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 similar and different to pacing for ME/CFS and long covid (where post exertional malaise is present), 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 system activation, decreases our tolerance levels for the activity being avoided and often also tolerance 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 gets overreacted to (we become more sensitive to it) often includes sitting and standing still and moving a certain way.  When systems are super sensitive all movements can trigger a protection response, doing certain activities and even thinking about doing a particular activity can create a pain response.  A quick note here about cause and pain, rarely does one specific thing cause pain or an increase in it, it’s complex and there are many variables that 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 too, 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 can potentially modulate pain
• Pacing can help with both nervous system regulation and retraining the nervous system.  So, it can be part of both managing and changing pain over time
• 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.

I use 5 P’s with people for pacing, if they find this helpful, these are planning, prioritising, play, purpose & problem solving.  I have a pacing handout, that includes these that I offer to the people I work with who are struggling with persistent pain, to support their exploration of pacing.

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.  Including a variety of activities, including exercise, in pacing is important, finding what’s helpful for you needs exploration.  There is a link to an exercise and persistent pain blog that 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 activities/tasks 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 the people who attend my 8 week Creating A Healing Path workshops for people with pain/fatigue/anxiety, and my 4 week nervous system regulation workshop series to do this.  Even though we didn’t specifically cover pacing in my Creating A Healing Path workshops 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 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:

• Planning & prorating tasks
• Problem solving
• 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 workshops  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 & integrative somatic practitioner 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, or the 4 week nervous system regulation workshop series click the links below:

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

https://unityphysio.co.uk/services/listening-to-our-inner-wisdom-workshops/

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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An increase in pain or fatigue that significantly disrupts your daily function and/or sleep for a few days or more is commonly referred to as a flare-up, some people use other terminology, for example a set-back.  Some things commonly go along with this including increased self-criticism, frustration, low mood, and loss of tolerance for some activities.

What is a compassionate flare-up plan:

A flexible plan, developed and implemented through a compassionate lens, of what you can do to self-manage what is happening, to calm things down and build things back up again.  It draws on previous experience of managing your pain and what is helpful for your wellbeing.

Why is compassion important?

Compassion is important in a flare-up plan as often people blame themselves, self-criticism and frustration commonly increase, which in turn turns up the pain volume and has other draw-backs like the impact on your mood.  Having a compassionate focus also encourages kindness, gentleness, courage and strength.  Compassion helps you support yourself and do what’s wise for you at that time, for example, asking for a little more help and support for a few days or weeks (there is both strength & vulnerability in asking for help).  Compassion has also been shown to help in many ways including decreasing self-criticism, rumination and stress, along with improving resilience & overall wellbeing.

Compassion encourages you to step back rather than pushing on regardless or stopping everything (neither of which are recommended) and ask yourself questions like ‘what can I do for myself out of kindness today’ (this is a question I love that I heard on a course with Dr Mary Welford).

‘Our compassionate self brings wisdom that illuminates the available choices & the possibilities flowing alongside them, along with what could be most helpful right now.’

What causes a flare-up?  There are many reasons and commonly it is a combination of things, including:

• Doing too much (this could be the boom-bust cycle if it happens regularly)
• Working to build tolerance and fitness levels up
• Choosing to do an activity outside of tolerance levels (some activities are worth this)
• A virus
• Increased stress
• Decreased sleep

It isn’t always easy to work out what has caused a flare-up, sometimes it helps to explore what had led up to it and other times it isn’t.  If you find you are having repeated flare-ups without any obvious contributors the best thing to do is usually to focus on actioning your compassionate plan.

Why do we need a flare-up plan?  Here are a few reasons:

• It helps you stay in control and feel confident with self-management.
• There are always flare-ups when living with pain and sometimes these are really difficult to deal with and sometimes feels like a million steps backwards have just happened at great speed.  A compassionate flare-up plan helps us remember the things that are helpful, what we can do to manage things, calm things down and build tolerance back up.  It’s not always easy when pain increases to think clearly, having a plan helps us take action away from getting caught up in things like self-criticism, rumination and anxiety.
• If we don’t have a plan we can end up getting stuck n a cycle of doing less and less, as a result we end up maintaining a new lower level as systems adapt to this and we lose fitness and tolerance for the activities we need and want to do.  This also affects confidence for doing daily activities amongst other things.
• Flare-ups can make people withdraw further from others, themselves and the world around them.  Retreat is a natural protection mechanism, this may be a helpful short-term strategy, however it is not helpful when it is repeated regularly in the long-term.  Retreat and disconnection are also things that turn up the pain volume and sensitivity, connection to others and ourselves is an important part of managing pain and overall wellbeing.
• Some things are worth the flare-up, these are the things that matter most to us.  You can make a mindful choice to do an activity, even though pain is likely to increase, because you feel the activity is worth it and knowing you have a compassionate plan to help you over the following days to find some ease can be reassuring.  So, a compassionate flare-up plan can help you take steps forwards towards your values and what matters most to you.

What to put in a compassionate flare-up plan?

This is individual to you and requires some exploration and reflection.  Grab a notebook and make some notes, if you are having a flare-up now use this experience and previous ones as you read to make notes, otherwise remember the last time or times you had a pain or fatigue flare-up that affected your function and sleep for a few days or more.

• Consider what may have contributed to the flare-up, if this is helpful (sometimes it’s not, notice if you get stuck in a look of self-criticism and guilt).  Compassionately acknowledge (a gentle tone, a helpful acknowledgement without criticism) this and what could be done differently next time, if anything.
• What helped you calm things down and build things up before?  What didn’t help before?
• Set yourself some easy short-term goals based on meaningful activities (what’s important to you, what do you most enjoy doing).
• Plan to gradually build things up to rebuild tolerance and fitness.  Align this with your goals and allow yourself flexibility to adjust things if needed along the way.
•  Moving little and often is usually helpful.  Remember to include movement in your plan.
• Prioritise what needs to be done and leave the rest or ask for help (it’s not a weakness to ask for help it’s a strength).  It can be frustrating leaving things, there are strategies that can help you manage this.
• Having flexibility & support from your employer is important, having open and honest discussions with them about what support could be helpful during a flare-up (for example, frequent short breaks) to helps things settle down again.
• Remember to change how you usually pace things for a short-time, you will have lower tolerance as the need for protection has be deemed to have increased (things are on high alert), pacing differently can help calm things down.  It is important to have a flexible plan for building things back up as you will otherwise adapt to the new lower level.
• Don’t stop everything and rest for more than a few hours at a time, it is usually better to do a small amount regularly with short rests.
• Notice self-criticism with self-compassion and unhook from unhelpful thoughts.  One way to do this is to say, for example, ‘I notice that I am thinking the thought that…’  Another is to write a compassionate letter to yourself to acknowledge how things are and that it’s not your fault, it is understandable & part of being human and living with pain.  There was a post on this on Unity Physiotherapy & Wellbeing’s Facebook page in September 2019 as part of Pain Awareness Month.  There is also guidance in The Compassionate Mind Workbook & Compassion Focused Therapy for dummies.  If you are unsure, or struggle with this, please get help from a suitably trained therapist.
• Practice self-compassion.  There is guidance in both books mentioned above, The Compassionate Mind by Professor Paul Gilbert and on Kristien Neffs website https://www.self-compassion.org
• Increase relaxation based activities, for example meditation, gentle stretching or anything you find calming.

• Integrate more things that stimulate the soothing system (this is part of the 3 circles model in compassionate mind training/compassion focused therapy).  I go through this in clinic with people, there is also guidance in the above books and this video by Chris Winson https://m.youtube.com/watch?v=peC-bB4DqXQ&fbclid=IwAR3b10RyukjKxkukeByQB4XQVeo0bMkVfjo1uvwggpamb09iTc0r-vpc07M
• Consider if you need medication in a bad flare-up or can you manage things effectively with other strategies.  If you need medication discuss this with your Doctor, Pharmacist or Non-Medical Prescriber, such as a Physiotherapist who has done additional training, how to optimize this.
• Focus on the present moment and the small steps rather than the set back and where you were.

Need further help?

Ask your physiotherapist or other healthcare provider for help if you are unsure of how to create your flare-up plan.  Creating individual compassionate flare-up plans is something I help people with at Unity Physiotherapy & Wellbeing.

‘A compassionate flare-up plan helps you keep returning to a life full of meaning & purpose with pain in the background’

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