Operant Approach Activity Pacing Interventions for the Management of Chronic Pain: A Systematic Review

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.

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.

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.

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.