OBJECTIVES: Operant approach activity pacing (undertaking activities according to quotas, eg, amount/time/goal rather than according to symptom severity) is advised for chronic pain. There is no standardised intervention that addresses all the components of operant approach activity pacing. This systematic review aimed to identify operant approach activity pacing interventions for chronic pain and explore their components, effectiveness, feasibility, and acceptability.
METHODS: Eligible studies included any type of evaluation (eg, randomised controlled trials, feasibility/pilot, and qualitative) among adults with chronic pain. Ineligible studies included interventions based on energy conservation/envelope theory/adaptive pacing therapy/symptom-contingency, and non-English language. Databases included: MEDLINE, Embase, CINAHL, AMED, PsycINFO, Cochrane CENTRAL, PEDro, OTseeker, and Web of Science (from database inception to March 26, 2025). Two independent reviewers extracted data, including descriptions of interventions (TIDieR checklist), appraised risk of bias (Joanna Briggs Institute checklists) and evaluated confidence in the research (GRADE). Findings were synthesised narratively.
RESULTS: Nine studies (10 interventions; 11 papers) were included (873 participants). Interventions were heterogeneous in content, length (2 to 11 sessions) and tailored/untailored to participants' baseline behaviors. Common intervention components were preplanning, activity-rest cycling/using rests and alternating activities/positions. Direction of effect (vote counting) was towards improved function, but mixed findings for pain/fatigue.
DISCUSSION: Studies showed mixed findings across outcomes, syntheses were limited to vote counting, with very low confidence in the evidence, limiting conclusions about effectiveness. The multiple components of activity pacing can be considered to further develop and test the effectiveness of operant activity pacing for chronic pain.
| Discipline Area | Score |
|---|---|
| Rehab Clinician (OT/PT) |  |
| Physician |  |
Physician rater
This systematic review found limited, low-certainty evidence for operant activity pacing in chronic pain. Across 9 studies, pacing interventions were associated with possible improvements in physical function, but effects on pain and fatigue were inconsistent. Although the review methods were rigorous, the included studies were generally small, heterogeneous, and at high risk of bias, preventing firm conclusions about effectiveness.
Physician rater
Pacing is supported by low empirical evidence. Operant (quota-contingent) pacing does not reduce baseline pain, only flare-ups. Acceptability is generally high; however, common barriers include habits, work and family demands, and the misconception that pacing requires slowing down. Limitations: vote counting only; high risk of bias (no blinding, unclear allocation concealment, no intention-to-treat); very low GRADE for pain/fatigue, low for function; small, predominantly female and white, English-speaking samples from high-income countries; 22 full texts unobtainable. No cost-effectiveness data; adverse events reported in only one study.
Physician rater
The evidence base is limited; however, there are practical implications: use pacing alongside multimodal rehabilitation instead of as a standalone method, set goals based on specific quotas rather than symptoms to improve focus and effectiveness, emphasize personalized goal-setting and activity diaries over device use for tailored care, and add booster sessions to sustain progress. Future RCTs should standardize protocols and incorporate validated pacing scales to enhance reliability and results.
Physician rater
This systematic review found limited, low-certainty evidence for operant activity pacing in chronic pain. Across 9 studies, pacing interventions were associated with possible improvements in physical function, but effects on pain and fatigue were inconsistent. Although the review methods were rigorous, the included studies were generally small, heterogeneous, and at high risk of bias, preventing firm conclusions about effectiveness.
, McMaster University