If they can put a man on the moon, they should be able to fix a neck injury: a mixed-method study characterizing and explaining pain beliefs about WAD

Abstract

Purpose: To use quantitative data characterizing whiplash-associated disorder (WAD)-related pain beliefs over time to develop qualitative analysis exploring experiences informing these beliefs. Method: A mixed-method design was used. Quantitative and qualitative data were collected concurrently at baseline and 3 and 6 months postmotor vehicle collision. WAD-related pain beliefs were quantitatively measured in a sample of adults with acute WAD. A subgroup of participants participated in an interview after each survey. Descriptive statistics quantitatively characterized beliefs at each measurement. High or low scores from survey beliefs subscales informed the semistructured interview. The qualitative component explored experiences informing endorsement of beliefs reported on the surveys using a meaning-focused approach. Results: Adjunctive meaning informing endorsement of beliefs related to cure, control, emotions and mystery was achieved. Qualitative analysis revealed a meta-theme labeled restitution, representing a desire to be “fixed”. Stigma also emerged as a potentially important contextual descriptor of WAD meaning. Conclusions: Restitution was the dominant underlying pattern of belief endorsement. While this may be adaptive early after WAD, it is problematic for meaning construction later on. Based on contemporary views on pain, identification of this narrative is important as it represents an incompatibility in the conceptualization of pain between patient and provider.

Implications for Rehabilitation

• The restitution narrative (the desire to be fixed or cured) is common to the formation of meaning throughout all stages of whiplash-associated disorder (WAD) injury, even in people experiencing chronic pain.

• Viewing WAD through a lens of restitution is adaptive early after injury, but is problematic as WAD persists and/or becomes chronic.

• Since experts have advocated a shift from treatment to management of persistent pain, patient beliefs about WAD may contradict educational messages delivered by health providers.

Keywords::

• Whiplash
• WAD
• mixed methods
• pain beliefs

Declaration of Interest: The authors report no conflict of interest.

Appendix A

Researcher reflexivity

Demographic reflexivity

I am a 34-year-old PhD candidate in the Faculty of Rehabilitation Medicine at the University of Alberta performing the current study as part of my PhD thesis project. I am a white Canadian male whose socio-economic status would be classified as “middle-class”. Prior to entering the PhD training program, I was trained as a physical therapist and worked clinically for 5 years. Throughout my practice years, I obtained specialized clinical training in manual therapy. I also developed an interest in chronic pain clientele and an interest in pain; in particular, the cognitive aspects of pain.

Personal reflexivity

Throughout training and practice as a physical therapist, my view on health and illness was primarily through the lens of the medical model (positivist/postpositivist). Literature that I read was primarily quantitative and I viewed research questions in a positivist/postpositivist perspective. Thus, entering the PhD program my comfort level was viewing health and illness in quantitative and positivist/post-positivist perspectives. As my studies in pain and research progressed I became more aware of the naturalistic paradigm. Given the large shift in considering a research questions from purely quantitative methods to one that includes naturalistic inquiry, I faced considerable challenges framing this positivist “upbringing”. This was compounded by the choice of using a mixed-methods approach. Moving from paradigm to paradigm required considerable reflection on my part to refamiliarize myself with the tenants of the naturalistic paradigm. While a qualitative researcher aims to explore inquiry with a blank-slate, this is, pragmatically not possible. Thus, I needed to be explicit in reflecting on how my considerable experiences in the quantitative paradigm potentially influenced my interpretations. In other words, qualitative analysis and interpretation does not occur tacitly for me. Throughout this process, I required peer debrief sessions to help ensure that I was facilitating subjectivity.

As a novice researcher undertaking my first qualitative analysis and interpretation as principal investigator, I was acutely aware of the immense responsibility of appropriately representing the research participants in the data analysis. I have employed measures to facilitate appropriate representation of the data (member checking), however appropriate representation of the data remained at the forefront of my mind throughout the process. Moreover, given the positivist/postpositivist influence from my clinical training and practice and the need to frame this aspect of my experience, raised the awareness of the issue of representation throughout the process. As a consequence, the analysis and interpretation of the data tips toward description and deduction as opposed to interpretation and induction. That is, I purposively stayed very close to the language used by the participants in the analysis process. In addition, the interviews are framed based on quantitative data that were constructed on views (cognitive-behavioural approach to pain) that I am familiar with. Therefore, existing theory either explicitly or implicitly influenced my interpretations (appropriately so given the design). This study is not theory building, so an inductive process is less appropriate.

I am strongly influenced by literature advocating a biopsychosocial approach to pain. More specifically, cognitive-behavioural based physical therapy interventions such as patient education. I am also engaged in literature in the followings areas: (1) consciousness theory applied to pain, (2) Arthur Frank’s illness narratives (restitution, chaos and quest), and (3) biological research related to placebo and nocebo effects. While much of this reading is congruent with a naturalistic paradigm, my beliefs in a biopsychosocial and subjective reality are likely to influence my interpretations. Indeed, I encouraged participants to discuss their subjective experiences and psychosocial aspects of their injury in cases when the focus was primarily biological.

As a researcher, I have an interest in understanding a particular subject matter. This is likely not lost on the research participants and the relationship between researcher and participant may very well yield discourse that differs from other relationships. Moreover, the research participant may view the researcher differently from a social perspective that may also influence a particular discourse unique to this relationship. Therefore, the experiences elicited in these interviews likely reflect motives surrounding increasing understanding of an individual’s experience for the purpose of illuminating a broader understanding that may be applied to others.

Ontological/Epistemological reflexivity

The primary factor to consider here is that the qualitative research occurred within the context of a quantitative study (i.e. a mixed-methods study). In other words, the inquiry was not purely naturalistic. Some may argue that mixed-methods research is in contrast to principles of naturalistic inquiry. However, considering the research question, a mixed-methods design was most appropriate. Thus, the interview guide is based on quantitative data so the interview was focused on particular beliefs as opposed to a purely naturalistic inquiry that may permit a more open inquiry to beliefs that may not be captured in a prefabricated measure. This issue is discussed above and I was aware of the need to frame the quantitative perspective when engaged in the qualitative analysis.

As a mixed-method approach integrates quantitative and qualitative paradigms that have very different views of reality, adhering to a particular framework is challenging. Thus, a purist perspective is difficult to defend. Instead, a pragmatic worldview guided the research process. That is, a moderate perspective to purist’s views was used. Much of the qualitative portion was conducted through a constructivist lens. Constructivism supports realism and subjectivism. Pragmatism values this perspective but views it more of a continuum. Whereas realism and subjectivism were influential in this study, it is acknowledged that a purist perspective is not entirely congruent with a mixed-method approach.

Appendix B

Sample interview guide

Qualitative interview guide

Research question: How do the lived experiences of patients with neck pain from whiplash inform their beliefs about their pain condition?

Introduction

“The purpose of this interview is for you to tell me more about your pain and to expand on what you told me in your survey. I am very interested in your information and experience. This information will help us to better understand neck pain after whiplash injury. I would like to remind you that the interview will be recorded. All of your information is confidential and you may choose not to answer any question that you are not comfortable with. You can turn off the recorder at any time”.

Contextualize the interview

a.	Can you describe to me what happened in the car accident? [Follow up: what were you feeling immediately after it happened? What were your initial thoughts about the accident??
b.	What does your neck pain mean to you. Follow-ups: what are some of the things you think about when you are in pain – what do you think those things mean; describe some of the feelings you have when you experience your pain – what does it mean when you feel that way?

Details about specific beliefs

• Based on your questionnaire, I interpreted that you believed/felt that your pain is mysterious, is that accurate??

• Tell me why you feel that way?

• Give me an example where you pain confuses you?

• What does it mean to you if does not fully understand their pain (or finds their pain confusing)??

• What do you think about/how does it make you feel not knowing enough about your pain?

• Mysterious items: No one has been able to tell me exactly why I am in pain, my pain is confusing, I don’t know enough about my pain, I can’t figure out why I am in pai?

• Based on your questionnaire, I interpreted that you believed/felt that your pain will not be permanent, is that accurate?

• Why do you feel that way?

• Tell me about some of your experiences that have led to this belief?

• Tell me about how being optimistic makes you feel (or optimism influence your recovery?

• Do you believe there is a cure for your pain (how do you define cure)?

• Permanence items: I used to think my pain was curable, but now I am not so sure, my pain is here to stay, pain is temp pblm in life, someday I’ll be 100% painfree, there is a cure for my pai?

• Based on your questionnaire, I interpreted that you believed/felt your pain was constant?

• Tell me why you feel that way?

• What experiences have you had that lead to this belief?

• What thoughts or feelings do you have when you reflect on experiencing continuous pain?

• Constancy items: there are times when I am pain free, I am continuously in pain, wake up and go to sleep with pain, my pain varies in intensity but is always with me?

• Based on your questionnaire, I interpreted that you believe pain is an sign of damage being done, is that accurate?

• Why do you feel that way?

• Can you give me an example?

• Have you ever experienced a time when you have felt pain, but not believed it to be a sign of damage being done? Tell me about this?

• Some people think emotions influence pain, what do you think about that?

• Now that we have talked a little about your pain, compared to when we starting talking, would you change anything about your meaning of pain?

• Interviewer summation: “What I heard in the interview was … (summarize key points), did I understand correctly? Is there anything that you were thinking about that we didn’t discuss that you would like to tell me about?”?

• Close interview: “Thank you for your time and for sharing your story”?

Appendix C

Details of trustworthiness analysis

Confirmability inquiry audit.

Detailed description of confirmability criteria to guide inquiry audit (per Lincoln and Guba, 1985)

1. Is the interpretation grounded in the data?

   Evaluate whether there is convergence between the thematic interpretation, coding and raw data?

2. Are the interpretations logical?

   Evaluate whether an appropriate analytic technique was selected?

   Evaluate whether the analytic technique was applied properly?

   Do category labels accurately describe the concepts?

3. Is the category structure clear and of adequate explanatory power?

   Is there an unintended mixture of levels of analysis?

   Is there an unclear method of analysis?

   Do the categories support an exhaustive account of the data?

   Do the categories describe the data/phenomena at the same level?

4. Is inquirer bias likely based on the investigator’s reflexivity account?

   While bias likely exists, does this bias misrepresent the data?

   Is there an imposition of inquirer’s own terminology in the data?

   Is there a sufficient description of the inquirer’s tacit processes (i.e. reflexivity account)?

5. Overall was the degree of confirmability acceptable?

   Are the efforts to ensure confirmability acceptable?

   Did the inquirer account for negative evidence?

   Did the inquirer accommodate negative examples?

Member check

The table below summarizes the findings from respondents (5) returning member check forms.

Table