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I’m sure you’ve all heard about pacing when it comes to managing your chronic pain. But what exactly is pacing? How do you do it? And why is it important? This post will tell you everything you need know.
Today’s post is a Guest Post from Brandon at Elevation Process. I was given free access to the online Chronic Pain course and learned so much about pain and the impacts it has. Brandon explains things clearly and simply and certain things just clicked as I was working through the modules – he is very knowledgeable in all things pain-related. His conversational style of delivery draws you in, as it does with this post.
Click here to read my review of the online chronic pain programme at Elevation Process.
I hope you all find this post useful and a huge thank you Brandon for taking the time to thoroughly answer mine and my reader’s questions.
And check out the 50% off discount code at the end of this article.
Hello Everyone. My name is Brandon Ulmer, and I work as a psychologist in the Canadian province of Alberta. A large portion of the people that I see in my practice are suffering from chronic pain and I have spent years working and teaching people how to manage their pain via scientifically proven pain management strategies.
Brandon from Elevation Process
I have emphasized the word “manage” in this case because the techniques we teach do not “cure” or “get rid” of pain, rather they are used as part of a plan to increase ones own quality of life with pain. The truth is that there is no cure for chronic pain and that everything we currently do for pain management (including medications, injections, massage, acupuncture etc.) are all interventions designed to turn down the volume on your pain, rather than to get rid of it per se.
That being said, there are many behavioral actions that we can take to reduce our own pain, of which pacing is by far the most important. I feel very fortunate to have been asked to write this guest post and hope that you find it useful to read!
Alice has provided me with a list of fantastic questions to answer related to the topic of pacing. Pacing is easy to understand conceptually, but hard to implement into your life. Be easy with yourself. I have never met anyone who is an expert with pacing their first time. This is a LIFESTYLE change that many of us don’t even want to do. It is however, critical to understand and implement into our lives if we want to move forward with chronic pain. With that, the questions:
What is pacing?
Pacing is really just a different way of engaging in movement that helps you to keep a regular amount of activity each day, regardless of whether you are having a “good” or a “bad” day. I hear from so many people that pain has taken away most of the activities that they formerly enjoyed; pacing is a way to get some of that back without making your pain worse. Sound interesting? Want to learn more?
In my experience, working with thousands of people with chronic pain or other health issues, we tend to do these two very common things:
- We avoid doing things which we think are going to make us feel worse.
- We base what and how much we do on how we feel.
Now you tell me, if we base how much we do on how we feel (and almost by very definition with chronic pain we never “feel” great), how much do we do? Not much….
Perhaps more damaging for us is the first point. When I avoid things that I think are going to make me feel worse I become very dependent on other people for assistance, and my life becomes very lonely as I start to miss out on social engagements and become isolated. This in turn has an effect on my mood and can lead to (among other things) major depression and anxiety disorders.
Avoidance, as a strategy, works well in the short term, however it can lead to trouble the longer we put off or avoid doing something. Think of cleaning your kitchen, for example; I am in a lot of pain today so I put that activity off and lay on the couch. Tomorrow, my pain hasn’t improved and I still have to clean the kitchen (to say nothing of the rest of the house).
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Why is pacing important?
Pacing is important for several reasons. As I mentioned previously, we do not currently have a cure for pain and the best that we can do is turn the volume down on pain. Pacing actually boosts the impact of interventional medicine (i.e. medications, injections, etc.) by keeping us from over-doing activity when we feel a bit better. By not engaging in over-activity when we feel better we can prolong the effects of the intervention and increase the likelihood that tomorrow will also be a “good” day.
Pacing is also important because it teaches us about our bodies, and what we can still do in particular. A lot of people feel as though they cannot do anything now that they have pain; this isn’t entirely true. We certainly have to adjust how we engage in activity (pacing), and we may have to limit the amount of time we engage in that activity, but most of us can still do things we enjoy on a modified basis; pacing can help us to identify this.
Pacing is really the guts of what pain management is all about. We simply cannot expect to feel any better as long as we are pushing our bodies harder than they can go. This point is difficult for people to grasp because often, even on our “good” days, we are functioning way below where we were when we weren’t in pain. Pacing is difficult because we have to re-learn how to engage in activity without making our pain worse; this often involves changing position, taking more rest breaks etc. We also have to quit comparing ourselves to who we were before our pain, as well as to work towards transitioning towards our new normal; both of which are easily said, but hard to do attain in practice.
How can I start pacing?
The first step towards starting to pace activity is to ask yourself why? What are you trying to accomplish? In other words, identifying a goal is very important. I suggest that goals be identified using the following acronym:
S – Specific. Your goals need to be specific, otherwise we often don’t accomplish them.
M – Measurable. Your goal should be something that you can track objectively to see progress.
A – Achievable. Pick something that is achievable. Remember that even mountain climbers have to stop at points in order to acclimatise their bodies.
R – Realistic. Your goal should be to increase activity in small increments (5-10%) at a time. Asking your body to do what it did before pain is not a realistic goal, for example.
T – Time Sensitive. Means how long are you going to work towards this goal before accomplishing it.
Also remember that accomplishing large goals can take time. Setting sub goals (and accomplishing them) can help to keep us motivated.
Once we’ve identified a goal that we would like to achieve, the next step is to identify what our tolerances levels are for basic activities; we generally test people standing, sitting and walking as these are the activities that we mostly engage in throughout our days. In order to identify our tolerance level, we generally have people time themselves once per day (for four total days) engaging in that activity. We ask them to time themselves until they feel “comfortably uncomfortable,” which is usually the point at which we switch position or shift in our chairs. DO NOT PUSH YOURSELF HERE.
After the four days, we add the four times together and divide by the number of measurements (i.e. 4) in order to get an average; this is your average tolerance time. This number means that you should be mindful to switch position regularly. Remember that it is normal for your tolerance times to be different; most of us can sit longer than we can stand or walk for example. It is also totally normal for your times to be a great deal smaller than you think they are initially. Remember that the point of this exercise is not to further disappoint or to depress you, rather we need an accurate picture of our new physical limitations so that we can work towards improving them from here.
Once you have tolerance levels for standing, sitting and walking, start slowly and work towards improving these times by increasing the time by 5-10% at a time; take however long to achieve this as you need. There isn’t a one size fits all for pacing and chronic pain. YOU decide when and by how much to increase your time level.
Why do some people find pacing difficult?
I think that most people find pacing to be difficult. It is difficult because it runs contrary to what so many of us do in our everyday lives. The message, specifically in westernised countries, is that “time is money” and we often get the impression that people are annoyed with us if we don’t fit that mold. This leads us to feel guilty, and to push ourselves ever harder in the attempt to be “normal” like everyone else. This is of course a losing proposition, as anyone with chronic pain knows all too well.
If we are ever to break this destructive cycle, we need to educate ourselves, and then make a decision to stop hurting ourselves by pushing too hard. There will be times in your life when you need to push – life is like that – but if we can learn to pace our activity on most days, our experience of pain should reduce.
If I could compare pacing to an animal, it would be to the noble turtle. The turtle moves at its own pace and isn’t influenced by others…. even predators. Stop trying to meet other people’s expectations and embrace your inner turtle!
Can pacing help me to do the things I enjoy to do?
Absolutely it can! The whole point of pacing activity is to get you back to living your life, including engaging in the activities that make life worth living for you. The key though, is to think about how you can implement pacing into those activities.
A personal example would be golfing in my own life. After many years of playing American football at a high level, I am left with chronic lower back pain myself. I use pacing on the golf course to keep my pain from getting worse. Now to be sure, I am not a good golfer by any stretch of the imagination. I enjoy getting out with friends on a beautiful summer day, in an idyllic setting, more than I care about what my score is. That being said, I adjust the activity to my own capability on a given day. If my back is too sore that day, I may not drive the ball from a tee box because this activity is particularly aggravating. I may drop my ball at my cart partners shot, or drop at the green and chip/putt on really bad days. The point is, pain hasn’t stopped me from engaging in an activity that I love; as long as I adjust it to fit my needs, that’s all that matters.
How can pacing help me take control?
Great question! A lot of people feel as though they have very little control over their lives with chronic pain. While it is true that one can experience a significant pain flare (often also called a setback) even while pacing their days, science has shown that the number of setbacks will decrease, both in frequency and duration, when you start to pace your life; this is also certainly something that we see in the clinic that I work at among pain patients. Once pacing “clicks” in your life, you decide when to push yourself or even if pushing yourself is worth it in this instance. That choice is really about re-taking control in your life. As I always tell people though, education is a double-edged sword in that once I know, I can’t say that I didn’t know. For example, once I know about pacing and deliberately choose to push myself, I am choosing to be in more pain. Sometimes that choice is worth it, sometimes it isn’t, but the point is…. I choose and accept the consequences of my choice.
What is the most important thing to consider when pacing?
I think that the most important thing to remember is: Stop. Don’t do that extra five minutes. It’s far better to do a little bit of work on a daily basis, then to push ourselves way too hard on one day and suffer the consequences for the next week.
I think an important thing to consider with pacing is the impact that this can have on my medication usage. Often we use medication in an attempt to continue to live life the way that we did before chronic pain. As we push ourselves harder, our medication usage goes up and we start to experience other side-effects associated with the medication themselves. This becomes a terrible spiral. I end up taking medications to mitigate the effects of my medications. Pacing can actually help us to prolong the effects of our medications and, even to reduce them in some cases.
I find it frustrating to pace my day. What can I do to overcome this?
As mentioned previously, pacing is frustrating. Persistence is key as it does get easier the longer that you do it. It truly does become second nature after a while, and you don’t even really think about it. I think that we really just need to come to a point where we are tired of continually hurting ourselves and increasing medications with no end in sight. Pacing, though frustrating, is the way to get off of the treadmill. This involves a significant lifestyle change that is never easy, but very much worth it in the end.
Understand that by choosing not to pace, you are making your pain worse. Then make the choice to stop hurting yourself and focus instead on taking care of yourself, rather than struggling to meet the external expectations of life.
People around me don’t understand why I’m pacing. What tips can you share to help me explain to others that I need to pace myself?
The key to resolving many difficulties between people in life is good communication. I encourage all of the patients that I see to share everything they have learned with their family and loved ones. The people closest to you do not want to see you in pain and usually welcome an opportunity to assist you in this way. When I can communicate, in a clear fashion, what pacing is and how they can help me to achieve my goals, everything gets much easier. It is a difficult conversation to have sometimes however.
Related to communication, recognise that sometimes it doesn’t matter how you communicate something to someone; if that person truly doesn’t believe that chronic pain is a real thing, there isn’t much that you (or any doctor for that matter) can say to dissuade them. We often lose close relationships in this way, which is always difficult. That being said, we need to surround ourselves with supportive people on this journey; if someone in your life isn’t supportive, it’s okay to keep that person at arm’s length for your own mental health.
How long should I do an activity or task before I have to stop?
This will depend entirely on the tolerance times that we calculated earlier. It will also depend greatly on the situation, as well as factors that are outside of our control (like the weather for example). I often encourage people to use the 3P’s:
Prioritise – prioritising means what has to be done today, or right now, and what can wait. We would all like to get everything crossed off of our list, but often this is just not possible with pain. Identify what must be done and go from there.
Plan – Once I’ve prioritised the things on my list, I need to develop a plan. Planning involves thinking in advance of some of the difficulties that you might encounter, and taking action ahead of time to plan for these. If I am going to the grocery store, for example, a plan would consist of the items on my list in relation to their location in the store so that I avoid taking more steps than I need to. It might also involve a rest in the store if they have a coffee stand available.
Pace – Now that I have my plan in place, I pace myself using the tolerance times that we identified earlier. Remember to stick to them and try to avoid doing that five extra minutes.
I feel like a failure when I have to stop what I am doing. What can I do?
This is also a great question, and one that many of us face on a daily basis. It’s important to remember that the emotion in this case (failure, guilt or shame) is often cause by a thought (perhaps “I’m defective or useless now”). When we are experiencing chronic pain, it is normal for our thoughts to become increasingly negative.
Did you know that depression and anxiety are 5X and 8X more likely to occur in pain patients, than in the regular community? That’s a staggering statistic and one of the reasons why psychologists have a role to play in pain management. In our little example above, a thought challenging exercise can help to identify and test the thought for validity (referred to as reframing by psychologists). The change in thought can cause a different emotion and change the outcome. In this case, if I can modify the thought to something like “it’s time to take care of myself by taking a micro-break,” I won’t feel so bad about stopping.
I would encourage anyone suffering with chronic pain to try and locate someone with whom they can speak about their pain to. This should be someone who isn’t part of your family/circle of friends. Psychologists trained in CBT (Cognitive Behavior Therapy) can help to address these thoughts, which are totally normal with chronic pain.
Sometimes I don’t want to do anything as my pain is so bad. Can I just do nothing?
NO! It is never okay to just do nothing. In fact, doing nothing can become a very harmful pattern of behavior and lead to, among other things, major depression. Always remember that something is better than nothing. On your bad days, by all means, reduce the demands on yourself. Do not retreat into your room, with the lights off, and binge watch Netflix. On your really bad days, having a shower, dressing and making a meal may be an accomplishment; this is better than the alternative though, and will leave you feeling a small sense of accomplishment. Reduce the demands, but do not avoid engaging in life.
I’ve heard of the spoon theory to help with pacing. What does this mean and is it helpful?
Spoon theory is really just a metaphor to describe the physical and mental limitations of someone who has disability or chronic illness. The metaphor goes that we all have a limited amount of energy (or spoons in this case) available each day, and that everything we do in our day expends energy (spoons). Once I have expended all of my energy, I cannot replace it without taking a rest and allowing my energy to return. As a metaphor, I have no issue with using it as a visual representation of the limits that we have to someone who does not experience difficulty with energy (and thus doesn’t have to worry about their number of spoons). For them, seeing the limited number of spoons, as well as what simple acts such as doing laundry can do to the number of spoons that we have, can be a powerful visual learning tool.
I do not necessarily think that it is helpful for the person who has pain. How many spoons does walking the dog take? Taking out the trash? Talking to a friend? I much prefer the folks whom I see to follow a timer for their activities and to learn to listen to their bodies. The number of spoons that it takes to walk your dog, for example, will change on a daily basis (specifically when your capacity for physical exercise increases). Following a goal and gradually increasing your time level accounts for this, spoon theory does not.
When I have the energy and my pain isn’t bad, I want to do more and this makes me feel good. Is this a bad thing?
We ALL feel this way and enjoy the sense of accomplishment that comes with a productive day. Inherently, there is nothing wrong with this. Where we can get into trouble though, is when we get into the habit of doing way too much, and then doing little to no activity the next day because of how much pain we are in. This is a pattern of activity called “activity cycling,” and it is the guaranteed path to disability. I understand why people do this: we are trying our best to engage in life the way that we did before we are in pain. Unfortunately, over time, this pattern of activity traps us into a pain cycle that can be very difficult to break out of.
As discussed previously, pacing helps us to break this cycle by doing a little bit of activity regularly, regardless of whether it’s a good or bad day, rather than pushing ourselves and then crashing. It’s amazing and you wouldn’t think about it, but you actually get more accomplished in the long run when you pace your activity. Please see the pictures describing activity cycling below:
On a good day, we get a lot accomplished
But we do too much and end up crashing the next day
Where the good times are never as good, and the bad
times get worse (and last for longer periods).
About Elevation Process
Elevation Process was formed from the belief that everyone should have access to education, and the right to make decisions that impact their own lives. I formed Elevation Process (EP) because of my own frustration in working within the public health system in Canada. The unfortunate reality is that there is never enough funding to satisfy the demand for mental health related services; worse, during times of economic hardship, mental health services are often the first to be cut. I could literally see people from sun up, to sun down, 7 days per week and still not satisfy the demand for services. This frustration was the primary impetus behind the formation of EP. What if everyone had access to information and education that could assist them to live better, more fulfilled lives? What if that information was distilled into scientifically based and supported strategies that people could trust? What if that information was readily available and accessible via any mobile device?
EP is a labor of love for me. Chronic pain management was chosen to be our first educational product because, in my experience, this is the group most marginalised within our society. I am very busy within my own life, however as time does become available I plan to introduce new educational courses and different ways of helping a greater number of people. My sincere goal is to help as many people as possible while I am on this earth; EP gives me the opportunity to do this by communicating my message to many more people than I could physically see in clinic. Many thanks for your time in reading this.
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Wow, what an amazing, educational, and fascinating post – do you agree?
Have you learned more about pacing?
How do you pace things to help manage your chronic pain?