text:
A Qualitative Study of Changes in Expectations Over Time
Among Patients with Chronic Low Back Pain
Seeking Four CAM Therapies
This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: BMC Complement Altern Med. 2015 (Feb 5); 15: 12 ~ FULL TEXT
Emery R Eaves, Karen J Sherman, Cheryl Ritenbaugh, Clarissa Hsu,
Mark Nichter, Judith A Turner, and Daniel C Cherkin
Department of Family and Community Medicine & School of Anthropology,
University of Arizona,
Tucson, AZ, USA.
emerye@email.arizona.edu
BACKGROUND: The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy.
METHODS: We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time.
RESULTS: Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.
CONCLUSIONS: The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.
Keywords: Chronic low back pain, Acupuncture, Chiropractic, Yoga, Massage, CAM, Expectations, Self-care, Pain management
From the FULL TEXT Article:
Use of complementary and alternative medicine (CAM) is common among chronic low back pain patients [1]. In addition to increasing clinical research that shows pain reduction resulting from CAM [2–5], CAM therapies are often associated with additional benefits [6, 7]. Although nearly forty percent of adults in the U.S. use some form of CAM [8], the motivations for people to choose CAM are not well understood. Bishop et al. [9] found that continued use of CAM was related to positive experiences with CAM, rather than with negative experiences or perceptions of conventional care. Despite inconsistent findings, many researchers have continued to argue that higher patient expectations of treatment benefits from CAM therapies enhance treatment effects for a variety of health conditions [10–14]. Further research is needed to understand the relationship between patients' expectations for treatment, practitioners' presentation of treatment, and outcomes or reports of satisfaction by patients [15–18]. Further, recent research differentiating hope from expectations has called for a re-examination of how patients themselves perceive their expectations of therapy and how these perceptions change over time in the context of a novel treatment experience [19–22].
Initial research has shown a correlation between use of CAM and high internal health locus of control (HLOC) and empowerment [23]. Murthy et al. [1] raise the possibility that CAM users are more engaged in their health care than others because they are already aware of the importance of maintaining their own health. However, questions remain regarding whether individuals entering CAM are more empowered and engaged in their own health prior to seeking treatment, or whether CAM therapies are involved in empowering patients to take a more active role in their health [1]. Evans et al. [24] report that "self-care talk" is interwoven through CAM consultations. Self-care recommendations were co-constructed by clients and practitioners, in particular because the therapeutic relationship includes patients as equal partners in their own care [24, 25].
Emerging evidence suggests that CAM has the potential to enhance patients' awareness of the interconnections among mind, body, and lifestyle and therefore to encourage patients to assume personal responsibility for their health and adopt more effective coping strategies [7, 26, 27]. In a review of responses to open-ended questions collected in several CAM clinical trials, Hsu et al. [6] found that participants reported outcomes such as increases in hope, relaxation, feelings of empowerment, body awareness, and ability to cope with back pain. Likewise, participants in cancer treatment trials reported that CAM use led to improvements in quality of life, ability to cope with stress, and increased sense of personal control over health [28]. In a study of individuals seeking CAM, Bann et al. [29] found that patients' reports of increased empowerment and reductions in symptoms were attributable to the patient-centered care and provider support that are particular strengths of CAM therapies. Williams-Piehota et al. [30] call for further research to determine whether CAM, and in particular, interaction with CAM practitioners, may contribute to behavior change.
Sherman et al. [15] reported that patients' predictions about the outcomes of acupuncture treatment became stronger predictors of treatment outcome over time, suggesting that participants revisit their expectations based on actual experience. Researchers exploring expectations among patients with chronic low back pain have reported that patients often prefer to disclose hopes, while being more cautious about disclosing expectations [20, 22, 31]. Bishop et al. [9] found participants often unwilling to commit to an evaluation of treatment, preferring to remain open. Being open to the future, retaining hope, and allowing for the possibility of improvement regardless of prognosis is common in chronic illness narratives [19, 32]. We have elsewhere reported that hopes are multifaceted and influence the way participants evaluate and report on their expectations and experiences of treatment [21]. Therefore, to explore changes in expectations over time without consideration of hope in the lives of participants would lead to a partial understanding of the way experiences are evaluated and expectations are updated over time.
In describing illness experiences, participants are continually revising expectations about the future as well as reconstructing the past and present to account for illness [33–35]. Hope is experienced in multiple forms, from cognitive and rational to deeply embodied states of being, sometimes transcending everyday reality [21, 36]. While expectations are constrained by a reality and rationality that may be felt as overly constrictive in the lives of chronic pain sufferers, "hoping appears to approach reality as something-in-formation, something-in-process, with the implication that one's own experiences to date are not the last word about oneself and reality, but that experience itself is still in process, with the possibility of a discovery to be made or a novelty to occur" [37].
In this qualitative analysis, we explore individuals' expectations and hopes as they change over time in the context of CAM treatment for chronic low back pain.
Qualitative interviews were conducted as part of a larger study of individuals with chronic low back pain seeking one of four CAM therapies (yoga, massage, chiropractic, acupuncture). See [22, 38] for additional information on overall study design and methods and Hsu et al. [22] for detailed participant demographic and therapy use characteristics. In analyzing interviews with CAM practitioners in an earlier phase of this study, Schafer et al. [38] reported that CAM practitioners (specifically acupuncturists, yoga teacher, chiropractors, and massage therapists) tried to help their clients have more realistic expectations of their treatment. Further, because participant expectations could change over time, the practitioners had continually managed them to enhance engagement and satisfaction with treatment. In an analysis focused on the pre-treatment interviews included here, Hsu et al. [22] reported that participants were reluctant to express optimistic expectations and often spoke interchangeably about their hopes and expectations. Expectations were modest, and centered around four main themes: pain relief, improved function, and less frequently physical fitness (primarily among yoga participants), and overall wellness. In this analysis, we include both baseline and follow-up interviews to examine how expectations change over the course of CAM treatment. The analysis presented here focuses on semi-structured open-ended qualitative interviews with 64 participants (23 in Tucson, AZ and 41 in Seattle, WA). Interviews were conducted with two categories of participants. One group had not yet begun or had only recently begun a new treatment. They were enrolled as "longitudinal participants" and were interviewed at additional timepoints after beginning treatment. Each interviewer conducted all three interviews with a given participant. A second group of participants who had already completed or were long-time users of one of the therapies were interviewed one time only and enrolled as "cross-sectional" participants. For interview timing and numbers of participants in each group, see Table 1. Eighteen participants who were enrolled longitudinally did not complete follow-up interviews. We reviewed their pre-treatment comments to make sure they were comparable to those with follow-up data, however, those participants who have no longitudinal component are not included in Table 1.
We recruited adults with chronic low back pain between the ages of 20 and 70 years, with at least 3 months of pain, and who rated their average back pain in the past week as 3 or higher on a 0 (pain is not at all bothersome) to 10 (pain is extremely bothersome) scale. Recruitment methods included: posters and brochures placed in clinics and yoga studios; online classified advertisements; and CAM practitioner referrals of new patients. In an effort to recruit a diverse sample, we also recruited individuals seeking care from a community clinic that offers massage and acupuncture treatments at no cost to patients and serves a primarily low-income, non-English speaking clientele. With the exception of those interviews, which were conducted in a private room in the clinic, all interviews were conducted by telephone. Four experienced interviewers, two of whom were fluent in Spanish, conducted interviews for the study. Five interviews were conducted and transcribed in Spanish and then translated into English. No differences other than slight variations in definition of terms were evident in Spanish language interviews. Exploration of the different meanings of expectation and hope in Spanish versus English is beyond the scope of this analysis.
Interview guides for longitudinal interviews were designed to elicit a broad range of information related to expectations, hopes, and beliefs about illness. Interview 1 (pre/early treatment) contained questions focused on: treatment history; pain severity and variability; expectations and reasons for trying therapy; expectations for broader life change; provider choice; difference between hopes and expectations; overall attitude and approach to life; stress and other life issues; and impact of pain on life. Interview 2 (after 1–2 weeks) contained questions focused on: changes in pain; initial impressions and experiences of treatment; experiences of surprise; changes in expectations; changes in hopes; stress and other life issues; self-care recommendations given by practitioner and intent to follow-through; and changes in thinking about pain or about life overall. Interview 3 (after 3 months) contained questions similar to interview 2, with increased focus on experience of relief; overall impressions of treatment; experiences of surprise; current expectations (for pain relief, better function, continuing treatment); changes in hopes; and intent to continue with self-care recommendations after treatment. Self-care recommendations from practitioners were explicitly included in the 2nd and 3rd interviews, but not clearly probed in the first interview. The cross-sectional interview (conducted once, shortly after first treatment) guide was derived from all the longitudinal interview guides to cover all relevant topics. Interviews varied in length from 20 to 45 minutes and were audio-recorded and transcribed verbatim. Study protocol and interview guides received approval from the Institutional Review Boards at Group Health Research Institute in Seattle and The University of Arizona in Tucson. All participants provided informed consent.
Interview transcripts were coded using qualitative data analysis software ATLASti [39] (for detailed description of codebook development see Hsu et al. [22]). The present analysis is focused on participants' reported expectations regarding pain, function, impact on life overall, and hopes, as well as indications of surprise, disappointment or satisfaction with CAM therapies. Qualitative data are useful for providing rich descriptions of complex phenomena [40] that can provide depth and understanding to issues not amenable to quantitative methods [41]. In reporting qualitative data, illustrative quotes are used to support observations and illustrate emergent themes [42].
We used a mixed-methods approach to qualitative data analysis. All transcripts were initially read by the research team and coded for a few key themes to gain a sense of the data. Later, more in-depth codes were determined through an immersion/crystallization approach [43]. After initial coding, we used an open-ended process of matrix analysis [44] to analyze changes in expectations within subthemes as well as changes in thematic emphasis over time. Matrix analysis was conducted as a process of decontextualization and recontextualization. This approach allows quotes of interest to be lifted out and examined more closely to observe change over time. Quotes are then recontextualized into the broader data set to make sure observations agree with the overall context and content of transcripts [43].
In the matrix analysis process, we compiled participant quotes into a grid or "matrix" with rows reflecting themes of interest and columns reflecting interview date. For each participant, the matrix included five themes of interest and two or three interview columns (dependent on number of interviews). For cross-sectional participants, the two columns distinguished between whether participants were referring to initial or current expectations. "Matrices" allowed us to observe change in each theme over time in participants' narratives, as well as changes in thematic emphasis over time (as illustrated in Tables below). To avoid potential limitations of this approach, cells could contain multiple quotes and quotes could be located in more than one cell. Data were then recontextualized by referring back to code reports and individual transcripts to corroborate observations.
Although the intention of our analysis was to focus on changes in expectations over time, we found that hopes were not separable from expectations in our participants' narratives. Due to engagement of the two concepts, we pay attention to the role of each in the results presented below. Likewise, we consider self-care, empowerment, and lifestyle impacts, as these emerged as central themes in post-treatment interviews. Quotes are identified with pseudonyms and which interview they pertain to.
Of the 64 participants, seventy-five percent were women. Sixty-five percent were Caucasian and 12 percent Hispanic. 15 participants were seeking chiropractic, 18 were seeking acupuncture, 13 were seeking massage, and 18 were seeking yoga. See Hsu et al. [22] for detailed participant characteristics.
Overall observations
Over the course of three interviews we noted differences in participants' emphasis. In pre- or early-treatment interviews, we flagged any mention of hoping for relief, cure, or reduction in pain level. Some said they had "no expectations" or were "not expecting much". Others reported they were not sure what to expect. In final interviews, expectations and emphasis were more oriented toward lifestyle and whole person connections. Participants were increasingly aware of the relationship between their bodily well-being and their social well-being, physical activity, diet, and overall lifestyle factors. They reported greater awareness of the chronic nature of their low back pain and greater acceptance of the ongoing nature of a need for pain management and self-engagement. Regardless of reduction in pain, almost all participants mentioned they now understood that continued maintenance activities would be required.
Quotes below are presented by therapy to illustrate patterns of change over time for each and to show overall similarities. In qualitative analysis of participants' descriptions of the lived experience of chronic pain, there is often a tension between identifying patterns and similarities among participants while providing a fair representation of the complexities and particularities of individual experience [34]. While the four participants in Table 2 are presented for their illustration of the overall trend we observed, we emphasize that individual narratives are complex, non-linear, and at times lacked internal consistency. These issues will be explored in later sections.
Becoming more "realistic"
Becoming more "realistic" was a common theme in participants' narratives. Although a few participants did report significant pain relief as a result of treatment, a more common outcome of treatment was an increased sense of being able to take control of one's pain, to manage it and to tend to one's own bodily well-being in a broader sense. Nora, below, offers a metaphorical representation of learning to care for her body as one would care for a garden.
I really thought that this was what I was tied to. You know, I was tied to this pain. That this pain was definitely a part of me and was going to be a part of me forever. And I don't think that the chiropractic work heals my back in the sense that, you know, we do some adjustments for five or six months and you're better and you're never going to have any discomfort in your back again. I think what it has done for me is that it has showed me that there are really good avenues to take care of your body. You know, besides anti-inflammatories and things like that. That it is -- it's caretaking, it's tending, you know, like you would tend to a garden. You know, you can plant all those wonderful tomato plants and lettuce but if you don't weed it and water it and fertilize it, they're not going to grow and flourish. So the chiropractic work is part of me tending my body. And if I don't do this, my body isn't going to flourish and grow and feel good. And bloom.
(Nora, Chiropractic participant, Seattle, Interview 3)
Here, emphasis has shifted from intense focus on pain to increased sense of bodily awareness and attention to more comprehensive care for the self both in relation to and independently of pain. This sense of shift toward a broader focus on the body, long-term well-being, and empowerment to take control over one's own search for wellness was central to participant narratives both three months into treatment and for participants who were longtime users of CAM. As Allan explains in a retrospective account of how expectations changed over the course of treatment, finding hope is a significant part of the process, as is a sense of control or feeling of being able to solve one's own problems.
I think my expectations got broader and deeper as I started to sort of advance, I think I started to feel positive that there was some hope and I could start thinking that there was kind of light at the end of the tunnel, at least partway through and I think that helped, believing that something positive was gonna happen, instead of going in like I did at first, where I just wasn't sure, and I was just hoping for anything. I think as I got to understand it better and patience and expectations and hopes at least got bigger, that eventually, I could solve, I guess solve more of the problems and feel better each time, each year, hoping there was a goal out there that I could attain.
(Allan, Yoga participant, Tucson, Cross-sectional)
Realism versus hope?: Multiple evaluations of accepting chronic pain and ongoing maintenance
Over the course of the interviews, participants seemed more aware of the chronic nature of pain and the need to shift from searching for cure to seeking maintenance strategies. While awareness and control appear in the above quotations as positive, these factors imply some degree of personal responsibility for their health [45]. Willingness to accept responsibility for their own health appeared to be a factor in how participants assessed and explained changes in pain level and experience. For some participants, increased awareness and acceptance of the need for maintenance strategies and self-care was described as a successful "outcome" of treatment. For others, similar experiences were relayed with a sense of disappointment at having learned that cure was unlikely. This highlights the heterogeneity in how participants respond to expectation management and co-construction of self-care and personal responsibility or control in interactions with CAM therapists [25, 38].
Cindy described her realization that managing chronic pain is a "lifelong burden". By comparing her goal-setting to that of a marathon runner, she finds some reassurance in being able to envision the stages toward "healing".
[Chiropractic has] helped me … I've realized I'm going to have to do this for the rest of my life, the stretching, the strengthening, you know? It has made me more conscious of how I sit and how I walk. I notice that now. I notice the steps I take. …I've become a lot more aware of my back and pain and realize my lifelong burden is to take care of it… it's helped me to realize and think of goals too… And it helps prepare me if I think about it mentally first, kind of like if you're a marathon runner or whatever you know? … I'll think of the stages that I will go through to be where I want to be on the healing.
(Cindy, Chiropractic participant, Seattle, Interview 3)
For other participants, however, increased awareness of the ongoing need for pain management, self-care, and long-term coping strategies led to decreases in hopefulness. Despite experiencing some benefit from seeing a massage therapist, Linda reported disappointment at realizing that massage would not cure her back pain. She points out, however, the realization that the pain is something she needs to attend to and which includes paying attention to posture and overall management of the pain in daily life.
I think the one thing that you had asked me about expectations is I just really thought it would be pretty much obtained by six weeks and I don't think it was to a level so that was a little surprising if not disappointing. But I think the only thing, I don't know if surprise is the word, but is that I learned is that I can't really -- and that when you have this sort of thing, you have to -- it's a huge part of life that you have to attend to. It's not something you can just have someone fix and then go home, you know. It's something that it's part of, you know, like when I sit at my desk, I have to get up from my desk. I have to kind of like move. It's not crippling but it just needs to be managed.
(Linda, Massage participant, Seattle, Interview 3)
Helen, a long-time user of CAM, explicitly equates being realistic with feeling more negative about pain as a lifelong issue. Accepting pain as a lifelong issue requiring continuous use of maintenance strategies, in this statement, is equated with being "doomed" to it.
I feel like the more I see [any kind of] specialist, the more I feel kind of doomed, like that I just have a screwed up back, because a lot of them will say things like, "Oh," like they'll think I'll have scoliosis, or like weird physiological issues and you know, it's made me feel a little bit like, OK, my whole life is going to be dealing with this, whereas I think early on as a runner and initially injured myself, like, 10 years ago, I didn't think of myself as somebody who had physical issues. So now I actually feel a little more negative about, or just realistic about the fact that I'll be dealing with this thing my whole life.
(Helen, Chiropractic participant, Tucson, Cross-sectional)
Case example: Leslie, Yoga participant, Seattle
Although not intended to be representative of the experience of all participants in this study, Leslie provides an example of how expectations change over time in the context of ongoing attempts to establish or maintain meaning in life with chronic pain. While some of her expectations are specific to yoga, the process of adapting and revising her initial expectations in response to change over time was common among participants, regardless of therapy. Over the course of her experience with yoga, Leslie adjusts her expectations, her sense of living in her body, and her explanations about what a reduction in pain means for her overall process of moving toward "healing". In her initial interview, Leslie expressed low expectations, explaining that she was "not an optimist" due to her experience with chronic pain. Leslie expected yoga to allow her to be proactive in managing her pain.
I don't [expect my life to change], I'm not an optimist by nature, certainly lost my optimism through this whole thing, I really don't expect much.
(Leslie, Interview 1)
I think yoga is probably one of those things that, again, for somebody who's my age and my history, it's proactive, it's a proactive treatment that lets you do something about your pain… [yoga will] give me a chance to do something about it myself.
After a few treatments, Leslie continued to express expectations about using yoga as "another tool", admitting she didn't "think there's any magic bullet to it all". She perceived a need for continued commitment to management and feared that this commitment could be undermined by "feeling a little bit better" as a result of yoga. In the second interview, Leslie reported further realization that pain reduction would not be sufficient in itself. She reiterated that a reduction in pain threatened to remove motivation for moving toward her goal of "healing". She hypothesized, however, that if yoga were to reduce pain it might substitute for the pain as a motivator toward continued attention to maintenance strategies and to her body.
I think my expectation would simply be that that yoga is another tool and I'm at a point I have enough momentum moving forward that yoga will help me build up that momentum and keep me progressing, 'cause I think this chronic pain and chronic injury, if you go, "Oh, I feel a little bit better". And then you sort of stay in your pattern, that's, you don't progress beyond, you have to constantly, constantly be pushing yourself … pain reduction doesn't actually mean that you've fixed your problem, until you're able to do the things you should be … so a reduction in pain isn't my goal, my goal is healing, and so my expectation of yoga is simply that it would be something to keep me moving forward at each level of progress.
In a final interview, after 6 yoga classes, Leslie reported having learned that pain is not a constant state, but rather can "ebb and flow". This realization appeared to impart a renewed sense of hopefulness with regard to the future.
I think I've learned that even though I've had this pain for so long that it feels really permanent and impermeable, I think I've learned that it can ebb and flow and it can be less painful and it can be like half the days in bad days instead of only ever having bad days. So that's been like probably a good thing to learn. Just that the pain is malleable, but it's changeable. I haven't felt like that in a very long time.
Interview narratives are not simply accounts of inner thoughts or feelings, but rather verbal processes in which individuals attempt to make sense of experiences and of their reactions [46, 47]. At a time when participants were actively seeking a novel treatment for pain, CAM care may have provided the additional benefit of assisting with attaining or regaining a sense of control, increased awareness, and a stance of acceptance toward the long-term implications of living with chronic low back pain.
Although some participants were already aware of the importance of maintaining their own health, even those participants who expressed acceptance of the need for strategies to maintain overall health and for manage chronic pain at baseline reported greater awareness of the need for these strategies and increased empowerment to make life changes at the three month follow-up interview. Sasagawa et al. [23] raised questions about whether participants seeking CAM were already more motivated and engaged in their own care than patients who did not seek CAM, or whether CAM increased their motivation. Our findings suggest the latter explanation may be true. Even those participants who were disappointed that the treatment did not result in improvements in key outcome domains expressed greater awareness of the need for self-care and of interconnections between pain and broader lifestyle factors.
We observed that among the participants we interviewed, evaluations of treatment outcomes were contingent not only on initial expectations, but also on whether or not participants viewed their low back pain as "chronic" or as something that could potentially be resolved or cured. There is a significant body of research on the potential therapeutic value of accepting the presence of chronic pain [48-50]. These researchers report that acceptance of the chronic nature of pain was associated with whether patients adopted effective or ineffective coping strategies [49, 51] as well as with better emotional, social and physical functioning [50]. Acceptance of pain often entails re-framing a new life in the present rather than attempting to return to a past version of "normal" [52] as well as acknowledgment that cure is unlikely and a shifting focus from pain to non-pain aspects of life [51, 53]. Huet and colleagues [54] reported that individuals only came to a point of acceptance after a process of grieving and regret. As Jackson [55] points out, individuals with chronic pain often view their pain as indicative of bodily damage. Experiencing pain that lasts longer than expected often leads individuals to seek diagnosis, legitimacy, and meaning, which can come to dominate individuals' lives [56] until they are eventually confronted with a discourse of adaptation that implores them to consider acceptance of life with pain [51]. In our analysis of interviews with patients about their expectations for treatment, we observed that narratives initially focused on whether or not the treatment could lessen pain or improve ability to participate in meaningful activities impacted by pain. In later interviews, emphasis shifted to be broader in focus, a shift from focus on pain to non-pain aspects of life that align with the features of accepting pain as described by Risdon et al. [51].
Thorne et al. [26] suggest that CAM therapies themselves are part of a complex process of self-care management. Interviews with CAM practitioners suggest that the practitioners see themselves as actively promoting self-responsibility and attention to the need for self-care [38]. Our findings with patients further corroborate this idea and are consistent with suggestions that interactions with CAM practitioners may contribute to positive behavior change, including an increased acceptance of personal responsibility for managing pain [30]. Thus, our findings contribute to a growing body of evidence suggesting that CAM may have the potential to increase patients' awareness of connections between lifestyle, mind, and body and to lead to perceptions of increased control over pain and self-efficacy for managing pain [7, 26]. Baarts and Pedersen [57] found that no matter whether CAM treatment was "successful", their interviewees reported increases in general well-being. They observed that this led to increased motivation to care for the self and body and not to dependency on a CAM practitioner.
These interviews were conducted as part of a study ultimately aimed at creating a questionnaire to measure participants' expectations in CAM clinical trials. Interviews focused on prior experience, beliefs about illness causation, attitudes toward the possibility of finding relief, and on expectations and hope for the treatment's outcome. Unfortunately, we did not ask participants about their expectations about the likelihood of self-care recommendations prior to treatment. Therefore, detailed analysis of their expectations about the likelihood of self-care recommendations prior to treatment and of others aspects of participants' experience with treatment (e.g., their satisfaction with more conventional treatments, changing beliefs about healing in general) is beyond the scope of the data. In addition, longitudinal interviews were conducted over a period of three months and use of CAM during that time period varied substantially, but tended to be less than what clinical trials offer. Interviews with long-term CAM users also included participants whose CAM use for back pain varied over the course of their lives. Participants were seeking multiple CAM therapies from different practitioners on their own. We are unclear how our findings would compare to persons seeking CAM for other conditions, which may differ in their natural history. Some researchers have reported, however, that the level of self-care and emphasis on empowerment and self-responsibility we observed is unique to CAM [25]. Because of the relatively small sample size and community based recruitment strategy, we focus on findings that were observed across all four therapies among back pain patients and therefore we do not comment on differences among therapies. Future research should consider not only how expectations change over time, but also how feelings of empowerment and control may require accepting a conception of wellbeing not centered around the possibility of cure.
Participants seeking one of four CAM therapies focused most of their expectations and hopes during initial interviews on whether or not the treatment could lessen their pain. In later interviews, where self-care was included in the interview guide, emphasis tended to be broader, shifting from needing to be "fixed" to an emphasis on the body as a work in progress, in need of ongoing attention and care from both the patient and the CAM practitioner. This trend toward attention to management, self-care and wellness, and increased acceptance of pain as chronic, was reported by participants seeking all four therapies. We also noted that this overall shift over time was evaluated in various ways by participants, depending on how they were able to orient their sense of self and understanding of illness toward ongoing management and engagement.
These findings suggest the value of further research into the potential of the CAM therapeutic process to assist patients in taking control of their health management and wellness. Sointu [58] argues that CAM use is becoming increasingly common because the "discourse of well-being" (9) embedded in CAM interactions (see also [24, 25]) resonates with how people understand their bodies and selves. Our data support the finding that CAM participants report greater awareness of the need for ongoing engagement in their own care, an increased sense of control or empowerment, and motivation to seek effective coping strategies. [ Editorial Comment: These are all things that conventional medicine struggles with.] A reconceptualization of healing to include recognition of the interconnectedness between health and lifestyle factors and of the lifelong need to seek well-being was reported among participants, regardless of whether treatment was perceived as "successful". Further research should consider how these attitudes and beliefs change over time, whether they are associated with important changes in behavior, and if so, what role CAM practitioners may play in supporting a positive view of changing ideas about self-care and healing.
The authors would like to thank the participants for providing their time and insight, and the project staff for assisting with recruitment and project support. This research was funded by grant Number R01 AT005809 from the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health, which supported data collection, analysis and writing of this manuscript. The contents of the manuscript are the sole responsibility of the authors and do not necessarily represent the official views of NCCAM.
ERE drafted the manuscript, assisted in interview guide development, recruited and interviewed participants, coded and analysed transcripts, and led data interpretation. KJS the Principal Investigator, conceived of and lead the design of the study, assisted in the interview guide development, read transcripts and helped interpret the data and draft the manuscript. CR helped design the study, participated in the development of the interview guide, read transcripts and helped interpret the data and draft the manuscript. CH helped design the study, led development of the interview guide, interviewed participants, coded data, and provided input on drafts of the manuscript. MN edited drafts of the manuscript and provided expertise in qualitative analysis and interpretation. JAT helped design the study, participated in the development of the interview guides, and provided input on drafts of the manuscript. DCC helped design the study, participated in the development of the interview guides, and provided input on drafts of the manuscript. All authors read and approved the final manuscript.
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internal health locus of control.
EXPLORE: The Journal of Science and Healing. 2008;4(1):38–41
Evans M, Paterson C, Wye L, Chapman R, Robinson J, Norton R, et al.
Lifestyle and self-care advice within traditional acupuncture consultations:
a qualitative observational study nested in a co-operative inquiry.
Paterson C, Evans M, Bertschinger R, Chapman R, Norton R, Robinson J.
Communication about self-care in traditional acupuncture consultations:
the co-construction of individualised support and advice.
Patient Educ Couns. 2012;89(3):467–75
Thorne S, Paterson B, Russell C, Schultz A.
Complementary/alternative medicine in chronic illness as informed self-care decision making.
Int J Nurs Stud. 2002;39(7):671–83
Pedersen IK, Baarts C.
'Fantastic hands'–but no evidence: the construction of expertise by users of CAM.
Soc Sci Med. 2010;71(6):1068–75
Sparber A, Bauer L, Curt G, Eisenberg D, Levin T, Parks S, et al.
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Bann CM, Sirois FM, Walsh EG.
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of patient empowerment.
The Journal of Alternative and Complementary Medicine. 2010;16(7):745–
Williams-Piehota PA, Sirois FM, Bann CM, Isenberg KB, Walsh EG.
Agents of change: how do complementary and alternative medicine providers play a role
in health behavior change?
Alternative Therapies in Health & Medicine. 2011;17(1):22–30
Di Blasi Z, Crawford F, Bradley C, Kleijnen J.
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BMC Health Serv Res. 2005;5(1):30
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Schafer LM, Hsu C, Eaves ER, Ritenbaugh C, Turner J, Cherkin DC, et al.
Complementary and alternative medicine (CAM) providers' views of chronic low back pain
patients' expectations of CAM therapies: a qualitative study.
Muhr T.
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ATLAS.ti Scientific Software Development GmbH; 2011.
Sofaer S.
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Qual Health Res. 2002;12(6):855–66
Sointu E.
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Buchbinder M.
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Med Anthropol Q. 2011;25(4):457–78
Butler J.
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McCracken LM.
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Curr Pain Headache Rep. 2006;10(2):90–4
McCracken LM, Eccleston C.
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McCracken LM, Zhao-O'Brien J.
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than the pain itself.
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understandings of acceptance of chronic pain.
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The Annals of Family Medicine. 2008;6(4):307–14
Huet HV, Innes E, Whiteford G.
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Jackson JE. Pain and bodies.
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Good M-JD, Brodwin PE, Good BJ, Kleinman A.
Baarts C, Pedersen IK.
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Theorizing complementary and alternative medicines: wellbeing, self, gender, class.
New York: Palgrave Macmillan; 2012.
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I found Nemo while snorkeling a few feet off the coast of a wild, deserted island in Fiji. His yellow-and-blue-striped body darted beneath my flippers, then disappeared into the winding blue, green, pink, and purple coral mountains of the serene undersea-scape surrounding us. I was miles from home—and a world away from reality.
Waya Island—located about twenty-five miles west of the Fijian capital of Nadi along the Yasawa chain of islands—is small and rustic, with a subtle charm. Governed by ancient traditions of the local villagers, Waya appears to pay little heed to the rest of the world. It has no stores, no restaurants, and no computers. (Not even Verizon can hear you now.) Four villages are scattered on one side of the island; a small budget resort—the Octopus—occupies the other.
The outstanding Octopus Resort consists of small, traditional Fijian huts called bures (pronounced boo-ray) nestled along the beachfront. Hammocks stretch between arching palm trees, and not a sound can be heard, save for the gentle lapping of rolling waves.
The Octopus caters to people of all ages, including families, children, and solo travelers. Its best feature, though, is the staff, who continuously outdo themselves with Bula dance productions, kava ceremonies, and fantastic meals, including the incredible lovo feast, prepared by wrapping the entire meal in banana leaves and cooking it underground. After dinner, a Chocolate Bunny, a delicious blended concoction of vodka, Baileys and Frangelico, is the perfect accompaniment to a Fijian sunset.
My bure was small and cozy. Tile floors led to a full bathroom with an outdoor shower, allowing me to gaze at the stars while I bathed. Meriam, my bubbly room attendant, was kind and giggly and she decorated my room with the brightest tropical flowers. Even Stan, my little stuffed duck and traveling companion, had flowers nestled in his fur.
I began each day by de-stressing with a book, sunglasses, and a beach chair, failing miserably to tan but relishing the warm sun. Yet as relaxing and as it is to do nothing, I was itching to explore. Waya Island has plenty to offer, and the Octopus supplies a range of activities for guests in search of adventure, including village tours, scuba diving, snorkeling, and fishing.
One night—over a dinner of steak medallions in a red wine sauce accompanied by a nice cabernet—it was announced that there would be a snorkeling excursion to a nearby island the next day to see the giant manta ray that lives off of Fiji's shores. My dining companions immediately signed up. When would I ever have this chance again? I added my to the list: Alexa Trotta, Bure 12. Yes, the one with the flower-wearing duck.
I'm not the greatest snorkler—I get water in my goggles and tend to paddle slowly. But on the morning of our excursion, I was the snorkel Diva! I was determined to get a glimpse of the magnificent manta ray.
The rush of flippers, arms, and legs was overwhelming as we rushed to catch up to the ray. Swimming madly against the rough current, I was about to lose hope when our guides pulled up alongside us in the motorboat, threw down a rope, and told us to hang on. The next few seconds were a panicked blur as I struggled to keep my hold on the slippery rope as we flew through pounding waves.
Suddenly, before I could fathom what was happening, the strings on my bikini became detached. I watched, horrified, as my only layer of coverage was ripped from body and tumbled over the waves. I let go of the rope and grabbed my wayward suit.
It was at this precise moment that I looked down and saw him beneath my paddling feet. The ray, gliding effortlessly in the waters below, was at least seven feet wide, and a strikingly elegant silver and purple. I was mesmerized. It wasn't until he passed and I looked up to see a massive following of swimmers heading my way that I realized I was half naked. I covered myself as best I could and reflected on my fleeting encounter with the giant ray—who apparently got the best show of all!
After our swim, my fellow divers and I enjoyed a scrumptious lunch of freshly caught fish smothered in coconut cream our multitalented guides had prepared. I felt tired yet satisfied—after so much excitement, it was nice to be lazy again.
In the days that followed, the friends I'd made on that snorkeling excursion and I drank our share of sticky tropical drinks. Together we attended a moving church service held in the local village of Nalauwaki. The service was packed and the day was hot and sweltering, yet the music that filled the humid air was so beautiful and eloquent that we forgot everything else around us.
Before boarding a plane back to the real world, I visited the famed Blue Lagoon, located at the northern tip of the Yasawas. The boat passed a variety of islands, some small atolls no bigger than a quarter mile, others larger and steeper and covered in fertile plant life. Almost every island boasted at least one or two resorts nestled on beaches or perched high on hilltops overlooking the ocean. Shining beneath the blinding sun, the Blue Lagoon held the clearest blue water I'd ever seen.
I hated to leave Fiji's pristine, unspoiled waters and lush foliage, those days of blissful unproductiveness, and my long-faded tan. I look back fondly on those unforgettable moments on the small Waya Island, and I will always remember the people—and sea creatures—I experienced them with.
Because the Yasawas are remote, it's important you bring everything essential that you need. Electricity and phone use is limited. Make sure that you have plenty of cash, as many resorts do not accept credit cards or checks.
Sunscreen is critical—sun exposure can be very harmful, particularly in this part of the world. To travel between islands, take the Yasawa Flyer, which runs daily from Nadi to Nacula (the northernmost of the Yasawa Islands), stopping at various resorts along the way. Tickets are $95 one way, per person.
For more information on how to get to Octopus Resort or any of the resorts in the Yasawa Island Group, as well as places to stay, check out Fiji Travel Vision.


Wale – Bickenhead (Freestyle) Music Mp3.
Wale – Bickenhead (Freestyle) : Wale puts it down over a Cardi B banger. Wale has been quietly enjoying a productive year, coming off the drop of his excellent Self Promotion EP.
Despite suffering from a bit of a tumultuous run, the project seemed to signal a return to form for the MMG rapper, led by the standout single "Negotiations." It seemed clear that Wale was returning to the fold with a newfound appetite, and as such, has continued his rampage accordingly.
Today, he's decided to borrow from Cardi B's Invasion Of Privacy, putting down his original slant on "Bickenhead." Naturally, the subject matter is vastly different from the original. Kicking things off with a variant of Cardi's singsong flow, Wale simmers a little before coming to a violent head.


text:
El topónimo Mercurín puede hacer referencia a:

 Mercurin, lugar español de la parroquia de Anceis, del municipio de Cambre, provincia de La Coruña, Galicia.
 Mercurín (Boimorto), parroquia civil española y lugar del municipio de Boimorto, provincia de La Coruña, Galicia.
 Mercurín (Folgoso de Caurel), aldea española de la parroquia de Seoane, del municipio de Folgoso de Caurel, provincia de Lugo, Galicia.
 Mercurín (Órdenes), parroquia civil española del municipio de Órdenes, provincia de La Coruña, Galicia.
 Mercurín (Valle de Oro), barrio español de la parroquia de Recaré, del municipio de Valle de Oro, provincia de Lugo, Galicia.

redpajama_set_name: RedPajamaWikipedia


text:
using System;
using System.Collections.Generic;
using System.Linq;
using System.Text;
using Microsoft.Xna.Framework;
using Microsoft.Xna.Framework.Graphics;

namespace MarioProject
{
    public class Mario
    {
        public IMario marioSprite;
        Texture2D texture;
        public Vector2 position;
        public Rectangle collisionRectangle;
        public enum size { small = 0, big, fire, dead }
        public enum state { standingRight = 0, standingLeft, runningRight, runningLeft, jumpingRight, jumpingLeft, crouchingRight, crouchingLeft, slidingRight, slidingLeft }
        public size marioSize;
        public state marioState;
        public Vector2 speed;

        public Mario(Texture2D Texture, Vector2 location)
        {
            position = location;
            texture = Texture;
            marioSprite = new SmallMarioStandingRightSprite(texture, 11, 12);
            marioSize = size.small;
            marioState = state.standingRight;
        }

        public enum collisionLocation { noCollision = 0, left, top, right, bottom };

        public int CollisionChecker (ICollidable objectSprite)
        {
            collisionRectangle = marioSprite.collisionRectangle;
            Rectangle intersect = Rectangle.Intersect(collisionRectangle, objectSprite.collisionRectangle);
	        if (intersect.IsEmpty)
            {
		        return (int)collisionLocation.noCollision;
	        }
            else if (intersect.Height <= 10)
	        {
                if (Math.Abs(intersect.Y - collisionRectangle.Y) < .05)
                    return (int)collisionLocation.bottom;
                else return (int)collisionLocation.top;
            }
	        else
            {
		        if (intersect.X == collisionRectangle.X) return (int)collisionLocation.right;
                else return (int)collisionLocation.left;
            }
        }

        public void Draw(SpriteBatch spriteBatch)
        {
            marioSprite.Draw(spriteBatch, position);
        }
    }
}

redpajama_set_name: RedPajamaGithub


text:
Yes .
Would Bill Cipher be a boss or optional super boss? It would be weird to visit Gravity Falls without Bill being the boss but with how powerful he is he's more optional super boss material.
chuman said:
5. donald could transform them into monsters to stop panic like in atlantica, halloween town and pride lands.
2&3. Haha I don't even remember Jumba's role too well, guess it's time to replay BBS!
4. I actually would love if they incorporated it into the computer realm or whatever it is and used the story instead of minigames, but everyone seemed worried about the whole video game thing being weird, and I wonder if the team would feel comfortable doing it or not, so minigames seemed "safer" though less interesting. But it would be really great if they could work it in!
5. Maybe like in Halloween Town they can get some sort of costuming that makes them just look like monsters, just like how Sully put the costume on Boo? Now I really want to see Sora in a monster suit.
i'm probably the only person waiting for a spectrobes world. it would fit in so nicely.
Not KHI Site Staff
Does it count if Disney was just the publisher?
Chaser said:
Disney Interactive Studios has stated that Spectrobes is its first original intellectual property; that is, a game not based on any film or TV program from its parent company.
apparently so. might i also add that jupiter, developer of the first two spectrobes games also developed chain of memories?
222 NE, 3rd Ave., Apt. No.2, Camas, WA, 98607
Well, the worlds (or characters) we need are the following...
Let it be known that not EVERYTHING here will make it in Kingdom Hearts III (knowing Disney, they'll probably want a Highschool Musical based world in place of Atlantica), I would actually like most of these choices to make it because they were great movies alone, and involving them in Kingdom Hearts III would probably help Sora or Kairi become Keyblade Masters or perhaps bring Xion back into the world of the living/existing...
1. Toy Story (trilogy) ~ We have asked, begged, and hoped to see Woody & Buzz in the Kingdom Hearts series, let Kingdom Hearts III be the game they appear in! Woody and Buzz could be world-exclusive party members, and the villains in their world could be Stinky Pete, Emperor Zurg, Lotso and his gang!
2. The Great Mouse Detective ~ Professor Rattigan is one of the reasons I'd like to see the Great Mouse Detective involved with Kingdom Hearts III, Savage Rattigan would also be one Hell of a boss fight! The other is that since Sora, Donald, and Goofy have changed their forms to fit into other worlds, wouldn't it be neat to see them change into mice?
3. Frozen ~ Not one of my favs, but it's going to be in Kingdom Hearts III (I beleive someone from the development team confirmed it). Frozen could be a fun snow-based level, and God knows we need more snow in our Kingdom Hearts games. Elsa would be a challenge for Sora to help, and it would be cute to see them at least have a moment to talk about family, and sure, Hans is an ass-wipe who doesn't get that much of a beating, so a boss fight against him would be fun!
4. Pocahontas ~ This movie was remarkable. And sure, if it was in Kingdom Hearts III, we would have to fight the Heartless, but when dealing with someone like Ratcliff, fighting doesn't HAVE to be accomplished, in the end, Sora's greatest test in becoming a Keyblade Master would be to work alongside Pocahontas and stop a war without fighting...
5. Monsters Inc. ~ Kingdom Hearts' central plots always seem to focus around Doors, so what if Monsters Inc. had a connection to the plot? Whatever it is, I'm sure it'll be fascinating. And I would enjoy fighting alongside Sully and Mike against Waternoose. Also, earlier, a user spoke to me about how Randall had a sad beginning around Monsters University, so maybe, Randall could be a little approachable than he was in the first movie, who knows?
6. Tangled ~ I don't always admit these things, but Rapunzel is sexy, alright?! OK, back on track, instead of Eugene, Sora, Donald, and Goofy would help her out of the tower. then Rapunzel would develop hidden feelings for Sora, it would be a fun story to see, except then, Kairi would ave to be in it to fight for her man. But Flynn will STILL have to be involved someway, also, we need Maximus and Pascal, the level based on Tangled wouldn't be the same without them!
7. Big Hero 6 ~ One of Sora's tests should involve the concept of how to deal with the death of another, so Big Hero 6 would be great to introduce such a test. Sora could help Hiro and Baymax find out more about Hiro's brother's death, and learn the meaning of helping a friend back on his feet. But it might be best that Kingdom Hearts III keeps this out because of how close the franchise is to MARVEL, and I must admit, even though it was a good Disney movie, I'm not that big into Disney owning MARVEL.
8. Wreck-It-Ralph ~ With Nintendo, Capcom and SEGA characters making the movie what it is, it's unlikely that we'll be getting a taste of Wreck-It-Ralph in our Kingdom Hearts series anytime soon. Still, what a world it would be, you cross into Ralph's world, Hero's Duty, then in Sugar Rush, it's dynamic, as will the boss fight with King Candy/Turbo!
9. The Princess and The Frog ~ It's not everyday Sora meets strong and independent women. Unlike Mulan though, Tiana is going to be a bad-ass and show Sora a thing or two about honest labor. Dr. Facilier however should up his game a notch and be more of a deadly enemy to Sora than in the movie. His kind of villain was interesting, clever, and sinister, so putting him in Maleficent's shoes could probably give his character the antagonistic boost he needs to be more than what Sora bargained for...
10. A Bug's Life ~ Bug versions of Sora, Donald and Goofy would be pretty cool, especially when they have to square off against Hopper and his army of Grasshopers! Flick and Francis would also be some fun party members to have on the team, and also, it could teach Sora how he shouldn't consider EVERYTHING he thinks of as useless.
11. Ducktales ~ To have a level based on America's favorite ducks would be a gnarly thing indeed. However, for a Ducktales level, I'm thinking of the plot focusing more on the movie since Merlock (who should be voiced by Christopher Lloyd again) was a pretty dark and overwhelming antagonist. The Beagle Boys however deserve to be in this world since their presence was known in the Mickey/Musketeers level in Dream Drop Distance, and that they were the first antagonists Scrooge had to deal with. Also, I recommend Webby, Gizmoduck, and Flint Glomgold in the level.
12. Talespin ~ Sure, the devlopers were close to adding the scrapped world of The Jungle Book, but I think Baloo would have more fun in an airplane than in some jungle. Airplane fights everytime you go to different places in the world, Baloo as a party member and a big brother figure to Sora and the others, Hell, Shere Kahn's role in the game could be an equivalent to Maleficent! I always thought Shere Kahn deserved the kind of role as a main antagonist of the Kingdom Hearts series...
13. Darkwing Duck ~ Silly is as silly does, and you can never have enough Super Hero levels. Darkwing Duck's world would be a fun level to explore, especially when villains like Steelbeak, Negaduck and Megavolt are involved! However, I'd like one of the visit stories to match the two-parter episode, 'Darkly Dawns The Duck' where Darkwing learns the importance of caring for others over fame, and faces criminal mastermind, Taurus Bulba (who should still be voiced by Tim Curry, if he recovers from his stroke soon that is).
14. Gargoyles ~ The series was breathtaking, the origin was magnificent, but if Sora and the others should pop by the Gargoyles-based world, it should be around the time Xanatos reawakens them. Sora in New York City, that would be an awesome place for a battle with demons, monsters, robots, Heartless, you name it! Elissa Maza, Goliath, and Hudson would be great party members, and I KNOW half of you want to duck it out against Demona!
15. Brave ~ Scottish princess, Merida, can bring out Sora's honesty, to help him live freely and have no regrets...until her mother changes into a bear! A boss fight with Mordu might be asking too much, but it WOULD be exciting to see. Besides, Merida would make a great party member!
Now, here are some worlds I'd like to see again...
Now it's probably not going to happen with any of these worlds, but I am honestly hoping that a few of these worlds would return with something new to bring to the table to make the worlds feel complete, just like Aladdin, The Nightmare Before Christmas, and Mulan.
1. Atlantica (The Little Mermaid) ~ I want Sora, Donald AND Goofy to change back to normal when they come up on dry land so they can visit Ariel in her digs and witness her and Eric's romance blossom. Also, Ariel is cuter when she's curious, so scenes where she confuses forks for brushes and her horse riding is something to consider. Ursula's my favorite Disney Villain to, so I'd like my last fight with her to be better than the one in Dream Drop Distance! Better yet, make her actually KNOW her enemy, if she roots out Sora's weaknesses, she could be a BRUTAL foe! And PS: NO MUSICAL MINIGAMES!!! Just keep the gameplay about fighting the Heartless and the Kingdom Hearts franchise should be forgiven for what happened in Kingdom Hearts II.
2. La Cit'e des Cloches (The Hunchback of Notre Dame) ~ First, a new world name, I don't speak or understand French. Also, I didn't enjoy the fact that a few characters like Jolly, the Archdeacon, and Clopin were missing, I want to see them in the world! I'd also like to see Quasimodo and Phoebus as party members and help Sora out. The Palace of Justice was also never explored, I would've loved to enter that place and take on a few guards! Also, Frollo should be fought in a boss fight, aided by Darkness of course. And I don't care what happens, make church things be involved! In Dream Drop Distance, Sora came into a church, yet, Christianity wasn't involved with it! I can't be more confused than that!
3. Beast's Castle (Beauty and the Beast) ~ Adding Belle's village would help bring out more of the Beauty and the Beast plot. I'd like Sora to meet with Belle's father, and also, to try and talk to Le Fou about how awesome he can be, he deserves a better role in life anyway. And yes, a boss fight with Gaston is HIGHLY recommended, as is a horse-back ride on Phillip and a wolf-pack trouncing!!
4. Neverland (Peter Pan) ~ Wendy's brothers, Jon and Micheal, were with her when Peter brought her to Neverland, yet in Kingdom Hearts, she's a solo adventurer. What if this time, those bros were with her? And what if actual Indians appeared? They would have to be what the Native Americans of today would consider acceptable though, and NO SMOKING, I know what our kids need, and they don't need to see kids smoke! And Captain Hook should have a few pirates on his ship other than Heartless, it's weird for a pirate ship to have only two pirates!
5. Olympus Colosseum (Hercules) ~ Hades isn't finished, THAT much is certain! If the world is available in Kingdom Hearts III, it should have Mount Olympus and Zeus in it, as well as an expanded version of the Town of Thebes. And if it's at all possible, group the Rock & Ice Titans with their bros, the Lava & Wind Titans! And lastly, I'd prefer him to pop up any chance he can in other worlds, but if Gilgamesh is going to appear anywhere, let it be in the Colosseum!
6. Symphony of Sorcery (Fantasia) ~ A world based on Fantasia is a dream come true...until you realize only Mickey and Chernabog appeared! I think we should have more characters in the level, and if it can be achieved, I would like the Chorus Room from Fantasia to be the access point to the other Fantasia worlds, where Hippos danced with Alligators, Mushrooms came to life and danced while sugarplum fairies decorated a forest with frost, and how about a boss fight with the T-Rex?! BAD ASS MOMENT!!!
7. Enchanted Dominion (Sleeping Beauty) ~ Maleficent received too much attention in Birth By Sleep, so if Kingdom Hearts III would re invent the world, I would like Sora, Donald, and Goofy to develop a good friendship with Rose/Aurora, Flora, Fauna, and Merrywether! I'd like to see Sora's face when he meets King Stephen and King Hubert, those two were pretty fun! And this world would be a great place for Sora to end his endless battle with Maleficent, THIS time, with the aid of Phillip!
8. Deep Space (Lilo & Stitch) ~ It may not be possible, but I would like to see Lilo in Kingdom Hearts III with Stitch by her side. Stitch would also make a great party member. And I'll be honest, Sora VS Dr. Jump, THAT would be epic, of course, not as epic as meeting Cobra Bubbles, then fighting Captain Gantu, either in physical combat or by ship (KH2 Gummi Ship Style bitches).
9. Deep Jungle (Tarzan) ~ First off, let it be known that there are legal issues regarding Tarzan. For now, nothing about Tarzan's involvement with Disney is allowed back into the Kingdom Hearts series, however, if the ban is ever lifted in regards to Kingdom Hearts III, then I would be happy to see the Tarzan story end properly. I'd like to see Jane develop feelings for Tarzan, they were cute together. And if Jane's father and Tantor could appear, then the story could feel half-way complete, especially when Clayton returns with his pirate crew to capture the gorillas! PS ~ Kerchak should have a speaking role, and possible death, he's a memorable character who deserved more of an important role.
10. Space Paranoids/The Grid (Tron: Legacy) ~ CLU, that is my reason for bringing the Tron universe back to Kingdom Hearts. In Dream Drop Distance, CLU learned EVERYTHING he needed to know about Sora and the Keyblade. What if, when Sora returns to Radiant Garden, CLU remembers Sora and abducts him, trying to duplicate the Keyblade program from Sora in order to come into the real world and conquer it? And Sam as well as his father, Flynn, could be citizens of Radiant Garden, who accidentally get involved with the Grid. Of course, you'd still want Tron/Rinzler involved, right?
And here's a list of worlds I'd like to see again from the Kingdom Hearts series...
Sure, most of these worlds won't make it to Kingdom Hearts III, but all I have to do is hope for a few, and the few on this list might come...
WARNING!!! THERE MAY BE SPOILERS!!!
1. Daybreak Town ~ Kingdom Hearts X's hub world was a mysterious and secluded world, where a massive castle/clock tower stood. What if Sora needed to head over here to find a clue to stopping the Keyblade War?
2. Land of Departure/Castle Oblivion ~ Sure, it's still Castle Oblivion, but a hunch tells me Ventus might be needing Sora's help to get him out and find a way to restore his master's castle...and see what's hidden inside!
3. Disney Castle/Disney Town ~ Let's just put two & two together and make a complete Disney World!
4. Destiny Islands ~ Sora, Riku, and Kairi, we know who they are, but we don't know the school they go to, their homes, their parents, their parents might not be so boring if they have something to hide from their kids...
5. Mirage Arena ~ If there was more of a story in this level, like in Olympus Colosseum, then we might have an amusing world to visit, where Final Fantasy characters are met and challenges are brought to the table!
6. Radiant Garden ~ The home world of Leon and Aerith is now fully rebuilt, even though homes and buildings are missing after the chaos that occurred during KH2. This world though would be great for Sora to meet with some 'old enemies who have now turned over a new leaf, including Even, who I imagine still has a score to settle with Sora, and Ienzo, who might take Ansem's place as the Wiseman of Radiant Garden. I'd also like Sora to meet with Aeleus, who was once Lexaeus, and fight alongside him!
7. Traverse Town ~ This world would be fun to revisit and meet some actual new faces. We might even see some former Organization Members-turned-human here...
8. Twilight Town ~ This is another place where you might find some former Organization members, and hey, how many of you want to see Vivi become more like his video game counterpart and develop a backbone while helping Sora? Also, how many of you want to see Hayner, Pence and Olette again?
9. Timeless River ~ This world introduced us to Disney's past and Mickey's first cartoons, but what if we came back here and saw Mickey's first colored cartoons? I remember the cartoon where Micky crossed into the looking glass and encountered a world where every inanimate object in his house was alive, then the cartoon where Mickey climbed a mountain with Donald and Pluto! What if Timeless River had scenarios like those?
10. Dark City (The World That Never Was) ~ Just that dark city, that's all I want to see. The castle, gone, destroyed, deserted or taken over by Maleficent. The city WON'T be the final level and will be a more expanded world to explore. Whatever's lurking in the dark alleys in the city might be worse than anything before, so I would like to see the Dark City return.
PS: I didn't want Keyblade Graveyard back because I wanted a new original place for a FINAL level, the best final levels are at least new and original.
And finally, here are some Square-Enix additions/worlds I would prefer to see/enjoy in Kingdom Hearts III...
These ideas may just be suggestions for bonuses or worlds (yes, I mean wolds like Disney's), but I am hoping that Square-Enix will take this to consideration. There were other ideas I had, but I think it would be better to keep them in Fullmetal Kingdom...Thank you all for reading.
Honorable Mentions ~ Higurashi: When They Cry, Final Fantasy VII, Final Fantasy VII: Advent Children, Star Ocean series, Final Fantasy XIII, Final Fantasy VIII, Final Fantasy XII, Final Fantasy Online (XI & XIV), Final Fantasy IV, Final Fantasy II, Final Fantasy III, Dirge of Cerberus: Final Fantasy VII, Pani Poni Dash, Dragon Quest series, The World Ends With You, Musashi, Chocobo Tales, and all other Square-Enix licensed/published franchises.
1. Fullmetal Alchemist ~ Whether it's a world or a few character guest stars, I'd like to see Sora, Kairi and the other heroes join forces with the Elric Brothers, Edward and Alphonse and perhaps Lan Fan. For supporting characters, I'd like to see Winry bond with Kairi, and Mustang, just because of how great he is. For Villains, I'd go for Dante, Selim, and King Bradley, they would be fun to fight, I would suggest the Homunculus, but fans of both the 2003 anime and Brotherhood would have a field day of understanding which ones to bring in...
2. Soul Eater ~ Maka's a good enough reason to bring Soul Eater into Kingdom Hearts III, she could be a party member in Daybreak Town or another level, still I'll bet most of the Soul Eater lovers would prefer Shibusen Academy as a world, right? Black Star would be a guest party member and Death the Kid would be a fun boss, less fanservice from Blair would be necessary, other than that, Lord Shinigami would be all we need to see alongside Soul, Tsubaki, the Thompson Sisters (Liz & Patti) and Asura (Optional Boss). There shouldn't be any villains in this level, they're not 'age appropriate', but Organization XIII could have their eyes set on their world...
3. A Certain Magical Index ~ Hopefully, Disney/Square won't be too censored around the concept of religion, but perhaps they could find a loophole in their rules and find some space for A Certain Magical Index. I would NOT recommend a world based on the series, I would prefer the characters show up in one of the original worlds (Hollow Bastion, Twilight Town, Traverse Town, Daybreak Town), especially Index, who could be more of a recurring ally, who could remind Sora of the importance of light. I also know a few of you crazy Railgun fans would LOVE to see sparks fly, so Misaka could also be involved in a boss fight and/or guest party member spot.
4. Final Fantasy IX ~ I know Vivi lives in Twilight Town, so it's understandable why Gaia, Terra, and Memoria are out of the question, but I found it upsetting how much Tetsuya Nomura didn't respect Vivi. He makes him some kind of follower of Seifer, which is completely unlike Vivi. I would like to see Vivi's role expanded, give him a story for Sora, Goofy and Donald to help him through, and make him a party member, it's just fun that way, especially since his reaction command could be related to the "Magic Sword" ability. Vivi's friends would be Eiko and Garnet, and his enemies would have to be the 3 Black Waltz's and Soulcage, who is somewhat one of Vivi's darkest enemies.
5. Final Fantasy "1" ~ The Kingdom Hearts series has been kind to Final Fantasies VII, VIII and X, and yes, I would like a few titles to get in on the respect to, but I would LOVE to see Sora head to where the Fantasy became 'Final', The Kingdom of Cornelia, where Garland has just started portraying the villain. In this level (or others), Sora could fight the Four Fiends, and perhaps take on Garland and THEN, Chaos, who I believe would be a great surprise Final Boss, after all, he literally is the Darkness Xehanort craves.
6. Final Fantasy X ~ We've seen Tidus, Yuna (and her stupid sequel friends), Wakka, and Auron, but wouldn't it be cool to see these characters together? Especially in a world like Spira, where Tidus and Yuna could start falling for one another while trying to break the cycle of Death. Seymour could also be introduced as the villain of the world, but Jecht, HE'S the one Sora should be seen fighting with, Dissidia style! And also, how many want to see Kimahri as a summon?
7. Final Fantasy IV ~ Golbez would be great to bring into the Kingdom Hearts universe. He could be the antihero who challenges the hero, and/or brings out their inner strength. He could help Sora remember that Darkness isn't 'JUST' evil, and that Sora should be honest and follow the right path.
8. Final Fantasy V ~ Sephiroth's a hardass who's ass is hard to spank, and I hope we still get to fight him in the 3rd KH game...in his turf, but I think it's high time we see Square-Enix bring in Gilgamesh, not just as a boss (optional or story-wise), but as a party member. And why not? Gilgamesh is fun, hilarious, and makes an enjoyable rival.
9. Final Fantasy XV ~ I admit, XIII had some interesting characters, and bringing a few of them in would be great (excluding Lightning when she becomes all servant-ish of course, AND Caius, he's so lame, I prefer the first villain Dysley), but if this game comes out before Final Fantasy XV, then I would recommend letting a few of the characters in as a sneak peak of what bad-asses are to come. Noctis could be an optional superboss, so that's something to look forward to.
10. Chrono Trigger ~ I'd say Dragon Quest, but all I would be suggesting for it is the inclusion of the Slime creature, which would be a fun summon to bring out, since there are so many different types of Slimes, so instead, I'm going to suggest ideas from it's cousin, Chrono Trigger. Sora, fighting alongside a mute named Chrono, (which could be a first for Sora since he hasn't really had disabled party members before), would be pretty epic, especially when you're traveling through time to oppose Organization XIII's quest to wreak havok.
And THESE were my ideas that Square-Enix could (or will not) use in Kingdom Hearts III.
The Walt Disney Company licensed the Kingdom Hearts franchise.
Square-Enix licensed Kingdom Hearts, Fullmetal Alchemist, Soul Eater, A Certain Magical Index, A Certain Scientific Railgun, Chrono Trigger, and the Final Fantasy franchise.
Funimation licensed Fullmetal Alchemist, Soul Eater, A Certain Magical Index, and A Certain Scientific Railgun.
Yen Press published the manga of Kingdom hearts, Fullmetal Alchemist, Soul Eater, A Certain Magical Index, and A Certain Scientific Railgun.
Bones Inc. & Aniplex licensed the animes Fullmetal Alchemist (2003) & Brotherhood and Soul Eater.
J. C. Staff licensed the anime of A Certain Magical Index & A Certain Scientific Railgun.
And that's the lists of worlds/characters I'd like to see in Kingdom Hearts III!
ThePumpkinQueen
Hiding inside the surprise Jack-O-Lantern
For worlds, I would love to see (Older) Snow whites world, Cinderella, sleeping beauty, Lady and the tramp, oliver and company among others. Though most of these have made at least apperences or hinted at.
Newer: I'd love to see Tangled, Frozen and since disney now has the rights to star wars. Would be fun to have a light saber keyblade. But i'm not sure realistically how the last one would flow in the rest of the series. Wouldn't mind a bit of marvel either. I think i read somewhere that they were debating on putting a marvel world in it.
Treasure planet would be amazing too. I'll be happy with whatever they put in the game as long as it remains to keep the flow that its managed to do the last two games and the imbetween games, and prequel.
ITeM21's post pretty much sums any other thoughts i have up.
keyblademaster45
A Big Hero 6 world, a Star Wars Rebels world, and the return of Ventus, Aqua, and Terra. I also want more Dream Eaters, Kairi with a Keyblade, and Roxas and Xion return as well.
I also want to play as Lea, and play as Mickey for a change. Seriously, we have never played as him before.
xion and roxas don't make since, xion disapeared , back into sora's memories, and roxas became apart of sora again. as long as we get a fair few new worlds i'll be happy
Antifa Lockhart
ThePumpkinQueen said:
The backhalf of the last couple games have been about Sora needing to save everyone, including them.
how about san fransokyo from Big Hero 6. SDG, Hyro, and Baymax? i'd like to see that.
Or a tangled world.
i think this could be it's story
SDG end up in Corona,in the middle of the woods. Suddenly,Donald sees the royal guard chasing a man.SDG try to cut the guy off,but instead end up falling off a cliff. When regaining consciousness, Sora looks up to find a white horse sniffing the ground, SDG assume that the horse must belong to the people chasing the man.They look around and Goofy spots the guy snooping off in a mysterious batch of moss. Goofy alerts the others, and they head off after him.
On the other side of the moss,the gang spots the man hanging off the tower, as they try to reach the guy, a group of Heartless cuts them off.The man escapes into the tower.Sora has an odd feeling the man is controlling the Heartless.
After defeating the Heartless,Sora uses his magic to lift them to the top,but once entering, Sora is knocked unconsious again.
After regaining consciousness, Sora looks around."Hey! Where's Donald and Goofy?!" says a surprised Sora.A figure appears from the shadows in the form of a young girl."Hi there." Sora says."Have you seen my friends Donald and Goofy?"Sora asked.The girl responds with"Um, you mean the dog and duck?" "Yeah, where are they?" Sora asked. Suddenly, Sora spins around to a familiar noise."Donald! Goofy!" Sora yells i happiness." Well, Hiya there Sora.(laughs)" Continued in part 2
Last edited by a moderator: Mar 1, 2015
Muke
keyblademaster45 said:
OOC: How is it with not double posting?
itwasmybedtime
I have to admit I would hate to see Star Wars in Kingdom Hearts, it just doesn't fit. I would really like to see Wreck-it-Ralph, I could totally see Sora helping in that world.
Zettaflare
While I should wait until I see the movie, I really like this piece of artwork of the main setting Spockanort posted for the upcoming film Zootopia. Just look at how creative and original the city looks
I would love to explore the city as Sora if Zootopia appears in the series at some point
ITeM21 said:
I've wanted a Gargoyles world for so long. ;n;
ChibiHearts249
Trapped in the Source Filmmaker
In my room, fighting off the Nightmares
Wow, that is ONE comprehensive list there. Gargoyles for sure, but I don't see Treasure Planet or Aristocats on there! XD
Tron Lives, but probably not in time for this movie to have a plot in KH3 :c (This is why Nomura should draw from Uprising for any Tron hijinks in KH3)
http://forums.khinsider.com/disney/163553-tron-3-tron-lives.html
The Dark Mamba
Corona California
Master Spockanort said:
It's a shame because I'd love to see The Grid in KH3 but it's a little too late now. The Grid would look spectacular on PS4. It was one of my favorite worlds.
There's always DDDHD.
Anyway, I have come to a semi-horrifying realization: THE STAR WARS WORLD MUST BE NABOO FROM PHANTOM MENACE.
SW in KH is happening, it just is. Square's been ripping it off over & over from Day 1, of course they're gonna jump at the chance to have the genuine article. But what I 've been struggling to figure out is which world would be the SW world. My gut instinct was to start with A New Hope. It is afterall the 1st movie & the most iconic. Would make the most sense for KH to start there, right?
Option A: The Death Star. At 1st glance this would seem the logical choice. Iconic scenes, multiple different rooms to fill out the world, Darth Vader showdown, the trash compactor monster, & the epic space battle at the end. Everything needed to make a great world. But there is a huge critical issue: The Death Star would have to be destroyed at the end of the world's story, meaning players can't explore it & get missed chests afterwards. It's extremely unlikely they would put in a disney world that'd cease to be explorable & you just can't have a Death Star & NOT blow it up at the end, so this is a no go.
Option B: Tatooine. Definitely enough locations to work with (Luke's farm, Obi Wan's home, Tusken Raider territory, Sand Crawler, Mos Eisley with streets, Cantina & starport) but it'd very anti-climatic without the player going to the Death Star which repeats the above problem.
So New Hope is a dead end & it'd make no sense to have the 1st SW world to appear in the KH series be the middle or end of a trilogy (although Endor theoretically could work), thus we kinda have to look to the other 1st films in trilogies.
Option C: The Force Awakens. Well I don't know nearly enough about what's gonna happen to gauge how well it can be adapted. Square could certainly get access to scripts, concept art & raw footage early enough to make it feasible. However it's still the issue that applies to ESB & RotJ: it's too far deep into the film series to work as a starting point for KH. Imagine if Pride Lands in KH2 was based on Lion King 2 instead of the 1st one? Wouldn't make a whole lot of sense, right? Thus at this point we must go in the opposite direction...
Option D: Naboo from Phantom Menace.
Okay I know what you're thinking, SW in KH3 at all is controversial enough as it is, why make it even more so by adapting what is easily the worse film in the whole franchise? Well the simple truth is It doesn't matter whether a movie is good or bad. What matter is what it contributes as a video game level.
In theory an utterly terrible movie in a KH game is fully justifiable if adds a lot to gameplay. For example PotC At World's End is completely nonsensical as a movie but damn if the prospect of that final battle with Davy Jones in KH isn't intriguing.
-Phantom Menace had more action focused on a single planet than any other film in the series. Aside from the podrace sequence (which granted Square is probably chomping at the bit to make into a mini-game), the film's entire conflict is on 1 world which is unique to the SW films & easier to make fit into a single KH world.
-The interior of the Trade Federation control ship is a far more negligible area than the entirety of the Death Star, making this a better suited target for the epic space battle finale.
-The variety of locations is IMMENSE. The forest the jedi land in, the underwater gungan city, grassy battlefield, the capitol city of Theed (I remember that name but not what the trash compactor monster was called. I should just turn in my nerd card right now), the royal palace that had multiple areas including scaling the palace walls which would be a great opportunity for flowmotion usage, & wherever the hell the Darth Maul duel took place. There's so many places even the Lego SW video game didn't use all of them.
-Speaking of which, Darth Maul himself. I'll be perfectly frank here: Vader would very likely suck as a boss. He's slower than 2.5's load times. Maul would have all of Vader's force powers plus the speed & agility necessary to make a bossfight, ya know, exciting.
Option E: Ok so maybe instead of the Death Star blowing up completely, it simply gets disabled by Luke's torpedoes. Does that work?

redpajama_set_name: RedPajamaCommonCrawl