The Chronic Pain Program

Lesson 3 elco
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back
Pacing and Activity Scheduling and
Movement
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Welcome to the summary for Lesson 3!
You have now seen Martha learn about chronic pain and how she has moved towards
acceptance of it.

She’s learnt about the complexity of chronic pain and the need to set small achievable goals.

In Lesson 3, Martha went to visit Paul, the physiotherapist. Here she learnt about the boom-bust
and surrender patterns common in chronic pain. They also talked about how to use pacing to
improve her level of activity and to meet her goals. Importantly Paul, the physiotherapist, explained
that there are four components to an exercise program but the most important part is to have fun.

This lesson summary is all about looking at movement and increasing your activity levels,
despite the pain.

Hope you enjoy the ride!

Don’t hesitate to contact us if you have any questions at any stage of this program by email on
contact@thiswayupclinic.org or by telephone 02 8382 1400. Good luck!

The Team from This Way Up.

www.thiswayup.org.au

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Your Checklist

TOPICS COVERED IN THIS SUMMARY

This summary is looking at your movement and how to increase your tolerance to activity.
Tick these topics off as you complete this summary:

1. Relationship between Pain and Activity

2. Recap – what do you know so far?
3. Importance of Pacing and Finding a Baseline
4. Daily Activity Scheduling
5. Components of an Exercise Program
6. Summary
7. Print and complete the Activity Scheduling
Worksheet (under the Resources section of the
program).

You do not need to complete the worksheet for the

whole week, but try at least 3 days in a row so that
you get a good sense of how you are spending your
time and see how you go.
8. Print and complete the Exercise Diary
This will help to monitor what movement you are doing and show you your
improvement over time.

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1. Pain and Activity

What is your relationship between pain and activity?

Overdoing it:
Do you push and pull through your pain,
fighting to get things done, only to overdo
it and collapse the next day? If you
answered yes, you follow an ‘overactive’
or ‘boom-bust’ pattern.

Under doing it:

Or do you submit to the pain and STOP all activity choosing to rest
instead? If you answered yes, you follow a ‘surrender’ pattern.

We are striving for a balance!

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 Boom-bust pattern
Often people with chronic pain will follow an overactive or boom-bust pattern. This
involves overdoing things on a “good” day, which increases the pain to the point where
they can’t do anything and then they have a “bad” day. This means that when people
try to return to activities after a break, they are increasingly unable to do so.

This vicious cycle can happen to you on a daily/weekly/fortnightly basis, and can often
result in the person becoming more unfit and de-conditioned.

Other problems associated with this cycle may include:

• The pain is usually worse after over-doing things and therefore you need a much
longer rest before you bounce back again.

• The pain (not you) controls how much you can do.

• It’s often hard to foresee what lies ahead because you don’t know when pain is
going to come, and so there is often a sense of uncertainty when you do things
or try to plan activities.

• It is difficult to keep working at a regular job (because of the good days and bad days).

• Increased sense of despair and a loss of confidence.

• Reduced sense of achievement.

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Fear Avoidance
Those who submit to their pain will often fear their pain, often believing that their pain is a
signal of new tissue damage. People who “surrender” to the pain stop activity, instead of doing
things they used to do.

Do you have a fear of:

Pain Having sex

The seriousness of the cause of pain The garden turning into a jungle
Not knowing Not playing sport
Not being believed Cracking noise from the spine
Not being compensated Nervous breakdown
Needing help Getting old
Certain movements; any movement Looking bad; becoming overweight
Re-injuring or making it worse Ending up in a wheelchair
Slowing the healing Driving; not being able to drive
Not being able to work What others think; losing friends
Having no income, or money Getting divorced; staying single
Not playing with the kids Therapy; needles; surgery
Not keeping the house clean

All of the fears above are common in people with chronic pain, so you may recognise some of
them. All sorts of fears can lead to a cycle of pain which can be difficult to break free from.

Some of the information that you receive from health professionals, friends, family and the media
may contribute to your fears. To face these fears, you need to be informed and understand as much
as possible about your body. And you will need to be brave – to travel on the road of recovery.

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Healthy coping Versus Unhealthy coping

There is a difference between healthy and unhealthy coping skills. People who use ‘healthy skills’
to cope with their pain, tend to manage their pain well in the long-term. In contrast, people who
use the unhealthy skills end up being worse off long-term. When you rely on using unhealthy
coping skills too much, it can lead you to feel trapped in your pain.

Healthy coping skills Unhealthy coping skills

Learning about the problem Avoiding activity

Exploring ways to move Doing nothing

Exploring and nudging the edges of pain Waiting for something to happen

Staying positive Remain pessimistic

Making plans Believing someone else has the answer

The Map of Fear Avoidance County (below) shows you how unhelpful coping skills lead you to a
pathway resulting in feeling trapped in your pain.

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2. Re-cap

Let’s remind ourselves of what we have covered in the program so far:

 Pain is our body’s normal way of protecting the body and helps healing when bodily tissue
is damaged
 Chronic pain occurs when the pain system becomes hyper-receptive despite no new
tissue damage
 Thoughts and feelings can trigger the pain system
 Avoiding activity will have a negative effect on pain by reinforcing the pain cycle - by
reducing your physical function, adding to unhelpful thoughts and low mood

The Pain Cycle:

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When you are doing less, your body weakens; muscles become weaker and shorter, joints,
ligaments and tendons become stiffer, cartilage and bones become weaker, the cardiovascular
system does not work as well as it could and mental processes become sluggish – for example
concentration becomes difficult and co-ordination is also affected. So your overall ability to
manage daily activities decreases. Therefore, when you try doing the same task the next day, you
will experience more pain, so you do less as a result.

Other problems associated with this cycle

• Pain is usually worse after over-doing things therefore you need a much longer
rest before you bounce back again
• Pain controls how much you can do not you
• It’s often hard to foresee what lies ahead because you don’t know when pain is
going to hit you and so you always have a sense of uncertainty when you do things
• Cannot keep working at a regular job (good days and bad days)
• Increase sense of despair and lose confidence

• No sense of achievement

•
3. Pacing your Activity

Pacing is all about breaking these patterns of activity and gradually increasing what you can
do.
Pacing is the best way to start an activity and increase your tolerance to it.

How to get started:

1. Choose an activity- this can be anything you wish to improve your tolerance to, for
example, reading, cooking, walking.

2. Find your activity baseline – take at least two days, and find out how much you can do
on these days - (make sure you choose at least one good day and one bad day so your
baseline is realistic).
Note: the more days you average out, the better. Take the average of these days and
then calculate 80%.

3. Example: Sitting.

As you can see in the table below, this person kept a record of her ‘sitting times’ on three
days. On Day 1, she sat 20 minutes before experiencing too much pain. On Day 2, she
could sit for 15 minutes until she experienced pain. On day 3, she could sit for 22
minutes. You can see how she had at least one ‘good day’ (i.e. The day she sat 22
minutes) and one ‘bad’ day (i.e. The day she sat for 15 minutes).

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 Once she had those ratings for the 3 days, she calculated the daily average (adding the
total of three days together and then dividing by the number of days). Finally, she
calculated 80% of that average (0.8 x 19 minutes) which ended up being 15 minutes.

Day 1 Day 2 Day 3 Average Baseline Your baseline is

(Average – 20%) 15 mins.
20 15 22 19 x .80 = 15.2 This is where you
mins mins mins =15 mins should start your
=19 mins pacing and build
up your sitting
tolerance.

4. Progress gradually – increase your activity by small amounts so that you can tolerate the
level on a good and bad day.

5. Stick to the plan regardless of how you are feeling.

6. Tried your best but still ‘flare up’ – i.e. have a painful day. This is because your alarm
system has become very sensitive over the years as a result of your condition; therefore,
it is not easy to completely avoid flare ups. If you do flare up, do not blame yourself and
stress out. Flare up is just your nervous system trying to over protect you. When you flare
up, it can be tempting to give up and forget what you have learned about pain. Be
persistent!
7. Plan your lifestyle- in the very beginning you will need to do more planning in your
everyday life. Try to start with happy activities that will interest you or do an activity
with someone you like or even just try to do it with your favourite music can be good.
When you have built up your confidence, you can then start to challenge yourself with
more difficult activities. It may all sound very simple, however, if you have had pain for a
long time you know it is not that easy. Your whole nervous system has changed while
you have had pain for all these years. However, if you stick to these principles, you will
gradually get there.

Additional hints in pacing:

 Start with easier tasks first. Get the hang of using pacing for easier tasks before you
tackle harder tasks. Do not rush, be patient, one step at a time.

 For any tasks that you must get done no matter what, still try to pace yourself. Take
frequent short breaks in between.

 Keep changing positions. Don’t stay in a single position for too long. MOVE!

 Get other people to help you, if necessary.

 Stick to your target and plan. Do not let pain dictate how much you are going to do. If
you have a “bad day”, still try to keep going according to your plan but have more rests
in between. If you have a good day, don’t overdo it; just stick to your plan.
 If you are unable to do the calculations above, don’t worry. Either ask for help, or keep a
record of what you can do for a few days, then to get your baseline, take a few minutes
off what you can do on a ‘good’ day.
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 Sometimes, people find it helpful to choose activities that they would like to improve and
workout a pacing program.

To help you Pace and Plan exercise, work out your own pacing program:

ACTIVITY GOOD DAY BAD DAY BASELINE INCREMENTS

4. Activity Scheduling

To help pace your activity, it’s important to start thinking about your daily activity schedule.
As Paul says in the lesson, when you pace and schedule your daily activity, you gain control over
what you do in the day rather than the pain controlling you. Planning (and doing) activities that
give you a sense of pleasure and achievement are a very important skill in managing your pain.
We know that when people experience chronic pain, they often stop doing the things that are
important to them, because the pain is high, or because they are afraid of the pain itself. This can
make them feel depressed, isolated, overwhelmed, and can lower their self-esteem. One way to
overcome this gradually, and to feel better about yourself, is to use Activity Planning.
We have included some useful tips below. Get started straight away – you will notice your mood
improves slowly over time. Remember to pace!

Pleasurable activities
Engaging in activities that you gain pleasure from and enjoy can help boost your mood and
manage your pain. Often when you are feeling down or in pain it is hard to come up with ideas of
enjoyable activities. It is helpful to prepare a list of activities you have enjoyed in the past. There
are some examples listed below but make sure you add your own:

Watch a funny movie Do a crossword Listen to some music

Cook a new recipe Look through some old photos Go to the beach
Talk on the phone Sit in the sun Go for a walk
Have a bath Read a new magazine Gardening
Write a story Sing Surf the net
Play computer games Visit a friend Go for a swim

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What are the activities you enjoy doing? Write down at least 5 pleasurable activities

1. painting

2. metal art

3. cooking

4. relaxing in pool

5. theartre

6. wathing videos

7.

Achievement activities
Engaging in activities that give you a sense of achievement help to boost your mood and
improve your self-esteem. Sometimes these activities may seem small, like getting out of bed
before 9am, but when you add them all together they help to give purpose and meaning to your
life. Sometimes you have to engage in these activities even if at first you don’t really feel like it.
Remember though, the long-term benefits will definitely be worth it. Often when you are
feeling down or in pain it is hard to come up with ideas of activities that give you a sense of
satisfaction or achievement. It is helpful to prepare a list of these activities. There are some
examples listed below but make sure you add your own. Everyone is different and it is
important to create the best plan for you.

Do a household chore Pay bills

Make an appointment Clear out the shed/garage/shelf
Mow the lawn Tidy a room
Complete an errand Help someone out
Do the ironing Fix something
Write a letter/email Make a time to catch-up with friends
Do some weeding/gardening Go to work
Finish an outstanding job Exercise
Cook a meal Make a box for unused items for charity
Complete a special project Finish a book

What are the activities that give you a sense of achievement? Write down at least 5
achievement activities:

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 1. compleate special project

2. enter comp

3. tidy area

4. finish art

5. submit assignment

6.

7.

For tips on Daily Activity Scheduling, please visit the Daily Activity Scheduling Worksheet in the
Extra Resources section.

If doing the blank worksheets at the end of the lesson summaries or in the extra resources don’t
work for you, use your calendar, diary, post-it notes, or phone to keep track of your activities
instead.
Remember: Doing something is always better than do nothing

5. Components of an Exercise Program

Exercise and the pain cycle

Often people with chronic pain will rest, or reduce their activity, thinking this will help in
relieving or getting rid of their pain. Although this approach may work for reducing acute pain,
unfortunately it does not work for chronic pain. We know that reduced activity will result in
reduced strength, stability, flexibility and fitness. This will all lead to a loss of physical function
and capability to perform activities. The more you rest, the harder it becomes to be active, and
even the simplest task becomes an effort.

How do you feel when you can’t do the things you would like to do on a daily basis?

Lack of activity and physical function will often lead to feelings of inadequacy, depression and
stress, particularly if you cannot work or socialise with friends. Unhelpful thoughts and moods
will in turn trigger the pain cycle.

REST → DECONDITIONING → POOR POSTURE AND BODY BIO-MECHANICS → PAIN FEELINGS O

INADEQUACY AND STRESS.

EXERCISE→ CONDITIONING → GOOD POSTURE AND BODY BIO-MECHANICS → LESS PAIN POS
FEELINGS

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 Components of an exercise program
An exercise program should cover the following components:

1. Cardiovascular fitness, e.g. walking, swimming.

2. Strengthening exercises, e.g. using body weight or resistance
3. devices. Stability exercises, also called core exercises.
4. Stretching exercises.

Exercise diary
An exercise diary is an excellent way to keep a record of what exercise you are doing and the
improvements you are making. An example of an exercise diary can be found at the end of this
summary. You can print this off and use it, or make up another version that suits you.

Other benefits of exercise

 Maintains muscle strength.

 Maintains core stability.
 Increases flexibility.
 Prevents cardiovascular disease.
 Helps in control of chronic disease, such as diabetes, high blood pressure, and
cholesterol.
 Helps to reduce the risk of disease, such as stroke, and colon cancer.
 Promotes joint health - helps in the nourishments and flow of synovial fluid during
movement .
 Helps to improve and maintain bone density.
 Helps to reach and maintain a healthy weight.
 Releases endorphins or “happy hormones”.
 Improves the quality of sleep.
 Promotes brain cell development, improving cognition and memory.
 Reduces depression and anxiety.

The most important thing to remember is to keep moving and to choose something that

is FUN!

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 *REMEMBER TO VISIT THE ‘MOVEMENT SECTION’ WHICH INCORPORATES DIFFERENT
EXERCISES. MOVEMENT IS KEY TO REGAINING CONTROL OVER YOUR PAIN.

6. Summary
The main points from this summary are:

1. Identify which activity pattern you follow – boom-bust or surrender?

Becoming aware of your relationship to activity and pain is the first step to
changing it.

2. It is essential to learn to monitor and plan your activity.

3. To help you to do this, print and fill out the Activity Scheduling example (on the next
page) and visit the Activity Scheduling Worksheet in the resources section for tips
and complete your own.
4. Pacing up your activity is the best way to increase your activity
tolerance.
This takes some planning and practice. Choose an activity that is important
to you and set out a pacing plan to follow.
5. An exercise program should have four components but most
importantly be fun!
Make sure you are moving throughout this program, and keep a track of the exercises
you are doing and the improvements you are making. Print out the exercise diary
below.

Don’t forget to check out the movement section for some exercise ideas and the
relaxation section!

Make sure that you come back soon and re-read Lesson 3 (and this Summary) soon.

Good luck!

The Team from This Way Up.

www.thiswayup.org.au

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Daily Activity Scheduling
Example of scoring pleasurable and achievement activities –
Make sure you visit the Daily Activity Scheduling in extra Resources to create your own:

Monday

Time Planned Activity Actual Activity P-score A-score

7am Get up. Do Tai Chi Rested in bed 0 0
Breakfast
8am Shower and get dressed Rested in bed 0 0
9am Read notes and do Got up. Breakfast 1 1
homework from online
course
10am Rest Watched TV 2 0
11am Household chores Showered 1 1
12pm Rest Walked 10 minutes to shops 3 3
1pm Have lunch As planned 5 5
2pm Go for a walk with neighbour Rested 1 1
3pm Rest Watched TV 2 0
4pm Call friends As planned 6 6
5pm Prepare and cook dinner As planned 3 5
6pm Have dinner with husband As planned 7 4
Tidy up As planned 1 6
7pm Rest and watch TV As planned 5 2
8pm Watch TV As planned 4 2
Relaxation Watched TV 2 1
9pm Read in lounge Watched TV 2 0
10pm Bedtime routine Watched TV 2 0
Sleep Fell asleep on lounge at 0 0
12.30am

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Exercise Diary
Activity
Week 1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Week 2
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Week 3
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Week 4
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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