Patients Chronic Pain due to Hypermobility

Pacing for Therapists

Lorraine Jacobs

Lorraine Jacobs

Post-viral fatigue has become very real for many people recovering from Covid-19, and many have not been able to return to their previous levels of activity. Often fatigue is triggered by the simplest of daily activities, and when they push hard to finish a task. Afterwards they may be exhausted and take hours or even days to

recover. We call this “boom-and bust behaviour”, and the cost of getting things done (boom) is persistent exhaustion (bust). Fatigue and persistent pain may often occur together and are managed in the same way.

Pacing for Therapists

With careful planning we can help people cope through this stage, and gradually start to increase their levels of activity. The aims is to reduce overactivity / underactivity cycling (fluctuating between high and low levels of activity) in order to improve  overall function and reduce the likelihood of exacerbating symptoms.

An activity pacing programme includes the following stages – the 4 Ps:


Setting some meaningful goals helps to give the person something to work towards.

This approach moves away from a symptom-contingent pacing strategy (that is pushing through and stopping when tired) as this often leads to symptom-led and potentially disabling behaviours. A quota-contingent pacing approach is based on time or tasks, and involves setting goals with a view to gradually increasing  activity levels, rather than reducing fatigue or other symptoms. This type of activity planning programme is in line with our current understanding of pain neuroscience.

Step 1 Planning – identifying WHAT activities and WHEN to do them.

The aim is to encourage consistent activity levels, and avoid the “boom-bust” scenario.

What activities?

Sit down together with some large sheets of paper or a whiteboard, a pen and some highlighters. Explain the approach. List all his or her daily tasks or activities, weekly activities, monthly activities and any special outings or fun events coming up soon. Highlight any essential daily activities. In a different colour highlight activities that other people can help with.

When can these activities be done?

Develop a plan of how any essential repetitive daily activities can be spread throughout a day. This could include changing the time of an activity, for example having a bath or shower in the evening rather than trying to fit it in during a busy morning. Meal preparation can be broken in to smaller tasks , for example the potatoes for an evening mead can be peeled in the morning (or not peeled at all). Weekly activities should be spread across the week, so that there is only one activity a day.

This stage is about identifying unhelpful behaviours and making adjustments. Family and friends can also be included in this planning stage, to get them to commit and or assist in the process.

Step 2 Prioritising – How IMPORTANT is the activity? How URGENT is it?

If the person’s “to-do” list still looks a bit full you may need to help with prioritising activities. Some daily activities are necessary, but others aren’t. A matrix can be a useful tool to prioritise activities:

Urgent Not urgent
Important Do it Schedule it
Not important Delegate it or find someone to help you with it Eliminate it

Decide which activities are worth expending, valuable supply of energy on based on :

  • What has to be done today? (Urgent and important)
  • What do you want to do today? (Important but not urgent)
  • What can be put off until another day? (Important but not urgent)
  • What can you ask someone else to do ? (Urgent but not important)
  • Any activity that is not urgent or important is probably a waste of valuable resources.

Step 3 Pacing – How to break up activities into manageable portions. Setting a baseline – this is the HOW

Step 1 was to ensure that there were no overloaded days

Step 2 was to ensure that activities were prioritised according their importance and urgency.

Step 3 is to ensure gradual increases in activity and avoiding the dreaded exhaustion.

This involves close monitoring of individual activities during a day, using a time-

based approach to determine the ideal periods of activity and rest “snacks”.

  • Select an activity in the urgent and important
  • What the maximum time that can be spent on this activity before fatigue sets in (not exhaustion). Note this time period, and reduce by 20% as a baseline for this
  • Or if this is too hard can experiment with the
  • Remind them that fatigue accumulates, and may only occur after activity, so the aim is to stop before pushing too hard and depleting their the energy store.
  • How long would they need to rest to recover from the activity?

Important points about the activity baseline

The baseline level should be safe and achievable so that the person can start with

a successful experience.

  1. If your activity baseline cannot be done five days per week then is too
  2. Some days your exercise may seem easy and it is tempting to do more. Don’t.

Stick to the baseline to avoid a boom-bust pattern.

  1. Do what you have planned to do, not what you feel you can do. It is important that your activity is undertaken at an easy and gentle pace. Increases in exercise duration and intensity will come
  2. You should take a short rest after exercise. This gives time for your muscles and cardiovascular

system to recover before your next activity and allows you to relax. Avoid resting for longer than 30 minutes, and rest in a sitting position.

What is a normal response to exercise?

You may be worried about what is a normal compared to an abnormal response to exercise.

Increases in breathing rate, heart rate and sweating are all normal, temporary responses to physical activity and exercise. Your muscles can feel heavy after exercise, and you may feel physically tired.

A mild stiffness in the muscles is also normal after exercise and is associated with positive changes in muscle strength. It does not indicate harm to your body and will gradually lessen over a few days. A warm bath followed by gentle stretching may help you feel more comfortable.

Step 4 What are some goals that they would like to work towards? This gives us the WHY

Set some meaningful and realistic goals to work towards. These can be activity related or sports related, depending on the individual’s needs, wants and preferences.

Step 5. Progressing activities?

Once the first week of activity/exercise at the baseline level is completed the person can start to increase the duration of exercise very gradually week by week. The increase in the length of time of exercise per day should be no more than 20%, an amount that your body can tolerate.

So – if the current exercise time is five minutes per day, then a 20% increase takes the time up to six minutes (added minutes: 5 x 0.2 = 1 minute).

Increase time first:
Progressing activities
The intensity – for example speed or load should only increase only once the exercise time has reached 30 minutes 5x/week. Increases should remain at weekly intervals. It is a good idea to set up a schedule of exercise and set the target or    goal to be achieved each week. These increases can be monitored using the Borg Scale of exertion.

Flare ups happen!

 Despite the 4Ps flare-ups can and do happen. These are normal, and not a sign of damage, but remind us that the protective systems of the body are still on high alert! They are often triggered by other things such as stress, or a bad night, or a disagreement with a someone. Understanding this can reduce the likelihood and intensity of flare-ups.

To manage a flare up – don’t stop being active, but rather return to a previous dose (which they know was safe) and reduce the increment of progression. Once the flare-up has settled the level of activity can be built up again.

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