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Using Mixed Methodology to Develop an Activity Pacing Questionnaire for

Chronic Pain/Fatigue

Dr. Deborah Antcliff

17th September 2015

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Background to activity pacing Background to mixed methodolgy Findings of the study

Aims:

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Background to activity pacing Activity pacing is frequently advised to help

manage long-term conditions Some anecdotal support for activity pacing Mixed empirical findings (Andrews et al., 2012) Guidelines cannot wholly recommend pacing

(NICE, 2007) Absence of a widely used pacing scale ‘Activity pacing’ lacks a clear definition

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What does pacing mean? “Energy management, with the aim of

maximising cognitive and physical activity, while avoiding setbacks/relapses due to overexertion” (NICE, 2007, p50)

“The regulation of activity level and/or rate in the service of an adaptive goal or goals” (Nielson et al., 2012, p465)

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What does that actually mean?

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Aim and design of the study

Aim: Develop an Activity Pacing Questionnaire (APQ) for chronic pain and/or fatigue

Design: Three stage mixed methods study

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Mixed methodology

Third research paradigm Combines quantitative and qualitative

methods Advantages Disadvantages

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Study design

Exploratory sequential design• Stage I: Developing APQ items (qual)• Stage II: Assessing APQ psychometric

properties (quant)Additional stage:• Stage III: Exploring APQ acceptability (qual)

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Stage I. Developing items

Consensus method: The Delphi technique Widely used in healthcare services ‘Rounds’ of questionnaires Expert panel

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Stage I. Developing items 3 Round Delphi technique Final expert panel: 4 patients, 3 nurses, 26

physiotherapists, 9 occupational therapists Round 1 generated 94 items Round 3 reduced this to 38 questions

• reached ≥70% consensus• addressed a number of facets of pacing• represented views of 6 other patients who completed

Round 1

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Stage II: Psychometric properties Quantitative, cross-sectional study; self-report

questionnaires Sample=311 patients with chronic pain/fatigue

(target 300, recruitment rate=20%) Test-retest=69 patients (target 60, response

rate=50%) 26-items with a 5-factor solution (5 ‘themes’) APQ demonstrated reliability (Cronbach’s

α=0.72-0.92), test-retest stability (ICC=0.50-0.78, p<0.001) and construct validity.

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Stage II. Five themes underlying APQ

Activity adjustment

Activity acceptance Activity

planning

Activity consistency

Activity progression

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Stage II. Five themes underlying APQAPQ Theme Example of questionActivity adjustment ‘I took a short rest from an activity so that

I could complete the activity later’Activity planning ‘I planned in advance how long I would

spend on each activity’Activity progression ‘I gradually increased how long I could

spend on my activities’Activity consistency ‘I kept to a consistent level of activity

every day’Activity acceptance ‘I was able to say “no” if I was unable to

do an activity’

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Stage II. Properties of APQ themesKey findings: Activity adjustment significantly associated with

• increased pain, anxiety, depression and avoidance

• but decreased function Activity consistency significantly associated with

• decreased fatigue, anxiety, depression and avoidance

• but increased function

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Stage III. Acceptability study Semi-structured telephone interviews with 16

patients Qualitative data analysed using Framework

analysis APQ is generally acceptable to patients Agreement with the five themes of pacing Four behaviour typologies:

• Task avoidance, Task persistence, Task fluctuation and Task modification (pacing)

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How the 3 stages fitted together

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Implications Activity pacing appears multifaceted

• Five themes: Activity adjustment, Activity acceptance, Activity planning, Activity consistency and Activity progression

A comprehensive scale has been developed for heterogeneous long-term conditions

The APQ-26 can be used to measure the effects of pacing to • add empirical evidence• measure patients’ changes in pacing behaviour/response

to treatment• assess treatment efficacy

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Questions?

Acknowledgements:Prof. Philip KeeleyDr. Malcolm CampbellDr. Steve WobyProf. Linda McGowan

Deborah.Antcliff@pat.nhs.uk

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References Andrews, N. E., Strong, J. & Meredith, P. J. (2012) Activity pacing, avoidance,

endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 93, 2109-21 e7.

Antcliff D., Campbell M., Woby S., Keeley P. (2015) Assessing the Psychometric Properties of an Activity Pacing Questionnaire for Chronic Pain and Fatigue. Physical Therapy (ePub ahead of print).

Antcliff, D., Keeley, P., Campbell, M., Oldham, J. & Woby, S. (2013) The development of an activity pacing questionnaire for chronic pain and/or fatigue: a Delphi technique. Physiotherapy, 99, 241-6.

NICE (2007) Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy). NICE Clinical Guideline 53. London.

Nielson, W. R., Jensen, M. P., Karsdorp, P. A. & Vlaeyen, J. W. (2012) Activity pacing in chronic pain: concepts, evidence, and future directions. The Clinical Journal of Pain, 29, 461-8.

White, P. D., Sharpe, M. C., Chalder, T., DeCesare, J. C., Walwyn, R. & PACE group. (2007) Protocol for the PACE trial: A randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurology, 7, 6-25.