Pacing for Chronic Pain to Prevent the Boom/Bust Cycle

This article takes a look at what the boom bust cycle is and how pacing techniques can help reduce pain and deliver lasting activity gains.

Living with chronic pain, it can be tough to figure out the level of functioning that is going to allow you to get things done without making your symptoms flare. There’s a fine line between doing too much and too little.

Avoiding activity because we fear it may increase our pain is maladaptive (meaning not helpful), but overdoing it and making your symptoms flare is also maladaptive! This sounds like you can’t win, but it’s about finding that balance.

What is the boom bust cycle?

When good days come around meaning that your pain is low, you have energy and you are ready to function. It can feel like you’ve won the lottery! It can be all too easy to decide you’re going to ‘make the most’ of this good day, trying to squeeze everything in that you haven’t been able to do.

Maybe the housework has been piling up, there are errands you’ve needed to run, you want to get some exercise in or you want to see family and friends. So you go ahead and try to do as much as you can during that good day, but you inadvertently do too much, making your symptoms flare, leaving you worse than you’ve been for a while. This is the boom bust cycle, or you may hear it referred to as the overactivity-underactivity cycle.

If this cycle continues, your good days will become less frequent and be much shorter, and your flares will become more regular, much longer and more severe.

Even though you may think you’re making the most of the time you have with low pain, you’re actually feeding into this vicious cycle and making your chronic pain worse.

What is pacing and how can it help?

So you’re supposed to exercise and not avoid activity, but you’re also supposed to not do too much? The solution to this dilemma is pacing. The term ‘pacing yourself’ is a well known one, meaning that you take things a step at a time, ensuring you get adequate rest, and not forcing yourself pushing past your limits.

The technique of pacing is done in relation to time, rather than to pain; for example you might do a pre-planned activity for 10 minutes and then rest, rather than doing it until you experience a flare or stopping as soon as you feel pain. This study provides a comprehensive definition, “Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet.”

Pacing can allow you to prioritize tasks that are most important to you so that you can engage in them to the fullest. It can also help you to set targets and gradually build up the activity you are doing to get your body accustomed to being active over time, therefore reducing the flares and increasing your level of functioning.

Six steps of pacing

  • Step one: Figure out your baseline

This simply means figuring out how long you can do a specific activity without experiencing a flare in symptoms. With chronic pain, it’s natural to feel some level of pain during activity, and to find that the pain increases somewhat after a period of activity, but that doesn’t equate to a flare. This step is about figuring out what you can manage without causing a real flare in your symptoms. 

 You need to establish how many times or for what length of time you can do one specific activity before it causes a flare in symptoms, and keep a record of that as your baseline. Ideally, figure out your limits over the course of three days, trying out the activity three times so that you can get an average. Then reduce that number by 20%: that’s your baseline! For example, if you can walk for ten minutes on average without a flare in symptoms, you would then reduce that by 20%, which would be 8 minutes.

  • Step two: Do that activity every day for a week

For a full week, every day, you will carry out that activity for the baseline of time – using our example, that would would be 8 minutes of walking per day. It’s a good idea to keep a record of your baseline and any increases in activity. A chart can really help with this: you can make one of your own, you may be given one by your therapist if they are helping you with pacing or there are plenty to be found online like this one.

  •  Step three: Increase the activity by a small amount

The next week you will increase your baseline time for that activity a small amount, for example by roughly 10% or more, and then engage in that amount of the activity every day. So in our example, you could now walk for an extra minute, bringing your walking to 9 minutes per day.

  • Step four: Continue increasing your activity gradually

Over the following weeks, you can continue increasing your activity gradually like this, building up your tolerance and training your brain and body away from pain. You may find that increasing it gradually each day is more beneficial than continuing to do the same amount of the activity for a full week, but ensure that you are always using very gradual increments. Reassessing your baseline every month or so can be helpful as you build up the activities you are engaging in.

If when you are increasing the activity you find that a flare is caused, then you can go back to the baseline or back a few steps, and work your way back up again. Setbacks don’t mean that the process isn’t working, it just means you need to try again so don’t let that put you off.

  • Step five: Break activities down and add more

It’s important to break bigger activities down into smaller bite size pieces in order to build your tolerance in the most productive way. As you get the hang of pacing, you can add more activities to your day and really start to get that high level of functioning back into your life.

  • Step six: Always take rests

It’s so important that you remember to plan rests into your activity schedule for the day. As the length of time you are engaging in one set activity extends, it’s important to actively plan breaks. For example, taking a rest of 5 minutes to sit down for every 20 minutes that you do housework, in order to prevent flaring. You can plan rests during longer activities, before you start a new activity and after you have finished with one.

You could choose to alternate tasks that take more energy with lighter tasks to give your body even more of a break. In our example you could do housework for 20 minutes, then take a 10 minutes rest to completely relax, then do a lighter task such as answering some emails which you can do sitting down.

The important thing to remember is, that even if you feel really good, you are having no pain and you feel like you could go on for much longer than your planned length of time, stop when the planned time is up. Even if you’re having a good day, still take the rests that you have planned. This study explains that, “Although it may be counterintuitive for some people with chronic pain to stop for rest breaks when they are not in a pain “flare,” pacing allows them to avoid a flare and continue with usual activities.”

On the same note, if you are having a bad day and don’t feel up to the activity, ensure you still engage in it for the set amount of time you have planned; this may be easier said than done and if you don’t feel able to complete the task, still praise yourself for trying and don’t be too hard on yourself. You can always try again the next day. If on bad days you need help to complete the task you have set for yourself, then don’t be afraid to ask for help from a loved one. This balance is key to pacing.

Setting goals

Once you’ve got the hang of pacing you can start to really set goals for your life and your future, knowing that your level of functioning is increasing and that you can live a full life. Setting goals can really help you to feel motivated. Having goals that you really care about achieving can help you to stay on track and make you feel that it’s worth putting that effort in despite your chronic pain. 

Goals can be as simple or complex as you like, but remember to break down more complex goals into smaller achievable stages so you aren’t putting too much pressure on yourself. Goals could be things such as spending more time with family or being able to go out for a walk all the way up to being able to go out to work or run a marathon! Whatever you want to achieve and what works for you, is what is most important; this whole process is about you being able to live the life that you want.

SMART goals

Using SMART goals can help you to figure out what activities you want to prioritize. SMART stands for:

Specific: setting very clear, small and specific goals helps you to maintain that focus and to know exactly what you are aiming for.

Measurable: this simply means that you are able to measure your process, so with pacing this would be increasing the length of time or the amount of times you are able to do each activity.

Achievable: it’s important that the goals you set for yourself are things that will push you forward but are also things that you are going to be able to achieve. As you achieve each goal your confidence in your ability and level of functioning will increase, seeing the positive outcomes from your own proactivity.

Realistic: being realistic about what stage you are at in your chronic pain recovery and what your situation is in other areas of your life, will help you to set goals that work for you.

Timely: setting a time frame on the goals you want to achieve can keep you feeling motivated to put that effort in because you know what the end date to tick off that goal is. Remember though that if you don’t achieve goals in a certain amount of time, this doesn’t mean you should be hard on yourself or give up; you can continue trying.

The purpose of setting these goals is to give you the motivation that you need to shape your future and help you beat your chronic illness in a realistic and adaptive way.

Can pacing alone reduce my chronic pain?

The process of pacing and avoiding the boom bust cycle can certainly improve your quality of life, increase your functioning and reduce your pain levels. Setting goals is a helpful way to stay motivated and taking things a step at a time is valuable, but you don’t have to introduce pacing to your life all on your own.

You can combine pacing with other treatments like mindfulness, cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT), physical therapy any medications you are on or any other treatments. In fact the concept of pacing is often part of these therapies, regularly used in CBT and graded exposure therapy, as mentioned in this study. Sometimes occupational therapists and other specialists will introduce pacing as a way to support patients in regaining their level of functioning.

More research needs to be done into pacing and the positive effects it can have for pain patients, as explained here, and more support and education in pacing given as standard from medical professionals to chronic pain patients.

Engaging proactively in techniques like pacing and seeking therapies that can reduce your pain symptoms over time, can help you to get back that control over your life that you may have lost. While it is challenging, it does take willpower and it is hard work, that hard work is so beyond worth it to be able to thrive and engage in the daily activities that allow you to live a full life.

References

  • The Clinical Journal of Pain: Volume 30, Issue 7, p 639–645, Nielson, Warren R. PhD.,  Jensen, Mark P. PhD., Karsdorp, Petra A. PhD.,Vlaeyen, Johan W. S. PhD.,(2014), “A Content Analysis of Activity Pacing in Chronic Pain: What are We Measuring and Why?”
  • The American Journal of Occupational Therapy, Susan L. Murphy; Angela K. Lyden; Dylan M. Smith; Qian Dong; Jessica F. Koliba, (2014), “Effects of a Tailored Activity Pacing Intervention on Pain and Fatigue for Adults With Osteoarthritis”
  • painHealth, (2019), “Pacing and goal setting”
  • painHealth, (2019), “Pacing guide”
  • Quality of Life Research, Deborah Antcliff, Philip Keeley, Malcolm Campbell, Steve Woby, Anne-Maree Keenan, Linda McGowan (2018), “Activity pacing: moving beyond taking breaks and slowing down”

Please note: This article is made available for educational purposes only, not to provide personal medical advice.

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