The clinical assessment of hand-arm vibration syndrome.

Vibration injury to the hands was first reported in 1911 in workers using compressed air tools [1]. Since then, mechanization has become more widespread, with a corresponding rise in the incidence of vibration injuries. Employers, legislators, machinery and tool manufacturers, and physicians in general have all been slow to recognize and effectively address the problem. Fortunately, some tool manufacturers in recent years have modified their tools to partially attenuate vibration transmission, and legislators have introduced safety guidelines, e.g. Health & Safety Executive (HSE) HS(G)88, and regulations to encourage recognition and reduction of the risk from vibration exposure at work. The recently published EU Directive 2002/44/EC on the minimum health and safety requirements regarding the exposure of workers to the risks arising from vibration (hand–arm and whole-body) [2], with specified exposure action and limit values, is very welcome. This, together with an HSE regulation to follow in 2005, will increase public knowledge and should result in less vibrationinduced injuries. Workers’ compensation schemes allowing vibration injury claims are ongoing, and lawyers have become increasingly interested and active on behalf of clients [3–5]. However, the uncertainty of diagnosis and lack of uniformity in the examination of subjects exposed to hand-transmitted vibration continue to be a matter of concern to many occupational and family physicians, employers, lawyers, and not least the worker who has developed symptoms. Numerous clinical and laboratory tests have evolved and become available over the years to assist physicians to evaluate the three components of hand–arm vibration syndrome (HAVS)—vascular, sensorineural and musculoskeletal—as defined by an international group who met in London in 1983 [6]. The tests vary from very simple to highly sophisticated, and their use is dependent on many factors, e.g. examination or screening time, the circumstances, need, availability and cost. Hence, inevitably, there has been a lack of uniformity on the tests that examining physicians use. The initial screening examination of a subject may be limited satisfactorily to the use of a history questionnaire to determine the symptoms and the nature of the vibration exposure, a clinical examination of the upper torso and some simple subjective tests. However, there is a need to exclude other possible causes of the symptoms and to verify the preliminary diagnosis. In these circumstances, blood analyses and the use of sophisticated subjective and objective tests in a hospital or special clinic are necessary to make an authoritative diagnosis and to grade severity accurately. Such an evaluation is essential for cases seeking compensation if both parties in the dispute are to be well served. Most patients referred to a hospital usually circulate between vascular, orthopaedic or hand surgeons, rheumatologists, neurologists and perhaps others, each one in turn offering an opinion on the presumed occupational disease without any clear understanding of the patient’s occupational environment or vibration exposure. Although consultants in these various specialities, by virtue of their specialist knowledge, have a contribution to make on the interpretation of the results of diagnostic tests conducted within their departments, the ultimate consultant to finalize the diagnosis of HAVS should be an experienced occupational physician or vascular surgeon with a special interest in this occupational disease. Regrettably, few countries in the world have centres of excellence staffed by occupational physician specialists for the examination of cases with vibration injuries. Because of the need to process quickly the >120 000 coal miners claiming compensation, the UK Department of Trade & Industry (DTI) established between 1998 and 2001 some 18 regional assessment centres, staffed predominantly by family physicians and ancillary staff. Unfortunately, anomalies in the screening process and the limited use of laboratory tests—all subjective except one vascular test, which was abandoned