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Medical issues surrounding vibration exposure & chronic pain



Plenary lecture by Prof Chris Oliver on "Medical issues surrounding vibration exposure & chronic pain". The UK Conference on Human Responses to Vibration #54UKHRV2019 is an opportunity for specialists from the UK and further afield to exchange information, disseminate research findings and get updated on current issues related to human exposure to vibration. Presented papers cover all aspects of hand-transmitted vibration, whole-body vibration and motion sickness. organisations since the first conference in 1968.
Medical issues
surrounding vibration
exposure & chronic pain
King James IV Professor Royal College Surgeons of Edinburgh
Retired Consultant Trauma Orthopaedic & Hand Surgeon,
Royal Infirmar y Edinburgh
Medicolegal Practice
Associate Research Fellow, Transport Research Institute,
Edinburgh Napier University Twitter @CyclingSurgeon
Prof Christopher W. Oliver
Trauma Orthopaedics
Hand & Wrist
Lecture contents:
Upper limb problems seen by a hand surgeon
Chronic Pain
Medical issues surrounding vibration
exposure & chronic pain
Carpal Tunnel Syndrome is
caused by compression of
the median nerve, which
controls sensation and
movemen t in the hand
It is not always caused by
work-related factors
Ulnar neuropathy
Neck & Plexus
Raynaud s - Medical
Carpal Tunnel Syndrome & Neuropathies
HAVS i s preventable, b u t on c e th e dam a g e is done it is permanent.
HAVS i s serious and disabling, and nearly 2 million people a re at risk.
Damage from HAV S can in c l u de the inability to do fine work and cold
can trigger painful finger b l a n ching a ttacks.
The costs to employe e s and to employers of inaction c o uld be high.
There are simple and cost-ef fective ways to eliminate r i sk of HAVS .
The Control of Vibration at Work Regula t ions focus on the elimination
or control of vibration exposure.
The long-term aim is to prev e n t new cases of HAVS o ccurring and
enable workers to r e m a i n at work without disability.
The most efficient and ef fective way of c ontrolling ex p o sure to h a nd -
arm vibration is to look fo r new or alternative work methods which
eliminate or reduce e x p o s u r e to vibration.
Health surveillance is vital to det e c t an d respond to early signs of
damage u k/vibration/hav/keyme s s a g e s . h t m
HSE key messages for HAVS
Exposure action value of 2.5 m/s2A(8) at which level
employers should introduce tec hnical and organisational
measures to reduce exposure.
Exposure limit value of 5.0 m/s2A(8) which should not be
HAVS regulations
Exposure Points System Ready -Reckoner
HAVS monitoring
Reflex sympathetic dystrophy
Sudecks atrophy
Minor causalgia
Post-traumatic pain syndrome
Painful post-traumatic dystrophy
Painful post-traumatic osteoporosis
Transient migratory osteoporosis
Complex regional pain syndrome
hand or foot
elbow rarely involved
shoulder common
frozen shoulder probably CRPS
hip in pregnancy
Sites of predilection
II with obvious nerve lesion
CRPS types
Preceding noxious event
Spontaneous pain or
hyperalgesia/hyperesthesia not limited to a
single nerve territory and disproportionate to
the inciting event
Oedema, skin blood flow (temperature) or
sudomotor abnormalities, motor symptoms or
trophic changes are present on the affected
limb, in particular at distal sites
Other diagnoses are excluded
Diagnosis IASP (1994)
Pain and hyperalgesia are the most
important symptoms.
75% of patients had pain at rest
Nearly all (100%) patients described
Mechanical hyperalgesia explains the
motion-dependent amplification of pain in
all CRPS patients.
Allodynia (brush-evoked pain)
Record Pain 0-10 Scale
Sensory disturbances
77% of CRPS patients have weakness.
Range of motion is reduced by oedema
in acute stages, in chronic stages
contraction and fibrosis
50 % tremor can be seen
30% myoclonus or focal dystonia
After a nerve lesion 45% of the patients
have exaggerated deep tendon reflexes
Motor disturbances
acute stages 81% patients have oedema
first months of CRPS skin is red and hot
chronic stages skin turns to bluish/cold
20% of CRPS cases are primarily cold
temperature difference between sides is
more than 1.0 °C
50% of the patients increased sweating
Test Tubes
Autonomic disturbances
50% of CRPS patients.
Increased hair-nail growth initially
Later reduced hair-nail growth
Severe cases atrophy of the muscles
with fibrosis and contracture can
Trophic changes
clinical examination
Radiography - spotty osteoporotic 48 weeks. 40%
Three phase bone scintigraphy - increased bone
MRI - exclude other diseases. CRPS oedema in deep
After gadolinium injection subtle enhancement is
seen which points to an increased permeability of
blood vessels but not really specific.
CRPS - Diagnostic Tools
Chronic release of neuropeptides?
central neuropeptide release facilitates
nociceptive sensitization
Nerve lesions
could explain increased skin temperature,
oedema and trophic changes
Sympathetic nervous system failure?
Sympathetico-afferent coupling?
Neurogenic inflammation, pain and
Chronic pain might effect cortical
processing of touch in CRPS
Long term activation of primary afferents
triggers cortical changes
Genetic mechanism?
Psychosomatic background
Why do some patients develop CRPS or
HAVS and others not?
aims CRPS therapy
relief of pain
maintenance or restitution of function
therapy has to start ASAP
Treatment CRPS
Role limited
Not indicated to release contractures
Amputation of a limb affected by severe
CRPS should be approached with great
caution. Unpredictable
Surgery may exacerbate CRPS or
precipitate a new attack
Surgery and CRPS
Sympathetic blocks
Radical scavengers
Calctionin biphosphanates
Gabapentin pregabalin
Specialist Pain Clinic
Drug Treatment CRPS
Functional restoration
Depression and anxiety
Occupational Therapy
Non-drug therapy CRPS
Factitious disorders of the upper limb
Body identity disorder
Factitious disorders of the upper limb
Non healing wounds
Factitious disorders of the upper limb
Costs high.
doctor/patient interface undermined by deception,
risk of litigation.
high index of suspicion/adequate notes
Knowledge of characteristic deformities useful.
Potential gain has many different forms.
CRPS Type 1 suspicion a full review of the hospital
records may indicate similar attendances to other
specialities or previous psychiatric problems.
La belle indifference
Patients with factitious disorders are ill
Psychology or Psychiatry
Factitious disorders of the upper limb
King James IV Professor Royal College Surgeons of Edinburgh
Retired Consultant Trauma Orthopaedic & Hand Surgeon,
Royal Infirmar y Edinburgh
Medicolegal Practice
Associate Research Fellow, Transport Research Institute,
Edinburgh Napier University Twitter @CyclingSurgeon
Prof Christopher W. Oliver

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