Chronic pain and pacing: cause or consequence?
Tim Austin presents a case of a patient with a complex pain condition who displayed numerous significant presenting signs and symptoms across the biopsychosocial spectrum.
Pacing is universally considered to be a key aspect in the management of chronic pain conditions, in part due to its supposed intuitive logic (Stanos & Chang 2019). Many patients readily identify their own ‘boom/bust’ approach to performing physical activities or functional tasks.
In clinical situations, discussions of pacing occur in one-on-one treatments through to intensive pain management programs. Advice on pacing will be given by almost every practitioner involved in pain management care (Stanos & Chang 2019).
The earliest serious exploration of the concept of pacing in the pain management literature revolved around the operant conditioning model (Fordyce 1968). Since that time, there has been increasing confusion around exactly what constitutes pacing, with two key contrasting approaches.
Firstly, ‘energy expenditure’ models have been described, related to taking rest breaks to reduce pain, which might have greater applicability in fatigue and fibromyalgia conditions.
The opponents of this approach suggest that such models (especially exhortations such as ‘take a rest’) could reinforce reduced activity and produce worse functional outcomes (Nielsen et al 2013). However, the literature has inconsistent definitions of activity avoidance and over-activity (Andrews et al 2012) and there is incongruence surrounding the suggested theoretical bases behind pacing (although the acceptance and commitment literature could be seen to explore this to some extent; see McCracken & Samuel 2007).
To address some of these ambiguities, there has been increasing emphasis in pain management that pacing involves much more than just ‘taking it a bit at a time’. Rather, pacing involves ‘pacing up’, meaning that goal-setting and pre-determined quotas are used to increase functional capacity. To some extent, this is a return to the original operant conditioning models (Fordyce 1968; Harding & Williams 1995).
As noted above, the language used with patients is crucial. Reflective listening and Socratic questioning often reveal key beliefs and motivators for behaviour, which strongly influence the adopted pacing style (Clark & Egan 2015). Motivational interviewing techniques aim to assist the patient to solve their own challenges with regards to adopting more value-driven behaviour (Jensen et al 2003).
Therefore, a patient’s naturally adopted approach to physical activity (their innate form of pacing) could be considered as being derived from the highly individual confluence of pain-related beliefs, behavioural reinforcers and other psychological variables (mood/ anxiety, PTSD etc). Nielsen’s excellent review (2013) and the proposed framework for understanding pacing by Andrews and Deen (2016) are worthwhile reading.
A patient with a complex pain presentation will now be discussed to highlight these issues around pacing.
Just over five years ago, Mr M (then aged 43) was riding his bicycle into a roundabout at about 20kph when he was hit by a car. He denied a loss of consciousness in the episode, but said that he was not able to remember part of the accident.
Mr M was covered under the third party Insurance scheme. At the beginning of the assessment, Mr M noted post-traumatic stress disorder (PTSD) related to the accident (diagnosed later by a psychologist).
Initially, Mr M experienced right thumb pain and noted his thumb at an awkward angle. He was taken to a nearby hospital, by which time he also noted left shoulder pain. A Bennett’s fracture of the thumb was diagnosed, which led to surgery three days later. He also had an MRI of his left shoulder soon after the accident that suggested that he had sustained a posterior dislocation.
Mr M described slow recovery from his thumb surgery, with ongoing pain which led to carpo-metacarpal (CMC) joint fusion eight months later. Mr M also described left wrist pain with a diagnosis of a scapholunate ligament injury, but no particular treatment was provided.
In the three to six months following the accident, Mr M described increasing right shoulder pain. Following MRI investigation, physiotherapy treatment and numerous orthopaedic reviews, he proceeded to capsular tightening surgery with biceps tenodesis two years after the accident.
Mr M also described significant neck pain, which never settled. This led to two surgical procedures, firstly three years after the accident to decompress the C4/5/6 levels, and then fusion of those levels a year later.
Mr M noted significant physiotherapy treatment throughout these procedures. He noted steady gains overall but was far from satisfied with the overall result due to ongoing pain and an inability to return to his desired level of function.
The physiotherapy had been stopped by his insurer approximately 12 months after the latest neck surgery (12 months before this assessment). He appealed that decision, resulting in an independent physiotherapy review, which Mr M said had recommended ‘a more “pain clinic” style of intervention due to the presence of central sensitisation’ (but he was not sure what this meant).
Mr M acknowledged that he was quite depressed throughout this whole situation and was also suffering PTSD, leading to psychiatry and psychology reviews. He was seeing a psychologist on an ongoing basis for management of his PTSD, rather than for specific pain-management assistance.
In the assessment, Mr M described pain in many areas of his body but was most bothered by anterior and posterior neck pain. He described a constant tight ache posteriorly in his neck together with a choking feeling anteriorly. These pains were worse with activities involving neck flexion and extension. If he spoke for more than five minutes, he started to get the choking feeling.
He noted constant aching pain in both shoulders, worse in the right than the left, with burning mostly anteriorly and superiorly. He also described tingling running down the lateral forearms and pain both in the left wrist (radial and volar) and right thumb/wrist (around the CMC joint predominantly).
Mr M said that the neck and shoulder pain were aggravated by lifting and carrying, and also by neck movement in any direction. He was restricted to lifting 2.5kg above head height, 3kg 30cms away from his body, or carry 3kg for 40m. Vacuuming, sweeping and mopping were painful, but he pushed himself to complete them.
He had recently helped his father mow the lawn and it took him five days to recover.
Mr M noted mainly passive ways of managing his pain, either by sitting down or stopping what he was doing. He said he usually pushed through the pain to get things done.
Mr M lived by himself following an ‘ugly’ separation from his wife two years ago. He had custody of his children (aged 15, 13 and 9 years) a number of days per fortnight. Mr M had worked in an administrative role in the financial sector throughout his rehabilitation. However, he noted that he was just completing 12 months of voluntary leave, which he had taken to try to improve his pain. He was looking forward to returning to work sometime in the next month or two but was anxious about how he would cope.
With regards to pain-related beliefs, Mr M described himself as an active person and wanted to keep pushing through the pain. He had had success with this approach in the past with sporting injuries. However, it was very frustrating that currently such an approach was not successful. He held a structural view of the basis of his pain, which was reinforced by his numerous surgeries. Hence, he believed pain on activity indicated perpetuation or worsening of damage and it distressed him that there may not be a surgical fix for his current symptoms.
He was depressed with the thought that he would be in this level of pain for the rest of his life and not be able to return to his desired level of physical functioning and psychological wellbeing. He noted a pre-morbid obsessive/compulsive nature, which he agreed encouraged a boom/bust approach to activity.
Mr M had been very active pre-injury, swimming up to 3km, paddling a kayak and bike riding up to 200km per week. He felt depressed by his inability to return to riding. He had been for a few bike rides (30km) in the last three months, but noted significant neck, shoulder and wrist pain.
He was currently swimming about 1500m three times a week, but this always aggravated his neck and shoulder pain. He needed to keep his head down in the water and not extend the neck too much. He noted that he did not particularly like swimming but thought it was good for him to do so.
Mr M had no regular stretching or any strengthening regimen.
Regarding his goals, Mr M wanted to be able to ride his bike for an hour, to return to kayaking and was hoping to walk a bit further than his current capacity of 30 minutes. He also wanted to have less pain performing home duties such as cleaning and carrying shopping bags. He wanted the upcoming return to work to be manageable; he had organised to start with 20 hours per week.
During the assessment and examination, Mr M’s mood was flat with little sense of hope for the future, but he desired something to be done. He was aware of the PTSD (notably related to cycling) but did not want to ‘let it beat him’.
On examination, there were numerous biological signs. Neck mobility was moderately to significantly restricted in all directions, with most pain on neck extension. Supine neck head holding was 15 seconds (significantly restricted—Harris et al 2005) and markedly painful.
Right shoulder flexion was to 170 degrees and left to 150 degrees, both leading to superior shoulder pain and excessive scapular elevation. Hawkins impingement was mildly positive through both shoulders. The left shoulder had a positive apprehension test.
Left wrist flexion was to 60 degrees (painful end point) and extension 75 degrees (mild pain only). Grip strength was 46kg on the right and 34kg on the left.
The neck was painful to palpate throughout (indicative of hyperalgesia), and equal left and right side. Cold hypersensitivity test demonstrated widespread alterations in sensation, with random areas of the left hand, arms, shoulders and neck demonstrating cold allodynia. Mr M was immediately intrigued by this, realising for the first time that something other than structural pathology was involved in his pain. Reflexes were intact.
Mr M was given the standard ePPOC questionnaires (Electronic Persistent Pain Outcome Collaboration).
In summary, Mr M presented with contributors across the biopsychosocial realm. The challenges of the case were the widespread nature of the pain, the multiple affected body parts, and mixed pain mechanisms (clearly nociceptive and nociplastic, with probable neuropathic features).
Mr M did not want any more surgery or investigations for surgery. He was happy to accept his wrist and hand pain but was unsure what he should do for his shoulders. He had some psychological awareness with regards to his PTSD and his boom/bust approach to performing activities. He did not grasp the relevance of stress to his pain situation.
Following the assessment, the first ‘treatment’ provided to Mr M was to participate in a pain formulation dialogue (Linton & Nicholas 2008, Engel 1977). A flow chart was generated together with Mr M, this then allowed for a discussion of the key barriers to progress. Mr M identified the aggressive approach to swimming, which consistently triggered a couple of days of increased headaches and right shoulder pain.
Previously, he was not willing to alter this approach, fearing that it would lead to reduced strength in the arm. A patient-centred discussion around the cold sensitivity findings was also used to demonstrate central nervous system adaptations as playing a role in his ongoing pain.
Mr M also participated in a short group pain education session (half day), which included an overview of the key items of patient education (Davies et al 2011). Mr M really enjoyed the session and saw the relevance of understanding his pain condition in a multi-dimensional manner. Treatment proceeded from this group program to individual sessions on a weekly/fortnightly basis, addressing the issues identified in the pain formulation.
The initial target was gentle stretching with controlled and relaxed breathing. This stretching was not to increase range of movement but rather to attempt to control the ‘tightness’ pain which he experienced.
This formed a very important self-management strategy for Mr M, which he practised regularly, leading to greater self-efficacy. A goal- centred approach to maintaining consistency with swimming rather than having to swim a certain distance was enormously important.
Over 4–6 weeks, Mr M voiced his surprise at what a difference this approach was making. He felt calmer and was developing a deeper sense of acceptance of his problem.
Gradually, over the following 3–4 months, rotator cuff strengthening and scapular stabilising exercises were incorporated, again in a paced way to reinforce that pain should be ‘in control, rather than out of control’.
While there were many different strategies involved in Mr M’s treatment that could be discussed here, a key issue in the case of Mr M was his use of pacing.
The framework noted earlier (Andrews & Deen 2016) can help make sense of Mr M’s situation, as there were interacting issues of mood, beliefs, personality, coping strategies and environmental considerations.
Five months after initial assessment, Mr M was maintaining four days per week of work with minimal time off. He was consistently swimming 1.5–3km three days per week. He had surprised himself by seeing an increase in his capacity to paddle his canoe, to 30 minutes.
HIs questionnaire scores show overall marked improvements in depression and stress (probably due to reduced catastrophic reactions to his activity), but still with ongoing challenges with self-efficacy and catastrophising.
So, why did Mr M start to make gains?
His view on his improvement five months after first assessment revolved around ‘managing my expectations’ and ‘having treatment from someone who perceived a bigger picture than just my injuries’. Therefore, pacing of swimming and gentle stretching increased self-efficacy to manage the neck and shoulder pain. It also built a sense of acceptance of the situation, which was easier to achieve without the significant pain flares that had been a feature of his earlier presentation.
Mr M was intrigued that he was able to build up to 3km of swimming and not experience the same exacerbations of pain.
Mr M ended up pacing better, not due to a generic approach, but through understanding how his personality, beliefs, coping strategies and mood all impacted on his attempts to be active. The contingency of his approach to getting better shifted from a fear of not getting better to an acceptance of his situation. This acceptance in turn allowed the pattern of thinking and activity to lead to improved function.
In a complex pain case, there are multiple dimensions that need to be explored. While pacing is universally acknowledged as being important, the literature on it is sparse. Pacing should be considered as the product of the interplay of numerous contributors, and a patient-centred approach should assist the clinician to determine an effective treatment strategy.
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Mr M provided consent for this case study.
Tim Austin, APAM, MACP, is a registrar undertaking Fellowship of the Australian College of Physiotherapists by Clinical Specialisation in the pain discipline. Tim works at Camperdown Physiotherapy and the Inner West Pain Centre in Sydney’s Inner West. He is the NSW representative on the APA Pain Group national committee. He also teaches on the Master of Pain degree program at the University of Sydney and is currently treasurer on the board of the Australian Pain Society.
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