The Relationship Between Pacing and Avoidance in Chronic Pain: A Systematic Review and Meta-Analysis


      • Meta-analysis of correlations between avoidance and pacing in chronic pain.
      • A small positive correlation was found overall and between single-item measures.
      • A moderate positive correlation was found between multiple-item measures.
      • Existing pacing measures may partially confound pacing with avoidance.
      • Measures that clearly differentiate pacing from avoidance are needed.


      Activity pacing is ubiquitous in chronic pain management and aims to reduce pain-contingent avoidance of activity to improve functioning. A meta-analysis, however, has linked pacing with higher levels of pain and disability. One potential explanation is an overlap between existing measures of pacing and avoidance, leading to links with poorer outcomes that are typically associated with avoidance. This study systematically reviews the evidence regarding the relationship between measures of pacing and avoidance. A search was conducted for studies measuring both constructs in adults with chronic pain. A meta-analysis of correlations between pacing and avoidance was conducted; 16 studies were included and a small positive correlation was found (r = .290, P < .001) overall. Single-item and multiple-item measures were also compared; a moderate positive correlation was found for multiple-item measures (r = .410, P < .001), which differed significantly from a small positive correlation found for single-item measures (r = .105, P < .001). Due to limited studies, independent analyses of individual subscales were not possible. Existing measures of pacing—particularly multiple-item measures—may partially confound pacing with avoidance. Further research is required to ensure that a reliable measure of pacing that distinguishes this construct from avoidance is available to adequately evaluate pacing instruction and the effect of pacing on key outcomes in chronic pain.


      This meta-analysis examines the correlation between pacing and avoidance in adults with chronic pain. Results indicate that existing measures may partially confound pacing with avoidance. Directions for future research are proposed to ensure that an adequate measure of pacing exists to evaluate its effect on key outcomes in chronic pain.

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        • 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
        • Antcliff D.
        • Keeley P.
        • Campbell M.
        • Oldham J.
        • Woby S.
        The development of an activity pacing questionnaire for chronic pain and/or fatigue: A Delphi technique.
        Physiotherapy. 2013; 99: 241-246
        • Bair M.J.
        • Robinson R.L.
        • Katon W.
        • Kroenke K.
        Depression and pain comorbidity: A literature review.
        Arch Intern Med. 2003; 163: 2433-2445
        • Biostat
        Comprehensive Meta-Analysis Version 3.
        Biostat, Englewood, NJ2005
        • Birkholtz M.
        • Aylwin L.
        • Harman R.M.
        Activity pacing in chronic pain management: One aim, but which method? Part two: National activity pacing survey.
        Br J Occup Ther. 2004; 67: 481-487
        • Blyth F.M.
        • March L.M.
        • Brnabic A.J.
        • Jorm L.R.
        • Williamson M.
        • Cousins M.J.
        Chronic pain in Australia: A prevalence study.
        Pain. 2001; 89: 127-134
        • Breivik H.
        • Collett B.
        • Ventafridda V.
        • Cohen R.
        • Gallacher D.
        Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment.
        Eur J Pain. 2006; 10: 287-333
        • Cane D.
        • McCarthy M.
        • Mazmanian D.
        Obstacles to activity pacing: Assessment, relationship to activity and functioning.
        Pain. 2016; 157: 1508-1514
        • Cane D.
        • Nielson W.R.
        • McCarthy M.
        • Mazmanian D.
        Pain-related activity patterns: Measurement, interrelationships, and associations with psychosocial functioning.
        Clin J Pain. 2013; 29: 435-442
        • Cohen J.
        A power primer.
        Psychol Bull. 1992; 112: 155-159
        • Crowley D.
        • Kendall N.A.
        Development and initial validation of a questionnaire for measuring fear-avoidance associated with pain: The Fear-Avoidance of Pain Scale.
        J Musculoskelet Pain. 1999; 7: 3-19
        • Demyttenaere K.
        • Bruffaerts R.
        • Lee S.
        • Posada-Villa J.
        • Kovess V.
        • Angermeyer M.C.
        • Levinson D.
        • de Girolamo G.
        • Nakane H.
        • Mneimneh Z.
        • Lara C.
        • de Graaf R.
        • Scott K.M.
        • Gureje O.
        • Stein D.J.
        • Haro J.M.
        • Bromet E.J.
        • Kessler R.C.
        • Alonso J.
        • Von Korff M.
        Mental disorders among persons with chronic back or neck pain: Results from the world mental health surveys.
        Pain. 2007; 129: 332-342
        • Esteve R.
        • Ramirez-Maestre C.
        • Peters M.L.
        • Serrano-Ibanez E.R.
        • Ruiz-Parraga G.T.
        • Lopez-Martinez A.E.
        Development and initial validation of the Activity Patterns Scale in patients with chronic pain.
        J Pain. 2016; 17: 451-461
        • 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
        • Huijnen I.P.
        • Verbunt J.A.
        • Peters M.L.
        • Smeets R.J.
        • Kindermans H.P.
        • Roelofs J.
        • Goossens M.
        • Seelen H.A.
        Differences in activity-related behaviour among patients with chronic low back pain.
        Eur J Pain. 2011; 15: 748-755
        • Jamieson-Lega K.
        • Berry R.
        • Brown C.A.
        Pacing: A concept analysis of the chronic pain intervention.
        Pain Res Manag. 2013; 18: 207-213
        • Jensen M.P.
        • Turner J.A.
        • Romano J.M.
        • Strom S.E.
        The Chronic Pain Coping Inventory: Development and preliminary validation.
        Pain. 1995; 60: 203-216
        • Johannes C.B.
        • Le T.
        • Zhou X.
        • Johnston J.A.
        • Dworkin R.H.
        The prevalence of chronic pain in United States adults: Results of an internet-based survey.
        J Pain. 2010; 11: 1230-1239
        • Karsdorp P.A.
        • Vlaeyen J.W.
        Active avoidance but not activity pacing is associated with disability in fibromyalgia.
        Pain. 2009; 147: 29-35
        • 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
        • Kroenke K.
        • Outcalt S.
        • Krebs E.
        • Bair M.J.
        • Wu J.
        • Chumbler N.
        • Yu Z.
        Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain.
        Gen Hosp Psychiatry. 2013; 35: 359-365
        • McCracken L.M.
        • Dhingra L.
        A short version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary development and validity.
        Pain Res Manag. 2002; 7: 45-50
        • McCracken L.M.
        • Eccleston C.
        • Bell L.
        Clinical assessment of behavioral coping responses: Preliminary results from a brief inventory.
        Eur J Pain. 2005; 9: 69-78
        • McCracken L.M.
        • Samuel V.M.
        The role of avoidance, pacing, and other activity patterns in chronic pain.
        Pain. 2007; 130: 119-125
        • McCracken L.M.
        • Vowles K.E.
        Psychological flexibility and traditional pain management strategies in relation to patient functioning with chronic pain: An examination of a revised instrument.
        J Pain. 2007; 8: 700-707
        • McCracken L.M.
        • Vowles K.E.
        • Gauntlett-Gilbert J.
        A prospective investigation of acceptance and control-oriented coping with chronic pain.
        J Behav Med. 2007; 30: 339-349
        • McNamee P.
        • Mendolia S.
        The effect of chronic pain on life satisfaction: Evidence from Australian data.
        Soc Sci Med. 2014; 121: 65-73
        • Murphy S.L.
        • Kratz A.L.
        Activity pacing in daily life: A within-day analysis.
        Pain. 2014; 155: 2630-2637
        • Nicholas M.K.
        When to refer to a pain clinic.
        Best Pract Res Clin Rheumatol. 2004; 18: 613-629
        • Nielson W.R.
        • Jensen M.P.
        Relationship between changes in coping and treatment outcome in patients with fibromyalgia syndrome.
        Pain. 2004; 109: 233-241
        • Nielson W.R.
        • Jensen M.P.
        • Hill M.L.
        An activity pacing scale for the Chronic Pain Coping Inventory: Development in a sample of patients with fibromyalgia syndrome.
        Pain. 2001; 89: 111-115
        • 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
        • Racine M.
        • Castarlenas E.
        • de la Vega R.
        • Tome-Pires C.
        • Sole E.
        • Miro J.
        • Jensen M.P.
        • Moulin D.E.
        • Nielson W.R.
        Sex differences in psychological response to pain in patients with fibromyalgia syndrome.
        Clin J Pain. 2015; 31: 425-432
        • Sharpe L.
        • Schrieber L.
        A blind randomized controlled trial of cognitive versus behavioral versus cognitive-behavioral therapy for patients with rheumatoid arthritis.
        Psychother Psychosom. 2012; 81: 145-152
        • Torrance N.
        • Smith B.H.
        • Elliott A.M.
        • Campbell S.E.
        • Chambers W.A.
        • Hannaford P.C.
        • Johnston M.
        Potential pain management programmes in primary care. A UK-wide questionnaire and Delphi survey of experts.
        Fam Pract. 2011; 28: 41-48
        • Van Lankveld W.
        • Van’t Pad Bosch P.
        • Van De Putte L.
        • Naring G.
        • Van Der Staak C.
        Disease-specific stressors in rheumatoid arthritis: Coping and well-being.
        Br J Rheumatol. 1994; 33: 1067-1073
        • Vlaeyen J.W.
        • Linton S.J.
        Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
        Pain. 2000; 85: 317-332
        • Vowles K.E.
        • McCracken L.M.
        Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes.
        Behav Res Ther. 2010; 48: 141-146
        • Vowles K.E.
        • McCracken L.M.
        • Sowden G.
        • Ashworth J.
        Psychological flexibility in coping with chronic pain: Further examination of the Brief Pain Coping Inventory-2.
        Clin J Pain. 2014; 30: 324-330
        • Vowles K.E.
        • Sowden G.
        • Ashworth J.
        A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain.
        Behav Ther. 2014; 45: 390-401
        • Vowles K.E.
        • Witkiewitz K.
        • Sowden G.
        • Ashworth J.
        Acceptance and commitment therapy for chronic pain: Evidence of mediation and clinically significant change following an abbreviated interdisciplinary program of rehabilitation.
        J Pain. 2014; 15: 101-113
        • White P.
        • Goldsmith K.
        • Johnson A.
        • Potts L.
        • Walwyn R.
        • DeCesare J.
        • Baber H.
        • Burgess M.
        • Clark L.
        • Cox D.
        • Bavinton J.
        • Angus B.
        • Murphy G.
        • Murphy M.
        • O’Dowd H.
        • Wilks D.
        • McCrone P.
        • Chalder T.
        • Sharpe M.
        Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): A randomised trial.
        Lancet. 2011; 377: 823-836
        • Williams A.
        • Eccleston C.
        • Morley S.
        Psychological therapies for the management of chronic pain (excluding headache) in adults.
        Cochrane Database Syst Rev. 2012; 11: CD007407