Testing A Newly Developed Activity Pacing Framework For Chronic Pain/ Fatigue: A Feasibility Study

Deborah Antcliff,1,2 Anne-Maree Keenan,2,3 Philip Keeley,4 Steve Woby,5,6 Linda McGowan2

1 Department of Physiotherapy, Fairfield General Hospital, Northern Care Alliance NHS Group, Bury, UK

2 School of Healthcare, University of Leeds, Leeds, UK

3 NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK

4 School of Nursing and Midwifery, Keele University, Staffordshire, UK

5 Department of Research and Innovation, Northern Care Alliance NHS Group, Salford, UK

6 School of Health and Society, University of Salford, Salford, UK

For more information: ali.ma@wecistanche.com

ABSTRACT

Objectives

To test the feasibility of using a new activity pacing framework to standardize healthcare professionals’ instructions of pacing, and explore whether measures of activity pacing/symptoms detected changes following treatment.

Design

Single-arm, repeated measures study.

Setting

One National Health Service (NHS) Pain Service in Northern England, UK.

Participants

Adult patients with chronic pain/fatigue, including chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis.

Interventions

A six-week rehabilitation program, standardized using the activity pacing framework.

Outcome measures

Feasibility was explored via patients’ recruitment/attrition rates, adherence and satisfaction, and healthcare professionals’ fidelity. Questionnaire data were collected from patients at the start and end of the program (T1 and T2, respectively) and 3months’ follow-up (T3). Questionnaires included measures of activity pacing, current/usual pain, physical/mental fatigue, depression, anxiety, self-efficacy, avoidance, physical/ mental function, and quality of life. Mean changes in activity pacing and symptoms between T1-T2, T2-T3 and T1-T3 were estimated.

Results

Of the 139 eligible patients, 107 patients consented (recruitment rate=77%); 65 patients completed T2 (T1-T2 attrition rate=39%), and 52 patients completed T3 (T1-T3 attrition rate=51%). At T2, patients’ satisfaction ratings averaged 9/10, and 89% attended ≥5 rehabilitation program sessions. Activity pacing and all symptoms improved between T1 and T2, with smaller improvements maintained at T3.

Conclusion

The activity pacing framework was feasible to implement and patients’ ability to pace and manage their symptoms improved. Future work will employ a suitable comparison group and test the framework across wider settings to explore the effects of activity pacing in a randomized controlled trial.

INTRODUCTION

Activity pacing is a principal coping strategy for patients with long-term conditions, including chronic low back pain, chronic widespread pain, fibromyalgia, and chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME).1–5 Chronic pain and chronic fatigue are known to coexist,6 7 and overlap in symptoms, including depression, anxiety, and disability.8–11 Conditions of chronic pain/ fatigue may share similar disease processes: physical deconditioning following underactivity/avoidance, pathophysiological/ psychological processes, and central sensitization.11–16 Treatments aim to reverse some of these processes: to improve physical/mental functioning, increase tolerance and improve quality of life.12 15 17 Recommended treatments include psychological therapies (eg, cognitive–behavioral therapy) and graded exposure to activity/exercise;15 16 of which activity pacing is a key component.18–20 Patients with chronic pain/fatigue may present with altered behaviors, including underactivity or avoidance of activities that are perceived as harmful or that may exacerbate symptoms; overactivity or excessive persistence to push through/distract from symptoms; or fluctuations between overactivity and under activity.21 Activity pacing provides an alternative behavior to enable patients to (re-)engage with activities in a manner that encourages their progression towards more regular or improved functioning.4 22 23 At present, there remains confusion regarding how activity pacing is defined or interpreted, and the effects on patients’ symptoms.5 24 25 There is no widely used guide to standardize how healthcare professionals instruct activity pacing to patients, and uncertainty whether different methods are required for symptoms of chronic pain versus chronic fatigue.3 26 This poses challenges how to advise patients with both chronic pain and fatigue. We have developed an activity pacing framework using an inclusive approach for patients who present at rehabilitation services with chronic pain and/or fatigue. 

Using the Medical Research Council guidelines for developing complex interventions, mixed methods were implemented to encompass theoretical and stakeholder standpoints.27 Mixed methods comprise quantitative and qualitative approaches to collecting and analyzing data.28 Stage I: Healthcare professionals' survey gathered opinions on activity pacing (n=92).4 These findings, together with existing research formed the first draft of the framework and accompanying appendices. Stage II: Nominal group technique refined the activity pacing framework using a consensus meeting between patients and healthcare professionals (n=10).29 During the development of the activity pacing framework, stakeholders included healthcare professionals and patients with the aim of increasing the clinical utility and acceptability of the framework (see online supplemental figure 1 Content of the Activity Pacing Framework: Theory and Overview, and Appendices and Teaching Guide booklets.) The conceptual model of the activity pacing framework (see figure 1) follows principles of quota-contingency and the operant approach (eg, setting goals according to time/distance/activity). The activity pacing framework is underpinned by concepts of rehabilitation with aims of improving physical and cognitive function; and engagement in, and satisfaction with meaningful activities, while managing symptoms.4 29 The activity pacing framework includes the potential for reversibility of some of the consequences of chronic pain/fatigue, such as the potential to reduce levels of disability. 

Together with containing themes of adjusting activities, planning and consistency, the activity pacing framework also includes themes of progression regarding the amount and/or variety of activities. Therefore, the activity pacing framework is considered to be a rehabilitative approach that moves forward from only adapting, or in some cases maladapting to the long-term condition. The activity pacing framework differs from energy conservation/adaptive pacing approaches which involve undertaking activities according to symptom severity (symptom-contingency) with an aim of reducing or avoiding symptoms.30 31 Within the current activity pacing framework, quota-contingency is advised alongside concepts of flexibility and choice to enable relevance and sustainability in conditions where symptoms may vary. The framework refers to all types of activities including work, household activities, cognitive activities, physical activities, exercise, and relaxation to increase its wider relevance for patients with chronic pain and/or fatigue, for varying abilities and behaviors. The aim of this study was to test the feasibility of using the activity pacing framework to underpin a rehabilitation program for chronic pain/fatigue. In preparation for a future clinical trial, specific objectives included: (1) Exploring participant recruitment/attrition rates and adherence/acceptability (for both chronic pain and fatigue); (2) Exploring healthcare professionals’ fidelity to the framework and (3) Exploring the suitability of the outcome measures, including the modified 28-item Activity Pacing Questionnaire (APQ-28).

METHODS

Study design

This single-arm, repeated-measures study is reported as a non-randomized feasibility study using the extended Consolidated Standards of Reporting Trials guidelines,32 33 (see online supplemental table 1). Quantitative questionnaire data were collected from patients at the start (T1) and end (T2) of the 6-week rehabilitation program, and at 3-month follow-up (T3). The study was prospectively registered (protocol available at ClinicalTrials.gov: NCT03497585). The acceptability of the framework, explored via interviews with patients and healthcare professionals, is reported elsewhere.34

Participant recruitment

Participants were identified from consecutive referrals to a rehabilitation program for chronic pain/fatigue in a Pain Service in Northern England, UK. All patients attended a minimum of one face-to-face appointment before referral to the program. Participants received the study information via the post 1week before attending the program and/or during the first session of the program. The consent form was completed either at home or during the first session.

Eligibility criteria

Eligible patients were aged ≥18 years, with symptoms for ≥3 months and with a general practitioner or hospital consultant diagnosis of chronic low back pain, chronic widespread pain, fibromyalgia or CFS/ME. Patients were required to read and write in English. Ineligible patients were those with evidence of serious underlying pathologies, such as a current diagnosis of cancer, or patients with severe mental health or cognitive functioning issues.

Sample size

A sample size of 50 patients has been recommended for feasibility studies to enable estimates of recruitment/ attrition, means/SD, and changes in means to prepare for future clinical trials.35 To attain a sample of 50 participants at T3, it was estimated that 340 patients may need to be approached to allow for a 50% recruitment rate at T1, a 40% attrition rate between T1 and T2, and a 50% return rate at T3.

Existing rehabilitation program

The existing rehabilitation program is comprised of six consecutive weekly sessions (each 3.5hours) delivered by healthcare professionals (pain specialist physiotherapists and psychological well-being practitioners). The program included understanding complex symptoms, sleep hygiene, graded exercise, goal setting, relaxation, and mindfulness. The pacing was instructed in one session but was not informed or standardized by any particular guide or framework.

Activity pacing framework standardized program

The existing 6-week program was modified through restructuring and standardization using the activity pacing framework. Activity pacing was formally instructed on two sessions (weeks 2–3). However, activity pacing was referenced throughout the program in relation to other coping strategies, for example, how activity pacing can assist graded exercise (weeks 1–5) or set-back management (week 6). In comparison to the existing rehabilitation program, the activity pacing framework standardized program included more in-depth discussions of activity behaviors (avoidance, overactivityunderactivity cycling, and excessive persistence) to assist patients to identify their current approach to activities. This aimed to facilitate patients’ recognition of which facets of activity pacing were most relevant to them. 

The two activity pacing sessions focused on the aims of activity pacing, barriers to activity pacing, facets of activity pacing (eg, breaking down tasks, switching between activities, having more consistent activity levels, allowing flexibility, gradually increasing the amount or variety of activities), and stages of activity pacing (introducing activity pacing, finding baselines, adjusting activities, planning, consistency, learning and progressing). Practical exercises included completing an activity diary to discuss patients’ activity patterns and setting goals in which activity pacing could be practiced (see online supplemental figure 2. Content of the rehabilitation program). Patients received a handout to summarise the key concepts of activity pacing. The healthcare professionals (as above) received training on the framework during a half-day session and could contact the lead researcher (DA) for any queries. All patients attended the standardized program, but patients chose whether to participate in the study through their optional completion of the study questionnaires and consent form.

Data collection

Feasibility outcomes

Measures of feasibility included participant recruitment/ attrition rates, adherence (number of sessions attended), acceptability (two satisfaction rating scales regarding the program content and length where 0=dissatisfiedand 10=fully satisfied), and missing data in the questionnaire. For every program, healthcare professionals completed a 13-item fidelity checklist based on the conceptual model of the activity pacing framework to ensure their inclusion of key elements from the framework. Each clinician was observed once by the lead researcher.

Clinical measures

The self-reported paper questionnaire booklets (T1, T2, and T3) included standardized clinical measures. T1 could be completed during session one or at home, T2 could be completed during session 6, and T3 was sent in the post to be completed at home. Telephone reminders were made if the T3 questionnaires were not returned within 2weeks. The T1 booklet contained demographic questions, in addition to the following measures included in T2 and T3: 1. Activity pacing was measured using the APQ-28. The 26-item APQ was initially validated among patients with chronic pain/fatigue and contained five subthemes: Activity adjustment, Activity planning, Activity consistency, Activity acceptance, and Activity progression (Cronbach’s alpha=0.72–0.92).36 (see online supplemental table 2, Five themes of the APQ-28 with examples.) Each item is scored between 0=‘never did this’ and 4=‘always did this’. Two items have been added that correspond to important aspects of activity pacing that emerged during the development of the activity pacing framework. The new items: APQ12: ‘I found a baseline amount of activities that I could do on ‘good’ and ‘bad’ days’ and APQ15: ‘I had a flexible approach with my activities’ were added to the subthemes of best conceptual fit (activity adjustment and activity acceptance, respectively). Each subtheme was calculated as a mean score. The APQ-28 subthemes, similarly to the following scales, permitted one missing item per subscale. 2. Current and usual pain was measured using two 11-point Numerical Rating Scales, where 0=‘no pain’ and 10=‘worst possible pain’.37 3. Physical fatigue (seven items) and mental fatigue (four items) were measured using the Chalder Fatigue Questionnaire, where scores of 1=‘much worse than usual’ and 4=‘better than usual’.38 Two subscale scores were summated where higher scores indicated less fatigue. 4. Depression was measured using the nine-item Patient Health Questionnaire-9, the items of which are based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition.39 

Items were rated between 0=‘not at all’ and 3=‘nearly every day’. Total scores of 1–4=minimal depression, 5–9=mild depression, 10–14=moderate depression, and ≥15=severe depression.39 40 5. Anxiety was measured using the seven-item Generalised Anxiety Disorder Assessment. Items were rated between 0=‘not at all’ and 3=‘nearly every day’. Total scores of 5–9=mild anxiety, 10–14=moderate anxiety, and ≥15=severe anxiety.41 6. Self-efficacy was measured using the 10-item Pain Self-Efficacy Questionnaire (PSEQ) where items were rated between 0=‘not at all confident’ and 6=‘completely confident’. Total scores of PSEQ ≥40 indicate those patients who are more likely to continue implementing coping strategies/behavioral changes and PSEQ ≤16 are considered low.42 7. Avoidance was measured using the ‘Escape and Avoidance’ subscale of the Pain Anxiety Symptoms Scale short version (PASS-20).43 The five items were rated between 0=‘never’ and 5=‘always’ where higher total scores indicated greater avoidance. 8. The physical and mental function were measured using the 12-Item Short-Form Health Survey (SF-12). Two subscale scores (out of 100) were calculated using the SF-12 software (V.2; 1-week recall) where higher scores indicated better function.44 9. Health-related quality of life was measured using the EQ-5D-5L (EuroQol five-dimensions, five-levels). The EQ-5D-5L was calculated as an index score.45 46 Data analysis Feasibility outcomes and participants’ demographics were analyzed using descriptive statistics. Clinical outcomes were estimated as changes in activity pacing and symptoms between T1-T2, T2-T3 and T1-T3 (mean change, 95% CIs). The validity of the modified APQ-28 was estimated using Cronbach’s alpha and item correlations, and sensitivity analyses explored the effects of including the two new APQ-28 items. Data were analyzed using IBM SPSS Statistics V.26 statistical software (IBM).

Patient and public involvement

Patient and public involvement (PPI) commenced during the initial planning stages of the mixed methods program to develop and test the activity pacing framework. A meeting with five PPI representatives discussed the study purpose and practical issues around the proposed methods (online survey, nominal group technique, and feasibility and acceptability studies). PPI guided on improving the accessibility of patients’ participation and reducing burden (eg, location and duration of meetings). A PPI representative has acted as an advisor on the study, involving commenting on study documents/questionnaire booklets and coding qualitative interviews. Acceptability interviews with patients explored practical issues surrounding the feasibility study,34 which will further assist the planning of a future randomized controlled trial (RCT) of activity pacing. RESULTS Recruitment and T1 data collection commenced in May 2018 and T3 data collection ended in December 2019 due to attaining the target sample.

Demographics

Among the 107 participants who completed the baseline (T1) measures, participants were predominantly female (n=92, 86.0%) with a mean age of 55.25±12.83 years. Low back pain was most frequently reported (n=79, 73.8%) and CFS/ME least frequently reported (n=12, 11.2%). Sixty-five participants (61.3%) reported two or more conditions of chronic pain and/or fatigue. Of the 12 participants with CFS/ME, 10 participants reported CFS/ME as their main condition, and 11 reported at least one comorbidity of LBP (n=7), chronic widespread pain (n=6), fibromyalgia (n=7) or another condition (n=3). (see table 1 for participant demographics and table 2 for baseline scores for activity pacing and symptoms.)

Feasibility outcomes

Recruitment and attrition (objective 1)

Of the 144 patients invited to participate, 139 were eligible (96.5%). The reasons for ineligibility included: three patients reported only neck pain, one patient reported neck/knee pain and one patient reported thoracic pain. Of the 139 eligible patients, 107 (77.0%) were recruited at T1, 69 (64.5%) completed the 6-week programme and 65 (60.7%) completed the T2 measures (attrition rate=39.3%). Fifty-two participants completed T3 (80.0% of T2; attrition rate from T1=51.4%). There were no serious adverse events (see figure 2). Of the 107 participants, the median number of rehabilitation program sessions attended was five (58.9% participants attended ≥5 sessions); 83.2% participants attended at least one activity pacing session and 56.1% attended both activity pacing sessions. Of the 65 participants who completed T2, the median number of sessions attended was six (89.2% participants attended ≥5 sessions); 100% of participants attended at least one activity pacing specific session and 54 (83.1%) participants attended both activity pacing sessions. There were no statistically significant differences between participants who completed T2 or dropped out in terms of demographics or baseline symptoms. Of the 12 participants with CFS/ME, six completed T2 (50%) and six completed T3 (100% of T2, 50% of T1); whereas 59 of the 95 participants without CFS/ME completed T2 (62%) and 46 completed T3 (78% of T2 and 48% of T1).

Acceptability of the rehabilitation program/questionnaires (objective 1)

On T2, participants rated their satisfaction of the length and content of the rehabilitation program as mean=8.8 (SD=1.7) and 9.1 (SD=1.5), respectively. The satisfaction of only those participants with CFS/ME was mean=9.0 (SD=0.9) and 9.2 (SD=1.0). There were minimal missing data in the questionnaire booklets (approximately 1%). Some participants wrote comments regarding their perceived benefits of implementing activity pacing and other coping strategies. Two participants wished for a longer program or a follow-up session (see figure 3 for examples of participants’ comments).

Fidelity to the activity pacing framework (objective 2)

Each healthcare professional observation demonstrated good adherence to the framework against a number of key points. Healthcare professionals reported 100% adherence in their fidelity checklists for each rehabilitation program. Healthcare professionals reported that some participants spent over 20min completing the questionnaire booklet and that not all patients completed the activity diaries.

Interventions between T2 and T3

Of the 52 respondents at T3, two patients received lumbar epidural steroid injections, one patient had acupuncture, one attended a chiropractor and one patient had knee surgery.

Clinical outcomes Validity of the APQ-28 (objective 3)

At T1, the two new APQ-28 items showed the ease of completion through minimal missing answers (Item APQ12=0 missing answers, Item APQ15=1 missing answers). The scores of the new items utilized the full range, and the mean scores (Items APQ12=1.67and APQ15=1.91) sat within the range of the other APQ-28 items (mean=1.17– 2.78). The new items demonstrated optimal fit with their allocated subthemes via highest interitem correlations and item-total correlations (item-total correlations: APQ12 and Activity adjustment, rs (106)=0.76, p<0.001; Item APQ15 and Activity acceptance, r(106)=0.68, p<0.001). The internal consistency for Activity adjustment increased with the addition of Item APQ12 (Cronbach’s alpha=0.86 to 0.88), and for activity acceptance with the addition of item APQ15 (Cronbach’s alpha=0.68 to 0.72).

The internal consistency of the other APQ-28 subthemes was: activity planning=0.86, activity consistency=0.80and activity progression=0.69.

Mean changes in activity pacing and symptoms (objective 3)

Between T1 and T2, all five APQ-28 subthemes mean scores increased, indicating improved activity pacing. There were small reductions in APQ-28 scores between T2 and T3. However, all five subthemes showed overall improvements between T1-T3, with Activity planning showing the greatest increases (see table 3). Sensitivity analyses showed marginal increases in mean changes following the addition of the two new APQ-28 items. Between T1 and T2, the mean scores of all symptoms improved. Current pain reduced more than usual pain. Physical and mental fatigue both improved, as did self-efficacy and quality of life. Mental function improved more than physical function. Depression, anxiety, and avoidance were all reduced. There was some deterioration in symptoms between T2-T3, but between T1 and T3, all symptoms demonstrated clear improvements except avoidance (−1.46, 95% CI −3.02to 0.10) and physical function (1.62, 95% CI −0.81to 4.06) (see table 4). Observing only the subgroup of participants with CFS/ ME, improvements were seen between T1-T2 and T1-T3 across all APQ-28 subthemes and symptoms.

DISCUSSION

This study fulfilled the original aims of testing the feasibility and acceptability of using a new activity pacing framework to standardize instructions of activity pacing to assist in planning a future effectiveness RCT. The study recruited to target patients with chronic pain and chronic fatigue demonstrated both improvements in activity pacing strategies and reductions in symptoms.

Feasibility

The activity pacing framework demonstrated feasibility through excellent fidelity to the framework by healthcare professionals via self-reported checklists and observations. Acceptability was demonstrated through patients’ high satisfaction scores. Not all patients completed the activity diaries, however, this was optional for patients to facilitate their own self-reflection. The recruitment rate (77%) was higher than estimated in the study protocol (50%). This was similar to a study exploring a 5-week exercise program for chronic hip pain (recruitment rate=76%),47; and this rate is considered ‘Good’ using cut-off levels of 80%=excellent and 70%=good from a feasibility study exploring a mind-body physical activity program for chronic pain.48 The attrition rate between T1 and T2 (39.3%) was as predicted in the protocol (40%), and lower than the 60% attrition rates reported across other studies investigating programs for chronic pain.20 The attrition rate between T2 and T3 (20.0%) was lower than predicted in the protocol (50%), and the target sample size proved feasible to attain. These recruitment/attrition rates will help to plan the progression criteria used in a future pilot RCT of activity pacing. Regarding treatment adherence, only 56.1% of participants recruited at T1 attended both activity pacing sessions. 

Many participants (n=18, 16.8%) dropped out after the first session and therefore did not attend any activity pacing sessions. Reasons for early drop-out often include unrealistic expectations of symptom improvement, low motivation, or confidence to commit to programs or behavioral changes.20 In comparison, attendance rates of both activity pacing sessions among those who completed T2 were 83.1%, and 89.2% of participants attended five or more sessions. This is comparable to adherence rates of 81% seen elsewhere,47; and adherence rates have been considered as ‘Excellent’ when 70% or more participants complete 75% of sessions.48 However, within this study, the interpretation of high attendance rates from those who completed T2 are considered more modestly following the dropouts after week 1. Participants reported the condition of low back pain most frequently and CFS/ME the least frequently, as per current prevalence rates.49 50 Our findings reiterate the high occurrence of comorbidities, and frequent coexistence of chronic pain among patients with CFS/ME.9 Participants with CFS/ME demonstrated improvements in symptoms following treatment, in comparison to other studies in which pacing has been ineffective.31 Disparate to the study by White et al31 the activity pacing framework encourages a rehabilitative approach that facilitates increased function rather than aiming to reduce symptoms. The effects of rehabilitative approaches to activity pacing for patients with both chronic pain and fatigue require further investigation using effectiveness trials.

Clinical outcomes

Activity pacing improved across all APQ-28 subthemes, the largest improvement being for Activity planning. This theme refers to planning activities, setting time targets, and assessing activity levels36; practical facets of activity pacing which may be more accessible to change. Comparably, participants showed smaller improvements in Activity acceptance. This subtheme includes setting realistic goals and allowing flexibility; facets that involve changing previous behaviors or self-enforced rules. The APQ-28 detected multidimensional changes in activity pacing, and the two new items appeared to complement the scale. Further study will fully validate the APQ-28 in a larger sample and estimate minimally important changes. The aims of the activity pacing framework are to improve patients’ function and quality of life. Improvements in physical function were seen between T1 and T2 (mean change=4.67) that were greater than the minimally clinically important change (3.29).51 There were also reductions in avoidance between T1 and T2. It is intended that the quota-contingent, operant approach of the activity pacing framework encourages a reduction in avoidance through setting meaningful and realistic goals towards activity, rather than stopping activities with the aim of reducing/avoiding symptoms as per energy conservation approaches. 

Similarly, in an RCT comparing an operant approach with energy conservation, Racine et al30 found the operant approach, but not energy conservation was associated with reduced avoidance among patients with fibromyalgia. This, together with greater improvements in depressive symptoms following the operant approach over energy conservation, led to recommendations towards the operant approach for patients with fibromyalgia.30 The current study found that pre–post-treatment (T1-T2) improvements in both avoidance and physical function showed some decline at 3months’ follow-up. The authors suggest that physical function may be a component of rehabilitation in which patients feel least confident, especially those with avoidant behaviors.20 This may have implications for future programs to integrate follow-up sessions to encourage longer-term maintenance of physical activity. In comparison, Racine et al30 found improvements in physical activity following both operant pacing and energy conservation approaches. 

Similar to this study, Racine et al30 implemented handouts, homework, and goal setting to encourage patients’ uptake of activity pacing. However, both of the interventions explored by Racine et al30 were of greater duration than the current study, comprising of 10 2hour stand-alone pacing sessions with a 3-month booster session. Within the current study, improvements in mental function between T1 and T2 (mean change=7.3) were better maintained between T1 and T3 (mean change=5.95); and both higher than the minimally clinically important change (3.77).51 Quality of life also improved between T1 and T2 (mean change=0.13) and much of this improvement was maintained between T1 and T3 (mean change=0.07); both changes exceeded the minimally important difference (0.037±0.008).52 The activity pacing framework additionally aims to increase patients’ self-efficacy. Improvements in self-efficacy were found between T1 (mean=25.29) and T2 (mean=36.29), which were well maintained at T3 (mean=34.68). 

Scores were lower than the ≥40 cut-offs. However, an improvement of >5.5 was attained which is considered a minimally important change.53 Both physical and mental fatigue improved, and improvements in mental fatigue appeared to be better maintained at T3. Comparisons to minimally important changes are unavailable. Psychological health improved following the rehabilitation program, including reduced depression scores from moderate to mild (T1=13.7, T2=7.1, T3=9.1); with a clinically significant reduction (≥5) between T1 and T2.40 Mean anxiety scores reduced (T1=9.9, T2=5.4and T3=6.10), and remained within the classification of mild anxiety.41 Although reductions in pain were not a direct aim of the current treatment, lower pain severity was reported. Despite the increased intensity of pacing sessions contained within the RCT comparing the operant approach to energy conservation, Racine et al30 found that neither pacing approach effectively reduced symptoms of pain or fatigue.

Strengths and limitations

This study was an early feasibility study that primarily aimed to explore whether a new activity pacing framework could be implemented in the clinical setting. While this study fulfilled its original aims, it is limited by the absence of a priori progression criteria. However, the findings from this study will help to inform the progression criteria that are used to determine whether to progress to a full clinical trial from a future pilot RCT. Despite recruiting to target, this sample was not powered with a control arm to determine treatment effectiveness. As per other studies exploring activity pacing, activity pacing was instructed as one component of the rehabilitation program.5 Therefore, improvements in symptoms may have resulted from any combination of coping strategies. A future RCT will implement a suitable control to explore the effects of activity pacing, while implementing the activity pacing framework in a clinically relevant setting, including alongside other coping strategies. 

The generalisability of this study is limited to a sample of predominantly females and of white ethnic origin. Recruitment occurred only at one Pain Service and this service had an existing rehabilitation program for both chronic pain and fatigue. Bias may have arisen through the lead researcher delivering the healthcare professionals’ training and undertaking the observations. Further work will test the activity pacing framework and study protocol across other healthcare services and explore feasibility and fidelity over wider geographical locations. It is unknown what potential bias was caused by the attrition rate. However, there were no differences at baseline between those who completed the program and those who dropped out. It is possible that patients who completed T2 and T3 possibly felt greater benefits from the treatment and were more motivated to respond to the follow-up questionnaires. The attrition rate may be reflective of some of the clinical challenges and missed appointments surrounding the complexity of chronic pain/fatigue. Further research could explore whether providing a follow-up treatment session improves commitment to activity pacing.

Click picture to Cistanche herba for anti-fatigue

Modifications for future study

Since more patients completed the T1 questionnaires during the rehabilitation sessions than at home, this may be the preferable mode of distribution of paper questionnaires. To lessen the time taken to complete the questionnaires, the PASS-20 may be considered for exclusion in future studies. The whole 20-item PASS scale was included for reliability and validity, but data specifically from the Escape and Avoidance subscale was explored. Modifications to the inclusion criteria may include patients with any chronic spinal pain, including cervical/thoracic pain due to the frequent and similar presentation at rehabilitation services.

Conclusion

To the authors’ knowledge, this is the first study to explore the clinical utility of a comprehensive activity pacing framework developed for both chronic pain and chronic fatigue. The newly developed activity pacing framework proved feasible to use clinically by healthcare professionals. Patients with both chronic pain and fatigue implemented greater activity pacing strategies following treatment, alongside reporting improvements in quality of life, psychological well-being, self-efficacy, pain, and fatigue. Physical function and avoidance improved to a lesser extent and for the shorter term. Future studies will use the activity pacing framework in an effective RCT to explore the effects of activity pacing on symptoms.

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