Occupational vibration syndrome: Patient cases

1. Occupational vibration syndrome:Patient cases Department of Occupational Medicine Finnish Institute of Occupational Health Markku Sainio Markku Vanhanen

2. Patient case 1 • Male forest worker, age 56 years sent to FIOH (9/02) by the insurance company because occupational disease had been suspected • After operation of bilateral carpal tunnel sdrs in 2/01 the numbness and clumsiness have not relieved (slightly progressed) and he is not able to return to work

3. Patient case 1 • Symptoms: • From the 80’s hands/feet cold sensitive, then finger tips occasionally white/cold/numb • At present, in cold, all fingers including thumbs from MCP-joints onwards and IV-finger numb • Induced by cold weather (< +15 deg) provoked by dampness even after 0,5 min exposure • WF symptoms relieve quickly in warm • Also for many years upper extremity numbness/tingling and clumsiness • Hands are constantly clumsy and weak • Upper extremity numbness provoked often at nights and driving a car

4. Exposure • From age 15 (excluding one army year) daily occupational use of chain saw in forest work • 7-8 hours/day upto 7 days/week about 9 months/year • Also, use of chain saw at free time • Held saw with both hands; right handed • Saws were with handle warming and vibration damping since it has been available

5. Differential diagnosis I • Previous health: • In youth, joint ache, but no disease in investigations • Since (~20 years) often aching joints in extremities, also low back and neck-shoulder region pain • Since 1999 investigations due to low back pain, pain of left upper extremity and the neck-shoulder region • No regular medication • Possible freezing of the extremities • No previous Raynaud • Depressed since divorce in 2001 • No smoking, alcohol use minimal, no family history of neurological or rheumatic disease

6. Differential diagnosis II • Previous studies: • X-ray revealed degenerative changes at lumbar region and age-normal cervical spine • ENMG revealed sensorimotor polyneuropathy, slowing down of median nerve conduction times at the carpal tunnel • etiology of polyneuropathy unknown (lab, x-ray chest, ultrasound of stomach normal) • depression • --> fibromyalgia, polyneuropathy NAS, depression => both carpal tunnels operated

7. Differential diagnosis III • Studies at FIOH 9/02-10/02: • Status: cardiovascularly (incl capillary circulation at nails, BP in both arms) normal, Carpal tunnel operation scars, Duputren’s conracture in IV-flexors • X-ray hands/wrists: degenerative changes at right wrist • Fysiatrist’s examination: work related findings in hands, but also age related changes in the back • Neurologist’s status: cold feet and fingers until MCP, mild hypesthesia by vibration in fingers and feet, and by sharp in feet

8. Differential diagnosis IV • Studies at FIOH 9/02-10/02: • Lab: La, CRP, Hb, leuk, MCV, tromb, liver ents, TSH, gluk, Kryoglobulin, RF, B12-vit, folate, ENA-ab norm • Finger pletysmography: Already at room temperature BP lower in right III-finger and at 17 deg BP drops to undetectable-->diagnostic to vasospasm • ENMG: Mild polyneuropathy. Some post operative improvement in median nerve conduction velocities. Both ulnar and median nerve conduction slower in right hand especially to the V finger. • Quantitative sensation thresholds: poly- and thinfiber neuropathy in all extremities

9. Conclusion • Traumatic vasospastic syndrome, T52.2Carpal tunnel syndrome, G56.0Polyneuropathy levis • Occupational VWF disease, including carpal tunnel syndrome, notice to the register of occupational diseases • Prevention of vibration and cold exposure in the future, not able to continue as a forest worker • professional rehabilitation not likely • Compensation from the insurance company (usually max 10% invalidity)??

10. Patient case 2 • Male carpenter, age 40 years sent to FIOH by a specialist in occupational medicine • Symptoms: • 1,5 years ago in autumn at first cold weathers left index finger occasionally white/cold/numb and stiff/painful • at first distal from the DIP- and now distal PIP-joint • induced by cold weather and also often by vibration • relieves under warm water • not able to work in cold weather, but with work arrangement, no sick leaves

11. Exposure • From age 16 use of different vibrating tools, altogether 23 years • before 1987: chain saw, concrete and soil vibrators, different grinding machines, pneumatic hammers • 1 - 8(-12) hours/day • after 1987: used more carpenter’s hand tools • 4 hours/day • Held to tools with both hands; right handed • Industrial hygienist: daily vibration before 1987 >5m/s2 sufficient to cause VWF. The use of the vibrator causes more vibration to the left hand.

12. Differential diagnosis I • Social anamnesis: • tobacco: 20 years, stopped for 4,5 years, now 10 cigarettes/day • alcohol: 24 bottles beer and 2 bottles of wine /month • Family history: • father carpenter with similar exposure, but no VWF, but rheumatic arthritis at age 70 • mother has hypertension

13. Differential diagnosis II • Previous health: • At age 15 fracture of right metacarpal V • 3 years ago traumatic work related distension in right shoulder; cuff rupture in MRI; operation soon • shoulder pain and arm numbness working arms in upright position and often at night numbness of IV-V fingers • No regular medication • No freezing of the extremities, no previous Raynaud • Previous studies: X-ray of left fingers normal, ENMG (upper extremities and left leg) relative slowing down in median nerve conduction times at the carpal tunnel, no polyneuropathy

14. Differential diagnosis III • Studies at FIOH 1/03-5/03: • Status (in January): cardiovascularly normal, left index finger more pale, colder and more hypesthetic than other fingers • Neurologist’s status: normal • Lab: La, CRP, Hb, leuk, MCV, tromb, liver ents, TSH, gluk, Kryoglobulin, RF, B12-vit, folate, ENA-ab norm • Finger pletysmography: Already at room temperature BP lower in left II-finger and at 18 deg BP drops to undetectable-->diagnostic to vasospasm • Fysiatrist’s examination: right shoulder abduction reduced to 80 deg, otherwise normal status

15. Conclusion • Traumatic vasospastic syndrome, T52.2 • Occupational disease, notice to the register of occupational diseases • Prevention of vibration and cold exposure in the future • Compensation from the insurance company (max 10% invalidity) • Clinical control at FIOH in 1 year