Informing — and knowing

Learning is perceived as a process of personal and social construction where people are actively involved in making sense of information they interact with, rather than passively receiving it (Kuhthau 2004). This cumulative and developmental process involves the whole person in thinking, acting, reflecting, discovering ideas, making connections, and transforming prior knowledge, skills, attitudes, and values into new knowledge (Dewey 1933).

I’m an educator for much of my time. When I think about it, I’ve been an educator for most of my clinical career – after all, when I helped people learn how to shower and dress again after a stroke, I was teaching. When I help someone work out how to organise their day to optimise energy levels, I’m teaching. And when I interact online in some of the Facebook groups I’m part of, I’m also teaching.

Teaching is the process of attending to people’s needs, experiences and feelings, and intervening so that they learn particular things, and go beyond the given.

When I look at what people do for continuing education, and also how we approach helping people with pain to understand something about how their nervous system works, I think we often do a fine job of providing information. “Information is to behaviour change as spaghetti is to a brick”, said Prof Bill Fordyce, father of behavioural approaches to pain management. As clinicians and educators we spend a great deal of time working out “what” people should/need to know. There’s talk of a “curriculum” for people living with pain so the basic concepts are provided. Information is the “what” – those facts, concepts and often context-free bites of data that are gathered together into information through analysing, cross-referencing, selecting, sorting, summarising or otherwise organising them (Stonier, 1997).

Perhaps where we’re less capable is in supporting people in the process of turning information into knowledge. Knowledge is about integrating information into meaning. It’s magic to see someone have that lightbulb moment when suddenly one bit of information connects with something else the person knows and it begins to make sense!

With CPD I wonder how many of us go to a course, then walk away with our heads jam-packed with new information – then when we walk into clinic we get caught up in the everyday of clinical life, and promptly forget how that new information we’ve stored relates to what we do.

I think the same when I listen to patients talk about what they’ve been told, perhaps about pain, or perhaps about ways they might do things – and they talk of these information bites as disconnected from their daily reality.

To me, the process of developing knowledge involves processing information into personal relevance. It means that, as we learn a new piece of information, we sift through what we already know and establish how the new information might be similar to or different from what we already know. We might ponder when, where, and how this new information can apply. We try using the new information to test its utility. We talk about “what does this mean” with other people as we do this.

A community of practice (Wenger) is a “group of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly”. In a community of practice, people who have become expert or more experienced in doing this activity share their expertise and “knacks of knowing” – novices spend time absorbing what the experts say and do, and ultimately learn to become expert themselves. Communities of practice are everywhere and in our internet and social media-based lives, communities of practice exist virtually as well.

Clinicians often turn to online discussions to carry out their process of turning information into knowledge. Through the debates and discussions (yes, and arguments and flame wars) clinicians become familiar with new information and discuss the implications for practice. It’s common to see clinicians use Instagram, Twitter, Facebook, blogging (yes!) as ways to not only produce information but to also make sense of it.

But when I think of comparable and positive opportunities for people living with pain who are also trying to make sense of the many different bites of information they’re provided with, I’m less certain there is a good place to go to be supported in this process. Much of our clinical treatment is carried out individually, one-to-one with patient. Because pain is invisible and so many people are hopeful the experience will be temporary, meeting with and discussing information about pain and ways to live with pain are rare. In fact, there’s plenty of evidence from research showing that people living with pain feel isolated, abandoned and judged (Cagle & Bunting, 2017; Collier, 2018; Wilbers, 2015). Not the best place to be when trying to put pieces of information together.

While as clinicians, we can offer much information – how good are we at helping people connect that information with what that person already knows? How can we – especially if we don’t experience pain? What would we know of the process of going to various therapists, being told many different things, of the highs and lows of benefits and failures?

I run a group programme called Springboard. It’s a six-week programme, one session a week, with home-based “missions” people can do over the week. I’ve always thought the magic happens not when I give out information, but when participants return with their experiences and share what they’ve learned with one another. I don’t the group is simply bridging a feeling of loneliness or stigma, although it certainly seems to do that. I think the magic happens because participants share what this information means to them, when participants help one another connect a new piece of information to what they already know. Because no-one knows better what the meaning of a new understanding is than people living with pain.

So I question us all. Clinicians – do we help people connect with others who are in the same boat to learn from one another? To make sense of what we try to tell them? People living with pain, do you have ways of sifting through new information so you can work out its relevance to you? Can we bring people together – experts in living well with pain and novices learning how this information might apply?

Cagle, J., & Bunting, M. (2017). Patient reluctance to discuss pain: understanding stoicism, stigma, and other contributing factors. Journal of social work in end-of-life & palliative care, 13(1), 27-43.

Collier, R. (2018). “Complainers, malingerers and drug-seekers”—the stigma of living with chronic pain. In: Can Med Assoc.

Dewey, J. (1933). How we think. a restatement of the relation of reflective thinking to the educative process (Rev. ed.), Boston, MA: D. C. Heath.

Kuhlthau, C.C. (2004). Seeking meaning: a process approach to library and
information services. (2nd ed.). Westport, CT: Libraries Unlimited.

Stonier, T. (1997). Information and meaning—An evolutionary perspective.
Berlin: Springer.

Wilbers, L. E. (2015). She has a pain problem, not a pill problem: Chronic pain management, stigma, and the family—An autoethnography. Humanity & Society, 39(1), 86-111.

Links and other good things from my intray

One of the great things about being an information junkie is the amount of cool stuff that I get to read via the internet and email.  So I thought I’d show you some of the stuff I’ve got in the last little while.

First up is the Pain Blog Carnival run by How to Cope with Pain.  The topic this month is Thankfulness, because it’s that time of the year.  We don’t have this event in New Zealand – shame really – because it’s a great idea to celebrate all that people are thankful for.  I’m especially thankful that I live here in New Zealand – it’s a beautiful country, beautiful scenery, wonderfully open and friendly people, and the lifestyle is incredible.  Not to mention that people in New Zealand can understand me, while in other parts of the world people can find my accent somewhat hard to follow!

Next is a regular newsletter I get from RTW Matters. This week is especially cool because it has notice of a new RTW guide for occupational therapists, published by the esteemed Canadian Institute for Work and Health, in collaboration with the Ontario Society of Occupational Therapists and College of Occupational Therapists, Ontario. I’ll be commenting on this soon, so come on back for more! (more…)

Who really has all the pieces of the puzzle?

I’ve worked in pain management for quite a while now, and longer in work rehabilitation, and seen the process from almost all sides.  For ages I thought that, as the health provider working with the person in the workplace itself, I had most of the pieces of the return to work puzzle.  I mean, I did have access to the medical information, progress reports from other health providers, I spoke with and met with the employer, the compensation agent or funder, and worked with the person…but I’ve revised my ideas since my own rehabilitation.

I’ve realised that the only person who has all the pieces of the puzzle is the person who is returning to work. This person is the only one who has been at every health care meeting, treatment session, and progress report.  This person is also the only one who has met with the employer, been a the at-work rehabilitation meetings, and been in ongoing contact with the compensation agent or funder.

I think the importance of this fact may not be made clear to the person very often – it certainly wasn’t made clear to me during my rehabilitation. Although I should have known, I didn’t – even with all my experience! (more…)

The art of chronic pain

Pain is invisible – and people with pain often find it difficult to express exactly what their pain is like in words… BUT art can express so much that words can’t and the art of chronic pain can be found in all sorts of places.

Today I was given a pamphlet from a nonprofit organisation called PAIN Exhibit in the US.  The organiser and creator of this group is Mark Collen, who has experienced chronic pain for over ten years.  If you go to the website, you’ll find some incredibly powerful images created by people who have chronic pain.  Some of the images are hard to look at, they’re so evocative.

Mark has published a brief pamphlet about chronic pain, and the website also has some information about chronic pain, but the main purpose of the site is to use art to communicate.  It is hoped that by communicating, people will find it easier to listen and learn more and eventually reduce ignorance and lack of treatment.

If you’ve a mind to look at more painful images – Flickr has some incredibly powerful images (not just photographs) of pain.  Again, some are very hard to look at, but clearly demonstrate the emotional impact that pain has.

Art has been used for expressing the impact of pain – collage can be used to by patients to express the impact of pain on parts of their lives and also to explore future options.  It’s also a great activity in which people can use their activity regulation, posture, distraction and other strategies while at the same time being involved in an expressive activity (there speaks an OT from years gone by!).

I couldn’t resist this illustration – by Jason Smith, from Endeavours Magazine, University of North Carolina, Chapel Hill.

A couple of geeky websites!

I just thought I’d post a couple of websites I’ve found over the past couple of days – using StumbleUpon. If you haven’t tried StumbleUpon, and you find yourself at a loose end, or just feel like ‘browsing’ the internet instead of watching TV, try it! Full of cool sites that show up randomly, or you can guide it by adding keywords for the areas you’re interested in.

Brain Explorer is a site put together by Lundbeck Institute. It has a wide range of information, but the bits I liked the most were the Brain Atlas section, and the gallery. Lots of great images, and relatively simple explanations.

Science Daily has a wealth of newsworthy links and posts. Headings of ‘Health & Medicine’, ‘Mind & Brain’, ‘Plants & Animals’, ‘Earth & Climate’ and more – videos, articles and images. Great reading, you can spend a long time on this site!

Zack Lynch blogs about Neurotechnology on Brain Waves. He lists a bunch of quite technical blogs that he regularly visits, as well as some links that are well worth browsing on Neuroresources. Latest blog entries include the Allen Spinal Cord Altas, What’s your Brain Age?, and a great video by Jill Bolte Taylor. Worth a visit!

And my final link for today – Changing Minds is a huge site with a whole bunch of information and links to factors that influence change. From Argument to Brand Management, Theories and Techniques, this site has plenty to keep you interested, especially if you’re curious about how to help people change. Definitely one to bookmark.

I hope you have a moment or two to spend perusing the links – they’re fun and you can spend lots of time just locating information, for the true information junkie like me!!

A quiz for you!

Sometimes what we need is a bit of a fun challenge – so here is yours for today…

Try and answer these questions – answers tomorrow!

1. Which type of pain process occurs when the nociceptive impulse reaches the cerebral cortex?


2. Chronic pain may result when the nervous system is unable to return to a state of:


3. Which type of pain arises from injury to the peripheral or central nervous systems?


4. Which of the following statements is true?

Chronic malignant pain continues after a pathological process has resolved.
Chronic nonmalignant pain is typically associated with hyperactivity of the autonomic nervous system.
A patient with multiple sources of pain can sense only two types of pain at a time.
Acute pain is associated with chronic diseases that are not life-threatening.

5. Pain assessment for osteoarthritis focuses primarily on:

Behavioral observation.
Curing the disease.
Neurologic test results.
Degree of restriction on normal activity.

6. Prostaglandins are substances generated by:

COX-3 enzymes.
Peripheral nociceptors.
Tissue trauma.

7. For patients with chronic disease, what is the preferred route of administration for opioid agents?


8. Which of the following are useful in counteracting the sedation that accompanies opioid analgesia?


9. Which type of nerve block is most commonly used for somatic pain occurring in the chest?


10. Cognitive-behavioral interventions include all of the following except:

Cognitive distraction.
Nerve block.

11. What is the psychiatrist’s role as a member of a pain management team?

Helping patients optimize their physical functioning.
Administration of analgesia directly into the central nervous system.
Use of behavior modification.
Conducting a comprehensive psychosocial history.

12. Which of the following members of the pain management team evaluates patients’ home and work sites and recommends adaptations?

Occupational therapists.
Home health assistants.
Physical therapists.
Social workers.

13. Which form of care refers to active total care of patients whose disease is not responsive to curative treatment?


14. Which of the following statements is true?

Biofeedback and acupuncture clinics are examples of a multidisciplinary approach.
A modality-oriented clinic typically offers multiple modes of therapy.
Treatment goals at multidisciplinary pain centers are primarily directed toward vocational counseling.
Interdisciplinary implies multidisciplinary care that is integrated and coordinated.

15. Managed care organization officials may be reluctant to adopt integrated pain management
programs because they believe:

The programs are too simplistic.
The nature of the pain experience is objective.
There is clear physical evidence for the causes of chronic pain.
The programs are thought to be too expensive.

Now for something sillier – take this test and see how you go!!

On the challenges of ‘doing research’

As a clinician and an educator I need to be aware of, and ‘do’ research. It’s not easy, even when I’m enrolled in a PhD programme! The problem is that so much ‘research’ is not finding out new stuff, it’s gathering existing information into a format that allows for ‘gaps’ in knowledge to be identified and then prioritised. And this isn’t sexy, isn’t visible, doesn’t result in publications, and is often undervalued. A bit like teaching/educating itself!

I don’t know what it’s like in the rest of the world, but here in NZ there are an awful lot of hoops to jump through to even begin collecting data, and this is pretty off-putting. And much of our research has to be based on short-term, fixed end-point research that can tie into the duration of a funding contract. With the thrust for research to be able to directly contribute to something pragmatic, the emphasis isn’t on philosophical or even basic science research, it’s on ‘what is happening now and what can be done about it’. Short, sharp, and applied.

So all the background, really integral parts of research are essentially invisible.

In putting together a PhD proposal, I feel like I’m breaking some new ground. And a whole lot of what I’m doing just isn’t going to be visible in my completed thesis – yet it’s incredibly important. I work primarily amongst scientists who like the hypothetico-deductive model – and I’m certainly not against that in any way. I just think there is a whole lot that happens before a hypothesis can be generated that is absolutely essential, but ignored. And this isn’t easy for scientists of the H-D persuasion. What do I mean?

Well – where did any hypothesis come from?

If we’re honest, it probably came from some sort of observation where someone saw a pattern or phenomenon that was ‘interesting’. It had to be more than a single occurrence because that could just be a ‘blip’ in the time-space continuum (ok, perhaps not there, but a ‘statistical blip’). It only becomes interesting when it happens often enough to be identified as a pattern. Pattern detection itself is influenced by past learning and models, or to bring the analogy back to research, to theory or past research. But it’s not entirely from past learning – new patterns are detected as people spend time immersed in data (otherwise known as ‘information’).


(it’s only after you’ve spent some time immersed in this picture that you’ll pick up the hidden man!)

The pattern recognition phase is not mentioned once in the H-D scientific method – yet it’s fundamental to original research (technically it generates what is called abductive reasoning, or inference to the best explanation, but more of that in later posts!) And Ethics Committees, and funding agencies seem to have trouble coping with non-H-D studies.

Exploring data to find patterns raises questions. Oh no – questions are messy and inconvenient. Questions like ‘I wonder why…’ – and all the ‘w’ questions (who, what, when, where, why – and how which is a complimentary ‘w’ word in this!) are about thoroughly describing a phenomenon or pattern. It’s only once we have a good description of it, can we then start to think about mechanisms to explain the ‘w’ questions.

But think back to your ‘research methods’ course…

How much time was spent on these topics:

– wondering and pondering

– graphing and describing

– philosophy and history

and how much was on:

– experimental design

– statistical analysis

– qualitative vs quantitative

In other words, I think many therapists may learn ‘techniques’ for research, but not an awful lot about why it needs to be done. And therapists learn a lot about confirmatory data analysis such as hypothesis development and statistical analysis, but not a lot about the messy end of making sense of raw data.

Yet – most of us deal with messy raw data every day. It’s the bread and butter of therapy. What we don’t do is systematically collect that data, then explore it so we can identify patterns.

Let’s think of some examples:

– there ‘seem to be’ a number of people who come to pain management with an erroneous understanding of what ‘pacing’ is (ie pacing equals ‘never allowing my pain to go above a certain level’)

– ‘some people’ attending pain management have trouble limiting their activity level rather than being deactivated

– ‘it looks like’ referrals come at different rates from different specialties

– ‘many’ people attend ‘many’ different pain management programmes, but are referred for more therapy

– people being referred to pain management ‘seem to have a lot of’ assessment but ‘less’ treatment

Each thing inside apostrophes is an unquantified phenomenon, and an opportunity for collecting information, then exploring it. Once the information is explored it’s possible to generate some competing explanations for the phenomenon.

For example, if we can identify that 70% of people with a pain duration of more than 18 months have 8 pain assessments, but 2 pain management programmes, and these people are funded by compensation funders; and that the remaining 30% of people with a pain duration of 18 months have 2 pain assessments, no pain management programmes, and are funded by general health funding, we can start to develop some explanatory hypotheses that can be systematically studied.

But this is messy, ‘nonproductive’ research. It doesn’t come up with ‘answers’. It doesn’t ‘explain’ things – it asks questions. It needs to lead to ‘more research’, it needs continuity of investigation so it doesn’t get dropped, and it is real.

In my PhD study, I’m looking to explore the ways people who cope in the community despite having chronic disease processes achieve important activities in their life despite pain. I’m basing this on the observation (that is supported by limited formal data) that there are more people who report pain and disability than are seeking treatment from pain management. I’m not sure what coping strategies I may find out about. I’m not sure how these people developed their skills. I don’t know whether the skills they use are the same as those developed in formal pain management programmes. I don’t have any hypotheses, I don’t have a control group (because I’m not ‘testing’ anything), I don’t want random sampling because I want to look at the widest range of coping skills there might be, I don’t want to eliminate people because they are ‘using high doses of opiates’ because this might be a coping strategy that works well for some people. And yet I’ve been asked whether I have any and all of these included or excluded in my study.

I’m using grounded theory – but grounded theory isn’t well known in the H-D world. It’s a well-recognised research strategy, but doesn’t adhere to the common precepts of the H-D model.

Part of the appeal of ‘doing research’ for me is not knowing what I may find out. The H-D model deliberately forces a researcher to decide before a study what he or she wants to find out. It’s certainly necessary for learning about ‘reality’ and ‘truth’, but in itself it’s not the only part of ‘doing research’.

This is one of quite a few posts I’ll be writing on science and therapy – keep watching!

Why is it important for therapists? As I said before, therapists work right inside ‘messy’ information all day, everyday. Learning to tolerate and manage this data allows us to notice important phenomenon. Perhaps things that haven’t yet been explored in depth, and that might generate new ideas and priorities for the confirmatory part of research.

If you’re keen on learning about abductive reasoning, I thank Associate Prof Brian Haig at Canterbury University for stimulating my thinking and exposing me to this line of science. Some of his writing includes:
Haig, B. D. (2007). Grounded theory. In N. J. Salkind (Ed.), Encyclopedia of Measurement and Statistics, Vol. 1 (pp. 418-420). Thousand Oaks: Sage.

Haig., B. D. (2006). Consistency tests establish empirical generalizations. Nature, 442, 632.

Haig, B. D. (2006). Qualitative research: A realist perspective. Proceedings of the 2006 Joint Australian and New Zealand Psychological Societies’ Conference, pp 150-154.

Haig, B.D. (2005). Exploratory factor analysis, theory generation, and scientific method. Multivariate Behavioral Research, 40, 303 -329.

Another paper to read is:
– this is a reasonably old paper but great reading.