The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for addressing Hand/Arm Vibration Syndrome (HAVS). These directives are designed to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in managing Hand/Arm Vibration Syndrome (HAVS) can depend on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding the management of Hand/Arm Vibration Syndrome (HAVS) should involve collaboration between the patient and their healthcare provider.
Hand Arm Vibration Syndrome (HAVS)
The term “hand arm vibration syndrome (HAVS)” has been in use since the 1980s to denote the cluster of adverse physiological responses linked to high-amplitude vibratory forces. Such forces are typically experienced through the use of hand tools like pneumatic drills, riveters, chain saws, or activities involving significant vibration, such as driving off-road vehicles.
Other terms used for these responses include Raynaud’s phenomenon of occupational origin, white fingers, dead fingers, traumatic vasospastic disease (TVD), and “vibration-induced white finger.” The negative effects of HAVS involve circulatory disturbances, sensory and motor issues, and musculoskeletal problems.
The adverse impacts of HAVS include circulatory problems associated with digital arteriole sclerosis, resulting in vasospasm and local finger blanching. Sensory and motor issues manifest as numbness, loss of coordination, clumsiness, and difficulty performing intricate tasks. Musculoskeletal problems include finger swelling, bone cysts, and vacuoles. There are also reported associations between carpal tunnel syndrome (CTS) and HAVS, linking exposure to vibration.
Epidemiological evidence suggests a latency period of 1 to 16 years of exposure before the onset of HAVS. Prevalence tends to decrease with changes in work practices, the introduction of anti-vibratory tools, and dampening actions. Pathophysiologic changes due to vibration are initially reversible, but prolonged and intense exposure may lead to progression or permanence of the disorder.
Diagnostic Studies
Cold Provocation Test, Cold Stress Thermography, Finger Systolic Blood Pressure, Vibrotactile Threshold Testing, Thermal Aesthesiometry, or Nerve Conduction Velocity Studies to Diagnose Hand Arm Vibration Syndrome
- Not Recommended: For diagnosing HAVS.
- Evidence: Lack of supporting evidence for the efficacy of these special studies in diagnosing HAVS.
Serologic Tests (Thrombomodulin, Soluble Intracellular Adhesion Molecule 1 [s1-CAM 1]) to Diagnose Hand Arm Vibration Syndrome
- Not Recommended: For diagnosing HAVS.
- Rationale: No serologic tests currently provide objective evidence or staging of HAVS.
Testing for Connective Tissue Disorders
- Not Recommended: For diagnosing HAVS.
- Rationale: There is no current serologic test providing objective evidence or staging for HAVS.
Medications
For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen may be considered as an alternative for patients not suitable for NSAIDs, although evidence suggests modestly less effectiveness.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic HAVS Pain
- Recommended: For treating acute, subacute, or chronic HAVS pain.
- Indications: NSAIDs are recommended as the first line of treatment, with over-the-counter agents as the initial option.
- Frequency/Duration: As-needed use may be reasonable for many patients.
- Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
- Recommended: For concurrent use with cytoprotective drugs in patients at high risk of gastrointestinal bleeding.
- Indications: Consider for patients at high risk, especially with a history of prior gastrointestinal bleeding, elderly individuals, diabetics, and cigarette smokers.
- Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers are recommended. Dose and frequency as per manufacturer.
- Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
- Discussion of risks and benefits for patients with known cardiovascular disease or multiple risk factors.
- Recommended: Acetaminophen or aspirin as first-line therapy for minimizing cardiovascular adverse effects.
- Preferred: If needed, non-selective NSAIDs over COX-2 specific drugs.
- Guidance for Aspirin Use: In patients on low-dose aspirin, NSAIDs should be taken at least 30 minutes after or 8 hours before daily aspirin.
Acetaminophen for Treatment of HAVS Pain
- Recommended: For treating HAVS pain, especially in patients with NSAID contraindications.
- Indications: All patients with HAVS pain, including acute, subacute, chronic, and post-operative.
- Dose/Frequency: As per manufacturer’s recommendations, on an as-needed basis.
- Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Opioids
- Not Recommended: For acute, subacute, or chronic HAVS pain.
Treatment
Smoking Cessation
- Recommended: Considering smoking as a risk factor for HAVS.
- Additional Advice: Avoidance of beta-blockers, sympathetic stimulants like caffeine, decongestants, and amphetamines, as they may act as potential triggers. Maintenance of hand and body temperature in cold environments can help prevent or reduce symptoms.
Rehabilitation
Rehabilitation following a work-related injury should prioritize restoring functional abilities for daily and work activities, aiming to return the injured worker to pre-injury status as much as possible.
Active therapy involves internal effort by the patient to complete specific exercises, while passive therapy relies on modalities delivered by a therapist to facilitate progress in an active therapy program and achieve objective functional gains.
Emphasis should be on active interventions over passive ones. Patients are advised to continue both active and passive therapies at home to maintain improvement levels. Assistive devices may be included in the rehabilitation plan to enhance functional gains.
Therapy: Active
Therapeutic Exercise
- Recommended: For treating functional deficits related to HAVS.
- Frequency/Dose/Duration: The total number of visits may range from two to three for mild deficits to 12 to 15 for more severe deficits, with documented ongoing objective functional improvement. If ongoing deficits persist, more than 12 to 15 visits may be indicated with documentation of functional improvement towards specific goals. A home exercise program should be developed and performed in conjunction with therapy.
- Evidence: Supporting the use of exercise for HAVS.
Work Activities
Vibration Exposure Work Restrictions for HAVS
- Recommended: Patients with HAVS should have work restrictions, limiting tasks to those not involving high-amplitude, low-frequency vibration exposures from hand-held tools.
- Indications: Applicable for HAVS resulting from high-amplitude, low-frequency vibration exposures through vibrating hand-held tools.
Cold Exposure Work Restrictions for HAVS
- Recommended: For select HAVS patients, work restrictions are advised for tasks not involving cold exposures.
- Indications: Relevant for HAVS not controlled through avoiding vibration exposures or for patients with recurring problems like vasospasm or other unresolved complications despite other treatments.
