Effects of cold and hand-arm vibration on the peripheral neurosensory and vascular system : an occupational perspective

Background In Swedish working life, exposure to cold and exposure to hand-arm vibration (HAV) are two common health hazards. Health effects of HAV in the neurosensory, vascular and musculoskeletal systems are collectively denoted hand-arm vibration syndrome (HAVS), and have been thoroughly studied. Effects of cold exposure in terms of effects on the peripheral neurosensory and vascular system are on the contrary limited, especially in an occupational setting. Effects of cold exposure or cold injury have not previously been assessed with quantitative sensory testing (QST). Commonly reported symptoms after exposure to HAV and after cold injuries, includes cold sensitivity and sensation of cold. Cold sensitivity can also occur without previous exposure to vibration or cold and may have a major impact on quality of life. Other possible risk factors for cold sensitivity need to be assessed. Sensation of cold hands could theoretically imply an early manifestation of damage to the neurosensory or vascular system, and therefore be of importance to enable early detection of vascular and neurosensory HAVS. The purpose of this thesis was to increase the knowledge about health effects from cold and HAV on the peripheral neurosensory and vascular system, with an occupational perspective. The aims were: first, to identify and evaluate health effects and sequelae in the peripheral neurosensory and vascular system due to cold injury and cold exposure; second, to investigate if sensation of cold hands is a predictor for future onset of Raynaud's phenomenon or paresthesia; and third, to identify possible risk factors associated with cold sensitivity. Methods A case series on 15 military conscripts with local cold injuries in the hands or feet, involving QST and symptom descriptions, was conducted to investigate the hypothesis that cold injuries can result in similar neurosensory and vascular impairments as in HAVS. To assess health effects of cold exposure, a cohort study on 54 military conscripts in cold winter military training, with cold exposure assessments, was conducted. Possible health effects were assessed after 14 months of military training, containing considerable cold exposure, by means of QST, Finger systolic blood pressure after local cooling (FSBP) and a questionnaire. To investigate if sensation of cold hands is a predictor for vascular or neurosensory HAVS we investigated a cohort of 178 employees at a manufacturing company where HAV was a common exposure. The cohort was followed during 21 years and both vibration exposure and health outcomes were assessed regularly. Questionnaire items were used to assess sensations of cold hands as well as signs of Raynaud’s phenomenon and paresthesia. To identify risk factors for cold sensitivity a case-control study was conducted involving 997iiiparticipants from the general population in northern Sweden. The study was cross-sectional and explored possible risk factors for cold sensitivity. Results Cold injuries and cold exposure were associated with reduced sensibility in QST and increase severity and prevalence of neurosensory and vascular symptoms. Our results did not show any impairment in peripheral blood flow due to cold exposure, detectable by FSBP. The risk of developing Raynaud's phenomenon was increased for workers previously reporting sensation of cold hands (OR 6.3, 95% CI 2.3-17.0). No increased risk for paresthesia in relation to a sensation of cold hands was observed. The identified risk factors for cold sensitivity were frostbite in the hands, rheumatic disease, nerve injury in upper extremities or neck, migraine and vascular disease. When analysing women and men separately, women’s risk factors were frostbite in the hands, rheumatic disease, migraine and cold exposure. Men’s risk factors were frostbite in the hands, vibration exposure and nerve injury in upper extremities or neck. BMI > 25 was a protective factor for both men and women. Conclusion Cold injury and cold exposure are associated with impairments in the neurosensory system, detectable by QST. Symptoms such as sensation of cold hands and white fingers indicate vascular involvement, even though no vascular impairments due to cold exposure could be detected by objective measurements. A sensation of cold hands is a risk factor for development of Raynaud´s phenomenon, but not for paresthesia. At the individual level, reporting cold hands does not appear to be useful information when considering the possibility of a future development of Raynaud’s phenomenon. Frostbite in the hands is a risk factor for cold sensitivity among both women and men. For women rheumatic disease, migraine and cold exposure are also independent risk factors, and for men, exposure to HAV. Being overweight is a protective factor for both women and men