Living with chronic pain can take away your sense of self. Things you once enjoyed doing may seem impossible now with the ebb and flow of your pain condition.

While playing with your kids at the park or going for long bicycle rides again may feel like only a daydream, working with your medical team to create activity modification and pacing plans can help you regain some of your quality of life.

Activity modification and pacing are unique in that they can provide benefit to almost everyone living with chronic pain, regardless of their condition or pain level—and they can look different for everyone. They include both a physical and emotional component, so individuals with pain may work with a physical therapist, occupational therapist, pain psychologist, or other mental health practitioner to implement these strategies. And there are plenty of ways to do them at home.

When pain limits movement and activity, an instinctive response may be to stop moving altogether—but that can actually make things worse, explains Rachel Zoffness, MA, MS, PhD, a pain and health psychologist and assistant clinical professor at the UCSF School of Medicine who frequently utilizes pacing strategies with her patients.

“A lot of things change when we have pain, but what research shows is that over time, a reduction in activity also will amplify pain,” Zoffness shares in an interview with the Run Smarter podcast. “While that strategy is great for a short-term, acute injury like a broken bone or a muscle tear, it actually is really bad for a chronic pain condition. So, behavioral strategies are: What can we do to change the way you’re managing pain, and what can we do better?”

Here’s what you need to know about activity modification and pacing.

Activity Modification: Helping You Move Again

Among the 2,275 individuals living with chronic pain who participated in U.S. Pain Foundation’s 2022 “A Chronic Pain Crisis” survey, activity modification was a top pain management strategy across many classes of conditions and pain levels. In fact, 73% of respondents said they find activity restriction or modification to be a helpful tool in managing their pain.

Activity modification may include removing an activity that leads to a pain flare or alternating it with lower-impact activities, such as walking one day and swimming or strength training the next. Equipment or assistive technologies may also make a certain activity or task more possible for individuals with pain. Some researchers and providers use augmented reality and virtual reality tools to help reduce or distract from chronic pain. Ergonomic or mobility devices can also make workspaces and home lives more accessible.

“The primary goal [of activity modification] is to have less pain interference, and to have greater function and greater control and autonomy over your pain,” says Christopher Joyce, PT, DPT, PhD, assistant professor in the School of Physical Therapy at Massachusetts College of Pharmacy and Health Sciences.

That starts with a thorough screening to ensure an activity is not causing additional damage to the physical and anatomical structures. Once a medical specialist clears a patient to participate in an activity, they can begin an activity modification plan.

Joyce uses a traffic light analogy to guide activity modification. First, identify the activity you want to do—such as climbing several flights of stairs or going for a walk. If you can do that activity with no increase in pain, or only a slight increase (for instance, 1 or 2 points on a 10-point scale) that eases quickly, then that’s a green-light activity—you can continue progressing it.

If you do the activity and your pain increases 1 or 2 points during or after the activity but returns to the original pain level after 24 to 48 hours, that’s a yellow light—stay at the same amount of the activity you did.

If you do the activity and the pain increases by more than 2 points and does not subside within 48 hours, that’s a red light—modify the activity in a way that makes it easier the next time you try it.

Modifications to the activity depend on the activity itself, but may include: doing less of it, doing it slowly, breaking it up and completing it in pieces (for example, taking one flight of stairs and then taking the elevator), or doing it with assistance (for example, using a cane or leaning on the hand rail), Joyce explains.

“It’s a lot of practicing and figuring out how to modify, but still engage in, the activities of your life that are meaningful to you,” he shares.

Pacing Plans: Gradual Exposure, Greater Freedom

Pacing strategies help people living with chronic pain gradually build endurance so that they can enjoy the activities they value most—more often and for longer periods of time. This therapy is not about pushing through the pain or a “no pain, no gain” mentality, Zoffness shares in an article she wrote for Psychology Today. However, some initial spikes or flares are to be expected and monitored.

“With pacing, the idea is to gradually increase the load or tension on tissues, allowing them proper rest and recovery time to break down and then build back up,” says Jeremy Skeens, PT, DPT, a physical therapist and clinic director at KC Rehab in Kansas City. “Patients often experience flare-ups and symptoms, and without knowing that that is a normal response to activity, they become reclusive to future endeavors… Oftentimes, it takes somebody who is well-educated and well-versed in explaining pain to the patient.”

Pacing is both a physical and psychological strategy. In addition to training the body to adapt to increased levels of activity, it also rewires the brain to adjust to those same changes, shares Zoffness, who outlines step-by-step pacing guidelines in her book, The Pain Management Workbook.

She likens pacing to training for a marathon. Most people would not wake up and try running 26 miles all at once without months of training—pacing is much the same.

“You have to do little bits at a time to get your brain and body ready for this race,” she explains to Run Smarter, noting that pacing plans can involve any type of activity, even fudge-making.

“A pacing plan for fudge-making might literally be, get off the couch and find Grandma’s fudge recipe in the kitchen and write down all the ingredients,” Zoffness tells Run Smarter. “That might be step one of our pacing plan. And step five of that plan might be, get in the car and drive to the grocery store… because that’s very hard for some people living with pain. So, it depends on your goal, and it depends on where you’re at.”

Getting Started

Physical therapists such as Joyce and Skeens work with other providers to incorporate activity modification and pacing into a patient’s personalized pain management plan. Pain psychologists such as Zoffness often are involved in the process as well, since there is a psychological aspect (and benefit) to incorporating these strategies. This multidisciplinary approach is an ideal way for people living with chronic pain to grab their condition by the reins and improve their day-to-day lives. It takes work, and it takes a team.

“The problem, of course, for all of us is we are all impatient,” Zoffness tells Run Smarter. “We all want a magic pill, and I include myself in this, too. Who doesn’t? Pain sucks.”

She adds, “The secret is, there’s no magic bullet.”

Learn More

As you use activity modification and pacing strategies to continue doing the activities you love, there are several activities Zoffness recommends for many individuals living with chronic pain.

These activities can be completed at various levels, modified as needed, and gradually increased through pacing. They include walking outdoors, stretching, Tai Chi, and more. Check out the full list here.

—Ashley Hattle

To learn more about the U.S. Pain Foundation’s Pain Awareness Month initiative, click here.