Risk factors for development and maintenance of chronic whiplash

Background: After experiencing whiplash accidents, most individuals recover rapidly. Others, however, develop chronic whiplash, a condition characterized by long lasting neck pain, somatic complaints and symptoms of anxiety and depression. Individuals with chronic whiplash report the condition to reduce their quality of life and ability to work. As most individuals recover from whiplash accidents without needing medical attention, identifying those at risk of chronic complaints, and in need of treatment, is important. Factors related to the whiplash accident, like speed and extent of damage to the cars, as well as findings from clinical imaging seem poorly correlated with outcome. Previous research indicates that socio-demographic factors, pre-injury somatic and mental health as well as coping might be associated with prognosis. However, as existing literature remains inconclusive, and much of the research is based on retrospectively collected data, more evidence is needed. Aim: The overall aim of the thesis was to investigate whether socio-demographic factors, pre- and post-injury health, use of health care and medications, and early coping preferences are associated with outcome after whiplash accidents. Method: In study one and two data from two waves of the large, Norwegian population-based Nord-Trøndelag Health Study (HUNT2 and HUNT3) was used. Study one investigated whether socio-demographic variables (such as age, gender, education) and health related variables (such as perceived health, health behavior and use of health-services, musculoskeletal complaints, somatic complaints, medical diagnoses and anxiety and depression) measured before the accident were associated with development of chronic whiplash. Study two investigated whether socio-demographic and health-related variables measured in individuals with whiplash were associated with recovery. Study three used prospective data from Denmark, following individuals with acute whiplash for a year. Coping and health care preferences reported during the first few days following the whiplash accident were described. The associations between early health care/coping preferences and outcome (neck pain/reduced capability to work) one year later were investigated. Results: The three studies in this thesis show that: Poor pre-injury health, both mental and somatic, is associated with development of chronic whiplash (study one). Similar health complaints reported among individuals with whiplash are associated with nonrecovery from the condition (study two). A high use of health care services and medications before the injury is associated with increased risk of developing chronic whiplash (study one). High use of health care and medications among individuals with whiplash is associated with non-recovery (study two). Patients’ coping preferences in the acute phase after whiplash injuries are associated with outcome in whiplash (study three): Reporting passive coping preferences and need of health care increase the risk of neck pain and reduced capability to work one year later. Individuals who prefer active coping and want to keep living as normal have a better prognosis. Conclusion: Chronic whiplash is a complex condition characterized by a broad range of complaints. Clinical imaging and accident related factors seem to be poor predictors of outcome. Poor pre-injury health and use of health services and medications are associated with subsequent chronic whiplash. Similar variables in individuals with whiplash are associated with non-recovery. Preferring use of health care and passive coping after whiplash is associated with non-recovery. As such chronic whiplash resembles functional somatic syndromes. Knowledge of prognostic factors might aid identification of individuals at risk of an adverse prognosis after whiplash, enabling earlier treatment for those most in need. However, health care in whiplash is often ineffective and might itself increase the risk of poor recovery. More research on treatment of whiplash is needed; in particular on whether targeting prognostic factors like those identified in this thesis can improve recovery

Long Waiting Times for Elective Hospital Care – Breaking the Vicious Circle by Abandoning Prioritisation

Background: Policies assigning low-priority patients treatment delays for care, in order to make room for patients of higher priority arriving later, are common in secondary healthcare services today. Alternatively, each new patient could be granted the first available appointment. We aimed to investigate whether prioritisation can be part of the reason why waiting times for care are often long, and to describe how departments can improve their waiting situation by changing away from prioritisation. Methods: We used patient flow data from 2015 at the Department of Otorhinolaryngology, Haukeland University Hospital, Norway. In Dynaplan Smia, Dynaplan AS, dynamic simulations were used to compare how waiting time, size and shape of the waiting list, and capacity utilisation developed with and without prioritisation. Simulations were started from the actual waiting list at the beginning of 2015, and from an empty waiting list (simulating a new department with no initial patient backlog).Results: From an empty waiting list and with capacity equal to demand, waiting times were built 7 times longer when prioritising than when not. Prioritisation also led to poor resource utilisation and short-lived effects of extra capacity. Departments where prioritisation is causing long waits can improve their situation by temporarily bringing capacity above demand and introducing “first come, first served” instead of prioritisation. Conclusion: A poor appointment allocation policy can build long waiting times, even when capacity is sufficient to meet demand. By bringing waiting times down and going away from prioritisation, the waiting list size and average waiting times at the studied department could be maintained almost 90% below the current level – without requiring permanent change in the capacity/demand ratio

Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial

Background In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC). Methods Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7). Outcomes: change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation. Results Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment. Conclusion As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.publishedVersio

Somatic symptoms beyond those generally associated with a whiplash injury are increased in self-reported chronic whiplash. A population-based cross sectional study: the Hordaland Health Study (HUSK)

Background Chronic whiplash leads to considerable patient suffering and substantial societal costs. There are two competing hypothesis on the etiology of chronic whiplash. The traditional organic hypothesis considers chronic whiplash and related symptoms a result of a specific injury. In opposition is the hypothesis that chronic whiplash is a functional somatic syndrome, and related symptoms a result of society-induced expectations and amplification of symptoms. According to both hypotheses, patients reporting chronic whiplash are expected to have more neck pain, headache and symptoms of anxiety and depression than the general population. Increased prevalence of somatic symptoms beyond those directly related to a whiplash neck injury is less investigated. The aim of this study was to test an implication derived from the functional hypothesis: Is the prevalence of somatic symptoms as seen in somatization disorder, beyond symptoms related to a whiplash neck injury, increased in individuals self-reporting chronic whiplash? We further aimed to explore recall bias by comparing the symptom profile displayed by individuals self-reporting chronic whiplash to that among those self-reporting a non-functional injury: fractures of the hand or wrist. We explored symptom load, etiologic origin could not be investigated in this study. Methods Data from the Norwegian population-based “Hordaland Health Study” (HUSK, 1997–99); N = 13,986 was employed. Chronic whiplash was self-reported by 403 individuals and fractures by 1,746. Somatization tendency was measured using a list of 17 somatic symptoms arising from different body parts and organ systems, derived from the research criteria for somatization disorder (ICD-10, F45). Results Chronic whiplash was associated with an increased level of all 17 somatic symptoms investigated (p<0.05). The association was moderately strong (group difference of 0.60 standard deviation), only partly accounted for by confounding. For self-reported fractures symptoms were only slightly elevated. Recent whiplash was more commonly reported than whiplash-injury a long time ago, and the association of interest weakly increased with time since whiplash (r = 0.016, p = 0.032). Conclusions The increased prevalence of somatic symptoms beyond symptoms expected according to the organic injury model for chronic whiplash, challenges the standard injury model for whiplash, and is indicative evidence of chronic whiplash being a functional somatic syndrome.publishedVersio

Alcohol consumption, life satisfaction and mental health among Norwegian college and university students

Objective: High-level alcohol consumption is common in, and central to, the student community. Among adults, high-level alcohol consumption, and sometimes also low, has been associated with poorer social integration and mental health. We aimed to investigate how alcohol consumption relates to life satisfaction and mental health among students in higher education. Methods: Data from the Norwegian study of students' health and well-being (SHoT, 2014, n = 9632) were used. Associations between alcohol consumption (AUDIT; abstainers, low risk, risky and hazardous consumption) and life satisfaction and mental health complaints, as well as number of close friends, and social and emotional loneliness were investigated using linear regression models. Crude models and models adjusted for age, gender and relationship status were conducted. Results: Students reporting hazardous consumption reported lower life satisfaction, more mental health complaints, and more emotional and social loneliness than students with low risk consumption. Students reporting risky consumption reported slightly reduced life satisfaction and more mental health complaints, but more close friends and less social loneliness. Abstainers did not report reduced life satisfaction or more mental health complaints, despite reporting fewer close friends and more social loneliness. Conclusion: High-level alcohol consumption among students might indicate increased risk of several problems in the future – but also currently. Our findings further imply that the quality of friendships might be more important for life satisfaction and mental health than the number of friends, but also that social integration in student communities might be more difficult for students who do not drink.publishedVersio

Long-term outcomes at 24- and 36-month follow-up in the intervention arm of the randomized controlled trial of Prompt Mental Health Care

Background: Whether long-term symptom improvement is maintained after treatment in services such as the Norwegian Prompt Mental Health Care (PMHC) and the English Improving Access to Psychological Therapies is not yet known. In this prospective study, we investigate whether improvements observed at 6-month follow-up are maintained at 24- and 36-month follow-up among clients who received PMHC. Method: Data from the treatment arm of the randomized controlled trial of PMHC were used (n = 459). The main outcomes were (reliable) recovery rate and symptoms of depression (PHQ-9) and anxiety (GAD-7). Primary outcome data at 24- and 36-months follow-up were available for 47% and 39% of participants, respectively. Secondary outcomes were work participation, functional status, health-related quality of life, and positive mental well-being. Sensitivity analyses with regard to missing data assumptions were conducted for the primary continuous outcomes. Results: Improvements were maintained at 24- and 36-month follow-up for symptoms of depression and anxiety, (reliable) recovery rate, and health-related quality of life. Small linear improvements since 6-month follow-up were observed for work participation, functional status, and positive mental well-being. Sensitivity analyses did not substantially alter the findings for symptoms of depression and anxiety mentioned above. Conclusions: Our findings support the long-term effectiveness of PMHC, but results should be interpreted with caution due to lacking follow-up data at 24- and 36-month in the control group, and substantial attrition.publishedVersio

Risky Drinking among Norwegian Students: Associations with Participation in the Introductory Week, Academic Performance and Alcohol-related Attitudes

AIMS – Substantial increase in heavy drinking upon transition from high school to college is common. Norwegian universities and university colleges arrange yearly introductory weeks to welcome new students. It has been questioned whether these events are too centered on alcohol. We aimed to investigate whether participation in the introductory week is associated with risky drinking (RD). We further aimed to investigate whether RD is associated with academic performance. Finally, we investigated whether alcohol-related attitudes are associated with both RD and introductory week participation. DESIGN – Data from the Norwegian study of students’ health and well-being (SHoT, 2014, n=13,663) were used. The odds ratio (OR) of RD was calculated for individuals having participated in the introductory week compared to others. Different measures of academic performance (having failed exams, study progression and study-related self-efficacy (SRSE)) were compared between individuals reporting RD compared to others. The association between attitudes and participation in the event and RD was investigated. RESULTS – Individuals having participated in the introductory week are more likely to report RD (OR (95%CI) = 2.41 (2.12-2.74)). Individuals reporting RD report lower SRSE and are more likely to have failed exams more than once. Study progression is unassociated with RD. Liberal alcohol-related attitudes are associated with participation in the event and RD. CONCLUSIONS – RD among students is associated with participation in the introductory week and with poorer academic performance. The university introductory week might be in danger of excluding individuals who do not drink much, or of promoting an unhealthy drinking culture among students.publishedVersio

Long Waiting Times for Elective Hospital Care – Breaking the Vicious Circle by Abandoning Prioritisation

Background: Policies assigning low-priority patients treatment delays for care, in order to make room for patients of higher priority arriving later, are common in secondary healthcare services today. Alternatively, each new patient could be granted the first available appointment. We aimed to investigate whether prioritisation can be part of the reason why waiting times for care are often long, and to describe how departments can improve their waiting situation by changing away from prioritisation. Methods: We used patient flow data from 2015 at the Department of Otorhinolaryngology, Haukeland University Hospital, Norway. In Dynaplan Smia, Dynaplan AS, dynamic simulations were used to compare how waiting time, size and shape of the waiting list, and capacity utilisation developed with and without prioritisation. Simulations were started from the actual waiting list at the beginning of 2015, and from an empty waiting list (simulating a new department with no initial patient backlog). Results: From an empty waiting list and with capacity equal to demand, waiting times were built 7 times longer when prioritising than when not. Prioritisation also led to poor resource utilisation and short-lived effects of extra capacity. Departments where prioritisation is causing long waits can improve their situation by temporarily bringing capacity above demand and introducing “first come, first served” instead of prioritisation. Conclusion: A poor appointment allocation policy can build long waiting times, even when capacity is sufficient to meet demand. By bringing waiting times down and going away from prioritisation, the waiting list size and average waiting times at the studied department could be maintained almost 90% below the current level – without requiring permanent change in the capacity/demand ratio

Long Waiting Times for Elective Hospital Care – Breaking the Vicious Circle by Abandoning Prioritisation

Background: Policies assigning low-priority patients treatment delays for care, in order to make room for patients of higher priority arriving later, are common in secondary healthcare services today. Alternatively, each new patient could be granted the first available appointment. We aimed to investigate whether prioritisation can be part of the reason why waiting times for care are often long, and to describe how departments can improve their waiting situation by changing away from prioritisation. Methods: We used patient flow data from 2015 at the Department of Otorhinolaryngology, Haukeland University Hospital, Norway. In Dynaplan Smia, Dynaplan AS, dynamic simulations were used to compare how waiting time, size and shape of the waiting list, and capacity utilisation developed with and without prioritisation. Simulations were started from the actual waiting list at the beginning of 2015, and from an empty waiting list (simulating a new department with no initial patient backlog). Results: From an empty waiting list and with capacity equal to demand, waiting times were built 7 times longer when prioritising than when not. Prioritisation also led to poor resource utilisation and short-lived effects of extra capacity. Departments where prioritisation is causing long waits can improve their situation by temporarily bringing capacity above demand and introducing “first come, first served” instead of prioritisation. Conclusion: A poor appointment allocation policy can build long waiting times, even when capacity is sufficient to meet demand. By bringing waiting times down and going away from prioritisation, the waiting list size and average waiting times at the studied department could be maintained almost 90% below the current level – without requiring permanent change in the capacity/demand ratio

Somatic symptoms beyond those generally associated with a whiplash injury are increased in self-reported chronic whiplash. A population-based cross sectional study: the Hordaland Health Study (HUSK)

Background Chronic whiplash leads to considerable patient suffering and substantial societal costs. There are two competing hypothesis on the etiology of chronic whiplash. The traditional organic hypothesis considers chronic whiplash and related symptoms a result of a specific injury. In opposition is the hypothesis that chronic whiplash is a functional somatic syndrome, and related symptoms a result of society-induced expectations and amplification of symptoms. According to both hypotheses, patients reporting chronic whiplash are expected to have more neck pain, headache and symptoms of anxiety and depression than the general population. Increased prevalence of somatic symptoms beyond those directly related to a whiplash neck injury is less investigated. The aim of this study was to test an implication derived from the functional hypothesis: Is the prevalence of somatic symptoms as seen in somatization disorder, beyond symptoms related to a whiplash neck injury, increased in individuals self-reporting chronic whiplash? We further aimed to explore recall bias by comparing the symptom profile displayed by individuals self-reporting chronic whiplash to that among those self-reporting a non-functional injury: fractures of the hand or wrist. We explored symptom load, etiologic origin could not be investigated in this study. Methods Data from the Norwegian population-based “Hordaland Health Study” (HUSK, 1997–99); N = 13,986 was employed. Chronic whiplash was self-reported by 403 individuals and fractures by 1,746. Somatization tendency was measured using a list of 17 somatic symptoms arising from different body parts and organ systems, derived from the research criteria for somatization disorder (ICD-10, F45). Results Chronic whiplash was associated with an increased level of all 17 somatic symptoms investigated (p<0.05). The association was moderately strong (group difference of 0.60 standard deviation), only partly accounted for by confounding. For self-reported fractures symptoms were only slightly elevated. Recent whiplash was more commonly reported than whiplash-injury a long time ago, and the association of interest weakly increased with time since whiplash (r = 0.016, p = 0.032). Conclusions The increased prevalence of somatic symptoms beyond symptoms expected according to the organic injury model for chronic whiplash, challenges the standard injury model for whiplash, and is indicative evidence of chronic whiplash being a functional somatic syndrome