Intervention
Activity Pacing Self-Management.
The APSM program consists of a stabilization phase and a grading phase (Nijs, Paul, & Wallman, 2008; Nijs et al., 2009). The stabilization phase focuses on coaching clients in how to perform daily life activities within the limits of their actual capacity.Daily life activitieswere defined as all responsibilities and desired activities in the areas of personal and child care, domestic care, productivity,and leisure. To appropriately pace activities, participants were instructed to estimate their current physical and mental capabilities (in terms of activity duration) before commencing an activity, keeping in mind the fluctuating nature of their symptoms.
The activity duration advised within the program was 25%–50% lower than the capacity participants reported to account for any overestimations. Each activity block was interspersed with breaks, with the length of each break equal to the duration of the activity.Breakswere defined as relative periods of rest, with the participant just relaxing or performing a different type of light activity. The emphasis on breaks is based on the observation that recovery from physical exertion is prolonged in people with CFS (Ickmans, Meeus, De Kooning, Lambrecht, & Nijs,2014; Ickmans, Meeus, De Kooning, Lambrecht, Pattyn, & Nijs, 2014; Paul, Wood, Behan, & Maclaren, 1999). The process of restructuring activity patterns involves significant behavioral change for people with CFS, and facilitation of this process can be beneficial (Abraham & Michie, 2008). Participants received education in the form of a booklet with evidence-based information on factors influencing fatigue and strategies to cope with fatigue and pace activities. Participants were asked to keep a diary recording the type of activity and time spent on all activities throughout the day during 7 days to increase their awareness and guide implementation of coping strategies.
Once clients are able to control their daily life activities without excessive feelings of fatigue, the grading phase can start. In this phase, activity and exercise level are increased gradually. Participants conferred with the therapist to set relevant and achievable personal activity and exercise goals, based on the prioritized activities reported in the COPM and diary results (e.g., “During two of my lunch breaks next week, I will walk for 400 m” or “For 2 days next week, I will prepare a warm meal in two time slots [preparation in the morning, finalization in the late afternoon]”). Strategies to reach these goals were discussed and performed in real life between two sessions. During the next session, participants reflected on activity performance, facilitators, and barriers and adapted their strategies and goals accordingly, whenever relevant and appropriate.