Using Mixed Methodology to Develop an Activity Pacing Questionnaire for Chronic Pain/Fatigue Dr. Deborah Antcliff

1. 1
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 APQ
APQ Theme Example of question
Activity 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 themes
Key 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
Stage I: Developed the APQ items
Item generation and consensus
(sample: clinicians and patients)
Stage II: Psychometric properties
Assessed APQ reliability and validity. Identified themes
of pacing emerging from Stage I (sample: patients)
Stage III: Acceptability
Explored acceptability and confirmed findings of
Stages I and II (sample: patients)

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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 Keeley
Dr. Malcolm Campbell
Dr. Steve Woby
Prof. 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.