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Year : 2004  |  Volume : 38  |  Issue : 3  |  Page : 170-174
Coping mechanism and its correlation with quality of life in upper limb post traumatic joint stiffness patients

Department of Orthopaedic Surgery and Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Background: Joint stiffness especially of upper limb joints following trauma may lead to psychological problems.
Method: This study was carried out on twenty-six consecutive patients between 18-45 years of age, of post-traumatic joint stiffness (PTJS) in upper extremity, to determine the type of coping mechanism and its effect on their quality of life. Coping checklist1 and WHO QOL-Brief Version2 questionnaires were used to assess the coping strategies and quality of life of these patients.
Results: Critical analysis of the data revealed that these patients commonly employed coping strategies like problem solving, positive cognition, avoidance, religious and magical thinking in that order.
Conclusion: The correlation analysis between the scores of coping strategies and quality of life showed that patients, who were high on avoidance coping skills, had better psychological functioning where as those who were high on external attribution, had low physical health

Keywords:  Post-traumatic joint stiffness; Upper limbs; Coping strategies; Quality of life.

How to cite this article:
Aggarwal A, Kohli A, Nagi O N, Kumar A. Coping mechanism and its correlation with quality of life in upper limb post traumatic joint stiffness patients. Indian J Orthop 2004;38:170-4

How to cite this URL:
Aggarwal A, Kohli A, Nagi O N, Kumar A. Coping mechanism and its correlation with quality of life in upper limb post traumatic joint stiffness patients. Indian J Orthop [serial online] 2004 [cited 2019 Dec 9];38:170-4. Available from:

   Introduction Top

With the increase in high-speed vehicular trauma, the number of patients with multiple fractures including intraarticular fractures and associated soft tissue injury has gone up considerably. This has led to considerable morbidity after the completion of the treatment. Joint stiffness is one of the important fall-outs of such injuries. Upper extremity fractures may result in ankylosis of the joints such as shoulder, elbow or hand, which may be quite disabling at times. This stiffness may hamper routine as well as certain other activities. The functional disability is more marked if dominant upper limb is affected. Such patient may resort to different coping mechanism in order to deal with the situation.

Coping is a process involving efforts on the way towards solution of the problem. Researchers have systematically examined coping strategies among different people. Some ways of coping seem to be better suited to certain kinds of situation than others. Coping would occur when an individual confronts a fairly drastic change or problem that defies familiar ways of behaving, requires the production of new behaviour and very likely gives rise to uncomfortable efforts like anxiety, despair, guilt, shame or grief, the relief of which forms part of the needed adaptation.

Pearlin and Schooler[3] reported that coping is a behaviour that protects people from being psychologically harmed by problematic social experience. They further added that coping protects by a) eliminating or modifying stresses, b) perpetually controlling the meaning of stressful experience, thus neutralizing its problematic character, or c) keeping emotional consequences within manageable bounds.

Quality of life (QOL) is an important issue for the large number of patients who may need to adapt to severe and chronic disability due to joint stiffness. The loss of mobility in the joints makes patient more dependent on others which affects their quality of life. Measuring quality of life can provide a detailed assessment of physical disability and treatment effects as well as the global impact of those effects on the person's daily life.

The data of QOL might be useful to predict patient's response to future treatment or for taking important decision for future treatment. For example, Hawker et al[4] found that both generic and disease specific QOL measurements were of value in assessing the well-being of patients receiving knee replacement surgery. Their findings demonstrate the absolute necessity of considering each person's individual assessment of what makes life worth living for them. Two people with the very same objective health status can have very different QOL, due to difference in expectations and coping ability.

Very few studies are available concerning the psychological variables in patients with orthopaedic problems. Previous studies are mainly on coping mechanisms in osteoarthritis[5] and psycho-educational interventions in arthritis[6]. Thus the present study was conducted to determine the quality of life and the coping strategies and the correlation between them in patients of post-traumatic joint stiffness in upper extremity.

   Materials and Methods Top


Twenty-six consecutive patients with posttraumatic joint stiffness in upper limbs attending the orthopaedic outpatient department with the following inclusion and exclusion criteria, was undertaken for this study. The patients included for the study were in the age group of 18 to 45 years of either sex, diagnosed as having post-traumatic joint stiffness (PTJS) in upper limbs of minimum six months duration after trauma. Post-traumatic joint stiffness (PTJS) is defined as residual significant restriction of functional range of motion of the joints, causing interference in the professional and/or daily activities. Exclusion criteria were i) patient with any chronic medical diseases such as asthma, epilepsy, tuberculosis, heart diseases etc., ii) patient with any past history of psychiatric illness, iii) head injury patients, iv) any neurological disease such as polio, epilepsy, etc.

Instruments used

  1. Sociodemographic profile sheet was used to collect the sociodemographic information i.e. name, age, sex and education etc. of the patient.
  2. Clinical profile sheet was developed to record the clinical features such as physical deformity, range of motion of the joints and diagnosis.
  3. WHO QOL –Brief Version2 questionnaire to measure the QOL. It covers four domains of physical health, psychological functioning, social relationships and environment with two additional items of general wellbeing.
  4. Coping Checklist[1] instrument was used to assess the coping strategies like positive cognition, negative cognition, problem solving, distraction, magical thinking, avoidance, religious, help seeking and external attribution.


Each patient was seated comfortably and consent was taken for participation in the study. All the questionnaires were administered to each patient individually. The sociodemographic, clinical features of the patients and the responses to the coping checklist and quality of life were noted down. The tests were administered strictly according to their prescribed instructions. They were assured that their results and the information obtained would be kept strictly confidential and used for research purpose only.

   Results Top

Twenty two of 26 patients were males. Twenty were married and 17 of them were in the age group of 31-45 years. As per the occupational status, 4 patients were professionals, 11 were from clerical background, 5 were from the skilled/ semi-skilled workers and 6 were students. As per educational status, 25 were literate.

Clinical examination showed that 11(42.4%) patients were between one to two years of duration of treatment. Eighteen (69.23%) patients underwent only one surgery. Fifteen (57.7%) patients presented with arthralgia at the time of interview. In terms of union of fractures, 25 (96.15%) patients showed complete union of fractures. One case presented with non-union. With regard to the presence of stiffness in the joints, shoulder and elbow joints were predominantly involved. Nineteen (73.1%) showed only one joint involvement [Table 1].

Severity of stiffness was calculated on the basis of the range of motion of the joint with respect to the normal range of motion. Global rating score of 0 was given to those having range of motion 75% compared to normal. One was given to those having ROM 50-75%, 2 to ROM 25-50%, and 3 to below 25%.

[Table 2] shows the percentage of coping strategies in patients with upper limb joint stiffness. Scores are in percentages of each coping strategy used in such patients. [Table 3] shows mean, standard deviation and range of scores of dimensions of quality of life. [Table 4] shows the intercorrelation of coping strategies and the dimensions of the QOL. Pearson's product moment correlation was calculated among all the fourteen variables.

From the inter-correlation table, it can be seen that positive cognitive scores have correlations with:

i) Distraction (r=0.57, df=24,p<.01),

ii) Magical thinking (r=0.39, df=24, p<.05)

iii) Religious (r=0.47, df=24, p<.05) and

iv) Help seeking (r=0.68, df=24, p<.01)

Scores of distraction have significant correlations with:

i) Magical thinking (r=0.50, df=24, p<.01)

ii) Religious (r=0.66, df=24, p<.01), and

iii) Help seeking (r=0.54, df=24, p<.05).

Scores of Magical thinking has significant correlation with religious (r=0.46, df=24, p<.01).

Scores of avoidance has significant correlation with psychological functioning (r=0.45, df=24, p<.05).

Scores of religious has significant correlation with help seeking (r=0.49, df=24,p<.01).

Scores of external attribution has significant negative correlation with physical health (r=-0.54, df=24, p<.01).

Scores of physical health have significant correlations with:

i) Psychological functioning(r=0.60, df=24,p<.01),

ii) Social relationships, (r=0.47, df=24,p<.05),

iii) Environment (r=0.60, df=24,p<.05), and

iv) General well being (r=0.75, df=24,p<.01).

Scores of psychological functioning have significant correlations with:

i) Social relationships (r=0.50, df=24,p<.01),

ii) Environment (r=0.72, df=24,p<.01), and

iii) General well-being (r=0.63, df=24,p<.01).

Scores of social relationships has significant correlation with general well-being i.e. (r=0.39, df=24,p<.05).

Scores of environment has significant correlation with general well being i.e. (r=0.62, df=24,p<.01).

   Discussion Top

In our study the coping strategies used were mainly problem solving (82.8%), positive cognition (66.8%), avoidance (56.3%), religious (55.56%), and magical thinking (50.8%) in that order.

Problem solving strategies in such patients includes talking to friends and family members, doubling efforts, taking active steps to fight out the problem, analyzing the problem, solving it in steps and taking help of guide-books etc. In a study done with subjects with spinal cord injuries, predominantly problem solving means of coping were utilized[7].

Positive cognition is the second most used coping strategy in such patients. In positive cognition there is acceptance, and comparing the self with others and feeling better off, looking at brighter side of the things to come.

Avoidance is the third most commonly used coping strategies in such patients. Here the individual refuses to think about the problem, seeks isolation, avoids being with people, keeps feelings to oneself. These strategies are mostly problem focused. It reflects cognitive and behavioral attempts to avoid telling about a stress and its implications or to manage the effect associated with it. Patients with osteoarthritis used problem and emotion focused strategies to manage their problems in their day-to-day life5,8. However in our study, coping strategies were more active problem focused and less emotion focused.

Religious coping strategies were the next commonly used, to deal with the stressful situation in the present study. In the Indian context, strategies like going to pilgrimage, attending bhajans, praying, attending religious discussions, making special offerings and reading religious or holy books, are the popular modes of adjustments. Manning[9] observed that spiritual and religious coping strategies in the form of reappraisal of God's power were mainly used in patients of breast cancer. These were positive in nature and affected QOL and/or life situations.

Magical thinking is another most commonly coping strategy used in such patients. Such patients believe in supernatural power, wear lockets or rings with stones, and consult faith healers with a hope of miracle to happen. They also consult the astrologers for the solution to their problem. Dalal[10] observed in the orthopaedic patients that they frequently blame themselves and cosmic factors (fate, Karma and God) for their health problems. Such beliefs played an important role in various treatment related decisions made by the patients.

Conversely the coping strategies used less frequently in post-traumatic joint stiffness in upper limbs were external attribution, negative cognitive, help seeking, and distraction. Curran[11] found that coping strategies characterized by worry, wishful thinking, and self-blame were associated with higher levels of depression and anxiety. Strategies focusing on problem solving and having a positive outlook were related to anxiety but to a lesser degree. Felton[12] in his study showed similar results.

On analysis of the kind of coping strategies used in relation to severity of illness, it was found that those with maximum severity (grade III) were usually employing problem solving, distraction, external attribution and avoidance in that order. Patients with moderate severity (grade II) revealed the use of coping strategies like problem solving and external attribution mainly. Those with mild severity (grade I) employed problem solving, positive cognition and external attribution in that order.

On examining the scores of QOL of patients with PTJS, we found that they had positive inclination towards all the aspects of quality of life i.e., physical health, psychological functioning, social relationships, environment and general well-being.

Examining the coping strategies in relation to quality of life, the study indicates that avoidance coping strategy leads to better psychological functioning of the patient. On the other hand negative correlation between external attribution and physical health shows that person who is high on external attribution has poor physical health.

Overall analysis of the inter-correlation matrix doesn't show much significant correlations in the dimensions of coping checklist and quality of life.

An extensive search of literature has revealed no such study in patients of post-traumatic joint stiffness. There appears to be an urgent need for intervention at the individual level in such cases. They need general guidelines on how to cope successfully with the problems and considerable stress due to restriction of joints movements after trauma. An integrated assessment of coping skills can be useful in formulating clinical case descriptions, treatment planning, and program evaluation. It can help to describe a person's coping responses to the specific stressful life circumstances, monitor stability and change in coping responses, compare individuals and groups, and examine how new life events affect a person's ways of coping as well as how coping response change an individual's life situation and functioning and affect his quality of life.

   References Top

1.Rao K, Prabhu GG, Subhakrishnan DK. Development of coping Checklist. Ind J Psychiatry. 1989; 31(2): 128-133.  Back to cited text no. 1    
2.WHOQOL-Brief Field trial version. Program on mental health. World health Organization; Geneva 1996.  Back to cited text no. 2    
3.Pearlin LL, Schooler C. The structure of coping. J Health Social Behaviour. 1978; 19:2-21.  Back to cited text no. 3    
4.Hawker G, Melfi C, Paul J, Green R, Bombardier C. Comparison of a generic (SF-36) and a disease specific (WOMAC) instrument in the measurement of outcomes after knee replacement surgery. J Rheumatol. 1995; 22:1193-1196  Back to cited text no. 4    
5.Downe-Wamboldt B. Stress, emotions, and coping: a study of elderly women with osteoarthritis. Health Care Women Int. 1991; 12(1): 85-98.  Back to cited text no. 5    
6.Hawley DJ. Psycho-educational interventions in the treatment of arthritis. Clin Rheumatol. 1995; 9(4). 803-23.  Back to cited text no. 6    
7.Wheeler G, Krausher R, Cumming C, Jung V, Steadward R, Cumming D. Personal styles and ways of coping in individuals who use wheelchairs. Spinal Cord. 1996; 34:351-357.  Back to cited text no. 7    
8.Lazarus R, Folkman S. Stress, appraisal, and coping. New York; Springer Publishing Co. 1984.  Back to cited text no. 8    
9.Manning, Juanita K. The effects of spiritual coping on quality of life and life satisfaction in women with breast cancer. Dissertation Abstract International-B. 2001 (April); 61/10:5237.  Back to cited text no. 9    
10.Dalal AK. Living with a chronic disease: healing and psychological adjustment in Indian society. Psychol Dev Soc. 2000; 12(1), 67-81.  Back to cited text no. 10    
11.Curran CA, Ponsford JL, Crowe S. Coping strategies and emotional outcome following traumatic brain injury: A comparison with orthopedic patients. J Head Tr Rehabil. 2000; 15(6): 1256-74.  Back to cited text no. 11    
12.Felton BJ, Revenson TA, Hinrichsen GA. Stress and coping in the explanation of psychological adjustment among chronically ill adults. Social Sc Med. 1984; 18:889-898.  Back to cited text no. 12    

Correspondence Address:
Aditya Aggarwal
# 123-C, Sector 24-A, Chandigarh 160023
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Source of Support: None, Conflict of Interest: None

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  [Table - 1], [Table - 2], [Table - 3], [Table - 4]


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