1. HAND-ARM VIBRATION SYNDROME (HAV) Results from exposure to vibration (4 to 5000 Hz); Time exposure:one month to 30 years

2. HAV: Symptoms / Signs: Circulatory (vasospasm) with local finger blanching); previously known as: vibration-induced white finger

3. HAV: First noticed on cold, wet, and windy morning, in the tips of the fingers most affected by vibration. Intermittent numbness or tingling often precedes actual blanching. Vasospasm rarely symmetrical, and reflects the subject’s grip on the vibrating tool. With continued exposure, vasospasm progresses proximally, and to other fingers. In advanced cases: cyanotic tinge, progressing to trophic skin changes (gangrene). Worse in smokers.

4. HAV: Symptoms / Signs - continued : Sensory & motor disturbances  numbness, loss of finger co-ordination and dexterity;  inability to perform intricate tasks. Musculoskeletal disturbances

5. TABLE 1 : Some tools associated with HAVs SANDER / BUFFERS:  Orbital sanders  Oscillating (jitter-bug)  Rotary burrs  Floor polishers / buffers GUNS:  Hilte  Rivetting  Chipping  Fettling  Needle  Kango GRINDERS:  Pedestal grinders  Disc grinders  Swing-beam grinders  Angle grinders  Straight grinders  Orthodontic DRILLS:  Jack-leg  Stoper  Plugger  Jack hammer  Spade  Diamond  Dental

6. TABLE 1 : Some tools associated with HAVs- continued OTHER:  High pressure hoses  Swaging  Vibrating pokers (concrete)  Grass trimmers SAWS:  Chain  Brush  Band  Concrete  Block IMPACT:  Wrenches  Pneumatic screwdrivers  Pneumatic knives

7. Some occupations associated with HAVs and type of tool Saws, screwdrivers, wrenches & needle guns  Carpenters Block saws  Bricklayers Wrenches, screwdrivers, Grinders, sanders, buffers & pneumatic knives  Autobody shop workers Wrenches, screwdrivers. Grinders, sanders & buffers  Assembly workers - aircraft - vehicle TYPE OF TOOLSOCCUPATIONS

8. Some occupations associated with HAVs and type of tool - continued Grinders (various), fettling & chipping guns  Foundry men Chainsaws, & brush saws  Foresters Hilte guns, & screwdrivers  Electricians Drills (various)  Die shop workers Guns (various), jack hammers, & vibrating pokers  Construction workers TYPE OF TOOLSOCCUPATIONS

9. Some occupations associated with HAVs and type of tool - continued Drills (various)  Miners Grinders, & impact wrenches  Millwrights Wrenches, & grinders  Mechanics Jack hammers, vibrating pokers, & concrete saws  Labourers Wrenches, grinders (various)  Iron workers TYPE OF TOOLSOCCUPATIONS

10. Some occupations associated with HAVs and type of tool - continued Grinders & fettling tools  Welders Rivetting guns & wrenches  Rivetters Handles & tongs  Press operators Hilte guns  Pipe Fitters TYPE OF TOOLSOCCUPATIONS

11. HAV: Diagnosis: Based on history, and on exclusion of other causes of Raynaud’s phenomenon:  primary Raynaud’s or constitutional white finger,  local trauma to digital vessels,  thoracic outlet syndrome,  peripheral vascular disease,  collagen diseases.

12. HAV: Laboratory tests: Doppler studies (for patency of limb blood vessels and blood pressure ratios in peripheral vessels);

13. HAV: Laboratory tests: Doppler studies Blood pressure of an affected digit pre- and post- cold stress), and cold air or water provocation tests (immersion of the digits in water or air for 2 to 10 minutes at 5 to 15 C with recording of skin temperature) to note any reactive hyperaemia while immersed, and delay in recovery afterwards.

14. HAV: Laboratory tests: Doppler studies Blood pressure of an affected digit pre- and post- cold stress), and cold air or water provocation tests Nerve conductions studies.

15. The Stockholm Workshop Scale for the Classification of Sensorineural Affects of the Hand-arm Vibration Syndrome Intermittent or persistent numbness, Reduced tactile discrimination and / or Manipulative dexterity. 3 SN Intermittent or persistent numbness, reduced sensory perception. 2 SN Intermittent numbness, with or without tingling. 1 SN Exposed to vibration but no symptoms.0 SN SYMPTOMSSTAGE The sensorineural stage to be established for each hand.

16. The Stockholm Workshop Scale for the classification of Cold-Induced Raynaud’s Phenomenon in the Hand-arm Vibration Syndrome As in stage 3, with trophic skin changes in the finger tips. Very Severe 4 Frequent attacks affecting all phalanges of the most fingers. Severe3 Occasional attacks affecting distal and middle (rarely also proximal) phalanges of one or more fingers. Moderate2 Occasional attacks affecting only the tips of one or more fingers Mild1 No attacks.0 DESCRIPTIONGRADESTAGE The staging is made separately for each hand. In the evaluation of the subject, the grade of the disorder is indicated by the stages of both hands and the number of affected fingers on each hand; example “2L(2) / 1R(1)”, “- / 3R(4)”, etc.

17. Management: Smoking cessation; Decrease or avoid exposure to vibration; Hold tools as lightly as possible, to decrease vibration transmission; Decrease vibration at source (anti vibration tools and proper servicing of tools; Ergonomic design (minimize strain on user):  high power to weight ratio;  low torque;  non-slip surface of handles to reduce the need to grip tightly.

18. Pharmacotherapy: Calcium channel blockers. ________ 1.Pelmear PL: Hand-Arm Vibration Syndrome. Mastromatteo Oration 1998. Annual Scientific Conference, OEMAC, October 6, 1998.