pain A practical theory for clinicians BF Lennox Thompson, PhD - - PowerPoint PPT Presentation

Living well with chronic pain

A practical theory for clinicians

BF Lennox Thompson, PhD Jeffrey Gage, PhD Ray Kirk, PhD University of Canterbury, Christchurch, New Zealand

What do you do when you see something weird?

First steps

And then I enrolled in a PhD

• To explore my observation that some people

live well despite

– Having moderate pain levels – Not being seen at pain management centres – There being no cure for their pain problem

Living well with chronic pain

• Rarely studied because?

– Difficult to access – Not demanding (ie uses few resources, not a priority) – Research focus is typically on what doesn’t work

• Little existing theory

BUT

• A consistent minority
• An empirical regularity (eg Karoly & Ruehlman, 2006;

Mortimer, Ahlberg & Group, 2003; Dominick, Blyth & Nicholas, 2011)

• Could we learn from them?

Paul Thurlby for the Guardian

Why not test a hypothesis?

• Existing theory explains disability, not

resilience

• No reasonable hypotheses to test
• Many assumptions needed to test hypotheses,

with limited empirical basis

• Relatively small population
• Wanting to begin with individual experience

first

Why grounded theory?

• Uses “real world” data to generate theoretical

relationships (hypotheses) between abstract concepts

• Systematic, complete methodology, not just a set
• f methods
• Answers the questions of why and how
• Especially in the absence of theoretical

explanation

• Reduces the problem of developing weak theory
• Pragmatic – must fit, work, be relevant and

modifiable

How does it work?

• Developed by Glaser & Strauss in 1964/65
• Divergent development since then

– Glaser’s Classical GT (pragmatist, realist) – Strauss and Corbin’s GT (post-positivist) – Charmaz’ constructivist GT(constructivist)

• All feature

– Constant comparison – Purposive iterative sampling – Coding and sampling carried out from the beginning – Codes derived from the data rather than from pre-existing theory – Saturation – Abductive reasoning

Why useful in pain research?

• Pain is subjective, rely on people telling us what is

going on

• Enables strong hypotheses to be developed for

future testing

• Allows for novel phenomena to be explored
• Examines and explains processes, interactions

both social and individual

• Integrates existing research
• Can directly inform clinical practice

Research strategy

• Identify members of the “resilient” population
• Ask them about their “main concern”
• Examine how they resolve their main concern

using data from them and about them

– Data can be qualitative or quantitative

• Constant comparison – systematically

compare each incident with each incident to develop concepts and relationships

Research Process

• Identify core concept - saturation

– coding is then focused on codes relevant to the core concept

• Develop theoretical coding (relationships

between the core and subsequent concepts)

• Memos document thoughts, hypotheses,

theoretical reflections and potential relationships

• Literature is integrated during theoretical

coding

Re-occupying self

• Main concern = achieving self-coherence
• Being comfortable with the self again
• Living with the self, knowing and integrating

aspects of self including self-with-pain

• Integrate the effects of pain on capabilities,

but pain does not define the self

• Occupations used to understand meaning of

pain, represent/enact valued aspects of self, elicit need for coping

Main concern = achieving self-coherence Re-occupying self Making sense Flexibly persisting

Diagnostic clarity Symptom understanding Occupational existing Coping Occupational engaging Future planning Deciding to get on with life Turning Point decision is influenced by a Trustworthy Clinician and Occupational Drive

“The real travesty of pain isn’t the pain part, it’s the failing to live part”

Implications

• Learning to “live well” is a process – takes

time

• “Tasks” within each phase need to be

completed before moving forward

• If tasks incomplete, individuals may be

distressed, disabled, stuck

• Treatment providers influential
• Coping is contextual, functional not

categorical

How this theory can be used

• Aligns well with ACT
• Consider the person’s place in the process of re-
• ccupying self
• Provide support appropriate for this phase
• Be explicit about:

– Chronicity – Safety to move – Your contribution as “trustworthy” support

• Enable symptom understanding – help develop

awareness of patterns/variations in pain

How this theory can be used

• Light the fire! Identify occupation the person

is passionate about

• THEN you can expand the coping repertoire

and how flexibly strategies are applied

• Use decisional balance when deciding
• Use NNT as part of deciding about treatment
• Values clarification can be useful if the person

can’t resume usual occupations

Contentious aspects

• Accepting pain as ongoing

– Some argue that pain reduction should be an

• ngoing focus
• Symptom understanding

– Includes monitoring variations, influences – Contrary to behavioural model

• Occupational existing

– Inability to plan for the future while making sense

Contentious aspects

• Coping strategies

– Contextual, not “active vs passive” – Range of strategies – Willingness to learn these depends on position in process

• Emphasis on re-occupying self

– Often not explicitly discussed – Requires focus on occupations the person values, not always “work” – Return to employment may be easier if the person gains confidence within a less demanding or more rewarding occupation (highly valued)

Limitations

• Substantive theory
• Probable explanation (abductive reasoning)
• Need to test hypotheses in different

populations

• Population initially drawn from people with

rheumatological conditions, may not apply to all people with chronic pain

More from Jo

Acknowledgements

My supervisors Dr Ray Kirk and Dr Jeff Gage, University of Canterbury My colleagues at Dept of Orthopaedic Surgery & Musculoskeletal Medicine, University

• f Otago, Christchurch

The participants who shared their experiences, and particularly Joletta Belton for allowing me to share excerpts from her blog

References

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