ORIGINAL ARTICLE

Coping style as a predictor of compliance with referralto active rehabilitation in whiplash patients

Robert Ferrari & Deon Louw

Received: 16 November 2010 /Accepted: 21 March 2011 /Published online: 6 April 2011# Clinical Rheumatology 2011

Abstract The objective of the study was to determine theodds ratio for compliance with referral to an activetreatment program according to coping style in a cohort ofacute whiplash-injured subjects. Sixty whiplash patientswere assessed within 1 week of their collision for theircoping styles and were then questioned 3 weeks later todetermine if they had complied with a referral for an activetreatment program. Coping style was assessed with theVanderbilt Pain Management Inventory. Adjusting for age,gender, and initial whiplash disability questionnaire scores,the odds ratio for compliance with therapy for subjects whohad a low active/high passive coping style was 0.15 (P=0.03) (95% CI, 0.03–0.86) relative to all other coping stylepatterns, whose odds ratios did not differ from each other.As a secondary outcome, the odds ratio for reportingprescription medication use for subjects who had a lowactive/high passive coping style was 6.7 (P=0.038) (95%CI, 1.1–40.4). Those whiplash patients who have a lowactive/high passive coping style are less likely to attend anactive exercise-based rehabilitation program and morelikely to use prescription medications in the first 3 weeksfollowing injury. Coping style may affect recovery fromwhiplash injury through issues of compliance with activetherapy and increased reliance on prescription medications.

Keywords Attribution . Outcomes . Pain .Whiplash injury

Coping styles are relevant to a number of issues regardingpatient compliance. Coping styles have been shown to predictnonattendance for diagnostic testing of coronary arterydisease among veterans [1], adherence to positive airwaypressure therapy [2], and the degree of distress duringrehabilitation following open heart surgery [3]. Coping refersto the strategies used to deal with the negative impact ofstress. Styles of coping have been classified in manydifferent ways, for example, cognitive vs. behavioralresponses [4] or problem solving vs. emotion-focused coping[5]. A common description of coping styles includes activevs. passive coping styles [5–8]. Active coping refers to thosecoping strategies that involve taking responsibility for painmanagement and include attempts to control the pain or tofunction in spite of pain. Passive coping refers to strategiesthat involve giving responsibility for pain management to anoutside source and/or allowing other areas of life to beadversely affected by pain [8]. Previous research hasassessed the factors associated with active and passivecoping in isolation. Passive coping is generally found to beassociated with increased severity of depression [8–10],higher levels of activity limitation [11], and helplessness [8,12]. Active coping has been found to be associated with lesssevere depression [8, 13], increased activity level [10], andless functional impairment [8], but to be unrelated to painseverity [9]. Coping style is not merely active or passive.Because there are items for both scales which may beendorsed by one individual, there is a range of four patternswhich may be observed, being combinations of high and lowactive or passive scores. Thus, an individual score may be acombination of any of: high active/low passive; high active/high passive; low active/low passive; and low active/highpassive.

A low active/high passive coping style has also beenshown to be a predictor of recovery rate from whiplash injury

R. Ferrari (*)Department of Medicine, University of Alberta Hospital,Edmonton, AB T6G 2B7, Canadae-mail: rferrari@shaw.ca

D. LouwEdmonton, AB, Canadae-mail: deon@suresurgery.com

Clin Rheumatol (2011) 30:1221–1225DOI 10.1007/s10067-011-1742-1

[14], wherein low active/high passive coping style was apredictor of a lower rate of recovery, but the mechanism ofthis is unclear. Certainly, reduced activity with a passivecoping style is one possibility, though this is difficult toascertain. Compliance with active rehabilitation may be anissue with passive coping style and a way to ascertain howcoping style affects rehabilitation, as these patients are morelikely to rely on medications and rest than activity.

The objective of the current study is to determine theodds ratio for attending an active rehabilitation program(compliance) according to coping style in a cohort ofconsecutive, acute whiplash-injured subjects.

Methods

Sample

This was a cohort study of consecutive whiplash-injuredpatients presenting within 7 days of their collision to a singlewalk-in primary care center. Patients with a motor vehiclecollision and suspected whiplash-associated disorder (WAD)were routinely referred from general practitioners at the clinic,directly to the researcher (RF) who was acting as a specialistconsultant within that clinic. The researcher/specialist gath-ered data on these subjects referred, the measurements beingconducted at the initial consultation as part of the routinemeasures provided to all patients (i.e., as part of usualassessment). Prospective subjects were further assessed forinclusion and exclusion criteria at the time of initial interview.WAD grade 1 or 2 patients were included if they were seatedwithin the interior of a car, truck, sports/utility vehicle, or vanin a collision (any of rear, frontal, or side impact), had no lossof consciousness, were 18 years of age or over, and presentedwithin 7 days of their collision. Patients were excluded if theywere told they had a fracture or neurological injury (i.e., grade3 or grade 4 WAD), had objective neurologic signs onexamination (loss of reflexes, sensory loss), previous whip-lash injury or a recollection of prior spinal pain requiringtreatment, no fixed address or current contact information,were unable to communicate in English, had nontraumaticpain, were injured in a nonmotor vehicle event, or wereadmitted to hospital. Ethical clearance was gained from theCollege of Physicians and Surgeons of Alberta.

A total of 69 prospective subjects were recruited andassessed over a period of 3 months, and from these nine wereexcluded (six due to previous history, three due to loss ofconsciousness). Thus, 60 subjects formed the cohort for study.

Survey questionnaire—coping style

After an appropriate, standardized history and physicalexamination, subjects then completed the outcome mea-

sure (compliance and prescription use), and the paincoping strategy was measured with the 18-item Vander-bilt Pain Management Inventory, an inventory developedto assess how patients manage pain [13]. The instructionsfor this questionnaire ask individuals to endorse copingstrategies used when their pain is of moderate intensity.Respondents rate how often they use each strategy on afive-point Likert scale. Scores range from 10 to 50 for thepassive scale and 8 to 40 for the active scale. To developcoping combinations, the active and passive coping scaleswere dichotomized using the median score as a cutoff forhigh and low scores. Härkäpää used the same procedure tosplit subscales from the Coping Strategies Questionnaire[15]. The median scores on the active and passive copingscale were thus calculated. Those with scores below themedian on both scales were classified as low active/lowpassive; those below the median on the active and abovethe median on the passive scale were classified as lowactive/high passive; those above the median on the activeand below on the passive scales were high active/lowpassive; and those above the median on both scales werehigh active/high passive. Carroll et al. [14] also found thisapproach useful.

Subjects then completed the Whiplash Disability Ques-tionnaire (WDQ). The WDQ is a modified version of theNeck Disability Index with 13 items designed to evaluatewhiplash-related disability, and has been validated, demon-strating that the WDQ has excellent short- and medium-term reproducibility and responsiveness in a populationseeking treatment for WAD [16–19]. It is particularly usefulsince it includes an assessment of pain levels andpsychological distress, both factors which predict recovery[20]. The patients were prescribed a standardized treatmentas appropriate with the physician blind to the WDQ andcoping instrument. The patients were advised to seekadvice on medications from their general practitioner, andthe purpose of the consultation was to develop a rehabil-itation program. Routinely, all subjects were referred for anassessment at a single physiotherapy center, by beingprovided with an address, phone number, and prescriptionfor rehabilitation. Patients were told that they would befurther assessed and possibly, based on this assessment,either discharged to home care and exercises or an exercise-based rehabilitation program. The location could varyaccording to the patient’s convenience. Subjects were askedto return for 3-week assessment even if improved, and werecontacted by phone if necessary to increase compliancewith the 3-week assessment.

Outcomes

At 3 weeks post-injury, subjects were interviewed in personor by phone to determine, by their self-report, if they had

1222 Clin Rheumatol (2011) 30:1221–1225

attended their first visit with the active rehabilitationprogram and if they were using prescription medicationsfor their injuries. There was no attempt made to verify theseresponses and the self-report was the only data gathered.Reasons for not attending were recorded.

All subjects were, at the time of the study, in a system ofnew legislation that places a cap on compensation forwhiplash grade 1 and 2, of $4,000, with a standardizeddiagnostic treatment protocol applied to each subject. Allsubjects had filed a claim with an insurance company toreceive treatment benefits.

Statistical analysis

Logistic regression was conducted with the independentvariables of age, gender, coping style pattern, and initialWDQ score, as predictors of compliance (yes or no) andprescription medication use (yes or no). As the distributionof age and WDQ scores may not be normal, thesecontinuous variables were also converted to categoricalvariables. For age, the clinically meaningful categories(shown to have prognostic significance) were age <40 andage >40. For WDQ, the clinically meaningful categorieswere scores in the low (0–40), medium (41–80), and high(81–130) range. The role of confounders and interaction termswas assessed by considering each potential confounder andinteraction term in turn in the model. If any single variable orinteraction changed any of the crude estimates by more than10%, they were entered in the final model. Results arepresented as odds ratios with 95% confidence intervals (CIs).Significance was set at P<0.05. All analyses were completedusing STATA/SE version 10.0 for Macintosh.

Results

Twelve subjects did not return to follow-up and werecontacted by telephone to gather outcome data, therethen being no losses to follow-up. The 60 subjects were21 males and 39 females with a mean age of 36.3±13.9 years. The mean WDQ score within 7 days of injury

was 66.3 (s.d.±23.2, range 25–124). The mean activecoping style score was 28.8±3.8 (40 is the maximumscore for active coping). The mean passive coping stylescore was 31.0±6.4 (50 is the maximum score for passivecoping). Using the median active and passive scores ascutoffs for high or low active or passive scores, fourgroups are identified as follows: 25% high active/lowpassive; 30% high active/high passive; 15% low active/low passive; and 30% low active/high passive. Thepercentage of subjects in each coping style category whowere compliant with referral to an active, exercise-basedrehabilitation program and the percentage in each categoryusing prescription medication are shown in Table 1.

A total of 15 of 60 (25%) subjects were not compliant withthe referral to an active, exercise-based rehabilitation program(six had chosen another type of therapy, four could not find aconvenient location and time, and five for unspecifiedreasons). A total of 29 of 60 (50%) were using a prescriptionmedication at 3 weeks post-injury (type unspecified).

In the modeling, age, gender, and initial WDQ score werenot significant predictors of either outcome or confounders.Only low active/high passive coping style pattern predictedcompliance and prescription medication use. The odds ratiofor compliance with therapy for subjects who had a lowactive/high passive coping style was 0.15 (P=0.03) (95% CI,0.03–0.86) relative to all other coping style patterns, whoseodds ratios did not differ from each other or 1.0. The oddsratio for reporting prescription medication use for subjectswho had a low active/high passive coping style was 6.7 (P=0.04) (95% CI, 1.1–40.4), and the odds ratio was notdifferent between all other coping styles (or 1.0). In otherwords (inverting the odds ratio for non-compliance), subjects

Table 1 Percentage of subjects in each coping style category whowere compliant with a referral for exercise therapy and who wereusing a prescription medication

Coping category % compliantwith referral

% using prescriptionmedication

High active/low passive (N=15) 93% (14/15) 33% (5/15)

High active/high passive (N=18) 56% (10/18) 50% (9/18)

Low active/low passive (N=9) 89% (8/9) 11% (1/9)

Low active/high passive (N=18) 44% (8/18) 89% (16/18)

Table 3 Logistic modeling odds ratio for use of prescriptionmedication according to coping style

Coping category Oddsratio for

P value Confidenceinterval

High active/high passive 1 Reference Reference

High active/low passive 0.27 0.10 0.06–1.3

Low active/high passive 6.69 0.038 1.1–40.3

Low active/low passive 0.12 0.07 0.01–1.2

Table 2 Logistic modeling odds ratio for compliance with referral forexercise-based rehabilitation according to coping style

Coping category Odds ratio P value Confidence interval

High active/high passive 1 Reference Reference

High active/low passive 3.24 0.35 0.28–38

Low active/high passive 0.15 0.03 0.03–0.86

Low active/low passive 2.15 0.56 0.17–28.0

Clin Rheumatol (2011) 30:1221–1225 1223

with a low active/high passive coping style pattern were 6.7times more likely to be non-compliant with a referral foractive, exercise rehabilitation than other coping style patterns(see Tables 2 and 3).

Discussion

This study shows that a low active/high passive copingstyle is associated with non-compliance with referral toan exercise-based rehabilitation program in the acutestages after whiplash injury. It is also associated with anincreased probability of using prescription medicationsrather than non-prescription medications. Given that lowactive/high passive coping style has been associated witha lower rate of recovery from whiplash injury [16], andgiven that active exercise-based rehabilitation is in generalsuperior to non-exercise-based approaches to whiplashinjury [21], this study contributes to our understanding ofhow this passive coping may be associated with thereduced rate of recovery.

The strengths of the study include the fact that thesewere consecutive whiplash subjects attending a primarycare walk-in clinic, a typical setting for presentation ofwhiplash victims, and thus these patients are likelyrepresentative of many primary care populations in Canada.The age and gender distribution and whiplash disabilityscores are typical of other whiplash populations studiedelsewhere [16].

There are a number of limitations. First, the samplesize is small. Although the odds ratios were statisticallysignificant, the confidence intervals are wide, reflectingthe small number of subjects. We did not find differencesbetween groups other than the low active/high passivegroup, and this could be due to lack of power in thestudy. Further studies with larger sample sizes areneeded. Also, the study did not directly assess psycho-logical distress and pain intensity directly, but theWhiplash Disability Questionnaire is an indirect measure.These are also predictive factors, as are age and gender,for which the study may have lacked power to detect aneffect on compliance or prescription medication use.Nevertheless, population-based studies suggest that cop-ing style remains an independent predictor of raterecovery even after adjusting for these latter factors,and therefore the effect of coping style on complianceand prescription medication use remains relevant. Therewas no verification of whether subjects complied withthe referral or a careful review of their actual medicationuse, and in fact, the prescription of medication may haveaffected the decision to comply with active rehabilitation.There is no data on when the subjects receivedprescription medications, but the author is aware that

few had any prescriptions at the outset of the study andwere asked to see their general practitioner if this wasdeemed necessary. In any case, this study relies on self-report, and timing of prescriptions is unknown. Futurestudies should examine compliance and prescriptions in amore objective manner. Finally, another limitation toconsider is that patients with a high passive coping stylemay not be only at higher risk for non-compliance withan active rehabilitation program, but with any referral fortherapy. This study cannot discern whether the non-compliance is directed primarily at active exercise-basedrehabilitation or any other modes of treatments.

In conclusion, this study adds to the understanding ofhow a passive coping style may affect the rate of recoveryfrom whiplash injury. Further studies on the behaviorsassociated with passive coping style in whiplash patientsare required and more routine assessment of coping stylesin clinical practice may assist health care practitioners toidentify those at risk for non-compliance with specifictreatments and/or greater tendency to use prescriptionmedications for their injuries. Those identified at high riskfor non-compliance could receive additional education andinstruction to improve compliance.

Disclosures None

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