Hand Arm Vibration Syndrome

Synonyms: HAVS, vibration white finger, VWF

Hand arm vibration syndrome results from many years of use of vibrating tools. It is classified as an industrial disease. It became a prescribed industrial disease in 1985. This means that those who suffer may be able to claim compensation under the industrial injuries scheme but only those with more severe disease and those in specified industries are able to benefit. Initially only the vascular component was recognised but the neurosensory component was included in 2007 (see Epidemiology, below). Further information should be available from the trade union, local Citizens Advice Bureau, local Health and Safety Executive (HSE) area office or the Environmental Health Department of the local council.

Disability is not limited to time at work or when using these tools but can interfere with hobbies and recreation.

Research suggests a role for the vasopeptide endothelin.¹

The number of new recorded cases of vibration white finger (VWF) assessed for Industrial Injuries Disability Benefit was 645 in 2005/2006 - down from 865 in 20004/2005. This was the lowest number of new cases in the last ten years.² However, in 2004 the Department for Work and Pensions recommended that the condition included sensorineural symptoms. 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 4.2 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 betablockers, 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.^7,8 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 but it may not in advanced cases.

It is unusual for vibration white finger (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.⁹

The main features are vascular and neurological.

• Vascular features are blanching of the fingers, especially after exposure to cold and with delayed or poor recovery thereafter. This is Raynaud's phenomenon, of which hand arm vibration syndrome (HAVS) is just one of many causes. Patients often report white fingers in the morning or after outdoor activity.
• Neurological features are 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.
• 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:¹¹

• 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.

• Raynaud's disease
• Scleroderma
• Buerger's disease
• Hypothenar hammer syndrome¹³
• Rheumatoid arthritis
• Thoracic outlet syndrome¹⁴

There is controversy about the interpretation of some tests for the purposes of industrial compensation, so a number of standardised investigations should be used.¹⁵ 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 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.¹⁶
• The cold provocation test 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.¹⁷

The Stockholm system is used to grade severity:

Vascular component

• Stage 1 - mild, with only occasional attacks affecting tips of one or more fingers
• Stage 2 - moderate, with occasional attacks affecting 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

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

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 4 hours a day this is called the A4 and for up to 8 hours a day the A8.¹⁹

Nondrug

Eliminate the source of vibration if possible or consider redeployment, keeping the body warm, stopping smoking.²⁰ 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.²¹

Hand arm vibration syndrome (HAVS) can have a considerable impact on the quality of life (e.g. pain, difficulties with daily activities, anxiety and depression).²³ Early redeployment can halt or reverse progression of symptoms but, in severe cases, these continue even after removal of source of vibration.²⁴ A longitudinal study from Japan found that the earlier the disease the more likely was recovery to occur. Continued use of vibrating tools was a bad prognostic feature but age, medical history and smoking seemed to have no effect.^7,19

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.²⁵ 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.²⁶

1. Bovenzi M, D'Agostin F, Rui F, et al; Salivary endothelin and vascular disorders in vibration-exposed workers. Scand J Work Environ Health. 2008 Apr;34(2):133-41. [abstract]
2. HSE; Health and Safety Executive. Prescribed industrial diseases; non-lung diseases in England, Wales and Scotland by disease
3. Palmer K, Coggon D, Bendall H et al; Hand-transmitted Vibration: Occupational exposures and their health effects in Great Britain HSE 1999
4. Work-related Upper Limb Disorders Statistics Information Sheet; Health and Safety Consultancy Ltd 2006.
5. The Highland Council; Guidance Notes on Hand-Arm Vibration Control 2007
6. Occupational Health Clinics for Ontario Workers Inc; Hand-Arm Vibration Syndrome. 2007
7. Ogasawara C, Sakakibara H, Kondo T, et al; Longitudinal study on factors related to the course of vibration-induced white finger. Int Arch Occup Environ Health. 1997;69(3):180-4. [abstract]
8. Ekenvall L, Lindblad LE; Effect of tobacco use on vibration white finger disease. J Occup Med. 1989 Jan;31(1):13-6. [abstract]
9. Barregard L, Ehrenstrom L, Marcus K; Hand-arm vibration syndrome in Swedish car mechanics. Occup Environ Med. 2003 Apr;60(4):287-94. [abstract]
10. Guide to good practice on Hand-Arm Vibration; EU Good Practice Guide 2006.
11. Pelmear PL; The clinical assessment of hand-arm vibration syndrome. Occup Med (Lond). 2003 Aug;53(5):337-41.
12. Millar J; Vibration Syndrome 1983
13. Cooke RA; Hypothenar hammer syndrome: a discrete syndrome to be distinguished from hand-arm vibration syndrome. Occup Med (Lond). 2003 Aug;53(5):320-4. [abstract]
14. Cooke RA; Thoracic outlet syndrome--aspects of diagnosis in the differential diagnosis of hand-arm vibration syndrome. Occup Med (Lond). 2003 Aug;53(5):331-6. [abstract]
15. Harada N, Mahbub MH; Diagnosis of vascular injuries caused by hand-transmitted vibration. Int Arch Occup Environ Health. 2008 Apr;81(5):507-18. Epub 2007 Sep 26. [abstract]
16. Mahbub MH, Harada N; Digital blood flow and temperature responses in palmar and dorsal skin induced by Int Arch Occup Environ Health. 2008 Jul;81(7):889-97. Epub 2007 Dec 5. [abstract]
17. Lawson IJ, McGeoch KL; A medical assessment process for a large volume of medico-legal compensation claims for hand-arm vibration syndrome. Occup Med (Lond). 2003 Aug;53(5):302-8. [abstract]
18. Gemne G, Pyykko I, Taylor W, et al; The Stockholm Workshop scale for the classification of cold-induced Raynaud's phenomenon in the hand-arm vibration syndrome (revision of the Taylor-Pelmear scale). Scand J Work Environ Health. 1987 Aug;13(4):275-8. [abstract]
19. HSE; Control the Risks from Hand-Arm Vibration. Health and Safety Executive 2005
20. Falkiner S; Diagnosis and treatment of hand-arm vibration syndrome and its relationship to carpal tunnel syndrome. Aust Fam Physician. 2003 Jul;32(7):530-4. [abstract]
21. Meloni M, Torrazza M, Ledda R; Effectiveness of therapy with iloprost in hand-arm vibration syndrome. Occup Med (Lond). 2004 Jun;54(4):261-4. [abstract]
22. Weir E, Lander L; Hand-arm vibration syndrome. CMAJ. 2005 Apr 12;172(8):1001-2.
23. Sauni R, Virtema P, Paakkonen R, et al; Quality of life (EQ-5D) and hand-arm vibration syndrome. Int Arch Occup Environ Health. 2009 Jul 11. [abstract]
24. Friden J; Vibration damage to the hand: clinical presentation, prognosis and length and severity of vibration required. J Hand Surg (Br). 2001 Oct;26(5):471-4. [abstract]
25. Pinto I, Staachini N, Bovenzi M et al.; Protection effectiveness of anti-vibration gloves: field evaluation and laboratory performance assessment Vibration Injury Network 2001.
26. HSE; Health and Safety Executive - Advice for Employers (2007).

• Trade Union Congress; Construction Information Sheet: Vibration White Finger 2004.
• Hand arm vibration; HSE 2009; Advice for Employers.
• Department for Work and Pensions; Report by the Industrial Injuries Advisory Council in accordance with Section 171 of the Social Security Administration Act 1992 reviewing the prescription of the vascular and sensorineural components of Hand-Arm Vibration Syndrome 2004.