Occupational

vibration syndrome: Patient cases

Department of Occupational Medicine Finnish Institute of Occupational Health Markku Sainio Markku Vanhanen

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

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

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

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

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

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

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

Conclusion

– Traumatic vasospastic syndrome, T52.2

Carpal tunnel syndrome, G56.0

Polyneuropathy 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)??

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

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/s 2 sufficient to cause VWF. The use of the vibrator causes more vibration to the left hand.

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

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

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

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