Journal-based CME article
Activity Pacing, Avoidance, Endurance, and Associations With Patient Functioning in Chronic Pain: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.apmr.2012.05.029Get rights and content

Abstract

Andrews NE, Strong J, Meredith PJ. Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis.

Objective

To systematically review the associations between different approaches to activity (ie, activity pacing, avoidance, or endurance) and indicators of patient functioning in chronic pain samples.

Data Sources

A key word search was conducted in PsycINFO, MEDLINE via Ovid, EMBASE, and PubMed up to March 2011.

Study Selection

To be included, studies had to (1) be written in English, (2) report on an adult chronic pain sample, and (3) report a correlation coefficient between at least 1 measure of 1 of the 3 “approach to activity” variables and an indicator of patient functioning.

Data Extraction

Two reviewers independently screened abstracts and full-text articles for eligibility and extracted the data. Results of correlation analyses were grouped on the basis of measure of approach to activity (pacing/avoidance/endurance) and the criterion variable measured (pain/physical functioning/psychological functioning), resulting in 9 categories. Random-effects modeling was then used to pool data across studies in each category.

Data Synthesis

Forty-one studies were eligible for inclusion. Results demonstrated that avoidance of activity was consistently associated with more pain, poorer psychological functioning, and more physical disability. While enduring with activity was associated with enhanced physical and psychological functioning, these relationships appeared to be dependent on the measure used, with measures more reflective of persisting with activities to the point of severe pain aggravation (overactivity) linked to poorer outcomes. Pacing was generally linked to better psychological functioning but more pain and disability.

Conclusions

Although causation cannot be determined, results of this study suggest that both avoidance of activity and overactivity are associated with poorer patient outcomes. Unexpected results relating to pacing may reflect either the ineffectiveness of pacing if not used to gradually increase an individual's activity level or the notion that individuals with better psychological functioning but more pain and disability are more inclined to pace activity.

Section snippets

Statement of Need

The way in which an individual with chronic pain habitually approaches activity engagement has long been thought to have an impact on his/her daily functioning. The premise that both avoidance of one's daily activities and overactivity (activity engagement that significantly exacerbates pain) are linked to functional decline is widely documented, with activity pacing thought to be a positive pain coping strategy.

However, evidence presented in previously published literature reviews highlights

Accreditation Statement

This journal-based activity has been planned and developed in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of Professional Education Services Group (PESG).

PESG is accredited by the ACCME to provide continuing medical education (CME) for physicians.

Credit Designation Statement

PESG designates this Journal-based CME activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

All other health care professionals completing continuing education credit for this activity will be issued a certificate of participation.

Educational Objectives

To support the attainment of knowledge, competence, and performance, the learner should be able to achieve the following objectives:

  • 1

    Describe the available evidence for a direct link between avoidance of activity and patient functioning in chronic pain.

  • 2

    Discuss the evidence of both positive and inverse associations between measures of endurance and patient functioning in chronic pain.

  • 3

    Discuss possible explanations for links between pacing and patient functioning in chronic pain.

Planning Committee

Nicole E. Andrews, BOccThy Hon 1; Jenny Strong, PhD; Pamela J. Meredith, PhD; Leighton Chan, MD, MPH; PESG staff.

Faculty Profiles & Disclosure Information

As a sponsor accredited by the ACCME, it is the policy of PESG to require the disclosure of anyone who is in a position to control the content of an educational activity. All relevant financial relationships with any commercial interests and/or manufacturers must be disclosed to participants at the beginning of each activity. The faculty of this educational activity disclose the following:

Nicole E. Andrews, BOccThy Hon 1

The University of Queensland, School of Health and Rehabilitation Sciences, Queensland, Australia

No financial conflicts to disclose.

Jenny Strong, PhD

The University of Queensland, School of Health and Rehabilitation Sciences, Queensland, Australia

No financial conflicts to disclose.

Pamela J. Meredith, PhD

The University of Queensland, School of Health and Rehabilitation Sciences, Queensland, Australia

No financial conflicts to disclose.

Leighton Chan, MD, MPH

Deputy Editor, Archives of Physical Medicine and Rehabilitation, Bethesda, MD

No financial conflicts to disclose.

PESG Staff

No financial conflicts to disclose.

Resolution of Conflict of Interest

PESG has implemented a process to resolve conflict of interest for each CME activity. In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, PESG has resolved the conflict by external content review.

Unapproved/Off-Label Use Disclosure

PESG requires CME faculty to disclose to the participants:

  • 1

    When products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not US Food and Drug Administration [FDA] approved); and

  • 2

    Any limitations on the information presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. Faculty may discuss information about pharmaceutical agents that is outside of FDA-approved labeling. This

Intended Audience

This program is intended for physicians and healthcare professionals responsible for the comprehensive care for individuals with chronic illness and disabilities.

Method of Participation

In order to claim credit, participants must complete the following:

  • 1

    Pre-activity self-assessment questions

  • 2

    Read the activity

  • 3

    Complete the CME Test and Evaluation. Participants must achieve a score of 70% on the CME Test.

Participants can complete the pre-activity self-assessment and CME Test and Evaluation online by logging on to http://acrm.cds.pesgce.com. Upon successful completion of the online tests and evaluation form, you can instantly download and print your certificate of credit.

To better

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For all CME certificate inquiries, please contact us at [email protected].

This continuing education activity is active starting November 1, 2012 and will expire October 31, 2013.

Estimated Time to Complete This Activity: 2.0 hours

Inclusion Criteria

To be included in this review, studies had to (1) be written in English, (2) report on a participant group of adults (>18y) with chronic pain (>3mo), (3) include at least 1 measure of 1 of the 3 approaches to activity (endurance, pacing, or avoidance) that measured patient behavior (not purely cognitions), (4) include at least 1 criterion measure of patient functioning (pain intensity, physical disability, or psychological functioning), and (5) report correlation coefficients (Pearson's r or

Study Selection

The process of study selection is presented in figure 1. Of the 1441 records identified through searches, 832 duplicate records were identified and removed. The remaining 609 abstracts were screened for eligibility. It was evident from abstract screening that 237 records did not examine the relationship between an approach to activity and patient functioning. A further 112 records were publication types that were ineligible for random-effects modeling (eg, a literature review). A number of

Discussion

To our knowledge, this is the first study to conduct a systematic review and meta-analysis investigating the relationship between different approaches to activity and patient functioning in chronic pain. Based on theoretical work, it was hypothesized that (1) both avoidance and endurance would be linked to poorer functioning and more pain and (2) pacing would be associated with less pain and higher levels of patient functioning. The results of this study were, however, mixed in their

Conclusions

To the best of our knowledge, this study was the first systematic review and meta-analysis to examine associations between different approaches to activity and patient functioning in chronic pain. Results provide support for associations between avoidance of activity and poorer outcomes including increased pain, poorer psychological functioning, and more disability. The relationship between endurance and functioning appeared to be dependent on the measure used. While persisting with activity in

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  • Cited by (0)

    In-press corrected proof published online on Aug 17, 2012, at www.archives-pmr.org.

    Supported by a Royal Brisbane and Women's Hospital Foundation Scholarship and the Cramond Fellowship in Occupational Therapy and Pain Management at the Royal Brisbane and Women's Hospital.

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

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