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

2. 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

3. 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 Patient case 1

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, T52.2 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)??

10. 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 Patient case 2

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/s 2 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