Cited by 124Musculoskeletal pain and rehabilitationPain Management and TreatmentFibromyalgia and Chronic Fatigue Syndrome Research

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Activity Patterns in Chronic Pain: Underlying Dimensions and Associations With Disability and Depressed Mood

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Kindermans, Hanne P.J., Roelofs, Jeffrey, Goossens, Marielle E.J.B., Huijnen, Ivan P.J., Verbunt, Jeanine A., Vlaeyen, Johan W.S.·2011·The Journal of Pain

DOI 10.1016/j.jpain.2011.04.009

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Abstract

Unlabelled Activity patterns are believed to play an important role in the development and perpetuation of chronic pain. So far, 3 important activity patterns have been studied: avoidance behavior, persistence behavior, and pacing behavior. Yet, empirical evidence is limited and inconclusive about the relationships between these activity patterns and important outcomes. Therefore, the present study was aimed at identifying activity patterns by means of factor analyses and determining their relationship with disability and depressive symptomatology in participants with chronic pain (N = 132). Items across different measurement instruments pertaining to 1 particular activity pattern were aggregated, and submitted to factor analysis. Results from 3 separate factor analyses revealed 6 distinct activity patterns: pain avoidance, activity avoidance, task-contingent persistence, excessive persistence, pain-contingent persistence, and pacing. In line with our hypotheses, pain and activity avoidance, and excessive persistence, were related to higher levels of disability and depressive symptomatology. In contrast to hypotheses, pacing was associated with worse outcomes as well. Interestingly, task-contingent persistence was related to lower levels of disability and depressive symptomatology. When controlling for pain and the other activity patterns, excessive persistence and activity avoidance were the most detrimental in terms of relations with depressed mood or disability. Task-contingent persistence appeared to be the least detrimental.Perspective Our findings suggest the existence of several activity patterns, which are differentially related to disability and depressive symptomatology, in participants with chronic pain. The present results are discussed in the light of previous findings, and may provide a new impetus for future studies on activity patterns in chronic pain research.

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Background
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BackgroundResult
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Background
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“, 2015) or no association of this pattern with functional limitation (Kindermans et al., 2011), in accordance with our results.”
BackgroundResultInfluential
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Method
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“Four subgroups have been identified [8,15]: (a) doers, who are characterized by high levels of task-contingent persistence, moderately high levels of excessive persistence and pain-related persistence, and low levels of the three types of pacing; (b) avoiders, who are characterized by high levels of pain avoidance, ac…”
Background
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“Selection of statements was based on a study of Kindermans [18].”
Influential
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Further development in the assessment of psychological flexibility: validation of the German committed action questionnaire
Terhorst, Y., Baumeister, H., McCracken, L. M., & Lin, J. (2020) · Health and Quality of Life Outcomes · doi:10.1186/s12955-020-01497-8 · Cited by 9
A randomized controlled trial on single-session mindfulness self-compassion interventions for Fibromyalgia Syndrome: evaluating interoceptive awareness, anxiety, and pain
Arey, D. L., Gerbi, A., & Sagi, A. (2024) · Current Psychology · doi:10.1007/s12144-024-07049-3 · Cited by 8
“These disruptions can contribute to increased anxiety, fear-avoidance behaviours, and maladaptive coping strategies, ultimately exacerbating FMS symptoms and functional impairment (Borg et al., 2015).”
Beyond activity patterns: The complex process of activity management among individuals with chronic musculoskeletal pain after an orthopaedic trauma
Mbarga, J., Favre, C., Ribeiro, C., Pichonnaz, C., Ancey, C., Foley, R.-A., Léger, B., & Lüthi, F. (2024) · European Journal of Pain · doi:10.1002/ejp.2246 · Cited by 8
“…despite pain is underpinned by both individual characteristics (psychic, identity, affective, motivational, and coping skills) (Esteve et al., 2017; Kindermans et al., 2011) and the value and priority given to a goal, which can overcome pain avoidance (Claes et al., 2014; Claes et al., 2015;…”
Influential
Social support for functional dependence, activity patterns, and chronic pain outcomes: A cross-lagged mediation panel study.
Bernardes, S. F., Brandão, T., de Matos, M. O., & Ferreira-Valente, A. (2024) · Health Psychology · doi:10.1037/hea0001370 · Cited by 8
Working Together and Being Physically Active Are Not Enough to Advise Uniformly and Adequately Low Back Pain Patients: A Cross-Sectional Study
Praz, C., Ducki, J., Connaissa, M.-L., Terrier, P., Vuistiner, P., Léger, B., & Lüthi, F. (2018) · Pain Research and Management · doi:10.1155/2018/4128913 · Cited by 8
“)ere is evidence of a relationship between the HADS scores and the patient’s pain chronification [46].”
Background
Osteoarthritis and Social Embarrassment
Kabel, A., Dannecker, E. A., Shaffer, V. A., Mocca, K. C., & Murray, A. (2014) · SAGE Open · doi:10.1177/2158244014537649 · Cited by 7
“Further research is required to determine whether or not multiple patterns of activity engagement and avoidance co-exist within one individual, as has been indicated in other studies (Kindermans et al., 2011; Mackichan et al., 2013; McCracken & Samuel, 2007).”
Result
Development and Initial Evaluation of the Patterns of Activity Measure—Pain Short Form
Cane, D. B., & Mazmanian, D. S. (2020) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000853 · Cited by 7
Shared and distinct effect mediators in exposure-based and traditional cognitive behavior therapy for fibromyalgia: Secondary analysis of a randomized controlled trial
Hedman‐Lagerlöf, M., Buhrman, M., Hedman‐Lagerlöf, E., Ljótsson, B., & Axelsson, E. (2024) · Behaviour Research and Therapy · doi:10.1016/j.brat.2024.104546 · Cited by 8
“Kindermans et al. (2011) found that excessive persistence was associated with greater disability and depressive symptomatology, while controlling for pain intensity.”
Why people with fibromyalgia persist in activity despite the increasing pain? A Delphi Study of the content of the Clinic Scale of Persistence in Activity in Fibromyalgia
Torres, X., Herrero, M. J., Martí, M., Conesa, A., Valdés, M., Arias, A., Gómez, E., & Collado, A. (2012) · Revista de Psiquiatría y Salud Mental (English Edition) · doi:10.1016/j.rpsmen.2012.03.004 · Cited by 6
Self-Regulatory Processes, Motivation to Conserve Resources and Activity Levels in People With Chronic Pain: A Series of Digital N-of-1 Observational Studies
McMillan, G., & Dixon, D. L. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.516485 · Cited by 7
“…previous research demonstrating that the context of a goal pursuit episode is associated with activity patterns (Karsdorp et al., 2010; Karsdorp and Vlaeyen, 2011; Schrooten Frontiers in Psychology | www.frontiersin.org 7 September 2020 | Volume 11 | Article 516485 FIGURE 1 | Time plots for all…”
Background
The Activity Patterns Scale
López-Roig, S., Peñacoba, C., Martínez‐Zaragoza, F., Abad, E., Catalá, P., Suso‐Ribera, C., & Pastor-Mira, M. D. L. Á. (2021) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000980 · Cited by 6
“Activity Pattern Scale Structure Fit Indices RMSEA CFI SRMR χ2/df 3 Factor Model 0.093 0.806 0.098 5.40 Avoidance (1, 6, 8, 11, 13, 16)* Persistence (2, 4, 7, 10, 15, 18, 20, 21, 22) Pacing (3, 5, 9, 12, 14, 17, 19, 23, 24) 6 Factor Model 0.066 0.908 0.062 3.17 Pain avoidance (1, 11, 16) Activity avoidance (6, 8, 13)…”
Influential
Task-Contingent Persistence is Related to Better Performance-Based Measures in Patients with Chronic Musculoskeletal Pain
Burrus, C., Vuistiner, P., Léger, B., Rivier, G., Hilfiker, R., & Lüthi, F. (2020) · Pain Research and Management · doi:10.1155/2020/1765456 · Cited by 5
The Role of Self-Efficacy and Activity Patterns in the Physical Activity Levels of Women with Fibromyalgia
Pérez, A. M. L., Collado‐Mateo, D., Gil-Arias, A., Gutiérrez, L., Écija, C., Catalá, P., & Peñacoba, C. (2023) · Biology · doi:10.3390/biology12010085 · Cited by 9
“Furthermore, previous studies have reported that activity avoidance patterns are associated with worse daily functioning [23,38].”
Background
Entstehung und Aufrechterhaltung von chronischen Schmerzen
Kappesser, J., & Hermann, C. (2013) · Psychotherapeut · doi:10.1007/s00278-013-1004-6 · Cited by 5
“Chronic disease · Pain measurement · Pain management · Neuronal plasticity · Fear-avoidance model 504 | Psychotherapeut 5 · 2013 CME zeitbegrenzter analgetischer Behandlung ist, sind Behandlungsziele bei chronischen Schmerzen der bessere Umgang mit Schmerzen, die Minderung der schmerzbedingten Beeinträchtigung und der…”
BackgroundInfluential
Beliefs about sharing illness experiences: Development of a scale and relationship with symptoms of fibromyalgia
Wroe, A. L., & Bowers, H. M. (2019) · British Journal of Health Psychology · doi:10.1111/bjhp.12376 · Cited by 5
¿Por qué las personas con fibromialgia persisten en la actividad a pesar del dolor creciente?: estudio Delphi sobre el contenido del Cuestionario Clínic de Persistencia en la Actividad en Fibromialgia
Torres, X., Herrero, M. J., Martí, M., Conesa, A., Valdés, M., Arias, A., Gómez, E., & Collado, A. (2012) · Revista de Psiquiatría y Salud Mental · doi:10.1016/j.rpsm.2012.03.001 · Cited by 5
Moving beyond the eigenvalue greater than one retention criteria in pain phenotyping research
Cardoso, J. S., & Cruz‐Almeida, Y. (2016) · Pain · doi:10.1097/j.pain.0000000000000520 · Cited by 5
Personality systems interactions theory: an integrative framework complementing the study of the motivational and volitional dynamics underlying adjustment to chronic pain
Kästner, A., & Petzke, F. (2024) · Frontiers in Pain Research · doi:10.3389/fpain.2024.1288758 · Cited by 5
“Consistent with other work (4, 7, 105), the authors conclude that endurance responses may not be longitudinally maladaptive if they are associated with ﬂ exible goal adjustment and the pursuit of self-compatible (i.e., approach-oriented) goals facilitated by intuitive self-soothing and…”
BackgroundResult
Translation, reliability, and validity of the German version of the Activity Patterns Scale (APS) in musculoskeletal pain: a methodological study
Boendermaker, S. H., Tirez, J., Morf, R., & Esteve, R. (2024) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-024-07986-x · Cited by 4
“These findings underscore the importance of accurately assessing and distinguishing between these two avoidance patterns in pain management interventions [23].”
BackgroundMethodInfluential
Overactivity in daily life
Murphy, S. L. (2015) · Pain · doi:10.1097/j.pain.0000000000000291 · Cited by 4
The Activity Management Inventory for Pain (AMI-P)
Racine, M., Jensen, M. P., Cane, D. B., Moulin, D. E., Vlaeyen, J. W. S., & Nielson, W. R. (2024) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000001198 · Cited by 3
Relationship between pain activity patterns, and physical and psychological aspects and sleep quality in women with migraine
Celenay, S. T., Korkut, Z., Karaaslan, Y., Lalecan, N., & Kazaz, T. G. (2024) · Women & Health · doi:10.1080/03630242.2024.2394791 · Cited by 3
“Studies frequently noted a connection between pacing pattern and low levels of disability, recognizing it as a functional behavior (Kindermans et al. 2011).”
Adaptive Homeostatic Strategies of Resilient Intrinsic Self-Regulation in Extremes (RISE): A Randomized Controlled Trial of a Novel Behavioral Treatment for Chronic Pain
Kent, M., Mardian, A. S., Hustead, M. L.-R., Gress‐Smith, J. L., Ciciolla, L. M., Kim, J. L., & Scott, B. A. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.613341 · Cited by 5
“…were assessed with PTSD Check List-5 (PCL-5, α = 0.94) (Weathers et al., 2013), Patient Health Questionnaire, Depression Scale (PHQ-9, α = 0.87) (Kroenke et al., 2001, p. 606–613), Generalized Anxiety Disorder (GAD-7, α = 0.90) (Sptizer et al., 2006, p. 1092–1097), Pain Catastrophizing…”
MethodInfluential
Samoobvladovanje kronične bolečine
Nemec, U., Pajnkihar, M., Turk, S. Š., Klanjšek, P., & Košič, A. (2019) · Slovenian Nursing Review · doi:10.14528/snr.2019.53.1.221 · Cited by 1
Validation of the Japanese version of the patterns of activity measure-pain in individuals with chronic pain
Enomoto, K., Adachi, T., Mibu, A., Tanaka, K., Fukui, S., Nakanishi, M., Iwashita, N., Sasaki, J., & Nishigami, T. (2022) · BioPsychoSocial Medicine · doi:10.1186/s13030-022-00248-z · Cited by 2
“Meanwhile, overdoing (also called “persistence” [6], “endurance” [7], or “confronting” [8]) is defined as the tendency to continue with activities despite pain.”
BackgroundResultInfluential
ÇOCUK VE ADÖLESAN KAYAK SPORCULARINDA AĞRI İLE İLİŞKİLİ AKTİVİTE PATERNLERİNE GÖRE STRES VE KAYGI DÜZEYLERİNİN İNCELENMESİ
Demirci, D., Karamancıoğlu, B., Hoşbaş, B. D., KIYICI, M., & Altunalan, T. (2023) · Spor ve Rekreasyon Araştırmaları Dergisi · doi:10.52272/srad.1266455 · Cited by 2
Development and validation of the PrePain questionnaire for predicting pain
Gedin, F., Hellerström, A., Blomé, S., Jensen, K. B., Andréasson, A., & Lalouni, M. (2025) · Scientific Reports · doi:10.1038/s41598-025-09044-5 · Cited by 1
Prognostic value of activity patterns and stress measures for persistent pain and disability in acute neck pain: a 3-month follow-up study
Morf, R., Kernwein, C., Jaeger, J., Reicherzer, L., Degenfellner, J., & Boendermaker, S. H. (2025) · Frontiers in Pain Research · doi:10.3389/fpain.2025.1686389 · Cited by 2
From accelerometer data to activity patterns in chronic pain: methodical reasoning is key
Doomen, A., Huijnen, I. P. J., Wittink, H. M., Evenhuis, T., Verwoerd, M. J., & Smeets, R. (2026) · Frontiers in Sports and Active Living · doi:10.3389/fspor.2026.1712235 · Cited by 1
“Recommendations should include accelerometer calibration, sampling frequency, epoch length, wear location, the use of ﬁlters, the number of days required to obtain a reliable representation of behavior, conversion methods and the validity of algorithms in real-life.”
Frequencies of persistence, activity pacing, fear avoidance and general stress in acute neck pain
Morf, R., Reicherzer, L., Degenfellner, J., Hasenbring, M. I., Erat, A., & Boendermaker, S. H. (2025) · Comprehensive Psychoneuroendocrinology · doi:10.1016/j.cpnec.2025.100308 · Cited by 1
“Despite this research gap, emerging evidence suggests that these overlooked patterns play a crucial role in cognitive pain processing and are thought to reflect different self-regulation strategies in pain, such as balancing activity and recovery or continuing behavior despite discomfort [7,9].”
Measuring affective, cognitive and behavioral responses to fatigue: validation of the Avoidance-Endurance Questionnaire adaptation to fatigue (AEQ-F) in patients with brain cancer
Hasenbring, M. I., Titze, C., Schlegel, U. S., & Kowalski, T. E. (2025) · Fatigue Biomedicine Health & Behavior · doi:10.1080/21641846.2025.2531728 · Cited by 1
A Break from Pain! Interruption Management in the Context of Pain
Gatzounis, R., Crombez, G., Schrooten, M. G. S., & Vlaeyen, J. W. S. (2018) · Pain Management · doi:10.2217/pmt-2018-0038 · Cited by 1
Durchhalten um jeden Preis?
Boendermaker, S. H. (2020) · Der Schmerzpatient · doi:10.1055/a-0969-4192 · Cited by 1
Physical functioning in low back pain : exploring different activity-related behavioural styles
Huijnen, I. P. J. (2011) · doi:10.26481/dis.20111117ih · Cited by 1
An examination of the role of self-regulatory fatigue in adaption to chronic pain
McMillan, G. (2019) · STAX · doi:10.48730/pjpn-xb16 · Cited by 1
Validation of the Japanese version of the Patterns of Activity Measure-Pain in Individuals with Chronic PainPreprint
Enomoto, K., Adachi, T., Mibu, A., Tanaka, K., Fukui, S., Nakanishi, M., Iwashita, N., Sasaki, J., & Nishigami, T. (2021) · Research Square · doi:10.21203/rs.3.rs-689513/v1 · Cited by 1
The role of mood, habitual goals and primed goals in painful and non-painful task persistence
Ranson, S. (2014) · doi:10.26481/dis.20141211sr
"Being" in pain : the role of self-discrepancies in explaining emotional well-being and activity patterns in chronic pain
Kindermans, H. P. J. (2012) · Research Publications (Maastricht University) · doi:10.26481/dis.20120301hk
PAIN AMONG WOMEN: PROSPECTIVE POPULATION STUDIES FROM A BIOPSYCHOSOCIAL PERSPECTIVE ON PAIN
Thomtén, J. (2012) · KTH Publication Database DiVA (KTH Royal Institute of Technology)

Authors: Kindermans, H. P. J., Roelofs, J., Goossens, M. E. J. B., Huijnen, I. P. J., Verbunt, J. A., & Vlaeyen, J. W. S.
Affiliations: Maastricht University (NL)
Corresponding author: Kindermans, Hanne P.J.
ORCID: Kindermans, Hanne P.J.
Roelofs, Jeffrey
Huijnen, Ivan P.J.
Verbunt, Jeanine A.
Vlaeyen, Johan W.S.
Venue: The Journal of Pain
Publisher: Elsevier BV
Published: 2011-10
Volume: 12
Issue: 10
Pages: 1049-1058
ISSN: 1526-5900 (ISSN-L)
DOI: 10.1016/j.jpain.2011.04.009
OpenAlex: W2047749593
Cited by: 124
References: 33
Citations by year: 2026: 7 · 2025: 9 · 2024: 11 · 2023: 7 · 2022: 3 · 2021: 11 · 2020: 14 · 2019: 14 · 2018: 7 · 2017: 5 · 2016: 7 · 2015: 8 · 2014: 6 · 2013: 5 · 2012: 9
FWCI: 4.92
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 4363 d)
Locations: Journal of Pain (publishedVersion)
PubMed (publishedVersion)
Research Publications (Maastricht University) (publishedVersion, other-oa)
Lirias (submittedVersion)
Research Publications (Maastricht University) (submittedVersion)
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
Keywords: chronic pain, activity patterns, pain avoidance, activity avoidance, pacing behavior, disability, depressive symptoms, coping strategies
MeSH terms: Adolescent, Adult, Aged, Avoidance Learning, Cognition, Depression, Disability Evaluation, Factor Analysis, Statistical, Female, Persons with Disabilities, Humans, Male, Middle Aged, Pain Measurement, Psychiatric Status Rating Scales, Surveys and Questionnaires, Young Adult, Chronic Pain

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Activity Patterns in Chronic Pain: Underlying Dimensions and Associations With Disability and Depressed Mood

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