Operant Learning Versus Energy Conservation Activity Pacing Interventions in a Sample of Fibromyalgia Patients: A Randomized Controlled Trial

Rational:

Activity pacing (AP) can be defined as "the regulation of activity level and/or rate in the service of a goal or goals" (Nielson, Jensen et Vlaeyen, 2012). This general coping strategy is widely used in chronic pain (CP) management both as a stand-alone treatment and as a component of multimodal treatment programs. However its potential benefits remain unproven; in fact, there is evidence that in some contexts, pacing may be a maladaptive coping response (Gill et Brown, 2009). Thus, more knowledge regarding the effects of this coping strategy is needed in order to determine if (and for whom) it is an effective pain management treatment.

Two models of AP are currently in widespread use. The Operant Learning (OL) approach uses positively reinforced activity quotas that are time and/or goal contingent, rather than pain-contingent, and these are gradually increased using "activity-rest" cycling (Fordyce, 1976). In contrast, the Energy Conservation (EC) approach focuses on patient energy expenditure, and seeks to achieve a balance between accomplishing important day-to-day activities and resting in order to reduce or avoid pain and fatigue (Hammond, 2004). Despite the ubiquitous use of these two forms of AP in clinical settings, little is known about either their individual or relative efficacy. Similarly, each approach involves multiple elements, and it is unclear which of these elements might be responsible for putative treatment effects. Two recent studies (Murphy et al., 2011 ; van Koulil et al., 2010) have provided some data regarding AP, but described somewhat contradictory results and did not provide clear theoretical bases for their interventions. Future research concerning the effectiveness of AP should: (a) define the contents of interventions based on theory; (b) avoid confounding AP with non-AP treatment elements; (c) examine the relative efficacy of these two theoretically different AP methodologies; and (d) identify the clinical populations that are most likely to benefit from AP treatment.

Fibromyalgia Syndrome (FMS) is a condition with a general population prevalence of approximately 3-5% and is estimated to have one of the highest psychosocial and financial impacts of all rheumatic diseases and chronic pain conditions. The predominant symptoms of FMS are chronic widespread pain and fatigue. Although there are no disease-modifying treatments available for this condition, Cognitive Behavioural and Multidisciplinary Treatment Programs, usually including some form of AP, are evidence-based and widely recommended. Because FMS is common, causes considerable suffering (personal, social and economic) and has been the frequent target of AP methods, it is particularly important to understand the efficacy of AP - both alone and as a part of multimodal treatment packages. However, before this step is taken, it is important to assess the efficacy of AP as a stand-alone treatment.

Research objectives: