There isn’t an agreed definition of pacing, I would define it as flexible way of structuring your day in a way that supports both function and wellbeing.  Pacing essentially means breaking down tasks and activities into manageable chunks with consideration of the different types of activities, including enough short rest breaks in your day and flexibly adjusting things each day/throughout the day as needed.  Pacing needs consideration of different activity types, for example what activities are more physical/cognitive/emotional and how they impact you.  It needs a number of things which I will touch on in this blog, especially awareness, compassion, noticing what’s present in our experience within our body (what’s embodied), flexibility, knowing our values & what’s most meaningful, and exploration.

Pacing is helpful for us all and more so when living with persistent pain and/or other health conditions.  A quick note here, pacing for persistent pain is different to pacing for ME/CFS and long covid (where post exertional malaise is present), there are similarities but its a different.  This blog is focusing on pacing when living with persistent pain.

The way I suggest exploring pacing with the people I work with includes discussing what pacing is and is not, there are some examples of what pacing isn’t below, perhaps the commonest misconception is that it means doing less.  I also encourage an understanding of nervous system regulation through a cognitive understanding and an embodied understanding (body based).  Part of this includes developing a toolbox of strategies and practices that support compassionate awareness & nervous system regulation, both I see as key aspects of pacing.   I often use the window of tolerance model by Dan Siegel, polyvagal theory by Stephen Porges and the three circles model from compassion focused therapy by Paul Gilbert as part of exploring understanding nervous system regulation in an embodied way.  I explore what’s meaningful with people and what their values are for a number of reasons, including because it helps people make choices about which activities to prioritise and engage in.

As already mentioned pacing can be misunderstood (and often is), here are some of the things pacing is not:

• A rigid/restrictive daily plan
• Doing less
• It’s not another thing to be ‘done’
• Only being able to do certain things a certain way
• Only doing things that don’t cause a pain flare

Pacing is not a rigid daily plan, it’s a way of flexibly adjusting our day as we move through it.  It is helpful for us to bring a non-judgemental compassionate awareness to how we are relating to our world (both the internal and the external), which is changing moment by moment.  From a place of being the compassionate observer we can take conscious wise action, where it’s possible to meet what’s needed (part of pacing).  A quick note here, there isn’t really any division between our internal world and the external world (not something we are exploring in this blog).

Avoiding doing things that tend to increase pain because of worry of a pain flare is not pacing and doing this over time this increases threat in systems, decreases our tolerance levels for the activity being avoided and often also for different activities.  It increases sympathetic nervous system activation (fight-flight), essentially there is more threat in systems and a sense of safety is lacking or has significantly decreased (pain is part of our threat system).  Tolerance levels decrease for a number of reasons, mainly due to an increase in sensitivity levels to different stimuli and a decrease in fitness levels.  Stimuli that becomes overreacted to (sensitivity) often includes sitting and standing still, moving a certain way or when systems are super sensitive all movements can trigger a protection response, doing certain activities and even thinking about doing a particular activity.  A quick note here about cause and pain, rarely does one thing cause pain or an increase in it, it’s complex and there are many variables we don’t see.

Another thing that pacing doesn’t mean is ignoring pain and pushing on regardless, this tends to ramp up the protection responses and sensitises systems more.  This is the opposite of avoiding activities, it is sometimes referred to as the boom-bust cycle (not a term I use unless someone is using it and relates to it in a helpful way).  Both avoidance and regularly exceeding tolerance levels by too much are both problematic.  A quick note here, choosing not to do something that doesn’t come from a place of threat may well not be avoidance.  Doing a lot more than tolerance levels tends to result in having to do less for a few days, or even longer, it increases sensitivity and the threat in systems.  Doing a lot less also increases sensitivity and threat in systems, along with tending to decrease strength and fitness as well.  However, doing a little more with a sense of safety, understanding your nervous system and using practices that help regulate your nervous system can help to gently nudge tolerance levels over time.

Pacing is not another thing to be ‘done’, it’s a way of flexibility adjusting to how we are and what feels needed throughout our day.  The way I see it is that pacing becomes a way of being that supports both effective function and our wellbeing.  For example, compassionately relating to ourselves and others, taking regular pauses in the day (these are needed for everyone, whether living with pain or not) and having nurturing daily practices that are part of a way of being and living, these could be seen as helpful habits.

(Image: my Grandad when he was 90 doing a meaningful activity – time in nature with one of his grandchildren – made possible by having something to sit on & only walking a very short distance)

How Can Pacing Help With Persistent Pain?

Pacing encourages people to work around their normal tolerance levels, this means knowing your baseline for different activities and where your soft limit/soft edge/soft boundary is.  This means knowing what level of different activities is generally ok (the baseline) and also having an embodied knowing (an awareness from what’s present in your body related to your whole experience).  Knowing your soft boundary includes knowing the whispers from your body that indicate you are near this point and indicate that taking a rest break or changing tasks would be helpful.  I have found it helpful over the years, with myself and working with others, to combine the cognitive understanding of a variable baseline with an embodied knowing of the signs we are near our soft boundary or soft limit.  One reason combining these is helpful is because our baselines are always changing and are impacted by many factors/variables, for example lack of stress and increased stress, and our body will reflect dysregulation consistently – we can come to deeply know it’s whispers when we listen compassionately.

Pacing can help in many ways, here are some of the ways it can help with managing and changing pain:

•  People living with pain can often more consistently do what needs to be done and what’s meaningful to them by breaking things down into more manageable chunks of activity interspaced with rest
• As well as taking short rest breaks changing to a different activity, for example changing more of a physical task for more of a cognitive one can be helpful
• With a pain flare-up things may need to be broken down into smaller amounts with more rest breaks to help systems to calm down
• Pacing can help people to engage more often and more fully in what’s meaningful along with using the strategies & practices that help them to manage pain
• It can help to modulate pain, for example taking a break and doing a breath practice helps to regulate the nervous system – down regulating the threat system and can potentially modulate pain
• Pacing can help with nervous system regulation and can help retrain the nervous system.  This is part of both managing and changing pain
• It can help to decrease sensitivity to different stimuli, increase tolerance & fitness over time along with other things

Pacing Tips

It can be helpful to have an understanding of why pain doesn’t necessarily equal harm, knowing that we are safe to do things even with pain.  Having an understanding around this is one thing that can help people to pace activities and create a sense of safety.

As already mentioned listening to the body and integrating enough rest, along with having daily practices that help to regulate the nervous system is important.  Many things can help to regulate the nervous system and help with pacing when living with pain, for example, breath practices, meditation, gentle yoga or other mindful movement, singing/humming, time in nature.  Exercise and including this in pacing is important, finding what’s helpful for you needs exploration, there is a link to an exercise and persistent pain blog I wrote in the resources at the end of this blog.

It is important to explore what is restful for you and the sort of rest that certain things offer, there are a number of different forms of rest which I am not going to go into in this blog.  The picture below is child’s pose, this is often referred to as a pose of rest in yoga and is known to be calming, grounding, restful and restorative.  It is important to remember just because something is said to be calming and restful it doesn’t mean it will be for you, this highlights again the importance of embodied awareness (what is showing up in the body).  Understanding what is showing up in your body and how your nervous system is responding is part of developing an embodied awareness.  I encourage people who attend my 8 week Creating A Healing Path workshops for people with pain/fatigue/anxiety to do this.  Even though we didn’t specifically cover pacing people reported pacing better and being more able to engage in what was meaningful to them, you can find the link for more information on these workshops at the end of this blog.

As already mentioned pacing is not rigid, it needs flexibility as everything is changing moment by moment.  Our internal and external environments are constantly changing, our tolerance levels and nervous system state are in a constant state of flux (with everything else), it another reason why having an embodied awareness matters.  We need a cognitive understanding combined with an embodied awareness of what practices and strategies are helpful when, along with the different ways that we can adapt them.  Without a body based understanding (embodied awareness) we will be running on cognitive understanding alone and missing out on what our nervous system is communicating and the wisdom of our body.

Here is a common example of how our tolerance levels and nervous system state are always changing, imagine that you haven’t been sleeping well for a few nights and you keep on doing things in the usual way.  There are some common impacts of this, including: increased fatigue, increased stress, making poorer food choices, getting hooked in unhelpful thoughts, and increased pain which may also stop you sleeping (one of the many cycles in pain).   Lack of sleep in itself sensitises systems, increases threat system activation, increases the perception of pain, our baselines and soft boundary change, and it impacts our concentration and focus.  So, rather than keeping doing things in the usual way we need to explore what’s helpful and adapt what we are doing.  This might look like breaking things down into smaller chunks than usual, having more rest breaks during the day, including more meditation, or having a few minutes outside a few times during the day, and doing less exercise than normal (the body responds differently to exercise with lack of sleep and it responds differently with persistent pain too).  Making these adjustments like these are examples of pacing.

When there is something that’s important for you to do and you know it’s over your tolerance levels one way to manage this is to engage in what gives more safety messages to your body via your nervous system for a few days before the event, during it if possible, and again for a few days after.    Factoring in more rest afterwards and even before the activity/day can be helpful.

Remember what is helpful on one day, or in one moment won’t be exactly the same as what’s needed in another.  This is why we need an embodied awareness (body awareness) and a toolkit of practices and strategies that we have explored and used regularly.  This helps us to select what feels most helpful and then notice how our nervous system and body are responding, adapting what we are doing from this as needed.

Here’s a list of some more examples that can be part of pacing with a flare-up of pain:

Modulate your usual activities, like with the example above

Use additional helpful strategies from your toolkit if needed, a few examples are mentioned above

Do what helps to regulate your nervous system more frequently during the day

  Practice self-compassion, an example would be reframing your language (the self-critic can get loud when things during a pain flare-up)

For some activities where you are doing less than you normally would due to a flare-up remember to ensure that you have a plan to build things back up gradually as things start to settle (something which can be forgotten).

Some questions you can ask yourself:

•  Do you pace your activities in a way that’s supportive for your wellbeing
• Do you make adjustments to your day for factors like lack of sleep and increased stress?
• Do you know your baselines for activities and do you the know the signs of your soft limit/soft edge/soft boundary?
• Do you do what’s important to you or do you avoid doing it out of fear of making the pain worse?
• Do you push on regardless?
•  Do you incorporate the helpful strategies/practices into your day or just when the pain is worse?
• Do you know what helps give you a sense of safety with doing different things?
• What daily practices/strategies support you?

In Summary

This blog has covered what I see as the basic principles of pacing when living with persistent pain, these are:

• Breaking things down into manageable chunks
• Understanding different activities (physical/cognitive/emotional) and your tolerance levels for them
• Integrating enough rest (with consideration of different forms of rest)
• Changing activities for a break is helpful (alongside having rest breaks)
• Having a cognitive understanding and an embodied awareness (body based understanding/knowing)
• Knowing the whispers from your body that you are near or at your soft limit/soft edge/soft boundary
• Using the practices and strategies that support you and help to regulate your nervous system and manage pain
• Remember there isn’t a right or wrong with pacing and it needs flexibility.  There isn’t a perfect way to pace!
• We need to be able to flexibly adjust during the day, this needs an embodied compassionate awareness & ongoing practice

No-one paces the same way, no-one walks in the same shoes, yet we create similar footprints.  This means that we can learn from each other and use the principles of things like pacing and different practices and adapt them to meet what’s needed.  There are common tools/practices/strategies that can help regulate the nervous system, manage and modulate pain, support wellbeing and effective function, these need adjusting for each person.  This is something I explore with people as part of 1:1 work and it is part of my 8 week Creating A Healing Path workshop series.  With regular practice people understand the many ways they can adapt practices to meet their needs and as part of exploration and regular practice they create their own toolkit of resources to manage and change pain.

Learning how to pace and manage pain is a journey of exploration that takes many directions, there isn’t a destination/an end point with pacing, instead pacing supports pain management and engaging with what matters each day.  I would say that understanding nervous system regulation, noticing how we are relating to ourselves and practicing embodiment (noticing what’s present in our body) are all key parts of pacing.

I have written this blog from my understanding of working as a pain specialist physiotherapist & wellness coach as well as lived experience of persistent pain, ME/CFS & PoTS.  If you would like to learn more about pacing and/or would like help with management of persistent pain in general get in touch to book your free 15 minute call to see how I can help.

If you would like to find out more about the 8 week online Creating A Healing Path workshop series for people with any condition associated with pain/fatigue/anxiety click the link below:

https://unityphysio.co.uk/services/ahealingpath/

Pacing Resources

There are a number of resources specifically for pacing for persistent pain and related topics, here are a few:

There is a little about nervous system regulation in part one of my healing blog https://unityphysio.co.uk/healing-within-connectedness-love-part-one/

This is a blog that I wrote on exercising with persistent pain and can help with pacing of exercise/physical activities https://unityphysio.co.uk/exercising-with-persistent-pain/

A blog written about pacing in the context of neuropathic pain http://livingwellpain.net/persistent-pain-pacing

A short pacing video https://www.paintoolkit.org/pain-tools

Q&A: Pacing & Chronic Illness http://natashalipman.com/qa-pacing-chronic-lllness-resting-pain-fatigue/

(Images in this blog: icon with heart in hands and man walking are authors own, childs pose image is from Shutterstock by Rasterbird, time for change image is from Shutterstock by Trueffelpix)

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On a side note to exercising with ongoing pain we need to all remember to take regular movement breaks during the day.  Exercising or being active for an hour after sitting all day is not enough.  We lead much more sedentary lives than we used to thanks to, such as, advancing technology and more use of our cars.  With the pressures of modern living it is important we think of ways to add in more regular movement into each day, creating new movement habits with regular practice.  Maybe this could include walking to work, parking the car further away from work or getting off the bus a few stops earlier, going to speak to someone in the office instead of sending an email, doing some squats whilst the kettle boils, standing during a phone call and going lifting alternate heels, there are many possibilities!  During the day remember to take regular movement breaks, these little movement snacks will also help your concentration and attention as well as your body.

I have noticed some common questions from people with persistent pain, including:

1. What exercise is helpful?

When choosing the exercise consider:

• Does it help you achieve your goals, maximize or maintain function?
• Do you enjoy it?
• Is it meaningful?
• If there is a variety of the types of exercise (mix of cardiovascular, flexibility, strengthening)
• Is the level achievable for you at present or do you need to modify some of the variables (see dosage tips below). Think of the Goldilocks rule – not too little, not too much, just right.
• Do you feel confident in modifying the variables or do you need to explore this with a physiotherapist?
• Do you understand your pain and have a toolkit that helps when you have a flare up?
• Do you have an understanding of pain not necessarily being correlative of what’s happening in the tissues – hurt doesn’t equal harm?

2. How do I know what’s enough for me and how do I avoid pain flare-ups?

For ages 19-64 The World Health Organisation recommends 150 minutes a week (30 minutes a day) of moderate intensity aerobic exercise (e.g. brisk walk, cycling, slow swimming), or 75 minutes a week of high intensity/vigorous aerobic exercise (e.g. running, a game of tennis, fast swimming), and twice a week strengthening of all major muscle groups.  Moderate intensity and high intensity aerobic exercise can be mixed, it has been said 1 minute of vigorous/high intensity aerobic exercise equates to 2 minutes of moderate intensity.  This amount of exercise could be something for you to work towards.  For some people with long-term conditions it’s not achievable, which is ok as long as the level of exercise being done is enough for adaptability.

What’s enough for one person may be too little or too much for another so this needs exploration, if it’s not something you feel confident to do on your own a physiotherapist can guide you. Remember the goldilocks rule here – not too little, not too much, just right! The only way we find what’s best for us is by testing and exploring, we learn through experience.  It’s important to remember a little bit of pain flare-up with persistent pain is ok, by a little I mean that it settles within 24 hours and doesn’t affect your daily function.  We need enough challenge for adaptability of body and nervous system and this can mean a little flare-up, sometimes we initially aim for no flare-up to build confidence and calm things down, we need to remember to build things up.  Start where you are at, find your baseline, if you have persistent pain this baseline needs to be a level where you don’t have a big flare-up that lasts a few days or longer (in the traffic light system below that’s red).  Find a level that feels achievable and comfortable for you.

The traffic light system:

You mainly want to be exercising in the green, amber is ok yet either needs increased awareness, a little adjustment to proceed, or modulation to change to a green light.  An amber light can mean too much too fast and needs evaluation, red is stop and significantly modify what you are doing and possibly seek guidance from a physiotherapist if needed.

Red – there is a severe flare-up during the exercise, 7 or more on a 0-10 scale, you don’t feel safe/are worrying about causing more pain or damage.  The pain flare continues after exercise for between 3 days and several weeks and you have a significant loss of ability in your daily function.   You need to stop when in the red, seek advice from a physiotherapist if you are often in the red.

Amber – pain flares during activity of 4-7 on 0-10 scale, yet you know you are safe.  This is a pause and proceed with awareness light, notice what happens as you continue and if things are settling or not continuing to intensify continue for few repetitions or 1-2 minutes. Afterwards pain persists by up to 3 numbers above your baseline and settles back to baseline within 24-48 hours, and only minimal effect on daily function.  If the after affects are longer or function is more affected make sure the next time you are in amber you modulate to green.  You may need to use some tools from your pain flare toolkit to help things settle.

Green – pain flares during activity 0-4 on 0-10 scale and settles in less than 24 hours with no loss of function.

When you know your baseline work there for a week, with a green traffic light, and if you feel confident to increase this the following week add a small amount more e.g. 5 more minutes duration or a 1-5% increase.  Remember hurt doesn’t equal harm, yet with ongoing pain when the body and nervous system are sensitive we need to calm things down, so working in green is the most helpful place to be.  We need enough challenge for adaption which may mean a little flare up, as the green shows.

Dosage variables you need to consider and can modify:

(Think Goldilocks here!)

• Frequency – how often you exercise each week
• Intensity – exertion level or amount of weight lifting
• Duration – how long each session is
• Type – cardiovascular, strength, flexibility/mobility
• Load – all the things that affect your homeostatic balance (e.g. sleep & stress)

If every day is too much for moderate intensity exercise start with every other day or even twice a week, it doesn’t matter where you start, remember it is more important that you know your baseline and make a start.  You could split the duration into two 15 minute moderate intensity aerobic exercise sessions rather than one 30 minute one to start with.  Make sure you do a mixture of exercise to include cardiovascular, strengthening and flexibility/mobility.

3. What to do if you have a flare up

• If you have a big flare up it can be a result of a combination of factors, rather than just exercise, for example imagine you have slept badly for few days, have more stress at work (increased load on your systems affecting homeostatic balance) and you do your usual level of exercise and experience a big flare-up and instead of being in green on the traffic light system you are in amber tipping into red or maybe you are in the red.  When this happens reflection on all the factors affecting you is important, modulate what you can and seek help when needed.
• What traffic light are you using, make sure you are in the green and re-evaluate your baseline.
• What tools do you have in your toolkit to help (e.g modulate activity, a little more rest between activities, meditation, hot bath).
• If having repeated flare-ups that you are struggling to manage seek help from a physiotherapist.

A few tips for awareness & modulation of mind & body when exercising with persistent pain:

• Notice what you are thinking – do you feel safe or are you worrying about a pain flare? If you don’t feel safe, make some adjustments so you do and then re-evaluate.  If you are worrying about making pain worse it usually does as systems are already on high alert.
• How are you feeling? Do you feel confident and safe or do you feel unsure and anxious?  If it’s the latter what can you do to change it, what do you need to know or feel to feel more confident and safe to exercise?
• Notice what happens to your breathing, are you holding your breath? If so can you soften your breath. Remember your breathing will change with moderate intensity exercise.
• Are you holding more body tension than is needed? Can you modulate it? If not change what you are doing to make it a bit easier & re-evaluate.

Tips for sticking to your exercise routine:

• Know your strongest motivators.  I talk to people about peeling back the layers like removing layers on an onion until you get to the core.

• Exercise with a friend or family member.

• Make sure the exercise you choose is enjoyable and/or meaningful to you.  Have fun, play, and be creative.

• Vary your exercise, maybe every 4-6 weeks, even a small change is helpful.  This is helpful for physical adaption as well as mentally.

• Set aside some time each day, if something else gets in the way that’s ok you can adjust your timetable.   If it is commonly being replaced by other things look at why: maybe you haven’t yet revealed your deepest motivators, maybe you are anxious about causing more pain, maybe you don’t enjoy the exercise you are doing, maybe you are not seeing changes and are wondering if it’s really helpful (you may need to seek help if this is happening or you may be able to explore and make changes yourself).

• Keep a record of what you have done each day you exercise.  Reflect on this at the end of each week and then plan next week’s exercise.

Summary

In summary, understand: what exercise you enjoy and what exercise is meaningful to you, your motivators, where your baseline is and think green traffic light; that there are different variables you can modulate in the dosage.  Remember hurt doesn’t equal harm and change is always possible.  Make regular movement snacks part of your daily routine. Seek help from a physiotherapist if needed.

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