Pacing in Chronic Pain Therapy (a.k.a. Doing Stupid Stuff in an Old House)

I live in an old house — like really old, 1884 to be exact, in one of the oldest parts of Saint Paul, the West Seventh Neighborhood, home to the largest garter snake population in Minnesota (I’m not sure about that, but it’s likely). There are a lot of projects in my old house. Mostly I like these projects, but sometimes they get me in trouble, or more accurately, I get myself into trouble. 

One of these projects involved an old screened-in porch that was, at the time, sporting three different colors of paint. Of course, I needed to paint it, and part of the painting involved painting the ceiling, which was beadboard, so there were hundreds of deep grooves in the ceiling, and hours of tilting my head backward, looking up. For someone with chronic neck pain, this was not a good project to take on.

Chronic Neck Pain and My Boom-Bust Cycle

I’m pretty sure some part of me knew I was in trouble almost immediately. And, I know there was a little voice in my head saying “don’t do it!” But, boy, was that ceiling ugly, and once I started, I didn’t want to stop. I painted that blasted ceiling for eight hours. My husband gently suggested that I stop halfway through and finish it the next day. I ignored him (Sorry, honey!).

Maybe for someone who hadn’t had a cervical spinal fusion 8 years ago and chronic neck pain, this would have been an uncomfortable project. For me, it was downright painful and led me right into a several-month-long pain flare. I ended up returning to physical therapy and taking more ibuprofen than I had in years. It was a powerful reminder to stay out of the boom-bust cycle.

Boom-Bust Cycle in Chronic Pain and Chronic Illness

Often when we deal with chronic pain or chronic illness, we get caught in what is called the “boom-bust” cycle. What does this mean? Essentially, you have a big spurt of activity, push yourself to your limits, and then you crash.

It makes sense that you would end up in this cycle — if you wake up and you’re feeling really good, and it’s been a while since you’ve felt good, naturally, you’d be excited. You can finally do what you’ve been wanting to do, so you do it. Or, maybe you just have something you’ve been wanting to do and are tired of letting the pain stop you. So, you push past the pain and then do it. But, then you pay for it, and you have to rest, usually for longer than you were active.

What’s Wrong with the Boom-Bust Cycle?

At a minimum, the boom-bust cycle leads to less activity and less functionality over time because you keep wearing yourself down.  Your life becomes less predictable because you don’t know if you’re going to be worn out from the day before. It gets harder to plan to social activities and fulfill obligations like work or parenting tasks. Worst case scenario, if you do something really stupid like paint a ceiling after a cervical spinal fusion, you could re-injure yourself or at least cause yourself a lot of pain.

Time-based Pacing vs. Activity-based Pacing

What to do instead? Instead of the boom-bust cycle, pacing is a much better alternative. Pacing is basically finding a way to slow down and/or limit your activity so that it helps you function better in the long run. Pacing comes in two forms, either time-based or activity-based. 

Activity-based Pacing

Most of us gravitate toward activity-based pacing. This means that you do the activity for as long as it takes to complete it. This can be problematic because instead of listening to your body’s limits, you pay attention to the demands of the task at hand. The problem is that the task at hand does not know what your body’s limits are, and often the limits of a task are beyond what one can reasonably do with chronic pain. 

It is possible to break down an activity into parts that are more manageable, like breaking down cleaning the bathroom into cleaning the toilet, cleaning the sink, mopping the floor, and doing these parts one at a time, resting between. This is much better than pushing yourself beyond your capacity to do it all at once, but this still is in the activity’s time, not yours.

Time-based Pacing

Time-based pacing, instead, is about figuring out how long you can comfortably do a task, and staying within those limits. This takes a bit of work in the beginning to figure out what your baseline limit is for the activities that tend to bother you. 

How to Do Time-based Pacing for Chronic Pain

Let’s say you wanted to establish a baseline for walking. Ideally, you would pick three different days (a mix of good days and bad ones) to see how long you can walk without pain. Your aim would be to measure how long you can walk before you feel pain. Then, add those times together and divide by three to get the average, then 80% of the average is your baseline.

 For example, if you can walk 20 minutes on the first day, 15 on the second day, and 30 on third day, you would have a total of 65 minutes. Divide by three to get 21.6 minutes, and multiply by .8 to get 17.28 minutes as your baseline. You can round up or down, it doesn’t really matter, but once you have your baseline, you know to stay within that limit most of the time. That doesn’t mean you have to limit yourself to 17.28 minutes of walking per day — it just means you need to rest or do another activity after about 17.28 minutes of walking before you start again.

Also, this does not mean you’re limited to only walking for 17.28 minutes at a time your entire life. The idea is, that over time, since you are not continually wearing yourself down, you are gradually building strength and stamina, so once you are quite comfortable regularly walking for 17.28 minutes at a time, you can experiment with adding a minute and seeing what it’s like to walk for 18.28 minutes at a time.

My Most Recent Painting Activity

I don’t paint ceilings anymore, but I did recently paint my living room. While time-based pacing was not something I implemented on this activity, I did make several improvements that made the experience a lot easier on my poor neck. 

Most importantly, I did not do this on my own. My mother offered to help, and I accepted her help. She flew all the way from Florida into snowy Minnesota winter just to help me with this project. I guess the cute grandkids were another reason to brave a St. Paul winter.

Also, since I know that looking up for extended periods of time makes my neck hurt, I asked my painting buddy to do the edge along the ceiling, while I did the edge along the baseboard. That helped a lot.

Finally, at the end of the painting day, I was exhausted. I had planned to make dinner to thank my mother for her help. However, my aching back and neck let me know that was not a great plan. So, with very minimal encouragement, I ditched those plans and we ordered pizza. For the next few days, I felt sore, but no medical attention or medication was needed. I successfully avoided the boom-bust cycle! Sometimes I can take my own advice.


ABOUT THE AUTHOR

Erin Brandel Dykhuizen, MA, MSW, LICSW is a psychotherapist who offers counseling for adults with PTSD, trauma symptoms, and chronic pain in St. Paul, Minnesota. She also works with individuals via remote, online counseling throughout the state of Minnesota. You can schedule an appointment and learn more about Erin’s Twin Cities therapy practice at erinbdlicsw.com, or reach Erin by phone at 651-998-8991.