Stockholm Workshop Scale Research Articles

Vocational rehabilitative decisions after symptoms and findings consistent with hand-arm vibration syndrome in the Swedish surveillance system – a mixed-method design

BackgroundEU workers exposed to hand-arm vibration should be offered health surveillance to detect early symptoms, and findings, of Hand-Arm Vibration Syndrome (HAVS). To execute the mandatory vocational rehabilitation, the employer needs to be aware of injuries found in the medical check-up. We aimed to analyse: 1) How physicians graded the neurosensory component of HAVS on the Stockholm Workshop Scale (SWS), compared to semi-objective findings. 2) What vocational rehabilitative decisions (VRD) were taken by physicians after examinations. 3) Whether the VRDs differed in relation to the SWS-grading.MethodsData came from 660 medical records - all examinations performed during twelve consecutive months in one large Swedish occupational healthcare company. 572 individuals had data on the SWS from the physician. For the qualitative analysis, we used the inductive-iterative immersion-crystallization method.Results60% of the examined workers had symptoms and 32% had semi-objective findings consistent with HAVS. The physicians’ SWS gradings were underestimated in 59% of the cases with semi-objective findings. The VRDs were classified, relative to communication with the employer, as: “Adequate” (57%), when no injury was present, communication had already taken place, was planned, or was no longer needed in the absence of further exposure, “Semi-adequate” (18%), if no plan for communication was yet established or only communicated through a document with a shorter time until next check-up, and “Inadequate”(25%), when patients refused (20%), or physicians failed to communicate with the employer, despite findings (80%). Underestimated SWS-gradings of HAVS were significantly associated with more “Inadequate” VRDs in the group with semi-objective findings.ConclusionsOccupational physicians underestimate the number of individuals with SWS 2–3 compared with semi-objective findings and regularly fail to communicate to the employer despite findings of HAVS. The underestimation of SWS-grading, followed by inadequate VRDs, excludes many workers from the employer’s mandatory protective measures which may lead to aggravation of an untreatable injury in the affected individual and development of HAVS in their similarly exposed colleagues.

Effect Of Neurodynamic Mobilization On Reducing Sensori neural Symptopms In Dawung Village Wood Craftsmen With The Risk Of Hand Arm Vibartion Syndrome (HAVS)

Hand Arm Vibration Syndrome (HAVS) is a disease caused by working with tools that produce vibrations that are transmitted to the arms and hands. Prolonged use of vibrating devices can cause sensorineural disturbances with complaints of numbness, tingling and decreased sensitivity. This is due to damage to the mechanoreceptors of myelinated A-? afferent nerve fibers due to exposure to vibration when working with vibrating tools. Neurodynamic mobilization functions to restore the plasticity of the nervous system and the ability of the nervous system. This study aims to determine the effect of neurodynamic mobilization on reducing sensorineural symptoms with the risk of HAVS in wood craftsmen in Dawung Village. The design of this study used a pre-experimental one group pretest-posttest design method. There are 15 samples of wood craftsmen who meet the criteria. The research instrument used the Stockholm workshop scale with data analysis using the Wilcoxon test. The results of the statistical test showed that the final result was p = 0.000, (p <0.05) which means that the effect of neurodynamic mobilization on reducing sensorineural symptoms in wood craftsmen in Dawung Village is at risk of HAVS. These results indicate that the neurodynamic mobilization intervention has effectiveness in increasing blood circulation in the nerves. The conclusion obtained is that neurodynamic mobilization has an effect on reducing sensorineural symptoms in wood craftsmen in Dawung Village with the risk of HAVS.

Concordance between the Stockholm Workshop Scale and the International Consensus Criteria for grading the severity of neurosensory manifestations in hand-arm vibration syndrome in a Swedish clinical setting

ObjectivesOccupational exposure to vibration using hand-held tools may cause hand-arm vibration syndrome (HAVS). Correct diagnosis and grading of severity are crucial in protecting the individual’s health and for workers’ compensation...

The effect of neural mobilization against sensorineural symptom reduction among hand-arm vibration syndrome survivor

Background: Hand-arm vibration syndrome (HAVS) is an occupational disease caused by exposure to vibration from work tools. Complaints often arise from sensorineural disorders that cause the arms and hands to tingle, numb, and experience decreased sensitivity. Neurodynamic mobilization is a manual therapy technique that utilizes tension and sliding movements that can reduce symptoms of sensorineural disorders. This study aims to determine the effect of neurodynamic mobilization on reducing sensorineural symptoms in patients with HAVS in welding workshop workers in Malang city.
 Methods: The design of this study used a pre-experimental approach with a one-group pretest-posttest design approach. There were 15 samples of welding workshop workers with symptoms of sensorineural disorders. The sample was given intervention for one month at a dose of 3x/week with one exercise consisting of 20x/set (10 slidings and ten tension) with three repetitions and a rest interval of 15 seconds/set. The assessment and evaluation instrument uses the Stockholm workshop scale. Data analysis was using the Wilcoxon test.
 Result: A significant decrease (p<0.000) in sensorineural symptoms among welding workshop workers in Malang city after a neurodynamic mobilization intervention was given.
 Conclusion: It can be concluded that providing neurodynamic mobilization decreases sensorineural symptoms of HAVS sufferers in welding workshop workers in Malang city.

Evaluation of neurological testing for hand-arm vibration syndrome.

The neurological component of hand-arm vibration syndrome (HAVS) uses the Stockholm Workshop Scale sensorineural (SWS SN) stages for classification. Proximal compressive neuropathies are common in HAVS and the symptoms are similar to SN HAVS. The SWS may not be a valid staging tool if a patient has comorbid proximal compression neuropathy. To evaluate the prevalence of proximal compression neuropathy in patients presenting for HAVS assessment and examine the association between compressive neuropathies and SWS SN. A standardized assessment protocol was used to assess 431 patients for HAVS at St. Michael's Hospital, Toronto, Ontario. The prevalence of median and ulnar compressive neuropathies was determined. The association between proximal compression neuropathies and SWS SN stage (0/1 versus 2/3) was evaluated using Chi-square and Fisher's exact tests as well as multivariable logistic regression. Most patients (79%) reported numbness and 20% had reduced sensory perception (SWS SN Stage 2/3). Almost half (45%) had median neuropathy at the wrist and 7% had ulnar neuropathy. There was no association between the SWS SN stage and median or ulnar neuropathy. Two neurological lesions should be investigated in patients presenting for HAVS assessment: compressive neuropathy and digital neuropathy. The prevalence of compressive neuropathies is high in patients being assessed for HAVS and therefore nerve conduction studies (NCS) should be included in HAVS assessment protocols. Comorbid proximal neuropathy does not affect the SWS SN stage; therefore, NCS and SWS SN seem to be measuring different neurological outcomes in HAVS patients.

Arterial abnormalities in the hands of workers with vibration white fingers \u2013 a magnetic resonance angiography case series

Vibration white finger (VWF) is a complication from exposure to hand-arm vibrations. Poor knowledge of the pathophysiology of VWF means that making an accurate prognosis is difficult. Thus, a better understanding of VWF’s pathophysiology is of importance.The purpose of this study was to investigate whether there were arterial abnormalities in the hands in patients with VWF and a positive Allen’s test, using ultrasound and MRA imaging.This was a case series where arterial abnormalities in the hands were investigated in ten participants with VWF and using prolonged Allen’s test (> 5 s). The participants had an average vibration exposure of 22 years and underwent Doppler ultrasound and Magnetic Resonance Angiography (MRA) to check for arterial abnormalities.The participants had VWF classified as 1–3 on the Stockholm workshop scale. Ultrasound and MRA identified vascular abnormalities in all participants, the predominant finding was missing or incomplete superficial arch. Also, stenosis was identified in four participants.This study reveals a high proportion of arterial stenosis and abnormalities in patients with VWF and a prolonged Allen’s test.

Lifetime vibration dose correlates with severity of the neurological component of hand-arm vibration syndrome among tyre shop workers in Kelantan, Malaysia

Introduction. Cumulative lifetime exposure to vibration is believed to contribute to more severe complications of hand-arm vibration syndrome (HAVS). Objectives. To determine prevalence of the neurological component of HAVS and the correlation between lifetime vibration dose (LVD) and neurological severity of HAVS among tyre shop workers in Kelantan. Methods. The cross-sectional study involved 200 tyre shop workers from two districts in Kelantan. Part one data were collected in the field using a questionnaire and hand-arm vibration was measured. Part two involved a set of hand clinical examinations (Purdue pegboard, Semmes-Weinstein monofilament and two-point discrimination tests) carried out for neurological component severity staging. LVD for each worker was calculated from data gathered in part one. For workers who had neurological symptoms, staging according to Stockholm workshop scales was done according to part two data. The strength of correlation between LVD and neurological stages was then determined using Spearman correlation. Results. Prevalence of neurological component was 37%. Spearman correlation between LVD and the neurological stages showed a moderate positive correlation. Conclusion. Cumulative lifetime exposure to hand-transmitted vibration is likely to be related to neurological severity of HAVS and therefore must be considered when assessing workers’ exposure to hand-arm vibration.

Neurosensory component of hand-arm vibration syndrome: a 22-year follow-up study.

BackgroundKnowledge about the long-term course of the neurologic component of hand–arm vibration syndrome (HAVS) is scarce.AimsTo study the course and prognostic factors of the neurosensory component of HAVS over a period of 22 years.MethodsForty male sheet metal workers, with a mean age of 60 (range 45–78) years at follow-up, were examined with a test battery in 1994 and 2017. At baseline, the sample comprised 27 workers with HAVS symptoms and 13 workers without HAVS symptoms. Among the 27 workers, 25 workers reported work-related hand–arm vibration during follow-up (mean 3639 h). In 2017, the mean time since vibration stopped was 8.4 years.ResultsAmong the 27 workers with HAVS in 1994, no overall statistically significant change was observed in hand numbness (Stockholm Workshop Scale), shoulder/arm pain (pain scale) or finger pain from 1994 to 2017. However, vibration exposure during follow-up was associated with increased finger pain. Cotinine, carbohydrate-deficient transferrin, glycosylated haemoglobin and folate were not associated with changes in neurosensory symptoms or manual dexterity (Grooved Pegboard) from 1994 to 2017. A diagnosis of HAVS in 1994 did not predict poor hand strength 22 years later. Isolated hand numbness (without white finger attacks) was more common at baseline than at follow-up.ConclusionsThis 22-year follow-up study indicates a tendency towards irreversibility of hand numbness and finger pain in workers with HAVS. Continued vibration exposure seems to predict increased finger pain. Our findings highlight the importance of HAVS prevention.

International consensus criteria for diagnosing and staging hand\u2013arm vibration syndrome

PurposeIn the 30 years since the Stockholm Workshop Scale (SWS) was published, the scientific literature on hand–arm vibration syndrome (HAVS) has grown and experience has been gained in its practical application. This research was undertaken to develop an up-to-date evidence-based classification for HAVS by seeking consensus between experts in the field.MethodsSeven occupational physicians who are clinically active and have had work published on HAVS in the last 10 years were asked to independently take part in a three-round iterative Delphi process. Consensus was taken when 5/7 (72%) agreed with a particular statement. Experts were asked to provide evidence from the literature or data from their own research to support their views.ResultsConsensus was achieved for most of the questions that were used to develop an updated staging system for HAVS. The vascular and neurological components from the SWS are retained, but ambiguous descriptors and tests without adequately developed methodology such as tactile discrimination, or discriminating power such as grip strength, are not included in the new staging system. A blanching score taken from photographs of the hands during vasospastic episodes is recommended in place of self-recall and frequency of attacks to stage vascular HAVS. Methods with the best evidence base are described for assessing sensory perception and dexterity.ConclusionsA new classification has been developed with three stages for the clinical classification of vascular and neurological HAVS based on international consensus. We recommend it replaces the SWS for clinical and research purposes.

Vascular component of hand-arm vibration syndrome: a 22-year follow-up study.

BackgroundVibration-induced white finger (VWF) is often assessed using the Stockholm Workshop Scale (SWS) and cold challenge plethysmography. However, long-term longitudinal studies using both methods are scarce.AimsTo study the long-term course and prognostic factors of VWF assessed with the SWS and photoplethysmography (PPG), and to examine the effects of lifestyle on PPG score, regardless of VWF status.MethodsForty male construction workers were examined with a test battery and clinical examination in 1994 and 2016/17.ResultsAt baseline, the sample comprised 27 workers with, and 13 without, symptoms of hand-arm vibration syndrome (HAVS). Thirty-five workers reported vibration exposure during follow-up. The mean age of the workers was 60 years (45–78) at follow-up. The paired t-test showed that PPG scores deteriorated from 1994 to 2017 in the 27 workers with HAVS in 1994 (mean difference 2.7 min, 95% confidence interval (CI) 0.2–5.2). However, there was no statistically significant change in SWS scores in these workers over time. Smoking and age were associated with PPG score deterioration. Vibration exposure during follow-up predicted SWS score deterioration: 1000 h of exposure predicted a deterioration stage of 0.09 (95% CI 0.03–0.16). Analysis of all 40 workers showed that 2017 PPG scores were associated with positive serum cotinine and self-reported smoking during follow-up.ConclusionsWhereas age and smoking predicted a PPG deterioration, continued vibration exposure predicted worsening of white finger symptoms. The association of PPG score and smoking should be considered in diagnostic and prognostic factor evaluations.

Response to 'the Stockholm Workshop Scale 30 years on-is it still fit for purpose?'

Response to 'the Stockholm Workshop Scale 30 years on-is it still fit for purpose?'

The Stockholm Workshop Scale 30 years on-is it still fit for purpose?

The Stockholm Workshop Scale 30 years on-is it still fit for purpose?

The Stockholm Workshop Scale 30 years on-Is it still fit for purpose?

The Stockholm Workshop Scale 30 years on-Is it still fit for purpose?

Assessment of coarse and fine hand motor performance in asymptomatic subjects exposed to hand-arm vibration

A frequently encountered exposure profile for hand-arm vibration in contemporary occupational setting comprises workers with a long history of intermittent exposure but without detectable signs of hand-arm vibration syndrome (HAVS). Yet, most of the published studies deal with developed HAVS cases, rarely discussing the biological processes that may be involved in degradation of manual dexterity and grip strength when it can be most beneficial - during the asymptomatic stage. In the present paper, a group of 31 male asymptomatic vibration-exposed workers (according to the Stockholm Workshop Scale) were compared against 30 male controls. They were tested using dynamometry and dexterimetry (modelling coarse and fine manual performance respectively) and cold provocation was done to detect possible differences in manual performance drop on these tests. The results showed reduced manual dexterity but no significant degradation in hand grip strength in the exposed subjects. This suggests that intermittent exposure profile and small cumulative vibration dose could only lead to a measurable deficit in manual dexterity but not hand grip strength even at non-negligible A(8) levels and long term exposures.

Re: Thompson A, House R, Manno M. Assessment of the hand-arm vibration syndrome: thermometry, plethysmography and the Stockholm Workshop Scale

Re: Thompson A, House R, Manno M. Assessment of the hand-arm vibration syndrome: thermometry, plethysmography and the Stockholm Workshop Scale

The sensitivity and specificity of thermometry and plethysmography in the assessment of hand-arm vibration syndrome

Finger plethysmography and thermometry are objective measures used to assess the vascular aspect of hand-arm vibration syndrome (HAVS). Research to date shows poor correlation between these tests and Stockholm Workshop Scale (SWS) vascular stage. Clinicians, researchers and compensation boards require objective means to diagnose and quantify HAVS. To define the specificity and sensitivity of thermometry and plethysmography using the SWS as the reference criterion. A secondary goal was to consider cut points for the tests optimizing sensitivity and specificity. A cross-sectional analysis was conducted on HAVS patients seen at an occupational medicine specialty clinic. Plethysmography and thermometry were analyzed using SWS vascular stage as the outcome variable. Logistic regression controlled for age, smoking and time since last vibration exposure and use of vasoactive medications. The sensitivity and specificity of the combined tests were calculated using varying cut points. A total of 139 patients consented to participate in the study. Plethysmography stage 1 or greater showed the highest sensitivity (sensitivity 94% and specificity 15%). Specificity was optimized combining plethysmography stage 3 and thermometry stage 3 (specificity 98% and sensitivity 23%). Maximal diagnostic accuracy was achieved by plethysmography alone setting the criteria for a positive test as being stage 1 or greater (70%). Neither plethysmography nor thermometry either alone or in combination demonstrated sufficient sensitivity and specificity to serve as an objective correlate for SWS vascular stage. All combinations of plethysmography and thermometry showed a lower specificity than sensitivity indicating that the SWS may be less sensitive in detecting vascular pathology than the objective tests.

Serological Tests for Diagnosis and Staging of Hand–Arm Vibration Syndrome (HAVS)

The current gold standard for the diagnosis and staging of hand-arm vibration syndrome (HAVS) is the Stockholm workshop scale, which is subjective and relies on the patient's recalling ability and honesty. Therefore, great potentials exist for diagnostic and staging errors. The purpose of this study is to determine if objective serum tests, such as levels of soluble thrombomodulin (sTM) and soluble intercellular adhesion molecule-1 (sICAM-1), may be used in the diagnosis and staging of HAVS. Twenty two nonsmokers were divided into a control group (n = 11) and a vibration group (n = 11). The control group included subjects without history of frequent vibrating tool use. The vibration group included construction workers with average vibrating tool use of 12.2 years. All were classified according to the Stockholm workshop scale (SN, sensorineural symptoms; V, vascular symptoms. SN0, no numbness; SN1, intermittent numbness; SN2, reduced sensory perception; SN3, reduced tactile discrimination; V0, no vasospasmic attacks; V1, intermittent vasospasm involving distal phalanges; V2, intermittent vasospasm extending to middle phalanges; V3, intermittent vasospasm extending to proximal phalanges; V4, skin atrophy/necrosis). All control subjects were SN0 V0. Seven out of 11 vibration subjects were SN1 V1, and 4 out of 11 were SN1 V2. A 10-cm(3) sample of venous blood was collected from each subject. The sTM and sICAM-1 levels were determined by enzyme-linked immunosorbent assay. The mean plasma sTM levels were as follows: control group = 2.93 +/- 0.47 ng/ml, and vibration group = 3.61 +/- 0.24 ng/ml. The mean plasma sICAM-1 levels were as follows: control group = 218.8 +/- 54.1 ng/ml, and vibration group = 300.3 +/- 53.2 ng/ml. The sTM and sICAM-1 differences between control and vibration groups were statistically significant (p < 0.0002 and p < 0.001, respectively). When reference ranges provided by Hemostasis Reference Lab were used as cut-off values, all sTM and sICAM-1 levels were within range, except three vibration individuals (27%) who had sICAM-1 levels greater than the reference range. This was not statistically significant (p = 0.08). When subjects were compared based on the Stockholm workshop scale, mean plasma sTM levels were SN0 V0 group = 2.93 +/- 0.47 ng/ml, SN1 V1 group = 3.59 +/- 0.25 ng/ml, and SN1 V2 group = 3.65 +/- 0.27 ng/ml, and mean plasma sICAM-1 levels were SN0 V0 = 219 +/- 54.1 ng/ml, SN1 V1 = 275 +/- 33.5 ng/ml, and SN1 V2 = 345 +/- 54.6 ng/ml. The difference in sTM level among the three groups was statistically significant (p < 0.001). The difference in sICAM-1 level among the three groups was also statistically significant (p < 0.002). The sTM and sICAM-1 levels are statistically higher in subjects with HAVS, with levels proportional to the disease severity. However, large population studies are needed to determine the "real-life" standard reference ranges for sTM and sICAM-1.

Grading of sensorineural disturbances according to a modified Stockholm workshop scale using self-reports and QST

The objective of the study was to apply, on a group of vibration exposed individuals, a proposed modification of the Stockholm Workshop scale for grading of sensorineural disorders by using self-reports and data from objective testing and to compare grading obtained through the two approaches. The study group consisted of 126 young persons with different individual levels of hand-transmitted vibration exposures. Effect measurements included a self-administered questionnaire and vibrotactile perception measurements and Purdue Pegboard testing. For grading using self reports three specific questions, believed to be good markers for complaints of intermittent numbness, sensory deficiency, and reduced performance in fine motor tasks, was picked out from the questionnaire. Results from vibrotactile perception and Purdue Pegboard testing were used for grading based on quantitative sensory testing. The sensorineural grading obtained by the two methods was then compared. The outcome showed that about 60% of all individuals within the study group are graded equally by the two methods for grading. The frequency of individuals graded at advanced SN stages were however higher when using QST, predominantly due to more positive cases for the Purdue pegboard test compared with the corresponding outcome from the self reports. The proposed modification of the grading scale reduces the in-built progressiveness and allows different combinations of sensorineural symptoms. The two grading methods seem to be somewhat correlated, something which may be considered as encouraging and promising for those who prefer to use, or must use one of the methods for grading. The proposed model for grading using self-reports should, however, be considered more as a conceptual idea for how this may be done. The models should be applied on a larger, more vibration exposed and more symptomatic study group, compared with the present study group, before any far-reaching conclusions can be drawn.

Assessment of the hand arm vibration syndrome: thermometry, plethysmography and the Stockholm Workshop Scale

The Stockholm Workshop Scale (SWS) provides a staging scheme for hand-arm vibration syndrome (HAVS) based on subjective history. Cold provocation finger thermometry and plethysmography are commonly used objective tests for the vascular component of HAVS. To examine the correlation between the cold provocation tests and SWS vascular stage. A secondary goal was to evaluate the correlation between cold provocation finger plethysmography and thermometry testing. Patients investigated for HAVS at St Michael's Hospital, Toronto, Ontario, were subjected to the same protocol including a questionnaire, clinical assessment and objective testing. Spearman correlation coefficients were calculated for the vascular tests with the SWS and for the vascular tests themselves. Logistic regression models controlled for age, smoking, use of vasoactive medications and time since last vibration exposure. One hundred and thirty-nine patients investigated for HAVS consented to participate in the study. The correlation coefficients for plethysmography (rho = 0.14) and thermometry (rho = 0.18) with the SWS were not statistically significant. Plethysmography and thermometry results were significantly correlated (rho = 0.47, P < 0.001). Logistic regression showed plethysmography and thermometry to weakly predict SWS vascular stage (OR 1.5 and 1.3, respectively). None of the potential confounders had a significant effect in the models. The results of plethysmography and thermometry did not significantly correlate with SWS vascular stage in this study. The objective tests did correlate with each other, suggesting that they are reliable measures of similar phenomena likely related to underlying vascular pathology.

Laser Doppler Imaging of Skin Blood Flow for Assessing Peripheral Vascular Impairment in Hand-Arm Vibration Syndrome

The objective of this study was to evaluate the usefulness of laser Doppler imaging (LDPI) of the skin blood flow for assessing peripheral vascular impairment in the hand-arm vibration syndrome (HAVS). The subjects were 46 male patients with HAVS, aged 50 to 69 yr, and 31 healthy male volunteers of similar age as controls. A cold provocation test was carried out by immersing a subject's hand on his more severely affected side into cold water at a temperature of 10 degrees C for 10 min. Repeated image scanning of skin blood flow of the index, middle, and ring fingers was performed every 2 min before, during, and after the cold water immersion using a PMI-II laser Doppler perfusion imager. The mean blood perfusion values in the distal phalanx area of the fingers were calculated on each image. The patients suffering from vibration-induced white finger (VWF, n=20) demonstrated significantly lower skin blood perfusion at each interval of the test as compared with those without VWF (n=26) and the controls (p<0.01, ANOVA). The blood perfusions in the HAVS patients were associated with the severity of the symptoms as classified by the Stockholm Workshop scale for vascular staging. When a subject was considered to be positive if any of the tested fingers showing a decreased blood perfusion and/or a delayed recovery pattern, the sensitivity was 80.0%, and the specificity was 84.6% and 93.5% for patients without VWF and the controls, respectively. These results suggest that the LDPI technique could provide detailed and accurate information that may help detect the existence of impaired vascular regulation to cold exposure in the fingers of workers exposed to hand-transmitted vibration.