Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis

Arch Phys Med Rehabil. 2012 Nov;93(11):2109-2121.e7. doi: 10.1016/j.apmr.2012.05.029. Epub 2012 Jun 21.


Objective: To systematically review the associations between different approaches to activity (ie, activity pacing, avoidance, or endurance) and indicators of patient functioning in chronic pain samples.

Data sources: A key word search was conducted in PsycINFO, MEDLINE via Ovid, EMBASE, and PubMed up to March 2011.

Study selection: To be included, studies had to (1) be written in English, (2) report on an adult chronic pain sample, and (3) report a correlation coefficient between at least 1 measure of 1 of the 3 "approach to activity" variables and an indicator of patient functioning.

Data extraction: Two reviewers independently screened abstracts and full-text articles for eligibility and extracted the data. Results of correlation analyses were grouped on the basis of measure of approach to activity (pacing/avoidance/endurance) and the criterion variable measured (pain/physical functioning/psychological functioning), resulting in 9 categories. Random-effects modeling was then used to pool data across studies in each category.

Data synthesis: Forty-one studies were eligible for inclusion. Results demonstrated that avoidance of activity was consistently associated with more pain, poorer psychological functioning, and more physical disability. While enduring with activity was associated with enhanced physical and psychological functioning, these relationships appeared to be dependent on the measure used, with measures more reflective of persisting with activities to the point of severe pain aggravation (overactivity) linked to poorer outcomes. Pacing was generally linked to better psychological functioning but more pain and disability.

Conclusions: Although causation cannot be determined, results of this study suggest that both avoidance of activity and overactivity are associated with poorer patient outcomes. Unexpected results relating to pacing may reflect either the ineffectiveness of pacing if not used to gradually increase an individual's activity level or the notion that individuals with better psychological functioning but more pain and disability are more inclined to pace activity.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Adaptation, Psychological
  • Anxiety / psychology
  • Avoidance Learning*
  • Chronic Pain / psychology*
  • Depression / psychology
  • Disabled Persons / psychology*
  • Humans
  • Mobility Limitation
  • Motor Activity*
  • Physical Endurance*
  • Stress, Psychological / psychology