Epidemiology

The number of new recorded cases of vibration white finger (VWF) assessed for Industrial Injuries Disability Benefit was 1045 in 2009/2010 - increased from 850 in 2008/2009.^[2] However, in 2004 the Department for Work and Pensions recommended that the condition include sensorineural symptoms which precede vascular changes. This extension to the eligibility criteria was formally accepted by the Government in 2007, resulting in an increase in claims in that year to 1,005. The Medical Research Council survey of 1997-1998 gave a prevalence estimate of 288,000 sufferers from VWF in Great Britain, of whom 255,000 were males and 33,000 females.^[3] In the past, numbers claiming compensation have been considerably swollen by former coal miners. A study in 1995 estimated that 3.8 million working days were lost in Britain in 1995 due to a musculoskeletal disorder affecting the upper limbs or neck.^[4] 

Risk factors

An essential risk factor is the use of vibrating tools. This is a sine qua non for any industrial claim. Frequencies ranging from 2 to 1500 Hz are potentially damaging but the most serious is the 5 to 20 Hz range. This may be a pneumatic drill, hammer drill, chainsaw or many other implements.^[5] Other risk factors are said to be beta-blockers, cigarette smoking and exposure to cold.^[6] The evidence with regard to smoking may be inconclusive but smoking is known to have an adverse effect on circulation. Vascular features are more common in a cold and damp climate. It is substantially a male disease but this probably reflects employment practices rather than predisposition. As a general rule, if caught early and effective action taken to prevent further insult, recovery will occur; however, it may not in advanced cases.

It is unusual for VWF to present in less than 10 years' exposure and duration and intensity of exposure are certainly risks. A study of Swedish car mechanics confirmed this but found that quite brief exposure to vibration each day was enough to induce the disease.^[7]

Presentation^[3][5][8]

The main features are neurological and vascular.

• Neurological features - responsible for the subjective numbness, tingling and pain and the neurological signs of sensory deficits, especially to fine touch discrimination and temperature. There is also reduced manual dexterity and muscle weakness with impaired strength of grip. 
• Vascular features are blanching of the fingers, especially after exposure to cold and with delayed or poor recovery thereafter. This is a secondary Raynaud's phenomenon and patients often report white fingers in the morning or after outdoor activity.
• There may be other manifestations from damage to bone and muscle. Dupuytren's contracture can result from cumulative trauma to the palm of the hand. Other effects that have been reported include exostoses and cysts in carpal bones, carpal tunnel syndrome and osteoarthritis.

For diagnosis, the following are required:^[9]

• Evidence of long-term exposure to vibration.
• Episodes of digital pallor, with or without confirmed sensorineural effects.
• Exclusion of other causes of Raynaud's phenomenon or sensory changes.
• Diagnosis would be supported by finding of associated musculoskeletal features, calluses on the hand, loss of sensation in the digits affected and muscle weakness. These may not be apparent in the early stages of disease.

Differential diagnosis

• Raynaud's disease
• Scleroderma
• Buerger's disease
• Hypothenar hammer syndrome^[10]
• Rheumatoid arthritis
• Thoracic outlet syndrome^[11]

Investigations^[9]

There is controversy about the interpretation of some tests for the purposes of industrial compensation, so a number of standardised investigations should be used.^[12] Tests available include:

• The vibrotactile threshold test, which is used to test the mechanoreceptors. They respond to stretch, edge and texture and the receptors respond at different frequencies. Measurements are taken from the median nerve (index finger) and the ulnar nerve (little finger) in each hand at two frequencies.
• The thermal aesthesiometry test, which assesses the thermal receptors' threshold. Readings are again taken from the median nerve and the ulnar nerve.
• The Purdue Pegboard test, which is a measure of dexterity and detects loss of fine movement to both hands.
• The grip force measurement test, which measures the grip strength of both hands. This test is not scored but is a useful indication of vibration damage to muscles of the hand and forearm.
• In addition, tests may be used to assess the vascular component. Finger systolic blood pressure measurement follows cooling of the digits and measures interruption of blood flow in response to cold. When interpreting results it should be noted that there is a difference in pressure between the dorsal and palmar surfaces of the hand.^[13]
• The cold provocation test, which provides visual evidence of blanching.

In 1999 a large number of coal miners needed assessment to provide evidence for legal proceedings. Pragmatically, it was considered that a symptomatic history, occupational history and a combination of vibrotactile thresholds, thermal aesthesiometry and cold water provocation testing would be sufficient to diagnose most cases.^[14]

Staging

The Stockholm system is used to grade severity:

Sensorineural component

• 0SN - exposed to vibrations but no symptoms.
• 1SN - intermittent numbness +/- tingling.
• 2SN - numbness (intermittent or continuous) with loss of feeling of touch.
• 3SN - numbness (intermittent or continuous) with loss of discrimination by touch +/- manual dexterity.

Vascular component

• Stage 1 - mild, with only occasional attacks affecting the tips of one or more fingers.
• Stage 2 - moderate, with occasional attacks affecting the distal or middle phalanges of one or more fingers.
• Stage 3 - severe, with frequent attacks affecting all phalanges of most fingers.
• Stage 4 - very severe, as Stage 3, plus trophic changes in fingertips.

Terminology

The hazard to health from vibration is usually assessed from the average acceleration level of the vibrating surface. A weighting is applied to take into account the variation in damage at different frequencies to give a frequency-weighted acceleration 'A' normally expressed in m/s². If the implement is to be used for up to four hours a day this is called the A4 and, for up to eight hours a day, the A8.^[15]

Management

Nondrug

Eliminate the source of vibration if possible or consider redeployment, keeping the body warm, and stopping smoking.^[16] Apply the principles outlined under 'Prevention', below.

Drugs

These have little part to play. Nifedipine or another calcium-channel blocker may be useful. Iloprost has been reported as promising in advanced disease.^[17]

Prognosis^[5][15][18]

HAVS can have a considerable impact on the quality of life (eg, pain, difficulties with daily activities, anxiety and depression).^[19] Early redeployment can halt or reverse progression of symptoms but, in severe cases, these continue even after removal of the source of vibration.^[20] A longitudinal study from Japan found that the earlier the disease, the more likely recovery was to occur. Continued use of vibrating tools was a bad prognostic feature but age, medical history and smoking seemed to have no effect.^[15][21] 

Prevention

If possible, a different technique should be used to avoid the exposure to vibration. Tools must be well-maintained. Several antivibration gloves are available commercially but their effectiveness in work situations is difficult to determine. Field trials suggest that what protection they might afford is not universally applicable across all occupations and they can be uncomfortable to wear.^[22] They should be changed when wet. Duration of exposure should be minimised and frequent breaks taken. For those at risk, periodic assessment is advised.

The Control of Vibration at Work Regulations 2005, which came into force in July 2005, placing a legal obligation on employers to assess and identify measures to eliminate or reduce risks from exposure to hand-arm vibration, ensure that control measures to reduce vibration are properly applied, and that information, training and health surveillance are provided.^[23]