Beliefs and Expectations for Recovery, Coping,
and Depression in Whiplash-Associated Disorders:
Lessening the Transition to ChronicityThis section was compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Spine (Phila Pa 1976) 2011 (Dec 1); 36 (25 Suppl): S250–S256 ~ FULL TEXT
OPEN ACCESS Linda J Carroll, PhD
Department of Public Health Sciences and Alberta Centre
for Injury Control and Research,
School of Public Health, University of Alberta,
Edmonton, Alberta, Canada.
Study design: Literature review and discussion.
Objective: To discuss the role played by beliefs, expectations, coping, and depression in the transition to chronicity in whiplash-associated disorders (WAD), and to discuss their clinical and research implications.
Summary of background data: Psychological factors are important in musculoskeletal pain problems. Recently, there has been attention paid to their role in the transition from acute to chronic WAD. However, most of this attention has focused on identifying and addressing the personal and behavioral aspects of psychological factors, and little focus on the social and societal influences shaping these factors in WAD patients.
Methods: A literature review was conducted to describe the evidence regarding the roles of beliefs, expectations, pain coping, and depression in WAD recovery. These psychological constructs and research findings were discussed in the context of efforts to improve beliefs, coping, and psychological well-being in WAD.
Results: There is consistent evidence negative beliefs about WAD are common in the general population and that poor expectations for recovery are associated with poor recovery. Pain coping and depression also appear to predict WAD recovery. The conceptual frameworks (such as social learning theory) for understanding these psychological constructs highlight the roles of interpersonal and societal factors. However, most research and clinical interventions related to these factors focuses on the individual, rather than also addressing the social context.
Conclusion: Beliefs, expectations, coping, and depression all predict WAD recovery. Efforts to address these factors should take a broad-based approach. These psychological constructs should be viewed as being developed and maintained within the broader social context of family, social networks, employment, and societal processes in general. There is need for a research and clinical paradigm, which acknowledges the interrelationships between internal processes and the social context in attempts to optimize recovery and functioning in those with WAD.
Keywords: whiplash; beliefs; coping; depression; recovery
From the Full-Text Article:
This paper focuses on the concepts of pain beliefs and recovery expectations, pain coping, and depression in whiplash-associated disorders (WAD), and will review evidence on their roles in the transition from acute injury to chronic WAD. The argument is made that the current tendency to view these concepts as individual risk factors—rather than a complex system of individuals interacting with their social context—may limit us in both our understanding of how these factors impact on WAD recovery and our knowledge of how to intervene effectively.
BELIEFS AND EXPECTATIONS FOR RECOVERY
Beliefs are the perceptual lens through which we construct an understanding of our environment and the situations we find ourselves in. [1] Thus, our beliefs about pain determine the way we make sense of the pain experience and form part of the basis of how pain is perceived. [2] Pain beliefs reflect a combination of stable personality traits, general philosophical assumptions about the nature of oneself and one's world, and beliefs specific to the experience of pain, for example, the belief that pain is a part of life or, alternatively, that pain is dangerous and should be avoided. [3] Expectations can be conceptualized as a particular type of belief—a belief about the future. For example, one might believe that one will recover rapidly from an injury (positive expectations for recovery). Expectations share some common ground with Bandura's construct of self-efficacy, which is the situation-specific belief in one's capability to successfully perform a particular behavior. [4] Understanding the concept of expectations also benefits from considering the placebo effect, which refers to symptomatic and physiological changes experienced by patients who are given an inert treatment, believing it an effective treatment. [5] That is, the expectation that a particular intervention will be effective plays a role in these nonspecific treatment effects. [6, 7] However, expectations are more general than either self-efficacy or placebo effect.
Expectations are important predictors of outcome in a number of health states. Some have theorized that this is because beliefs and expectations mediate the transition from acute condition to outcome. [8–13] However, the lack of a widely accepted theoretical framework for “expectations” contributes to a plethora of often conflicting approaches to understanding the role of expectations in the experience of pain. [5] A social-cognitive framework proposed by Janzen et al may be helpful in understanding expectations and the role they play in outcome of pain conditions (such as WAD). [14] This model suggests that expectations are shaped by beliefs and assumptions about the world, and by the social and cultural context. In this model, social learning theory is important in that expectations can develop through vicarious learning (observation of others) and through others’ suggestions as well as through personal experience. This becomes a cyclical process, in which expectations are affected by experience (one's own or others’), which in turn, has an influence on expectations. This process is both longitudinal and cyclical, and expectations can generalize from one situation to another. [14] For example, if expectations in one type of situation are strengthened by personal experience and/or by observations of others’ experiences, that individual may have similar types of expectations in a novel situation. This suggests that when experiencing WAD (a novel experience), the person's initial expectations for recovery will be consistent with their “typical” expectations, although of course if these expectations are not met, the expectations will be modified. Thus, this model suggests that pain recovery expectations are best understood as a dynamic interaction between stable personal characteristics and world views, situational-specific cognitive appraisals, personal experience, observations of others in similar circumstances, and the individual's particular cultural and social context.
Expectations and Whiplash-Associated Disorders: Transition From Acute to Chronic: The Evidence
The idea that expectations for WAD recovery are affected by the cultural and social context has garnered support by findings that there are differences across countries (specifically, Lithuania, Greece, Germany, and Canada) in beliefs about how quickly individuals think they would likely recover if they were to suffer a whiplash injury. [10, 15, 16] In these studies, Canadians have the poorest expectations. Another study indicates that almost 60% of a Canadian sample without WAD believes that, if they were to experience a whiplash injury, at least some of the resultant symptoms would be chronic. [17] A comparison of recovery-related beliefs and expectations (in an uninjured Canadian sample) across scenarios involving neck pain from WAD, neck pain from a work injury and arm/shoulder pain from a work injury revealed that the anticipated recovery of neck pain from WAD was poorer than anticipated recovery from the other two types of injury. Only 18% anticipated that if they were to suffer a whiplash injury, the symptoms would settle quickly and they would be able to get back to normal activities. Only 40% believed that a whiplash injury would not mean a long period of time off work. [18]
There is less information about expectations of those who have actually suffered a recent WAD. These studies show that only 24% of a Canadian sample and 27% of a Swedish sample reported having very good expectations for recovery. [19, 20] However, even within similar cultures, social environments, and socio-political milieus, there is variability in what outcome people with WAD expect. We know little about the actual determinants of expectations for WAD recovery; however, from the limited research in this area, it would appear that (not surprisingly) those with greater pain intensity and depressed mood have lower expectations for recovery and are less likely to expect to return to work. [21, 22] In these studies, males, younger persons, those with lower education and lower income, those with a prior history of neck injury and those with a history of moderate to severe musculoskeletal pain (prior to the crash) also had poorer recovery expectations. The latter two associations are interesting, because they suggest that — in addition to crash-related symptoms—prior experience with neck injury and with pain may guide current expectations. However, to date, there have been no studies examining specific cultural, social, or socio-political contexts, which might also affect one's expectations.
There is good support from two large (n = 6,015 and 1,032) population-based longitudinal cohorts that expectation to recover is an independent predictor of actual WAD recovery. After adjusting for relevant confounders such as initial pain and symptoms, health, and sociodemographic characteristics, expecting to return to work and positive expectation for general recovery predicted faster recovery, as assessed by global self-ratings of recovery, pain, and pain-related disability. [19, 20, 23] These findings were supported in a smaller study (n = 114) by Vetti et al, [24] who reported that WAD recovery expectations (but not MRI findings of upper neck ligament high-signal changes) predicted neck pain and disability at 1 year. Interestingly, those researchers also found that post-traumatic stress predicted prolonged neck pain for those with high expectations, but not for those with low expectations for recovery.
No study has yet identified the mechanism through which expectations have an effect on recovery. In a cross-sectional study, Söderlund and Asenlöf demonstrated that expectations in WAD (i.e., self-efficacy expectations) mediated the relationship between pain intensity and concurrent disability. [25] However, no longitudinal studies have assessed the temporal relationships among pain intensity, expectations, and disability. Nor can we be certain that modifying peoples’ expectations for recovery improves their recovery. As one of their components, most educational interventions involve providing information and reassurance about recovery, which should improve patient's expectations. Positive studies about the effectiveness of these interventions would provide indirect evidence about the effect of modifying expectations (although it is also possible that it is the other components in educational interventions, such as the advice to exercise and to return to usual activities as quickly as possible, that are the modality of treatment effectiveness). However, at this point in time, it is difficult to come to any conclusions about the effectiveness of educational interventions in improving WAD recovery because of limited evidence and conflicting findings. [26, 27] Fortunately, two large randomized studies to examine the effectiveness of education in early WAD are ongoing, and these should provide a better understanding of this issue. [28, 29]
COPING WITH PAIN
Coping is usually defined as purposeful psychological or behavioral efforts to manage “external and/or internal demands that are appraised as taxing or exceeding the resources of the person.” [30] Pain is one of those taxing situations — by definition, an unpleasant sensory and emotional experience (http://www.IASP-Pain.org). In brief, then, pain coping is usually understood as a set of intentional, goal-directed psychological, and/or behavioral efforts to minimize the physical, psychological, or social harm of pain.
Early theories of coping focused almost exclusively on the individual, assuming that how individuals deal (cope) with stressors is determined primarily or even solely by their personality. Thus, coping style was originally seen as a stable trait, changing little across time or situations, and largely independent of interpersonal or environmental influences. Later theorists proposed that coping is also shaped by situational factors (such as life circumstances and the particular problem) and by the social and cultural influences. [31–33] Thus, like expectations, coping is best conceptualized as embedded within the interpersonal relationships and the social and political environmental context in which that person lives.
Coping With WAD Pain: Transition From Acute to Chronic: The Evidence
Much of the current coping literature involves chronic pain. This section focuses on the much smaller fund of evidence on the role of coping in the transition between acute and chronic WAD. As for expectations, there is a body of work examining how noninjured individuals believe they would cope with whiplash injuries if they were to sustain one. One recent study suggests that uninjured individuals who expected they would experience poor symptom recovery after a (hypothetical) whiplash injury were also likely to anticipate using passive coping strategies (e.g., withdrawing from activities), whereas those with better expectations for hypothetical recovery anticipated using “active” coping strategies (e.g., exercising). [17] Interestingly, although 50% of uninjured persons believed that staying active and exercising is important in coping with work-related neck pain or arm/shoulder injuries, fewer believed that they should cope in this manner if they were to have neck pain from a whiplash injury. [18]
Although examining beliefs about coping in an uninjured population can be informative (especially if such beliefs affect future coping in the event of an actual WAD), it is more directly salient to discuss how those with WAD actually cope and the impact this has on their recovery. Several studies suggest no association. A cross-sectional study of WAD patients shows that after adjusting for pain catastrophization, other forms of pain coping were not associated with concurrent disability or depression. [34] However, this study could not address the prognostic role of coping.
There have been several longitudinal studies conducted. In a sample of 141 patients presenting to an emergency department within 2 days after a traffic crash, Kasch reported no association between coping, as assessed by the Millon Behavioral Health Inventory, and recovery. [35] However, this measure of coping is not specific to pain, but relates to how individuals cope with health problems in general. Thus, it is unclear whether these findings relate to the role of pain coping and WAD recovery. In addition, it is often difficult to draw firm conclusions from prognostic studies with small sample sizes. The general rule of thumb is that for the estimates of the coefficients to be stable and reliable, there must be at least 10 outcome events per variable included in the statistical model. This means that for statistical stability of a multivariable analysis, a small study can include only a few factors, which leads to the risk of results being confounded. [36, 37] For the earlier study, eight possible predictors were included in the statistical model, which, using the general rule of thumb for sample size, would have required a minimum of 80 outcome events to have confidence that the estimates of effect were stable. With an actual count of fewer than 20 outcome events in that study, findings need to be viewed with caution.
Is pain coping prognostic of recovery in WAD? There is evidence that some forms of pain coping have prognostic value. One large population-based study (n = 2,320) shows that frequent use of “passive” pain coping strategies (utilized within the first 6 weeks post-injury) has an independent association (after controlling for relevant confounders) with slowed recovery, especially when the injured individuals also had depressed mood. [38] In another study (n = 130 presentations to emergency departments), those endorsing “adaptive coping” strategies to deal with their pain within 1 month of their injury (e.g., high levels of activity, receiving support from significant others) had a better WAD prognosis. [39]
It should be noted, however, that only 14 of the participants reported no pain at follow-up; given that the two multivariable regression analyses included six and nine (respectively) variables in the models, using the minimum of 10 outcome events per variable rule, those estimates of effect may be unstable and should be viewed with caution. There is also evidence from one large population based study (n = 2,280, with appropriate multivariable analysis) and one smaller study of patients presenting to emergency departments that feelings of helplessness, which suggests passive coping, predict slowed WAD recovery (n = 82; with only 27 outcome “events,” the sample size of the latter study did not permit thorough assessment of aggregate confounding, so again, findings should be interpreted cautiously). [40, 41] Given the limited number of large studies, one cannot draw conclusions with a high degree of certainty. However, a recent systematic review concluded that the current best evidence suggests that coping appears to be important in WAD prognosis. [42]
In addition, a clear interpretation of these findings is made more difficult by the fact that there are many different coping questionnaires arising from different constructs of “coping,” and the concept of coping is, itself, very heterogeneous. In addition, although current conceptual views about the construct of coping generally highlight the importance of social environment factors as well as personal factors in coping, assessments of how individuals cope tend to focus exclusively on the individual. Thus, coping questionnaires may not adequately capture individuals’ coping experiences and practices. In the broader pain literature, there is a body of knowledge about those who use effective coping strategies versus those who use less effective coping. However, this research, too, has tended to focus on individual characteristics rather than the context in which effective coping strategies are used. For example, those who cope effectively with their pain tend to have a generally positive mood, are not fearful of their pain and have a high sense of self-efficacy (i.e., a sense of control, feeling able to succeed). [38, 43–47]
These individuals exhibit resilience—they cope consistently well, they adapt well, they function effectively, and they enjoy a fulfilling life despite their pain. [48–50] Those who are resilient, despite their pain problem, tend to be optimistic, to have the capacity for positive social engagement, and have a sense of purpose in life. [48] However, we also know from non-WAD studies (primarily studies of back pain in workers) that coping and resilience can be adversely affected by external factors such as employers’ attitudes and behaviors, [51] certain compensation factors, [52, 53] and interpersonal conflict. [54] Clearly we need to expand our views and investigations of coping to understand how personal and contextual factors interact in coping with acute WAD, and the resultant impact on recovery.
DEPRESSION
There is a plethora of evidence for a strong relationship between depression/depressive symptomatology and chronic WAD. [55–60] Interestingly, there is also evidence that for a substantial proportion of persons with whiplash injuries, depressed mood appears to emerge in the early stages of recovery. [43, 56, 59] For over half of those with early post-injury depressed mood, these symptoms resolved quickly; however, for almost 40%, these depressive symptoms were recurrent or persistent. [43] Not surprisingly those with greater initial pain, more WAD symptoms and prior mental health problems were more likely to become depressed within the first few weeks of their injury, and those with the greatest pain and the most post-crash anxiety were also more likely to experience recurrent or persistent course of depression. [43, 61] This leaves the question of whether early depressive symptoms are an important prognostic factor in WAD recovery.
Depression/Distress and Whiplash-Associated Disorder Pain: Transition From Acute to Chronic: The Evidence
There are several studies examining the relationship between post-injury depression/psychological distress and WAD recovery. Virtually all studies (several of them are large cohort studies) that examine depression and subsequent WAD recovery provided support for this relationship. [38, 59, 62–64] There is also evidence from a large, population-based cohort that when early onset post-crash depression ran a recurrent or persistent depression course, WAD recovery was slower, although this descriptive study did not adjust for confounding. [43] In another large cohort study that adjusted for other relevant factors, early post-WAD depression has also been linked to later development of widespread body pain. [62]
There have been discrepant findings. A small (n = 78) cohort study by Radanov et al reported no association between depression and WAD recovery. [65] However, with 21 outcome events and almost 20 predictor variables included in the statistical model, it is unlikely that the estimates were stable. One relatively large study (n = 557) [66] found a univariable association between depression and poor WAD outcome, but depression was not a significant predictor of pain in the multivariable analysis. The same kind of results for depression were reported in another small study (discussed in the previous section; n = 14 outcome events, so estimates from the multivariable analyses may be unstable). [39] However, on the whole, the evidence appears to support a link. There are many potential explanations of this association, although none have been clearly shown to be definitive. One possible explanation relates to the association between depression and somatosensory abnormalities. [67–69] Another explanation may relate to the well-established linkages among depression, lowered levels of activity and passive coping; [38, 44, 70–72] that is, those who are depressed after their injury are more likely to cope passively and less likely to mobilize their neck, to exercise, or to resume their usual activities—which are shown to be effective when part of an intervention for WAD. [27]
NEED FOR A BROADER APPROACH TO THE ISSUE
The psychosocial factors of beliefs and expectations for recovery, pain coping, and depression all appear to have prognostic value for WAD outcome, although the quantity and quality of the evidence varies. Treatment programs geared toward providing information about WAD and its positive prognosis (i.e., improving expectations), and encouraging mobilization, exercise and return to usual activity (linked with active coping and improved mood) have had some success in WAD recovery. [27] However, in addition to individual interventions, there may be some value in taking a broader approach to addressing the psychosocial risk factors for chronicity. In Canada, Australia, Scotland, and Norway, mass media campaigns have effectively changed the general public's beliefs about the importance of staying active when experiencing back pain. [73–77] Given the especially negative beliefs about WAD among the general population, mass media attempts to similarly inform the public about WAD may be helpful in counteracting current fears about WAD.
Moreover, pain is not simply a personal, internal matter. People with WAD have a multitude of community systems and social structures to deal with, and these systems and structures can have a huge impact on beliefs about pain, reactions to it and coping patterns. The most immediate are the kinship and friendship networks. It can be no surprise that family and friends could affect individuals’ expectations, coping and psychological reactions to the injury. For example, despite being told by one's health care providers that WAD has a good prognosis and that being active — despite the pain — is important, family and friends may counteract that advice by encouraging rest and inactivity because of their own beliefs about pain and WAD. The workplace has an important impact on recovery from back pain. For example, if an employer demonstrates respect and strong support, and stays in regular communication with employees with work-related back pain, those employees are more positive about recovering, are less likely to take time off work and have shorter work absences. [51] It seems likely that this is also true for the employee with WAD.
From studying coping in other kinds of adverse situations, we know that positive social engagements enhance positive attitudes and effective coping while interpersonal conflict inhibits these. [54] The ability to sustain positive social relationships and positive social support depends not only on individual characteristics but also on social opportunities. It is not uncommon, for example, to hear of whiplash claimants having adversarial relationships with their insurance providers. Although the direct impact of this kind of conflict on expectations, coping and psychological well-being has not been studied in WAD, it is not unreasonable to believe that it may play a negative role. Self-efficacy (which is linked with positive recovery expectations) is frequently seen as an individual attribute, but the concept arose from social learning theory, and is determined, not only by self perception but by social experiences. [78] Yet — despite the fact that our frameworks for understanding beliefs, expectations, coping and depression highlight the roles of interpersonal and societal factors, and despite the increasing body of empirical work that underlines the importance of these factors in adaptation of those with pain problems — the vast majority of research and clinical efforts to enhance patients’ coping and psychological well-being target the individual. At best, the employer may be brought into the equation with the goal of facilitating the employee's successful return to work.
Treating these psychological factors as entirely individual phenomena narrows our efforts to address the problem. That view encourages a deficit-based approach that focuses on the individual — identifying personal and behavioral aspects of beliefs, coping, and psychological distress that lead to negative outcomes, identifying gaps in the person's resilience, and developing strategies to ameliorate these. To make real progress in improving beliefs, coping, and psychological well-being in WAD, we may need to incorporate a research and clinical paradigm that acknowledges the complex relationships between internal and social/societal processes that impact on how well the person with WAD pain can function in their lives. Novel approaches to exploring the relationships among the biological/medical, psychological, and social aspects of WAD recovery might include (but are not limited to) such approaches as qualitative and mixed methods research, multilevel modeling, and structural equation modeling.
CONCLUSIONS
Beliefs, expectations, coping, and depression all appear to predict WAD recovery. Efforts to address these factors should take a broad-based approach. These psychological constructs should be viewed as being developed and maintained within the broader social context of family, social networks, employment, and societal processes in general. There is need for a research and clinical paradigm, which acknowledges the interrelationships between internal processes and the social context in attempts to optimize recovery and functioning in those with WAD.
Key Points
A number of psychological factors, including pain beliefs, recovery expectations, coping, and depressive symptomatology have been shown to be associated with recovery of whiplash-associated disorders (WAD).
These psychological constructs are best understood as an interaction between the individual's internal processes and behavior and the social context in which the individual lives and functions.
To make real progress in improving beliefs, coping, and psychological well-being in those with WAD, we should incorporate a research and clinical paradigm that acknowledges these complex interactions between the individual and his or her social environment.
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