Pacing in Chronic Pain: The Non-Avoidant Pacing Scale and the Role of Pain Intensity

Abstract

The overarching aim of this thesis was to better understand the measurement and role of pacing in chronic pain management. Pacing aims to improve functioning in chronic pain by redressing pain-contingent and pain-avoidant activity patterns. However, despite being widely recommended and utilised, pacing has been associated with higher levels of pain and disability. These findings may be the result of inadequate measurement of pacing due to overlap with avoidance. Given the cross-sectional nature of these studies, findings may also reflect individuals being more inclined to engage in pacing when pain or impairment is higher. Finally, there may be differential effects of pacing dependent on pain intensity. A systematic review and meta-analysis of the correlations between existing measures of pacing and avoidance revealed a positive correlation across 16 studies. The Non-Avoidant Pacing Scale (NAPS) was developed to differentiate pacing from avoidance by emphasising key pacing behaviours and responses to flare ups that are not contingent on or avoidant of pain. Exploratory and confirmatory factor analyses in a sample of 283 adults with chronic pain revealed an eight-item scale with good internal consistency. Further validation in a sample of 173 treatment-seeking adults with chronic pain replicated the initial structure and internal consistency. Unlike existing measures, the NAPS was not correlated with poorer functioning, and shared some correlations with better physical and psychological functioning. Baseline pacing, as measured by the NAPS, was correlated with better physical and psychological functioning at three-month follow-up in a sample of 203 adults with chronic pain. Moderated regression analyses revealed significant conditional effects such that pacing predicted less interference, psychological distress, and catastrophising, and more self-efficacy at moderate or high pain intensity. Increases in pacing, as measured by the NAPS, were also correlated with improvements in physical and psychological functioning in a different sample of 97 adults completing a multidisciplinary pain management program. Moderated regression analyses revealed significant conditional effects such that pacing predicted less interference and psychological distress at moderate or high pain intensity. A combination of measurement error, cross-sectional phenomena, and the fact that pacing is not necessarily universally beneficial appear to be likely contributing factors in associations between earlier measures of pacing and poorer outcomes in chronic pain. These findings highlight a number of theoretical and clinical implications that warrant consideration in evaluating existing research on pacing, the measurement of pacing, and its use in chronic pain management.