After quake aftermath

Once again I’m lead to pondering the different ways my situation has affected me, and what might be helpful to mitigate some of the less frequently mentioned aspects of coping in a disaster.

Like many people, I’m still managing with quite limited power, water that is a trickle (not enough pressure to fill a toilet cistern let alone the hot water cylinder!), and the hassles of finding a supermarket and shops that are open, a petrol station before I run out of gas, and ways to dispose of human waste matter safely.

I posted before about the loss of cues that usually help me to maintain my normal routine.  With the loss of these cues, and changes to my usual routine, as well as the inevitable anxiety that comes with repeated aftershocks (Is that a truck going by or an aftershock? When will this aftershock stop? Is that crack in my driveway getting bigger? What about the one in my wall?), it’s no wonder that now, 13 days after the quake, I’m feeling fatigued.

Now while some people would argue that I’m somewhat inclined to be over-active (One medical report written about me after my concussion described me as having a ‘frenetic’ level of activity!), I generally like to have a routine.  I like to shop in the same place, with a list, on the same day every fortnight.  I like to go to the same service station, use the same route to and from the places I go.  My daily activity pattern is similar from day to day.  I find this helps me maintain a sense of security (no, I’m not obsessive about it!), and it helps reduce the amount of brain power needed to make decisions.  This is not what is happening right now! I’m starting to get tired.

And my thoughts turn to the people I work with, people with chronic pain.  While some have routines that serve them well, many don’t.  Some are too active in parts of the day, slumping into a ‘bust’ period at other parts of the day.  Some are quite chaotic and don’t have a regular routine at all.  Others are inclined to stop altogether.  Many, in response to stressors, find their pain flaring up and have trouble thinking clearly to organise their response to daily demands.

I was handed a leaflet prepared by the NZ College of Clinical Psychologists in response to the Christchurch Earthquake.  (Go here for their page for the people of Canterbury) The leaflet reminds people to maintain, amongst other things, routine and says ‘familiarity is comforting’.  It’s true.

It also says stay connected (we need each other),  save your energy (keep if for important things), lifestyle (balance is healthy), safety (protect yourself in every way).

I totally agree.

What I wonder is whether the people who seek our help, particularly people compromised by chronic pain with its associated fatigue, reduced cognitive capacity, influence on mood and anxiety and sleep, can put this advice in place.

What can we do after an event like this to support people with chronic pain?  I see an enormous amount of effort being put in place to support the immediate needs of people around me.  While not all the efforts are as coordinated as I’d like (not a portaloo in sight in my street, despite five households of folk in their 80’s, while a colleague who lives in an area with water and power has THREE of the darned things within 100 m of home!) those basic concerns are being addressed.  There is a concerted effort by the clinical psychologists to establish an acute stress response service.  There is counselling for people.  There are resources for people with disabilities who need help with environmental modifications. 

BUT – and you knew there would be one –  nothing about HOW to maintain routines, how to stay connected, to save your energy, to maintain a healthy balanced lifestyle or to be safe (emotionally and physically).  And not a lot for the weeks and months ahead of us all when we’re feeling fatigued, grumpy from poor sleep, dealing with cold and wet weather and poor roading and limited consultation from Powers That Be.

This is a call for occupational therapists, in particular, to begin thinking about ways to proactively engage with vulnerable people in the community to help return some control and routine to lives disrupted by not only disaster, but pain as well.  And no, I don’t mean focusing on patients, or people who have already been identified as having disabilities or special needs, or even those who go out and look for help.  This is a time to be positive about preventing loss of those things that maintain self efficacy and internal locus of control in people who are vulnerable.

I don’t think GP’s centres are always the best place for this kind of help – after all, people who are vulnerable may not be the same people who seek help.  I think of the households of elderly folk down my street – none of them have sought help.  We need to move beyond thinking in ‘health = medical’ and into ‘health = living’.  People with pain often don’t look for help, hence my PhD. 

How could we do this kind of wellbeing work? I think the Welfare Centres that we have established all around Christchurch as part of the response to this quake could do with an occupational therapist who could be available to talk with people about how to retain their routines and habits.  Then I wonder if supermarkets and pharmacies and shopping malls might be the next best places to set up shop.  Posters perhaps.  In libraries, pubs, cafes, and most particularly, takeaway shops.  Maybe leaflet drops in neighbourhoods. 

What do you think?

Friday in Christchurch

Despite the devastation, there are some wonderful sights in Christchurch right now.  This one (above) made me smile today.

And this one was taken in Nelson after we had turned back to return to Christchurch last week.  Cheerful things, sunflowers, and glorious colour on a rather gloomy and very grim day.

Living well with chronic pain: A grounded theory study

While ‘coping’ with chronic pain has been studied extensively, the people usually studied have been those seeking treatment, and because of this, little is known about how people cope well despite their pain.  A large group of people experiencing ongoing pain do not seek treatment, and while there is speculation that factors such as personality or social support may be associated with this, there is very little known about how this group of people have developed coping skills, or the strategies they employ.

Consequently there is a lack of theory to explain how some people with chronic pain continue with important activities despite their pain.

My PhD study is intended to develop a theoretical understanding (using a grounded theory methodology) of how people cope well despite their pain, identifying the range of coping strategies used by these people, when these skills are used and when they are not, and the relationship between different strategies and how they are used during coping efforts.

Through this research, I will generate theoretical explanations grounded in the data obtained from people who cope well, so that clinicians are supported in their work to develop existing strengths and resources in people who seek treatment to support their pursuit of a ‘normal’ life as they view it. The theory developed within this study may also help to explain how some people live less ‘well’ with their pain, and how clinicians may be able to help this group.

A grounded theory methodology has been chosen to develop an explanatory theory that focuses on strengths, resources and diversity in people who have persistent pain but cope well.

Grounded theory is a method for developing theoretical explanations about social processes developed from qualitative and quantitative evidence gathered from a variety of sources.

The grounded theory process involves:

(1)     obtaining information from participants through interview

(2)     analysing the information using a process called ‘constant comparative analysis’ which involves coding the material obtained, generating mutually exclusive categories and finally, describing the relationships between the categories (usually stemming from a single ‘core’ category)

Analysis begins as soon as the first pieces of data are collected from participants, and further information is obtained to ensure the broadest variability of the phenomenon under investigation is identified. Information may be obtained by interview, but also from questionnaire data, and extant theory from the literature.

The developing theory gradually becomes more abstract through the process of describing relationships between categories.  The research does not start with a theory or hypothesis to prove, disprove or extend. Existing theory is regarded alongside observations taken directly from the data.  This increases the potential for the completed theory to be close to the everyday reality of both participants and clinicians (Elliott & Lazenbatt, 2005). The process requires the researcher to identify as many underlying similarities and diversities as possible within the data.  As a result, new explanations for the patterns that exist are generated, and the widest range of possible patterns or phenomena is integrated (Skeat & Perry, 2008).

Grounded theory is used to develop a model directly from the data obtained from participants, which ensures the resulting theory ‘fits’, ‘works’, is relevant and be modifiable as new data becomes available.

It is a complete methodology and researchers using grounded theory are cautioned to adopt the whole approach rather than selectively use parts of the process (Weed, 2009).

Participants will also be asked to complete three questionnaires, either alone or with the researcher.  Responses from these questionnaires will be entered into analysis in the same way as interview data.

The first participants to be recruited to this study will be people with diagnoses of ankylosing spondylitis or rheumatoid arthritis, working and living in the local community, using medication for disease management but otherwise self-identified as ‘well’.   Between 15 – 40 participants are generally sought for a grounded theory, but the total number and participant characteristics will be dependent upon the emerging theory and data saturation (that is, when no new theoretical constructs are generated).

How can you help?

As you know, Christchurch sustained the second of two major earthquakes one week ago.  I was about to proceed with recruiting participants for this study within the Canterbury region.  In view of our circumstances I don’t think it’s appropriate to proceed with this at this time.  It leaves me with a fairly tight time-frame to identify suitable participants so that I can complete work on this before the end of 2011.

I’m therefore going further afield to identify people who might be interested in being part of this study.

My plea is for anyone reading my blog who might have ideas about how to identify people who live ‘well’ in the community and meet the inclusion criteria above and who are not in Christchurch, to drop me a line.  My original strategy included local swimming pools (with spa and sauna), adverts in local newspapers, GP practices, Rheumatology clinics and libraries.  I also intend to use Arthritis NZ newsletter.  I had been intending to restrict recruitment to Christchurch – but clearly that’s not going to be the best approach, at least right now.

If you have any ideas – please let me know in the comments below, or  fill out this form (it’ll be emailed direct to me and won’t appear in the comments section):

Elliott, N., & Lazenbatt, A. (2005). How to recognise a ‘quality’ grounded theory research study. Australian Journal of Advanced Nursing, 22(3), 48-52.

Skeat, J., & Perry, A. (2008). Grounded theory as a method for research in speech and language therapy. International Journal of Language & Communication Disorders, 43(2), 95-109.

Weed, M. (2009). Research quality considerations for grounded theory research in sport & exercise psychology. Psychology of Sport and Exercise, 10(5), 502-510.

Friday Meditation

As you know, Friday is about getting ready for the weekend.  Today I decided not to pass on some of the horrendous puns shared with me by one of my esteemed colleagues (although I may drop just one in because I can!).  Instead I thought this poem is a chance to consider being ‘in the now’, something clinicians working in pain management really need.

Salutation To The Dawn

Look to this day!

For it is life, the very life of life.

In its brief course

Lie all the verities and realities of your existence:

The bliss of growth,

The glory of action,

The splendor of achievement,

For yesterday is but a dream

And tomorrow is just a vision,

And today well lived makes every yesterday a dream of happiness

And every tomorrow a vision of hope.

Look well, therefore to this day!

Such is the salutation to the dawn.



Oh, a pun?  As you read this, remember I have to work with the person who passed it on…sigh…

She was only a whiskey maker, but he loved her still.

A rubber band pistol was confiscated from algebra class, because it
was a weapon of math disruption.

No matter how much you push the envelope, it’ll still be

A dog gave birth to puppies near the road and was arrested for

I wondered why the baseball kept getting bigger.  Then it hit me.

Two fish swim into a concrete wall.  One turns to the other and says

A year in review

This is the third year I’ve written this blog.  As the year ends, numerous people will be reviewing the year, reflecting on the good, the bad and the indifferent, and like them, I will too.

What has been the same this year is the endless need to repeat to all and sundry the following:

  • All chronic pain starts with acute pain – maybe if we were able to effectively manage risk factors for developing chronic pain in people when they first present for help with their pain, my job would be less in demand.
  • All pain, whether acute or chronic, is a psychological experience – and can’t be understood without an appreciation of the biopsychosocial model.
  • Because pain is a psychological experience means that we can’t divide pain into nociception and the psychological response to that nociception – because the two are indivisible.  Our brains are not just ‘waiting for’ peripheral events to reach them – the brain is not a blank slate, it’s actively involved in determining which aspects of our experience ‘we’ will experience.
  • There is not a lot new under the sun in pain management really.  Not a lot of new drugs (mostly they’re derivatives of opium, or they’re old drugs that have been adopted for new uses), and not a lot of new procedures, and no, not even a lot of new psychosocial/nonpharmacological treatments.  With, perhaps, the exception of brain retraining a la Moseley, and the introduction of acceptance and mindfulness based treatments.

What has been different this year?

  • More discussion across ‘Web 2.0’, or the medium of the internet – Facebook, Twitter, blogging and email.
  • More detail of the aspects of the cognitive behavioural approach to pain management that is influential to change, and along with that, more recognition that one size does not fit all.
  • More detail of what works for whom and when.
  • More need to not only assess – but also treat people!
  • More recognition that people with pain live in a network of relationships with other people, within communities and sociopolitical systems including legislation, and that all of these have an influence on the person’s ability to cope.
  • Increasing recognition that the health provider relationship has as much influence on the individual as his or her own beliefs.  Yes folks, what we say and how we say it does have an effect! Maybe not quite what we had expected, but definitely we have an effect.
  • More awareness that it’s not so much WHO delivers self management, but that self management IS delivered that is important!

In Christchurch, we’ve had the momentous earthquake and the aftermath.  Internationally we have had wars, rumours of wars, pestilence and plague – and yes we’ve even had locusts (in parts of Australia!).  Once again I’ve made friends with people from all around the world, all sorts of professional backgrounds, all sorts of interests in pain and pain management.  And I’ve continued to learn – from fellow clinicians, colleagues, patients, the journals I’ve read, the blogs I’ve read, the discussions (and maybe even arguments!) I’ve had – all have prompted me to think and learn and question.

And once again, I reflect on the incredible nature of science and the way in which I, as a clinician, ‘stand on the shoulders of giants’ to learn more.  To know that no ‘fact’ is sacred – that if there is evidence there to challenge a ‘received’ view, even a view that I’ve cherished, then it’s my duty to look at that evidence in the face and check it out.  There is no need to resort to mysticism, nor to hold to magical beliefs, or sacred texts.  Research is there for us all to learn from, and it’s my privilege to help share it to people who may not have the time or access to the information I do, and by doing this I might have a chance to help people live lives that are a bit better in quality than if I had written nothing.  At least that’s what I hope happens!

I’m incredibly thankful to the people who take time to comment and question me.  I’m not a guru, I’m definitely blinkered in my own perception of what I see, and I admit to being somewhat biased.  That’s another reason for writing – by putting my thoughts out to the interweb, hopefully people can bounce ideas off what I write – and then ask me questions!  And in doing that, I learn too.

2011.  Who knows what it will bring.  I expect (and yes, hope) it will bring even more questions!  Do ya feel like coming along for the ride?!

Friday Funnies

SuperTherapist decided that if she gave out any advice today, she may just need to fear for her life, so she asked me to help out. SuperTherapist may need your help to vanquish the peripheralist demons from her memory – therapeutic videos to soothe the soul.

If you haven’t heard them before – and you get a chance to see them live – just GO! These guys are at least partially responsible for the odd sounds coming from my house over the last day…

And an example of virtuosity of another kind…

Enjoy your weekend!