Mottled Raynaud's phenomenon and hand-arm vibration syndrome: followed up for 10 years.

Vibration white finger is a form of secondary Raynaud's phenomenon (RP) caused by the use of handheld vibrating tools. RP usually appears on the extremities of the fingers, and its borders are well recognised. No reports have been published on 'mottled' RP in continuous observation from the onset to the disappearance of RP. A man in his 60s who had been using vibrating tools such as jackhammers and tampers for 30 years presented with sensations of coldness, burning and numbness. Whole-body cold exposure was performed outdoors in winter, and RP was photographed continuously. 'Mottled' RP can be defined as triphasic colour changes: white, blue and red. The patient was taken off work, kept warm and medicated. His symptoms improved slightly after 10 years of follow-up, but the RP did not disappear. 'Mottled' RP is rare and refractory and should be recognised as a form of RP.

A Study on Vascular Regulators as Early Biomarkers of Hand Arm Vibration Syndrome.

OBJECTIVES: Purposes of this study are to study the changes in expression of vascular regulators after vibration exposure and during the onset of vibration-induced white finger (VWF) and to screen for vascular regulatory factors that could be used as early biomarkers of HAVS. METHODS: Using judgmental sampling from a Chinese factory, workers with VWF and hand-transmitted vibration exposure but without VWF were selected for research. Blood samples were taken from all subjects, and the levels of nine of the vascular regulators were measured using ELISA. RESULTS: Receiver operating characteristic curve analysis was performed on nine vascular regulators to assess their diagnostic sensitivity for VWF with the following area under the curve results: PGI 2 = 0.861, ANP = 0.840. CONCLUSIONS: Collectively, PGI 2 and ANP exhibited the most potential for the early diagnosis of HAVS.

Vinculin Identified as a Potential Biomarker in Hand-Arm Vibration Syndrome Based on iTRAQ and LC-MS/MS-Based Proteomic Analysis.

Local vibration can induce vascular injuries, one example is the hand-arm vibration syndrome (HAVS) caused by hand-transmitted vibration (HTV). Little is known about the molecular mechanism of HAVS-induced vascular injuries. Herein, the iTRAQ (isobaric tags for relative and absolute quantitation) followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) proteomics approach was applied to conduct the quantitative proteomic analysis of plasma from specimens with HTV exposure or HAVS diagnosis. Overall, 726 proteins were identified in iTRAQ. 37 proteins upregulated and 43 downregulated in HAVS. Moreover, 37 upregulated and 40 downregulated when comparing severe HAVS and mild HAVS. Among them, Vinculin (VCL) was found to be downregulated in the whole process of HAVS. The concentration of vinculin was further verified by ELISA, and the results suggested that the proteomics data was reliable. Bioinformative analyses were used, and those proteins mainly engaged in specific biological processes like binding, focal adhesion, and integrins. The potential of vinculin application in HAVS diagnosis was validated by the receiver operating characteristic curve.

Concordance between the Stockholm Workshop Scale and the International Consensus Criteria for grading the severity of neurosensory manifestations in hand-arm vibration syndrome in a Swedish clinical setting.

OBJECTIVES: Occupational exposure to vibration using hand-held tools may cause hand-arm vibration syndrome (HAVS). Correct diagnosis and grading of severity are crucial in protecting the individual's health and for workers' compensation claims. The International Consensus Criteria (ICC) has been suggested to replace the widely used Stockholm Workshop Scale (SWS). The aims were to, in a clinical setting, assess the concordance between the SWS and the ICC neurosensory severity grading of vibration injury, and to present the clinical picture according to symptoms, type of affected nerve fibres and the relation between vascular and neurosensory manifestations. METHODS: Data were collected from questionnaires, clinical examination and exposure assessment of 92 patients with HAVS. The severity of neurosensory manifestations was classified according to both scales. The prevalence of symptoms and findings was compared across groups of patients with increasing severity according to the SWS. RESULTS: Classification with the ICC resulted in a shift towards lower grades of severity than with the SWS due to a systematic difference between the scales. Affected sensory units with small nerve fibres were far more prevalent than affected units with large nerve fibres. The most prevalent symptoms were numbness (91%) and cold intolerance (86%). CONCLUSIONS: Using the ICC resulted in lower grades of the severity of HAVS. This should be taken into consideration when giving medical advice and approving workers' compensation. Clinical examinations should be performed to detect affected sensory units with both small and large nerve fibres and more attention should be paid to cold intolerance.

Hand-arm vibration syndrome among harvesting farmers: A cross-sectional study from Pakistan.

BACKGROUND: Constant use of hand-held vibratory tools may cause health issues, including hand dysfunction, among farmers. Thus, exposure to these vibratory instruments may cause hand-arm vibration syndrome (HAVS). OBJECTIVE: The study aimed to measure the prevalence of HAVS and evaluate neurological and vascular symptoms among farmers. METHODS: This cross-sectional study included 20 villages in Pakistan and used a three-part questionnaire to collect data from farmers exposed to vibration while farming. The study included demographics, the Health Surveillance Questionnaire, and the Stockholm Workshop Classification Scale. SPSS version 22 was used for the data entry and statistical analysis. RESULTS: 433 (43%) participants had musculoskeletal discomfort and 568 (57%) had hand vibration. Raynaud phenomenon was evident in 430 (43%) participants, whereas carpal tunnel syndrome was found in 218 (22%). Tingling was reported by 255 participants (26%), and numbness was reported by 543 (54%). According to the grading of neurological symptoms, 461 (46%) participants were exposed to vibration but did not experience any symptoms, placing them in stage 0. 185 (18.5%) participants with HAVS with infrequent episodes affecting just the tips of one or more fingers were categorized in stage 01 based on grading of vascular symptoms. CONCLUSION: HAVS are common among harvesting farmers, with the most noticeable vibrations occurring in the shoulder region. Similarly, most farmers had no vascular symptoms, and most were exposed to vibration but had no neurological symptoms.

Evaluation of neurological testing for hand-arm vibration syndrome.

BACKGROUND: The neurological component of hand-arm vibration syndrome (HAVS) uses the Stockholm Workshop Scale sensorineural (SWS SN) stages for classification. Proximal compressive neuropathies are common in HAVS and the symptoms are similar to SN HAVS. The SWS may not be a valid staging tool if a patient has comorbid proximal compression neuropathy. AIMS: To evaluate the prevalence of proximal compression neuropathy in patients presenting for HAVS assessment and examine the association between compressive neuropathies and SWS SN. METHODS: A standardized assessment protocol was used to assess 431 patients for HAVS at St. Michael's Hospital, Toronto, Ontario. The prevalence of median and ulnar compressive neuropathies was determined. The association between proximal compression neuropathies and SWS SN stage (0/1 versus 2/3) was evaluated using Chi-square and Fisher's exact tests as well as multivariable logistic regression. RESULTS: Most patients (79%) reported numbness and 20% had reduced sensory perception (SWS SN Stage 2/3). Almost half (45%) had median neuropathy at the wrist and 7% had ulnar neuropathy. There was no association between the SWS SN stage and median or ulnar neuropathy. CONCLUSIONS: Two neurological lesions should be investigated in patients presenting for HAVS assessment: compressive neuropathy and digital neuropathy. The prevalence of compressive neuropathies is high in patients being assessed for HAVS and therefore nerve conduction studies (NCS) should be included in HAVS assessment protocols. Comorbid proximal neuropathy does not affect the SWS SN stage; therefore, NCS and SWS SN seem to be measuring different neurological outcomes in HAVS patients.

Cryoglobulins and cold agglutinins for hand arm vibration syndrome.

BACKGROUND: Hand arm vibration syndrome (HAVS) is a condition caused by hand transmitted vibration from the use of hand-held vibrating tools or workpieces. The disease affects the vascular, neurological and musculoskeletal systems. The vascular component of HAVS is a form of secondary Raynaud's phenomenon. Other causes of disease must be excluded before attributing the cause to hand transmitted vibration. AIMS: To evaluate the prevalence, and utility of testing for, cryoglobulins and cold agglutinins in patients with HAVS symptoms. METHODS: A retrospective cohort study of 1183 patients referred for HAVS clinical assessment at St. Michael's Hospital, Toronto, Canada, between 2014 and 2020. The standard operating procedure at the clinic includes a detailed clinical and exposure history, physical examination, objective investigations and blood tests. Data were retrieved from patient chart review and laboratory investigation results for all cases with cryoglobulin and cold agglutinin testing. RESULTS: A total of 1183 patients had a serum cryoglobulin measurement. Eleven patients (1%) were positive. Seven positive results were 'low titre' (1% positive) and the other four results were 2%, 6%, 9% and 18%. The patient with a 9% positive cryoglobulin titre had previously diagnosed Sjögren's syndrome. There were no positive cold agglutinin tests in the 795 patients tested. CONCLUSIONS: Routine testing for cryoglobulins and cold agglutinins in patients with HAVS symptoms is not recommended because test positivity rates are negligible. Testing may be considered if the clinical history or routine blood investigations suggest evidence of underlying cryoglobulinaemia or cold agglutinin disease.

The clinical consequence of using less than four sensory perception examination methods in the Swedish surveillance system for Hand-Arm vibration syndrome.

OBJECTIVES: The Swedish surveillance system aiming to reveal undetected Hand-Arm Vibration Syndrome (HAVS) in workers exposed for vibrations is regulated by the provision AFS 2019:3. The goal for the surveillance system is to diagnose HAVS, as well as to find workers at risk for developing HAVS due to other conditions. The national guidelines stipulate examination using at least two out of four hand sensory examination methods (SEM); monofilament (touch), two-point discrimination (discriminative), tuning fork (vibrotactile), and Rolltemp (thermotactile). The aim of this study was to examine the clinical consequence of using less than four of these SEMs. METHODS: We collected data on SEMs from the medical records of all individuals that went through the specific surveillance medical check-up in a large occupational health service for 1 year. We then calculated the number of workers found with HAVS when using one, two, or three SEMs, and compared with the result from using all available SEMs. RESULTS: Out of 677 examined individuals, 199 had positive findings in at least one SEM. The detection rate for these findings was on average 47% when using one SEM, 71% using two SEMs, and 88% using three SEMs (out of 100% detection when all four SEMs were used). CONCLUSIONS: If fewer than four sensory examination methods are used for surveillance of HAVS, many workers with incipient injuries may stay undetected. This may lead to further exposure resulting in aggravation of injury.

Effect of the level of manual performance disability caused by exposure to vibration among sailors working on sailing speed vessels.

BACKGROUND: hand-arm vibration is one of the typical annoying physical factors. Hand-arm vibration syndrome (HAVS) is a disorder caused by vibrating working tools which vibrate hands beyond the threshold. Long-term HAVS may result in damage to blood vessels, chronic numbness in the fingers, bone injury, and muscular weakness. People are exposed to high-rate noise vibration in a variety of situations, including vessel employment and operating in tiny boats. Moreover, the extant study was conducted to examine manual function disability levels caused by Sailing Speed Vessels (SSV) vibration. METHODS: The extant study was quasi-experimental research in which, 52 male sailors in SSVs were chosen as the experimental group, and 27 office personnel were selected as the control group. The demographic factors questionnaire, DASH questionnaire, grip and pinch strength tests, the neurosensory exam, and the skill-dexterity test were all employed in this study. SPSS23 software was used to analyze the data. RESULTS: The findings suggested that the experimental group experienced greater vibration disorder symptoms than the control group. Because the experimental group had a higher score, the individuals experienced poorer circumstances in terms of arm, shoulder, and hand impairment as compared to the control group. The mean grip strength of hands and fingers in two hands of the experimental group was lower than the control group (P < 0.05). There was a statistically significant relationship among grip strengths of both experimental and control groups (P < 0.05). There was a reduction in skill and dexterity of both dominant and non-dominant hands of members in the experimental group. According to the statistical tests, there was no significant association between dominant (P = 0.001) skills and non-dominant (P = 0.010) hands in experimental and control groups. There was not also any significant relationship between skill and dexterity of both hands (P = 0.001) and the dominant hand tweezer test (P = 0.001) in two experimental and control groups. There was a statistically significant association between experimental and control groups in terms of assembly skill and dexterity (P = 0.482). CONCLUSION: Individuals who are at risk of vibration experience less physical and sensory function. DASH score, grip strength, skill, and dexterity could predict the reduction in physical function disability.

Carpal tunnel syndrome and Raynaud's phenomenon: a narrative review.

BACKGROUND: Raynaud's phenomenon (RP) is a recognized symptom associated with carpal tunnel syndrome (CTS) and is also the vascular manifestation of hand arm vibration syndrome (HAVS). The symptoms of HAVS and CTS are such that there is a significant possibility of misdiagnosis and an incorrect attribution of vascular and sensory symptoms. An understanding of the relationship between RP and CTS is essential when undertaking health surveillance of vibration-exposed workers presenting with combined vascular and sensory symptoms. AIMS: To clarify the relationship between CTS and Raynaud's phenomenon. METHODS: A systematic search was undertaken of studies that reviewed links between CTS and Raynaud's phenomenon (RP). RESULTS: A total of 4170 papers were identified, with 21 articles that were then reviewed in full, including 1 meta-analysis of 8 studies. Eighteen papers, not included in the meta-analysis, were found including 3 case control studies, 9 case reports, 2 prospective studies and 4 retrospective reviews. Papers were reviewed on the basis of the diagnostic criteria used for CTS and RP. Our review of the literature confirms a substantial body of evidence of a relationship between RP and CTS. CONCLUSIONS: It is recommended that assessment of vibration exposed individuals who report concurrent RP and separate sensory symptoms suggestive of, or compatible with CTS, should formally exclude CTS before attributing symptoms to HAVS.

Serum Metabolites in Hand-Arm Vibration Exposed Workers.

OBJECTIVE: To investigate whether low molecular organic biomarkers could be identified in blood samples from vibration exposed workers using a metabolomics. METHODS: The study population consisted of 38 metalworkers. All participants underwent a standardized medical examination. Blood samples were collected before and after work shift and analyzed with gas chromatography time-of-flight mass spectrometry. Multivariate modeling (orthogonal partial least-squares analysis with discriminant analysis [OPLS-DA]) were used to verify differences in metabolic profiles. RESULTS: Twenty-two study participants reported vascular symptoms judged as vibration-related. The metabolic profile from participants with vibration-induced white fingers (VWF) was distinctly separated from participants without VWF, both before and after vibration exposure. CONCLUSION: Metabolites that differed between the groups were identified both before and after exposure. Some of these metabolites might be indicators of health effects from exposure to vibrations. This is the first time that a metabolomic approach has been used in workers exposed to vibrations.

Sensory perception testing by monofilaments in the digits of controls and workers with HAVS.

OBJECTIVE: To determine if heavy manual work affects sensory perception in the digits and whether Semmes-Weinstein monofilaments (SWM) can be used as a screening tool to detect sensory neuropathy in the digits of workers exposed to hand-transmitted vibration (HTV). METHODS: A cross-sectional study of office workers, heavy manual workers not exposed to HTV and workers with hand-arm vibration syndrome (HAVS). Sensory perception was measured in the digits by SWM using a forced-choice method to determine variability by sex, age, hand and digit. Frequency distributions were used to determine limit values and linear weighted kappa for intra-digit variability. Poisson regression was used to explore the relationship between sensory perception by SWM and abnormalities of thermal and vibration perception in the hands of workers with HAVS. RESULTS: The sensory perception threshold of office workers did not vary by hand or digit. It was significantly lower in women < 30 than women aged ≥ 30 years. The 95th percentile for heavy manual workers was 1.00 (95% CI 0.60-1.00) and significantly higher than for office workers at 0.16 (95% CI 0.16-0.16). Heavy manual workers > 50 years had the highest threshold at 1.40 (95% CI 1.00-2.00). Weighted kappa for reliability was 0.63 (95% CI 0.53-0.70). A mean SWM threshold of ≥ 1.0 gram-force had a 79% sensitivity and 64% specificity for detecting abnormalities of thermal and vibration perception in the ipsilateral index and little fingers of workers with HAVS. CONCLUSIONS: SWM are a useful screening tool for detecting sensory loss in the digits of workers exposed to HTV.

[New international criteria for evaluating vascular hand-arm vibration risk and staging and-arm vibration syndrome]. / Nuovi criteri internazionali per la valutazione del rischio vascolare e la stadiazione clinica della sindrome da vibrazioni mano-braccio.

SUMMARY: Recently, a supplementary methodology to improve the assessment of occupational exposures to hand-transmitted vibration (HTV) and a revision of the clinical staging of the hand-arm vibration syndrome (HAVS) have been proposed. The Technical Report ISO/TR 18570:2017 provides guidance on a supplementary method to that defined in ISO 5349-1:2001 for measuring and reporting HTV exposures; the method provides an improved assessment methodology for evaluating vascular hand-arm vibration risks (vibration induced white finger). On using a Delphi procedure, an international panel of experts has achieved consensus to develop an updated staging system for the vascular and neurological disorders of the HAVS, previously defined in the Stockholm Workshop Scale (1986); a new classification has been proposed with three stages for vibration related vascular and neurological effects. This paper provides details on the new international criteria for the assessment of vibration induced vascular risk and for the clinical staging of the vascular and neurological components of the HAVS.

International consensus criteria for diagnosing and staging hand-arm vibration syndrome.

PURPOSE: In the 30 years since the Stockholm Workshop Scale (SWS) was published, the scientific literature on hand-arm vibration syndrome (HAVS) has grown and experience has been gained in its practical application. This research was undertaken to develop an up-to-date evidence-based classification for HAVS by seeking consensus between experts in the field. METHODS: Seven occupational physicians who are clinically active and have had work published on HAVS in the last 10 years were asked to independently take part in a three-round iterative Delphi process. Consensus was taken when 5/7 (72%) agreed with a particular statement. Experts were asked to provide evidence from the literature or data from their own research to support their views. RESULTS: Consensus was achieved for most of the questions that were used to develop an updated staging system for HAVS. The vascular and neurological components from the SWS are retained, but ambiguous descriptors and tests without adequately developed methodology such as tactile discrimination, or discriminating power such as grip strength, are not included in the new staging system. A blanching score taken from photographs of the hands during vasospastic episodes is recommended in place of self-recall and frequency of attacks to stage vascular HAVS. Methods with the best evidence base are described for assessing sensory perception and dexterity. CONCLUSIONS: A new classification has been developed with three stages for the clinical classification of vascular and neurological HAVS based on international consensus. We recommend it replaces the SWS for clinical and research purposes.

Raising awareness of hand-arm vibration syndrome (HAVS) using posters.

BACKGROUND: Hand-arm vibration syndrome (HAVS) is caused by prolonged occupational exposure to hand-transmitted vibration. Although HAVS is preventable, disease awareness and prevention knowledge are lacking in high-risk workplaces; this may contribute to under-diagnosis, delays in seeking care, and poor health outcomes. Posters may be used to increase awareness in the workplace. OBJECTIVE: To conduct a pilot survey in workers with HAVS about poster use in their workplaces, their recommendations for poster campaigns and training programs, and their evaluation of HAVS awareness and prevention posters. METHODS: All eligible HAVS patients in the Occupational Health Clinic at St. Michael's Hospital, in Toronto, Canada, were asked to complete a questionnaire on workplace poster use and to evaluate a set of HAVS posters. RESULTS: Fifty workers participated; almost all were males, aged 50 and older, working in construction. Most indicated having non-HAVS specific awareness posters in their workplaces. There was a positive evaluation of the design, content, and potential usefulness of the posters. The poster depicting finger blanching stood out most. The poster depicting anti-vibration gloves rated highest for relatability and effectiveness at conveying disease importance. CONCLUSIONS: Participants supported the proposed use of industry-specific HAVS awareness posters in their workplaces. Future research should evaluate the effectiveness of these posters in the workplace.

Síndrome vibratorio mano-brazo: revisión literaria / Hand-arm vibratory syndrome: literary review

Resumen El síndrome vibratorio mano-brazo forma parte de la categoría de enfermedades ocupacionales o asociadas al trabajo, específicamente aquellos trabajos manuales en los que se utilicen herramientas vibratorias, como taladros, moledoras, martillos neumáticos, sierras y cualquier otra que transmita energía vibratoria directamente a la mano y brazo del trabajador. La descripción de los primeros casos de este síndrome tuvo lugar hace ya más de un siglo, y con el desarrollo industrial se volvió progresivamente, en una entidad más importante en cuanto a la discapacidad y la pérdida de calidad de vida que genera en los pacientes, así como las pérdidas económicas y de horas laborales que produce a nivel mundial, en especial en los países más desarrollados en donde su prevalencia es notablemente mayor. En el presente artículo se ha realizado una revisión literaria acerca de los principales signos y síntomas de esta enfermedad, su clasificación, fisiopatología y métodos de diagnóstico. También se abordarán los mecanismos de prevención así como el pronóstico y evolución de los pacientes una vez han sido diagnosticados.

Abstract Hand-arm vibration syndrome is part of the occupational or work-related illness category, specifically those manual workers using vibratory tools such as drills, grinders, pneumatic hammers, saws and any other tool that transmits vibratory energy directly to the Hand and arm of the worker. The description of the first cases of this syndrome took place more than a century ago, and with the industrial development it became progressively, in a more important entity as far as the disability and the loss of quality of life that generates in the patients, As well as the economic losses and hours of work that it produces worldwide, especially in the more developed countries where its prevalence is significantly higher. In this article a literary review has been carried out on the main signs and symptoms of this disease, its classification, pathophysiology and diagnostic methods. The mechanisms of prevention as well as the prognosis and evolution of the patients once they have been diagnosed will also be addressed.