Fitbit Activity, Quota-Based Pacing, and Physical and Emotional Functioning Among Adults With Chronic Pain

  • Victoria A. Grunberg
    Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts

    Division of Newborn Medicine, MassGeneral for Children, Boston, Massachusetts
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  • Jonathan Greenberg
    Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
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  • Ryan A. Mace
    Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
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  • Jafar Bakhshaie
    Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
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  • Karmel W. Choi
    Psychiatric & Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts

    Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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  • Ana-Maria Vranceanu
    Address reprint requests to Ana-Maria Vranceanu, PhD, One Bowdoin Square, 1st floor, Suite 100, Boston, Massachusetts 02114.
    Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
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      • Fitbits are a promising tool to help promote consistent activity in patients with chronic pain.
      • In our 10-week mind-body program, Fitbit step counts peaked at weeks 6 and 8.
      • Achieving step goals was linked to improved physical function (self-report, 6MWT) and anxiety.
      • Achieving step goals was not associated with ActiGraph performance or depression.
      • Mind-body skills and quota-based pacing using Fitbits may enhance chronic pain outcomes.


      Physical activity can improve function in patients with chronic pain, however, adherence is low, in part due to inconsistent activity patterns. Smart wearable activity trackers, such as Fitbits, may help promote activity. In our program for chronic pain, we examined: 1) Fitbit activity patterns (ie, step count, moderate-to-vigorous physical activity (MVPA), sedentary behavior), and 2) whether achievement of weekly, individualized Fitbit step goals was associated with functional outcomes. We conducted a secondary analysis of Fitbit data from our 10-week mind-body activity program for chronic pain (GetActive-Fitbit arm, N = 41). Participants self-reported emotional and physical function and completed performance-based and accelerometer-based assessments. From week 1 to week 10, 30% of participants increased >800 steps; 32.5% increased MVPA; and 30% decreased sedentary behavior. Only step count significantly changed across time with mean steps peaking at week 8 (M = +1897.60, SD = 467.67). Fitbit step goal achievement was associated with improvements in anxiety (ß = -.35, CI [-2.80, -.43]), self-reported physical function (ß = -.34, CI [-5.17, 8.05]), and performance-based physical function (ß = .29, CI [-71.93, 28.38]), but not accelerometer-based physical function or depression. Adhering to individualized Fitbit step goals in the context of a mind-body activity program may improve anxiety and self-reported and performance-based physical function.


      We examine Fitbit activity patterns and the association between quota-based pacing and functional outcomes within a mind-body activity program for adults with chronic pain. Complementing quota-based pacing and coping skills with Fitbits may be a useful approach to promote activity engagement and behavior change in chronic pain populations.

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        • Amorim AB
        • Pappas E
        • Simic M
        • Ferreira ML
        • Jennings M
        • Tiedemann A
        • Carvalho-e-Silva AP
        • Caputo E
        • Kongsted A
        • Ferreira PH
        Integrating Mobile-health, health coaching, and physical activity to reduce the burden of chronic low back pain trial (IMPACT): A pilot randomised controlled trial.
        BMC Musculoskelet Disord. 2019; 20: 71
        • Andrews NE
        • Strong J
        • Meredith PJ
        Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: A systematic review and meta-analysis.
        Arch Phys Med Rehabil. 2012; 93 (e7): 2109-2121
        • Baer RA
        Mindfulness training as a clinical intervention: A conceptual and empirical review.
        Clin Psychol Sci Pract. 2003; 10: 125-143
        • Barchek AR
        • Baez SE
        • Hoch MC
        • Hoch JM
        The relationship between musculoskeletal injury and objectively measured physical activity levels: A critically appraised topic.
        J Sport Rehabil. 2020; 29: 243-247
        • Birkholtz M
        • Aylwin L
        • Harman RM
        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
        • Cadmus-Bertram LA
        • Marcus BH
        • Patterson RE
        • Parker BA
        • Morey BL
        Randomized trial of a fitbit-based physical activity intervention for women.
        Am J Prev Med. 2015; 49: 414-418
        • Cain KL
        • Conway TL
        • Adams MA
        • Husak LE
        • Sallis JF
        Comparison of older and newer generations of ActiGraph accelerometers with the normal filter and the low frequency extension.
        Int J Behav Nutr Phys Act. 2013; 10: 51
        • Cheng S-T
        • Leung CMC
        • Chan KL
        • Chen PP
        • Chow YF
        • Chung JWY
        • Law ACB
        • Lee JSW
        • Leung EMF
        • Tam CWC
        The relationship of self-efficacy to catastrophizing and depressive symptoms in community-dwelling older adults with chronic pain: A moderated mediation model.
        PLOS ONE. 2018; 13 (Tan MP, editor)e0203964
        • Choi L
        • Liu Z
        • Matthews CE
        • Buchowski MS
        Validation of accelerometer wear and nonwear time classification algorithm.
        Med Sci Sports Exerc. 2011; 43: 357-364
        • Chu AHY
        • Ng SHX
        • Paknezhad M
        • Gauterin A
        • Koh D
        • Brown MS
        • Müller-Riemenschneider F
        Comparison of wrist-worn Fitbit Flex and waist-worn ActiGraph for measuring steps in free-living adults.
        PLOS ONE. 2017; 12 (Buchowski M, editor)e0172535
        • Crombez G
        • Eccleston C
        • Van Damme S
        • Vlaeyen JWS
        • Karoly P
        Fear-avoidance model of chronic pain: The next generation.
        Clin J Pain. 2012; 28: 475-483
        • Cuschieri S
        The STROBE guidelines.
        Saudi J Anaesth. 2019; 13: S31-S34
        • Czajkowski SM
        • Powell LH
        • Adler N
        • Naar-King S
        • Reynolds KD
        • Hunter CM
        • Laraia B
        • Olster DH
        • Perna FM
        • Peterson JC
        • Epel E
        • Boyington JE
        • Charlson ME
        From ideas to efficacy: The ORBIT model for developing behavioral treatments for chronic diseases.
        Health Psychol. 2015; 34: 971-982
        • Daenen L
        • Varkey E
        • Kellmann M
        • Exercise Nijs J:
        Not to exercise, or how to exercise in patients with chronic pain? Applying science to practice.
        Clin J Pain. 2015; 31: 108-114
        • Dworkin RH
        • Bruehl S
        • Fillingim RB
        • Loeser JD
        • Terman GW
        • Turk DC
        Multidimensional diagnostic criteria for chronic pain: Introduction to the ACTTION–american pain society pain taxonomy (AAPT).
        J Pain. 2016; 17: T1-T9
        • Evenson KR
        • Wen F
        Performance of the ActiGraph accelerometer using a national population-based sample of youth and adults.
        BMC Res Notes. 2015; 8: 7
      1. Faust L, Purta R, Hachen D, Striegel A, Poellabauer C, Lizardo O, Chawla NV: Exploring Compliance: Observations from a Large Scale Fitbit Study. Proc 2nd Int Workshop Soc Sens [Internet] Pittsburgh PA USA: ACM; page 55–602017 [cited 2022 Mar 23]. Available from: 10.1145/3055601.3055608

      2. Fitabase: Research Device Data and Analytics [Internet]. Available from:

        • Garin O
        • Ayuso-Mateos JL
        • Almansa J
        • Nieto M
        • Chatterji S
        • Vilagut G
        • Alonso J
        • Cieza A
        • Svetskova O
        • Burger H
        • Racca V
        • Francescutti C
        • Vieta E
        • Kostanjsek N
        • Raggi A
        • Leonardi M
        • Ferrer M
        the MHADIE consortium: Validation of the “World Health Organization disability assessment schedule, WHODAS-2” in patients with chronic diseases.
        Health Qual Life Outcomes. 2010; 8: 51
        • Geneen LJ
        • Moore RA
        • Clarke C
        • Martin D
        • Colvin LA
        • Smith BH
        Physical activity and exercise for chronic pain in adults: An overview of cochrane reviews. Cochrane pain, palliative and supportive care group, editor.
        Cochrane Database Syst Rev [Internet]. 2020; 2017 ([cited 2022 Mar 23]. Available from:)
        • Glaviano NR
        • Baellow A
        • Saliba S
        Physical activity levels in individuals with and without patellofemoral pain.
        Phys Ther Sport. 2017; 27: 12-16
        • Goldenberg DL
        • Kaplan KH
        • Nadeau MG
        • Brodeur C
        • Smith S
        • Schmid CH
        A controlled study of a stress-reduction, cognitive-behavioral treatment program in fibromyalgia.
        J Musculoskelet Pain. 1994; 2: 53-66
        • Gordon R
        • Bloxham S
        Influence of the Fitbit Charge HR on physical activity, aerobic fitness and disability in non-specific back pain participants.
        J Sports Med Phys Fitness [Internet]. 2017; 57 ([cited 2022 Mar 23]. Available from)
        • Greenberg J
        • Lin A
        • Zale E
        • Kulich RJ
        • James P
        • Millstein R
        • Shapiro H
        • Schatman M
        • Edwards R
        • Vranceanu A-M
        Development and early feasibility testing of a mind-body physical activity program for patients with heterogeneous chronic pain; the getactive study.
        J Pain Res Volume. 2019; 12: 3279-3297
        • Greenberg J
        • Mace RA
        • Funes CJ
        • Silverberg ND
        • Iverson GL
        • Caplan DN
        • Vranceanu A-M
        Pain catastrophizing and limiting behavior mediate the association between anxiety and postconcussion symptoms.
        Psychosomatics. 2020; 61: 49-55
        • Greenberg J
        • Popok PJ
        • Lin A
        • Kulich RJ
        • James P
        • Macklin EA
        • Millstein RA
        • Edwards RR
        • Vranceanu A-M
        A mind-body physical activity program for chronic pain with or without a digital monitoring device: proof-of-concept feasibility randomized controlled trial.
        JMIR Form Res. 2020; 4: e18703
        • Greenberg J
        • Singh T
        • Popok PJ
        • Kulich RJ
        • Vranceanu A-M
        Sustainability of improvements in physical and emotional function following a mind–body physical activity program for chronic pain.
        J Altern Complement Med. 2021; 27: 360-364
        • Gusmer RJ
        • Bosch TA
        • Watkins AN
        • Ostrem JD
        • Dengel DR
        Comparison of FitBit® Ultra to ActiGraphTM GT1M for Assessment of Physical Activity in Young Adults During Treadmill Walking.
        Open Sports Med J. 2014; 8: 11-15
        • Hardcastle SJ
        • Jiménez-Castuera R
        • Maxwell-Smith C
        • Bulsara MK
        • Hince D
        Fitbit wear-time and patterns of activity in cancer survivors throughout a physical activity intervention and follow-up: Exploratory analysis from a randomised controlled trial.
        PLOS ONE. 2020; 15 (Bergman P, editor)e0240967
        • Hartman SJ
        • Nelson SH
        • Weiner LS
        Patterns of fitbit use and activity levels throughout a physical activity intervention: Exploratory analysis from a randomized controlled trial.
        JMIR MHealth UHealth. 2018; 6: e29
        • Hayashi K
        • Kako M
        • Suzuki K
        • Takagi Y
        • Terai C
        • Yasuda S
        • Kadono I
        • Seki T
        • Hiraiwa H
        • Ushida T
        • Nishida Y
        Impact of variation in physical activity after total joint replacement.
        J Pain Res Volume. 2018; 11: 2399-2406
        • Jackson W
        • Zale EL
        • Berman SJ
        • Malacarne A
        • Lapidow A
        • Schatman ME
        • Kulich R
        • Vranceanu A-M
        Physical functioning and mindfulness skills training in chronic pain: A systematic review.
        J Pain Res Volume. 2019; 12: 179-189
        • Jaeschke R
        • Singer J
        • Guyatt GH
        Measurement of health status.
        Control Clin Trials. 1989; 10: 407-415
        • Janevic MR
        • Shute V
        • Murphy SL
        • Piette JD
        Acceptability and Effects of Commercially Available Activity Trackers for Chronic Pain Management Among Older African American Adults.
        Pain Med. 2020; 21: e68-e78
        • Kaleth AS
        • Slaven JE
        • Ang DC
        Does increasing steps per day predict improvement in physical function and pain interference in adults with fibromyalgia? Daily step count increase and fibromyalgia improvement.
        Arthritis Care Res. 2014; 66: 1887-1894
        • Karlsson L
        • Gerdle B
        • Takala E-P
        • Andersson G
        • Larsson B
        Experiences and attitudes about physical activity and exercise in patients with chronic pain: A qualitative interview study.
        J Pain Res Volume. 2018; 11: 133-144
        • Kurklinsky S
        • Perez RB
        • Lacayo ER
        • Sletten CD
        The efficacy of interdisciplinary rehabilitation for improving function in people with chronic pain.
        Pain Res Treat. 2016; 2016: 1-6
        • Law LF
        • Sluka KA
        How does physical activity modulate pain?.
        Pain. 2017; 158: 369-370
        • Lee I-M
        • Shiroma EJ
        • Kamada M
        • Bassett DR
        • Matthews CE
        • Buring JE
        Association of step volume and intensity with all-cause mortality in older women.
        JAMA Intern Med. 2019; 179: 1105
        • Mannerkorpi K
        • Nordeman L
        • Cider Å
        • Jonsson G
        Does moderate-to-high intensity nordic walking improve functional capacity and pain in fibromyalgia? A prospective randomized controlled trial.
        Arthritis Res Ther. 2010; 12: R189
        • Marrie RA
        • Zhang L
        • Lix LM
        • Graff LA
        • Walker JR
        • Fisk JD
        • Patten SB
        • Hitchon CA
        • Bolton JM
        • Sareen J
        • El-Gabalawy R
        • Marriott JJ
        • Bernstein CN
        The validity and reliability of screening measures for depression and anxiety disorders in multiple sclerosis.
        Mult Scler Relat Disord. 2018; 20: 9-15
        • Meade LB
        • Bearne LM
        • Sweeney LH
        • Alageel SH
        • Godfrey EL
        Behaviour change techniques associated with adherence to prescribed exercise in patients with persistent musculoskeletal pain: Systematic review.
        Br J Health Psychol. 2019; 24: 10-30
        • Michie S
        • Abraham C
        • Whittington C
        • McAteer J
        • Gupta S
        Effective techniques in healthy eating and physical activity interventions: A meta-regression.
        Health Psychol. 2009; 28: 690-701
        • Minns Lowe CJ
        • Kelly P
        • Milton K
        • Foster C
        • Barker K
        “WALK30×5”: A feasibility study of a physiotherapy walking programme for people with mild to moderate musculoskeletal conditions.
        Physiotherapy. 2020; 107: 275-285
        • Morrill MI
        • Mace RA
        • Greenberg J
        • Lin A
        • Choi KW
        • Vranceanu A-M
        An exploratory analysis of accelerometer-measured physical activity and emotional functioning in patients with chronic pain.
        J Acad Consult-Liaison Psychiatry. 2021; 62: 234-242
        • Motl RW
        • McAuley E
        • Sandroff BM
        Longitudinal change in physical activity and its correlates in relapsing-remitting multiple sclerosis.
        Phys Ther. 2013; 93: 1037-1048
        • Nicholas M
        • Vlaeyen JWS
        • Rief W
        • Barke A
        • Aziz Q
        • Benoliel R
        • Cohen M
        • Evers S
        • Giamberardino MA
        • Goebel A
        • Korwisi B
        • Perrot S
        • Svensson P
        • Wang S-J
        • Treede R-D
        • The IASP Taskforce for the Classification of Chronic Pain
        The IASP classification of chronic pain for ICD-11: chronic primary pain.
        Pain. 2019; 160: 28-37
        • Oliveira JS
        • Sherrington C
        • Paul SS
        • Ramsay E
        • Chamberlain K
        • Kirkham C
        • O'Rourke SD
        • Hassett L
        • Tiedemann A
        A combined physical activity and fall prevention intervention improved mobility-related goal attainment but not physical activity in older adults: a randomised trial.
        J Physiother. 2019; 65: 16-22
      3. Outcomes measurement information system: Brief Guide PROMIS Depress. Instrum. 2015. Available from:

      4. Outcomes measurement information system: Brief Guide PROMIS Anxiety Instrum. 2015. Available from:

        • Paul SS
        • Tiedemann A
        • Hassett LM
        • Ramsay E
        • Kirkham C
        • Chagpar S
        • Sherrington C
        Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults.
        BMJ Open Sport Exerc Med. 2015; 1e000013
        • Pilkonis PA
        • Choi SW
        • Reise SP
        • Stover AM
        • Riley WT
        • Cella D
        • PROMIS Cooperative Group
        Item banks for measuring emotional distress from the patient-reported outcomes measurement information system (PROMIS®): Depression, anxiety, and anger.
        Assessment. 2011; 18: 263-283
        • Rayner L
        • Hotopf M
        • Petkova H
        • Matcham F
        • Simpson A
        • McCracken LM
        Depression in patients with chronic pain attending a specialised pain treatment centre: Prevalence and impact on health care costs.
        Pain. 2016; 157: 1472-1479
        • Redelmeier DA
        • Bayoumi AM
        • Goldstein RS
        • Guyatt GH
        Interpreting small differences in functional status: The six minute walk test in chronic lung disease patients.
        Am J Respir Crit Care Med. 1997; 155: 1278-1282
      5. Reeve B, Hays R, Bjorner J, Cook K, Crane P, Teresi J, Thissen D, Dennis Revicki, Weiss D, Hambleton R, Liu H, Gershon R, Reise S, Lai J-S, Cella D: Psychometric evaluation and calibration of health-related quality of life item banks: Plans for the patient-reported outcomes measurement information system (PROMIS). 45:S22–31, 2007.

        • Reid RER
        • Insogna JA
        • Carver TE
        • Comptour AM
        • Bewski NA
        • Sciortino C
        • Andersen RE
        Validity and reliability of Fitbit activity monitors compared to ActiGraph GT3X+ with female adults in a free-living environment.
        J Sci Med Sport. 2017; 20: 578-582
        • Ringeval M
        • Wagner G
        • Denford J
        • Paré G
        • Kitsiou S
        Fitbit-based interventions for healthy lifestyle outcomes: Systematic review and meta-analysis.
        J Med Internet Res. 2020; 22: e23954
        • Rounsaville BJ
        • Carroll KM
        • Onken LS
        A stage model of behavioral therapies research: Getting started and moving on from stage I.
        Clin Psychol Sci Pract. 2001; 8: 133-142
        • Semanik P
        • Lee J
        • Pellegrini CA
        • Song J
        • Dunlop DD
        • Chang RW
        Comparison of physical activity measures derived from the fitbit flex and the ActiGraph GT3X+ in an employee population with chronic knee symptoms.
        ACR Open Rheumatol. 2020; 2: 48-52
        • Shin G
        • Feng Y
        • Jarrahi MH
        • Gafinowitz N
        Beyond novelty effect: A mixed-methods exploration into the motivation for long-term activity tracker use.
        JAMIA Open. 2019; 2: 62-72
        • Smith BH
        • Fors EA
        • Korwisi B
        • Barke A
        • Cameron P
        • Colvin L
        • Richardson C
        • Rief W
        • Treede R-D
        • The IASP Taskforce for the Classification of Chronic Pain
        The IASP classification of chronic pain for ICD-11: Applicability in primary care.
        Pain. 2019; 160: 83-87
        • Sturgeon JA
        • Dixon EA
        • Darnall BD
        • Mackey SC
        Contributions of physical function and satisfaction with social roles to emotional distress in chronic pain: A Collaborative Health Outcomes Information Registry (CHOIR) study.
        Pain. 2015; 156: 2627-2633
        • Teylan M
        • Kantorowski A
        • Homsy D
        • Kadri R
        • Richardson C
        • Moy M
        Physical activity in COPD: Minimal clinically important difference for medical events.
        Chron Respir Dis. 2019; 16147997311881642
        • Treede R-D
        • Rief W
        • Barke A
        • Aziz Q
        • Bennett MI
        • Benoliel R
        • Cohen M
        • Evers S
        • Finnerup NB
        • First MB
        • Giamberardino MA
        • Kaasa S
        • Kosek E
        • Lavand'homme P
        • Nicholas M
        • Perrot S
        • Scholz J
        • Schug S
        • Smith BH
        • Svensson P
        • Vlaeyen JWS
        • Wang S-J
        A classification of chronic pain for ICD-11.
        Pain. 2015; 156: 1003-1007
        • Tudor-Locke C
        • Craig CL
        • Brown WJ
        • Clemes SA
        • De Cocker K
        • Giles-Corti B
        • Hatano Y
        • Inoue S
        • Matsudo SM
        • Mutrie N
        • Oppert J-M
        • Rowe DA
        • Schmidt MD
        • Schofield GM
        • Spence JC
        • Teixeira PJ
        • Tully MA
        • Blair SN
        How many steps/day are enough? For adults.
        Int J Behav Nutr Phys Act. 2011; 8: 79
        • Umeda M
        • Kim Y
        Gender differences in the prevalence of chronic pain and leisure time physical activity among US adults: A NHANES study.
        Int J Environ Res Public Health. 2019; 16: 988
        • Westfall P
        • Troenfle J
        • Pennello G
        Multiple McNemar Tests.
        Biometrics. 2010; 66: 1185-1191
        • Williams GC
        • Gagné M
        • Mushlin AI
        • Deci EL
        Motivation for behavior change in patients with chest pain.
        Health Educ Emerald Group Publishing Limited;. 2005; 105: 304-321
      6. World health organization: Guidance on community mental health services: promoting person-centred and rights-based approaches [Internet]. Guid. Tech. Packag. Community Ment. Health Serv. Promot. Pers.-Centred Rights-Based Approaches. Geneva: World Health Organization; 2021 [cited 2022 Mar 23]. Available from:

      7. World Health Organization: Physical activity [Internet]. 2020. Available from:

        • Zhaoyang R
        • Martire LM
        • Darnall BD
        Daily pain catastrophizing predicts less physical activity and more sedentary behavior in older adults with osteoarthritis.
        Pain. 2020; 161: 2603-2610