Hand-Arm Vibration Syndrome: Clinical Evaluation and Prevention P.L. Pelmear, MD; and W. Taylor, MD, DSc Increasing recognition by workers that blanching of tholr ‘fingors may bo duo to hand-arm vibration exposure from tho tools they use at work and their consequent claims for com- pensation emphasiza a need for botter clinical evaluation and prevention. We describo the symptoms and signs, and enumer- ate the diagnostic procedures (both soreening and laboratory) necessary to establish the diagnosis and severity grading of subjects with hand-arm vibration syndrome. Although effoc- tive treatment of the condition other than avoidance of furthor vibration exposure is still boing researched, prevention is all important. Tho necessary stops are identified. aynaud’s phenomenon, so named after Maurice Ray- maud who described it in 1862," may be defined as intermittent constriction of the peripheral vessels (ar- torioles and veins) with consequent color change of the skin of the extremities such as pallor, cyanosis, or both. ‘The phenomenon commonly precipitated by exposure to ‘cold may occur primarily, as in Raynaud’s disease, or in association with a number of conditions or diseases. ‘With Raynaud’s disease (or constitutional white fin- ger) the distinguishing features are familial predispo- sition (from 5% to 10% incidence in the male industrial population), higher incidence among women than men (6/1), early onset with over 60% of those predisposed experiencing the phenomenon by age 30, bilateral ap- pearance of the phenomenon in response to stress as well as cold, and the absence of any predisposing disoaso or trauma, From tho Honlth and Safty Support Branch, Chast Clini, Mlnitxy of Labour, Toronto (Dr Felmonr, Direstor). ‘Address corrospandenoe to Dr P. L. Poimear, Health and Safety Support Branch, Chest Cline, and Floor, 880 Bay St, Toronto, Ontario, ‘Canada M78 207, 090-17930/04/s814-114489.00/0 (Corgeeht© by American Calg ef Ocopatonl Medline 1144 ‘The more important sesondary causes of Raynaud's phenomenon include the connective tissue diseases (scle- rodorma, lupus erythomatosis, and rheumatoid arthri- tis), any disease or condition causing obstruction of blood vessels (eg, thoracic outlet syndrome, cervical rib, atherosclerosis, or dysglobulinaemia), neurological con- ditions with muscle impairment (eg, poliomyelitis or syringomyelia), vinyl chloride intoxication, injury to the extremities, causing blood flow interference (eg, lacerations or frostbite), and cumulative trauma (og, from vibration) leading to vascular changes. Vibration- induced Raynaud’s phenomenon often has been called vibration white finger (VWF) or white hand, but by international agreomont now is ealled hand-arm vibra tion syndrome (HAVS). By agreomont of scientists at an international mosting in London in 1989° vibration syndrome has been defined 1s « disease with the following components, all poriph- eral: ciroulatory disturbances (vasospasm with local finger blanching “white finger”), sensory and motor disturbances (eg, numbness, loss of finger dexterity), and musculoskeletal disturbances (musolo, bone, and joint disorders). Vibration as a cause of Raynaud's phenomenon was first reported by Loriga in 1911.° Compressed air tools ‘wore tho cause, and this was confirmed by other authors in 1918" who studied stonecutters using pneumatic ‘hammers in the limestone quarries of Bedford, Indiana, USA. ‘Dr Alico Hamilton® examined 181 stonecuttors and carvers, and her description of the symptoms and hhas not been surpassed in the literature. Her description of the complaints was restricted to the hands, ‘The recognized hazardous work tools and situations {for hand-arm vibration exposure, too numerous to men- tion, include all compressed air tools (eg, chipping ham- mers, jacklog, stoper, and road drills) and gasoline or electric driven tools (eg, polishing and grinding tools and chain saws), Hand-Arm Vibration Syndrome/Pelmear & Taylor‘Symptoms and Signs Vascular Effects After a variable period, depending on the amount of vibration recelved and the sonsitivity of the subject, blanching of a fingertip occurs after exposure to cold. ‘The affected finger is numb when blanched, and, in severe cases, there may be some persistent permanent ‘numbness or reduced sensitivity between attacks. ‘The blanching attacks are precipitated by exposure to cold, damp conditions, particularly in the morning and at night, when the subject's metabolic activity is low, after handling cold objects, or immersion in water. Attacks are more common in winter than in summer, but eventually they will occur all year round. With continued exposure to vibration, the blanching attacks bocome more frequent. Typically they last from a few minutes to 1 hour, and terminate with reactive hyper- emia and often considerable pain. During an attack, ‘touch, pain, and temperature sensitivity are often groatly reducod and in somo subjects this may persist, causing permanent impairment, Initially, the blanching is localized to the tips of the fingers most exposed to the vibration source, but even- tually it spreads to involve all fingers as far as the ‘metacarpophalangeal joints and the tips of the thumbs. ‘The palms of the hands are rarely affected. The blanch- ing does not usually ocour at work except during rest periods, but in some subjects the vibration stimulus itself will induce blanching if the fingers are cold, ‘These symptoms and signs are in response to patho- logical and physiological changes in the tissues of the fingers. The development process is not entirely clear, and several hypotheses have been proposed. It is sug- gested that the first response to vibration is @ relaxation ‘of the small blood vessels and an increase in permeability of the vessel wall with a resulting accumulation of exudate. Later, hypertrophy of the muscle layer of the ‘blood vessels occurs, with consequent hypersusveptibility to contraction when stimulated by cold. In normal cireumstances, sympathetic tone arising from the hypothalamus (coarse contro!) causes vasocon- striction through a-adrenergic stimulation of the digital vessels, but it also affects tho mast cell mombrano producing a release of histamine and vasodilation (fine control) after a delay of seconds. It has been suggested by Lafferty ot al® that trauma damages the local mast ccolls, s0 the vasoconstriction in such cases is prolonged. It is now known that the a-adrenergic receptors are of two types: a; in the vessel wall, which are preferen- tially stimulated by phenylephrine, and ay localized closer to the vessel lumen, which are preforentially stimulated by azepexole. Vasoconstriction induced by a, activity is reduced, and that induced by ay activity is augmented by cooling. Ekenvall and Lindblad” have domonstrated that porsons with VWF have a reduced response to a stimulation, presumably due to local trauma. Hence these patients with more responsive az receptors have an exaggerated response to cooling. Eventually the lumen of the blood vessel is reduced due to the muscle hypertrophy and to secondary throm- bbosis consequent upon a sluggish blood flow. In advanced cases, fibrotic changes occur within the hypertrophic muscle. This may be an additional factor for the pro- longed spasm with delayed relaxation on reexposure to warmth, @ typical feature in such casos. Ultimately, ‘with complete obliteration of blood vessels, trophic or gangrenous changes may occur, as reported in a few ‘The symptoms and signs and the frequency of attacks may be such that the subject, apart from taking imme- diate preventive action to koop warm and to avoid cold ‘exposure, has to curtail customary domestic and leisure activities. Socially, this may mean avoiding outdoor pursuits such as gardening, fishing, swimming, and watching outdoor entertainment. Ultimately, it may involve a chango of work to avoid further vibration exposure or limiting job selection to warm environ- ments, Working on construction sites, especially during the winter, is impossible. ‘A grading indox by stage of symptoms and social and ‘work interference, described by Taylor and Polmoar,’* proved useful to express clinically the stage of soverity of VWF. It has been revised and updated by the Stock- holm Workshop scales,'®"* which separate the vascular and sensorineural stages (Table). The Taylor/Pelmear grading did not address the neurological effects except ‘those upon social, domestio, and leisure activities and manual dexterity. The only reference was OT/ON, and this symptoms grade was for the early vascular neurop- athy. Hence, the separate staging for the sensorineural, symptoms is advantageous. Howover, the Stockhalm ‘TABLE ‘Stocstcim Workshop Seales ‘Grade Deseriton Vascular 0 No attacks 1 Mis ‘Occasional attacks affect- ing ony the tips of one or more fingers 2 Moderate Occasional attacks affect- ing distal and middlo| (rarely also proximal) Dhalanges of one oF moe fingors 3 Severe Frequent aitacks afecting ‘al phalages of most f- gers 4 Very severe Asin stage 3, with trophic skin changin th inger ips Sensorineuralt Symptoms osn Exposed to vibration but no symptoms 18N intermittent numbness, with or without tinging 2sn Intermittent or persistent numbness, re- ‘ducing sensory perception 3sn Intermittent or persistent numbness, re- ‘ducing tactile discrimination and/or ma- nipuiatve dexterity * Staging Is made separately for each hand, 2L2/1R()- + Staging is made separately for each hand. Journal of Occupational Medicine/Volume 33 No. 11/November 1991 1145vascular staging does not quantify effects upon domestic loisure and hobby activities. As in the Taylor-Pelmear staging, the Stockholm system requires objective tosts to support the grading. When there is difficulty in verifying the grading, the Compensation Boards are advised, and a grading level determined from the clinical objective tests performed in a laboratory with the ap- propriate instrumentation is giver Of persons under 50 years old with VWF severity no greater than stage 2 vascular, an estimated 80% will ‘completely rocover to stage 1 or 0 if they avoid further vibration exposure. Those who do not will progressively deteriorate, Older subjects and those with severity stage 3 on discontinuing vibration expoaure will tend to re- main static, although some will continue to deteriorate. ‘Tho noninvasive vascular tests used to examine pa- ents now include the Doppler for systolic pressure measurement of popliteal, ulnar, and radial arteri plothysmograph for finger blood flow before and after cold stress; finger systolic pressure before and after local cooling; and cold water immersion for 8 to 10 minutes with finger temperature recording. From tho results of these tests, vasospasm can be confirmed and Its severity graded, Neurological Paresthesia directly after tho use of a vibrating tool and at night is common, Nightly sleep-disturbing par- esthesias are also typical of carpal tunnel syndrome, but this is quito often associated. Numbness, which occurs with blanching of the fingers, may persist with do- creased tactile and temperature sonsitivity to a lessor or greater dogreo between attacks in subjects more severely affected with the vascular componont. Impair- ment of skin sonsitivity and the increased vibration perception threshold may reflect the functional distur’- ‘ance of the peripheral nerves, of the sensory nerve endings, or of the mechanoreceptors, including the Pa- cinian corpuscles."* The Pacinfan corpuscles, the quick- adapting receptors, and the two types of slow-adapting receptors aro the most important mechanoreceptors in, the skin involved in the sonse of touch. In a fow subjects the neurological symptoms predominate and loss of ma- ulative skill also may occur." Recovery from neurop- thy after discontinuation of vibration exposure is I ikely than reversal of the vascular effects. Tho sonso- rineural Stockholm seale permits staging of those symp- toms. Workers with nourophysiologic symptoms compatible with hand-arm vibration syndrome have a decrensed sensory nerve conduction velocity from the fingers to the wrist!™"® as well as an increased motor and sensory latency and reduced. conduction velocity in the ulnar and median nerves of the forearm.'* ‘These findings are consistent with the concept of a direct patho- physiologic offect of vibration on the poriphoral nerves ‘and nerve endings. Lukas," who noted reduced conduction velocities in the terminal parts of the ulnar and median nerves in workers following long vibration exposure times (usu- ally more than 10 years), suggests that the vascular 1146 component may play an important role in the develop- mont of damage and may be the cause of the neuropathy. But, as observed by Pyykkko and othors,!* neuropathy among forest workers bears no relationship to the se- vority of the vascular component, and the two may occur indopendontly, suggesting separate mechaniams. ‘Muscle fatigue and weakness in the hands and arms of forest workors wore noted by early rescarchers and have been demonstrated objectively.®"** Many workers, with or without symptoms of neuropathy, have di creased muscle strength after years of hand-arm vibra- tion exposure. This sooms to be duo to a neuromuscular fault which causes incomplete muscle contraction, be- causo muscle volume remains normal. The use of vik Dating tools is also associated with a significant d crease in manipulative dexterity;' muscular weakness may be due partly to a disturbance of the fine control of tho hand muscles. Tho physiological effect is not well understood. The reaction of denervated muscle tissue to vibration is to relax,** indicating that vibration may Interfere directly with tho contractile substances in ‘muselo (myosin and actin), proventing their cross-link age and muscle contraction. In an intact muscle, a momentary decrease in muscle force also is observed ‘when the musolo or tendon is exposed to vibration.** Howover, Radwin ot al have demonstrated that hand ‘tool vibration can introduce disturbances in neuromus- cular control resulting in excessive grip strength. ‘This may increase the risk of cumulative trauma disorders. Skin sonsitivity can bo evaluated by the old estab- lished tests for loss of light touch, pain, and tempera- ture; by use of the depth sonse and 2-point iscrimina- neurometer, using three sinusoidal frequencies (2000 ‘Hz, 250 Hz, 6 Hz) of electrical stimulus to assoss median and ulnar poriphoral function to tho index and little fingors.** Such tosts are subjective and prone to subject bias and, thus, are of limited value unless they can bo linked to evoked response interpretation. Nerve conduc- tion tosts of the sensory and motor components of the median and ulnar nervas are essential to detect vibra tion-induced neuropathies and carpal tunnel compres- sion. A grip dynamometer will measure grip strength. Apart from tho hand-arm symptoms and signs ‘additional effect noted in VWF casos has been the sus- coptibility to increased hearing loss," Bone and Other Effects ‘There are many reports of cyst formation in bones," but this is a common finding in manual workers. Studies conducted by James et al” and Harkonen et al*” found no statistical ,differences between vibration-exposed workers and manual worker control subjeots. Bone cysts occur because of synovial fluid extrusion from joints and not from reduced blood flow. Gemne and Saraste® con- ducted a literature evaluation of the radiological docu- mentation of bone and joint pathology in the hands and arms of workors using vibratory tools and established Hand-Arm Vibration Syndrome/Pelmear & Taylorthat the allegation that hand-arm vibration causes an ‘excess prevalence of bone cysts, vacuoles, Kienbock’s Aisease, or pseudoarthrosis of the scaphold had not been validly documented. They concluded that the observed large variation in tho prevalence of skeletal disorders may bo explained by biodynamic and ergonomic differ- ences between various occupations. Kionbock’s disease, because it is a sequel to disruption of the blood supply, is of particular interest. There appears to be a certain “at-risk Iunate” with either a Umited intraosseous blood supply or a deficiency in point to repeated ‘compression fractures and segmental in- terruption of the intraosseous blood supply as the causes, Stahl® reported that only 2% of patients with horizontal lunate fractures developed Kienbock's dis ‘ease, although Beckenbaugh et al‘ reported that 67% of pationts had evidence of fracture or fragmentation at the time of diagnosis. Ribbans reported the condition in an elderly women with scleroderma and Raynaud's disease. He suggested that the vascularity associated with her connective tissue disorder and the increased ‘use of her right hand were the causo. Hence the low incidenco in hand-arm vibration-exposed workers may ‘be duo directly to the trauma or may be secondary to vasospasm, but it is not yet proved. Duputrens contrac- ture is often presont in hand-arm vibration-exposed workers, Direot trauma or the vibration stimulus may bbe the causo, but the incidence has been insufficient to permit @ definitive conclusion, The same is true of soleroderma, which sometimes develops in vibration- exposed workers. Prevalence ‘The prevalence of HAVS in working groups, as deter- mined from epidemiological studies, can vary consider- ably because of labor turnover. Therofore, it is not a reliable indicator of the exposure risk. The latent intor- val, which is the time betwoon first exposure to hand- arm vibration and onset of first blanching of a fingertip to cold, is a better indicator for detormining tho risk factor of a particular work tool or work situation. The Intent intervals differ with each work situation but in general they are: for pedestal grinding from 8 months to 20 years, depending on tho nature of the grinding ‘wheel and the size of the metal piece; for fettling, from 4 to 7 years; for swaging, 6 months to 1 year; for hand grinding, from 5 to 15 years; for non-antivibration saws, 4 to 5 years, and for antivibration chain saws, from 7 to 10 years. gnostic Procedures Initially it was thought that a single test would be suffiolent to establish a diagnosis, but it is now appre. ciated that multiple teste are required to confirm and grade the severity of the vascular and neurological symptoms. To make a satisfactory clinical diagnosis, the following rogimen should be adopted: 1, Obtain a complete history of presenting com- plaints, medical history, family histery, and occupa- tional history with emphasis on nature and length of exposure to vibratory tools. ‘The history should specifically elicit symptoms of possible collagen or rheumatoid disease, large vessel obstruction, exposure to digital trauma, homotological dyscrasias, and use of vasoconstrictor medication: 2, Conduct a completo physical examination with om- phasis on the musculo-skelotal, cardiovascular and neu- rological systems to note particularly pulses, rash skin thickening, trophic changes, joint abnormalitis and musoular and neurological defects. 8, Record responses to specific screening tests. (a) For vascular assessments: Allen's test (wrist vessel compression). (b) For thoracic outlet assessment: Ad- son's test (rotation of nock with deep inspiration). (c) For carpal tunnel syndrome assessmont: Tinel’s test (percussion of carpal tunnel); Phalen’s test (flexion of wrist). (@) For nerve impairment: dynamometer test (grip strength), aesthesiometer tests (depth sense and 2-point perception). ‘4, Laboratory investigations, (a) Blood tests: blood count and differential erythrocyte sedimentation rate, urie acid, rheumatoid factor, antinuclear antibodies, oryoglobulins, and sorum protein cloctrophoresis. (b) Urine tests: urinalysis for proteinurea and glycosuria. (©) Roentgonograms (if not done previously): cervical spine and hands to identify cervical rib, arthritic, and coystio changes. ‘5. Special investigations as and when indicated. (a) Doppler and plethysmography of aystolic pressures and blood flow, before and after cold stress (10°C for 8 minutes) for each digit. (b) Finger systolic pressure, before and after cooling to 10°C of the middle or worst finger, using the noncooled thumb as the reference. (c) Cold water immorsion for 8 to 10 minutos at 10° or 16°C with finger temporature recording of all digits. (a) Nerve conduction: motor and sensory response for me- dian and ulnar nerves with conduction velocity evalua- tion, (e) Vibrotactile sensitivity measurements: vibro- gram thresholds at 8 to 500 Hz with 0.5 Newtons probe pressure on middle or worst finger. (f) Current percep- tion threshold measurements: three sinusoidal frequen- (2000 Hz, 250 Hz, 5 Hz) of electrical stimulus to ‘the index and little fingers to assoss median and ulnar nerve peripheral function, (g) Audiomotry: thresholds ‘at 500-8000 Hz. ‘Assessment ‘The symptoms, signs, and objective evidence accu- mulated from the above diagnostic procedures can con- firm with reasonable certainty the presence of Ray- naud’s phenomenon and a grading on the Stockholm soale, Tts attributability to hand-arm vibration oxpo- sure, if this is the case, is confirmed by the work history and vibration measurement of the tools."” The control, of hand-arm vibration, however, is multifaceted, and Journal of Occupational Medicine/Volume 33 No. 11/November 1991 1147the National Institute for Occupational Safety and Health criteria** provides the latest and most completo overview of the hazards, biologic effects, methods of protection, standards, and research need: Treatment ‘To restore circulation to blanched fingers, immersion in warm water has beon recommended by some, but swinging the arms along with warmth to the body is probably more usoful at the onsot of an attack. For the prevention of blanching the most useful and important, ald is the wearing of warm, dry clothes to maintain a raised body tomporature. For vory severe cases, el00- ‘rlcally heated gloves aro recommended for winter wear. New therapies continue to be proposed and evaluated, bbut the most useful to reduce vasospasm soem to be calcitim channel antagonists, mainly Nofedipine 80 to 40 mg/day (maximum 80 mg). Peripheral skin vasodl- lation ‘with enhanced tissue oxidation occurs. Side ef fects may be reduced by starting with e small dose. Alternatives are thymoxamine, an a adrenoceptor an- ‘agonist to block vasoconstriction in tho skin while maintaining overall vascular resistance; Stanazolol (Winstrol or Stroma) a fibrinolytic activity enhancing Agent to be used only in advanced casos whon othor methods have failed; and Prostanolds (Prostaglandin E,, Prostacyclin, or Toprost) by intravenous infusion to educo platelot adhesiveness and to cause generalized vasodilation."® Sympathectomy does not give consist- cently good results and is used less frequently today than proviously. ‘Thore is no therapy at present for tho neurological symptoms other than removal from vibration exposure. Surgery for associated carpal tunnel symptoms should be avoided. Prevention ‘The important steps to be taken in prevention are: 1, Identification of the hazard by vibration measure- ‘ment and reduction at the source or transmission. 2. Limitation of exposure to within the Amorican Conference of Governmental Industrial Hygionists guidelines and International Standards Organization standard 6849 by work rotation or avoidance of expo- sure (if possible) by use of alternative work mothod: 8, Use of antivibration gloves and antivibration pads on tools and chain saws, 4. Regular and effective maintenance of tools and chain saws, 5. Education and training of workers to grip tools and chainsaws lightly, consistent with safe work prac- tive. 6. Medical surveillance, i periodic. 7, Health education of workers to avold smoking and to wear warm clothes to maintain a high body temper- ature, 1148 In Ontario, Canada, the Workers’ Compensation Board has received claims for vibration white finger ssince 1944 and has accepted claims since the 1950s. References 4, Raynaud M. Do P'asphyxio locale ot doa gangrine symétrigue dos extrimits, Paris: Rignos, 1969, 2, Gomne G, Taylor W. Bator forward, In: Game G, Taylor W, cis, Hand-arm vibration and the central autonome nervous ayetem, ‘Special volume, J Zow Freq Nolee Vibration. 1889; XI 3. Loriga G. Pnoumetic tools, Quoted by Teleky, I~ Qcoup Health ‘Suppl 1.0. 1898;1-12. “4, Cottingham GB, Statements of Phyetc 9 Reporting on Bohall of tho Employees and the Emplayers, Bulletin 236, US Bureau Labor Stat 1016;19:128. 5. Hamilton A. A Study of Spastio Anaemia In tho Hands of ‘Stonocuttors, Bulletin 896. Washington, DO: US Bureau of Labor role of histamine, Zaneot 1985:2:013-818, 7. Bkanwall L, Lindblad LE, Ie vibration white Singer 8 primacy sympathotic norva injury? Br J Znd Rd, 1986;48:702-708. '8, Walton KW. The pathology of Raynaud's phenomenon. In: ‘Taylor W, od. Vibration Syndrome, New York: Academie P 1974:100-119, 9, Soyring M. Maladies from work with compressed alr dri, Bull Hyg. 1901;8335. 10. Baler TW, Allon BV. Tho dlagnostio valuo of artertography report of a case. Mayo Gln Proe Staff Bet. 193611:800. 11, Barker NW, Hines BA. Artoral ocelusion In the hands and ‘gers ansotated with repeated occupational trauma, Maye Clin Proc Stat Moot. 1994;10:348. 12, Taylor W, Polmoar PL. Vibration White Flagor In Industry. San Diogo, Calf: Academie Press, 1878: 0x1, 18. Gomne G, Pyyko , Taylor W, Pelmear PL. The Stockholm workshop soale for the slassifiention of cold-induced Raynaud's phe- ‘omonon inthe hand-arm vibration ayndromo (Ravieion ofthe Taglor- Pelmosracslo) Sonnd J Work Environ Health, 1987;8:276-278, 14. Brammer AJ, Taylor W, Lundborg G. Sonsorinoural stages of ‘tho hand-arm vibration syndrome. Seand J Work Environ Health 1087;8:978-288, 18. Lundstrom RIL, Responses of mechanoreceptve affront unite tm tho glabrous akin of the human hand to vibration, Soand J Work Environ Healt, 1986;12:418-416. 16. Banletar PA, Smith PV. Vibration induced white fing ‘dexterity. Br J Ind Mod, 1972;20:004-207. AM. Neuropathy and the autonome analyas of eleotromyographio signals from vibration exposed workers, ‘Scand J Work Environ Health, 1O7T:8108~134, 18, Sakurai , Mutoba T. Peripheral nrvo reaponses to hand-arm vibration, Sound J Work Environ Hoaith.1806;18-432-494, 19. Seppalainon AM, Nerve conduction inthe vibration syndrome, ‘Scand J Work Environ Health. 1870;1:82-84, 20, Soppalainon AM, Peripheral neorepathy in forestry workers: & ‘eld study. Scand J Work Bnviron Health, 1979:3:100-111. 21, Lukas E. Poripheral nervous epatom and hand-arm vibration exposure. In: Brammer AJ, Taylor W, ede. Vibration Bifects on the Hand and Arm in Industry, Now York: John Wiley & Sone, 1989:09~ “. and 120, Pyykko 1 ota. A longitudinal study ofthe vibration syndrome Jn Finnish forestry workers. In Brammar Ad, Taylor W, eds, Vibration ‘Bieots on tho Hand and Arm in Industry. New York: John Wiley & ‘ons; 1980:187. 28, Furkllla M. Grip forco in vibration disease, Scand J Work Environ Health, 1978;4:168-166. ‘4. 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Hand-erm vibration in the otlology ‘othering los ln umber Jacks, Br J Ind Mod, 1981:28281-260. 1, Tat M, Kurumetani N, Mariyama 7. Vibration-induced white fMngore and boating loss, Lancet. 1969:258. 12, Pelmear PL, Leong D, Wong L, Rove J, Pike M, Hand-arm vibrato ayndrome and hearing lors in hardrock miners, J Low Freq Nolse Vib. 1887;6:49-66, 88, Hellstrom G, Andorsen XL. Vibration injuries in Norwegian foros workers, Br J ind Mod, 19722288, ‘24, Kumlin T, Wikrt M, Sumal P. Radiologicel changes in carpal ‘metacarpal bones and phalanges caused by chain saw vibration, ‘Br J led Med, 1879;80°21 {, Puranen J, Vuorinen P, Vibration syndrome in Pelmeer PL, eds. Vibration Whito Flagar in Industry. Now Yor ‘Academic Pres, 1976:49-61, 87, Hartonen H, Rilhimakt H, Toa , o a. Symptoms of vibration syndcome and radiographle findings In the welts of lumberjacka, Br ‘Find Med, 1986;41:199-100. 98, GemneG, Saraste H. Bone and joint pathology in workers uaing hand-held vibratory tacle—An overview. Soend J Work Baviron Health, 1987;19:200-300, ‘39. Golberman RH, Bouman TD, Monon J, Akeson WH, The vas- cularty of tho Tunate bone end Kienbock’s dieoase, J’ Hand Surg. 1980;5:272-278, 40, Stahl F. On Lunstomalecln (Klonbook’s Disease), A clinfoat ‘nd reontgonologic study, especially on ite pathogenesis and the late results of Immobilization treatment, Aste Ohlr Soand Suppl. Beokonbaugh RD, Shives TO, Dobyns JH, Linsoheld RL. Kien- ‘ock’s Disease: The natural history of Klenbook's isbaso and cone ration of lana fractures, Clin Orthop. 1980;140:08-106, “42, Ribbana WJ. Klonbock's disease: to ununual cases, J Hand ‘Surg. 1988;138:485-465. 43. Polmear PL, Leong D, Taylor W, Nagalingam M, Fung D, ‘Meusuremont of vibration ofhand-hel tole weighted or unweighted? ‘J Ocoup Med. 1989;31:902-008, ‘44, Wasserman DE, The control aspects of occupational hand-arm wibration, App! Ind Hye. 1969;8:29-26 ‘46. Ocoupational expocure to hand-arm vibration, Criteria for « ‘ecorimonded standard 1989. Washington, DO: US Dopt of Health and ‘Human Services (National Institute for Occupational Safety and Health) publioation 69-1 ‘48. Cooko ED, Neo +1900;300:565-555. le cerebral palsy babi are born with cerebral paley. Istrative costs of maybe $5 million. dunk Science in the Courtroom, IV ook at how junk scionce attends to the vory real tragedy of corebral palsy. ‘The junk science theory here is that obstetrical malpractice is an important causo of cerebral palsy, that better uso of electronic fetal monitoring and more aggressive ‘use of the scalpel for cesarean delivery would often prevent the affliction. Most are in fact doomed long before an obstetrician comes noar ‘thom, Wo know this from, among numerous other scientific sources, a study by tho National Institutes of Health, That study, the most complete of its kind, surveyed some 54,000 pregnancies at 12 hospitals botweon 1959 and 1966. The results of a study this size are about as solid as medical scfence can supply. As Jonas H. Ellenberg of the National Institute of Nourological Disorders and Stroke told UPI, “The evidence is very convincing that complications during labor and delivery are not responsible for the meaningful proportion of ca Aospite the almost complete absence of (a) scientific basis for these claims, cerebral palsy cases remain enormously attractive to lawyers . But 400 (eay) of those had a complicated delivery. ‘Thoso cases aro tho most likely to arrive in court, And there the facts are reviewed chronologically, so that the jury sees the undisputed trauma first, the disputed nogligonce socond, (and) the undisputed cerebral palsy third. It is a perfect setup for misinterpreting sequence as cause. Litigatod a more 40 times, with a one-in-two success rate, thet setup can bring a small law firm a one-third share of $60 million or so in settlements, on an upfront investment for expert witness fees and admin- —From ‘Junk Science in the Courtroom.” by P. ‘Huber. Forbos 1991; 148:1:68 (Excerpted from the ‘author's book, Galileo's Revenge: Junk Science in the of cerebral palsy.” And yet, - Some 4,000 babies a year Courtroom.) Journal of Occupational Medicine/Volume 33 No. 11/November 1991 1149