spotless house and well-kept garden, but is awake most nights from 3am with lower back pain. Her mood is suffering, and she is yelling at the kids more often.

Retirement was always going to be Karl’s time for himself. His knee pain has been diagnosed as moderate osteoarthritis, but he is determined to keep walking his 18 holes of golf even though he spends the next day on the couch. Lately he has been playing less as he needs two days to recover after each round.

Tom, Gita and Karl demonstrate the three approaches to activity that are not helpful for pain conditions:

  • Underactivity – avoiding activity, often for fear of pain 
  • Overactivity – excessively pushing through despite pain at the time or later 
  • Overactivity-Underactivity – also known as the boom-bust cycle. This involves excessively engaging in activity and flaring up pain, followed by periods of inactivity to ‘recover’ 

Underactivity can lead to weakness, stiffness and consequent reduced function. Overactivity is rarely sustainable in the long term, and boom-bust behaviour usually leads to progressively less activity over time. 

Each of these activity types can further sensitise the nervous system and perpetuate pain. As social life, exercise and daily tasks become more challenging, psychological distress is likely to increase. When activity is dependent on pain levels the individual can feel like they have lost control of their lives and that their condition and pain control them.

What is pacing and how can it help?

Activity pacing, or ‘pacing up’ is a method of regaining control and gradually building functional levels in a systematic and manageable way. Pain will often reduce throughout this process, but the focus is on building strength and endurance, achieving goals and improving quality of life rather than necessarily eliminating pain. Having a healthcare professional trained in pain management to guide the process and problem solve along the way is helpful, as is the understanding of family and friends. The expectations we put on ourselves and by others are not always in our best interests. They need to be recognised and managed.

Here is a simple guide to pacing:

  • Choose an activity that you would like to carry out eg walking, cycling, gardening. You can also use this method for building tolerance to more static tasks like sitting at a desk.
  • Establish your baseline. Over three to five days measure the maximum amount that you can do before your pain level increases and work out the average. If you walked 8 minutes, 12 minutes and 10 minutes over three days, your average maximum was 10 minutes. 
  • Start at 80% of your maximum level to make sure it is achievable.  In the walking example, you would therefore start at 8 minutes.  You may want to do the activity just once a day, or if you know you recover relatively quickly you could start with twice per day.
  • Stick to this same level on most if not all days of the next week. This means even if you have more pain that day, you still do your set amount. Remember; you are in control, not your pain. Importantly, if you feel like you’re having a really good day you must still stick to the same amount and not do more. The aim is to even out your activity levels, slowly build tolerance and prevent flare ups.
  • Each week increase your chosen activity by a small amount. About 10% usually works well. In our walking example this would mean an increase from 8 minutes to almost 9 minutes. Stick to this new activity level for one week, then increase by 10%.
  • Stay in control through flare ups.  If you have a significant flare up, reduce the amount of the activity but try not to go right back to your baseline level. Gradually build up again.

Keeping an activity diary is a great way to track progress over time. Activity pacing takes patience and dedication, but IT WORKS!