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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Persistent pain (also known as chronic pain) is a specialist area/field in healthcare, it’s an area that I have specialised in and wanted to share a little on what this means.  A little background on physiotherapy training, following completion of a physiotherapy degree physiotherapists take different paths, traditionally this always started with a junior rotational post in a hospital.  This now varies, on graduating a physiotherapist may start work as a junior rotational physiotherapist working in different areas within a hospital, or they may start working as a junior therapist within a community therapy team, or they may go straight into private practice on a graduate development program, usually this is within musculoskeletal physiotherapy.  Some physios work generically and others specialise in one area or a few areas, doing additional training and having the appropriate level of support and experience to develop a specialism, which is always ongoing.  Physiotherapists work in many areas, here are some of them: musculoskeletal (MSK), respiratory, cardiac rehab, neurology, paediatrics, care of the elderly, falls, learning disability, mental health, persistent pain, ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome), long covid and palliative care.

Pain specialist physiotherapists have done additional in-depth training on top of their degree and usually have experience in a variety of areas.  Additional training includes exploring pain neuroscience more in-depth than at undergraduate level, psychologically informed practice training (includes integrating the core principles from, such as, acceptance and commitment therapy, compassion focused therapy and cognitive behavioural therapy), other pain related training and other related training including coaching.  They keep up to date with the evidence base on pain and understand the many myths that exist within healthcare and society about pain and the impacts of these.  Pain physios usually have many years experience of helping people learn to live well with pain and change pain too.  They value, listen and learn from the lived experience of those they work with and the wider lived experience community.

Pain physiotherapists use a whole person centred biopsychosocial model (many use a biopsychosocial-spiritual approach – this includes what’s meaningful and gives purpose) and take a holistic/integrative approach to care.  We aim to understand the whole person and their world and hold a compassionate non-judgmental space for understanding and hearings someones story/journey and to support exploration.  We encourage people to build compassionate self-awareness and to hold a curiosity and a willingness to explore what may be helpful and supportive for them.  Pain physiotherapists aim to empower people, for example, to be able to engage in what’s meaningful and develop a set of strategies to help manage and change pain.  We help people to be able to fully engage with life again and what’s most meaningful.   We work closely with other professionals involved in someone’s care, such as a psychologist and occupational therapist.

Pain physiotherapists understand that pain is complex and multi-faceted and that’s linked to the fact human beings are complex, this is why we have often done a variety of training exploring the different areas of being human.  Each pain specialist physio works by integrating all their knowledge and skills in a way that is blended with the knowledge, skills and experiences of each person they are working with, creating individualised care.  Each pain physiotherapist works a little differently as they integrate their knowledge, unique skill set and experiences into their work.  No one therapist has the same knowledge, skills and clinical experience, just as no-one person is exactly the same.  It is important to mention that we all follow the Chartered Society of Physiotherapy (CSP) guidelines and those of the Health and Care Professions Council (HCPC).  When using knowledge and skills that don’t class as physiotherapy (according to what is set out by the CSP), we adhere to the best practice within those professional guidelines as well.

How To know if Someone Has the Relevant Knowledge, Skills & Experience?

Read what qualifications, training & experience they have on their website and if it’s not available to read on there its ok (and I would recommend it) to ask.  It is ok to ask what someones experience and background is.  Some therapists will offer a free short call, I do this, one reason being it helps people decide if working with them feels potentially helpful.

My Knowledge, Skills & Experience In Persistent Pain

Following my junior rotations in a hospital I chose to specialise in neurology and persistent pain and over the years have done many trainings, lots of reading, had support from more experienced clinicians and worked with many people with persistent pain.  I have worked in chronic pain for over 14 years, in the last 3-4 years I’ve stopped my neurology work and transferred this specialism to being a special interest in working with people with ME/CFS, long covid and PoTS, alongside still working with people with persistent pain.  One of my roles has been working as an advanced practitioner physiotherapist in pain, I did this for 4 years alongside my private work.

Here’s some of my training:

BSc (Hons) Physiotherapy

Life coaching qualification

NLP practitioner training

Yoga teacher training (200hr)

80hr trauma-informed yoga and embodied resilience course

Two weekend yoga courses for physios taught by physios who are yoga teachers

8 week psychologically informed practice course with the Physiotherapy Pain Association

Compassion focused therapy (CFT) for healthcare professionals 2 day course

8 weeks CFT training

A few different ACT courses up to intermediate level

Pain coaching course

Explain pain course

Graded motor imagery course

Functional nutrition & chronic pain certification

The above list is a small percentage of the training I have done, there has been a lot more training and reading over the years in addition to what is listed above.  There is other training related to the special interests I have in ME/CFS, long covid and PoTS, and the yoga and coaching parts of my work.

Remember Chronic Pain/Persistent Pain Is a Specialist Area

Chronic pain/persistent pain is a specialist area and it it important that when people are struggling with persistent pain that they see clinician(s)/therapist(s) who have knowledge, skills and experience in this area.  Persistent pain includes many diagnoses including fibromyalgia, chronic low back pain, chronic headaches, CRPS, and many others.

This wasn’t the easiest thing to explain in a short (ish) blog post but hopefully it makes sense and you can see the value in seeing a pain specialist physiotherapist  or an MSK physio with a special interest in persistent pain.  Remember it’s ok to ask what someones background and experience is in working in chronic pain.

If you need help with persistent pain and would like to see if I can help please get in touch to book a free 15 minute call to discuss.

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