Rheumatoid arthritis can make activities more difficult to accomplish. It can cause severe fatigue and pain. RA can also complicate how you manage to divvy up your time each day, much less find time to exercise or stay physically active.
In a recent study, researchers in the Netherlands asked the question - "Are people with rheumatoid arthritis who undertake activity pacing at risk of being too physically inactive?" (Cuperus, 2012). (subscription may be required)
"Pace Yourself" - That’s what many of our doctors or physical therapists tell us to do. Stop before you wear yourself out or cause physical injury. Don’t overdo it.
Sounds good to me.
What is Activity Pacing?
Activity pacing is a common strategy taught in pain management programs whereby you can tackle a task by going slower and taking breaks or breaking activities into smaller pieces (Murphy, 2008). Rachel Feinberg, PT, writes that "pacing is not about decreasing the intensity of an exercise, doing less activity, or being unproductive. Pacing is actually the exact opposite. Pacing is a tool that allows you to change the way you perform or complete an exercise or activity so that you can successfully increase strength, tolerance, and function." (Feinberg, 2008)
In a small pilot study involving persons with osteoarthritis, the use of activity pacing was associated with less physical activity. Reports of going slower, taking breaks, and breaking activities into smaller pieces were reflected in lower levels of physical activity. Many of the participants who used higher amounts of pacing techniques were the same participants who reported higher levels of pain and fatigue throughout the day (Murphy, 2008). It may be that pacing yourself is a natural reaction to pain and fatigue.
Inactivity in RA Patients
In a study involving 5,235 RA patients across 21 countries, only 13.8% of all patients reported physical exercise (i.e., â‰¥ 30 minutes with at least some shortness of breath and sweating) 3 or more times weekly. The majority of the patients were physically inactive with no regular weekly exercise. Greater than 80% of RA patients in 7 countries received no regular physical activity, 88.1% in Argentina. In 12 countries, 60-80% RA patients were inactive with 68.8% in USA reporting no regular physical exercise. In Finland, 32.1% RA patients exercise more than 3 times weekly, with an additional 39.1% exercising once or twice weekly, leaving only 28.8% inactive (Sokka, 2008).
In a recent US study of RA patients, 42% of participants were inactive during a 7-day surveillance period. Inactivity was defined as "no sustained 10-minute periods of moderate-to-vigorous intensity physical activity" (Lee, 2012). Patients wore an accelerometer to collect data on their physical activity. Factors most strongly related to inactivity were lack of strong motivation for physical activity which nearly tripled the chances of being inactive (2.85:1) and lack of strong beliefs in the benefits of physical activity (2.47:1).
Dangers of Activity Pacing?
In the original study which caught my eye, Cuperus et al. "hypothesize that by instructing activity pacing, physical inactivity - rather than physical activity - is instigated." Researchers continue, "Therefore, 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." (Cuperus, 2012)
An interesting aspect of their research project was the division of the 30 participants into two groups: an adequate pacing group, comprising participants labelled as good or somewhat good activity pacers and a non-adequate pacing group, comprising participants labelled as bad or somewhat bad activity pacers.
What makes a good or bad pacer? Even the two assessors in the trial initially disagreed on the classification in 37% (11/30) of the cases. The authors do not suggest what makes a good vs. bad activity pacer. Ultimately, nine participants (30%) were categorized as adequate pacers, while 21 (70%) were non-adequate pacers. No significant differences were apparent in demographic or disease-related characteristics between groups.
Participants wore accelerometers to measure activity and 21% (6/29) were categorized as ‘sufficiently active’ according to the Dutch Physical Activity Norm. Each of these patients were also classified as non-adequate pacers. Conversely, all nine patients who classified as adequate pacers were not sufficiently active. Researchers found that non-adequate pacers were significantly more active than adequate pacers (p=0.025) (Cuperus, 2012).
Cuperus et al. conclude:
- Activity pacing is associated with undertaking less physical activity.
- Therapists should stop supporting activity pacing, but should start promoting physical activity and exercise.
- Commonly used methods to elicit patients’ activity patterns overestimate actual activity levels.
- People with rheumatoid arthritis are at risk of physical inactivity.
What do you think of this small research study? Do you feel that pacing yourself leads to being less active? How much exercise/activity do you really engage in each week?
Cuperus N, Hoogeboom TJ, et al. Are people with rheumatoid arthritis who undertake activity pacing at risk of being too physically inactive? Clin Rehabil published online 10 February 2012. DOI: 10.1177/0269215512437417
Feinberg R and Feinberg S. Pacing Means Moving Ahead and Not Falling Behind. The American Chronic Pain Association (ACPA) Chronicle, December 2008. Reprinted at http://www.cfidsselfhelp.org/library/pacing-means-moving-ahead-and-not-falling-behind
Lee J, et al. The public health impact of risk factors for physical inactivity in adults with rheumatoid arthritis. Arthritis Care & Research 2012; DOI: 10.1002/acr.21582
Murphy SL, Smith DM, Alexander NB. Measuring Activity Pacing in Women With Lower-Extremity Osteoarthritis: A Pilot Study. Am J Occup Ther. 2008;62(3):329-334.
Sokka T, et al. Physical Inactivity in Patients With Rheumatoid Arthritis: Data From Twenty-One Countries in a Cross-Sectional, International Study. Arthritis & Rheumatism (Arthritis Care & Research) 2008;59(1):42-50. DOI 10.1002/art.23255
Lisa Emrich is a patient advocate, accomplished speaker, author of the award-winning blog Brass and Ivory: Life with MS and RA, and founder of the Carnival of MS Bloggers. Lisa uses her experience to educate patients, raise disease awareness, encourage self-advocacy, and support patient-centered research. Lisa frequently works with non-profit organizations and has brought the patient voice to health care conferences and meetings worldwide. Follow Lisa on Facebook, Twitter, and Pinterest.