Patient-related aspects on WAD

University dissertation from Stockholm : Karolinska Institutet, Department of Clinical Neuroscience

Abstract: Forces acting on the neck at a motor vehicle accident (MVA) can result in soft tissue injuries, commonly considered as "whiplash injuries", with different clinical manifestations, Whiplash Associated Disorders (WAD). The pathogenesis of WAD is obscure and the diagnosis is mainly based on history and symptoms. There is no known effective treatment and the human suffering and the socio-economic burden due to WAD are obvious. The Quebec Task Force proposed a WAD-classification of injury severity and a follow up schedule in 1995. We investigated the predictive value of the classification proposed by the Quebec Task Force. The results indicate that female gender, neck or shoulder pain before the accident and self reported emotional distress at the time of the accident were significant risk factors for chronic neck pain. The WAD classification and the follow-up regimen had no predictive value. Coping can be defined as making purposeful efforts to manage or counteract the negative impact of stress. The different coping strategies in the acute phase after the injury were recorded using the Coping Strategies Questionnaire (CSQ). However the CSQ did not appear to be appropriate for predicting chronic symptoms. Psychological factors have been reported to be a consequence of chronic pain rather than a causative factor. We investigated psychiatric morbidity by comparing a group of patients with chronic symptoms after a whiplash injury to an age and gender matched control group of fully recovered persons. We used the Structured Clinical Interview (SCID), which is a rigorous psychiatric tool that has not been used in WAD-studies before. The results indicate that persons developing chronic symptoms after this type of injury more often had a history of psychiatric illness, especially depression, than those without persisting symptoms. The immune system is known to be affected by trauma but the possible involvement of the immune system during the disease process in WAD is not known. Effector molecules including chemokines and their receptors could play a role in WAD. We studied the immune response in blood mononuclear cells (MNC) from patients in the acute phase after a whiplash injury (WAD) and, for reference, patients with ankle sprain, patients with multiple sclerosis (MS) and healthy subjects. Enzyme-linked immunospot (ELISPOT) assays were used to examine numbers of MNC secreting certain proand anti-inflammatory cytokines. The acute WAD patients showed a systemic increase of the proinflammatory TNFalpha and IL-6 and of anti-inflammatory IL-10; these cytokine alterations became normalized after 14 days. Control patients with ankle sprain showed cytokine profile changes similar to those observed in the WAD group, when examined within 3 days after trauma, implicating that measurements of the cytokines under study (IL-6, IOL10, TNFalpha and INFgamma) do not discriminate between these two types of minor trauma. In contrast, there were no differences for cytokine profiles between patients with WAD examined 14 days after the whiplash injury and healthy subjects. A further study of the systemic immune response was done in patients who had an acute whiplash injury (measured within three days after the trauma and again after 14 days) and for reference, in healthy controls. Flow cytometry was used to study percentages of mono-nuclear(MNC) and CD3+T cells expressing certain chemokines and the chemokine receptor CCR-5. In conclusion we found a systemic dysregulation in percentages of RANTES and CCR-5 expressing MNC and T cells. However the changes were transient which was considered to be in accordance with a posttraumatic reaction from a minor trauma.

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