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== Scientific evidence == ===In ME/CFS === Pacing has been used in several multi-component treatment trials. In 1996 Goudsmit conducted a controlled trial for patients with post-infectious fatigue syndrome. Pacing was one component of a multidisciplinary treatment protocol prescribed by Darrel O. Ho-Yen<ref>Ho-Yen DO. Better recovery from viral illnesses. 3rd ed. Inverness: Dodona Books, 1993.</ref> which also included medical care, emotional support and advice on avoiding stress. More than 80% of patients reported feeling better. At 6 months there was a significant difference between controls on outcome measures such as fatigue or self-efficacy. Twenty-three percent of the patients had improved to such a degree that they were discharged.<ref name=":2" /><ref name=":3" /> In 2004 [[Renee Taylor]] offered a similar multidisciplinary program to 47 ME/CFS-patients in a randomized clinical trial.<ref name=":4" /> This study was part of the Chronic Fatigue Syndrome Empowerment project, a federally funded research project designed to develop and evaluate the effects of a consumer-driven rehabilitation program for individuals with chronic fatigue syndrome. Participants received four months of illness management groups followed by seven month one-on-one self-advocacy training. Besides pacing the program focused on economic self-sufficiency, coping skills and nutritional advice. Results indicated that overall quality of life had significant improved in the treatment group – a remarkable finding, since trials on cognitive behavioral therapy or graded exercise therapy, often fail to improve quality of life in ME/CFS patients.<ref>{{Cite book | url =https://www.ncbi.nlm.nih.gov/books/NBK379582/| title = July 2016 Addendum | last = Smith | first = M. E. Beth | last2 = Nelson | first2 = Heidi D. | last3 = Haney | first3 = Elizabeth | last4 = Pappas | first4 = Miranda | last5 = Daeges | first5 = Monica | last6 = Wasson | first6 = Ngoc | last7 = McDonagh | first7 = Marian | date = Dec 2014|publisher=Agency for Healthcare Research and Quality (US)|language=en}}</ref> Further evidence supporting pacing, comes from research on the [[Energy Envelope Theory|envelope theory]], an energy management strategy developed by Leonard Jason which is based on similar principles. Patients are advised to stay within the envelope; meaning the limits the disease has imposed upon them. Patients who over-exert themselves are advised to cut back while those who have been inactive for a long time are encouraged to gradually increase their activity. An analysis of the activity pattern of 144 ME/CFS patients showed that those who extend their activities beyond their energy envelope, experience more disability.<ref>{{Cite journal | last= Jason | first = Leonard | last2 = Muldowney | first2 = Kathleen | last3 = Torres-Harding | first3 = Susan | date = May 2008| title = The Energy Envelope Theory and myalgic encephalomyelitis/chronic fatigue syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/18578185|journal=AAOHN journal: official journal of the American Association of Occupational Health Nurses|volume=56|issue=5|pages=189–195|issn=0891-0162|pmid=18578185}}</ref> These results were confirmed in a larger 2017 study involving 429 patients from different locations.<ref name=":10">{{Cite journal | last = O'Connor | first = Kelly | last2 = Sunnquist | first2 = Madison | last3 = Nicholson | first3 = Laura | last4 = Jason | first4 = Leonard A. | last5 = Newton | first5 = Julia L. | last6 = Strand | first6 = Elin B. | date = 2017-01-01| title = Energy envelope maintenance among patients with myalgic encephalomyelitis and chronic fatigue syndrome: Implications of limited energy reserves|url=https://www.ncbi.nlm.nih.gov/pubmed/29231037|journal=Chronic Illness|pages=1742395317746470|doi=10.1177/1742395317746470|issn=1745-9206|pmc=5750135|pmid=29231037}}</ref> Furthermore, a prospective study of 44 patients who were part of a study on nonpharmacological interventions in ME/CFS, showed that “those who were within their energy envelope before treatment showed more improvement in physical functioning and fatigue compared to those outside of their energy envelope."<ref name=":11">{{Cite journal | last = Brown | first = Molly | last2 = Khorana | first2 = Neha | last3 = Jason | first3 = Leonard A. | date = Mar 2011| title = The Role of Changes in Activity as a Function of Perceived Available and Expended Energy in Non-Pharmacological Treatment Outcomes for ME/CFS|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164291/|journal=Journal of clinical psychology|volume=67|issue=3|pages=253–260|doi=10.1002/jclp.20744|issn=0021-9762|pmc=3164291|pmid=21254053}}</ref> In several large patient surveys, respondents indicated they’ve found pacing to be helpful in managing ME/CFS. A 1999 survey (n = 820) by the CFIDS Association of America (now Solve ME/CFS initiative) showed that 71% of patients rated pacing as helpful.<ref name=":5" /> In a survey conducted by Action for ME (n = 2338) in 2001, 89% of the respondents found pacing to be helpful.<ref name=":6" /> These results were confirmed in a follow-up study by Action for ME in 2008.<ref>{{Cite web|url=https://afme.wordpress.com/category/survey-2008/| title = Survey 2008 « Action for M.E.|website=afme.wordpress.com|language=en|access-date=2018-08-19}}</ref> {| class="wikitable" ! colspan="7" |Action for M.E.’s survey results on treatments in 2001 and 2008<ref name=":12">[https://www.actionforme.org.uk/uploads/pdfs/pacing-for-people-with-me-booklet.pdf Pacing for people with ME]. Action for ME. December 2013.</ref> |- ! ! colspan="2" |Helpful ! colspan="2" |No change ! colspan="2" |Made Worse |- | |2001 survey |2008 survey |2001 survey |2008 survey |2001 survey |2008 survey |- |Pacing |89% |82% |9% |15% |2% |3% |- |CBT |7% |50% |67% |38% |26% |12% |- |GET |34% |45% |16% |21% |50% |34% |} Another large survey set up by the ME Association (n =1428) showed patients preferred pacing over CBT or GET and judged this approach to be more appropriate to their needs. The survey concluded: <blockquote>“Pacing was consistently shown to be the most effective, safe, acceptable and preferred form of activity management for people with ME/CFS and should therefore be a key component of any illness management programme […]The benefit of Pacing may relate to helping people cope and adapt to their illness rather than contributing to a significant improvement in functional status.”<ref name=":7" /> </blockquote> === In the treatment of chronic pain === While pacing is a highly endorsed clinical strategy in the treatment of chronic pain, empirical evidence to support its effectiveness is currently lacking. Raichel et al. for example found that pacing was correlated with higher levels of pain interference in 157 patients with spinal cord injury.<ref>{{Cite journal | last = Raichle | first = Katherine A. | last2 = Hanley | first2 = Marisol | last3 = Jensen | first3 = Mark P. | last4 = Cardenas | first4 = Diana D. | date = Sep 2007| title = Cognitions, Coping and Social Environment Predict Adjustment to Pain in Spinal Cord Injury|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2045649/|journal=The journal of pain : official journal of the American Pain Society|volume=8|issue=9 | pages = 718–729|doi=10.1016/j.jpain.2007.05.006|issn=1526-5900|pmc=2045649|pmid=17611163}}</ref> In a study by Ersek et al. pacing was positively associated with physical disability and pain intensity in the elderly.<ref>{{Cite journal | last = Ersek | first = Mary | last2 = Turner | first2 = Judith A. | last3 = Kemp | first3 = Carol A. | date = Nov 2006| title = Use of the chronic pain coping inventory to assess older adults' pain coping strategies|url=https://www.ncbi.nlm.nih.gov/pubmed/17074625|journal=The Journal of Pain: Official Journal of the American Pain Society|volume=7|issue=11 | pages = 833–842|doi=10.1016/j.jpain.2006.04.002|issn=1526-5900|pmid=17074625}}</ref> Kindermans et al. reported a correlation between pacing and higher levels of disability and symptoms of depression. According to the authors, “this seems to suggest that pacing, as it is currently measured, might reflect a (hidden) form of avoidance behavior.”<ref>{{Cite journal | last = Kindermans | first = Hanne P. J. | last2 = Roelofs | first2 = Jeffrey | last3 = Goossens | first3 = Marielle E. J.B. | last4 = Huijnen | first4 = Ivan P.J. | last5 = Verbunt | first5 = Jeanine A. | last6 = Vlaeyen | first6 = Johan W.S. | date = Oct 2011| title = Activity patterns in chronic pain: underlying dimensions and associations with disability and depressed mood | url =https://www.ncbi.nlm.nih.gov/pubmed/21704568|journal=The Journal of Pain: Official Journal of the American Pain Society|volume=12|issue=10|pages=1049–1058|doi=10.1016/j.jpain.2011.04.009|issn=1528-8447|pmid=21704568}}</ref> Using accelerometers to track activity levels, Cuperus et al. were able to demonstrate in a more objective manner that pacing was associated with lower activity. This led the authors to conclude that “activity pacing might not only be ineffective, it might even be potentially harmful, as inactivity-related comorbidities increase the risk for mortality and negatively influence quality of life.”<ref>{{Cite journal | last = Cuperus | first = Nienke | last2 = Hoogeboom | first2 = Thomas J. | last3 = Neijland | first3 = Yvette | last4 = van den Ende | first4 = Cornelia Hm | last5 = Keijsers | first5 = Noël Lw| date = Nov 2012| title = Are people with rheumatoid arthritis who undertake activity pacing at risk of being too physically inactive?|url=https://www.ncbi.nlm.nih.gov/pubmed/22327885|journal=Clinical Rehabilitation|volume=26|issue=11|pages=1048–1052|doi=10.1177/0269215512437417|issn=1477-0873|pmid=22327885}}</ref> In a 2012 review Andrews et al. concluded that “pacing was generally linked to better psychological functioning but more pain and disability.”<ref>{{Cite journal | last = Andrews | first = Nicole E. | last2 = Strong | first2 = Jenny | last3 = Meredith | first3 = Pamela J. | date = Nov 2012| title = Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis|url=https://www.ncbi.nlm.nih.gov/pubmed/22728699|journal=Archives of Physical Medicine and Rehabilitation|volume=93|issue=11|pages=2109–2121.e7|doi=10.1016/j.apmr.2012.05.029|issn=1532-821X|pmid=22728699}}</ref> Since then, several explanations have been put forward to explain these bleak results. Susan Murphy argued that there might be a difference between how patients and clinicians view pacing. According to Murphy patients' intrinsic view on pacing is mostly symptom-contingent and directed at reducing pain, while those of clinicians is time-contingent and aimed at increasing activity levels.<ref>{{Cite journal | last = Murphy | first = Susan Lynn | last2 = Kratz | first2 = Anna Louise | date = Dec 2014| title = Activity pacing in daily life: A within-day analysis|url=https://www.ncbi.nlm.nih.gov/pubmed/25267209|journal=Pain|volume=155|issue=12|pages=2630–2637|doi=10.1016/j.pain.2014.09.028|issn=1872-6623|pmc=4353388|pmid=25267209}}</ref> An appropriate assessment of pacing should thus occur after instructions by a clinician, to account for these differences.<ref>{{Cite journal | last = Murphy | first = Susan L. | last2 = Clauw | first2 = Daniel J. | date = Jun 2010| title = Activity pacing: what are we measuring and how does that relate to intervention?|url=https://www.ncbi.nlm.nih.gov/pubmed/20381246|journal=Pain|volume=149|issue=3 | pages = 582–583|doi=10.1016/j.pain.2010.03.031|issn=1872-6623|pmid=20381246}}</ref> Murphy also suggested pacing should be tailored to the individual patient by using physiological measures obtained during an exercise test, as targets.<ref>{{Cite journal | last = Murphy | first = Susan L. | last2 = Lyden | first2 = Angela K. | last3 = Smith | first3 = Dylan M. | last4 = Dong | first4 = Qian | last5 = Koliba | first5 = Jessica F. | date = Nov 2010| title = Effects of a tailored activity pacing intervention on pain and fatigue for adults with osteoarthritis|url=https://www.ncbi.nlm.nih.gov/pubmed/21218677|journal=The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association|volume=64|issue=6 | pages = 869–876|issn=0272-9490|pmc=3655423|pmid=21218677}}</ref> Her ideas were tested in a large trial of 193 patients with osteoarthritis, but once again results were disappointing. Both the general and tailored pacing group, were worse off than the patient group receiving usual care.<ref>{{Cite journal | last = Murphy | first = Susan L. | last2 = Kratz | first2 = Anna L. | last3 = Kidwell | first3 = Kelley | last4 = Lyden | first4 = Angela K. | last5 = Geisser | first5 = Michael E. | last6 = Williams | first6 = David A. | date = Jul 2016| title = Brief time-based activity pacing instruction as a singular behavioral intervention was not effective in participants with symptomatic osteoarthritis|url=https://www.ncbi.nlm.nih.gov/pubmed/26963847|journal=Pain|volume=157|issue=7|pages=1563–1573|doi=10.1097/j.pain.0000000000000549|issn=1872-6623|pmc=4912409|pmid=26963847}}</ref> Because some studies<ref>{{Cite journal | last = Nielson | first = Warren R. | last2 = Jensen | first2 = Mark P. | date = Jun 2004| title = Relationship between changes in coping and treatment outcome in patients with Fibromyalgia Syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/15157683|journal=Pain|volume=109|issue=3|pages=233–241|doi=10.1016/j.pain.2004.01.002|issn=0304-3959|pmid=15157683}}</ref><ref>{{Cite journal | last = Cane | first = Douglas | last2 = Nielson | first2 = Warren R. | last3 = McCarthy | first3 = Mary | last4 = Mazmanian | first4 = Dwight | date = May 2013| title = Pain-related activity patterns: measurement, interrelationships, and associations with psychosocial functioning | url =https://www.ncbi.nlm.nih.gov/pubmed/23247000|journal=The Clinical Journal of Pain|volume=29|issue=5 | pages = 435–442|doi=10.1097/AJP.0b013e31825e452f|issn=1536-5409|pmid=23247000}}</ref> did find positive results for pacing in the treatment of chronic pain conditions, Deborah Antcliff argued that the term pacing, denotes several different aspects. In the Activity Pacing Questionnaire (APQ), the questionnaire she helped develop, 5 factors were differentiated: activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance.<ref>{{Cite journal | last = Antcliff | first = Deborah | last2 = Campbell | first2 = Malcolm | last3 = Woby | first3 = Steve | last4 = Keeley | first4 = Philip| date = Sep 2015 | title = Assessing the Psychometric Properties of an Activity Pacing Questionnaire for Chronic Pain and Fatigue|url=https://www.ncbi.nlm.nih.gov/pubmed/25908522|journal=Physical Therapy|volume=95|issue=9|pages=1274–1286|doi=10.2522/ptj.20140405|issn=1538-6724|pmc=4556956|pmid=25908522}}</ref> Research by Antcliff suggested that adjustment, acceptance and progression were associated with worsened symptoms, while consistency was correlated with improved symptoms.<ref>Antcliff DC. (2014). [https://www.escholar.manchester.ac.uk/api/datastream?publicationPid=uk-ac-man-scw:227500&datastreamId=FULL-TEXT.PDF The development of an activity pacing questionnaire for chronic pain and fatigue.] Phd thesis. Faculty of Medical and Human Sciences, University of Manchester. </ref> This has pushed Antcliff to promote the use of a time-contingent graded increase in activity levels, as an essential element in the definition of pacing.<ref>{{Cite journal | last = Antcliff | first = Deborah | last2 = Keeley | first2 = Philip | last3 = Campbell | first3 = Malcolm | last4 = Woby | first4 = Steve | last5 = Keenan | first5 = Anne-Maree | last6 = McGowan | first6 = Linda | date = Jul 2018| title = Activity pacing: moving beyond taking breaks and slowing down | url =https://www.ncbi.nlm.nih.gov/pubmed/29396652|journal=Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation|volume=27|issue=7|pages=1933–1935|doi=10.1007/s11136-018-1794-7|issn=1573-2649|pmc=5997723|pmid=29396652}}</ref>
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