RESEARCH
ARTICLE

This thesis was added
14 July 2002

The Presenting Symptoms Associated With Arachnoiditis And The Experience Of Living With Them In Everyday Life

A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University

by Christine Hopkins - 1998

Chapter Nine: Discussion.

The primary aims of this exploratory study were to provide a description, based within a nursing theoretical framework, of the symptoms associated with arachnoiditis and the experience of living with those symptoms. The chosen theoretical framework is the science of unitary human beings (Rogers, 1970, 1986, 1990, 1992, 1994) in which the descriptions are focused on the person and their world, a perspective considered by Rogers to be unique to nursing (ibid).

The study results describe field patterns as revealed at interview. These descriptive patternings arise from two aspects of a person’s being, human field patterns, which describe the experiences identified by the participants as symptoms, and human-environmental field patterns, which describe the associated experience of living with those symptoms in everyday life.

Within the person, symptoms manifest as human field patterns, not as the property of a part. Symptoms, such as pain and physical dysfunction, manifest as reflections of the physical body. The ways in which they manifest impact on the person’s opportunities in life and on their power to make choices about their lives as they live and move in their world. Because the life process of a person cannot be separated from their environment, the process involved is actually that of the human-environmental field (Malinski, 1997). The interactions between these two are expressed through the three principles of homeodynamics (Rogers, 1990). The principle of integrality reflects the constantly changing nature of the processes between the person and their environment. The principle of resonancy reflects the harmonies and disharmonies inherent in those changing relationships. The principle of helicy reflects the ways in which symptoms affect the continuity, innovation, unpredictability and diversity of the human and environmental field patterns.

The focus on symptoms required clarification of the way participants use the word ‘symptom’. On being asked to say what the word symptom meant to them, two participants named specific symptoms rather than defining the term. Another named a disease. For the others, symptoms transcend the particular disease. The use of personal pronouns in their definitions place symptoms as integral with the whole person, more than simply part of a disease classification and more than just one summatory word, such as pain. Symptoms are descriptions. They are what you tell others about the way you are, key events that attract your attention and make you aware that something wrong is going on inside yourself.

For participants, therefore, symptoms are evidence of disharmony, and their presence creates an implicit understanding that some disease process, in this case, arachnoiditis, must be taking place. The disease, just as much as the symptoms, is integral with their whole person. What might be termed a confusion on the part of participants as to the accepted definitions of symptoms as subjective and signs as objective evidence of disease reflects the view that manifestations of the human field cannot be dichotomised as objective or subjective (Rogers, 1970). The insistence on signs as necessary evidence before symptoms can be accepted as valid emerges from the data as one of the primary concerns held by participants, summed up in the experiences as issues of belief.

Rogers (1994) commented that the study of anatomy and physiology might well be condensed in future nursing courses as nurses are going to be working with people, not practising physiology or anatomy. Brownrigg (1992) noted the importance of the nurses’ role in providing information to those in hospital who have arachnoiditis and who had felt their concerns were not understood. Study participants experienced concerns about the lack of understanding they perceived amongst those who care for them in the community and feel it is important to know their carers are knowledgeable. In view of this identified need for specific information, pathophysiological detail relating to symptoms is considered as important, indeed, essential knowledge for nurses working with those with arachnoiditis and, as such, consistent with a Rogerian perspective of people as unitary human beings. To the people who experience them, symptoms are percepts, revealed by the senses and coming unbidden into their lives (Cowling, 1990). As revealed by pattern appraisal, symptoms symbolise vital descriptions of pattern experiences, perceptions and expressions that provide nurses with details of feelings, sensations and concerns on which to focus therapeutic nursing options.

Eliciting the presence of predetermined symptoms was not a focus of the interviews. Participants described only the symptoms they associated with arachnoiditis. In hindsight, this interview technique led to some confusion as to which symptoms participants felt they should describe. This deficit was revealed by two incidents. One participant emailed further symptoms and experiences to the researcher after interview. At her request, this communication was included in the interview data. Another incident reflected evolving group awareness of associated symptoms when discussion at a support group meeting attended by the researcher revealed excessive sweating as a symptom common to several women present, including a study participant who had not mentioned it because she had not linked it to arachnoiditis until that moment. Overall, these shortcomings of interview technique are not thought to have seriously compromised the study and such omissions would be remedied in a pattern appraisal related to therapeutic care, the ongoing nature of which would reveal all symptoms over a period of time.

Study participants have many symptoms they associate with arachnoiditis, but no two have identical ones. Even those with confirmed arachnoiditis have differing combinations of symptoms. The range and variation of symptoms described by participants is consistent with the view that in arachnoiditis the distribution of lesions is so haphazard and specific to each individual case that no two cases will have the same distribution and location of pain (Bourne, 1990). It is also consistent with Rogerian perspectives on the uniqueness of each individual.

Of those with confirmed arachnoiditis, the only two symptoms shared by all four are lower limb weakness and mobility problems, neither of which are definitive symptoms of arachnoiditis. Of these four, three have problems with falling, the fourth does not. The three who fall also have numbness in areas of their feet. Three have constant burning spinal pains, one has no pain. Of those with unconfirmed arachnoiditis, four also have constant burning pain in their spines.

In addition, there are other unexplained symptoms, such as the yellow perspiration experienced by two and the night sweats of a third, the fatigue that overwhelms and severe migraine-like headaches. These symptoms perplex and concern those who experience them. There appeared to be a strong need to understand why various symptoms occur.

Of the symptoms described at interview, pain emerged as the predominant concern for all but one of the participants. The difficulties in researching pain using rigorous scientific methods were recognised by Rogers (1970). Even in assessment, anyone other than the person with the pain cannot be truly aware of what it is like and must rely on the person’s description. Those in the study perceive the qualities of the pain associated with arachnoiditis as largely unknown except to those who experience it.

The majority of the pain experiences described fall within the broad category of chronic nonmalignant pain for which no truly satisfactory or generally agreed upon definitions exists (McCaffery & Beebe, 1989). Chronic pain is simply an operational term specifying a symptom and its duration (Terenius, 1992). It is, however, recognised as one of the most pervasive and expensive health care problems of modern times, an entity in its own right noted for its highly destructive effect on the person’s life (Baquie, 1989; LeFort, 1992; Melzack, 1992; Hitchcock, Ferrell, & McCaffery, 1994; Coe, 1997).

The ‘back pain’ mentioned in the literature reviewed emerges from participants’ descriptions as a burning spinal pain. This spinal burning is a distinguishing quality of the pain the majority of participants associate with symptomatic arachnoiditis and is described as burning like a match, a fire or an overhot, hot water bottle. For two, it has an ice burn or freezer burn quality. For some, it proved incomparable with anything in their experience and they were lost for words to describe it. This spinal pain is remittent in nature, constantly present, but with flare ups of extremely severe exacerbations, often brought about by ordinary everyday activities, such as sitting, standing or walking, and relieved only by lying down for a period of time. The pain is mostly of a radiating nature, spreading outward from the spine into the pelvis, hips and thighs in those with lumbar region symptoms and out into ribs and shoulders in those with symptoms in the thoracic area. It is described by one as a passing out, and by another as a cancer like, sort of pain. Other descriptors include stabbing, grabbing, vice-like, sharp, tight and splintered. For two, there is also a particularly burning, raw pain centred in the coccyx, identified by one participant as cauda equina pain. Bourne (1990) links the bizarre, diffuse, constant, causalgic burning of the intractable pains associated with cauda equina lesions to the poorly localised patterns of paleospinothalamic pain.

Trying to attribute single cause and effect is inconsistent with Rogerian science. Medical perspectives also urge great caution in prematurely attributing simple peripheral or central factors as explanations for the puzzling variability of pain in relation to nerve damage (Wall, 1992). This puzzle is deepened by the fact that chronic pain is never present in 100% of the cases with the pathology to which the pain may be attributed (ibid), as was indicated in this study by the participant who had no pain.

The referral of pain to other areas of the vertebral column and surrounding musculature is noted as a component of intractable pain of spinal cord origin (Tasker, DeCarvalho & Dolan, 1992) and by Bonica (1991) as a component of central pain. Symptomatic arachnoiditis is therefore likely to have a multi-site pain experience and this is borne out by the findings of this study. The multi-faceted nature of their pain experience is marked. As well as the burning back pain, there are also headaches of an incapacitating nature, musculoskeletal pain from injuries from falls, further pain from the cramping and spasms, and secondary musculoskeletal pain from pain-spasm-pain tensions in the postural muscles of their torso. Bone pains, joint pains, myofascial and referred pain patterns, burning foot pain and angina are also described. In light of this variability, unless a detailed pain history is taken for each person, it is likely that health professionals may have an inaccurate understanding of the pain experience of individuals with symptomatic arachnoiditis. For those in this study, their pain is certainly much more than the ‘low back pain’ noted in much of the literature examined.

Although the literature review identified mono- and poly-radicular pain as a possibility in arachnoiditis, no participants used those terms. However, five experience shooting nerve pains in their legs that they term sciatica. The distribution of this pain is not always in the sciatic area, indicating the involvement of other nerves. No participant described the pattern of burning pain at the insteps, the inner aspects of the knees and the lumbo-sacral area noted by Bourne (1990) as found only in lumbo-sacral arachnoiditis, but a more focused inquiry may have elicited such a description.

That pain experiences can overwhelm the individual and consume every aspect of their lives (Ferrell, 1995) is borne out by this study. Five participants think their pain tolerance levels are higher than those of people without constant pain. Pain tolerance levels are defined as the greatest level of pain the person is prepared to put up with (Bowsher, 1993). Twenty years earlier, Bonica (1973) noted that people with chronic pain do not become accustomed to it but instead seem to become more sensitive and suffer more, with prolonged disabilities that could be obviated with proper management. Participants may tolerate their pain but that seems to be because they feel they have no option. Eight daily tolerate levels of pain that are clearly disabling. For seven participants, the pain is sufficiently severe to interfere with the most basic of activities such as sitting and standing. Full-time work is possible for only one participant. Only two others have part-time, paid employment. Others require help at home with aspects of their housework and yet persist in undertaking tasks that they know will make them feel worse, purely for the satisfaction of feeling briefly useful. This desire to be useful is reflected in the literature on chronic pain. Not being able to work or do chores was seen as the worst problem associated with chronic pain (Hitchcock, et al. 1994).

Through the presence of their symptoms, particularly pain, marriages and relationships with friends, family and children have been impaired. Educational plans and career options have been broken. Financial security has been lost, affecting many of the choices participants can make that might maintain their health or relieve their pain, a finding which supports research showing that disabled people become poor and that, once poor, disability is likely to increase (McKenzie, 1996). Simple pleasures like playing with their children or enjoying a game of cards are not possible without significant consequences in terms of pain, energy loss or risk to personal safety. As in some other painful conditions, the majority of problems seem to be associated more with the disabling effect of the pain than with the underlying pathology (Moran, 1994).

While pain has been seen as an initiator of positive changes in life, providing an enhanced sense of purpose (Ferrell, 1995), for those with arachnoiditis, pain is simply not relieved sufficiently to allow participants to experience a life that reaches anywhere near their full potential. The greater part of their energies are focused on getting through the day. Participants identify the strength that enables them to live day by day with their symptoms as determination. It is determination that helps them achieve a degree of involvement in activities the able-bodied could undertake without a second thought.

However, determination alone, especially in regards to pain, is not always enough. Determination has not enabled participants to realise their dreams, satisfy their needs and respond positively to environmental challenges, as was suggested by McWilliam, Stewart, Brown, Desai and Coderre (1996). Instead, participants spoke of a loss of control when their pain reached high levels. Keeping in control was important to them and maintaining that control was the focus of their determination. Wells (1994) investigated the relationship between control beliefs and distress and disability in relation to chronic nonmalignant pain and found support for the hypothesis that the greater control one perceives themselves as having, the better a person adjusts to chronic symptoms. However, adjustment is not a concept consistent with Rogerian thinking. Even the term ‘control’ implies a reining in, rather than a transcending of, the symptom and, as such, is not consistent with the science of unitary human beings.

Fatigue was the next most disabling symptom, with nearly half of the participants experiencing an extraordinary degree of fatigue. Fatigue is a recognised concomitant of pain (McCaffery & Beebe, 1989; Hitchcock, et al., 1994), although not of arachnoiditis. The participant with no pain did not mention fatigue as a problem for him. The overwhelming nature of the fatigue described by other participants was striking, but it is less clear to both the researcher and to the affected participants whether their fatigue is associated primarily with the pain, as two participants believe, or with other factors, such as chronic fatigue symptoms and fibromyalgia (Bohr, 1995).

Piper (1994) outlines various attempts to classify fatigue, with the most useful classification for nurses seen as acute or chronic. Piper (ibid) also reports on a physiological classification of central fatigue which may result from impaired transmission down the spinal cord. Further investigation into this possibility may establish a link with arachnoiditis which could be of relevance when considering a choice of therapeutic possibilities.

Fatigue, like pain, is a symptom which health professionals must usually accept as being as severe as the person says it is, because there may be little objective evidence to validate the experience. To be clinically valid, measures must analyse patient’s descriptions. Potempa (1994) notes that most of the fatigue instruments currently available were developed for non-clinical populations, particularly in the area of sports medicine relating to muscle fatigue, and that the development of tools for clinical populations had been so difficult as to lead to abandonment of the construct as too difficult to measure. As with pain, it seems the most helpful nursing assessment or pattern appraisal of fatigue is likely to be a description using the person’s own words (Piper, 1994).

One tool, used in nursing research and which could be useful in clinical practice, is the Pearson Bryar’s scale, which rates fatigue on a lay language scale ranging from ‘extremely peppy’ to ‘ready to drop’ taken at various points over a twenty four-hour period (Cohen & Hardin, 1994). This scale’s focus on the whole person makes this a measure consistent with a unitary perspective.

Fatigue is recognised as multidimensional, with some specificity to disease states (Potempa, 1994). Finer & Melander (1985) describe the interwoven links between pain, fatigue, medication, lack of exercise and lack of mental stimulation. Ferrell (1995) notes that the extent to which pain results in extreme fatigue is particularly impressive. Why this should be so is still unclear. Sleeplessness is a major factor in fatigue in people with painful rheumatoid arthritis (Crosby, 1994). However, sleeplessness was not noted by participants in this study, even by those who sleep poorly, as a major factor in their fatigue. The effects of lack of exercise on fatigue is another consideration. Study participants did not, on the whole, take part in regular exercise programmes. While there is a recognised correlation between lack of exercise and fatigue, the difficulties of exercising with the severe pain participants report and the recognition that exercise does worsen their pain, makes maintaining fitness very difficult. Swimming causes embarrassment and difficulty in accessing the facility. Physiotherapy pools are not readily accessible for maintenance programmes.

The physical effort spoken of by participants in relation to the accomplishment of even quite simple activities and the relentless nature of their pain can be compared to other literature relating to pain, for example, in those with rheumatoid arthritis (Crosby, 1994). For those with arachnoiditis, the benefit to be gained from forcing oneself to exercise through increased pain and the possibility of increased fatigue, in the hope of improving general fitness is hard to determine at present. Only effective pain management allowing pain-free exercise is likely to reveal any correlation between pain, lack of exercise and fatigue, and fatigue and arachnoiditis per se. If arachnoiditis has an autoimmune component, then there may be a shared biophysiological correlation between fatigue as a symptom of arachnoiditis and fatigue associated with other autoimmune diseases such as multiple sclerosis, rheumatoid arthritis, and chronic fatigue syndrome. The possibility of an admixture of these two components of fatigue indicates that effective pain management alone may not relieve some participant’s fatigue.

Living with both pain and fatigue creates a dilemma for participants expending energy in a forced interaction with their world to distract themselves, mostly from the pain. This creates a balancing act of sorts, since they must juggle the need for distraction against the limitations of fatigue, the exacerbation of pain and the limitations of mobility problems. The nursing literature notes both the advantages and disadvantages of distraction. One disadvantage is that others may doubt the existence of the severity of the pain if the technique is successful (Edgar & Smith-Hanrahan, 1992). Another disadvantage is that the fatiguing nature of distraction techniques indicates their use for short periods of less than two hours (Edgar & Smith Hanrahan, 1992). Participants have devised distraction activities to use throughout their day, but may not be choosing the most beneficial options. The exhausting nature of some of the distractive activities chosen reflects a lack of mutuality in the flow of energy, which is predominantly from the human field to the environmental energy field in people who already seem to have reduced energy, manifested as fatigue, in their field patterns.

Techniques, such as rhythmic breathing exercises, music (McCaffery & Beebe, 1989; Edgar & Smith-Hanrahan, 1992) which may allow for a mutual energy flow less fatiguing to participants are not mentioned by participants. Piper (1994) suggests that unnecessary energy expenditure can be decreased by an increase in dependency on others. To a certain extent, this is already evident in participants’ lives, through provision of homehelp by ACC, but such dependency has other unwanted effects such as feelings of uselessness. A lack of obvious or recognised reasons for inactivity can, as several participants reported, lead to accusations of laziness from others. None of the participants reported their pain as being worse in the morning, a linkage to emotional upset, as compared to worsening pain throughout the day, which is seen as more likely to be due to organic causes (Srivastava, 1994).

Other expressions of symptom experiences included feeling depressed, having a diagnosis of depression, feeling suicidal and planning for suicide. Such feelings are field functions manifested as integrating forces that encompass the totality of the individual (Rogers, 1970). Depression is a recognised concomitant of chronic pain (Ferrell, 1995) and the prevalence of depression in those with chronic pain is recognised as being substantially higher than in those without pain (Hitchcock, et al., 1994). Because of its constancy, lumbo-sacral arachnoiditis pain is considered more depressing and debilitating to patients (Bourne, 1990) than other back pains. However, although ‘depression’ as a pathological label (Tuyn, 1994) was accepted by some participants, it was specifically denied by others, who instead felt it was perfectly reasonable to feel depressed in their situation.

A linkage between depression and suicidal feelings which respond to pharmaceutical intervention was made by two participants, supporting the need for early detection of suicidal ideation in people with chronic pain (Hitchcock, et al., 1994). The planning for suicide as a fully knowing life choice spoken of by some participants appears more akin to euthanasia than to depression-associated suicide. The prevention of such actions may be impossible if the person truly feels a continuation of their incurable and unbearable state is all the future has to offer. It could be argued that, far from a knowing choice, such a decision is made because no other options are apparent. Suicide or euthanasia then becomes no choice at all but an expression of the ultimate in extreme powerlessness.

Changes in human-environmental field patterning reflect in the interactions participants have with their worlds. Foremost among these changes for participants are mobility problems, which have had far-reaching effects in their lives. An inability to move freely in their world is linked to a number of symptoms, including a tendency to fall unexpectedly, pain, fatigue and, sometimes, depression. Mobility problems reflect a major imbalance in an individual’s sense of integrality with their environment. A lack of resonancy is engendered by those around them either disbelieving the presence, or the severity of, their symptoms, or not understanding the ways in which the symptoms affect their ability to undertake physical movements. The helical patterning of their lives reflects a lack of forward movement relating to an apparent closing down of the number of opportunities open to them as future life choices. Mobility difficulties affect peoples’ abilities to function in household and employment tasks. They alter their ability to interact with their family, participate in social events, use cars, go for walks, play sport and enjoy hobbies such as gardening. Unwanted lifestyle changes occur in relationships, in parenting, in work opportunities, in financial circumstances and in hopes for the future as a result of those difficulties.

However, these difficulties appear to occur less because of motor impairments alone, than through associated pain, which further limits movement. The participant who has no pain, although the eldest of the participants, has remained largely independent and has few difficulties in living his life much as he expected he would in retirement. For others, pain and mobility difficulties create a ripple effect flowing as energy changes throughout every aspect of their lives. Descriptions of reasons why and how participants seek relief focus largely on pain management strategies, although relief is also sought for decreases in lower limb function, bladder and bowel problems, sweating, depression and problems with sleeping.

Social isolation is a marked feature of participant’s lives with pain. It is recognised that many people do not leave their homes when their pain is uncontrolled, isolating themselves rather than be seen in pain (Ferrell, 1995). Although concealing their problems is a feature of several of the participant’s lives, this is not necessarily for reasons of pain alone. Changed financial circumstances contribute to a decreased ability to enjoy activities, such as a meal out or using the spa bath, because the cost always has to be factored in. Participants dislike constantly having to relate their problems instead of enjoying general conversation of an everyday nature. Managing the information relating to a chronic condition is therefore a factor in determining participant’s attendance at social activities. They must cope, not only with the pain and associated disability, but also with deciding whether to tell people why they cannot sit, walk, dance or collect their meal from the buffet. Admi (1995) compared the historical perspectives on the decision to reveal disability or not as concealment because of immaturity in dealing with the problem, or as denial of the disease, contrasting with a third option of total public visibility as a self-empowerment technique against discrimination. In this study, those who spoke of telling others about their condition tended to a fourth option, not telling unless absolutely necessary because they do not see it as anyone else’s business.

Relationships had foundered, reflecting the impact of chronic pain on partners and families. Several participants mentioned the difficulties partners had, or currently have, in understanding their symptoms and needs. No participant mentioned counselling support for partners during these relationship crises, supporting Schwartz and Slater’s (1991) claim that spouses of chronic pain patients may represent a population in need of support in their own right.

Quality of life is a term commonly used in reference to those with chronic conditions, but particulate views which identify variables of a biopsychosocial being are not considered congruent for the study of unitary human beings and their lives (Parse, 1994). Instead, asking participants to consider themselves at their best and their worst placed the assessment as a unitary percept centred in the life of the person. This brief review of the worst and best of daily life with arachnoiditis tended to have a common link, namely, participants’ perceptions of their ability to function independently in daily life, reflecting, most disturbingly, a high level of disability linked largely to pain, as an immobilising factor in their lives. Eight of the eleven participants perceived themselves as closer to the worst they could imagine being for most of their waking hours than to the best they could imagine, with seven frequently reaching between eight and ten at their worst. To be feeling this bad for most of the time creates great personal costs in, as Baquie (1989) put it, forging ahead while feeling awful. On a pain scale such high levels as this would indicate an unacceptable level of pain and suffering. As a general indicator of disharmony in their field patterns, the levels of distress and disability revealed by this study attest to the need for consideration of a whole range of different options for those with arachnoiditis.

Although participants manage to get through each day, they are relatively pessimistic as to their hopes for their futures. They all hope not to deteriorate further but are uncertain as to the likelihood of not getting any worse. Nursing studies on uncertainty in illness indicate people have difficulty making sense of their illness events when they are marked by ambiguity, complexity, informational deficiencies and unpredictable outcomes (Mishel, 1988, 1990), all of which have been features of participants’ experiences. Uncertainty is also seen as consistently associated with emotional distress, reduced quality of life and poorer adjustment to life with illness (Mishel, 1995) and as a pervasive, stressful accompaniment of illness that strongly influences the ability to reach their greatest potential in their circumstances (Mast, 1995). Whether this is specifically so for the participants was not a focus of the study. However, there is an overall sense of uncertainty in their situations, revealed by participants’ general lack of plans, apart from suicide, for their futures. For some, this relates to a lack of explanatory information about their mobility problems and how much worse they might get, and for others to a general pessimism, tinged with a further uncertainty as to whether any potential medical advances will occur in time to be of benefit to them.

Pervasive in Rogers’ writings, and in those of her followers, is a perception of people as integral with a spiritual oneness of creation that transcends particular religious traditions. Three participants mentioned ongoing spiritual beliefs as important in their lives. While it has been stated that pain has a tremendous influence on spirituality, and that particular religious traditions influence perceptions of the meaning of pain (Ferrell, 1995), this is not apparent in this study. There is no acceptance of the idea of their situation as a punishment. Instead, there is a perception of aloneness felt by participants, who sense that others, including health professionals, do not understand their situation. In face of this sense of aloneness, a pragmatic attitude seems to have developed. Pragmatism is considered to be a manifestation of lessened diversity in field patterning (Rogers, 1990). Participants reflect a pragmatic acceptance of the incurability of their situation, even though that acceptance remains tinged with hope that medicine may one day offer an effective answer. They accept, with regret, their enforced isolation. They endure the intractable nature of their pain. They accommodate the need for long periods of rest. These thoughts and actions are based more on getting through each day than on finding spiritually based ontological meanings in their pain experience.

This study indicates there is something more to living with the symptoms associated with arachnoiditis than with many other chronic health problems in which a high degree of normality in everyday life can be maintained. Indeed, some participants have been diagnosed with other conditions, for example, asthma and diabetes, which do not impact on their lives in anywhere near the same overwhelming way. The differences would seem to be centred around the pain and, for some, the fatigue. Pain and fatigue are more disabling than the muscle weakness, lower limb motor problems or even the paralysis of one participant. It is these symptoms that send them to their beds, prevent them from working and interrupt their enjoyment of family and social life.

The study findings also indicate the complexity of the situations in which those with arachnoiditis find themselves. The reported lack of success of most therapeutic options appears to leave health professionals who would seek to work with those with arachnoiditis little in the way of therapeutic answers. It is this general sense of helplessness and hopelessness that an altered world view based on a Rogerian perspective would seek to change. Instead of being seen as incurable and intractable, their situation reflects a need for planning for mutual repatterning that seeks to re-establish positive helical movement and a new harmony and integrality in their lives. Possibilities for the implemention of this optional view will be discussed in the next chapter under implications for nursing.