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Activity Pattern Profiles: Relationship With Affect, Daily Functioning, Impairment, and Variables Related to Life Goals

Open AccessPublished:January 04, 2017DOI:https://doi.org/10.1016/j.jpain.2016.12.013

      Highlights

      • Four subgroups of patients can be distinguished according to their activity patterns.
      • The subgroups were: doers, avoiders, medium cyclers, and extreme cyclers.
      • Doers had higher optimism, positive affect, functioning, and less impairment.
      • Doers had the highest goal balance.
      • Medium cyclers had the highest conflict between pain and nonpain-related goals.

      Abstract

      The aim of this cross-sectional study was to identify subgroups of patients on the basis of their activity patterns and to investigate their relationship with life goals, optimism, affect, and functioning. The sample was comprised of 276 patients with chronic musculoskeletal pain. Hierarchical cluster analysis was performed on the activity pattern variables and the resulting clusters were compared using 1-way analysis of variance. The 4-cluster was the optimal solution. The 4 clusters comprised: 1) avoiders: patients with high levels of avoidance and low levels of persistence, who use pacing to reduce pain, 2) doers: patients with high levels of persistence and low levels of pacing and avoidance, 3) extreme cyclers: patients with high levels of avoidance and persistence and low levels of pacing, and 4) medium cyclers: patients with moderately high levels of avoidance and persistence and high levels of pacing. Comparison of the clusters showed that doers had the most adaptive profile, whereas avoiders, followed by extreme cyclers, had unhealthy profiles. Doers showed a high level of optimism and a good balance between goal value, expectancy, and conflict.

      Perspective

      It is useful to distinguish profiles on the basis of various activity patterns. In contrast to profiles characterized by avoidance, profiles characterized by high persistence and low avoidance were associated with adaptive results. Patients with this profile also showed a high level of optimism and a good balance between goal value, expectancy, and conflict.

      Key words

      Chronic pain interferes with daily activities and goals and changes the way in which patients engage in such activities. The activity patterns of patients play a crucial role in their well-being. Traditionally, 3 activity patterns have been distinguished: avoidance, persistence, and pacing. Avoidance has been defined as the reduction in physical or other daily activities with the aim of minimizing pain increases
      (eg, “Because of my pain most days I spend more time resting than doing activities.”). The persistence pattern involves continuing with activities despite pain
      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice.
      (eg, “When I am in pain I just keep on doing what I was doing.”). Pacing is characterized by dividing daily activities into smaller tasks
      • Gill J.R.
      • Brown C.A.
      A structured review of the evidence for pacing as a chronic pain intervention.
      (eg, “I usually take several breaks.”). A meta-analysis
      • Andrews N.E.
      • Strong J.
      • Meredith P.J.
      Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: A systematic review and meta-analysis.
      of the relationship between different approaches to activity and functioning in chronic pain patients reported that activity avoidance was linked to worse physical and psychological functioning and increased pain. The results concerning the association between persistence and functioning depended on the measure used: instruments that assessed overactivity were associated with poorer outcomes, whereas instruments that assessed persisting with activity despite pain were associated with positive outcomes. Finally, pacing was associated with better psychological functioning and higher levels of pain and disability.
      Recently, Kindermans et al
      • Kindermans H.P.
      • Roelofs J.
      • Goossens M.E.
      • Huijnen I.P.
      • Verbunt J.A.
      • Vlaeyen J.W.
      Activity patterns in chronic pain: Underlying dimensions and associations with disability and depressed mood.
      identified more specific patterns: pain avoidance (avoidance behavior in the presence or anticipation of changes in pain); activity avoidance (avoidance refers to the patients' condition of being in pain rather than the fluctuating pain experience); task-contingent persistence (behavioral persistence in finishing tasks or activities despite pain); excessive persistence (doing too much, not respecting one's physical limits, and experiencing the rebound effects of heightened activity levels); pain-contingent persistence (the level of experienced pain as the determinant of the behavior performed with activity fluctuating over time as a result); and pacing (dividing daily activities into smaller tasks).
      Nielson et al
      • Nielson W.R.
      • Jensen M.P.
      • Karsdorp P.A.
      • Vlaeyen J.W.
      Activity pacing in chronic pain: Concepts, evidence, and future directions.
      • Nielson W.R.
      • Jensen M.P.
      • Karsdorp P.A.
      • Vlaeyen J.W.
      A content analysis of activity pacing in chronic pain: What are we measuring and why?.
      proposed that pacing measures should be developed that address a specific pacing behavior with a single goal. They identified the following pacing behaviors: breaking tasks into smaller, manageable tasks; taking frequent short rests; and slowing down. They proposed the following as the main aims of pacing: increasing activity levels, energy conservation for valued activities, and pain reduction. The recently developed Activity Patterns Scale (APS)
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      incorporates the specific activity patterns reported by Kindermans et al
      • Kindermans H.P.
      • Roelofs J.
      • Goossens M.E.
      • Huijnen I.P.
      • Verbunt J.A.
      • Vlaeyen J.W.
      Activity patterns in chronic pain: Underlying dimensions and associations with disability and depressed mood.
      and the aforementioned suggestion by Nielson et al
      • Nielson W.R.
      • Jensen M.P.
      • Karsdorp P.A.
      • Vlaeyen J.W.
      Activity pacing in chronic pain: Concepts, evidence, and future directions.
      • Nielson W.R.
      • Jensen M.P.
      • Karsdorp P.A.
      • Vlaeyen J.W.
      A content analysis of activity pacing in chronic pain: What are we measuring and why?.
      on the assessment of pacing.
      Activity patterns are interrelated and patients do not exclusively report one activity pattern. Cluster analysis has been used to identify 4 homogeneous patient subgroups (avoiders, medium cyclers, extreme cyclers, and doers) on the basis of their scores on different activity pattern subscales.
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      Avoiders were characterized by moderately high avoidance and pacing and low confronting. Both cyclers subgroups were characterized by high confronting; extreme cyclers also showed high levels of pacing and avoidance and for the medium cyclers, the levels of pacing and avoidance were more moderate. The doers showed high levels of activity despite pain and low levels of pacing and avoidance.
      Within the framework of fear-avoidance models,
      • Vlaeyen J.W.
      • Linton S.J.
      Fear-avoidance and its consequences in chronic musculoskeletal pain: State of the art.
      an avoidant behavioral style provoked by excessive fear of pain, movement, and reinjury plays a central role in pain chronification. Nevertheless, as the avoidance-endurance model has highlighted,
      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice.
      not all chronic pain patients display this pattern. Some patients even show an opposite behavioral pattern; namely, persistence of activity despite pain. A recent review
      • Van Damme S.
      • Kindermans H.
      A self-regulation perspective on avoidance and persistence behavior in chronic pain: New theories, new challenges?.
      highlighted the importance of studying the motivational mechanisms underlying activity patterns to explain why individuals engage in avoidant or persistent behaviors. From a motivational perspective, activity patterns are conceived not solely as a product of pain, but as a product of the self-regulation of current goals in the context of pain.
      • Van Damme S.
      • Kindermans H.
      A self-regulation perspective on avoidance and persistence behavior in chronic pain: New theories, new challenges?.
      Goal conflict results when 2 goals compete for the same resources, particularly time and energy. Chronic pain interferes with daily activities and goals and consequently patients may need to negotiate competition between their goals for limited physical and cognitive resources. Several experimental studies have shown that the activation of competing goals attenuates pain avoidance behavior
      • Claes N.
      • Crombez G.
      • Vlaeyen J.W.
      Pain-avoidance versus reward-seeking: An experimental investigation.
      • Claes N.
      • Karos K.
      • Meulders A.
      • Crombez G.
      • Vlaeyen J.W.
      Competing goals attenuate avoidance behavior in the context of pain.
      • Van Damme S.
      • Van Ryckeghem D.M.
      • Wyffels F.
      • Van Hulle L.
      • Crombez G.
      No pain no gain? Pursuing a competing goal inhibits avoidance behavior.
      and nonpain goal pursuit inhibits attention to pain.
      • Schrooten M.G.
      • Van Damme S.
      • Crombez G.
      • Peters M.L.
      • Vogt J.
      • Vlaeyen J.W.
      Nonpain goal pursuit inhibits attentional bias to pain.
      However, cross-sectional studies have suggested that distress results from goal conflict on the basis of the findings that goal conflict correlated with worse affect, less life satisfaction, poor self-rated physical health, higher pain ratings,
      • Emmons R.A.
      Personal strivings: An approach to personality and subjective well-being.
      • Emmons R.A.
      • King L.A.
      Conflict among personal strivings: Immediate and long-term implications for psychological and physical well-being.
      • Hardy J.K.
      • Crofford L.J.
      • Segerstrom S.C.
      Goal conflict, distress, and pain in women with fibromyalgia: A daily diary study.
      • Karoly P.
      • Ruehlman L.S.
      Motivation implications of pain: Chronicity, psychological distress, and work goal construal in a national sample of adults.
      • Riediger M.
      • Freund A.M.
      Interference and facilitation among personal goals: Differential associations with subjective well-being and persistent goal pursuit.
      and more pain-related fear.
      • Karoly P.
      • Okun M.A.
      • Ruehlman L.S.
      • Pugliese J.A.
      The impact of goal cognition and pain severity on disability and depression in adults with chronic pain: An examination of direct effects and mediated effects via pain-induced fear.
      However, the finding that goal conflict has detrimental effects on well-being has not always been replicated, which suggests that contextual or situational factors may play a role.
      • Gorges J.
      • Esdar W.
      • Wild E.
      Linking goal self-concordance and affective reactions to goal conflict.
      Optimism is one such factor,
      • Affleck G.
      • Tennen H.
      • Zautra A.
      • Urrows S.
      • Abeles M.
      • Karoly P.
      Women’s pursuit of personal goals in daily life with fibromyalgia: A value-expectancy analysis.
      as well as self-efficacy, which has been considered to be a critical appraisal directing the choice to actively pursue a goal.
      • Arends R.Y.
      • Bode C.
      • Taal E.
      • Van de Laar M.A.
      The role of goal management for successful adaptation to arthritis.
      • Karoly P.
      • Lecci L.
      Motivational correlates of self-reported persistent pain in young adults.
      • Karoly P.
      • Okun M.A.
      • Ruehlman L.S.
      • Pugliese J.A.
      The impact of goal cognition and pain severity on disability and depression in adults with chronic pain: An examination of direct effects and mediated effects via pain-induced fear.
      • Karoly P.
      • Ruehlman L.S.
      Motivation implications of pain: Chronicity, psychological distress, and work goal construal in a national sample of adults.
      • Knittle K.P.
      • De Gucht V.
      • Hurkmans E.J.
      • Vlieland T.P.
      • Peeters A.J.
      • Ronday H.K.
      • Maes S.
      Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis.
      It has been shown that although optimistic persistence in goal pursuit was linked to higher goal conflict, such conflict did not undermine adjustment, because optimists were more efficient at balancing the benefits and costs of their conflicting goals.
      • Segerstrom S.C.
      • Solberg Nes L.
      When goals conflict but people prosper: The case of dispositional optimism.
      The aim of this study was to identify the profiles of patients on the basis of their scores on the different activity pattern subscales that comprise the APS,
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      and to compare the resulting subgroups in relation to affect, daily functioning, impairment, and variables related to life goals. The present study constitutes a relevant contribution because it attempts to replicate previous findings on activity pattern subgroups,
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      while including new and innovative dimensions of the pacing, persistence, and avoidance constructs measured using the APS. To our knowledge, it is also the first study to investigate the relationship between activity patterns and motivational mechanisms. On the basis of previous research,
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      it was postulated that 4 subtypes would be identified: extreme cyclers, medium cyclers, avoiders, and doers. It was also postulated the doers would report better daily functioning and positive affect and less functional impairment and negative affect than avoiders and extreme cyclers. Regarding goal-related variables, it was postulated that doers would be more optimistic and more efficient at balancing the benefits and costs of their conflicting goals, despite experiencing more conflict between their most valued pain-related goal and their most valued nonpain-related goal.

      Methods

       Procedure

      This study was part of a larger research project,
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      which was approved by the University of Málaga Ethics Committee. Participants were recruited through 2 local associations of patients with fibromyalgia, an association of patients with rheumatic diseases, 1 physiotherapy unit, and through doctors working at the Pain Unit of the Hospital Costa del Sol. The data were collected between January 2015 and February 2016. Individuals were considered eligible for inclusion if they met the following criteria: at the moment of participation in the study they were experiencing pain and had been experiencing pain for at least the past 6 months; they were between 18 and 65 years old; they were not being treated for a malignancy, terminal illness, or psychiatric disorder; they were able to understand the Spanish language (spoken and written); and they were able to understand the instructions and questionnaires. Patients were informed of the study aims, confidentiality was assured, and informed consent was obtained. Each participant had a semistructured interview with a psychologist to obtain demographic, social, and medical history data; their current goals and subjective goal conflict were elicited using a method developed by Emmons
      • Emmons R.A.
      Personal strivings: An approach to personality and subjective well-being.
      (for details, see the section, Goals and goal value). Subsequently, they completed self-report questionnaires in the order described in the Self-Report Instruments section.
      Three psychologists took part in data collection. They were trained in the application of the protocol to guarantee the standardization of the assessment process and were blinded to the study design and hypotheses. The patients were always assessed in their usual health center or in the facilities of the associations. Each session lasted approximately 1 hour.

       Participants

      Three hundred eighty-five patients were invited to take part in the study. Of these patients, 82 refused participation, 17 did not meet the inclusion criteria, and 10 were eliminated because of incomplete data.
      The final sample comprised 276 chronic pain patients (196 women and 80 men). The average age was 52 years (SD = 8.83). At the time of the study, 71.30% were married or cohabiting. Regarding employment, 35.10% were active workers, 26.80% were retired, 22.10% were unemployed, and 15.9% were homemakers.
      A total of 34.40% had completed high school education and 40.70% had completed primary education. Median pain duration was 12.49 years (SD = 11.05). The participants had musculoskeletal pain at different locations: The most frequent site of pain was the lower back (49.3%), followed by generalized pain conditions such as fibromyalgia (23.2%), pain in the upper shoulder and upper limbs (15.6%), pain in the lower limbs (11.6%), and pain in other areas (.30%).

       Variables and Instruments

       Goal Assessment

       Goals and goal value

      Current goals were elicited using a method developed by Emmons.
      • Emmons R.A.
      Personal strivings: An approach to personality and subjective well-being.
      Participants were asked to list their current goals (ie, objectives that they are trying to accomplish at the time), and were given examples of approach and avoidance goals. They were asked to list goals on the basis of what they were trying to do rather than whether they had been successful and “to list as many or as few” as they were currently trying to or attain or avoid.
      Thus, every participant produced a single list of goals and then rated each one on a 5-point Likert-type scale for 4 dimensions of goal value
      • Emmons R.A.
      Personal strivings: An approach to personality and subjective well-being.
      : commitment (“How committed are you to this goal?”), importance (“How important is this goal to you in your life?”), anticipated joy (“How much joy or happiness do you or will you feel when you are successful in this goal?”), and anticipated sorrow (“How much sorrow or unhappiness do you or will you feel if you fail to succeed in this goal?”). The value of each goal was represented by the sum of the scores on commitment, importance, anticipated joy, and anticipated sorrow. In the present study, the internal consistency of the measurement of goal value ranged from α = .75 to α = .80. As shown below, to be able to calculate the variable “balance between goal expectancy, anticipated joy, and conflict,” a question was included to assess expectancy (“How confident are you that you will be able to accomplish this goal?”).
      • Segerstrom S.C.
      • Solberg Nes L.
      When goals conflict but people prosper: The case of dispositional optimism.
      Because these variables were negatively skewed, analyses (except descriptive statistics) were performed on squared-transformed variables to reduce the influence of more extreme cases.
      Two independent judges analyzed the answers and determined whether the goals were related or unrelated to pain. Interjudge reliability was very satisfactory (κ = .96). The following variables were considered: total number of goals, number of pain-related goals, number of nonpain-related goals, and goal value.

       Subjective conflict between the most valued pain-related goal and the most valued nonpain-related goal

      Subjective conflict was assessed using the Striving Instrumentality Matrix.
      • Emmons R.A.
      Personal strivings: An approach to personality and subjective well-being.
      The goals previously listed by the participants were placed in the rows and columns of a matrix. The participants were asked to compare each pair of goals and rate the degree of conflict between them on a 5-point scale where 0 = not at all, 1 = very little, 2 = somewhat, 3 = definitely, and 4 = extremely. Goal conflicts were defined as the degree to which 2 goals used the same resources, such as time, money, or energy, or the degree to which the pursuit of one goal interfered with the pursuit of another goal. Examples were given.
      Taking into account the aims of this study, goal conflict was operationalized as the conflict between the most valued pain-related goal and the most valued nonpain-related goal. Most patients reported at least 1 pain-related and 1 nonpain-related goal. When this was not the case their score on goal conflict was 0.

       Balance between goal expectancy, anticipated joy, and conflict

      The balance between expected joy on goal attainment, expectancy (the likelihood of attaining the goal), and conflict is a useful index of effective goal strategy management. The balance was calculated by adapting and applying the formula developed by Segerstrom and Solberg Nes
      • Segerstrom S.C.
      • Solberg Nes L.
      When goals conflict but people prosper: The case of dispositional optimism.
      :
      R=(λes)


      where: λ = attainment expectancy of the most valued nonpain-related goal, e = expected joy on attainment of the most valued nonpain-related goal, and s = subjective conflict between the most valued pain-related goal and the most valued nonpain-related goal.
      The higher the value of R, the greater the balance. Differences in scaling were solved by transforming these 3 variables to have an SD of 1 before calculating R.

       Self-Report Instruments

       Dispositional optimism

      Dispositional optimism was assessed using the Spanish version of the Life Orientation Test Revised (LOT-R).
      • Otero J.M.
      • Luengo A.
      • Romero E.
      • Gómez J.A.
      • Castro C.
      Personality Psychology: Practice book [in Spanish].
      • Scheier M.F.
      • Carver C.S.
      • Bridges M.W.
      Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test.
      The LOT-R consists of 6 scored items (items 1, 4, and 10 are positively worded and items 3, 7, and 9 are negatively worded) plus 4 filler items. Respondents indicate the extent to which they agree with each item on a 5-point Likert-type scale ranging from 0 (strongly disagree) to 4 (strongly agree). The total score of the LOT-R was used to reflect the general expectancy of a positive outcome, with higher scores representing higher levels of optimism. The optimism and pessimism subscale scores were calculated by summing the positive and negative items, respectively. In the present study, the LOT-R total score had a Cronbach α of .85. Cronbach α for the optimism and pessimism subscales were .85 and .70, respectively. The Spanish LOT-R has shown adequate criteria validity.
      • Ferrando P.J.
      • Chico-Librán E.
      • Tous J.M.
      Psychometric properties of the Life Orientation Test [in Spanish]..
      • Librán E.C.
      • Piera P.J.

       Positive and negative affect

      Positive and negative affect were assessed using the Spanish version of the Positive and Negative Affect Schedule,
      • Sandín B.
      • Chorot P.
      • Lostao L.
      • Joiner T.E.
      • Santed M.A.
      • Valiente R.M.
      The PANAS scales of positive and negative affect: Factor Analytic Validation and Cross-cultural Convergence [in Spanish].
      • Sandín B.
      • Valiente R.M.
      • Chorot P.
      Instruments for the assessment of psychosocial stress.
      • Watson D.
      • Clark L.A.
      • Tellegen A.
      Development and validation of brief measures of positive and negative affect: The PANAS scales.
      which is one of the most reliable, valid, and efficient means to measure these aspects. It is comprised of two 10-item scales. The instrument has shown appropriate stability over a 2-month time period. The Spanish Positive and Negative Affect Schedule also has excellent construct and criterion validity. In this study, the Positive Affect and Negative Affect scales had a Cronbach α of .92 and .89, respectively.

       Self-efficacy

      Self-efficacy was assessed using the Spanish adaptation of the General Self-Efficacy Scale.
      • Baessler J.
      • Schwarcer R.
      Self-Efficacy Assessment: Spanish Adaptation of the General Self-efficacy Scale [in Spanish].
      • Sanjuán-Suárez P.
      • Pérez- García A.M.
      • Bermúdez-Moreno J.
      The General Self-efficacy Scale: Psychometric data from the Spanish Adaptation [in Spanish].
      This instrument assesses people's stable beliefs about their ability to appropriately manage a wide range of life stressors. The instrument has shown adequate validity. In this study, the instrument showed high internal consistency (α = .97).

       Impairment and functioning

      Impairment and functioning were assessed using the Impairment and Inventory,
      • Ramírez-Maestre C.
      • Esteve R.
      A new version of the Impairment and Functioning Inventory for patients with chronic pain (IFI-R).
      which consists of 30 items each referring to a specific activity associated with 1 of the following areas: household (eg, make the beds), autonomous behavior (eg, dress by yourself), leisure (eg, go to a bar or cafe), and social relationships (eg, visit friends). Patients are asked if they performed an activity during the previous week (or during the previous month for certain activities). If they did not perform the activity, they are assigned a score of 0; if they did, they are asked how often they performed it, answering on a 4-point scale (1 = between 1 and 2 times, 2 = between 3 and 6 times, 3 = between 6 and 9 times, and 4 = 10 or more times). If they did not perform the activity, they are asked if they practiced this activity before the onset of their chronic pain. The instrument provides an index of daily functioning, and an index of activity impairment. The ‘daily functioning index’ is calculated by adding the frequencies at which every activity is performed. The ‘activity impairment index’ is calculated by adding the total number of activities that the patients have given up since pain began. This approach differentiates between present functioning and impairment and is useful in assessing patients with a long history of pain, concerning for whom the degree of deterioration is at least as informative as the current level of functioning.
      • Ramírez-Maestre C.
      • Esteve R.
      A new version of the Impairment and Functioning Inventory for patients with chronic pain (IFI-R).
      In this study, the global scales were highly reliable (daily functioning, α = .88; impairment, α = .97).

       Pain intensity

      Patients were asked to rate their mildest, average, and worst pain during the past 2 weeks, as well as their current pain, on a scale ranging from 0 to 10, with a “0” indicating “no pain” and “10” indicating pain as “intense as you could imagine.” A composite pain intensity score was calculated for each participant by calculating the average of the mildest, average, worst, and current pain.
      • Jensen M.P.
      • Turner P.
      • Romano J.M.
      • Fischer L.D.
      Comparative reliability and validity of chronic pain intensity measures.

       Activity patterns

      The APS
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      consists of 24 items grouped into 8 three-item subscales: pain avoidance (α = .78), activity avoidance (α = .77), task-contingent persistence (α = .87), excessive persistence (α = .80), pain-contingent persistence (α = .89), pacing to increase activity levels (α = .80), pacing to conserve energy for valued activities (α = .86), and pacing to reduce pain (α = .79). Participants are asked to indicate to what extent the statement applies to them on a 5-point scale ranging from 0 (not at all) to 4 (always). The instrument showed adequate reliability as well as structural, convergent, and criteria validity.
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.

       Statistical Analysis

      Correlation analyses were performed to examine the relationship between the activity pattern subscales and optimism, pessimism, optimism-total, positive affect, negative affect, self-efficacy, daily functioning, functional impairment, pain intensity, total number of goals, number of pain-related goals, number of nonpain-related goals, goal conflict, and goal balance. Correlations were interpreted following the guidelines proposed by Cohen,
      • Cohen J.W.
      Statistical Power Analysis for the Behavioral Sciences.
      wherein low correlations range from .10 to .29, moderate correlations range from .30 to .49, and high correlations range from .50 to 1.
      Hierarchical cluster analysis was performed on the activity pattern variables. The objective of cluster analysis is to profile individuals into specific groups that reveal patterns that show similarities and differences between groups. This analytic approach was chosen because the aim of this study was to identify homogeneous subtypes of patients by considering their scores on the different activity pattern subscales that comprise the APS. As suggested by previous research,
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      it was assumed that the activity patterns were inter-related and that patients would not exclusively report 1 activity pattern. The sample size recommended for cluster analysis must be at least 2 × m, where m equals the number of clustering variables
      • Dolnicar S.
      Using cluster analysis for market segmentation – typical misconceptions, established methodological weaknesses and some recommendations for improvement.
      ; in this study, the 8 patterns of activity were the clustering variables (2 × 8 = 256). Thus, the sample size (N = 276) was adequate. The hierarchical cluster analysis was conducted using the Ward method with squared Euclidean distance. Before cluster analysis, all variables were standardized (Z-score) to obtain similar metrics. The scree plot (elbow criterion) was used to select the optimal number of clusters. After clustering, a postcluster analysis was performed to determine which variables differentiated the clusters. Postcluster analysis was performed using a χ2 test for categorical variables and 1-way analysis of variance (ANOVA) for continuous variables. Bonferroni post hoc tests were used to correct for multiple comparisons. All analyses were performed using SPSS version 21 (IBM Corp, Armonk, NY).

      Results

       Correlation Analyses

      Table 1 shows the correlation analyses of the activity pattern subscales and optimism, pessimism, optimism-total, positive affect, negative affect, self-efficacy, daily functioning, functional impairment, pain intensity, total number of goals, number of pain-related goals, number of nonpain-related goals, goal conflict, and goal balance.
      Table 1Correlations Between the APS Subscales and Optimism, Pessimism, Optimism-Total, Positive Affect, Negative Affect, Daily Functioning, Functional Impairment, Pain Intensity, Total Number of Goals, Number of Pain-Related Goals, Number of Nonpain-Related Goals, Goal Conflict, and Goal Balance
      VariablesPain AvoidanceActivity AvoidanceTask-Contingent PersistenceExcessive PersistencePain-Contingent PersistencePacing to Increase Activity LevelPacing to Conserve Energy for Valued ActivitiesPacing to Reduce Pain
      Optimism−.16**−.33**.21**−.09−.00.07.08.07
      Pessimism.30**.43**−.17**.18**.07.11.06−.02
      Optimism-total−.25**−.42**.21**−.15*−.04−.02.02.05
      Positive affect−.26**−.41**.36**−.06.03.04.12*.08
      Negative affect.14*.39**−.16**.35**.17**−.09−.12*−.04
      Self-efficacy−.24**−.35**.27**−.12.00−.06.01.12*
      Daily functioning−.37**−.48**.34**.20**.20**.14*.09−.10
      Functional impairment.38**.52**−.27**.00.00.10.06.05
      Pain intensity.20**.31**−.12*.11.01.04−.17**−.02
      Total number of goals−.01−.01.04.14*.17**.02.08.08
      Number of pain-related goals.09.12−.06.07.05.02.01.04
      Number of nonpain-related goals−.14*−.08.07.09.12*.01.06.05
      Goal conflict−.07−.09.03.13*.02.06.09.16**
      Goal balance−.19**−.22*.12*−.05.02−.07−.05.04
      *P < .05.
      **P < .01.

       Cluster Analysis of Activity Patterns

      Hierarchical cluster analysis using the Ward method with squared Euclidean distance was applied to the 8 activity pattern variables. Fig 1 shows the scree plot of the distance coefficients from the hierarchical cluster analysis. The elbow criterion is defined as the step in which a significant jump in distance coefficients occurs subtracted from the number of cases (ie, 276, step 272.). Use of this criterion shows that the 4-cluster solution is the optimal number of clusters for the variables. The distribution of patients within the 4-cluster solution was as follows: 21.01% (n = 58, cluster 1), 28.26% (n = 78; cluster 2), 28.62% (n = 79; cluster 3), and 22.10% (n = 61, cluster 4). Although the clusters found were similar to those of McCracken and Samuel,
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      they were not identical, because the APS differentiated more activity patterns than the instrument used by these authors. We used their labels and differences with respect to their results are highlighted: cluster 1, extreme cyclers; cluster 2, medium cyclers; cluster 3, avoiders; and cluster 4, doers. Avoiders were characterized by high levels of pain avoidance, activity avoidance, and pacing to reduce pain with low levels of the 3 types of persistence, pacing to do more things, and pacing to save energy for valued activities. Doers were characterized by high levels of task-contingent persistence, and moderately high levels of excessive persistence and pain-related persistence with low levels of the 3 types of pacing. Extreme and medium cyclers were both characterized by high levels of pain-related persistence, but extreme cyclers had high levels of avoidance, moderately high levels of task-contingent persistence, and excessive persistence, and low levels of the 3 types of pacing. Medium cyclers had high levels of the 3 types of pacing and moderately high levels of pain avoidance, activity avoidance, task-contingent persistence, and excessive persistence. Fig 2 shows the APS subscales scores for the 4 patterns of activity obtained.
      Figure thumbnail gr1
      Figure 1Scree plot of the distance coefficients in the steps of the cluster analysis.
      Figure thumbnail gr2
      Figure 2APS subscale scores for 4 derived activity management clusters: extreme cyclers, medium cyclers, avoiders, and doers. Abbreviations: painavo, pain avoidance; actiavo, activity avoidance; persitask, task-contingent persistence; persiexce, excessive persistence; persipain, pain-contingent persistence; paceactiv, pacing for increasing activity level; pacener, pacing for conserving energy for valued activities; pacepain, pacing for pain reduction.
      We performed ANOVAs to analyze the differences between the scores of the 4 clusters obtained on the APS. Overall significant effects were found for all the subscales (Table 2).
      Table 2Means, SDs, and ANOVAs for Comparisons Between Activity Pattern Clusters in the APS Subscales
      Variable1 Extreme Cyclers2 Medium Cyclers3 Avoiders4 DoersF3,272PSignificant Intercluster Differences (P < .05)
      Pain avoidance8.12 (2.51)7.50 (2.27)8.28 (2.28)3.52 (1.37)68.25.0001 > 4, 2 > 4, 3 > 4
      Activity avoidance8.05 (2.15)6.56 (2.24)7.59 (2.58)4.11 (2.48)34.03.0001 > 2, 1 > 4, 2 > 4,

      3 > 2, 3 > 4
      Task-contingent persistence6.90 (2.95)5.87 (2.50)3.42 (1.85)9.16 (1.66)75.91.0001 > 3, 2 > 3, 4 > 1,

      4 > 2, 4 > 3
      Excessive persistence5.43 (2.59)6.10 (2.93)2.96 (2.36)6.74 (3.75)23.68.0001 > 3, 2 > 3, 4 > 3
      Pain-contingent persistence8.72 (2.40)8.45 (2.59)4.19 (2.58)7.20 (4.02)37.37.0001 > 3, 1 > 4, 2 > 3,

      2 > 4, 4 > 3
      Pacing to increase activity level3.43 (2.19)7.53 (1.99)1.70 (2.02)1.74 (2.18)130.43.0001 > 3, 1 > 4, 2 > 1,

      2 > 3, 2 > 4
      Pacing to conserve energy for valued activities1.99 (1.50)7.37 (2.22)1.57 (1.92)1.26 (1.47)184.62.0002 > 1, 2 > 3, 2 > 4
      Pacing to reduce pain4.19 (2.65)7.71 (2.57)7.86 (2.52)3.13 (2.53)60.48.0002 > 1, 2 > 4, 3 > 1,

      3 > 4
      NOTE. Data are presented as mean (SD) except where otherwise noted.

       Activity Pattern Cluster Comparisons

      A series of χ2 tests and ANOVAs were used to compare the clusters on categorical and continuous variables related to the patients’ demographic and clinical characteristics. There were gender differences between clusters χ2 (3, N = 276) = 9.76, P < .05. The proportion of men (30%) was higher than the proportion of women (17.3%) in the extreme cyclers cluster; the proportion of women (32.7%) was higher than the proportion of men (17.5%) in the medium cyclers cluster; the proportion of men (32.5%) was slightly higher than the proportion of women (27%) in the avoiders cluster. There were no significant differences between clusters on the primary location, χ2 (9, n = 273) = 15.68, P < .07; however, it is striking that 40.6% of the patients with relatively generalized pain syndromes were located in the avoiders cluster. The clusters did not differ in age, civil status, or education, but did differ on pain duration (in years), F3,264 = 3.25, P < .022, because the medium cyclers had experienced pain for more years (mean = 14.74) than the doers (mean = 9.31).
      We performed ANOVAs to analyze the differences between clusters on optimism, pessimism, positive and negative affect, self-efficacy, daily functioning, functional impairment, and pain intensity. The clusters were also compared on several goal-related variables (total number of goals, number of pain-related goals, number of nonpain-related goals, goal conflict, and goal balance). As shown in Table 3, doers showed significantly higher optimism and positive affect and lower pessimism and pain intensity than avoiders. Doers also showed significantly higher daily functioning and significantly lower functional impairment than the other 3 clusters. In relation to the goal-related variables, doers showed a higher goal balance than medium cyclers.
      Table 3Means and SDs for Comparisons Between Activity Pattern Clusters
      Variable1 Extreme Cyclers2 Medium Cyclers3 Avoiders4 DoersF3,272PSignificant Intercluster Differences (P < .05)
      Optimism7.84 (2.71)8.03 (3.17)6.99 (3.20)8.39 (3.17)2.70.0464 > 3
      Pessimism5.24 (2.84)5.51 (2.91)5.80 (2.61)4.40 (2.76)3.12.0273 > 4
      Optimism- total14.60 (4.97)14.51 (5.14)13.19 (5.48)16.02 (5.54)3.26.0224 > 3
      Positive affect29.62 (9.40)31.75 (7.80)28.09 (8.95)33.77 (7.98)5.80.0012 >3, 4 > 3
      Negative affect27.66 (9.26)24.36 (7.37)27.92 (8.26)25.10 (8.86)3.30.0213 > 2
      Self-efficacy68.83 (20.66)70.55 (19.07)67.16 (21.75)75.97 (18.42)2.37.071n.s.
      Daily functioning44.85 (11.27)51.29 (15.17)40.33 (13.20)57.53 (11.77)2.44.0002 > 1, 2 > 3, 4 > 1, 4 > 2, 4 > 3
      Functional impairment5.64 (4.14)4.21 (3.85)6.09 (6.49)1.84 (4.03)10.15.0001 > 4, 2 > 4, 3 > 4
      Pain intensity5.98 (1.71)6.39 (1.65)6.65 (1.41)5.78 (1.76)3.99.0083 > 4
      Total number of goals2.71 (1.11)3.01 8 (1.11)2.86 (.92)2.97 (.98)1.12.344n.s.
      Number of pain-related goals.79 (.69).74 (.50).78 (.50).66 (.57).79.50n.s.
      Number of nonpain-related goals1.89 (1.24)2.27 (1.18)2.08 (.97)2.31 (1.10)1.82.114n.s.
      Goal conflict1.15 (1.53)1.92 (1.79)1.46 (1.29)1.38 (1.53)3.06.0462 > 1
      Goal balance7.50 (5.83)7.46 (5.07)8.54 (5.18)10.06 (4.99)3.44.0174 > 2
      Abbreviation: n.s., not significant.
      NOTE. Data are presented as mean (SD) except where otherwise noted.
      Medium cyclers showed higher positive affect and lower negative affect than avoiders. Medium cyclers also had higher scores on daily functioning than avoiders and extreme cyclers. Regarding goal conflict, medium cyclers had significantly higher scores than extreme cyclers.

      Discussion

      The aim of the present study was to identify patient profiles on the basis of their scores on different activity pattern subscales which comprise the APS,
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      and to compare these groups in relation to affect, daily functioning, impairment, and variables related to life goals. Four groups were identified in cluster analysis: extreme cyclers, medium cyclers, avoiders, and doers. Significant differences were found between clusters. Taking into account that the APS distinguishes more types of activity patterns than the Pain and Activity Relations Questionnaire, the 4 groups were similar, but not identical, to the ones identified by McCracken and Samuel.
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      In line with previous research,
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      the correlational analyses showed that activity avoidance was associated with more negative outcomes than pain avoidance. As expected, task-contingent persistence was associated with adaptive results, whereas excessive persistence was associated with negative results. However, in contrast to previous research,
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      the 3 pacing subscales only showed low correlations with the outcome measures. This result could be explained by the fact that the frequency of use of pacing in this sample was low, especially pacing to increase activity levels and pacing to conserve energy for valued activities.
      Avoiders were characterized by high levels of pain avoidance, activity avoidance, and pacing to reduce pain with low levels of the 3 types of persistence, pacing to do more things, and pacing to save energy for valued activities. These results are in line with previous research, which showed that pacing, when practiced to reduce pain, could be functionally equivalent to avoidance.
      • Esteve R.
      • Ramírez-Maestre C.
      • Peters M.L.
      • Serrano-Ibáñez E.R.
      • Ruíz-Párraga G.T.
      • López-Martínez A.E.
      Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
      • McCracken L.M.
      • Samuel V.M.
      The role of avoidance, pacing, and other activity patterns in chronic pain.
      Thus, it would appear useful to distinguish between different types of pacing depending on the goal of the behavior.
      In sharp contrast to avoiders, doers were characterized by high levels of task-contingent persistence and moderately high levels of excessive persistence and pain-related persistence with low levels of the 3 types of pacing and the lowest levels of pain and activity avoidance. Comparisons showed that most of the differences between groups were between doers and avoiders. As postulated, doers had significantly higher scores than avoiders in optimism, positive affect, and daily functioning. In contrast, avoiders had significantly higher scores than doers in pessimism, functional impairment, and pain intensity. Doers had significantly higher scores than the other 3 groups in daily functioning and significantly lower scores than the other groups in functional impairment. These results show that a behavior pattern characterized by “doing” despite pain has more adaptive results than a pattern characterized by avoidance even when this pattern has elements of excessive persistence.
      • Andrews N.E.
      • Strong J.
      • Meredith P.J.
      Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: A systematic review and meta-analysis.
      These results highlight the association between avoidance and pain intensity in the avoider profile. As some authors
      • Crombez G.
      • Eccleston C.
      • Van Damme S.
      • Vlaeyen J.W.
      • Karoly P.
      Fear avoidance model of chronic pain. The next generation.
      have pointed out, pain functions as a signal of bodily threat that will disrupt ongoing behavior, and so its association with avoidance should not be underestimated.
      According to these results, the patients’ general expectations about the likelihood of achieving their goals
      • Carver C.S.
      • Scheier M.F.
      • Segerstrom S.C.
      Optimism.
      (ie, optimism and pessimism), and their positive/negative affect are related to how they regulate their activity (ie, patterns of avoidance and persistence). The correlational analysis also showed that optimism was positively correlated with task-contingent persistence and negatively correlated with pain avoidance and activity avoidance; the opposite pattern of correlations was observed for pessimism. Optimism was also associated with higher persistence. Doers had the highest goal balance. These results are in line with previous research,
      • Segerstrom S.C.
      • Solberg Nes L.
      When goals conflict but people prosper: The case of dispositional optimism.
      which showed that optimists are persistent because they expect to overcome adversity
      • Affleck G.
      • Tennen H.
      • Zautra A.
      • Urrows S.
      • Abeles M.
      • Karoly P.
      Women’s pursuit of personal goals in daily life with fibromyalgia: A value-expectancy analysis.
      ; however, this is not simply sterile persistence because they are also more flexible in their goal management.
      • Hanssen M.M.
      • Vancleef L.M.
      • Vlaeyen J.W.
      • Hayes A.F.
      • Schouten E.G.
      • Peters M.L.
      Optimism, motivational coping and well-being: Evidence supporting the importance of flexible goal adjustment.
      That is, when they repeatedly fail to attain certain goals, they substitute these goals with attainable goals
      • Duke J.
      • Leventhal H.
      • Brownlee S.
      • Leventhal E.A.
      Giving up and replacing activities in response to illness.
      • Rasmussen H.N.
      • Wrosch C.
      • Scheier M.F.
      • Carver C.S.
      Self-regulation processes and health: The importance of optimism and goal adjustment.
      because they are sensitive to the contextual parameters
      • Geers A.L.
      • Wellman J.A.
      • Lassiter G.D.
      Dispositional optimism and engagement: The moderating influence of goal prioritization.
      • Pavlova M.K.
      • Silbereisen R.K.
      Dispositional optimism fosters opportunity-congruent coping with occupational uncertainty.
      that are linked to a positive affect that may broaden their perspectives.
      • Fredrickson B.L.
      The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions.
      In line with previous research,
      • Segerstrom S.C.
      • Solberg Nes L.
      When goals conflict but people prosper: The case of dispositional optimism.
      the present study postulated that doers would experience more conflict between their most valued pain-related goal and their most valued nonpain-related goal than the other groups; contrary to our expectations, the doers did not obtain the highest scores in goal conflict. It must be taken into account that, in this study, goal conflict was operationalized as the conflict between the most valued pain-related goal and the most valued nonpain-related goal instead of a general measure of goal conflict. Perhaps, the measure used in the present study did not capture the tendency of optimists to engage in many life goals. No significant differences were found among the 4 groups in the total number of goals or in the number of pain-related or nonpain-related goals. It should be emphasized that there was little variability in these variables.
      Medium cyclers had the highest score in the conflict between the most valued pain-related and nonpain-related goals; in addition, their score was significantly higher than the score of the extreme cyclers. Medium cyclers could also be labeled as ‘pacers’ because this group had the highest scores on the 3 pacing subscales. They were also were characterized by high levels of pain-related persistence, and moderately high levels of pain avoidance, activity avoidance, task-contingent persistence, and excessive persistence. The proportion of women was higher than the proportion of men in the medium cyclers group, which had been experiencing pain for a significantly longer time than the doers group. Medium cyclers showed significantly higher levels of positive affect and significantly lower levels of negative affect than avoiders, and had better daily functioning than extreme cyclers and avoiders. In summary, the medium cyclers group appeared to put into action all the different patterns of activity at a high level and, after the doers, showed better adaptation than avoiders and extreme cyclers. It could be speculated that medium cyclers are motivated by the conflict between a pain-related and a nonpain-related goal, and that they use a wide range of patterns of activity that they fine-tune depending on the circumstances leading to adaptive results. This profile may develop over time; thus, future longitudinal research could investigate if patients evolve from a doer profile to a medium cycler profile. On the basis of previous experimental studies,
      • Claes N.
      • Crombez G.
      • Vlaeyen J.W.
      Pain-avoidance versus reward-seeking: An experimental investigation.
      • Claes N.
      • Karos K.
      • Meulders A.
      • Crombez G.
      • Vlaeyen J.W.
      Competing goals attenuate avoidance behavior in the context of pain.
      • Van Damme S.
      • Van Ryckeghem D.M.
      • Wyffels F.
      • Van Hulle L.
      • Crombez G.
      No pain no gain? Pursuing a competing goal inhibits avoidance behavior.
      it would have been reasonable to expect that the presence of conflict between the most valued nonpain-related goal and the most valued pain-related goal could have been associated with an attenuation of avoidance behavior. Instead, in the present study, goal conflict appeared to be associated with a moderately high use of persistence, avoidance, and pacing in all their forms and with adaptive results. This finding is in contrast with the results of several cross-sectional studies, which showed that distress results from goal conflict.
      • Emmons R.A.
      Personal strivings: An approach to personality and subjective well-being.
      • Emmons R.A.
      • King L.A.
      Conflict among personal strivings: Immediate and long-term implications for psychological and physical well-being.
      • Hardy J.K.
      • Crofford L.J.
      • Segerstrom S.C.
      Goal conflict, distress, and pain in women with fibromyalgia: A daily diary study.
      • Karoly P.
      • Okun M.A.
      • Ruehlman L.S.
      • Pugliese J.A.
      The impact of goal cognition and pain severity on disability and depression in adults with chronic pain: An examination of direct effects and mediated effects via pain-induced fear.
      • Karoly P.
      • Ruehlman L.S.
      Motivation implications of pain: Chronicity, psychological distress, and work goal construal in a national sample of adults.
      • Riediger M.
      • Freund A.M.
      Interference and facilitation among personal goals: Differential associations with subjective well-being and persistent goal pursuit.
      Finally, extreme cyclers were characterized by high levels of pain-related persistence and the 2 forms of avoidance, by moderately high levels of task-contingent persistence and excessive persistence, and by low levels of the 3 types of pacing. They had a low level of daily functioning and a high level of functional impairment; after avoiders, this profile experienced the most disabling effects. As mentioned, they also had the lowest score in goal conflict; this score was significantly lower than that of the medium cyclers. Extreme cyclers are characterized by high persistence and avoidance at the same time, and so it could be speculated that their behavior is mainly controlled by the fluctuations in pain intensity along with the limited motivational influence of nonpain-related goals. This hypothesis could be tested in future research with the use of daily diaries.
      One of the suggestions of the avoidance-endurance model is that positive mood may be a risk factor for excessive persistence behavior and subsequent disability as a result of overuse.
      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice.
      This hypothesis was not supported by the results of the present study because although doers had the highest score on positive affect, they had the lowest levels of functional impairment. It should be borne in mind that this profile is characterized by high levels of the 3 forms of persistence, and not simply by excessive persistence.
      Self-efficacy has been considered to be a critical appraisal that directs the choice to actively pursue a goal.
      • Karoly P.
      • Ruehlman L.S.
      Goal cognition and its clinical implications development and preliminary validation of four motivational assessment instruments.
      In contrast, Carver and Scheier
      • Carver C.
      • Scheier M.F.
      On the Self-Regulation of Behavior.
      emphasized the importance of the expectation itself that the goal will be achieved (ie, optimism). In this study, optimism (at least in relation to patterns of activity profiles), seemed to play a more important role than self-efficacy because no significant differences were found between groups in self-efficacy.
      The present study has a number of limitations. First, the only method used was self-reporting. Shared method variance may have contributed to the results. Future research should not only rely on self-reports, but should also use objective measures of activity patterns.
      • Van Damme S.
      • Kindermans H.
      A self-regulation perspective on avoidance and persistence behavior in chronic pain: New theories, new challenges?.
      Nevertheless, the objective measurement of activity patterns remains a controversial issue because the patterns actually performed by people are not only the result of their habitual style, but are also the result of contextual factors in which motivational elements play a central role. It is only with difficulty that objective measures can capture these aspects.
      • Andrews N.E.
      • Strong J.
      • Meredith P.J.
      Avoidance or incapacitation: A discussion on definition and validity of objective measures of avoidance, persistence and overactivity.
      The results on goal balance should be taken with caution because the use of a compound score to express the balance between goal expectancy, anticipated joy, and conflict
      • Segerstrom S.C.
      • Solberg Nes L.
      When goals conflict but people prosper: The case of dispositional optimism.
      could be limited by the fact that the measurement errors in each of the original scores are inherited by the new compound score. Second, the cross-sectional nature of the study does not allow causality to be inferred. Finally, because the variability in the number of goals expressed by the patients was low, goal conflict was operationalized as the conflict between the most valued pain-related goal and the most valued nonpain-related goal; future studies should consider the total amount of conflict between all goals.

      Conclusions

      This study supports the therapeutic approaches proposed within the framework of the Fear-Avoidance Model aimed at the extinction of avoidance behaviors such as graded exposure in vivo
      • Vlaeyen J.W.
      • Morley S.J.
      • Linton S.J.
      • Boersma K.
      • de Jong J.
      Pain-Related Fear: Exposure-Based Treatment of Chronic Pain: Exposure-Based Treatment.
      and those that emphasize engaging in activities linked to valued nonpain life goals despite pain (eg, Acceptance and Commitment Therapy
      • McCracken L.M.
      • Morley S.
      The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management.
      ). On the basis of our results, these interventions could be reinforced by techniques aimed at strengthening the expectations that personal goals can be achieved (eg, Best Possible Self, which aims to increase optimism
      • Hanssen M.M.
      • Peters M.L.
      • Vlaeyen J.W.
      • Meevissen Y.M.
      • Vancleef L.M.
      Optimism lowers pain: Evidence of the causal status and underlying mechanisms.
      • Meevissen Y.M.
      • Peters M.L.
      • Alberts H.J.
      Become more optimistic by imagining a best possible self: Effects of a two week intervention.
      • Peters M.L.
      • Flink I.K.
      • Boersma K.
      • Linton S.J.
      Manipulating optimism: Can imagining a best possible self be used to increase positive future expectancies?.
      • Peters M.L.
      • Meevissen Y.M.
      • Hanssen M.M.
      Specificity of the best possible self intervention for increasing optimism: Comparison with a gratitude intervention.
      ). As several studies have shown, optimism could counteract the fatigue in self-regulation resources, which is common in patients who have chronic pain.
      • Boselie J.J.
      • Vancleef L.M.
      • Smeets T.
      • Peters M.L.
      Increasing optimism abolishes pain-induced impairments in executive task performance.
      • Solberg Nes L.
      • Carlson C.R.
      • Crofford L.J.
      • de Leeuw R.
      • Segerstrom S.C.
      Individual differences and self-regulatory fatigue: Optimism, conscientiousness, and self-consciousness.

      Acknowledgments

      Asociación de Fibromialgia de Marbella (AFIMAR), Asociación de Fibromialgia y Síndrome de Fatiga Crónica de Málaga (AFIBROMA), Asociación Malagueña de Artritis Reumatoide (AMARE), Centro de Salud Carihuela, and the Agencia Sanitaria Costa del Sol collaborated in this study.

      References

        • Affleck G.
        • Tennen H.
        • Zautra A.
        • Urrows S.
        • Abeles M.
        • Karoly P.
        Women’s pursuit of personal goals in daily life with fibromyalgia: A value-expectancy analysis.
        J Consult Clin Psychol. 2001; 69: 587-596
        • Andrews N.E.
        • Strong J.
        • Meredith P.J.
        Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: A systematic review and meta-analysis.
        Arch Phys Med Rehabil. 2012; 93: 2109-2121
        • Andrews N.E.
        • Strong J.
        • Meredith P.J.
        Avoidance or incapacitation: A discussion on definition and validity of objective measures of avoidance, persistence and overactivity.
        Clin J Pain. 2015; 31: 670-672
        • Arends R.Y.
        • Bode C.
        • Taal E.
        • Van de Laar M.A.
        The role of goal management for successful adaptation to arthritis.
        Patient Educ Couns. 2013; 93: 130-138
        • Baessler J.
        • Schwarcer R.
        Self-Efficacy Assessment: Spanish Adaptation of the General Self-efficacy Scale [in Spanish].
        Ansiedad y Estrés. 1996; 2: 1-8
        • Boselie J.J.
        • Vancleef L.M.
        • Smeets T.
        • Peters M.L.
        Increasing optimism abolishes pain-induced impairments in executive task performance.
        Pain. 2014; 155: 334-340
        • Carver C.
        • Scheier M.F.
        On the Self-Regulation of Behavior.
        Cambridge University Press, Cambridge, England1998
        • Carver C.S.
        • Scheier M.F.
        • Segerstrom S.C.
        Optimism.
        Clin Psychol Rev. 2010; 30: 879-889
        • Claes N.
        • Crombez G.
        • Vlaeyen J.W.
        Pain-avoidance versus reward-seeking: An experimental investigation.
        Pain. 2015; 156: 1449-1457
        • Claes N.
        • Karos K.
        • Meulders A.
        • Crombez G.
        • Vlaeyen J.W.
        Competing goals attenuate avoidance behavior in the context of pain.
        J Pain. 2014; 15: 1120-1129
        • Cohen J.W.
        Statistical Power Analysis for the Behavioral Sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale, NJ1988
        • Crombez G.
        • Eccleston C.
        • Van Damme S.
        • Vlaeyen J.W.
        • Karoly P.
        Fear avoidance model of chronic pain. The next generation.
        Clin J Pain. 2012; 28: 475-483
        • Dolnicar S.
        Using cluster analysis for market segmentation – typical misconceptions, established methodological weaknesses and some recommendations for improvement.
        Aust J Market Res. 2003; 11: 5-12
        • Duke J.
        • Leventhal H.
        • Brownlee S.
        • Leventhal E.A.
        Giving up and replacing activities in response to illness.
        J Gerontol. 2002; 57: 367-376
        • Emmons R.A.
        Personal strivings: An approach to personality and subjective well-being.
        J Pers Soc Psychol. 1986; 51: 1058-1068
        • Emmons R.A.
        • King L.A.
        Conflict among personal strivings: Immediate and long-term implications for psychological and physical well-being.
        J Pers Soc Psychol. 1988; 54: 1040-1048
        • Esteve R.
        • Ramírez-Maestre C.
        • Peters M.L.
        • Serrano-Ibáñez E.R.
        • Ruíz-Párraga G.T.
        • López-Martínez A.E.
        Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
        J Pain. 2016; 17: 451-461
        • Ferrando P.J.
        • Chico-Librán E.
        • Tous J.M.
        Psychometric properties of the Life Orientation Test [in Spanish]..
        Psicothema. 2002; 14: 673-680
        • Fredrickson B.L.
        The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions.
        Am Psychol. 2001; 56: 218-226
        • Geers A.L.
        • Wellman J.A.
        • Lassiter G.D.
        Dispositional optimism and engagement: The moderating influence of goal prioritization.
        J Pers Soc Psychol. 2009; 96: 913-932
        • Gill J.R.
        • Brown C.A.
        A structured review of the evidence for pacing as a chronic pain intervention.
        Eur J Pain. 2009; 13: 214-216
        • Gorges J.
        • Esdar W.
        • Wild E.
        Linking goal self-concordance and affective reactions to goal conflict.
        Motiv Emot. 2014; 38: 475-484
        • Hanssen M.M.
        • Peters M.L.
        • Vlaeyen J.W.
        • Meevissen Y.M.
        • Vancleef L.M.
        Optimism lowers pain: Evidence of the causal status and underlying mechanisms.
        Pain. 2013; 154: 53-58
        • Hanssen M.M.
        • Vancleef L.M.
        • Vlaeyen J.W.
        • Hayes A.F.
        • Schouten E.G.
        • Peters M.L.
        Optimism, motivational coping and well-being: Evidence supporting the importance of flexible goal adjustment.
        J Happiness Stud. 2014; 16: 1-13
        • Hardy J.K.
        • Crofford L.J.
        • Segerstrom S.C.
        Goal conflict, distress, and pain in women with fibromyalgia: A daily diary study.
        J Psychosom Res. 2011; 70: 534-540
        • Hasenbring M.I.
        • Verbunt J.A.
        Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice.
        Clin J Pain. 2010; 26: 747-753
        • Jensen M.P.
        • Turner P.
        • Romano J.M.
        • Fischer L.D.
        Comparative reliability and validity of chronic pain intensity measures.
        Pain. 1999; 83: 157-162
        • Karoly P.
        • Lecci L.
        Motivational correlates of self-reported persistent pain in young adults.
        Clin J Pain. 1997; 13: 104-109
        • Karoly P.
        • Okun M.A.
        • Ruehlman L.S.
        • Pugliese J.A.
        The impact of goal cognition and pain severity on disability and depression in adults with chronic pain: An examination of direct effects and mediated effects via pain-induced fear.
        Cogn Ther Res. 2008; 32: 418-433
        • Karoly P.
        • Ruehlman L.S.
        Goal cognition and its clinical implications development and preliminary validation of four motivational assessment instruments.
        Assessment. 1995; 2: 113-129
        • Karoly P.
        • Ruehlman L.S.
        Motivation implications of pain: Chronicity, psychological distress, and work goal construal in a national sample of adults.
        Health Psychol. 1996; 15: 383-390
        • Kindermans H.P.
        • Roelofs J.
        • Goossens M.E.
        • Huijnen I.P.
        • Verbunt J.A.
        • Vlaeyen J.W.
        Activity patterns in chronic pain: Underlying dimensions and associations with disability and depressed mood.
        J Pain. 2011; 12: 1049-1058
        • Knittle K.P.
        • De Gucht V.
        • Hurkmans E.J.
        • Vlieland T.P.
        • Peeters A.J.
        • Ronday H.K.
        • Maes S.
        Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis.
        Arthritis Care Res (Hoboken). 2011; 63: 1613-1619
        • Librán E.C.
        • Piera P.J.
        Psicothema. 2008; 20 ([in Spanish]): 408-412
        • McCracken L.M.
        • Morley S.
        The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management.
        J Pain. 2014; 15: 221-234
        • McCracken L.M.
        • Samuel V.M.
        The role of avoidance, pacing, and other activity patterns in chronic pain.
        Pain. 2007; 130: 119-125
        • Meevissen Y.M.
        • Peters M.L.
        • Alberts H.J.
        Become more optimistic by imagining a best possible self: Effects of a two week intervention.
        J Behav Ther Exp Psychiatry. 2011; 42: 371-378
        • Nielson W.R.
        • Jensen M.P.
        • Karsdorp P.A.
        • Vlaeyen J.W.
        Activity pacing in chronic pain: Concepts, evidence, and future directions.
        Clin J Pain. 2013; 29: 461-468
        • Nielson W.R.
        • Jensen M.P.
        • Karsdorp P.A.
        • Vlaeyen J.W.
        A content analysis of activity pacing in chronic pain: What are we measuring and why?.
        Clin J Pain. 2014; 30: 639-645
        • Otero J.M.
        • Luengo A.
        • Romero E.
        • Gómez J.A.
        • Castro C.
        Personality Psychology: Practice book [in Spanish].
        Ariel Practicum, Barcelona1988
        • Pavlova M.K.
        • Silbereisen R.K.
        Dispositional optimism fosters opportunity-congruent coping with occupational uncertainty.
        J Pers. 2013; 81: 76-86
        • Peters M.L.
        • Flink I.K.
        • Boersma K.
        • Linton S.J.
        Manipulating optimism: Can imagining a best possible self be used to increase positive future expectancies?.
        J Posit Psychol. 2010; 5: 204-211
        • Peters M.L.
        • Meevissen Y.M.
        • Hanssen M.M.
        Specificity of the best possible self intervention for increasing optimism: Comparison with a gratitude intervention.
        Terapia Psicológica. 2013; 31: 93-100
      1. Phillips H.C. Rachman S. The Psychological Management of Chronic Pain: A Treatment Manual. Springer, New York1996
        • Ramírez-Maestre C.
        • Esteve R.
        A new version of the Impairment and Functioning Inventory for patients with chronic pain (IFI-R).
        PM R. 2015; 7: 455-465
        • Rasmussen H.N.
        • Wrosch C.
        • Scheier M.F.
        • Carver C.S.
        Self-regulation processes and health: The importance of optimism and goal adjustment.
        J Pers. 2006; 74: 1721-1747
        • Riediger M.
        • Freund A.M.
        Interference and facilitation among personal goals: Differential associations with subjective well-being and persistent goal pursuit.
        Pers Soc Psychol Bull. 2004; 30: 1511-1523
        • Sandín B.
        • Chorot P.
        • Lostao L.
        • Joiner T.E.
        • Santed M.A.
        • Valiente R.M.
        The PANAS scales of positive and negative affect: Factor Analytic Validation and Cross-cultural Convergence [in Spanish].
        Psicothema. 1999; 11: 37-51
        • Sandín B.
        • Valiente R.M.
        • Chorot P.
        Instruments for the assessment of psychosocial stress.
        in: Sandín B. Psychosocial stress: Concepts and clinical consequences [in Spanish]. Klinik, Madrid2008: 275-358
        • Sanjuán-Suárez P.
        • Pérez- García A.M.
        • Bermúdez-Moreno J.
        The General Self-efficacy Scale: Psychometric data from the Spanish Adaptation [in Spanish].
        Psicothema. 2000; 12: 509-513
        • Scheier M.F.
        • Carver C.S.
        • Bridges M.W.
        Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test.
        J Pers Soc Psychol. 1994; 67: 1063-1078
        • Schrooten M.G.
        • Van Damme S.
        • Crombez G.
        • Peters M.L.
        • Vogt J.
        • Vlaeyen J.W.
        Nonpain goal pursuit inhibits attentional bias to pain.
        Pain. 2012; 153: 1180-1186
        • Segerstrom S.C.
        • Solberg Nes L.
        When goals conflict but people prosper: The case of dispositional optimism.
        J Res Pers. 2006; 40: 675-693
        • Solberg Nes L.
        • Carlson C.R.
        • Crofford L.J.
        • de Leeuw R.
        • Segerstrom S.C.
        Individual differences and self-regulatory fatigue: Optimism, conscientiousness, and self-consciousness.
        Pers Indiv Diff. 2011; 50: 475-480
        • Van Damme S.
        • Kindermans H.
        A self-regulation perspective on avoidance and persistence behavior in chronic pain: New theories, new challenges?.
        Clin J Pain. 2015; 31: 115-122
        • Van Damme S.
        • Van Ryckeghem D.M.
        • Wyffels F.
        • Van Hulle L.
        • Crombez G.
        No pain no gain? Pursuing a competing goal inhibits avoidance behavior.
        Pain. 2012; 153: 800-804
        • Vlaeyen J.W.
        • Linton S.J.
        Fear-avoidance and its consequences in chronic musculoskeletal pain: State of the art.
        Pain. 2000; 85: 317-332
        • Vlaeyen J.W.
        • Morley S.J.
        • Linton S.J.
        • Boersma K.
        • de Jong J.
        Pain-Related Fear: Exposure-Based Treatment of Chronic Pain: Exposure-Based Treatment.
        2nd ed. Lippincott Williams & Wilkins, Philadelphia2015
        • Watson D.
        • Clark L.A.
        • Tellegen A.
        Development and validation of brief measures of positive and negative affect: The PANAS scales.
        J Pers Soc Psychol. 1988; 54: 1063-1070