Cold Provocation Test Research Articles

Significance of finger coldness in hand-arm vibration syndrome

To evaluate the relationship between subjective symptoms of coldness in fingers and peripheral circulation in patients with hand-arm vibration syndrome (HAVS). Thirty-five male patients confirmed to have HAVS as an occupational disease took part in this study. Their mean age was 62 years (SD 5) and all were chain-saw operators exposed to vibration for an average of 25 years. Their annual health examination included the history of their daily habits (smoking, drinking, and therapeutic exercise), report of subjective symptoms such as coldness, numbness and tingling in the fingers, and a physical examination; laboratory tests consisted of skin temperature measurement, and pain and vibration perception under conditions of cold provocation. A frequently used method of cold provocation, immersion of the left hand up to the wrist in water of 10°C for 10 min, was used. Finger coldness was classified into 3 groups according to its severity: mild group (n=8), moderate group (n=17) and severe group (n=10). There was no significant difference in age or occupational background between the groups. A significant association was found between finger coldness and prevalence of Raynaud's pheno menon (p<001, χ(2)). The mean skin temperature was significantly lower with the severity of finger coldness (ANOVA, p<0.05). In the cold provocation test, there was no significant difference between skin temperature and coldness at 5 min and 10 min after immersion, though a difference was observed immediately after immersion. No significant difference was observed in the relationship between finger coldness and vibrotactile threshold before, during or after the cold provocation test. The severity of coldness in the fingers is significantly related to skin temperature. The severity of finger coldness reflects the extent of peripheral circulatory vasoconstriction. Coldness in the fingers may be a good warning of potential problems in peripheral, circulatory function.

Preliminary Study on the Assessment of Peripheral Vascular Response to Cold Provocation in Workers Exposed to Hand-Arm Vibration Using Laser Doppler Perfusion Imager

Measurements of changes in finger skin blood flow with laser Doppler perfusion imaging (LDPI) in response to cold provocation test (10 degrees C, 10 min) were performed in 12 men suffering from vibration induced white finger (VWF) and 13 exposed controls. The mean perfusion values in both groups reduced markedly as a result of immersion of the hand in cold water. In the controls, however, the mean value increased gradually until the end of the cold provocation, while that in the VWF subjects remained at the lowest level. After removal of the hand from the cold water, the skin blood perfusion in the controls recovered rapidly and nearly reached the baseline value. In the VWF subjects, it had a slight increase immediately following the cold immersion but no tendency to rise as the time span increased. Analysis of covariance controlling for possible confounders revealed that the VWF subjects had significantly lower perfusion values compared to the controls in the last several minutes of the cold provocation and the following recovery. These findings suggest that the LDPI technique enables visualizing and quantifying the peripheral vascular effects of cold water immersion on the finger skin blood perfusion and thus has the potential of providing more detailed and a&curate information that may help detect the peripheral circulatory impairment in the fingers of vibration-exposed workers.

Diagnostic Significance of Cold Provocation Test at 12°C

Diagnostic Significance of Cold Provocation Test at 12°C

The diagnostic value of finger systolic blood pressure and cold-provocation testing for the vascular component of hand-arm vibration syndrome in health surveillance

Hand-arm vibration syndrome (HAVS) is a complex condition with vascular, sensorineural and musculoskeletal components. A number of quantitative tests have been used for assisting in the diagnosis of HAVS and grading disease severity. To investigate and compare the diagnostic value of finger systolic blood pressure (FSBP) and rewarming of finger skin temperature (FST) following cold-provocation testing, in the assessment of vascular HAVS. Twenty-four individuals with vascular HAVS (Stockholm Workshop stage 2 or 3V) and 22 control subjects underwent FSBP measurements at 30, 15 and 10 degrees C and monitoring of FST following immersion of the hands in water at 15 degrees C for 5 min. There was a significant reduction in median FSBP% in the vascular HAVS group in the change in FSBP from 30 to 15 degrees C adjusted for brachial blood pressure (FSBPC%). There was no difference in the median time for FST to rewarm by 4 degrees C between HAVS cases and controls. The sensitivity and specificity of FSBP to discriminate between the groups varied between 44 and 61% and 91 and 95%, respectively. The sensitivity and specificity for the time for FST to rewarm by 4 degrees C were 71 and 77%. There is little evidence that the described form of finger rewarming after cold-provocation testing is a useful diagnostic test for vascular HAVS, although it may have some moderate influence in ruling out vascular problems. Based on our data, the FSBP may also have limited use in confirming a positive diagnosis of vibration-induced vascular problems. The higher specificity of the FSBP test suggests it may have some value in ruling out the vascular component of HAVS. The data from this study do not confirm the diagnostic power of FSBP for the vascular component of HAVS reported by a few other investigators.

Author's reply: Cold provocation testing and hand-arm vibration syndrome – an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners (Br J Surg 2003; 90: 1076 – 1079)

Author's reply: Cold provocation testing and hand-arm vibration syndrome – an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners (<i>Br J Surg</i> 2003; 90: 1076 – 1079)

A medical assessment process for a large volume of medico-legal compensation claims for hand-arm vibration syndrome.

The judgement on preliminary issues of nine lead cases of suspected hand-arm vibration syndrome (HAVS) in former coal miners in the UK ruled that there was evidence of damage and breach of duty of care (Armstrong and Others v. British Coal, 1996). In anticipation of > 120 000 cases and at significant cost, a handling agreement was prepared in 1999. This recommended a single medical assessment process (MAP) to determine general damages for which almost 200 doctors attended 2 days of training. This paper outlines the assessment process and the results to date. Seventeen test centres across the UK were commissioned. Standardization of the performance by both the doctors and technicians within individual examination centres and across all centres was necessary. A pragmatic solution using 'best available assessment techniques', whilst at the same time coping with the large number of claimants, was required. Doctors were trained to administer questionnaires for clinical symptoms, past medical history and occupational history, and a standardized clinical assessment pro-forma. Three standardized tests were used: vibrotactile thresholds, thermal aesthesiometry and cold water provocation testing. A modification of the Stockholm Workshop Scales and scoring system was adopted. At time of writing, 52 490 claimants had been assessed by the MAP. Analysis of results showed that 5% were assessed at 0SN, 15% at 1SN, 18% at 2SN (early), 28% at 2SN (late), 33% at 3SN, 21% at 0V, 13% at 1V, 38% at 2V and 28% at 3V. It is concluded that the MAP is a practical and time-efficient tool for assessing a large volume of claimants with suspected HAVS. Further analysis of the process and staging is required to confirm its validity as a medico-legal examination.

Cold provocation testing and hand-arm vibration syndrome--an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners.

Hand-arm vibration syndrome (HAVS) is a major industrial disease that causes considerable morbidity among workers exposed to vibration. Compensation is paid to those affected in civil claims against employers and (in the UK) in claims made under Social Security legislation rules for Prescribed Disease A11. Diagnostic tests have been proposed but most are not objective. The cold provocation test (CPT), which is objective, is often included in the evaluation of HAVS. A continuous audit was made of the findings recorded at the 18 HAVS test centres in the UK established to evaluate miners. The audit, and its outcome, were monitored by the Medical Reference Panel who advise the Department of Trade and Industry. This audit report constitutes the second analysis of the findings relating to the CPT. The CPT, with measurement of digital rewarming times, is of no value in assessing vibration-induced damage to the hands. In its present format, the CPT should not be used for evaluating the vascular component of HAVS.

Diagnostic aspects of vibration-induced white finger.

Vibration-induced white finger (VWF) is a secondary type of Raynaud's phenomenon (RP) caused by exposure to hand-arm vibration. The present review concerns the cold-provoked attack of RP in vasospastic VWF. It concentrates on the most common clinical and laboratory methods used to diagnose RP in vibration-exposed subjects. Some physiological aspects of the attack of RP are mentioned to elucidate the diagnostic principles of the tests. Anamnestic diagnostics by medical interviews and questionnaires as well as cold-provocation tests with detection of finger colour, finger systolic blood pressure (FSP), recovery time of finger skin temperature and recovery time of normal nail colour after nail compression are mentioned. The discriminative capacity and the reproducibility of the tests are discussed. Cold-provocation tests with detection of finger colour or zero FSP during cooling are recommended to be used if an attack of RP has to be registered for diagnostic or medico-legal purposes in individual cases. An abnormal reduction in FSP during cooling makes a history of RP very probable and is a suitable laboratory test for groups of subjects. Both recovery tests may be useful screening tests in field studies of vibration-exposed subject groups.

Evaluation of Finger Skin Temperature by Cold Provocation Test for Diagnosis of Hand-Arm Vibration Syndrome

Evaluation of Finger Skin Temperature by Cold Provocation Test for Diagnosis of Hand-Arm Vibration Syndrome

Raynaud’s phenomenon in idiopathic carpal tunnel syndrome

In a previous study the prevalence of Raynaud’s phenomenon (RP) in patients with idiopathic carpal tunnel syndrome (CTS) was found to be 60% which is much higher than that in the general population. We undertook a further study of the same cohort of patients have both CTS and RP and who had an open release of the carpal tunnel, to observe the effects of the operation on RP. We observed whether the symptoms of RP improved, and repeated the cold provocation tests to see if the arterial pulse which was decreased before operation would recover. We rated the outcome as good when the patients showed both an improvement of the symptoms of RP and a normal pulse amplitude after exposure to cold, fair when the pulse amplitude recovered to more than two-thirds of that before exposure, and poor when cold hypersensitivity was persistent or showed the same degree of decreased pulse amplitude as observed before operation. Of the 18 patients with both conditions, ten (56%) had good and four (22%) fair results, with a mean recovery time of 4.2 months (6 weeks to 1 year) after operation. If the vasospasm seen in RP is an expression of vasomotor irritation in the carpal tunnel, these findings suggest that local compression of vasomotor fibres in the carpal tunnel can also be relieved by the release of this structure. Careful consideration, however, is still required in treating patients with both conditions since in some cases. RP may be superimposed or it may have other origins.

Raynaud's phenomenon in idiopathic carpal tunnel syndrome

In a previous study the prevalence of Raynaud's phenomenon (RP) in patients with idiopathic carpal tunnel syndrome (CTS) was found to be 60% which is much higher than that in the general population. We undertook a further study of the same cohort of patients have both CTS and RP and who had an open release of the carpal tunnel, to observe the effects of the operation on RP. We observed whether the symptoms of RP improved, and repeated the cold provocation tests to see if the arterial pulse which was decreased before operation would recover. We rated the outcome as good when the patients showed both an improvement of the symptoms of RP and a normal pulse amplitude after exposure to cold, fair when the pulse amplitude recovered to more than two-thirds of that before exposure, and poor when cold hypersensitivity was persistent or showed the same degree of decreased pulse amplitude as observed before operation. Of the 18 patients with both conditions, ten (56%) had good and four (22%) fair results, with a mean recovery time of 4.2 months (6 weeks to 1 year) after operation. If the vasospasm seen in RP is an expression of vasomotor irritation in the carpal tunnel, these findings suggest that local compression of vasomotor fibres in the carpal tunnel can also be relieved by the release of this structure. Careful consideration, however, is still required in treating patients with both conditions since in some cases. RP may be superimposed or it may have other origins.

Cross sectional study of a workforce exposed to hand-arm vibration: with objective tests and the Stockholm workshop scales

OBJECTIVESMedical surveillance of workforces exposed to vibration has been recommended with the Stockholm workshop scales. The aims of this study were (a) to evaluate how the results of the objective...

Prevalence of Raynaud’s phenomenon in patients with idiopathic carpal tunnel syndrome

Both idiopathic carpal tunnel syndrome (CTS) and Raynaud’s phenomenon (RP) are common, and may have similar clinical symptoms. The degree of their coexistence is uncertain. We have examined 30 patients, who were diagnosed clinically and electromyographically as having idiopathic CTS, for the presence of RP using a cold provocation test with photoplethysmography. The patients’ hands were exposed in water at 10°C for five minutes. A total of 18 patients (60%) was found to have RP; this is much greater than would be expected from the prevalence in the general population. Raynaud’s phenomenon should be considered when treating patients with CTS because of the possibility of coexistence and the similar symptoms of these two disorders.

Prevalence of Raynaud's phenomenon in patients with idiopathic carpal tunnel syndrome.

Both idiopathic carpal tunnel syndrome (CTS) and Raynaud's phenomenon (RP) are common, and may have similar clinical symptoms. The degree of their coexistence is uncertain. We have examined 30 patients, who were diagnosed clinically and electromyographically as having idiopathic CTS, for the presence of RP using a cold provocation test with photoplethysmography. The patients' hands were exposed in water at 10 degrees C for five minutes. A total of 18 patients (60%) was found to have RP; this is much greater than would be expected from the prevalence in the general population. Raynaud's phenomenon should be considered when treating patients with CTS because of the possibility of coexistence and the similar symptoms of these two disorders.

A four-year follow-up study on subjective symptoms and functional capacities in workers using hand-held grinders.

Fifty-three grinders in the metal industry were re-examined 4 years after their first examination. Information about age, occupation, daily vibration exposure, drinking and smoking habits, and presence of subjective symptoms such as vibration-induced white finger (VWF), and numbness and pain in the fingers was collected during the first and second examination. Cold provocation test (10 degrees C/10 min) was also employed to evaluate disturbances in the peripheral circulatory and peripheral nerves in all subjects. The frequency-weighted vibration acceleration of various types of hand-held tools was measured. There was no subject with VWF at the first examination; however, during the course of follow-up, two cases (3.8%) of VWF with latent interval of more than 25 years were diagnosed. Prevalence of numbness in the fingers and shoulder stiffness was significantly higher at the second examination. When the prevalence of subjective symptoms was tested by the subjects' total operating time (TOT) during the 4-year follow-up period, those whose TOT was equal to or more than 2500 hours showed higher prevalence compared to the other subgroup. The paired values of recovery rate of finger skin temperature and vibration sensation threshold after the cold water immersion test were significantly different at the first and second examination. On average, the diminution of hand-grip force during the 4-year follow-up course was 7.4%; the difference being significant at 0.01 level. Significant differences in the paired data of pinching power and tapping ability could be detected. The frequency-weighted vibration acceleration of various tools was in the range of 1.1-4.6 m/s2. It was concluded that: (1) prolonged occupational exposure to the vibration of hand-held grinding tools should be considered as a risk factor causing disturbances in the hand-arm system of the operators; (2) the results of recovery rate of finger skin temperature and the vibration sensation threshold seemed to be appropriate indicators for the assessment of peripheral vascular and peripheral nerve disturbances in workers exposed to hand-arm vibration; and (3) to reduce the subjects' physical stress, attention should be paid to ergonomic factors.

A prospective study of the cold response of digital vessels in forestry workers exposed to saw vibration.

To investigate the occurrence of vibration-induced white finger (VWF) and the cold response of digital vessels in a group of 68 forestry workers who underwent a first clinical examination in 1990 and were then reexamined in 1995. The forestry workers were divided into three groups: group A (n = 27), active workers who did not have VWF in 1990 and continued to use chain saws; group B (n = 29), workers who did not have VWF in 1990 and retired before 1995; and group C (n = 12), active or retired workers who had VWF in 1990. The subjects underwent a medical interview, a complete physical examination, and a cold provocation test, which were performed by the same physicians at both surveys. The cold test consisted of measurement of the finger systolic blood pressure (FSBP) after local cooling to 10 degrees C, expressed as a percentage of the pressure recorded at 30 degrees C (FSBP%10 degrees). Three new cases of VWF occurred during the follow-up period among workers who had used only antivibration (AV) chain saws. The vasoconstrictor response to cold was unchanged in group A and improved in group B (P < 0.001). A significant decrease in VWF symptoms and abnormal response to cold was observed in group C (P < 0.05). As a result of preventive measures curtailing saw usage time in the VWF workers, the daily vibration exposure in group C was lower in 1995 than in 1990 (P = 0.02). In the retired workers, FSBP%10 degrees was positively related to the time since the cessation of work with chain saws (P < 0.01). The findings of this follow-up study indicate that a reduction in or cessation of exposure to vibration has a beneficial effect on finger-blanching symptoms and the cold response of digital vessels. The occurrence of new cases of VWF in subjects whose work experience was limited to AV chain saws argues for the maintenance of health surveillance in these workers.

Evaluation of finger skin temperature by cold provocation test for diagnosis of vibration induced white finger (VWF).

Clinical data of workers (40-69 yrs) operating chain saws for a ten-year period from 1986 to 1995 were analyzed to assess the evaluation standard of finger skin temperature for a cold provocation test (10 degrees C 10 min). Screening points of finger skin temperature for screening 191 workers with a vibration induced white finger (VWF) were obtained from receiver operating characteristic (ROC) curves. The screening points at 5 min and 10 min after a cold provocation were approximately equal to 50th percentiles of 217 workers with no symptoms (NS group). The screening points of recovery rates at 5 min and 10 min after a cold provocation almost agreed with 50th percentiles in NS group. A new evaluation standard was prepared in reference to these screening points and finger skin temperatures by fraction in NS group. The new one will be useful for the health care of workers operating vibrating tools under present working conditions.

Is vibration-induced white finger a reversible syndrome if vibration is stopped?

The purpose of the study was to investigate if vibration-induced white finger may be a reversible symptom after cessation of vibration exposure. Fifty-nine welders, previously employed by a ship building company and who had shown various levels of vibration-induced vasospastic symptoms in the hand were interviewed 5 to 6 years after closure of the company. Out of the 43 patients exposed to no or insignificant vibration subsequently, 28 claimed improvement, 11 claimed unchanged problems and four complained of worse problems. Twelve of these patients had the cold provocation test repeated at follow up. One patient showed the same result as 5 years earlier, six showed improvement and five showed much improvement. Of 16 patients with continued vibration exposure none showed subjective improvement, nine claimed unchanged problems while seven patients were worse. It is concluded that vibration-induced white finger is not a progressive condition following cessation of exposure to vibration. On the contrary it may be static or even reversible to some extent.

Diagnostic value of finger thermometry and photoplethysmography in the assessment of hand-arm vibration syndrome.

Digital photoplethysmography and skin thermometry are both measures of circulation in the skin of the fingers. These methods and a cold provocation test were performed on 29 chain-saw workers grouped in stages 0, 1, 2, or 3 according to the Stockholm Workshop scale of hand-arm vibration syndrome, and on 16 controls. The reduction of photoplethysmographic amplitude after the cold test reflects the degree of vasoconstriction, and the recovery rate demonstrates passive vasodilatative capacity. Both tests were found to distinguish all vibration--exposed subjects, including those without clinically manifest vibration-induced white fingers, from the controls. With a 75% reduction in photoplethysmographic amplitude as a discriminating threshold, the sensitivity for the detection of Raynaud's phenomenon was 62% and the specificity, 87%. The discriminating threshold of 90% for recovery rate yielded a sensitivity of 69% and a specificity of 72%.

Hand-arm vibration syndrome among travertine workers: a follow up study.

In a six year follow up study of the handarm vibration syndrome, 62 stoneworkers operating hand held vibrating tools in 10 travertine quarries and mills were first investigated in 1985 and then in 1991. The frequency weighted acceleration of vibration from the rock drills and stone hammers used by the travertine workers exceeded 20 m/s2, indicating a hazardous work activity according to the proposal of the EC directive for physical agents. A clinical examination and a cold provocation test were repeated with the same procedures as those adopted at the time of the first survey. The stoneworkers were divided into groups according to current work state: active stoneworkers who continued to use powered tools during the follow up (n = 21, median exposure time 22 years), and ex-stoneworkers with retirement vibration free intervals of three years (n = 22, median exposure time 27.5 years) and of six years (n = 19, median exposure time 20 years). In the group of active stoneworkers, a 38% onset a new cases of vibration-induced white finger (VWF) was found during the follow up (p < 0.01). Among the retired stoneworkers affected with VWF (n = 24), one recovered from VWF, one showed improvement, 20 remained stationary, and two deteriorated. The ex-stoneworkers experienced no significant change in sensorineural disturbances and a decrease in musculoskeletal symptoms of the upper limbs. At the cold provocation test, the currently active stoneworkers with VWF showed, on a group basis, a delayed finger rewarming time between the two examinations (p = 0.002). An abnormal response to cold provocation persisted in the fingers of the ex-stoneworkers with VWF, even in those reporting subjective improvement. These findings indicate a tendency towards the irreversibility of sensorineural and VWF symptoms in a group of ex-stoneworkers with prolonged exposure to high vibration levels in the past. The increased occurrence of VWF in the active stone workers after a few extra years of vibrating tool usage argues for an urgent implementation of preventive measures in the stone industry.