From my usage of the word ‘pacing’, it should not require people to leave a task half-done if they do not want to. Or is that paternalistic? Do you think that people are “medicalising lives” when the aim is to explain and understand why some people experience greater disability and distress than others, despite reporting the same pain intensity? The “5 minute break” was obligatory for everyone every 45 minutes, there was no rationale for using it, it interrupted flow, and people HATED it. Moderate exercise increases expression for sensory, adrenergic, and immune genes in chronic fatigue syndrome patients but not in normal subjects. Surely if researchers are claiming to use their biopsychosocial expertise to help patients, and yet the most significant impact of their work is to cause social harm, that’s a fair reason to be critical of the biopsychosocial approach. These deviations from the trial’s protocol have led to a situation in which the trial’s two primary outcome measures would allow a patient to be classed as ‘recovered’ even if they had reported a worsening of symptoms. BTW Soula has given her permission for me to share her video with my students. There is good evidence that psychosocial management using a biopsychosocial model helps people. The way people fill in questionnaires can be easily affected by psychosocial manipulation and management, but more objective and reliable measures of health seem to respond less readily. Andrews, Strong & Meredith (2012) completed a systematic review of activity pacing in relation to avoidance, endurance and functioning. Today I hope to add to that by summarising a few of these recent papers, and discussing some findings from my PhD research. Activity Pacing in Chronic Pain: Concepts, Evidence, and Future Directions. 2011], Another study of interest posed the question: “can physiological concentrations of metabolite combinations (protons, lactate and ATP) evoke sensations of fatigue when injected into skeletal muscle?” Indeed, low concentrations of these metabolites evoked sensations related to fatigue, whereas higher concentrations evoked pain. … The source suggested that successful treatments could reduce the numbers of people with mental health issues claiming the benefits by up to 90 per cent.”, “These people readily acknowledged they didn’t rely on waiting for a cure or pain relief, but actively sought ways to get on with life.”. I don’t think that using the BPS has resulted in more harm than good. A similar approach should be taken with pharmaceutical and other interventions, I’ve just focused more on biopsychosocial management above. It seems ludicrous for a government to embark upon an experiment in social engineering that is based upon his “model”. American Journal of Occupational Therapy, 62(3), 329-334. * psychology :135, technique for managing fatigue or pain levels in people with chronic illnesses or disabilities, https://en.wikipedia.org/w/index.php?title=Pacing_(activity_management)&oldid=981267998, Short description with empty Wikidata description, Articles with unsourced statements from May 2020, Creative Commons Attribution-ShareAlike License, choosing activities based on available energy, This page was last edited on 1 October 2020, at 08:51. People with chronic pain indicate that they use pacing in studies within the qualitative literature. In the accompanying editorial it was claimed that the trial showed a recovery rate of 30%, using a “strict criterion” for recovery: “a score for both fatigue and physical function within the range of the mean plus (or minus) one standard deviation of a healthy person’s score”. Learn how your comment data is processed. “Most existing analgesics for persistent pain are relatively ineffective, have a high side effect burden or abuse liability and, more important, do not reduce pain in all treated individuals. I think that discussions around dualism often require a lot of work, as it’s easy for people to use words in slightly different ways. Pacing is commonly used to help manage conditions that cause chronic pain or chronic fatigue. They used “anything that works” and picked and chose from all the various resources available. These involve pacing your exercise and daily activity so as not to flare-up your pain levels and gradually expand your physical activity. It was a computerised system that stopped the keyboard for five minutes with no over-ride. You can have confidence there is a high level of evidence that pacing works for many people living with chronic pain. Thanks Bronnie. I think that you’ve misunderstood me though. @ John Quintner: Thanks for mentioning your paper. 65 and under: was part of the entry criteria, and taken to indicate that a patient’s fatigue was “severe and disabling”, as required by the Oxford criteria for CFS. Eindt, thank you for your valuable contributions on issues that are dear to my heart but go way beyond the context of this discussion. What if they don’t want to participate in these approaches? that it gained real importance. A political problem if ever there was one. I’m a bit daunted by the volume of your reply, and in view of my own limitations as an individual and a person with chronic pain, I’m not going to respond to what you’ve said. Unfortunately, the PACE trial had dropped actometers as an outcome measure, even though the devices had been bought and used at the outset of the trial. I wrote about that a few months ago. And I’ve found that people have a great deal of trouble telling other people that they need to pace, because they feel judged and afraid they will be seen as shirking if they do so. In our 2008 paper (Pain Medicine and its Models: helping or hindering) we made the point that in practice this so-called model too easily defaulted to “biomedical,” with its inherent dualistic (body/mind) thinking. I think it is a much more complex matter than is first apparent. For many people, identifying what a person CAN do is incredibly difficult – what’s the difference between hurts and harms? . – I’m aware of the PACE trial. I think that they should have access to a safe place to live, and a liveable income. This study used actigraphy to monitor movements, and correlated this data with self-reported pain and fatigue. Jamieson-Lega, Berry and Brown (2013) scanned the literature and sought feedback from stakeholders from a range of disciplines, and developed a concept map for the term. Aylward has recently been on tour with you, and I’ve noticed a few NZ disability campaigners attacking him and his work. I think it’s made people’s lives worse and has been used to promote quackery. http://occupylondon.org.uk/scrap-atos-10000-cuts-and-counting/ I’m not sure how reliably one can tie these sorts of deaths to the biopsychosocal reforms implemented, but there certainly have been a number of deaths and suicides reported that do seem to be very directly linked. Social constructs are far more complex (I think I’ve said that before). Self-management – the process of using pacing involves independently integrating the practice once the skill has been developed. Exp Physio 2014; 368-380. Eindt, thanks for your insights. Brain, Behav Immun 2012; 26: 1202-1210. All manner of claims were made about how biopsychosocial welfare reforms would help remove perverse incentives, encourage people to take control of their lives, and empower the sick and disabled… we’ve recently seen figures showing that even fewer people are now moving from disability benefits into work than they were previously. Bronnie, one good way to begin to tackle this problem might be to show (with her permission) Soula Mantalvanos’ short film – The Hurting Strings – to medical students well before they complete their course. I don’t think the notion of responsibility arises from an artificial attempt to add something in that isn’t present already – my reading of the literature suggests that it’s when these unwritten rules are violated by people (eg they “look too well”, or “they’re not recovering fast enough”) that the general population becomes frustrated and can’t understand why the person is “breaking the rules”. is a concept some doctors and many other health professionals struggle with. I can’t respond to the use of it in policy, it’s not my area of expertise – but again, why write off a useful model simply because some people misuse it, and more to the point, what do we replace it with? Of course, with a more functional hat on, I’d like to see “exercise” considered equivalent to “activity” or “occupational engagement” because this invokes lots of those wonderful contextual elements including motivation, emotion, cognition and so on – and it’s more directly relevant to daily life and reducing disability. I think your depiction of the biopsychosocial model/framework as reconceptualising the sick role is not accurate. “understanding and accepting that hurt doesn’t equal harm”. * chronic pain management @John, I think that was a comment/amendment made in the Australasian version of the endorsement. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. The Minister for Welfare reform said that their approach is founded on the biopsychosocial model. Aylward helped to fund this large and expensive biopsychosocial CFS trial through his role of DWP CMO, and attended the trail’s steering committee meetings as an observer, along with another DWP official. To improve your fitness, you need to undertake a little more each week and move your baseline up. Maybe we just don’t know? Bronnie, thank you for an excellent summary of the current literature on pacing in relation to coping with being in pain. How do you think medical educators can help new doctors refrain from dualist thinking? Hence I suggest to people that they consider their condition to be something like the canary in the mine, or an early warning system to indicate that, for them, their lifestyle could do with a little adjustment, or they need to build up or down to the level of “stress” they’re exposed to. You had already covered it here: https://healthskills.wordpress.com/2011/04/27/working-inside-the-envelope-or-pushing-the-boundaries/. “Overall, present treatment options result in modest improvements at best, & part of chronic pain management should include dialogue with the patient about realistic expectations of pain relief, & bring focus to improvement of function … Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients … do not always occur with concurrent improvement in function … These results suggest that none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain & to have a major effect on physical & emotional function in most patients with chronic pain. These people readily acknowledged they didn’t rely on waiting for a cure or pain relief, but actively sought ways to get on with life. :135 Pacing typically involves: Pacing has been used to help manage a wide variety of different illnesses and disabilities, including neuromuscular diseases like Charcot-Marie-Tooth disease (CMT), rheumatoid or immune-mediated diseases like rheumatoid arthritis, juvenile arthritis and fibromyalgia, chronic fatigue syndrome, and Ehlers–Danlos syndromes (EDS). , In many health conditions, there are no clinical trials to establish the effectiveness of pacing.
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