From: BMC Musculoskelet Disord. 2010 Jul 13;11(1):158.
Whiplash was defined in 1995 by the Quebec Task Force as a neck injury mechanism and may result in injuries within the musculoskeletal and /or neurological system. The Quebec Task Force developed a system for grading Whiplash Associated Disorders : whiplash associated disorders I-II (symptoms without known pathology), III (symptoms and neurological signs), and IV (symptoms and cervical fracture and/or dislocation).
Grade I and II patients represent up to 90 % of “whiplash injury claims”. The proportion of patients who reports pain and disability six months after the accident (i.e. chronic whiplash associated disorders) varies substantially between studies and countries. However, a recent review suggests that approximately 50% of the patients with whiplash associated disorders will report neck pain symptoms one year after their injuries. Patients with chronic whiplash associated disorders report high levels of neck pain, headache, and shoulder pain often accompanied by neck stiffness, dizziness, fatigue, sleeping problems, concentration problems, allergy, breathing disorders, hypertension, cardiovascular disorders, digestive disorders, depression, anxiety, and impairment in cognitive performance. A recent study of a large population-based cohort of victims of car accidents, found that isolated neck pain was rare and that pain from multiple body areas was most commonly reported.
Expectations and coping styles might influence the outcome and prognosis after whiplash injuries. The Cognitive Activation Theory of Stress describes stress response as a general normal, healthy, and necessary alarm. There may be a risk of illness and disease only if the arousal is sustained. The level and duration of the alarm depends on the expectancy of the outcome of stimuli, as well as the results from specific responses available for handling the situation. Therefore, the cognitive activation theory of stress model emphasizes the importance of coping as positive response outcome expectancies. This means that if the individual expects to be able to handle a situation with a positive result (coping), the activation will be short and do no harm. Kivioja et al. found no evidence that early coping strategies influenced the prognosis after whiplash injuries. Others, however, found that high levels of passive coping strategies are associated with a slower recovery after whiplash injury, and that certain coping strategies for pain, such as catastrophizing, is associated with increased risk of disability, and that the importance of coping strategies seem to increase over time. In general, there is considerable controversy as to the importance of psychological factors for developing chronic whiplash associated disorders.
The importance of insight into coping strategies has been emphasized for chronic pain patients such as fibromyalgia, tension-type headache, chronic back pain, and chronic temporomandibular disorder. However, there is little qualitative insight into the ways persons with chronic whiplash associated disorders cope on a day to day basis. Such insight may provide the clinician with a better understanding of lay health recourses, and, possibly, provide a better starting point for suggesting strategies or discussing potentially maladaptive strategies to patients suffering pain following whiplash. Furthermore, Russell & Nicol suggested that whiplash associated disorders patient recovery may be increased if the clinicians better understand patient experiences. In the present study the authors identify what is described as dominant whiplash symptoms, and the behavioral strategies used to cope with whiplash associated disorders.
The aim of the present study was to identify dominant whiplash symptoms, and the behavioral strategies used to cope with these. Participants stated dominating symptoms to be neck and head pain, sensory hypersensitivity, and cognitive dysfunction. In describing their dominating symptoms participants gave emphasis to a fluctuating level of pain – dividing their life into what they described as a repeating cycle of good and bad periods. To cope with these symptoms, maintaining the good periods and avoiding or shorten the bad periods, they used rest, exercise, and social withdrawal. Participants expressed a constant notion of alternating or balancing between these coping strategies following the intensity of symptoms, or the expectancy of participating in situations or events that might trigger pain.
Participants reported severe neck and head pain, sensory hypersensitivity, and cognitive dysfunction as their main complaints. These symptoms are reported in several other studies. The pain was not described as being on a permanent level, but, rather, as fluctuating from a severe and intolerable level of pain to a more manageable pain. This fluctuating pattern was by the participants described as having bad and good periods. The symptoms were closely connected together as one could cause the onset of the other. Such a pattern of fluctuating pain and incapacity which is difficult to predict and manage, has also been reported in other studies on chronic pain, and it affects not only own health, but also family life and social activities.
A main finding in this study was how participants divided everyday life into good and bad periods, and how they adjusted their coping strategies according to this. Participants expressed a constant notion of alternating between or balancing their three main coping strategies; rest, exercise, and social withdrawal. If the balance – viz choosing and implementing the best strategy – was not maintained pain could be triggered or bad periods prolonged. The strategies were, primarily, chosen based on the intensity of symptoms, but it was also reported in the focus groups that the same strategies, mostly rest and social withdrawal, were used as means to prepare for, or unwind from, possible pain triggering situations or events.
Lazarus & Folkman’s cognitive-phenomenological model of stress and coping discriminates between active and passive coping strategies. Active or problem-focused strategies are used to target the source of stress and reduce it, whereas passive or emotional-focused strategies are mostly concerned towards adapting to the stress or problem. Most of the participants in this study used exercise, i.e. active coping strategies in good periods as they experienced that it reduced pain. Passive coping strategies, such as rest and social withdrawal, were mostly used to endure pain and to maintain the important balance as the participants were afraid of provoking bad periods. Social withdrawal may be interpreted as a direct consequence of their lifestyle changes, but participants also perceived it as a coping strategy per se – primarily used to avoid triggering the pain brought on by being exposed to noise, concentrating, or focusing too much.
Contrary to the Lazarus use of coping strategies, the Cognitive Activation Theory of Stress suggests that it is not the strategy or way of coping that is the most important issue, but the expectancy of the result. In the good periods our participants engaged in behaviors they expected to improve their circumstances – regular exercise being the most important one. The use of rest and social withdrawal were also used in good periods as a way of ‘charging the batteries’ for special events. The participants expected and experienced positive results of these behaviors, i.e. coping in the terminology of the cognitive activation theory of stress model.
However, what participants referred to as bad periods was characterized by unremitting pain often leading to frustration, depression, and social isolation. The participants had to socially withdraw and rest during these periods. In bad periods they felt that the symptoms took control of them, and that there was nothing they could do but rest and wait for a good period. Several participants experienced depression due to their situation. Within the cognitive activation theory of stress model helplessness or hopelessness develops when there is either no relationship or a negative relationship between what the individual attempts to do and the outcome. This may lead to sustained arousal, which, in turn, could lead to illness and disease such as depression and chronic fatigue syndrome.
The participants expressed that, to some degree, they could control or predict bad periods; consequently they tried to balance their life to avoid these periods. The constant notion of trying to balance; the restrictions and sacrifices behind their coping strategies took its toll on everyday life. The pattern of coping strategies described in this study was in accordance with other studies on patients with chronic pain, and was perceived as effective for these participants. However, it could be discussed whether or not the behavioral strategies, even though they might lead to positive response outcome expectancies, are adaptive or not. Most participants expressed a wish to be able to participate in working life. Nevertheless, only three in 14 participants had been able to maintain a work situation. So, although the strategies used were considered the most beneficial – or the only way to adjust their life, it is questionable whether or not they led to progress or just maintained the pattern of alternating good and bad periods. Knowledge of patients’ self-initiated coping strategies may give the clinician a better understanding of the patients’ frame of reference; how they organize everyday life to cope with their problems, and, accordingly, establish a better starting point for discussing potentially maladaptive strategies.
Participants reported severe neck and head pain, sensory hypersensitivity, and cognitive dysfunction as their main complaints. To cope with these complaints, and their fluctuating nature, three main strategies were used; rest, exercise, and social withdrawal. The participants portrayed that maintaining a balance between these coping strategies helped control the pain.
