Table 2.

Stage assessment of Raynaud's Phenomenon.

Stage Condition of digits Work and social interference

00 No tingling, numbness, or No complaints
blanching of digits

OT Intermittent tingling No interference with

activities

ON Intermittent numbness No interference with activities

TN Intermittent tingling and No interference with activities
numbness

ol Blanching of one or more No interference with activities
fingertips with or without
tingling and numbness

02 Blanching of fingers Slight interference with home
beyond tips. Usually and social activities. No
confined to winter interference at work.

03 Extensive blanching of Definite interference at work,
digits. Frequent at home, and with social
episodes in summer as well activites. Restriction of
as winter. hobbies.

04 Extensive blanching. Most Occupational change to avoid
fingers. Frequent episodes further vibration exposure
in summer and winter. because of severity of signs

and symptoms.

NOTE: Complications are not used in this grading.

50


Page 2 - NIOSH Human Subjects Research Participant Document

3.

10.

Benefits are as indicated in the Purpose and Benefits
Section in Part I.

If alternative procedures advantageous to me are avail-—

able, they are specified in Attachment A; and if they become
available during the project, the procedure most advantageous
for me will be indicated and used or an explanation will be
given to me as to use of any other procedure.

My inquiries will be answered by the project director or
other personnel involved in the project or by Mr. Donald
Wasserman, whose phone number is 513-684-8485.

I am free to terminate my consent and to discontinue
participation in the project at any time without prejudice
to myself.

My identity and my relationship to any information (1)
disclosed by me in completing any project questionnaire
and (2) reported by me or derived from me during my
participation in the above named project shall be kept
confidential and will not be disclosed to others without
my written consent except as required by law and except
that such information will be used for statistical and
research purposes in such a manner that no individual
can be identified. I understand that if any information
is found out concerning me that _can endanger the health
and safety of others, this information will be given to
the proper authority.

If any of my medical records are required for purposes
of this project, a separate written consent for release
of the records will be requested from me.

There will be questions that I will be asked to answer,
and my inquiries concerning the questions will be answered
by Mr. Donald Wasserman, whose phone number is 513-684-8485.

A report uf any significant information from the study that
specifically concerns me, including medical information,
will be furnished by the Project Officer or his designated
representative to me or to my designated physician(s) upon
completion of the study or earlier if appropriate.

114


2. Light-touch (anterior and posterior aspects of wrists, palms, and
digits) using a swath of cotton brushed across these areas.

3. Pain induced by pinprick (anterior and posterior aspects of wrists,
palms, digits).

4. Temperature sensing (anterior and posterior aspects of wrists,
palms, digits) locally applied at a constant 40°C. A new,
pencil-type soldering iron with a round, flat tip was plugged into
the output of an AC variable line transformer (Superior Electric
Co.). The line voltage (and, hence, the iron tip temperature) was
adjusted to produce a constant 40°C tip temperature, which was
periodically monitored during the test day.

After performing the clinical sensory tests, the second physician took a
medical history and did a special examination of the fingers and hands. The
second physician assessed a preliminary stage for the subject at the end of
his examination and tests (according to the stages of VWF given in Table 2).

The subject then moved to Station V (X-ray), Station VI (depth sense and
two-point discrimination), and Station VII (photocell plethysmography). A
sample of subjects also went to Station VIII (dynamic compliance). The
study team members at Stations V, VI, VII, and VIII did not know or have

access to the preliminary stage assessment. They also did not know the
results of the interview or examination.

At the end of each day of testing, both physicians reviewed the medical data
without knowing or considering the results of the objective clinical testing
(i.e., X-ray, depth sense, two-point discrimination, and photocell
plethysmography), and they decided upon a final stage assessment.

=16=


RIGHT BACK

145


« 3LB

12LB...

13LB..

14LB... vse SLB

LEFT BACK

140

1LB,


VIBRATION WHITE FINGER DISEASE IN U.S. WORKERS
USING PNEUMATIC CHIPPING AND GRINDING HAND TOOLS
I: Epidemiology

Project Director
Donald Wasserman

Team Leaders
W. Taylor, Medical-Clinical Testing
V. Behrens, Epidemiology
S. Samueloff, Clinical-Objective Testing
D. Reynolds, Engineering Testing

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Centers for Disease Control
National Institute for Occupational Safety and Health
Division of Biomedical and Behavioral Science
Cincinnati, Ohio 45226

September 1982


Table 65. Classification of VWF stages by temperature and pain
sensory tests on the basis of a blanching classification
rule,

Classes of Blanching Using Rule*

Total Percent
Actual No Blanching Blanching Actually Correctly
VWF Stage Symptoms Symptoms in Stage Classified
00(control)
00(exposed) 122 53 175 70%
OT, ON, and TN (false
positives)
01, 02, and 03 7 65 72 904%
(false
negatives)
Total in
blanching 129 118 247
classes
Percent of
blanching
classes in 95% 55% 76%
actual VWF stage
*Blanching Classification Rule
Temperature Pain test
test result result
N N = no blanching symptoms
N A
A N = blanching symptoms
A A

Note: Twenty-one workers were excluded because of abnormal skin
temperatures,


Table 10. Medical Conditions of Secondary Raynaud's

Phenomenon in the Study Population.

Carpal tunnel syndrome
Severe burn of digit(s)
Frostbite of digit(s)
Scleroderma of digit(s)
Laceration(s) of digit(s)
Extensive hand trauma

Crush injury to digit(s)
Severe clubbing of digit(s)
Operations on digit(s)
Severe arthritis

Mallet finger deformity
Hand deformity

Amputation of digit(s)

High blood pressure (hypertension)
Heart disease
Cardiovascular disease
Peripheral vascular disease
Diabetes

Parkinson's disease

Von Recklinghausen's disease

Table 11. Medical Exclusion Groups.

Hand or digit trauma or disease
High blood pressure
Special diseases

Mixed - more than one medical condition
(except Primary Raynaud's Disease)

Primary Raynaud's Disease

59


RIGHT FRONT

143


Table 22. Number of workers with symptoms at finger segments
for workers using both hands on chisel (exposed group
only) (N=14).

Number of workers reporting
blanching at finger segments,
N=4

Number of workers reporting
numbness at finger segments,
N=11

Number of workers reporting TINGLING

tingling at finger segments,
N=9

LEFT HAND RIGHT HAND

70


6. Unlike the chain saw field, little or no data are available on
pneumatic tool work processes. To date (1975), there are
virtually no morbidity data or reliable vibration measurements of
workers operating pneumatic tools or electrical grinding tools. A
definite need exists for studies that will accurately define the
dose-response relationship of workers using pneumatic tools.

7. This conference emphasized the difficulties in performing
engineering measurements on percussive tools that have attendant
high acceleration levels. These levels sometimes result in
destruction of the measuring accelerometers.

8. Engineering models of the hand-arm system and their relation to
vibratory tools have been devised; however, their validity must be
tested.

oe In the early 1960s, it was claimed that occupational white fingers
in the United States was nonexistent. This claim was probably
incorrect since recent estimates indicate that approximately 1.2
million workers are exposed to hand-arm vibration in the United
States.

10. The FAO/ECE/ILO Joint Committee on Forest Working Techniques
appealed at this conference for worldwide medical monitoring of
vibration-induced white fingers and a uniform reporting system
identifying faulty chain saws.

This conference became a major catalyst for subsequent NIOSH hand-arm
vibration activities, with recommendations 4 through 9 (inclusive) acting
as the basis for this study.

PRESENT STUDY DEVELOPMENT

After the Conference ended, the NIOSH Vibration Study Team obtained the
interest and cooperation of both labor and management to conduct a study of
pneumatic chipper and grinder workers at multiple plant sites. A
preliminary study protocol was drafted, and in January 1977 a meeting was
held to finalize the study protocol. At this meeting of representatives
from labor and management, occupational physicians, and knowledgeable
international consultants, it was agreed that:

1. Laboratory studies were needed to confirm the field study
usefulness of the proposed objective clinical tests
(recommendation 4 above).

2. Additional engineering work would be needed to assure that
measuring transducers would not be destroyed during vibration
measurements (recommendation 7 above).

Consequently, from January 1977 through September 1977, the following
activities occurred:


INTERVIEWER: Checked BY
DATE OF INTERVIEW:
MO DAY YR
SUBJECT IDENTIFICATION
CASE NO.:
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY:
STATE ZIP CODE
PERSONAL DATA
1, TELEPHONE ¢ )
AREA CODE
2. _RACE/ETHNIC 1. White, not of Hispanic Origin
CODE 2. Black, not of Hispanic Origin
3. Hispanic
4. American Indian or Alaskan Native
5. Asian or Pacific Islander
6. Other
3. SEX 1. Male 2. Female
4. What is your date of birth? (month/day/year) yh hi
5. Are you right-handed OR left-handed?

19


125


APPENDIX E
TOOLS USED BY EXPOSED WORKERS ON CURRENT JOBS, PAST JOBS WITH

PRESENT EMPLOYERS, AND PAST JOBS WITH PAST EMPLOYERS (EXPOSURE
GROUP 1 ONLY)

-169-


Table 17. Consistency between VWF symptoms from questionnaire
and clinical diagnosis of VWF. Medical exclusion
cases omitted.

VWF Staging (clinical diagnosis)

VWF Symptoms

(from questionnaire) 00 or ON IN OL 02 03
No reported symptoms 141 0 1 1 0 0 (0)
Tingling only i 24 0 1 0 0 0
Numbness only 0 0 25 (0) 0 0 (0)
Tingling and numbness 0 0 0 46 (0) (0) (0)

Blanched (white)
fingers only 1 10) 0 0 7 3 0

Blanched (white) fingers
and tingling 0 (0) 0 0 11 6 0

Blanched (white) fingers
and numbness 0 0 0 0 2) 6 at

Blanched (white) fingers;
tingling and numbness (0) 0 0 (0) 18 26 9

Missing Data ay 0 0 1 0 0 0

65


deemed to confound chipping hammer exposure. Gasoline-powered chain saws
would also be considered incompatible but no workers reported using this
tool in combination with a chipping hammer. Thus, one worker was excluded
from the exposed group for jackhammer use on his current job. On past jobs,
workers with current job titles of chipper, reported using jackhammers,
riveting hammers, and air tampers in combination with chipping hammers.
Again only the jackhammer/chipping hammer combination was rejected if the
past job was for more than 4 months duration, or if for less than 4 months
duration and the current job was of less than 12 months duration. This time
restriction was applied to the use of any of the tools in Table 5 when not
used in combination with a chipping hammer. This selection criteria for
past jobs excluded 18 more workers from the exposed group and placed them in
exposure group 6 (see below for details of exposure group 6).

Workers who used the tools in categories C and D (see Table 8) on past jobs
for less than 4 months (total of all past jobs with C and D tools) when they
had held their current job for greater than 12 months were included in the
exposed group. This criteria was applied because it seemed unnecessarily
strict to exclude workers who had used these tools, especially jackhammers
and chain saws, on single summer jobs or for very short-term employment
(mostly as general laborers).

Five workers were excluded from the exposed group because of exposure to
vibrating hand tools in Category E that had occurred during off the job
activities or hobbies. Four of these five workers had used gasoline-powered
chain saws for more than two years off the job (see below under exposure
group 7).

In summary, 235 workers were included in the exposed group. Of these
workers, four (see Table 7) did not report using a chipping hammer on their
current job, but all these workers reported using pneumatic grinders. They
were nevertheless included in the exposed group. Appendix E shows the
distribution of tool usage for current and past jobs among the exposed group.

THE CONTROL GROUP - EXPOSURE GROUP 2

Workers were selected for the control group who had never used a vibrating
hand tool on any jobs, present or past. In addition, workers who used hobby
tools in Category E were not included in the control group. Only two
potential control workers had significant hobby exposure and were placed in
exposure group 8. Seventy-two workers met the criteria for a control; 51 of
them from the foundries and 21 from the shipyard. Seven of the acceptable
control workers had used a hobby tool from Category F.

EX-CHIPPERS - EXPOSURE GROUP 3

Workers who did not use a chipping hammer on their current job and did not
have a current job title for a chipper but had held at least one past job

where they had used a chipping hammer were called ex-chippers. The effects
of not being currently exposed to hand-arm vibration upon the reversibility
of VWF are not known. For some severe cases of VWF, the disease is

irreversible. It is not known how the reversibility of VWF varies with

SoS


Table 44.

Mean years on jobs
using a chipping
hammer

Median years on jobs
using a chipping
hammer

Range of years on jobs
using a chipping hammer

Years on jobs using a chipping hammer for
foundry workers by VWF stage.

VWF Stage

00 OT ON TN ol 02 03
N=25 N=14 N=l0 N=29  N=29  N=33 N57
Bae: 1.6 2.2 1.5 2.6 4.0 4.9
1.0 0.9 1.6 ie 2.4 4.0 4.6
0.2 0.2 0.2 0.2 0.5 0.8 1.9

to to to to to to to
14.5 4.4 7.0 5.0 9.5 18.2 9.9

Table 45.

Mean years on jobs
using a chipping
hammer

Median years on jobs
using a chipping
hammer

Range of years on jobs
using a chipping
hammer

Years on jobs using a chipping nammer for shipy.
workers by VWF stage.

VWF Stage
00 oT ON TN ol 02 and 03
N=21 N=6 N=10 N=10 N=5 N=6
7.6 9.0 10.6 19.6 18.1 16.8
5.6 8.3 8.2 17.9 17.3 9.1
0.1 2.4 0.1 4.4 4.7 3.6
to to to to to to
27.9 16.7 27.2 41.9 33.4 38.9

94

ard


3. When the starting date of the earliest job using a chipping hammer
occurred later than June 30 of the onset year, the onset date was
set as December 31 of the onset year.

These criteria were chosen for consistency and conservatism. Criteria 2 and
3 are conservative because they tend to make the latency longer. Tables 25
through 30 give adjusted and unadjusted latencies of tingling, numbness, and
blanching for exposed workers at the foundries and shipyard. Unadjusted
latencies are the full-time period from the starting date for the earliest
job involving the use of a chipping hammer to the onset date of the
symptom. Adjusted latencies, calculated differently, are adjusted for the
periods of time during the unadjusted latency period when the worker was not
employed or worked on jobs where he did not use a chipping hammer.

The degree of adjustment required for each VWF stage group is summarized in
Table 31. The VWF stage of 03 had the highest proportion of workers who had
some jobs where they did not use chipping hammers. Two shipyard workers at
VWF stage 03 had very long periods when they did not use chipping hammers
and these workers contributed greatly to the large number of mean years when
workers in stage 03 did not use chipping tools before the onset of numbness
and blanching. (The tingling onset dates for these two workers were
missing.) The wide disparity for stage 03 between mean and median years
when chipping tools were not used is due to these two outliers. Stage ON
also had a relatively higher proportion of workers not on chipping jobs for
long periods before the onset date of numbness. For most symptoms and
stage combinations, the mean and median latencies were closer after
adjustment because of the reduction of outlying high latencies. Latencies
in the low end of the range were almost unchanged by adjustment. The
adjustment had the most dramatic effect (as would be expected from the data
in Table 31) on the latency of numbness for stage ON workers at the
foundries, latency of numbness for stages 01, 02, and 03 at the shipyard,
and blanching latency for stage 03 at the shipyard.

The mean and median latencies of tingling were less than those of numbness
and these were both less than the latencies for blanching within both the
foundry and shipyard populations. The shipyard had much longer average
latencies for all three symptoms than the foundries. On the average,
workers at the foundries had acquired symptoms of VWF within 2 years while
workers at the shipyard required at least 13 years for all symptoms to
occur. At the shipyard, the median latencies were much less than the
means. Fifty percent of workers with blanching at the shipyard had
blanching within 9 years. At the foundries 50 percent of the workers had
blanching within 1 year and 5 months.

As a measure of VWF risk, the latency of a symptom is not as dependent on
the length of time a population has been exposed to hand-arm vibration as
the prevalence of VWF stages. The latency for blanching is usually longer
than the latency for tingling and numbness.

Two populations with similar exposure characteristics could have disparate
prevalences of VWF cases at stages 01, 02, 03, and 04 but similar latencies
of blanching because the population with the lower prevalence had less

=30=


Case Number

AMP. BLA.

CAL.

CYN.

F.T.U.

CARD NO. 3

DIGITS

J.S. K.P.

SC.-LA.

TRe=FRA.

FS.

LDTP

LDTD

LD11

LD12

LpD13

Loa

LD22

Card No. 03

Case Number

AMP. BLA.

| |

CAL.

CYN.

F.T.U.

CARD NO. 4 7

JS. K.P.

SC.-LA.

F,S

LD23

TR.—PRA,

LD31

LD32

LD33

LD41

LD42

LD43

Card No. 04

7155-

Card Columns

1-4
6-15
16 - 25
26 = 35
36 - 45
46 - 55
56-— 65
66 - 75
79 - 80
1-4
6-15
16 = 25
26 - 35
36 - 45
46 - 55
56 - 65
66 - 75
79 - 80


Table 6. Job titles excluded from the group of workers
currently using chipping and grinding tools.

Percentage of workers
reporting use of chipping

Job title (for current job) hammer on current job
Pneumatic supervisor 50% (1 of 2)
Pipe fitter 25% (1 of 4)
Test specialist 50% (1 of 2)

Table 7. Job titles of workers currently using
chipping and grinding tools.

Percentage of workers
reporting Use of
chipping hammers on

Job title (for current job) current job
Boiler maker 1004 (7/7)
Casting salvage 100% (28/28)
Chip and grind heavy 100% (42/42)
Chip intricate 98% (56/57)
Chip and grind 98% (58/59)
Propellor finisher 96% (24/25)
Pneumatic tool operator (PTO) 97% (30/31)
PTO test specialist 100% (7/7)
Reclaimer 100% (1/1)
Ship fitter 100% (1/1)
Tank specialist 100% (1/1)

55


IILB

ILB

LEFT BACK

139


exposed group to the study population is relatively unchanged before (fourth
column) and after (first column) the workers in the medical exclusion groups
have been subtracted out. Although the prevalence of Primary Raynaud's
disease is lower in the exposed group (1%) than in the control group (44),
the sum proportion of medical exclusions in the exposed group (13%) and
control group (12%) is essentially the same. Both these observations
indicate that the distribution of medical exclusion cases in the exposure
groups is similar, and eliminating them from some analyses will not bias the
results.

The WF staging for medical exclusion cases is given in Tables 14. As this
table shows, not all medical exclusion cases have WF disease because the
physicians designated workers as medical exclusion cases without knowledge

of their White Finger staging. The proportion of medical exclusion cases
who have advanced stages of WF (i.e. stages 01, 02, and 03) is almost the
same in the exposed group (4.7%) and the control group (4.24). This
observation adds to the basis for leaving medical exclusion cases out of
further comparative analyses. The number of medical exclusion cases is
small, and they do not contribute substantial information; however, leaving
them in the analyses may produce bias. RESULTS GIVEN IN THE REMAINDER OF
THIS VOLUME ARE FOR WORKERS WHO ARE NOT IN ANY OF THE MEDICAL EXCLUSION
GROUPS.

=26=


Table 9. Number and Percentage of Workers in the

Exposure Groups (column percents, c%).

Exposure group Total Foundries Shipyard
Exposed group, 235) 159 76
experp 1 (61%) (60%) (624)
Control group, 72 51 21
expgrp 2 (19%) (19%) (17%)
Ex-chippers, 30 23 7
expgerp 3 (8%) (9%) (64)
Mixed past exposed, ES; 12 yy
expgerp 4 (3%) (54) (1a)
Mixed current =) 0 )
exposed, expgrp 5 (2%) (0%) (7%)
Confounded chippers, 19 OME 8
expgrp 6 (5%) (4%) (74)
Exposed with hobby 5 5 0
exposure, expgrp 7 (1%) (2%) (0%)
Control with hobby 2 2 0
exposure, expgrp 8 (1%) (GES) (04%)

38


Table 46. Number (column percent) of foundry workers in exposure
categories (years on jobs using a chipping nammer) and

VWF stage categories.

Exposure category
(years on jobs using
a chipping hammer)

Less than or = 1.5 years

Greater than 1.5 but less
than or = 3.0 years

Greater than 3.0 years

Column totals

00

14(564)

3(124%)

8(32%)

25(100%)

VWF stage category

OT, ON

& TN ol 02 & 03
32(60%)  13(45%) 7(17.5%)

14(272%) 5(174) 7(17.54)

7(13%) —-11(38%) =. 26 (65%)

53(100%) 29(100%) 40(100%)

Chi-square value: 29.8, 6 D.F., p less than 0.00001
Kendall's Tau-B value 0.31, p less than 0.0001

95

Row
total

66

29

52

147


CARD NO. 9

Card Columns

Case Number 1-4
AMP. BLA. CAL. CYN. F.T.U. J.S. K.P. SC.-LA. TR.-FRA. F.S.
RVIP 6-15
RVID. 16 - 25
RV11 26 - 35
RV12 E 36 - 45
RV13 46 - 55
RV21 56 - 65
RV22 66 - 75
Card No. 09 79 - 80
CARD NO. 10
Case Number | [| | | 1-4
AMP. BLA. CAL. CYN. F.T.U. J.S. K.P. SC.-LA. TR.-FRA. F.S.

RV23 H 6-15
RV31 16 - 25
RV32 26 - 35
RV33 36 - 45
RV41 46 = 55
Rv42 56 - 65
RV43 66 - 75
Card No. 10 79 - 80

QO = Absent 1 = Present EXCEPT FOR CALLUS
For Callus: 0 = None 1 = Mild 2 = Moderate 3 = Severe

-158-


APPENDIX B

STUDY QUESTIONNAIRE

by


significantly to the exposure time to the chipping hammer and VWF stage
model.

The relationship of current job title to VWF stage for workers in the
exposed group was also investigated. As with exposure time, this variable
had to be looked at separately for the foundry and shipyard industries
because of the differences in job title descriptions and work designations.
For the shipyard population, no significant differences resulted when the
current job title was compared with VWF stages (see Table 48). In Table 48,
job titles and VWF stages have been categorized because of the small numbers
in cells.

The results for the foundries were very significant (see Table 49). The
proportion of workers whose current job title was casting salvage, decreased
as the severity of the VWF stage increased. The casting salvage group had a
high percentage of workers in stage 00 compared with the other job title
groups. The proportion of workers in the chip/grind-heavy and chip/grind
group increased as the severity of the VWF stage increased. A similar
pattern was found for workers in the chip intricate group, who had the
highest percentage of workers in the severest VWF stages (i.e., 02 and 03).
This association of current job title to VWF stage for the foundry
population was highly statistically significant (see Table 50). Exposure
time did not contribute to this association between current job title and
VWF stage.

Casting salvage workers are an hourly paid group who clean imperfect
castings. They are paid on an hourly basis because the imperfect castings
are difficult and time-consuming to clean. Each imperfect casting requires
a different method to bring it to an acceptable standard. The workers in
the other three groups (chip/grind-heavy, chip/grind, and chip intricate)
are paid on a piece-work basis. These workers have an incentive to work
fast and clean a large number of castings. At both foundries, workers did
not tend to change job title groups within the cleaning department. In
addition, chipping and grinding workers at the foundries were usually new,
young employees who trained into one of the chipping/grinding job title
groups and stayed there until they could progress to a different department
because of increased seniority.

Table 51 shows the distribution of exposed workers according to shift and
industry. A cursory look at the foundries indicates an association between
shift and VWF stage. As Table 52 illustrates, however, the relationship is
due almost entirely to the unbalanced distribution of job title groups by
shift. Two-thirds of the chip intricate group are on the day shift, while
the other two job title groups are about evenly divided between day (or
first) shift and second (or swing) shift (only 6% of foundry workers were
not on first or second shift). For each shift group, the percentage of
workers by job title and VWF stage categories is essentially the same.

Other occupational variables such as glove usage and position while working
were unrelated to VWF staging. For glove usage especially, the percentage
of workers not wearing gloves was very small (see Table 53). Additionally,
no workers were found who had worked with vinyl chloride (another cause of
white finger) on previous jobs to an extent to warrant special analyses.

ep


Table 30. Latencies of blanching for workers in the shipyard (exposed group
only). Latencies are adjusted and unadjusted for the number of
years that workers did not use chipping hammers before the onset of

blanching.
Adjusted latencies Unadjusted latencies

VWF Stage (in years) (in years)
ol (Nn = 5)

Mean 15.7 15.7

Median 16.5 16.5

Range 3.9 - 27.4 3.9 - 27.4
02 (NE =F)

Mean 14.5 14.5

Median 8.0 8.0

Range 4.5 - 30.9 4.5 - 30.9
03 (N = 3)

Mean 8.1 21.1

Median 4.5 23.9

Range 1.8 - 18.0 4.5 - 35.0
01,02, and 03(N = 11)

Mean 13.3 16.8

Median 8.8 16.5

Range 1.8 - 30.9 3.9 - 35.0

78


ACKNOWLEDGMENTS

The Vibration Study Team of the National Institute for Occupational Safety
and Health gratefully acknowledges the interest and help that the following
people and organizations gave throughout the various phases of planning,
preparing, and performing this study: Dr. E. Harris, Dr. W. Parr,
Dr. F. Dukes-Dobos, Dr. B. Craft, Dr. C. Xintaras, Mr. W. Kelley,
Mr. T. Sandlin, Mr. G. Laumann, Ms. oD. Hamilton, Dr. G. Lawton,
Dr. D. Hoeffler, Dr. TT. Markham, Dr. H. Hursh, Dr. J.C. Guignard,
Dr. J. Pearson, Mr. J. Wolfe, Dr. D. Kerr, The Indiana Laborers’ Training
Institute, The Bedford, Indiana, Chamber of Commerce, Bedford Times Mail
newspaper, radio station WBIW, B & K Company, Mr. G. Rasmussen, Mr. A. Romo,
and those companies, unions, and volunteer worker subjects without whose
help this study could not have taken place. We especially thank Ms. Deborah
Hamilton, Mrs. Mary Swenk, and Ms. Frankie Smith for preparation of the
manuscript.

EPIDEMIOLOGY MANUSCRIPT TECHNICAL REVIEWERS

Sweden

I. M. Lidstrom, M.D.

United States

H. Hursh, M.D.
J. Burg, Ph.D.
T. Wilcox, M.D.




INSPECTION OF UPPER EXTREMITIES

Subject ID

A B oC
ILB Ca ha GG 5
IILB ba; Ud ok}

A B Cc
113 tl) fit)
2B WS TE 1
3LB (ok CET 69
4LB t) ¢) 0)
SLB t) ct) )
6LB {1 ¢) 0)
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1S + 77


percentage of yes answers to 9 of the 17 questions compared with
workers with tingling and numbness only (TN).

6. Among workers with tingling, numbness and blanching (1B, 2B, and
3B) the percentage of yes answers increased from 1B to 2B to 3B for
9 of the 17 questions. For the other 8 questions, 1B, 2B, and 3B
had similar percentages of yes answers.

Ts The question regarding aching in the fingers had the highest
percentage of yes answers for 8 of the 10 exposed groups (i.e., EO
through 3B) and the next to highest for the other two exposed
groups.

Tables 35 through 37 show the percentage of yes answers to these 17
questions by VWF stages. The questions have been separated into three
logical groups:

ies Questions about pain and aching in the arms and hands.
2. Questions about difficulty doing things.

36 Questions about pain, tingling or numbness while performing
activities.

The chi-square statistic for homogeneity, trend, and linearity (70) was
calculated for the proportions of yes and no answers for each of these 17
questions by VWF stage (as shown in Tables 35 through 37). The number of
yes answers to questions about pain, tingling, and numbness while swimming
or gardening were too few to do a meaningful analysis. For the remaining 15
questions, the chi-square test for homogeneity and trend were significant at
the 99% level (except for pain and aching in the shoulder, which was
significant at the 98% level). Not all of the trends in the proportions
were linear. In the responses to the following questions, proportions by
VWF stage did not depart significantly from linearity: pain in the hand;
pain and aching in the shoulder; difficulty doing fine work; difficulty
handling coins; difficulty distinguishing hot and cold objects; pain,
tingling, and numbness (PIN) while traveling to work; PIN while watching
sports outdoors; and PTN while doing other hobbies. Because answers to
these questions are not necessarily independent, significance tests are
gross estimates. A multivariate analysis seemed unduly elaborate for these
questions since the proportions in Tables 35 through 37 speak for themselves.

Other health-related factors are thought to be associated with VWF.
Information about two of these factors, tobacco smoking and alcoholic
beverage consumption, was asked on the questionnaire. Tobacco smoking was
hypothesized to be associated with VWF because nicotine is a
vasoconstrictor, and alcohol consumption was hypothesized as related because
alcohol is a vasodialator.

Tables 38 and 39 show tobacco smoking and alcoholic beverage drinking habits
of exposed and control workers by VWF staging. Both past and present (i.e.,

at the time of the survey) tobacco smoking habits were asked on the

=33—


MEDICAL QUESTIONNAIRE

KEYPUNCH INSTRUCTIONS

-152-


Table 16. Prevalence of VWF in the exposed group*
(row percents).

VWF Staging
00 OT, ON and TN Ol, 02, and 03

Exposed

workers —

Foundries

N = 147 17% 36% 47%
Exposed 364% 45% 19%
workers ~

Shipyard

N = 58

Total N = 205 22% 39% 39%

* Medical Exclusion Groups not included.

64


Table 25. Latencies of tingling for workers at the foundries (exposed
group only). Latencies are adjusted and unadjusted for the number
of years that workers did not use chipping hammers before the
onset of tingling.*

VWF Stage Adjusted latencies Unadjusted latencies
(in years) (in years)

oT (N = 13)
Mean
Median
Range 0.1 - 2.8 0.1

0.9
0.3
= 2.8

TN (N = 27)
Mean 0.9
Median 0.4
Range 0.1 - 4.5 0.1 - 16.7

or
oo

01,02, and 03 (N=54)

Mean 1.7 1.9
Median 0.8 0.8 5
Range 0.1 = 13.6 0.1 - 14.5

All stages (N = 94)

Mean 1.3
Median 0.5
Range 0.1 - 13.6 0.1 - 16.7

or

*Data were missing for three workers.

73


W108 -©0/7/5-5 7

FILE COPY

TECHNICAL REPORT )

VIBRATION WHITE

FINGER DISEASE in

U.S. WORKERS USING
PNEUMATIC CHIPPING and.
GRINDING HAND TOOLS

I: EPIDEMIOLOGY


Table 52. Current job titles for all foundry shifts(row percents).

VWF Stage

Day shift 00,0T,ON TN,01,02,03 Row totals
Casting salvage and 9 3) 12
reclaimer 75% 25% 100%
Chip and grind, heavy, and 13 2) 40
chip and grind 32.5% 67.5% 100%
Chip intricate 6 27 33

18% 82% 100%
All other shifts 00,0T,0N TN,01,02,03 Row totals
Casting salvage and 8 5 1s}
reclaimer 62% 38% 100%
Chip and grind, heavy, and 10 23 33.
chip and grind 30% 70% 100%
Chip intricate 3 Mi} 16

19% 814 100%

Table 53. Glove usage and position by industry (for exposed group).

Usage of gloves while working with
vibrating hand tools (current job)

Foundries Shipyard
Yes 98% 97%
No 2% 3%
Usual position while working
(current job)
Foundries Shipyard
Sitting 1% 0%
Standing 99% 69%
Both sitting 0% 31%

and standing

99


DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
ROBERT’A. TAFT LABORATORIES
4676 COLUMBIA PARKWAY, CINCINNATI, OHIO 45226

OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE. $300

Special Fourth Class -Book

POSTAGE AND FEES PAID
U.S. DEPARTMENT OF HHS
HHS 396

DHHS (NIOSH) Publication No, 82-118


HOBBIES

1. Have you ever had any hobbies in which you use vibratory hand tools?
qT. YES NO 8 DK

IF YES ASK:

26 What kind of hobby?

3. What kinds of vibratory hand tools do/did you use?
4. In what year did you first start doing this?

5. In what year did you stop doing this?

6. Have you had any other hobbies using vibratory hand tools?
HOBBY TOOL START YEAR END YEAR
19 19
7__CURRENT
19 19
7_ CURRENT
19) 19__
7__ CURRENT

122


INSPECTION OF LOWER EXTREMITIES

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158-77


FOREWARD

From the onset, it was obvious that this project would require a multivolume
report. Each volume would represent a discrete effort, complete in itself,
without regard to other areas of the project (such as epidemiology or
engineering). All the detailed results of a given project area would be
contained in a volume of the project report, since we simultaneously
attempted to meet the specific needs of engineers, physicians,
physiologists, etc. We recognized that a separate publication bringing
together the salient findings of all areas of this large study would also be
necessary.

Volume I (epidemiology) and Volume II (engineering) represent a straight-
forward presentation of the study results. In Volume I, as well as Volume
IL, we have chosen not to discuss, interpret, or speculate on various
aspects of the results. These discussions will be given in a separate,
all-encompassing publication that combines the results of all areas of the
project. By taking this approach, we are able to meet the needs of those
readers interested in detailed findings as well as those readers mainly
concerned with the conclusions drawn from all aspects of the study.

D. Wasserman
Project Director

Adi


Table 54. Presence of joint swellings on chisel
and throttle fingers (row percents).

Chisel Fingers or Throttle Fingers
Fingers on Non- or Fingers on
Dominant Hand Dominant Hand
Joint Swellings Joint Swellings

WWF Stage Absent Present Absent Present

00 (control) 56 1 53 4

N= 57 98% 2% 934% Th

00 (exposed) 30 4 29 5}

N = 34 88% 12% 85% 15%

OT and ON 27 6 28 5

N = 33 82% 18% 85% 15%

TN 28 7 30 5

N = 35 80% 20% 864 14%

ol 23 9 27 5

N = 32 72% 28% 84% 164

02 and 03 BS) 9 35 %)

N = 44 79% 21% 804 20%
Chi-square value = 14.2 Chi-square value = 3.9
5 D.F. p = 0.015 5 D.F. p = 0.56
Kendall's Tau-B value Kendall's Tau-b value
= 0.19, p less than 0.0001 = 0.10 p less than 0.05

100


OCCUPATIONAL HISTORIES AND EXPOSURE GROUPS

Interviewer-administered questionnaires were used to obtain data about occu-
pational histories from the 385 male workers participating in the study,
(see the Study Questionnaire, Appendix B). The information collected for
each job with present and past employers is given in Table 3. A maximum of
four jobs with a present employer and five jobs with past employers were
recorded in computer files. Present employer refers to the employer at the
time the survey was conducted. The occupational histories provided the
fundamental information for assigning workers to exposure groups. Data were
also obtained about the use of vibrating hand tools during hobby activities
(see Table 3). A maximum of three hobbies were recorded.

Verbatim responses of subjects were recorded on questionnaires for the
following occupational history and hobby variables: department number, job
title, tool types, past employers, type of company, and hobby type. All of
these variables except for past employers were numerically coded for the
computer files. Frequently more than one tool was listed by workers for
each job. Single tools were not given a code, instead unique combinations
of tools were assigned different codes. The code descriptions and their
frequency of occurrence for these variables are given in Appendix D.

The current job (i.e., the job with the present employer at the time of the
survey) was recorded for all workers studied. For jobs other than the
current one, only jobs requiring the use of vibrating hand tools were
recorded on the questionnaires; this included past jobs with present
employers and past jobs with past employers. Table 4 summarizes the number
and percent of these jobs.

The occupational history variable "vibrating hand tool used on the job"
yielded the most information about exposure to hand-arm vibration. Since
the purpose of this study was to investigate workers using pneumatic
chipping and grinding tools on their current jobs, tool codes that included
a chipping hammer were of primary interest. Grinding tools were included
because they are usually used in combination with chipping hammers.
Chipping hammers and grinders were not the only hand-held vibrating tools
used by the workers studied on their present and past jobs (see Appendix D,
Tools). Hand-arm vibration exposure from some of these tools confounds
exposure to chipping and grinding tools because their occupational use has
been shown to cause VWF.

The information used to determine which tool exposures would confound
exposure to chipping and grinding tools was taken mainly from the little
vibration measurement data available and the results of previously
mentioned, epidemiologic studies. For some of the tools in Appendix D,
however, data do not exist. For these tools, as much knowledge as possible

pS


ODMADOS TNO AZMOVWMV m<—Ayrc]eco

100 -

905

705

505

405

30+

204

104

Figure 4,

LATENCY OF TINGLING
FOUNDRIES AND SHIPYARD
(VWF STAGES OT,TN,01,02,03 — EXPOSED GROUP)

2)

LEGEND: SITES #=-=s FOUNDRIES
++ SHIPYARDS

T T

D T T T T =
0 5 10 15 20 25 30 35

YEARS WORKING WITH A CHIPPING HAMMER
BEFORE ONSET OF TINGLING

80


Table 27. Latencies of numbness for workers at the foundries (exposed group
only). Latencies are adjusted and unadjusted for the number of
years that workers did not use a chipping hammers before the onset
of numbness.*

Adjusted latencies Unadjusted latencies
VWF Stage (in years) (in years)
ON (N = 9)
Mean Ee8 4.5
Median 1.2 1.8
Range 0.1-6.4 0.1-22.3
TN (N = 27)
Mean 0.9 1.8
Median 0.4 0.4
Range 0.1-4.5 0.1-16.7
01,02, and 03 (N = 44)
Mean 1.8 2.0
Median 1.2 1.4
Range 0.04-13.6 0.04-14.5
All Stages (N = 80)
Mean 1.5 2.2
Median 0.7 0.8
Range 0.04-13.6 0.04-22.3

*Data were missing for two workers.

75


number . Size reduction also made field measurements more feasible.
Accelerometers capable of measuring vibration from percussive pneumatic
tools have only been available in the last few years. The problems with
accelerometers stem from the very high impulsive vibration levels that
cause destruction of the accelerometers as well as problems of spectral
accuracy at the low frequency end of the measurement (referred to as DC
shift). The greater number of measurement studies have measured
gasoline-powered chain saws (30).


26.

27.

28.

29.

30.

31.

32.

I36

34.

35.

36.

37.

38.

39.

Suzuki, H. 1978. Vibration Syndrome of Vibrating Tool Users in a
Factory of Steel Foundry. Jap. J. Ind. Health, 20:261.

Iwata, H. 1968. Effects of Rock Drills on Operators. Part 2. Survey
and Examination on Raynaud's Phenomenon. Industrial Health. 6(1-2):37.

Chatterjee, D. S., A. Petrie, and W. Taylor. 1978. Prevalence of
Vibration-Induced White Finger in Fluorspar Mines in Weardale. Brit.
J. of Ind. Med. 35:208.

Pelmear, P., and W. Taylor. 1975. The Results of Long-Term Vibration
Exposure with a Review of Special Cases of Vibration White Finger in
Vibration White Finger in Industry. Academic Press.

Part IV, Chain Saw Presentations. 1977. In: Proceedings of the
International Occupational Hand-Arm Vibration Conference (D. Wasserman,
W. Taylor and M. Curry). DHEW (NIOSH) Publication No. 77-170.

Cargile, C. H. 1915. Raynaud's Disease in Stonecutters Using
Pneumatic Tools. J. Am. Med. Assoc. 64:582.

Cottingham, C. C. 1917. Cited in the President's Monthly Report,
Stonecutters Journal. FLA Si Comments on the President's Monthly
Report, ibid., 32:9.

Rothstein, T. 1918. Report of the Physical Findings in Hight
Stonecutters from the Limestone Region of Indiana: An Effect of the
Air Hammer on the Hands of Stonecutters. Bulletin 236, U.S. Department
of Labor, Bureau of Labor Statistics, Industrial Accidents and Hygiene
Series, No. 19.

Leake, J. P. 1918. Health Hazards from the Use of the Air Hammer in
Cutting Indiana Limestone. Public Health Reports. 33:379.

Dart, E. E. 1946. Effects of High Speed Vibrating Tools on Operators
Engaged in the Airplane Industry. Ocucp. Med. 1:515.

Pecora, L. J. 1960. Survey of Current Status of Raynaud's Phenomenon
of Occupational Origin. J. Am. Ind. Hyg. Assoc. 21:80.

Wasserman, D., D. W. Badger, T. E. Doyle, and L. Margolies. 1974.
Industrial Vibration - An Overview. J. Am. Soc. Safety Eng.
19(6):19-38.

Williams, N., and E. B. Byrne. 1974. An Investigation to Determine
the Qualitative and Quantitative Extent of Health Records and Injury
Claims Records of Workers Exposed to Hand Tool Vibration in U.S.
Industry. Final Report, NIOSH Contract No. HSM-99-73-56.

Wasserman, D. E., W. Taylor, and M. G. Curry, editors. 1977.

Proceedings of the International Occupational Hand-Arm Vibration
Conference. DHEW (NIOSH) Publication No. 77-170.

a5


TOOL NAMES FREQUENCY

Fine Grinders

Hydraulic and Air Machine

Impact Wrench; Chipper

Impact Wrench; Grinders; Drills

Impact Wrench

Impact Wrench; Chipper; Grinder

Impact Wrench; Chipper; Grinder; Sander
Impact Wrench; Grinder

Jackhammer 2:
Jackhammer; Chipper; Drills

Machine Gun

Jackhammer; Drill

Jackhammer; Chipper; Grinder

Needle Guns; Bumble Bees; Buffers
Pneumatic Drill

Pneumatic Lug Remover

Pneumatic Hammer; Drill

Riveting Hammer; Drill

Riveting Hammer; Chipper; Grinder; Saw; Drill
Router; Sander; Planer

Router; Sander

Sander

Tamping Hammer; Grinder; Chipper

Tamper

Torque Gun

Vibrators to Pack Ground

Air Hammer; Cement Vibrator

Air Hammer; Air Tamper

Skill Saws; Air Hammer

Power Shread; Cement Vibrator

Air Drill; Air Nail Gun

Pneumatic Brushes

Grinders; Rebarcutter

Grinder; Air Chisel

Jackhammer; OMC Machine

Scaling Hammer; Chipping Hammer; Air Tools
Cement Drill; Impact Wrench; Roto Hammer

a a a a a OO a a CC a OO OS

-162-


TNTW

TNS

TNG

TNWC

TNWS

TNPG

TNOH

Table 37.

Percentage of yes answers to questions about pain, tingling,

or numbness during activities (see Table 32 for legend of row

symbols).

00 (control)
N=63

0%
0%
0%

0%

0%

2%

00 (exposed)
N=46

24h

VWF Stage

87

oT

ON

TN

N=20 N=20 N=39

15%

15%

10%

10%

04

154%

36%

154%

31%

26%

OL
N=34

12%

02
N=30

614

3h

03

N=L0

604

1U4

404%

604

504

204

504


TOOLS FOR JOBS

TOOL NAMES

Air Chisel

Air Tools for Mechanics
Air Drill; Grinders
Air Grinder

Air Gun

Air Hammer; Drill
Air Hammer; Grinders

Air Hammer; Grinders; Pneumatic Saws; Pneumatic Drills

Air Hammer; Pencil Grinders
Air Tampers
All Pneumatic Tools

Pneumatic Tools; Grinders; Sanders

Air Wrench
Buffer; Drill

Chipper;

Chipping Hammer; Saws; Grinders; Riveting Hammer
Chipping Hammer; Grinder; Planer; Chisel

Drills; Saw

Chain Saw

Chipper;
Chipper;
Chipper;
Chipping
Chipping
Chipping
Chipping
Chipper;
Chipper;
Electric
Electric
Electric
Electric
Electric
Chipper;
Electric
Grinder;
Grinder;
Electric

Grinders;

Grinders

Grinders;

Grinder; Drills
Grinder; Drill; Sander
Grinder
Hammer; Grinders; Saws
Chisels

Gun
Hammer

Drill; Impact Wrench
Grinder; Saw; Sander
Drill

Impact Drill; Jackhammer
Drill; Saw

Nut and Bolt Remover
Saw; Jackhammer
Grinder; Riveter
Riveter
Drill; Saw

Needle Gun; Deck Crawler
Saw

Saws

Drills

Hand Chisel

-161-

FREQUENCY

~

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Neoe ro
FOr RE ENUF UPURNUNNOVEEE

~

a
FONE RRP PRP PRP EPRNENEUW BNW


Table 18. Workers with inconsistencies between VWF symptoms
on questionnaire and VWF diagnosis.

a

A test specialist at the shipyard with a past history of using a
chipping hammer (ex-chipper-EXPGRP 3). This worker answered yes to the
question on the questionnaire concerning blanched fingers. The
physicians recorded that he nad only one attack of blancned fingers
during World War II, when he was exposed to extreme cold while on guard
duty in the army. Because he experienced no tingling or numbness, ne
was staged 00.

A propeller finisher at the shipyard with no past jobs involving the use
of vibrating hand tools (exposed - EXPGRP1). This worker had a history
of arthritis, was sensitive to the cold, and was on astnma medication.
Although the physicians had recorded TN on the questionnaire, he
answered no to the questions regarding tingling and numbness. Tne
physicians reviewed this inconsistency and decided to accept the
diagnosis, although no record was made of tingling and numbness for this
worker.

A pneumatic tool operator at the shipyard (for 1 year) who had used a
jackhammer at a pavement company for 10 years (confounded chipper -
EXPGRP 6). Although this worker gave a negative response to tne
question concerning numbness, a medical examination and interview
established that he had intermittant numbness . Thus, he was staged ON.

A core finisher at Foundry 1 with no history of using vibrating hand
tools (control - EXPGRP 2). This worker answered yes to the question
regarding tingling. During a medical review of his data, however,
physicians noted that tingling had occurred in 1961 and had not
reoccurred since then. He was staged 00.

A chip intricate worker at Foundry 1 (for 1 year) with no past jobs
involving the use of vibrating hand tools (exposed - EXPGRP 1). He
answered yes to the tingling and numbness questions on the questionnaire
but gave a "don't know" answer regarding finger blanching. The
physicians recorded the same symptoms and a stage ot TN.

A chipper/grinder at Foundry 1 (for 1 year) and no past jobs involving
the use of vibrating hand tools (exposed - EXPGRP 1). Altnough tnis
worker answered yes to tingling and no to numbness on the questionnaire,
the physicians determined that he had numbness and tingling during
exposure to’cold (while snowmobile riding) he was staged TN.

A chip/grind, heavy worker at Foundry 1 with one past jop involving the
use of a pneumatic drill to install air conditioners (exposed EXPGRP

1). He answered "don't know" to all three symptoms on the
questionnaire, The physicians recorded that he didn't have any symptoms

of VWF and was staged 00.

66


VWF STAGING AND LATENCY

As stated previously, the results given in the remainder of this volume are
for workers who are not in any of the medical exclusion groups. Table 15
presents the VWF staging for workers in the study by exposure group and
industry. As expected, all of the workers in the control group did not have
VWF (i.e. stage 00) after medical exclusion cases were eliminated. The
results in Table 15 have been summarized in Table 16. This table shows the
prevalence of VWF in the exposed group. The prevalence of VWF (stages 01,
02, and 03) in the two foundries was higher than in the shipyard
population. The overall population VWF prevalence is strongly influenced by
the VWF prevalence in the foundries which had a larger study population than
the shipyard. Chi-square tests for association between exposure and Vw
were carried out for the exposed and control groups, with and without
medical exclusion cases, for the total population, and by industry. All
tests were highly significant (p less than 0.0001), which confirmed a
statistical association between hand-arm vibration exposure and VWF.

Three primary symptoms are important in diagnosing VWF: 1) blanching, 2)
numbness, and 3) tingling of the fingers. The VWF staging reflects the
importance of these symptoms, which people with VWF often will have after
exposure to cold or during sleep. Workers in this study were asked about
these symptoms during questionnaire interviews before they were clinically
interviewed, examined, and diagnosed by the physicians, and again when
clinically interviewed. Table 17 is a comparison of the questionnaire
responses for these VWF symptoms and the VWF staging from the clinical
diagnoses. This table displays the consistency of reporting for these
different methods of collecting the same data variables. An inconsistency
existed between the questionnaire and diagnosis data in only seven workers.
The data for these seven workers were reviewed by the project medical
doctors; Table 18 gives the explanations for these inconsistencies.

When a worker reported symptoms of finger blanching, numbness, or tingling,
the location of these symptoms on the fingers were recorded for each finger
segment (see Study Questionnaire, Appendix 8). Tables 19 through 22
summarize symptom location data for workers in the exposed group. Some
observations about the data presented in these tables follow:

1. For all three symptoms the thumb was less affected than the other
fingers. The thumb on the throttle of the chipping hammer was more
affected by all three symptoms than the chisel thumb. Workers
reported more numbness and tingling of the thumb than blanching.

2. For all symptoms and fingers the distal segment of the fingers was
most affected and the proximal segment least affected (with the
middle segment in between).

==


PAST JOBS WITH PRESENT EMPLOYERS (EXPOSURE GROUP 1)

TOOLS

Chipping Hammers
Pneumatic Grinders
Pneumatic Impact Wrench
Pneumatic Drills
Pneumatic Saws
Electric Drill

PERCENT OF PAST JOBS
WITH PRESENT EMPLOYERS

FOUNDRIES SHIPYARD
1&2
(N=75)* (N=16)*
97% 63%
96 8L
1 0
0 19
13
©

* Total number of past jobs with present employer.

-171-


TEMPERATURE, PAIN, AND LIGHT-TOUCH SENSORY TESTS

Temperature, pain, and light-touch sensory tests were performed on each
worker. The methods used to perform these three tests are given in the
section, "Methods: Medical-Clinical Testing." Before these tests were
performed, the skin temperature of the fingertips, webs, and palms were
measured. If the skin temperatures were abnormal (below 85°F) and the
hands could not be warmed, the sensory tests were considered invalid.
Twenty-one workers in the control and exposed groups had abnormal skin
temperatures and their sensory test results were excluded.

In each of the three tests, a normal or abnormal response for each finger
was recorded. This gave 30 (3 tests times 10 fingers) test results for each
worker. The results for the 10 fingers were summarized (by the physician
who performed the sensory test) into one result for each test according to
the following criteria:

1. If the subject had only normal responses for the digits of both
hands, the subject was determined to be normal for that test.

2. If the subject had one or more abnormal responses, the subject was
determined to be abnormal for that test except when all the abnormal
responses could be attributed to medical causes such as scars or
lacerations (then the subject was determined to be normal).

The number of workers in each VWF stage who had any possible combination of
normal and abnormal responses to the sensory tests is given in Table 61. The
control group had normal responses to all three tests except for one worker
(this worker tested abnormal to temperature sensing). Ninety percent of the
workers with blanching (VWF stages 01, 02, and 03) tested abnormal to the
temperature or pain test (an abnormal response to the light-touch test
always accompanied an abnormal response to one of the other two tests in
this group).

On a population basis, the association between sensory test results and VWF
stage was highiy significant as measured by both the chi-square test (p less
than 0.001) and the lambda measure of proportional reduction in error

(p less than 0.001) (70). On an individual basis, though, these tests do
not accurately predict the VWF stage of a worker. This is due primarily to
the contradictory results for workers in stages OT, ON, and TN. These
workers had 42% who were normal to all three tests, with the rest abnormal
for at least one of the three tests (40% of this group were abnormal on both
the temperature and pain test).

The results shown in Tables 62 and 63 demonstrate that the light-touch test
added very little information and may somewhat confuse the interpretation of

=39=


Table 62. Percentage of workers in each VWF stage with zero
to three abnormal responses on the temperature,
pain, and light-touch tests (column percents).

00 00 OT
(control) (exposed)

All normal
responses 98% 67% 61%

One Abnormal
response 2% 19% 17%

Two Abnormal
responses 0% 7% 11%

Three Abnormal
responses 04% 7% 11%

VWF Stage
ON TN
44% 31%

64% 114
28% 41%
22% 174%

ol

9%

28%

41%

224

02

13%

13%

29%

45%

Table 63. Percentage of workers in each VWF stage with zero
to two abnormal responses on temperature and pain
tests (column percents).

00 00 OT
(control) (exposed)

All normal

responses 98% 74% 614

One abnormal
response 2% 16% 17%

Two abnormal
responses 0% 10% 22%

VWF Stage
ON TN
504 31%

0% 25%
50% 44%

108

OL

9%

354%

56%

02

13%

26%

61h

03

11%

89%

03

33%

67%


13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25)

Tiilila, M. 1970. A Preliminary Study of the "White Finger" Syndrome
in Lumberjacks Using Thermographic and other Diagnostic Tests.
Work-Environment-Health. 7:85.

Miura, T., K. Kimura, Y. Tominaga, and K. Kimotsuki. 1966. On the
Raynaud's Phenomenon of Occupational Origin due to Vibrating Tools -
Its Incidence in Japan. Rep. of the Institute for Science of Labor,
No. 65.

Allingham, P. M. and R. D. Firth. 1972. The Vibration Syndrome New
Zealand Med. J. 76(486):317.

Hellstrom, B., I. Stensvold, J. R. Halvorsrud, T. Vir. 1970. Finger
Blood Circulation in Forest Workers with Raynaud's Phenomenon of
Occupational Origin. Int. Z. Angew Physiol. 29:18.

Axelesson, S. A. 1977. Progress in Solving the Problem of Hand-Arm
Vibration for Chain Saw Operators in Sweden, 1967 to Date. In:
International Hand-Arm Vibration Conference (D. Wasserman, W. Taylor,
and M. Curry). DHEW (NIOSH) Publication No. 77-170.

Taylor, W., and P. L. Pelmear. 1975. Vibration White Finger in
Industry. Academic Press, London.

Lidstrom, I. M. 1977. Vibration Injury in Rock Drillers, Chiselers
and Grinders. In: The International Occupational Hand-Arm Conference
(D. Wasserman, W. Taylor, and M. Curry). DHEW (NIOSH) Publication No.
77-170.

Mikulinskii, A. M. 1967. The Effect of Vibration of Various Ranges of
High Frequency on Some Physiological Functions of the Organisms of
Working Men. Gig. Trudor. i Prof. Zubolavaniga, 11:48.

Agate, J. N., H. A. Druett, and J. B. L. Tombleson. 1946. Raynaud's
Phenomenon in Grinders of Small Metal Castings. Brit. J. Ind. Med.
3:167.

Bovenzi, M., L. Petronio, and F. D. Marino. 1980. Epidemiologic
Survey of Shipyard Workers Exposed to Hand-Arm Vibration. Int. Arch.
of Occup. and Envr. Hlth. 46:251.

Asanova, T. P. 1975. Vibration Disease Among Workers Using Portable
Power Tools in Finnish Shipyards. Proceedings of the Finnish-Soviet-
Scandinavian Vibration Symposium in Helsinki.

Glass, S. W. 1979. Vibration Analysis of High Cycle 5400 Hand
Grinders Used on Flat Steel Plates. Arbete Och Halsa, 1979:32.
Stockholm.

Hunter, D., A. I. C. McLaughlin, and K. M. A. Perry. 1945. Clinical
Effects of the Use of Pneumatic Tools. Brit. J. Ind. Med. 2:10.

ahha


FAMILY HISTORY

1. Have any of your blood relatives (parents, brothers, sisters) been told py
a doctor that they have white fingers or Raynaud's disease?
L YES 2 NO 8 DK
IF YES ASK:
2. Which relatives have this?
3. Do any of your other blood relatives have "white fingers"?

IF YES ASK:

4. Which relative?

SPECIFY "OTHER" RELATIVE

5.
hobby?

(ENTER RELATIVE CODE. E.G., 1 FOR MOTHER) 1

Have any of your blood relatives ever been told by a doctor that

1 YES 2

NO 8 DK

(RELATIVE CODE #)

Has he/she (have they) ever used vibratory hand tools at work,

RELATIVE CODE

1 Mother 4 Sisters
2_ Father 5__Cousins-M
3__ Brothers 6__Cousins-F

7__Other

or ina

YES 2 NO 8 DK RELATIVE

1 YES 2 No 8 DK RELATIVE
1 YES 2 no 8 DK RELATIVE
tney have

any of the following health conditions?

High blood pressure?
Diabetes?

8. Cardiovascular diseases
Arthritis?

10. Do any of them have frequent pain

aching in their joints?

TESSYES
1__YES
1__YES
DaayES

or
1__YES

129

2

2

2

2

NO 8 DK
NO 8 DK
NO 8 DK
NO 8 DK
NO 8 DK


results for these sensory tests. Of the 60 workers who were abnormal for
the light-touch test, 93% were abnormal also for the temperature and/or pain
test. Of the four workers who were abnormal for the light-touch test only,
three of these workers were in stage 00 of the exposed group. All of the
control group workers had normal responses to the light-touch test. The
workers in VWF stage 01, 02, and 03, however, did much worse on this test
than on the other two tests. Of the 72 workers in the blanching stages (VWE
stages 01, 02, and 03) 58% showed normal response on the light-touch test.
Tables 64 and 65 use two classification rules to show how well the results
of the temperature and pain sensory tests can be used to classify workers
into VWF stages. Table 64 divides workers into two groups: those without
symptoms of tingling, numbness or blanching and those with one or more of
these symptoms. This classification rule is best for correctly classifying
workers who are normal to both tests as being in stage 00. The false
negative rate is high (29%), however, and 81% of these false negatives were
in the VWF stages of OT, ON, and TN.

The second classification rule (Table 65) uses the temperature and pain test
results to classify workers into those without blanching symptoms and those
with blanching symptoms. This classification is best for correctly
classifying workers in stage 01, 02, and 03. The false positive rate is
high (45%) however, 77% of these false positives were in the VWF stages of
OT, ON, and TN. If the workers in these tingling and/or numbness stages are
excluded from the analysis, the sensory tests would accurately predict the
VWF stage of workers with or without blanching symptoms. This analysis is
unrealistic, of course, because workers of all VWF stages can be present in
a population.

-40-


Table 21. Tingling of finger segments.

Percent reporting tingling at each finger segment among all wno
reported tingling (exposed group only)(N = 120)

*Left hand for those using *Right hand for those using
left hand on chisel, N = 104 left hand on chisel, N = 104
*Right hand for those using *Left hand for tnose using
right hand on chisel, N = 6 right hand on chisel, N = 6

One worker had missing data
Nine workers used both hands on chisel (see Table 22)

69


Table 31. Years of work on jobs not involving the use of chipping hammers
for workers with tingling, numbness, or blanching (exposed group

only).

OT
Number of workers 4
Percentage of stage group 20%

Mean years of work not
involving the use of
chipping hammer 6.6

Median years of work not
involving the use of a
chipping hammer 1.8

Range of work years not
involving the use of a
chipping hammer 1.3

Mean years of work without
a chipping hammer before 1.6
the onset of tingling (N=2)

Mean years of work without
a chipping hammer before
the onset of numbness =

Mean years of work without
a chipping hammer before
the onset of blanching -

6.3

(n=3)

79

VWF Stage

TN ol

6 3

15% 9%
5.0 0.9
FS) 0.7
+08 = 0.2
15.6 1.9
5.0 1.9
(N=6) (N=1)
50 1.9
(N=6) (N=1)
- 1.9
(N=1)

03

704

6.4

1.3

+04

33.2

1.0

(N=2)

10.7
(N=4)

10.3
(N=4)


questionnaire, but only present consumption of alcoholic beverages was
asked. Statistical tests for association of the two factors (both
separately and in various combinations) to VWF staging did not show any
significant relationships. Although the control group of workers under 25
years of age had significantly fewer smokers than the exposed group of the
same age group, there was no association between smoking and VWF stage
groups among the exposed population. For alcoholic beverage consumption,
the levels of drinking were almost identical among the control and exposed
group and VWF stage groups.

The occurrence of most diseases is associated in some way with age. Date of
birth was ascertained for each worker in the study population. Tables 40
through 43 characterize the ages of the population by exposure, medical, and
industry groups. The exposed group from the foundries was much younger than
the exposed group from the shipyard, while the reverse was true of the
control group (see Tables 40 through 42). When industries are combined, the
exposed and control groups have similar age distributions (see Table 42).
The workers excluded for medical reasons were in general older (see Table
43) because many of the medical conditions that confound a diagnosis of VwF
are diseases of older age.

Statistical tests of association did not reveal any relationships between
age and occurrence or stage of VWF. This result is expected since the data
show that exposed foundry workers were relatively young and had a high
prevalence and short latency for VWF. Control workers spanned all age
groups and none had VWF. Even among shipyard workers, age had no
significant effect on the probability of having VWF. Exposure to hand-arm
vibration remains the primary factor associated with VWF. The length of
time exposed and the type of exposure will be discussed in the next section.

=3G%


OCCUPATIONAL HISTORY

READ: Now I'm going to ask you about all tne jobs you've held,
including part-time jobs and military service. I'd like to
begin with your present job, here at (Insert-Employer), and
go back to your first job.

JOBS WITH PRESENT EMPLOYER

1. What department do/did you work in?

2. What is/was your occupation or job title?

3. In what month and year, did you start working on this/that job?

4. And, in what year and month did you stop working on tnis/that job?

5. Are/were you a full-time OR part-time employee?

6. What shift do/did you regularly work? (Do you work 7 to 3, 3 to ll, OR

11 to 7?) fir

7. On this/that job, do/did you use any vibratory hand tools?

IF YES ASK: 8. What kind of vibratory hand tool?
9. Did you use any other vibratory nand tools?

10. Do/did you do most of your work sitting OR standing?

11. Do/did you almost always wear gloves while working with a vibratory

hand tools?

12. Have you had any other jobs here at where you used

vibratory hand tools?
(IF YES: REPEAT Q. 1-11. ASK Q. 12 UNTIL YOU HAVE RECORDED ALL JOBS
WHERE VIBRATORY HAND TOOLS WERE USED.)

DEPARTMENT JOB TITLE DATES FULL-TIME TOOL GLOVES
START/END PART-TIME TYPE POSITION

ia T FI T_SITTING 1_ YES
2 PT 2_STANDING 2 NO
2a T FT I_SITTING 1_ YES
2 PT 2_STANDING 2_NO
a T Fr i__7-3 T_SITTinc 1_ YES
2 PT 2 3-lL 2_STANDING 2_NO

= 3_ 1-7

4—_ ROTATE
La st 2 NE SE Fx} T_SIttinc 1_ YES
2 PT 23-11 2_STANDING 2_NO

3_-7

4 ROTATE

120


Table 58. Relationship between joint swellings, knuckle pads,
or calluses and years working on jobs using a chipping

hammer (row percents).

Chisel Fingers Throttle Fingers

Joint Swellings

Absent Present
Less than 1.5 years at foundries (67) (17) (Joint swellings
or less than 10.0 years at shipyard 804% 20% on throttle
fingers not
Greater than 1.5 years at foundries (76) (18) significant.)
or greater than 10.0 years at shipyard 814 19%
Chi-square prob. = 0.86
Knuckle pads Knuckle pads
Absent Present Absent Present
Less than 1.5 years at foundries (57) (27) (62) (22)
or less than 10.0 years at shipyard 68% 32% 74% 264
Greater than 1.5 years at foundries (51) (43) (64) (30)
or greater than 10.0 years at shipyard 54% 46% 68% 32%

Chi-square prob. = 0.064 Chi-square prob. = 0.40

Calluses Calluses
Absent Present Absent Present
Less than 1.5 years at foundries (45) (39) (35) (49)
or less than 10.0 years at shipyard 54% 46% 42% 58%
Greater than 1.5 years at foundries (38) (56) (20) (74)

or greater than 10.0 years at shipyard 404

Chi-square prob. = 0.079

104

604% 21% 79%

Chi-square Prob. = 0.003


Part I.

II.

U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service

Center for Disease Control

National Institute for Occupational Safety and Health

Cincinnati, Ohio 45226
Project Description

Project Title and Number: Prevalence of Raynaud's Disease in
Chippers and Grinder Operator's Using
Vibrating Hand Tools (G-21, 7-9277328)

Project Director: Mr. Donald Wasserman
National Institute for Occupational
Safety and Health
4676 Columbia Parkway
Cincinnati, Ohio 45226
Telephone: (513) 684-8485

Purpose and Benefits: The major purposes of this study is
to determine the prevalence of (VWF)
Vibration White Finger syndrome
(Raynaud's Disease) and relate this to vibratory hand-tool use
and vibration dose testing a work population of chippers and
grinders known to be exposed to vibrating tools. Further, the
results from this study will be uSed to (1) establish a dose-

‘response relationship regarding vibration effects for the studied

populations; (2) provide preliminary technical guidelines to tool
manufacturers for the reduction of vibration in the tool types
studied, and (3) investigate the validity of certain medical tests
for early detection of VWF syndrome.

CONSENT TO PARTICIPATE

qT, >» age » hereby voluntarily agree
to cooperate in the above named study and to undergo the tests
listed in Attachment A. The study has been discussed with me and
I have been given a copy of this document. I understand that:

1. The procedures and tests to be followed are as stated in
Attachment A with those procedures which are experimental
so identified.

2. Attendant discomforts and risks are as noted in Attachment A
and, except as noted, are minimal and provision has been made
for any necessary emergency medical care, and I have been told
what to do if I have any reaction.


U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE
Public Health Service
Centers for Disease Control

National Institute for Occupational Safety and Healtn

STUDY QUESTIONNAIRE

Prevalence of Raynaud's Disease in Chipper and Grinder
Operators Using Vibrating Hand Tools

CDG/NIOSH (C)TF 2.214

9-77

118


RIGHT FRONT

142


++12RB

++13RB

RIGHT BACK

146


DISCLAIMER

Mention of company names or products does not constitute endorsement by the
National Institute for Occupational Safety and Health.

OMB Project Approval Number 68-S77056

DHHS (NIOSH) Publication No. 82-118

NOTICE: Companion Vol. ILI (Engineering Testing) was previously
published as DHHS (NIOSH) Publication No. 82-101 and is currently

available from NTIS, Springfield, VA 22161, U. S. A. Telephone
(203)487-4650

sip K


ILF

LEFT FRONT

136


Table 48.

Boiler maker
Chip and grind
Propeller

finisher

Pneumatic tool

operator (PTO) and PTO test

Current job titles of shipyard workers (exposed group);

row percents shown.

40%

specialist and Ship Fitter

Table 49.

Casting salvage
and reclaimer

Chip and grind,
heavy

Chip and grind

Chip intricate

VWF Stage Category

OT & ON TN,O1L,02&03
2 2
28.54 283.54
4 3
45% 334%
5 6
30% 35%
by 10
20% 404

Current job titles of foundry workers (exposed group);

row percents shown.

VWF Stage
00 oT ON TN ol
10 4 3 1 4
40% 16% 12% 4h 16%
6 2 3 8 7
19% 6% 9% 25% 22%
5 5 2 13 7
12% 12% 5% 324% 17%
4 3 2 vs il
8% 6% 4h 14% 23%

yy

13
37%

03

or
x


2
Table 8. Tool categories referenced in Figure 3.

Tool category

A = Chipping hammers without jackhammers or gasoline-powered chain
saws
B = All tools except those in Categories A, C, and D (does not

include hobby tools)

C = Jackhammers, gasoline-powered chain saws, riveting hammers, air
tampers and bumble bees without chipping hammers

D = Jackhammers and gasoline-powered chain saws with chipping hammers
E = Chain saws and chipping hammers used as hobby tools

F = All hobby tools except for those in E

N = No vibrating hand tool

57


10.

11.

12.

REFERENCES

Raynaud, M. 1888. Local Asphyxia and Symmetrical Gangrene of the
Extremities. M.D. Thesis, Paris, 1862. IN: Selected Monographs.
London, New Sydenham Society.

Loriga, G. 1934. Pneumatic Tools: Occupation and Health. In:
Encyclopedia of Hygiene, Pathology, and Social Welfare, Vol. 2,
International Labour Office, Geneva, Switzerland.

Hamilton, A. 1918. A Study of Spastic Anemia in the Hands of
Stonecutters: An Effect of the Air Hammer on the Hands of
Stonecutters. Bulletin 236, United States Department of Labor, Bureau
of Labor Statistics, Industrial Accidents and Hygiene Series, No. 19.

Seyring, M. 1930. Disease Resulting from Work with Compressed Air
Tools. Arch. Gewerbepahtol. Gewerbehyg. 1:359.

Hunt, J. J. 1936. Raynaud's Phenomenon in Workmen Using Vibrating
Instruments. Proc. Royal Soc. Med. 30:171.

Telford, E. D., M.- B. McCann, and D. H. MacCormack. 1945. Dead Hand
in Users of Vibrating Tools. Lancet. 2:359.

Agate, J. N., and N. A. Druett. 1947. A Study of Portable Vibrating
Tools in Relation to the Clinical Effects They Produce. Brit. J. Ind.
Med. 4:141-163.

Ashe, W. F., W. T. Cook, and J. W. Old. 1962. Raynaud's Phenomenon of
Occupational Origin. Arch. Environ. Health. 5:333-343.

Ashe, W. F., and N. Williams. 1964. Occupational Raynaud's. Arch.
Environ. 9:425.

Grounds, M. D. 1964. Raynaud's Phenomenon in Users of Chain Saws.
Med. J. of Australia. 1(8):270.

Brubaker, R. L., D. V. Bates, C. J. G. Mackenzie and P. R. Eng. 1982.
The Prevalence of Vibration White Finger Disease Among Fallers in
Coastal British Columbia. Report from Department of Health Care and
Epidemiology, University of British Columbia.

Huzl, F., R. Stolarik., J. Marnerova, J. Jankova, and J. Skora. 1971.
Damage Due to Vibrations When Felling Timber by Power Saws. Pracov.
Lek. 23(1):7.

-43-


JOB TITLE

Heavy Equip. Opr.
Hull Maint. Tech.
Installers

Iron Worker
Laborer

Lathe

Lay-Out

Leadman

Machine Opr.
Machine Tool Opr.
Machinist

Maint. Helper
Manager

Materials Handler
Mechanic
Millwright

Molder

Moulding

Mover

N.C. Opr.

Painted Tr. Svcmn.
Painter

Planer

Pneumatic Super.
Punch Press Opr.
Parts Handler
Propeller Finisher

PTO (Pneumatic Tool Opr.)

Pipe Fitter
Radial Driller
PTO Test Spclst.
PTO Test Spec. FM.
PTO Instructor
Reclaimer

Rigger

Rod Straightener
Sand Mixer
Shaving Hauler
Seaman

Sgt.

Sect. Foreman

Sheet Metal Mechanic

Ship Wright

Ship Fitter
Siding Applicator
Tank Specialist
Test Specialist
Tire Man

Tool Room Mach.
Supervisor

FREQUENCY

fw
PRE ERNEFUWNE RP WEEE ORR PYRE OP PRP ENE ERNE RFP RNNOUE POWER PORE WER


TABLE 41

Percentage of Exposed and Control Workers in Age Groups

PERCENTAGE
1
|
1
'
35 +
1
'
1
'
Bu ¢
‘
|
!
1
25+
'
'
!
1
20 +
!
'
'
'
1S +
1
1
1
'
10 +
'
'
'
'
5+
1 24222
| 22222
1 22222
1 22272
<2i

227227
22222
227222
22227
Z22zZz
22222
22222
22272
22272
22722
22277
22222
72277
22272
22227
22222
722722
22222
722227
22222
22227
77222
22222
22222
22222
22227
ZZZ2z
YYYYY
yYyyyy
yyyyy
yyyyy
XXXXX
XXXXK
XXXXX
Win wlt
www
Wuuww
Wwe

21925

22277
272l2
27222
27222
22722e
22272
222772
22722
222272
27222
22222
22222
Z22zz
22222
27227
yYYYY
YYYYY
YYYYY
XXKXY
XxxXX
XXXKK
XXXXX
XXXXX
KXXIK
Www
Ww Woe
www

26=30

PERCENTAGE BAR CHART

2272722
72222
Z22Zz
Z222Z
7227272
yYYYY
YY
yYYyy
XXXXX

Sie35

axa

22272
72222
KXXXK
AXXXX

3o-40

EXPOSED
EXPOSED
CONTROL
CONTROL

22722
YYYYY
XXX

a1eds

Age groups

FOUNDRIES
SHIPYARD
FOUNDRIES
SHIPYARD

22272
YYYYY
yyyyy
YYYYY
XXXXX

46050

YYYYY
XXXXX

51-55

YYYYY
YYYYY.
yyyyy

So-o0

vYYYY
YYYYY
YYYYY

ol+


WORKSITES AND WORKPRACTICES

Three workplace sites were investigated in this study: two gray-iron
foundries and a shipyard. The pneumatic tools used in the foundries and
shipyard were Type 2 chipping hammers, vertical grinders, and horizontal
grinders. These same tool types are competitively made by various
manufacturers.

The chipping tool (also called an impact hammer) generally produces 2100
blows/minute (corresponding to a 35-Hz repetition rate). It weighs about 12
pounds and its length can vary from 12 to 15 inches (depending on the
manufacturer). The diameter of the rear handle is approximately 1.5 inches.
The diameter of the chisels used with these hammers is approximately 3/4
inch, while the chisel length can vary from a few inches to 2 feet. The
characteristics of the working end of the chisels differ somewhat depending
on the chisel application. The worker must be able to change chisels
quickly; thus the chisel is inserted freely into the bore of the chipping
hammer barrel and is not usually retained by the hammer barrel while in
use. The chisel, if not held by the operator's hand or not working against
resistance, will shoot out of the barrel; therefore, most operators grasp
the chisel at all times while using the chipping hammer. The foundries
studied used pneumatic horizontal grinders accommodating 6- or 8-inch
grinding wheels. These units rotate from 4500 to 6000 rpm (corresponding to
75 to 100 Hz). They weigh about 14 pounds and their length is from 20 to 25
inches. Vertical grinders were used in the shipyard that accommodated
similar grinding wheels and ran at about the same speed as the horizontal
grinders. The vertical grinders weighed about 8 pounds.

For all these pneumatic tools, air pressure was in the 90 to 110 psi range.
Each of the three worksites studied had a central tool crib and a_ repair/
maintenance station for these tools.

A description of the work situation for each of the foundries and shipyard
follows.

FOUNDRY NO. 1

Foundry No. 1 was a large, high-volume production, gray-iron foundry
manufacturing large castings weighing more than 100 pounds, such as
vehicular castings (engine blocks, transmission cases, etc.). The casting
metal used was a gray iron that falls under the Class 30 Gray Iron
designation. This type of metal is a pearlitic (nodular) iron having a
minimum of 30,000 psi tensile strength with a general hardness range of 187
to 255 BHN (Burnell Hardness Number).

7-


5. Noninvasive (i.e-, does not pierce the skin) objective medical
testing which would include:

a. X-rays of both hands (Anterior-Posterior and lateral)
b. depth sense and two-point discrimination
c. photocell plethysmography

6. Engineering tests for a sample of workers would measure vibration
energy impinging upon both hands of participants. The technique
used (called dynamic compliance) involves grasping a handle (in a
variety of hand orientations) attached to a small electronically
driven table-top shaker. Various vibration frequencies are
sequentially applied to the shaker in a swept fashion from 5 to
1000 Hz. A vibration impedance transducer is sandwiched between
the handle being grasped by the subject and the moving piston of
the shaker; from this transducer, energy impinging upon the hand
can be determined by calculation. The subject's grip strength
would also be measured. Exposed and control groups would be
compared.

Total testing time per subject for the above procedures would be 2.5
hours. As required under U.S. Law, strict confidentiality of individual
worker identity as well as individual medical information would be (and has
been) maintained throughout this study. In addition to the above
individual worker tests, the following engineering measurements would be
made.

Once the types and models of the chipping and grinding tools had been
ascertained, a few of the exposed workers would be asked to work with these
tools at a work station. Measures of vibration would be obtained while a
chipper/grinder worker used the tool. Vibration amplitude (i.e., accelera-
tion) and vibration signature (i.e., spectrum) would be analyzed. In
addition, the time per day a tool is used and the various hand-arm
positions during use would be investigated. Engineering measures would be
related to a standardized biodynamic coordinate system established by the
International Standards Organization (ISO).

The results of engineering testing are discussed in Volume II (68) of the
study report. The results of the objective clinical tests will be

published in scientific journals at a later date.

Subsequent sections of this report will review in detail the questionnaire
results and medical-clinical data analyses and results.

eS


Table 47. Number (column percents) of shipyard workers in exposure
categories (years on jobs using a chipping hammer) and VWF

stage categories.

Exposure category

(years on jobs using VWF Stage
a chipping hammer) Category

00 OT & ON
Less than or = 5.0 years 10 (47%) 7 (44%)
Greater than 5.0 but
less than or = 15.0 years 9 (43%) 3 (19%)
Greater than 15.0 years 2 (10%) 6 (374%)
Column totals 21 (1004) 16(1004)

Chi-square value: 9.9, 4 D.F., p = 0.041
Kendall's Tau-B value: 0.29, p = 0.002

96

TN,01,02«03

5 (24%)

5 (244)

11(524)

21(100%)

Row
Total

22

17

19

58


CARD NO. 1

MEDICAL CODING SHEET

Card Columns

Case Number | 1-4
Blood Pressure
Right Arm Left Arm
Sys. | i 6-11
Dia. | [| 12-17
Pulses
Right Left
Radial 0 = Nothing Felt 18 - 19
Brachial | 1 = Just Perceptible 20 - 21
Dorsalis —> 2G Risen
Pedis 3 = Increased 22 = 23
Tibialis ; 4 = Greatly Increased
Ant. = 24 - 25
Heart 1
Rate | t | _Beats/Minute 26 - 28
Rhythm L] 1 = Regular 2 = Irregular 29
Murmurs im 0 = Absent 1 = Present 30
Arms LFA LBA RFA RBA
Significant Traum | | | | 31 - 34
Scars | | | 35 - 38
Deformities [ | [| 39 - 42
Skin Lesions | 43 - 46
Needle Marks ! | 47 - 50
Q= Absent 1 = Present
Card No. 01 79 - 80

=153-


CARD NO. 5

Card Columns
Case Number | | f= 4
AMP. BLA. CAL. CYN. F.T.U. J.S K.P. SC.-LA. TR,-FRA, F. S
LVTP 6-15
LVTD 16 =) 25
LV11 26 - 35
Lv12 36 - 45
Lv13 46 - 55
LV21 56 - 65
1Lv22 66 - 75
Card No. 05 79 - 80
CARD NO. 6
Case Number | | | | | | 1-4
AMP. BLA. CAL. CYN. F.T.U. J.S. K.P. SC.-LA. TR.-FRA. F.S.
Lv23 6-15
LV31 16 = 25
1V32 26 - 35
1LVv33 36 - 45
LV41 46 - 55
LV42 56 - 65
1LV43 66 - 75
Card No. 06 79 - 80

~156-


APPENDIX D.

CODE DESCRIPTIONS AND FREQUENCIES FOR CODED OCCUPATIONAL HISTORY
AND HOBBY VARIABLES

-160-


DIFFERENTIAL DIAGNOSIS

In this study every worker was examined by two physicians. The first
physician performed a generalized medical examination and the second
physician a special examination of the hands and fingers. The data
collected during these examinations (see Methods: Medical-Clinical Testing)
were used along with health history and medication usage data from the study
questionnaire to determine if workers had secondary Raynaud Phenomenon
attributable to causes other than vibration. (The section "Raynaud's
Phenomenon of Occupational Origin" discusses the medical conditions that may
produce a manisfestation of Raynaud's Phenomenon.)

The initial diagnosis and staging for Raynaud's disease and phenomenon were
made before any determinations of the medical conditions that confound a
diagnosis of VWF. The final differential diagnosis for VWF was made after
the data were collected (except for cases of Primary Raynaud's disease,
which were diagnosed at the time of the survey). For all cases of secondary
Raynaud's phenomenon, the determination was carried out by the physicians
without knowledge of the workers’ employment and exposure histories and the
white finger staging. For exposed workers with a positive diagnosis of
secondary Raynaud's Phenomenon, the separation of workers into those with
“white fingers (WF)" and those with "vibration white fingers (VWF)" is based
upon the presence (WF cases) or absence (VWF cases) of any confounding
medical conditions that could explain the signs and symptoms of Raynaud's
Phenomenon.

Table 10 lists the medical conditions found among workers in this study that
could cause them to be classified as cases of secondary Raynaud's phenomenon
due to causes other than vibration. In this report, these workers are
called "medical exclusions". Some workers with these medical conditions
(especially frostbite and lacerations of the digits) were not considered
medical exclusions. Workers were ultimately considered medical exclusions
according to the clinical judgement of the examining physicians. Some of
these medical conditions were found in as few as one worker; therefore, for
purposes of confidentiality, these medical conditions were grouped into five
medical exclusion groups (see Table 11). Table 12 gives the frequency and
proportion of workers in these five groups for the total population and by
industry. For secondary Raynaud's Phenomenon due to causes other than
vibration, workers were assigned to only one medical exclusion group; it
they had Primary Raynaud's disease and another condition, they were assigned
to the Primary Raynaud's group. The prevalence of Primary Raynaud's Disease
in this population is very small (2.6%).

The relationship between medical exclusion groups and exposure groups is
shown in Table 13. Medical exclusion groups 1 through 4 (from Table 11) and
exposure groups 3 through 8 have been combined in this table. Some observa-
tions about Table 13 are necessary. The proportionate contribution by the

=-25-


DEPARTMENT NUMBER

95

96
100
104
108
U2
116
NOW)

COMPANY

Air Conditioning
Aluminum Mfg.
Automobile Mfg.

Body Shop

Boiler Repair
Elevator Mfg.

Hog. Building Mfg.
Stg. Building Mfg.
Carwash Equipment Mfg.
Casting Pumps

Cement Contractor
City Government
Concrete
Construction

Crane Operation
Drywall Construction
Electric Instal.
Electrical Engineering
Engineering

Fence Construction
Formica Mfg.

Foundry

Gas Station

General Contractor
Graphics

Grain Bins
Helicopter Mfg.

Iron Works

Hot Water Heater Mfg.
Locomotive Operation
Machine Shop
Machinery Mfg.
Locomotive Parts Mfg.
Crane Mfg.

TYPE OF COMPANY

-166-

FREQUENCY

1

2
27
106
33
L

1

L

FREQUENCY

PERE WPN EEE PROP EN PORE BW EUR RP PPP PN ee


Table 60. Arthritis, Dupuytren's contracture, carpal tunnel
Syndrome, and tendonitis in exposed and control workers
(not including medical exclusion cases; row percents),

Control
Exposed

Control
Exposed

Control
Exposed

Control
Exposed

Arthritis
Absent Present
95% 54%
97% 3%

Dupuytren's contracture

Absent Present
100% 04%
99% 1%

Carpal tunnel syndrome

Absent Present
100% 0%
99% 1%
Tendonitis

Absent Present

98% 2%
95% 5%

106


HEALTH HISTORY

I'm now going to read a list of health conditions. Have you ever been told by
a doctor that you had any of the following conditions? Please answer YES or

NO to each one.
(READ EACH CONDITION AND RECORD A RESPONSE. IF YES, ASK THE SECONDARY

QUESTION BELOW.)

SECONDARY QUESTIONS

IF YES ASK:
DATE In what year were you first told about tnis condition?
(For Q. 10: In what year did you first notice this?)
CONDITION RESPONSE DATE CONDITION RESPONSE DATE
1. Rheumatic 1 _ YES 19 6. Psoriasis? 1 YES 19)
fever? 2__NO 8 DK 2 NO & DK
8 DK 8 DK
2. Any type TosYES 19 7. Raynaud's L YES 19
of heart 2_-NO 8 DK Disease or 2 NO 8 DK
trouble? 8 DK "white 8 DK
finger"?
3. High blood 1_ YES 19 8. Any kind of L YES 19
pressure? 2__NO 8 DK circulatory 2 NO fo} DK
8_ DK problem in 8 DK
your hands
or feet?
4. Neuritis? 1__YES 19 9. Arthritis? 4 YES 19
2__NO 8 DK 2 NO 3 DK
8 DK 8 DK
5. Diabetes? 1__YES 19 10. Do you 1 YES 19
2__NO 8 DK frequently 2 NO 3 DK
8 DK have aching 8 DK

or pain in
your joints?

127


HOBBY TOOLS
HOBBY TOOLS

Air Chisel

Pneumatic Tools; Grinders; Sanders
Air Wrench

Chain Saw

Electric Drill

Electric Drill; Saw

Electric Saw

Electric Saw; Electric Drill; Router
Chisel; Drill; Saws

Grinder; Saw; Drill; Lathe

Impact Wrench; Electric Saw

Motor

Pneumatic Drill

Saber Saw

Saber Saw; Ban Saw; Sander Saber Saw; Electric Drill

Chain Saw; Saber Saw; Skill Saw
Sander

Sander; Power Saws

Sander; Drills

Sander; Saw; Drills

Sander; Saber Saw

Skill Saw

-168-

FREQUENCY

Oe


Table 1. Differential diagnosis--Raynaud's Phenomenon

Primary:
1. Raynaud's Disease
Secondary:

1. Connective Tissue Disease

2. Trauma
i. Direct to extremities

ii. To proximal vessels
by compression

3. Occlusive Vascular Disease

4. Dysglobulinaemia

5. Intoxication

6. Neurogenic

Constitutional white finger

a. Scleroderma

b. Systemic lupus erythematosus

c. Rheumatoid arthritis

d. Dermatomyositis

e. Polyarteritis nodosa

f. Mixed connective tissue disease

a. Following injury, fracture, or
operation

b. Of occupational origin
(vibration)

c. Frostbite and immersion syndrome

a. Thoracic outlet syndrome
(cervical rib, scalenus anterior
muscle)

b. Costoclavicular and hyper-
abduction syndromes

a. Thromboangiitis obliterans
b. Arteriosclerosis

c. Embolism

d. Thrombosis

a. Cold haemagglutination syndrome
- Cryoglobulinaemia
- Macroglobulinaemia

a. Acro-osteolysis
b. Ergot
c. Nicotine

a. Poliomyelitis
b. Syringomyelia
c. Hemiplegia

49


Table 57.

VWF Stage

00 (control)
N = 57

00 (exposed)
N = 34

OT and ON
N= 33

TN
Nis: 35

ol
N #732

02 and 03
N= 44

Presence of calluses on chisel
and throttle fingers (row percents).

Chisel Fingers or Throttle Fingers
Fingers on Non- or Fingers on
Dominant Hand Dominant Hand
Calluses Calluses
Absent Present Absent Present
39 18 34 23
68% 32% 60% 40%
23 16L 15 19
68% 32% 44% 56%
20 13 13 20
61% 39% 39% 61%
13 22 lL 24
37% 63% 31% 69%
12 20 7 25
37% 63% 22% 784
15 29 9 35
34% 66% 20% 80%
Chi-square value = 21.9 Chi-square value = 21.8
5 D.F. p = 0.0005 5 D.F. p = 0.0006
Kendall's Tau-B value Kendall's Tau-B value
= 0.25, p less than 0.0001 = 0.27, p less than 0.0001

103


Table 19. Blanching of finger segments.

Percent reporting blanching at each finger segment among all who
reported blanching (exposed group only)(N = 80)

*Left hand for those using *Right hand for those using

left hand on chisel, N = 70 left hand on chisel, N = 70
*Right hand for those using *Left hand for those using
right hand on chisel, N = 4 right hand on chisel, N = 4

Two workers had missing data
Four workers had both hands on chisel (see Table 22)

67


manifolds, etc.). The casting metal was the same type as that used in
Foundry No. 1.

In this plant, the chippers and grinders were not teamed and each man was
paid on a piecework basis. Castings were brought to the workstation via a
forklift truck and pallet. A variety of small castings were handled with
more grinding than chipping taking place. The same types of tools used in
Foundry No. 1 were used here. Chisel lengths varied from 3 to 12 inches and
were not, as a rule, as long as those used in Foundry No. l.

The men in Foundry No. 2 were also incentive workers. Chipping and grinding
time varied depending on the casting type, e-g-, an 85-pound oil pan took
about 10 minutes to complete, whereas a 44-pound manifold took about 1.5
minutes to complete. Here, again, there were a few hourly, reclaim/salvage
operators (10 pieceworkers for each reclaim/salvage operator).

Each man wore earmuff hearing protection as well as a ventilated hood. At
least one glove was worn and, at times, both hands were gloved, depending on
operator preference. The estimated work time was 4 hours grinding, 3 hours
chipping, 0.5 hour casting manipulation, and 0.5 hour break time. At the
Foundry No. 2 machine shop, setup men were also examined who were not
exposed to hand-arm or whole-body vibration.

The training given to workers was discussed with the supervisors. The
workers progressed gradually as their skill level increased. A new worker
was placed on the midnight-to-8:00 a.m. shift where the workload was lighter
than on the other two shifts. As his skill level increased, the trainee was
eventually transferred to another shift. Almost no specific training was
given regarding a preferred method of working with the vibrating tools.

SHIPYARD

At the large shipyard operation investigated, ship propellers and large
ships of all descriptions were built, repaired, and modified. The workers
at this shipyard used the same chipping hammer that was used in the
foundries, and a rotary type grinder not very different from the foundry
type grinder.

Observations of workers using pneumatic chipping and grinding tools and
discussions with supervisors in two departments related how the workers used
these tools. Department X included men who worked in the holds of ships.
Department Y included workers who chipped and ground propellers. All worked
on a single daily work shift and all were hourly employees. The metals
chipped by workers in both departments were: a nickel-aluminum, bronze
alloy, and mild steel.

DEPARTMENT X

The men in this department worked in the holds of ships and used both
pneumatic chippers and grinders. They also used other pneumatic tools such
as pneumatic drills, saws, riveters, and sanders. An average 8-hour work
day consisted of 4 hours of chipping, 2 hours of grinding and other

-19-


Table 34. Percentage of "'yes'"' responses to questions about symptoms
8 y P Gh

co EO ue N TN BL TB NB 1B 2B 38

TRSL 0% 4%, 9% 5h 30% 0% 25% 29% 434 44% 40%
AF 0% 26% 624 35% 70% 50% 754 43% 644 61% 604
PH 0% 9% 384 154 57% 104 564 29% 64% 44% 60%
WPA 8% 13% 19% 25% 62% 504 37% 144 574 52h 60%
EPA 8% 9% 24% 10% 46% 30% 31% 0% 21% 52% 60%
SPA 8% 33% 19% 45% 27% 0% 374 29% 434 304 40%
DFW 3% 9% 19% 154 234 30% 31% 43% 21% 48% 604%
DFB 2% 44 54 0% 24% 20% 64 04 144 44% 504
DHC 0% 9% 9% 204 27% 40% 19% 29% 29% 44% 50%
DDHC. 2% 2% 19% 10% 16% 0% 25% 04 294 264 304
TNTW 0% 24 19% 154 38% 204 44% 29% 504 654 604
TNS 0% 0% 0% 0% 0% 04% 04% 04% 04“ 4% 104%
TNG 0% 0% O04 104 164 04 04 0% Th 13% 40%
TNWC 0% 6% 9% 5% 39% 104 12% 144 144 524 004
TNWS 0% 24 14% 5% 16% 204 124 29% 36% 264 50%
TNPG 0% 04 144 5% 32% 10% 12% 14% 144 39% 504
TNOH 2% 4% 9% 10% 28% 20% 19% 0% 144 39% 50%

Explanation of column and row symbols.*

Symptom Categories Column Symbols
No symptoms — control co
No symptoms — exposed EO
Tingling only de
Numbness only N
Tingling and numbness only TN
Blanching only (Stages 01 & 02) BL
Tingling only and blanching

(Stages 01 and 02) TB
Numbness only and blanching

(Stages 01 and 02) NB
Tingling, numbness, and blanching

(Stage 01) 1B
Tingling, numbness, and blanching

(Stage 02) 2B
Tingling and/or numbness and

blanching (stage 03) 3B

*Explanation of Row Symbols given in Table 32.

85




Table 20. Numbness of finger segments.

Percent reporting numbness at each finger segment among all
who reported numbness (exposed group only) (N = lll)

*Left hand for those using *Right nand for those using
left hand on chisel, N = 90 left hand on chisel, N = 90
*Right hand for those using *Left hand for tnose using

right hand on chisel, N = 8 right hand on chisel, N = 8

One worker had missing data
One worker had missing data for hand on chisel
Eleven workers had both hands on chisel (see Table 22)

68


Table 26. Latencies of tingling for workers at the shipyard (exposed group
only). Latencies are adjusted and unadjusted for the number of
years that workers did not use chipping hammers before the onset
of tingling.*

Adjusted latencies Unadjusted latencies

VWF Stage (in years) (in years)
oT (N = 6)

Mean 4.9 51

Median 2.2 2.9

Range 0.2-14.9 0.2-14.9
TN (N = 9)

Mean a3) 9.8

Median 5.6 5.6

Range 0.04-26.6 0.04-30.7
01,02, and 03 (N = 6)

Mean 12.2 12.2

Median 9.7 9.7

Range 0.04-30.9 0.04-30.9
All Stages (N = 21)

Mean 8.9 9.1

Median 4.0 4.2

Range 0.04-30.9 0.04-30.9

*Data were missing for two workers.

74




Table 56.

Presence of finger swellings on chisel
and throttle fingers (row percents).

Chisel Fingers or
Fingers on Non-
Dominant Hand

Finger Swellings

Throttle Fingers or
Fingers on
Dominant Hand

Finger Swellings

Absent Present Absent Present
VWF Stage
00 (control) 54 3 57 0
N= 57 95% 5% 100% 04%
00 (exposed) 31 3 33 1
N= 34 91% 9% 97% 3%
OT and ON 28 5 29 4
N = 33 85% 15% 88% 12%
TN 31 4 31 4
N = 35 89% 11% 89% 11%
ol 26 6 30 2
N = 32 81% 19% 94% 6%
02 and 03 38 6 40 4
N= 44 86% 14% 91% 9%

Chi-square value = 8.4
5 D.F. p=0.14
Kendall's Tau-B value

= 0.12, p less than 0.02

Chi-square value = 4.7

5 D.F. p = 0.45
Kendall's Tau-B value

= 0.10, p less than 0.05

102


Table 24. Workers who had trouble sleeping because of tingling
and/or numbness in hands or fingers (exposed group only,
number ( ) and row percents).

VWF Stage NO YES
OT 90% (18) 10% (2)
On 95% (19) 5% (1)

IN 72% (28) 28% (11)
ol 74% (25) 26% (Y)
02 64% (23) 30% (13)
03 60% (6) 40% (4)

72


Table 50. Number (column percents) of foundry workers in current job title
categories and VWF stage categories (exposed group).

VWF Stage Category

00 OT&ON TN&OL 02803
Casting salvage
and reclaimer 10 (40%) 7 (29%) 5 (94) 3 (8%)

Chip and grind,
heavy and 11 (44%) 12 (50%) 35 (60%) 15 (374)
chip and grind

Chip intricate 4 (16%) 5 (21%) 18 (314) 22 (55%)

Chi-square value: 26.2, 6 D.F., p = 0.0002
Kendall's Tau-B value: 0.33, p less than 0.0001

Table 51. Distribution of exposed workers according to shift
and industry.

Foundries
Shift at current job Percent on snift
7-3 pm 58%
3-11 pm 36%
11-7 am 3%
Rotate 3%
Shipyard
Shift at current job Percent on shift
7-3 pm 814
3-11 pm 16%
11-7 am 04
Rotate 34

98


Table 32. Questionnaire Responses - Row Symbols.

Have you had trouble sleeping
because of numbness or tingling

in your hands or fingers? TRSL
Do you ever have aching in your fingers? AF
What about pain in your hands? PH

Do you ever have pain or aching
in any of the following parts of

your body?

wrists WPA
elbows EPA
shoulders SPA

Do you have difficulty doing any
of the following activities?

doing fine work DFW
fastening buttons DFS
handling or picking

up coins DHC
distinguishing between

hot and cold objects DDHC

Do you have pain, tingling or numbness in your hands or fingers when you
do any of the following things?

traveling to work TNIW
swimming TNS
gardening TNG
washing your car TNWC
watching sports outdoors TNWS
playing games TNPG
doing other hobbies TNOH

83


PAST JOBS WITH PAST EMPLOYERS (EXPOSURE GROUP 1)

PERCENT OF PAST JOBS
WITH PAST EMPLOYERS

FOUNDRIES SHIPYARD
bec?
TOOLS (N=41)* (N=58)*
Pneumatic Grinders 81% 72%
Chipping Hammer a2 72
Pneumatic Impact Wrench 12 10
Jackhammer** 10 0
Pneumatic Drill 7 0
Electric Saw 5 0
Air Tamper** Zz: 0
Electric Drill 2 2
Sander 2 7
Skill Saw 2 0
Cement Vibrator 2 0
Air Nail Gun Z v)
Scaling Hammer 2 0
Cement Drill 2 0
Roto Hammer 2 0
Pneumatic Saw 0 3
Pneumatic Riveting Hammer** 0 3
Needle Gun te) 2
Pneumatic Lug Remover 0 2
Router 0 3
Planer 0 3

* Total number of past jobs with past employers.

** These tools were subject to some restrictions; see the
definition of exposure group in Occupational Histories and
Exposure Groups.

-172-

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51


54.

55.

56.

57.

58.

59.

60.

6l.

62.

63.

64.

65.

66.

67.

68.

Brockelhurst, T. 1945. Pseudo-Raynaud's Disease Due to Electric
Vibratory Tools. The Medical Press. 213:10.

Pyykko, I. 1974. The Prevalence and Symptoms of Traumatic Vasospastic
Disease Among Lumber jacks in Finland: A Field Study.
Work-Environment—Health. 11:118.

Peters, F. J. 1946. A Disease Resulting from the Use of Pneumatic
Tools. Occup. Med. 2:55.

Marshall, J., E. W. Poole and W. A. Reynard. 1954. Raynaud's
Phenomenon due to Vibrating Tools. Neurological Observations.
Lancet. 1:1151.

James, P. B., J. R. Yates, and J. C. G. Pearson. 1975. An
Investigation of the Prevalence on Bone Cysts in Hands Exposed to
Vibration. In: Vibration White Finger in Industry. Academic Press,
London.

McLaren, J. W. 1968. Quoted by Iwata, H. in Industrial Health
(Japan). 6:47.

Wilson, R. H., W. F. McCormick, D. F. Tatum, and J. TI. Creech. 1967.
Occupational Acroostheolysis. J. Am. Med. Assoc. 201:577.

Golding, F. C. 1959. A Textbook of X-Ray Diagnosis by british
Authors. Vol. 4, p- 240.

Esau, P. 1928. Zentralbl. fur. Chip. 55:1803.

Brailsford, J. F. 1936. Pathological Changes in Bones and Joints
Induced by Injury. Brit. J. Med. 2:657.

Farkkila, M., I. Pyykko, 0. Korhonen, and J. Starck. 1979. Hand Grip
Forces During Chain Saw Operation and Vibration White Fingers in
Lumberjacks. Brit. J. of Ind. Med. 36:336.

Farkkila, M., I. Pyykko, 0. Korhonen, and J. Starck. 1980.
Vibration-Induced Decrease in the Muscle Force in Lumberjacks.
European J. of Applied Physiology, 43:1.

Agate, J. N. 1949. An Outbreak of Cases of Raynaud's Phenomenon of
Occupational Origin. Brit. J. Ind. Med. 6:144.

Pyykko, I. 1975. Vibration Syndrome: A Review. In: Vibration and
Work Proceedings of the Finnish-Soviet-Scandinavian Vibration Symposium
in Helsinki. p. l.

Wasserman, D., D. Reynolds, V. Behrens, W. Taylor, S. Samueloff and
R. Basel. 1981. Vibration White Finger Disease in U.S. Workers Using
Pheumatic Chipping and Grinding Tools II: Engineering DHHS (NIOSH)
Pub. No. 82-101.

SAye


certain fractures, lacerations and operations can disturb the peripheral
circulation as does frostbite of the fingers and hands.

Taylor and Pelmear (18) have given a clinical description of VWF: ‘The
early clinical manifestations of VWF are, as early reports emphasized,
trivial. At first the signs and symptoms of VWF pass unnoticed, do not
interfere with the work situation and there is no interference with either
social activities or recreation. Slight tingling and/or numbness of the
fingers is noticed, followed later, and this may take years, by an attack of
finger blanching confined in the first instance to a finger tip and,
subsequently, with further vibration exposure, extending to the base. The
provocative agent is cold but there are other factors involved in the
trigger mechanism, e.g., central body temperature, metabolic rate, vascular
tone of the vessels (early morning, especially, prone to attacks) and
emotional state. An attack will last 15-60 minutes but in advanced cases
may extend from 1 to 2 hours. The recovery phase is signalled by the
appearance of a red flush -- a reactive hyperaemia -- usually seen in the
palm and advances from the finger base. Due to repeated ischaemic attacks
in advanced cases, touch and temperature sensation is impaired. There is a
loss of dexterity and an inability to do fine work. Eventually, with
further vibration exposure the number of blanching attacks is reduced to be
replaced by a dusky, cyanotic appearance of the digits leading to
nutritional changes in the finger pulps. Ultimately, small areas of skin
necrosis appear at the fingertips."

To estimate the severity of the white finger condition, this study used a
system that Taylor successfully developed and used (18, 39, 47, 48). From
the results of a clinical interview (occupational and health history, and
the degree of social impairment and interference with hobbies) and a
clinical examination, the white finger sufferer is placed into one of the
stages in Table 2.

At stages 1 and 2, attacks as described above occur mainly in the winter and
especially during the early morning, either at home or enroute to work (as a
result of cold steering handles or wheels of vehicles). Employees outside
in all weather are most prone to early morning attacks, e.g., forestry
workers with long vibration exposure. Previous studies have shown that as
vibration exposure time increases, the number of VWF attacks tends to
increase (18,48). During stage 2, employees may report interference with or
limitation of activities outside their work, e.g., gardening, fishing,
swimming, car washing, home car maintenance, and woodworking. These
activities have one factor in common: they may be done in a _ reduced
environmental temperature which triggers an attack of VWF.

In stage 3, there is definite cessation of hobbies, thus curtailing the
subject's enjoyment of his leisure. VWF attacks will occur in summer as
well as winter. Other problems that arise are interference with work,
particularly out-of-door work (such as forestry); difficulty in undertaking
fine work such as electronics; difficulty in picking up small objects such
as coins; difficulty in buttoning and zippering items of clothing; inability
to distinguish between hot and cold objects; and clumsiness of fingers with
increasing stiffness of the finger joints.

-9-


differences between the control and exposed groups were found in regard to
abnormal wrist and finger mobility. Among workers not medically excluded,
the number with these health disorders was too small to do any statistical
analyses. When workers medically excluded were included in this analysis,
the numbers still remained too small.

=38—.


8.

10

1l.

12.

13.

14.

15.

16.

The mean, median, and range of latencies for each symptom (tingling,
numbness and blanching) were presented according to VWF stage and
industry. Latencies were adjusted for the years when workers did
not use chipping hammer. Graphs of the cumulative percentage of
workers at latency intervals (in years) indicated a sharp increase
in workers acquiring VWF symptoms. This increase was up to the
median point for foundry workers and up to the 30% point for
shipyard workers. Based on this increase and the large gaps

between mean and median latencies due to outliers, median latencies
may be a more meaningful measure of VWF latencies.

The median latency (unadjusted) for blanching was 1.4 years among
foundry workers and 16.5 years among shipyard workers. lLatencies
for tingling and numbness were less than those for blanching.

Workers were asked to respond to sets of questions about a) pain and
aching in parts of the arms and hands, b) difficulty performing
specified activities, and c¢c) pain, tingling or numbness when
performing certain activities. The percentage of workers responding
positively to these set of questions showed a statisticaly
significant increase as severity of VWF stage increased.

No association was found between VWF stages and tobacco smoking,
alcoholic consumption habits, or age.

The age distribution of the exposed and control groups was very
similar, although age did not show any relationship to acquisition
of VWF.

The severity of the VWF stage (as measured by Kendall's Tau-b
measure of association) increased significantly in proportion to the
number of years that the foundry and shipyard workers used chipping
hammers on the job. Therefore, exposure time to pneumatic chipping
and grinding tools was a significant risk factor for VWF in the
populations surveyed.

For foundry workers a significant association was found between
current job title and VWF stage. The job title group with the
greatest proportion in stage 00 (without VWF) worked on an hourly
basis, while the job title group with the greatest proportion in
stages 02 and 03 (the most severe stages) included only piece
workers. fe

Of the six digit conditions recorded, only joint swellings on the
chisel hand and knuckle pads on the throttle hand were significantly
associated to VWF without also being associated to exposure time.

Sensory tests for temperature, pain, and light-touch were
significantly associated to VWF stages on a population basis, but
did not distinguish well on an individual basis because of the
results for the VWF stages of OT, ON, and TN.

he


Table 23.

VWF
Stage

ON
OL

03

Stage

ol
02
03

Occurrence of tingling, numbness, and blanching in warm or cola
weather (exposed group only, number ( ) and row percent).

TINGLING

Cold/cool weather Warm weather
63% (12) 37% (7)
47% (18) 53% (20)
524% (12) 48% (11)

37% (10) 63% (17)

25% (2) 754% (6)

5 = Don't know

NUMBNESS
Cold/cool weather Warm weather
77% (13) 23% (4)
43% (15) 57% (20)
44% (7) 56% (9)
44% (12) 56% (15)
30% (3) 70% (7)

6 = Don't know

BLANCHING
Cold/Cool weather Warm weather
94% (30) 6% (2)
719% (27) 21% (7)
56% (5) 44% (4)

4 = Don't know
1 = Missing data

71


Form Approved
O0.M.B. 068- S77056,
Exp. October 1978

U. S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE
Public Health Service
Center for Disease Control

National Institute for Occupational Safety and Health

MEDICAL INFORMATION

Prevalence of Raynaud's Disease in Chipper and Grinder
Operators Using Vibrating Hand Tools

COC / NIOSW (C) TF 2.21K 133

9-77


FOR
AND

ll.

12,

13.

Do you have difficulty doing any of the

14.
15.
16.

17.

EACH YES ANSWER, CHECK WHETHER OR NOT A SPECIFIC LOCATION WAS REPORTED,

MARK THE LOCATION ON THE DIAGRAM.
BE MORE THAN ONE NUMBER ON ONE AREA OF THE DIAGRAM.

USE THE NUMBER OF THE QUESTION:

THERE

Do you ever have pain OR aching in any of tne following parts ot your body:

Wrist? 1 YES.....In the right OR left wrist?
2 NO

Elbows? 1___YES.....In the right OR left elbow? oO
2 NO

Shoulders 1 YES.In the right OR left shoulder?.1

2 NO

Doing fine work? L
Fastening buttons? 1
Handling or picking up coins? 1
Distinguishing between hot/cold objects? rh

RIGHT
LEFT

RIGHT

LEFT

RIGHT
LEFT

following activities?

YES 2 NO 8 _ DK
YES 2 NO 8 DK
YES 2 NO 8 DK

NO 8 DK

YES 2

Do you have pain, tingling, OR numbness in your hands or tingers when you do

any of the following things?
18. Traveling to work? 1__YES 2__NO 8 DK
IF YES ASK:
19. How do you get to work? L DRIVES CAR
2 RIDES MOTORCYCLE
3 RIDES PUBLIC TRANSPORTATION
IF "OTHER" SPECIFY: 4 OTHER
20. Swimming? i___YES 2__ NO 8 DK
Gardening? 1 YES 2 NO 8 DK
Washing your car? 1___YES 2__NO 8 DK
Watching sports outdoors? 1__YES 2 NO 8 DK
Playing games 1__YES 2 NO 8 DK
Doing other hobbies? 1-_YES 2. NO 8 DK

IF YES: SPECIFY

126


HAND-ARM VIBRATION RESEARCH IN THE UNITED STATES

As early as 1918, studies of Raynaud's Phenomenon in the United States were
reported among stone cutters (31, 32) using vibrating hand tools. These
workers were studied by Hamilton (3), Rothstein (33), and Leake (34). In
1946 Dart (35) described the effects of vibrating hand tools on 112 workers
in the aircraft industry. He noticed that these workers complained of pain
and swelling in the fingers and hands; showed an abnormal response to a cold
provocation test; and exhibited tenosynovitis. Later in the early 1960s
Ashe et al. (8) and Ashe and Williams (9) reported that seven hard-rock
miners had been clinically diagnosed as having Raynaud's Phenomenon.
Surprisingly, however, Pecora (36) surveyed a group of occupational
physicians in the United States about VWF and concluded: "A preliminary
survey of the literature on the incidence of Raynaud's phenomenon of
occupational origin in this country revealed a conspicuous lack of
information concerning both the number of workers affected and the number
using small hand-held vibratory tools. An attempt was made to estimate the
number of workers using vibrating tools and the number afflicted with
Raynaud's phenomenon of occupational origin. All of the information thus
gathered indicates that Raynaud's phenomenon of occupational origin may not
be completely evaluated, but it may have become an uncommon occupational
disease approaching extinction in this country."

The next occupational hand-arm vibration studies in the United States did
not occur until 1974 when a survey carried out by the National Institute for
Occupational Safety and Health (NIOSH) indicated that an estimated 8 million
workers were exposed to occupational vibration in U.S. industries (370).
Some 6.8 million were exposed to whole-body vibration and some 1.2 million
to hand-arm vibration. These estimates were based on surveys of a multi-
plicity of U.S. industries. In 1974, Williams (who had collaborated with
Ashe in the early 1960s) and Byrne completed another study for NIOSH (38).
This study was an attempt to determine the quality, quantity, and
availability of suitable health records (from which NIOSH might later
conduct epidemiological studies that would identify and quantify the
occupational hand-arm vibration problem). Although this study was not
exhaustive, the results indicated that of the few records available in the
United States, the records of companies employing large numbers of workers
using vibrating hand tools were the best. Particularly disturbing, however,
were William's reports of informal talks with some workers whose hands
appeared blanched. Many of these workers told him that they knew they had
Raynaud's Phenomenon, but lived with it and tolerated it because they feared
loss of employment should they report the malady (38). In October 1975,
NIOSH held an international, occupational, hand-arm vibration, conference to
discuss in depth the epidemiologic, medical, physiological, and engineering
aspects of VWF and vibration measurements. The presentations and discus—
sions were later published as a Proceedings (39). The conference summary
and recommendations follow:
Pe


MEDICINES

1. During the last six months, were you regularly taking any kind of tapiets,
pills, or other medicines?
1 YES 2 NO 38 DK

IF YES ASK: 2. What were you taking?
3. Were you taking any other medicines?

4. What about non-prescription medicines; things anyone
can buy at the store or grocery?

VERBATIM RESPONSE

5. Are you now taking any kind of medicine on a regular basis?

1 YES 2 NO 8 DK

IF YES ASK:
2. What are you taking?
3. Are you taking any other medicines?

4. What about non-prescription medicines; tnings anyone
can buy at the store or grocery?

VERBATIM RESPONSE

9. Are you allergic to any kind of drug or medicine?

1 YES 2 NO 8 DK

IF YES ASK:

10. What kind of drug/medicine?
SPECIFY

11. Are you allergic to any kind of food?

ay YES 2 NO 8 DK

IF YES ASK:

10. What kind of food?
SPECIFY

128


40.

41.

42.

43.

44,

45.

46.

47.

48.

49.

50.

51.

52.

53.

Samueloff, S., R. Miday, D. Wasserman, V. Behrens, R. Hornung, T.
Doyle, and W. Asburry. 1981. Pheripheral Vascular Insufficiency Test
using Photocell Plethysmography. J. Occupational Medicine. 23 (9):
643-646.

Carlson, W., S- Samueloff, W. Taylor, and D. Wasserman. 1979.
Instrumentation for Measurement of Sensory Loss in the Fingertips. J.
Occupational Medicine. 21(4):260-264.

Wasserman, D., W. Carlson, S. Samueloff, W. Asburry, and T. Doyle.
1979. A Versatile Simultaneous Multifinger Photocell Plethysmography
System for Use in Clinical and Occupational Medicines J. Medical
Instrumentation. 13(4): 232-234.

Wasserman, D., T. Doyle, and W. Asburry. 1978. Whole-Body Vibration
Exposure of Workers during Heavy Equipment Operation. DHEW (NIOSH)
Publication No. 78-153.

Taylor, W., D. Wasserman, V. Behrens, D. Reynolds, and S. Samueloff.
Stonecutters of Bedford, Indiana Revisited. (In Preparation).

Brit. Med. J. 1980. Pathophysiology of Raynaud's Phenomenon.
281:1027-8.

Goyle, Ke Be and J. A. Dormandy. 1976. Abnormal Blood Viscosity in
Raynaud's Phenomenon. Lancet. 1317-8.

Taylor, W., editor. 1974. The Vibration Syndrome. Academic Press,
London.

Pelmear, P. L. 1973. An Epidemiological Study of Raynaud's Phenomenon
of Occupational Origin. M.D. Thesis, University of London.

Edsall, D. L. 1918. Report to Surgeon General Blue on the Supposed
Physical Effects of the Pneumatic Hammer on the Workers in Indiana
Limestone. Bulletin 236, U.S. Department of Labor, Bureau of Labor
Statistics, Industrial Accidents and Hygiene Series, No. 19. PP.
114-123.

Stewart, A. Me, and D. F. Goda. 1970. Vibration Syndrome. British J.
Ind. Med. 27:19.

Hardgrove, Me A. Fe, and N. We Barker. 1933. Pneumatic Hammer
Disease: A Vasospastic Disturbance of the Hands in Stonecutters.
Proc. Staff Meeting, Mayo Clinic. 8:345.

Junghanns, He 1937. Damage to Blood Vessels as a Result of Prolonged
Vibration when Working with Compressed Air Tools - An Occupational
Disease. Arch. for Klin. Chirurgie. 188:466.

Seyring, Me 1931. Maladies from Work with Compressed Air Drills.
Bull. Hyge 6:25.

=h6=


ABSTRACT

A multidisciplinary study of 385 workers at two foundries and a shipyard was
performed to determine the health effects of using pneumatic chipping and

grinding tools on the job. This report presents the analyses of the
questionnaire and medical examination data. Occupational histories were
used to define exposure groups, and medical data were used to identify
workers with confounding medical conditions. The exposed group, without

confounding medical conditions, comprised 534 of the total study population
and the medically selected, control group comprised 164.

For the exposed group, the prevalence of vibration-induced white finger
(VWF) (stages 01, 02, and 03) was 47% in the foundries and 19% in the
shipyard. The prevalence of neurologic stages (OT (intermittent tingling),
ON (intermittent numbness), and TN (intermittent tingling and numbness)) was
36% in the foundries and 45% in the shipyard. None of the workers in the
control group had Raynaud's Phenomenon (those with confounding medical

conditions were excluded). Graphic representation of the latencies of the
three primary VWF symptoms of tingling, numbness, and blanching showed the
median to be a more meaningful measure of VWF latencies. The median

latencies of blanching were 1.4 years in the foundries, and 16.5 years in
the shipyard. The median latencies of numbness were 0.8 year in the
foundries and 9.5 years in the shipyard, while for tingling the median
latencies were 0.6 year and 4.2 years, respectively.

In addition to VWF prevalence and latency results, the symptomatology of VwF
was examined in depth along with the relation of VWF symptoms to social and
hobby impairment indicators. An association was found between exposure
variables, such as years on jobs using a chipping hammer and current job
title, and the severity of VWF. Occurence of digit conditions, recorded
during medical examinations, were analyzed for their relation to VWF
severity and years of vibration exposure. The ability of three sensory
tests to distinguish the stages of VWF is also presented.


JOB TITLE FREQUENCY

Sheet Metal Worker
Truck Driver
Utilities

Welder

Well Cleaner

rFOrWN

DEPARTMENT NUMBER

DEPARTMENT NUMBER FREQUENCY

=
uo
2

Dau
FOS
wow

~ we
Nn oo
iS

PR RPP RP rr rr UNWONORP ER CH RFORP DEEN RENORENUNWOAE

-165-


CARD NO. 2

Card Columns

Case Number 1=6
Hands (Palm and Dorsum)
LP LD RP RD
Trauma 6=9
Blanching 10° = 13
Cyanosis | [| | 44 = 17
Hyperaemia | 18 - 21
Skin Lesions [| 22 = 25
Scars | 26 - 29
Lacerations | 30)= 33
0 = Absent 1 = Present
Callus | | | 3G) = 37.

0 = None 1= Mild 2- Moderate 3 = Severe

Card No. 02 79 - 80

-154-


Table 15. VWF staging by industry and exposure groups (medical
exclusion groups not included).
VWF Staging

Exposure Group 00 oT ON TN ol 02 03 and 04
Exposed~Foundries, N=147 25 14 10 29 29 33 7
Exposed-Shipyard, N=58 21 6 10 10 5 2: 3
Control-Foundries, N=42 42 = = = = = =
Control-Shipyard, N=21 21 = = = = = =
Ex-chippers-Foundries, N=18 ) (0) 1 2 1 4 1*
Ex-chippers-Shipyard, N=4 3 0 oOo 1 0 0 )
Mixed past exposed-Foundries,

Nell 11 - = = = = -
Mixed past exposed-Shipyard,

Nad =) ag oa = = = =.
Mixed current exposed-
Foundries ,N=0 oS = = = = = =
Mixed current exposed-
Shipyard ,N=9 6 0 1 il 1 0 0
Confounded chipper-Foundries,

N=10 1 3 a 3 ai 0 0
Confounded chipper-Shipyard

N=6 2 (0) 2 2 0 10) 10)
Exposed W/hobby-Foundries, N=5 2 0 0 1 wt JL 0
Exposed W/hobby-Shipyard, N=0 —- = = = ae = =
Control W/hobby-Foundries, N=1 1 - = ~ es = =
Control W/hobby-Shipyard, N=0 = - = = = = S

TOTAL N=333 144 24 26 49 38 41 tau

* Only stage 04 case

63


Information about workpractices was gained from observations of workers
while they used the chipping and grinding tools to clean castings and from
discussions with department supervisors and foremen. The men worked in
teams of two. Each team's workstation consisted of a semienclosed cubicle
(approximately 10 feet long by 5 feet wide). Approximately 20 of these
stations were lined up side by side. Compressed air (90 psi) was brought to
each workstation to power two Type 2 chipping hammers (with assorted
chisels, each from 1 to 3 feet long) and two rotary grinders (with 6- and
8-inch grinding wheels). Each cubicle had a waist-high steel table. Above
this table was an electric hoist used to manipulate large castings, which
were brought to these workstations via a continuous, overhead, chain
conveyor or by a forklift truck containing pallets of castings.

The men on these teams were paid on a piecework basis. After they received
the casting at their steel table, one man immediately began chipping the
burrs off the visible faces of the casting. The other man followed by
grinding the area just chipped. After doing one to three surfaces, they
would interchange tools. Sometimes they chipped simultaneously (e.g., one
on the surface metal and the other in the deep cylinder cavities of an
engine block). All visible surfaces were chipped and ground. A team could
completely chip and grind an 800-pound transmission case, for example, in an
average of 54 minutes.

On occasion, some castings were “burnt"--sand from the mold had impregnated
itself on the casting. These were extremely difficult castings to chip and
grind and were usually sent to a single “reclaim/salvage chipper/grinder".
This worker was paid as an hourly employee, not on a piecework basis. The
ratio of two-man teams to reclaim/salvage chipper/grinders was 10 teams to 1
reclaim man.

The piecework teams operated their chipping and grinding tools at full
throttle and used a tightly coupled palm grip to clasp the chipping tool at
both ends. Their grip strength was approximately 6 pounds of force for each
hand. The hand holding the chisel was always gloved because the chisel
became very hot. Occasionally the hand holding the rear handle was gloved.
Pneumatic grinders were held in the same way as the chipping tools.

The gloves were of medium weight leather or similar man-made materials. All
chippers and grinders wore earmuffs and a ventilated hood connected to a
filtered compressed-air supply line (See Figure 2).

Based on observations and discussions with supervisors, in a normal 8-hour
shift each chipper and grinder spent an average of 3.5 hours chipping, 2.5
hours grinding, 1.5 hours manipulating and moving castings, and 0.5 hour on
break time. The reclaim/salvage (hourly) worker averaged about the same
time as the pieceworkers (except that he worked longer on much fewer
castings). This plant had about five or six different types of castings.

FOUNDRY NO. 2

Foundry No. 2 is another large, high-volume production, gray-iron foundry
manufacturing small (less than 100 pounds) vehicular castings (oil pans,

-18-


Table 13. Medical exclusions by exposure group--row

percents (r%) and column percents (cé).

Medical Exclusion Group

Exposure No medical Medical Primary
group exclusion exclusion Raynaud's
groups 1-4 Disease Total

Exposure 205 27 3 235
Group 1 (87r%) (12r%) (ir’) (Looré)
(exposed) (62cZ%) (64c%) (30%) (61c4)
Exposure 63 6 3 de
Group 2 (88r%) (82%) (4rk%) (Looré)
(control) (19%) (14c4) (30c4%) (19¢4)
Exposure 65 9 4 78
Groups (83r%) (12r%) (5r’) (100r%)
3 through 8 (19c%) (22c%) (40c%) (20c%)
Total 333 42 10 385

(86r%) (11r%) (3r4) (100r4)

(100c%) (100c%) (100¢4) (100c%)

61


+ 12LF

.-13LF

+ 14LF

LEFT FRONT


Table 4. Jobs with present and past employers.

Number Percent of total

Current jobs with
present employers 385 56%
Past jobs with
present employers 147 214
Past jobs with
past employers 160 23%

Total 692 1004

Table 5. Tools causing confounding exposure.

Jackhammer

Chain saw

Riveting hammer

Air tamper (as used in construction industries)
Bumble bee

Tool code descriptions for the above tools* (from Appendix D)

Air tampers

Chain saw

Electric impact drill; jackhammer
Electric saw; jackhammer
Jackhammer

Jackhammer; drill

Needle Guns; bumble bees; buffers
Riveting Hammer; drill

Saber saw; electric drill; chain saw
Tamper

Vibrators to pack ground
Jackhammer; OMC machinery

(*Tool Code Descriptions for these tools combined with Chipping Hammers are
not shown ~ see Table 8 and the Description of Exposure Group 1.)

54


result from injuries to more proximal portions of the nerves. Pyykko (55)
found that 81% of his population of lumberjacks who used chain saws
experienced numbing of the hands especially at night. He attributed this to
nerve damage. Peters (56) reported pain, throbbing, and burning in those
fingers most intimately in contact with the vibrating tool. He also
reported that workers' hands felt numb and frozen. He found a positive
correlation between the method by which the tool was held and the sensory
changes. Sensation to touch, pain, and temperature in that portion of the
hand in closest contact with the tool was diminished or absent. Marshall et
al. (57) also noted impaired sensibility to light touch and pinprick. From
observations on pneumatic tool operators, Mikulinskii (20) confirmed that
exposure to vibration causes an increase in the threshold of sensitivity in
the hand most exposed.

Bone Cysts

From work done on chain sawyers and controls, James et al. (58) found
vacuolar formations (or cysts) in the bones of the wrist and hand, and
concluded that the differences between the occurrence of cysts in controls
(33%) and vibrated workers (44%) were not statistically significant.

Other X-ray testing has identified decalcification and vacuoles in the
carpal bones (25, 59), osteolysis of the distal phalanges (59, 60), and
deformations of the metacarpal and carpal bones (61) in vibration exposed
workers. In all instances, the lesions had been related to severe or
recurrent trauma. Golding (61) has also remarked that small cysts can occur
with recurrent mild trauma or as a result of severe trauma. Esau (62)
reported that single cysts can occur in the carpus and can involve more than
one bone. Brailsford (63) has reported cysts in pneumatic drill users.

Muscle, Bone, and Joint Disorders

Farkkila et al. (64, 65) have reported a decrease in muscle force in chain
saw operators, with the maximal decrease occurring during vibration exposure.

Agate et al. (21, 66) reported skeletal changes in regions of the wrist and
elbow joints. Low frequency vibration (less than 100 Hz) is transmitted
through the hands as far as elbow and shoulder joints with possible
arthritic and periarticular changes occurring. Bovenzi et al. (22) found
radiological signs of osteoarthritis at the wrists and shoulders in a
population of shipyard caulkers using pneumatic chipping hammers and
grinders.

In addition, the following disorders have been related to vibration
exposure: joint pain and stiffness, tendonitis of fingers and wrists, and
carpal tunnel syndrome and Dupuytren's contracture involving the palmar
fascia. Because numerous systems other than hand blood circulation have
been related to vibration exposure, the terminology of "Vibration Syndrome"
is often used to describe the combined effects of the exposure (67).

iil


36 The middle finger on each hand was most affected by all three
symptoms.

4. Exposed workers reported blanching on both hands, but they reported
more blanching on the chisel hand (i-e., the hand on the chisel of
the chipping hammer).

Sis For workers reporting blanching of the fingers, the fingers on each
hand were affected in the same order: the middle finger most
affected, then ring finger, index finger, little finger, and the
thumb least affected.

6. For exposed workers reporting numbness and tingling, the hand on
the throttle was more affected by these symptoms than the chisel
hand.

Te For reports of numbness, the middle, ring, and index fingers on
each hand were similarly affected, while the little finger and
thumb were less affected.

8. For reports of tingling the middle finger was most affected; the
ring and index fingers were similarly affected, and the little
finger and thumb less affected on each hand.

Observations 6, 7, and 8 about numbness and tingling did not change when
workers with blanching and numbness and/or tingling were separated from
workers with numbness and/or tingling only. When workers with blanching
only were separated from workers with blanching and numbness and/or
tingling, the patterns of finger blanching changed somewhat. Although the
number of workers was small (10 workers), those with blanching only had a
greater difference between the fingers of the chisel and throttle hands
(e.g., 8 out of 10 workers had blanching on the tip of the middle finger on
the chisel hand while only 3 out of 10 had blanching on the same location of
the throttle hand).

Fourteen workers who reported blanching, numbness, or tingling used the
chipping hammer in both their right and left hands. All of these workers
were from the shipyard, and all reported using chipping hammers. Five of
them had current job titles of pneumatic tool operator, five were chipper
and grinder workers, three were propeller finishers, and one was a Boiler
Maker. In some ways their fingers were affected differently by the three
symptoms compared to other workers in the exposed group (see Table 22).
Their index fingers and especially thumbs were highly affected by numbness,
tingling, and blanching; however, they seemed to favor the left hand on the
chisel (i.e., right handedness) because their left hands were more affected
by blanching while the right hand was more affected by numbness and tingling.

When a worker responded positively to having symptoms of tingling, numbness
or blanching of the fingers, he was asked if the symptoms occurred in cool
or cold weather or in warm weather. Cold exposure is a stimulus to attacks
of VWF and its symptoms. The occurrence of symptoms in warm weather would
indicate a greater severity of the disease. Although respondents were asked

2985


EXAMINATION OF UPPER EXTREMITIES

Card 15, Col.

Subject ID 1-5
Palpation
RIGHT _ LEFT
Brachial: beats/min. |_|_| | beats/min. 6-17
Radial: beats/min. beats/min.
Findings
Axilla: Positive [ ] Negative [] Positive [ ] Negative [ ] 18 - 19
Describe: Describe:

Test Measurements

a) Skin thickness

RIGHT LEFT
Biceps a Biceps om 20 - 25
Triceps mn Triceps mm 26-3
Forearm TMm Yorearm mm 32\=' 37)
b) Mobility range
RIGHT LEFT
Wrist None [ ] Partial [ ] Full [ ] None [ ] Partial [ ] Full [ ] 38 - 39
Fingers None [] Partial [] Full [ ] None [ ] Partial [ J] Full [ ] 40 - 41
Describe: Describe:
First 3 Characters of Last Name 1S= 41,

16
148


69.

70.

71.

Agresti, S., and B.F. Agresti. 1979. Statistical Methods for the Social
Sciences. Dellen Publishing Company, San Francisco.

Armitage, P. 1971. Statistical Methods in Medical Research. Blackwell
Scientific Publications. Oxford amd Edinburg.

SAS Supplemental Library User's Guide. 1980. SAS Institute, North
Carolina.

-48-


METHODS: MEDICAL-CLINICAL TESTING
OVERALL TESTING SEQUENCE

The medical-clinical testing was carried out in a specially designed 45-by
10-foot climate-controlled trailer (see Floor Plan, Figure 1). When
possible, exposed and control subjects were tested at random. Subjects
entered and reported directly to the reception station (1) where they were
logged in and given gloves to warm their hands. The subject .then proceeded
to station II where voluntary consent forms and details concerning
confidentiality were explained and signed; the study questionnaire was then
administered. Next, the subject moved to station III where a general
medical examination was performed. At station IV, the subject's hands were
tested for temperature, and tests were conducted for light touch, pain, and
temperature sensing. Then additional medical history was taken. At station
V, X-rays of each hand (both AP and lateral) were taken and immediately
processed. The subject then moved to station VI where depth-sense and
two-point discrimination tests were done. At station VII, photocell
plethysmography was performed. (This represented the last testing station
for all but a sampling of workers who proceeded to station VIII where the
dynamic compliance testing was done.) Each subject spent approximately 2
hours in the medical trailer (and some spent a half hour in the engineering
truck for dynamic compliance testing).

Log-In (Station I)

As each subject entered the trailer, he was logged in and given a pair of
warm workman-type soft gloves. He was instructed to wear the gloves at all
times except during the test periods, to keep his hands warm. Taylor and
Pelmear (18, 47, 48) have found that hand testing cannot be done with cold
hands and/or during a VWF attack, (which is usually precipitated by cold).

Study Questionnaire (Station II)
The subject consent form (see Appendix A) was used to brief each volunteer
and obtain their consent to participate voluntarily in the study. The

subject signed one copy and retained an identical version of what was signed.

The questionnaire (see Appendix B) which was then administered by
experienced and trained interviewers, contained the three parts:

Part I - Demographic data such as ethnic group and date of birth;

present (i.e., at the time of the survey) and past
occupational history and hobby tool history (see Table 3).

SRS


EXTREMITY INSPECTION

Instructions for examining physician concerning extremity diagrams on following pages:

Perform inspections of both hands and arms, front and back using the coded criteria listed
below. Place in each diagram the letter or letters corresponding to the items listed below

in their exact location. (Example: If the right thumb had a scar on the front side, then

in the area designated 1RF on the right front diagram, the position of the scar would be
drawn in with a code letter "C" placed near it; if the scar extended down this same thumb to
the palm, then draw in the length and ground shape of the scar indicating a "c" in areas

1RF, 2RF, 15RF. Also check off the computer coding boxes "C" for 1RF, 2RF, and 15RF. Please
shade in the diagram the number of segments at each finger (including thumbs) on both hands
which are white or blue in a severe attack. Indicating a letter "J' for blanching and "x"

for cyanosis. The corresponding computer coding boxes for J and K will also need to be checked

off. In all cases us2 multiple letters when multiple conditions exist in the same areas.

Inspection Criteria (hand-arm)

Code Letter Conditions
A Amputations
B Deformities
c Scars
D Needle Marks
E Skin Lesions
F Knuckle Pads
G Swelling of Joints
u Finger Tip Ulcers
I Subungual Hemorrhages
A) (Color) Blanching
K (Color) Cyanosis

3

135


oOmmMADOS TNO AZMOWMVI m<—Ayrcseco

1004

904

805

705

605

504

30+

204

104

Figure 5.

LATENCY OF NUMBNESS
FOUNDRIES AND SHIPYARD
(VWF STAGES ON,TN,01,02,03 — EXPOSED GROUP)

LEGEND: SITES === FOUNDRIES
~—— SHIPYARDS

T T a T \ T T T

0 5 10 15 20 25 30 35 40

YEARS WORKING WITH A CHIPPING HAMMER
BEFORE ONSET OF NUMBNESS

81


JOB TITLE

Abr. Rh. Blst. Opr.
Aircraft Handler
Aircraft Maintenance
Appr. Pipe Fitter
Assembler

Asst. Foreman
Attendant

Auto Mechanic

JOB TITLE

Automatic Screw Mach. Opr.

Auto. Cutoff Machine Opr.

Aviation Elec. Tech.
Bench/Floor Hand
Boiler Maker
Boiler Opr.
Carpenter

Casting Salvage
Cement Finisher
Chip/Grind Heavy
Chip Intricate
Chip and Grind
Chipper/Caulker
Cleanup

Combat Engr.
Construction Worker
Core Maker
Disassembly
Driller
Electronics

Driver
Engineer/Gunner
Electrician
Fitter

Flask Repair
Foreman

Forester

Fine Control Appr.
Foundry Worker
Forklift Truck Driver
Inspector

Helper

Hand Cleaner

-163-

FREQUENCY

e ~
SPE ENFREUNENEP PPE

RNP PREFER PWR ERE PENERENEW


EXPOSURE VARIABLES AND VWF STAGING

The results presented in the section "VWF Staging and Latency" clearly
showed a highly significant association between use of chipping and grinding
tools on the job and vibration white finger disease. This chapter will
address the relationships between time and intensity of exposure to hand-arm
vibration from chipping and grinding tools and severity of VWF.

For workers in the exposed group, the number of years that chipping hammers
were used on the job was calculated. The starting and ending dates and tool
codes (see Table 8) recorded for each job were used to calculate the total
number of years that chipping hammers were used on the job. Part-time jobs
added half the number of years as full-time jobs. The current jobs of the
exposed workers were always included in this calculation.

Tables 44 and 45 give the mean, median, and range of years for jobs
requiring the use of chipping hammers by VWF stage for the foundry and
shipyard industries. The shipyard workers had been employed on jobs using
chipping hammers much longer than the foundry workers. This is consistent
with the older age of the shipyard population. In both industries, the
average length of time that chipping hammers were used increases with the
increasing severity of the VWF stage. The significance of this relationship
was tested using Kendall's Tau-B measure of association (69). This
statistic tests for the association between two ordinal variables. The
Kendall's Tau-B test results are given in Tables 46 and 47. Categories used
in these tables were formed because they maximized cell size. For both the
foundry and shipyard populations, the positive relationship between years on
jobs using chipping hammers and severity of VWF stage was highly significant.

In the foundry population, the workers without VWF (stage 00) had a
relatively long mean exposure time (i.e., years on jobs using chipping
hammers). This result was due to the contribution of 3 workers (out of the
25 workers in stage 00) who had more than 12 years experience using a
chipping hammer on jobs. The presence of these outliers in this stage group
is reflected in the relatively short median exposure time of 1 year.

The median and mean exposure times for foundry workers in stages OT, ON, and
TN did not differ considerably. Exposure times first increased at the
blanching stages of 01, 02, and 03. In the shipyard population and for
the VWF stages of TN, 01, 02, and 03, the length of exposures to chipping
hammers was similar and actually decreased somewhat at stages 02 and 03.
This decrease was due to two workers in stage 03 who reported more years on
jobs using only grinding tools than years using a chipping hammer. Based on
the logistic multiple regression model (71) the years on jobs using
vibrating hand tools other than chipping hammers was found not to contribute

235s


Table 28.

Latencies of numbness for workers at the shipyard (exposed group
only). Latencies are adjusted and unadjusted for the number of
years that workers did not use chipping hammers before the onset
of numbness,*

Adjusted latencies Unadjusted latencies

VWF Stage (in years) (in years)
ON (N = 8)
Mean 7.9 8.1
Median 6.5 6.5
Range 0.08 - 18.9 0.08 - 20.9
TN (N = 9)
Mean 9.3 9.8
Median 5.6 5.6
Range 0.04 - 26.6 0.04 - 30.7
01,02,and 03 (N = 9)
Mean 13.2 17.8
Median 8.0 16.5
Range 037 = 3120 0.7 = 38.9
All stages (N = 26)
Mean 10.2 12.0
Median 6.8 9.5
Range 0.04 - 31.0 0.04 - 38.9

*Data were missing for three workers.

76


COMPANY FREQUENCY

Tractor Mfg.

Wagon Mfg.

Masonry

Heavy Equipment Mfg.
Muffler Instal.
National Guard

Oil Production
Painting

Pavement

Pipe Mfg.

Pre-Fab Houses
Propellor Mfg.
Radiator Mfg.
Railroad's Operation
Refrigerator Mfg.
Road Construction
School j
Ship Building 1
Steam Turbine Mfg.
Steel Mfg.

Tool and Dye
Tractor Foundry
Tree Service

Truck Mfg.

U.S. Air Force

U.S. Army

U.S. Coast Guard
U.S. Navy

CRN WUNEF REDE WBENENP ERE FENEP WORE

HOBBY
HOBBY NAME FREQUENCY

Auto Body Work
Auto Work
Carpentry
Cutting Logs
Cutting Trees
Farm

Firewood

Home Repair
Mechanic

Model Railroads
Motor Repair
Race Cars
Refinish Wood
Wood Work

=
BNP RPP NPR RP ORNE

-167-


Table 3. Information collected on each participant.

Present employer

1. Department number

2. Job Title

3. Starting date

4. Ending date

5. Full-time or part-time

6. Shift

7. Vibrating hand-tool types

8. Position: sitting and/or standing
9. Glove usage

Past employer

1. Name of past employer

2. Type of company

3. Starting date

4. Ending date

5. Full-time or part-time

6. Job title

7. Vinyl chloride exposure
8. Vibrating hand-tool types

Information collected for each hobby with a vibrating hand tool

1. Type of hobby

2. Vibrating hand-tool type
3. Starting date of hobby
4. Ending date of hobby

53


Table 29. Latencies of blanching for workers in the foundries (exposed group
only). Latencies are adjusted and unadjusted for tne numper of
years that workers did not use chipping hammers before the onset
of blanching.

Adjusted latencies Unadjusted latencies
VWF Stage (in years) (in years)

Ol (N= 29)
Mean 1.4
Median 0.8
Range 0.04 - 8.9 0.04 - 8.9

or
wou

02 (N = 33)
Mean 2.2 2.6
Median 1.7 1.7
Range 0-2 = 13.6 0.2 - 14.5

03 (N= 7)
Mean ies)
Median . 1.5
Range 0.2 - 4.0 0.2 - 5.4

01,02, and 03(N = 69)
Mean
Median é
Range 0.04 - 13.6 0.04 - 14.5

Ce
Wo 00

2.0
1.4

77


Form Approved
O.M.B. 068- S7705&
Exp. October 1978

U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
Center for Disease Control
National Institute for Occupational Safety and Health

Cincinnati, Ohio 45226

Prevalence of Raynaud's Disease in Chipper and Grinder

Project Title:
Operators Using Vibrating Hand Tools

COC / NIOSH (C) TF 2.21
TAL


Page 3 - NIOSH Human Subjects Research Participant Document

11. SIGNATURE DATE
Subject

SIGNATURE DATE
Parent or Guardian

INVESTIGATOR
Name, Title and Signature
Til. REQUEST AND AUTHORIZATION FOR RELEASE OF INFORMATION
As OF » hereby request and authorize the

Project Director to inform the following physicians whose names
and addresses I have entered below of any significant findings
from the above named study concerning me. (Do not leave blank.
Write "No" where you do not wish to give a name and address).

1. My Personal physician(s):

Dr.

Street:

City:

2. (Company), (Other) physician:

Dr.
Street:
City:
Signature Date
B. FT » hereby do/do not request and

authorize the Project Director to allow the presence as a
medical observer of (plant physician) Dr.

as I am undergoing the study procedures, tests, and medical
examination listed in Attachment A.

Signature Date

Iv. Since a project questionnaire is required, it will constitute this
Part IV as a separate attachment to be retained by the Project
Director. A copy of the questionnaire is not retained by the
participant.

115


was gathered about their operating characteristics and their types of
on-the-job uses. The project's medical and engineering team reviewed all
available information on each tool and decided upon a set of tools whose
occupational exposure would confound exposure to chipping and grinding tools
(see Table 5). Confounding exposure was considered in this study to mean:
1) hand-arm vibration exposure severe enough to produce VWF in a
biologically and statistically significant proportion of a worker population
and/or 2) vibration characteristics of the tool that are similar to those of
the tool studied with the highest vibration levels (i.e. the chipping
hammer).

The tools in Table 5 were part of the criteria for exclusion from the group
of workers currently exposed to chipping and grinding tools. These
currently exposed workers were selected by first examining the current job
titles of all workers who reported using a chipping hammer on their current
job. Fourteen job titles were identified and all workers with these job
titles were examined for tool usage on their current job. For 3 of the 14
job titles, 50% or less of the workers reported use of a chipping hammer on
their current job (see Table 6). All of the workers with these three
current job titles were from the shipyard group. Workers with the remaining
ll job titles (see Table 7) were considered for inclusion in the exposed
group.

The decision diagram in Figure 3 and the selection criteria and tool
categories in Table 8 show how workers were selected from the study
population for the exposed and control groups. The objective of the
selection criteria for the exposed group was to maximize the number of
workers in the exposed group without including workers who had confounding
exposures, since asssociations between VWF and other factors cannot be
demonstrated to be statistically significant without a sufficiently large
exposed group.

The objective in selecting the control group was to choose workers who had
not used vibrating hand tools but had similar occupational backgrounds and
working environments to the exposed group. The control workers selected in
this study have never used vibrating hand tools on any of their jobs. This
criterion is strict but was considered necessary to increase the likelihood
of finding differences between exposed and control workers. A discussion of
each exposure group follows:

THE EXPOSED GROUP - EXPOSURE GROUP 1

Two hundred and fifty-nine workers with current jobs having job titles
listed in Table 7 (i.e. current job title for chipper) were considered for
inclusion in the exposed group. Twenty-four of these workers were excluded
from the exposed group because of confounding exposures on present and past
jobs and activities off the job.

Three chippers reported using riveting hammers and one reported using a
jackhammer on current jobs in combination with a chipping hammer. All four
workers were from the shipyard. The riveting hammer, formerly a common tool
in the shipyard industries, is now used infrequently, but the jackhammer was

==


Subject ID

IRB

IIRB

1RB
2RB
3RB

4RB

SRB
ORB
7RB
8RB
ORB

10RB

LIRB

13RB

14RB

LL

0)

tJ
(1
{J

HT

INSPECTION OF UPPER EXTREMITIES

0)

First 3 Characters of Last Name

Right Back

15
147

01
1

1
{1

Card 12, Col.

=")

6-14

E5)—123

24 - 35
36 - 46
47 = 57
58 - 68

Card 13, Col. (Subj.
5

39 - 49
50 - 50

Cards 12,13,14,Cols.

2 Ment |


CURRENT JOBS (EXPOSURE GROUP 1)

PERCENT OF CURRENT JOBS

FOUNDRIES SHIPYARD
1&2

TOOLS (N=159)* (N=76)*
Chipping Hammers 99 96
Pneumatic Grinders 99 92
Pneumatic Drills 0 58
Pneumatic Saws 0 57
Pneumatic Impact Wrench 0 4
Pneumatic Riveting Hammer** 1) 4
Pneumatic Sander 0 3
Planer 0 1
Pneumatic Tamping Hammer (not the 0 He

same as an air tamper; this is a

chipping hammer with a tamper

inserted instead of a chisel) 0 L

* Total number of current jobs; also total number of workers in
these groups.

** Subject to some restrictions; see definition of exposure group
1 in Occupational Histories and Exposure Groups.

-170-




In this part of the interview, I'll be asking you about your social habits.

SMOKING HISTORY

1. Do you now smoke cigarettes? 1 YES 2 NO
IF NO:
2. Have you ever smoked cigarettes? L YES 2 NO

IF NO TO Q. 1 AND Q. 2: GO TO PIPE SMOKING

ASK EX-SMOKERS:

3. How old were you when you gave up
smoking cigarettes? AGE 3 DK

4. How old were you when you started

smoking cigarettes regularly AGE * 8 DK
6 NEVER REGULARLY
5. On the average, how many cigarettes
do/did you smoke a day? CIG/DAY 8 DK
6. DO/did you inhale the cigarette smoke? 1 YES 2 NO 8 DK

PIPE SMOKING

7. Do you now smoke a pipe? it, YES 2 NO
IF NO:
8. Have you ever smoked a pipe? L YES 2 NO

IF NO TO Q. 7 AND Q. 8 GO TO CIGAR SMOKING

ASK EX-PIPE SMOKERS:
9. How old were you when you
gave up smoking a pipe? AGE 8 DK

10. How old were you when you

started smoking a pipe regularly? AGE 8 DK
6_____NEVER REGULARLY

11. How many bowlsful of tobacco do/did
you smoke per week? BOWLFULS/wk 8 DK
12. Do/did you inhale the pipe smoke? a YES oR NO 8 DK

130


INSPECTION OF UPPER EXTREMITIES

Subject ID

A BC
ILF br Nard
LILF EI)

A B oC
1LF ay (oy) ts)
2LF LON T9963}
3LF {1 01 0)
4LF Cy Er b.
SLF E’ty (4
6LF ea eae iba
7LF Ca fe)
8LF Yt 4
OLF CY £3 04
10LF (3 02
11LF CTT tas
12LF (eM ih
13LF Ore)
14LF (1 01 0)
1SLF (ok ede 10))

First 3 Characters of Last Name

tJ

Left Front

{J
1

t)
i

F

t)
(oy

138

G
We}
3}

a

0)
{]

I

{)
t]

Card 3, Col.

=)

6-14

1S ==23

24 - 35
36 - 46
47 ~ 57
58 - 68

Card 4, Col. (Subj.
I 5)

39 - 49
50 - 60
61 - 71

5)

iB Ecs ear

28 - 38
39 - 49
50 - 60

Cards 3,4,5, Cols.

1SE= 77:


INSPECTION OF UPPER EXTREMITIES

Subject

A BC
IRF Coy St
IIRF COS

A B C
IRF {2 £2 £4
2RF EN EM ES
3RF 3) Tea} te 3)
GRE eal lea) 23]
SRF eo Leon ea
ORF ie ea}
7RF WU [toh ie)
8RF (ay ey
ORF eo) oh 109)
10RF (1 €) 01
11RF Cy 0
12RF tt £4
13RF (ae jay
14RF CY t2 ©)
15RF CJ 03 i

First 3 Characters of Last Name |

Right Front

12
144

Card 9, Col.

shies

6-14

15:= 23

24 - 35
36 - 46
47 ~ 57
58 - 68

Card 10, Col. (Subj.
ID 1-5)

6- 16
17 - 27
28 - 38
39 - 49
50 - 60
61 - 71

Card 11, Col. (Subj.
ID 1-5)

6-16
17)= 27
28 - 38
39 - 49
50 - 60

Cards 3,4,5, Cols.

15) = 77,


MEDICAL EXAMINATION VARIABLES AND VWF STAGING

The study team physicians used much of the information recorded from the
medical examinations (see Appendix C, Medical Coding Sheet) to determine if
a worker should be medically excluded (see section on "Differential
Diagnosis"). Only a few of the medical examination variables were intended
for statistical analysis. These variables include certain digit conditions
such as cyanosis, finger tip ulcers, joint swellings, knuckle pads, finger
swellings, and calluses; wrist and finger mobility; and certain health
disorders such as arthritis, Dupuytren's contracture, carpal tunnel
syndrome, and tendonitis.

Results of associations between digit conditions and VWF staging are given
in Tables 54 through 58. The number of workers with cyanosis and fingertip
ulcers was too small for a meaningful analysis. The results for the other
digit conditions were summarized for all fingers on each hand. The fingers
on the dominant hands of the control workers were grouped together for
analyses with the throttle fingers of the exposed workers and the opposite
for chisel fingers (see section on "VWF Staging and Latency," Tables 19
through 22 for explanation of chisel and throttle hands). These analyses
did not include exposed workers who used both hands on the chisel and
control workers who were ambidexterous.

The number of workers with joint swellings on chisel fingers, knuckle pads
on chisel and throttle fingers, and calluses on chisel and throttle fingers
increased significantly with the increasing severity of VWF staging. Table
58, however, shows that some of these associations were due primarily to
relationships between some of these digit conditions and the number of years
that a chipping hammer was used. Especially in regard to calluses on chisel
and throttle fingers the significant association of years using chipping
hammers to both VWF staging and calluses indicates that calluses acquired
from tool use cannot be separated statistically from those linked solely to
VWF (see section on "Raynaud's Phenomenon of Occupational Origin, Secondary
Complications").

For joint swellings on the chisel fingers and knuckle pads on the throttle
fingers, there was no association of these digit conditions to years using
chipping hammers. In other words, the proportion of workers with joint
swellings on chisel fingers and knuckle pads on throttle fingers was
unchanged whether the worker had shorter or longer periods of chipping
hammer tool usage. On the throttle hand, the majority of the knuckle pads
were located on the throttle index finger. No fingers on the chisel hand
had a predominant proportion of joint swellings.

Tables 59 and 60 present the results of wrist and finger mobility and the
health disorders mentioned at the beginning of this section. No significant

eae


Contents
Forewardesssoee See c eee cecccccccnccessccccecccccscecsveselil
Abstractese.
Vibration Study Team.
Acknowledgements.»
Introduction.
Raynaud's Phenomenon of Occupational Origin.
Study Objectives and Protocol.....e.
Methods: Medical-Clinical Testing.
Worksites and Workpracticeseseccoeee
Occupational Histories and Exposure GroupSeesee.
Differential Diagnosis..
VWF Staging and Latencye.
Health-Related Variables and VWF Staging.
Exposure Variables and VWF Staging...
Medical Examination Variables and VWF Staging..
Temperature, Pain, and Light-Touch Sensory Tests
Summary and Conclusions...
Referencesesceceses
Tables and Figures.
Appendixes
A. Subject Consent Form.
B. Study Questionnaires...
C. Medical Information Forms...
D. Code Descriptions and Frequencies for Coded Occupational
History and Hobby Vardabless<cciewicccreescviecseveescecsceeseese sc LOU
E. Tools Used By Exposed Workers on Current Jobs, Past Jobs
With Present Employers, and Past Jobs with Past Employers.

2169

ix


exposure time. In examining two populations the prevalences of all stages
and the latencies of all symptoms must be compared with the exposure times
of VWF stage groups.

Figures 4 through 6 graphically present the unadjusted latencies for
tingling, numbness, and blanching. These figures show the graphs of the
cumulative percent of workers with these symptoms over time. The graphs for
all three symptoms at the foundries appear to show an expotential increase
in the percent of workers who acquired VWF symptoms (among those who had the
symptoms) with increasing exposure time to vibration from chipping hammers.
For the shipyard, the graphs seem to resemble linear increases in the
percent of workers with symptoms over time, but the slopes appear to be very
steep up to a cumulative 30% of workers and less so from 30% to 1002.

The median latencies may have been much less than the mean latencies for
these symptoms because of the steep increases in workers affected up to the
50% point. The median may be a more meaningful measure of latency than the
mean where these types of increases are observed.

—31—


APPENDIX A

SUBJECT CONSENT FORM

11.


In stage 4, the severity of the VWF and the interference with work, social
activities, and hobbies are such that the subject must change his
occupation. In the severest forms, the arteries of the fingers are
obliterated by the closure of the lumen. This sequence of progressing
stages arises from the cumulative effect of vibration transmitted to the
hands with the regular, prolonged use of vibrating tools found in certain
industrial processes. Despite a considerable amount of research, little is
known about the basic physiology of VWF. Also little is known, with any
degree of precision, about the vibration parameters (vibration acceleration,
spectrum, and energy into the hand) responsible for the resulting VWF.

OTHER COMPLICATIONS OF RAYNAUD'S PHENOMENON OF OCCUPATIONAL ORIGIN

A multitude of medical conditions have been thought to be associated with
VWF. Some of these relationships have been examined experimentally or in
field studies, others have not. Some of these relationships are discussed
here:

Callus

Edsall (49) observed that callus formation on the palmar surfaces of the
fingers was particularly noticeable on stone cutters using pneumatic

hammers. “Hard pads of thickened skin are usually seen on the fingers
exerting the most pressure on the vibrating tool or metal object, but a
general swelling of one or more fingers is also quite common." Stewart and

Goda (50), in noting the callus on the finger pads of vibration-exposed
persons, hypothesized that this was the cause of vibration white finger.
They suggested that the callus formation results in a fall in the volume of
blood that can be held in the capillaries in a segment of the finger, and in
the ability of the capillaries to react to changes caused by either a rise
or fall in body temperature. Thus, temperature-induced changes in the blood
volume may become visible--the hands become “cold-weather sensitive". No
pathological or physiological evidence is given to support Stewart and
Goda's hypothesis.

Nerve Injury

The early investigators in the United States mentioned some decrease in
sensory perception in the affected hand. Subsequently, Hardgrove and Barker
(51) described permanent sensory changes in the hands that did not follow
peripheral nerve trunk distribution, and Junghanns (52) noted a disturbance
in the sense of touch and in sensitivity to cold in the fingers.

Seyring (53) drew attention to three people with wasting of the muscles of
the hand and loss of sensation in the areas supplied by the ulnar nerve. She
attributed this to pressure on the nerve. Hunter et al. (25) also observed
ulnar paralysis.

Brockelhurst (54) found that touch sensation was normal but that thermal
sensation in the fingers, especially the tips, was impaired. Decreased
sensory perception in localized areas is frequently thought to be caused by
localized trauma. Dart (35) observed that localized loss of sensation may

=10=


1975 NIOSH Hand-Arm Vibration Conference Summary and Recommendations

Le Epidemiological and followup medical field studies of chain saw
operators in England, Sweden, and Poland indicate that
unexposed populations the prevalence of “white fingers" is 6 to 84%
and, in the vibration exposed groups, the prevalence varies from 6
to 89%. As a result of these studies (and competitive pressures),
numerous chain saw manufacturers have changed their tool designs
to incorporate antivibration mounts. To reduce the number

severity of VWF attacks, additional corrective measurements,

as wearing gloves, heated rest shelters, and warm clothing, have
been introduced by the U.K. Forestry Commission to maintain

constant core body temperature.

2. The interval of time between the first exposure to vibration and
the first appearance of a white fingertip has been designated "the
latent period." This period varies from 1 to 5 years, with a mean
of between 2 to 3 years in chain sawyers. In the limited field
studies that have been performed on pneumatic tool and pedestal
grinder operators, the latent interval can vary from less than 1
year to as long as 8 to 10 years, depending on the vibration

exposure, the time, and the intensity of the vibration.

result of these studies, a white finger classification system has

been devised to define stages of severity.

3. Examination of chain saw operators has led to an emphasis on the
actual measurement of the vibration impinging upon the workers and

attempts to correlate these measurements with medical

Evidence from longitudinal prospective studies performed
England and Sweden, suggest that the new antivibration chain saws

have reduced the prevalence of white fingers.

4. There was general agreement of the need to develop objective tests
to diagnose VWF and identify the severity of the disease.
Although the variety of neurological, temperature, and vascular
tests (previously studied) differentiated statistically between
vibration-exposed and control groups, they failed on an individual

basis.

Die In order to redesign their tools intelligently, chain
manufacturers and manufacturers of other vibratory hand tools
require a dose-response relationship from the medical data and
vibration measurements. Until such time, designers cannot assume
that antivibration tool design will reduce the prevalence of white
fingers. To date, statutory regulations for vibrating tools have

been imposed in only a few western countries.

=5-




Il SYMPTOMS

(ASK EACH Q. MARKED WITH * . FOR EACH YES ANSWER, ASK THE SECONDARY QUESTIONS
BELOW. FOR LOCATION, CHECK WHETHER OR NOT A SPECIFIC HAND LOCATION WAS
REPORTED, AND MARK THE LOCATION ON THE DIAGRAM. USE THE NUMBER OF THE
QUESTIONS: E.G., A .5 ON A FINGER TIP FOR A SUBJECT WITH NUMBNESS ON THAT PAKT
OF THE FINGER. THERE MAY BE MORE THAN ONE NUMBER ON ONE AREA OF THE DIAGRAM. )

SECONDARY QUESTIONS
IF YES ASK:

LOCATION Where do you usually have this?
(On what finger or fingers? Where on your finger?)

OCCURENCE Do you usually have this in warm weatner OR in cool or cold
weather?
ONSET In what year did you first notice this?
SYMPTOMS RESPONSE LOCATION OCCURENCE ONSET
*1. Do your fingers, or parts 1 YES 1__ REPORTED 1 WARM 19
of your fingers ever turn
white? 2: NO 8 DK 2__COOL/COLD 8_ DK
8 DK 8__DK
IF YES ASK:
2. Do your fingers usually turn white in the:
Morning?....
Afternoon?.
OR
At MighE?)sjcc:c0
NO USUAL TIME..
*3. Do you ever have tingling
in your fingers?
RESPONSE LOCATION OCCURENCE ONSET
1 YES 1_REPORTED 1 WARM 19
2 NO 8 DK 2_¢ OOL/COLD 8_ DK
8 DK 8” DK

123


Table 55.

VWF Stage

00 (control)

N =) 57

00 (exposed)
N = 34

OT and ON
N= 33:

TN

N = 35

ol

N= 32)

02 and 03
N = 44

Presence of knuckle pads on chisel
and throttle fingers (row percents).

Chisel Fingers or
Fingers on Non-
Dominant Hand

Knuckle Pads

Absent Present
50 ih
88% 12%
23 11
68% 32%
21 12
64% 36%
18 17
51% 49%
22 10
69% 31%
24 20
55% 45%

Chi-square value = 18.3

5 D.F. p = 0.003
Kendall's Tau B value
= 0.20, p less than 0.0001

101

Throttle Fingers
or Fingers on
Dominant Hand

Knuckle Pads

Absent Present
48 9
84% 16%
28 6
82% 18%
26 re
79% 21%
19 16
54% 46%
22 10
69% 31%
31 13
70% 304%

Chi-square value = 12.5
5 D.F. p = 0.028
Kendall's Tau-B value

= 0.14, p less than 0.02


Table 12. Frequency and Proportion of Workers in the
Medical Exclusion Groups (column percents).

Medical Total
exclusion population Foundries Shipyard
group (N*=385 ) (N=263) (N=122)
Hand/digit ll 8 3
trauma/disease (2.9%) (3%) (2.5%)
High blood 11 5 6
pressure (2.9%) (1.9%) (4.9%)
Special 9 6 3
diseases (2.3%) (2.3%) (2.5%)
Mixed ll 3 8
diseases (2.9%) (1.1%) (6.6%)
Primary 10 fi 3
Raynaud's (2.64%) (2.7%) (2.5%)
disease
All Medical 52 29 23
Exclusions (13.6%) (11.0%) (19.0%)
(Total)

*
N=number of workers

60


Part II — An individual medical history concerned with white finger and
medical problems that confound a diagnosis of VWF;
blood-relative medical history; and medication usage.

Part III - Smoking and alcoholic consumption histories.

Medical Examinations (Stations III and IV)

Each subject was examined sequentially by two physicians. The data recorded
by the first physician was used to screen subjects for Raynaud's Phenomenon
or White Finger due to causes other than vibration. The second physician
performed clinical sensory tests and diagnosed the presence or absence of
White Finger or VWF. The medical examination by the first physician
included the following:

1. Systolic and diastolic blood presssures taken twice on right and
left arms.

DES The radial, brachial, dorsalis pedis, and tibialis anterior pulses,
both right and left.

3. The rate and rhythm of the heart and presence of murmurs.

ee Arm inspection for trauma, scars, deformities, skin lesions, and
needle marks.

5. Hand examination for trauma, blanching, cyanosis, hyperaemia, skin
lesions, scars, lacerations, and calluses.

6. Finger examinations for amputations, blanching, cyanosis, calluses,
finger tip ulcers, joint swellings, knuckle pads, scars,
lacerations, trauma, fractures, and finger swelling.

Ts Wrist and finger mobility.

8. Detection of tendonitis, carpal tunnel syndrome, Dupuytren's
contracture, and arthritis.

As a precautionary measure, subjects with raised blood pressure (as
determined by the first physician), or who had a history of cardiovascular
disease were allowed to continue testing up to, but not including, Station
VIL (photocell plethysmography).

The following tests were performed by the second physician:

ds Skin temperature (finger tips, webs, and palms) was measured with
the use of a Yellow Springs thermistor mounted on a small, pencil-
like wooden dowel; the reading was taken on a Yellow Springs
Readout. If the temperature was below 30°C, the hands and
fingers were warmed by gloves until the skin reached that
temperature.

=15=


MEDICAL EXAMINATION

Subject ID | | |

Blood Pressure (mm Hg)

Right Arm Systolic/Diastolic

Left Arm Systolic/Diastolic

Eyes: Fundoscopic Examination (check)

Right Left
Arteries: Normal [ ] Abnormal [ ] Normal [ ]
Veins: Normal [ ] Abnormal [ ] Normal [ ]
A/V crossing: Normal [ ] Abnormal [ ] Normal [ ]
Exudate: Absent [ ] Present [ ] Absent [ ]

Other Fundoscopic Findings (describe)

Abnormal [ ]
Abnormal [ ]

Abnormal [ ]

Card 2, Col.

Mouth:
Cheilosis Abseat [ ] Present [ ]
Tongue: Normal [ ] | Redness [ ] Atrophy [ ]

Other: (describe)

Heart:
Positive Findings: YES [ ] No [ ]

If yes, specify:

First 3 Characters of Last Name

134

1-5
6-11
12-17
18 - 19
20 - 21
22 =23,
24 - 25
26

27

28

75 97


INTRODUCTION
HISTORICAL BACKGROUND

In 1861, Dr. Maurice Raynaud wrote an M.D. thesis entitled "Local Asphyxia
and Symmetrical Gangrene of the Extremeties" (1). This thesis included the
first description of "a condition, a local syncope where persons, who are
ordinarily females, see under the least stimulus one or more fingers

becoming white and cold all at once. The determining cause is often the
impression of cold. The cutaneous sensibility also becomes blunted and
then annihilated." This clinical condition of “white finger" or "dead

hand," which affects about 5 to 8% of the general population, has now
passed into the terminology of clinical medicine as Primary Raynaud's
Disease. The blanching attacks, usually affecting the fingers symmetri-
cally, are relatively minor in the early stages of the disease. A small
proportion (1% or less) may, however, become progressively more severe and,
over a period of years, lead to blue cold fingers, wherein the skin becomes
atrophic, later ulcerated, and finally gangrenous.

By the end of the 19th century, other conditions giving rise to Raynaud's
Disease were recognized, particularly the association of vibratory tools
with intermittent attacks of cold-induced pallor. Loriga (2) first
described "vascular spasm," or white finger, in the hands of miners using
pneumatic tools. Hamilton (3) studied miners using drills in the limestone
quarries of Indiana and described "spastic anaemia of the hands."
Researchers in the 1930s, showed that white finger syndrome was on the
increase, as reported by Seyring (4), who studied fettlers in iron
foundries; by Hunt (5), who studied riveters using pneumatic tools; and by
Telford et al. (6), who described white fingers in men working with
electrically driven high-speed rotating tools in a warm environment. In
1946 and 1949, Agate and Druett (7) examined 230 men who were grinding
excess metal from small castings that were hand-held against 2-foot
diameter grinding wheels. Of this total, 163 (70%) had a history of white
fingers. At this time, the "white finger" condition appeared to be arising
from the effects of prolonged hand exposure to vibration and the condition
was referred to as "Raynaud's Phenomenon of Occupational Origin" and later
as "Vibration-Induced White Finger" or VWF.

In 1962 and 1964, Ashe and his colleagues (8, 9) investigated a small group
of hard-rock mine drillers from Saskatchewan, seven of whom were examined
in the hospital. As part of the hospital investigations, arteriographies
and biopsies of the digital arteries were performed. In the worst cases,
extensive damage to the digital artery with narrowing of the lumen was
demonstrated. These investigations illustrated that in severe cases exten-
sive pathological damage to the arteries of the fingers could arise as a

sy


APPENDIX C

MEDICAL INFORMATION FORMS

132


pneumatic tool use, and 2 hours of performing other nonvibratory activities.
On occasion, the chipping could extend to 5.5 hours per day.

One man trained all of the men in this department on the use of pneumatic
chipping hammers. All chippers were instructed to use their body for
leverage and thereby absorb some of the vibration energy from the chipping
hammer. Their arms were to be held close to the body with the arm braced by
the body, knee, etc., for extra leverage. Generally, the chipping hammer
chisel was guided with the first finger and thumb or the flat palm of the
hand. The chisel was rarely in complete contact with the fingers. The back
handle was loosely clasped with the fingers. The chippers were trained to
hold the chipping hammer in either hand and wore leather gloves on both
hands, principally for heat reduction. Generally, they operated the
chipping hammers for 15-to 20-minute periods without resting. They also
sharpened their own chisels, customizing them to their preferences. The
length of the chisel was from 3 to 5 inches.

The men in this department basically performed two types of operations:
tamp and cut. The tamping operation included tamping and packing metal and
other caulking compounds into holes. Metal was welded into holes and the
chippers tamped the metal to form a smooth surface.

To use the chipping hammer for cutting, excess metal had to be removed from
the weld. Sometimes, they had to hold the chipping hammer over their heads
to perform cutting operations. Workers also used chisels to cut through
bulkheads. For these operations the workers guided the chisel with the flat
part of the palm while gripping the back handle tightly with the other
hand. During nearly all of the chipping, the worker used the chipper at
full throttle. The workers used both horizontal and vertical pneumatic
grinders to do finishing work.

DEPARTMENT Y

The men in this department cleaned and shaped ship propellers. Because of
the high precision required for finishing propellers, the workers progressed
very slowly. It was not unusual for a worker to work from 40 to 50 weeks on
a newly cast propeller. A worker first chipped the entire surface of one
side of a propeller and then ground the surface. When completed on one
side, the propeller was turned over and the operations were repeated on the
other side.

While chipping a propellor the worker leaned into the chipping hammer with
his body, pushing on the back handle of the hammer with the palm of his
hand. He guided the 3-to 5-inch long chisel with the palm of his hand.
Thus, his fingers never contacted the surface of the chisel and rarely
contacted the back handle. Each worker wore one glove on the hand that
guided the chisel. The hand that pushed against the back handle remained
ungloved so that the worker's hand was free to "feel" the throttle trigger
of the hammer. Workers operated this tool at 1/2 to 3/4 throttle. They
chipped in 15-to 30-second bursts with a 2-to 3-minute rest period between
bursts. On the average, 3 hours per day were spent chipping, 3 hours
grinding, and the remainder in nonvibratory activities.

~20-


CARD NO. 7

Card Columns

Case Number | 1-4
AMP. BLA. CAL. CYN. F.T.U. J.S. K.P. SC.-LA. TR. -FRA. F.S~
RDTP 6-15
RDID 16 - 25
RD1L 26 - 35
RD12 36 - 45
RD13 46 - 55
RD21 | 56 - 65
RD22 66 - 75
Card No. 07 79 - 80
CARD NO. 8

Case Number [| iL] im Ll hasty

AMP. BLA. CAL. CYN. F.T.U. J.S. K.P. SC.-LA. TR.-FRA, FS

RD23 6 - 15
RD31 16 = 925
RD32 260935
RD33 36 - 45
RD41 : 46 - 55
RD42 56 — 65
RD43 6602875
Card No. 08 79 - 80

-157-


Table 38 continued

Definitions of tobacco smoking categories

Nonsmoker
Ex-smoker
Moderate cigarette

smoker

Heavy cigarette
smoker

Moderate cigar
or pipe smoker

Heavy cigar or
pipe smoker

Does not currently smoke cigarettes, cigars, or
pipes and has never smoked or inhaled them.

Does not currently smoke cigarettes, cigars, or
pipes but has formerly smoked and inhaled them.
Currently smokes less than a pack a day.

Currently smokes a pack or more a day.

Currently smokes cigars or pipes but does not
inhale them; has never smoked or inhaled
cigarettes.

Currently smokes and inhales cigars or pipes;
has never smoked or inhaled cigarettes.

89


CIGAR SMOKING

13. Do you now smoke cigars? 1 YES 2 NO 8 DK
IF NO:
14. Have you ever smoked cigars? L YES 2 NO 8 DK

IF NO TO Q. 13 AND Q. 14: GO TO ALCOHOL CONSUMPTION

ASK EX=CIGAR SMOKERS
15. How old were you when you stopped smoking cigars? AGE 8 DK

16. How old were you when you started

smoking cigars regularly? AGE 8 DK

6 NEVER REGULARLY

17. How many cigars do/did you smoke a week? CIGARS /wk 8 DK
18. Do/did you inhale the cigar smoke? 1 YES 2 NO 8 DK

ALCOHOL CONSUMPTION

1. Have you drunk as many as 20
alcoholic beverages in your entire life? 1 YES 2 NO

IF NO: INTERVIEW IS FINISHED

2. Do you now drink alcoholic beverages? 1 YES 2 NO
IF _NO:

3. How old were you when you gave up drinking? AGE 3 DK
4. How old were you when you first started drinking? AGE 8 DK

5. On the average, how many beers do you

drink per day? BEER/DAY BEER/WK
(IF DOES NOT DRINK A BEER PER DAY ASK:
"HOW MANY PER WEEK") 7__LESS 1/WK 8 DK
6. About how many bottles of wine do you
drink per week? WINE/WK WINE/MO
7 LESS 1/MO 8 DK

7. About how many cocktails or drinks of other
liquor do you have per week? DRINKS/WK DRINKS/MO
7___LESS 1/MO DK

131


ODBMADOSE TNO AZMOWMV m<—AyYrc]e=co

Figure 6.

LATENCY OF BLANCHING

FOUNDRIES AND SHIPYARD
(VWF STAGES 01,02,03 — EXPOSED GROUP)

LEGEND: SITES === FOUNDRIES
~—+—- SHIPYARDS

T T T T

10 15 20 25 30 35

YEARS WORKING WITH A CHIPPING HAMMER
BEFORE ONSET OF BLANCHING

82

40


result of prolonged exposure to vibration transferred from the tool to the
hand.

From 1964 onward, an association appeared between Raynaud's phenomenon and
chain saws. The chain saws were used extensively in the British forestry
industry. By 1968-1969, when chain saw operators had accumulated 8 to 10
years of continuous use, complaints of VWF were reported in Britain. The
vibration of the two-stroke internal combustion engine (reciprocating
forces of the single cylinder two-stroke) is transmitted through the
handles to the operators' hands causing white finger disease. Prevalence
rates among workers in certain forests (where sawyers were working 5 to 6
hours per day, 5 days a week) were greater than 904. Because of the
increasing VWF prevalence rates and the deteriorating clinical state of the
hands of chain saw operators, the British Forestry Commission in 1970
issued workers newly designed antivibration (A/V) saws.

By far the majority of VWF field surveys have investigated the gasoline-
powered chain saw in a variety of countries (Australia (10), Canada (11),
Czechoslovakia (12), Finland (13), Japan (14), New Zealand (15),
Norway (16), Sweden (17), and the United Kindgom (18). Most other
epidemiologic VWF surveys have investigated pneumatic tools, especially
rock drills (19) different types of hand grinders (19-24) riveters (25)
chipping hammers (3,19,22,23,25,26) and jack-leg type drills (14,27,28).
Another pneumatic tool of importance is the jackhammer (also called road
drill, concrete breaker, or road ripper). The use of jackhammers has not
been studied in a population of workers because the user populations are
very small and widely dispersed. Nevertheless, jackhammer use has been
associated with symptoms of VWF (14,25) and a jackhammer operator had one
of the severest cases of Raynaud's Phenomenon reported (29) (gangrene of
the fingers) that could not be attributed to causes other than vibration.

Electric hand-held tools have received very little attention for a number
of reasons. The vibration levels of electric tools are assumed to be lower
because 1) electric motors are mechanically balanced systems (e.g., the
gasoline-powered chain saw as opposed to the electric chain saw), 2) most
electric tools are of the continuous rather than impact type, and 3)
pneumatic tools can be operated more economically at higher torque and
speed than electric tools. Electric tools are not used as often as
pneumatics in mass production processes for economic reasons. Air supply
is readily accessible in factories and since pneumatic tools do not have
internal motors (as electric ones do), they are less expensive to make,
buy, and maintain. Generally, electric tools are sporodically used on jobs
for a short time, such as the use of electric drills, saws, sanders,
routers, and planers by a carpenter.

Meaningful and definitive measurements of vibration levels from hand tools
have only been obtained in the last 10 years. The state of the art of
electronics technology has only recently permitted the development of

equipment to analyze these measurements. Fast Fourier Transform Analyzers
are needed to perform spectral analysis of vibration levels at various
frequencies. Until the advent of semiconductors and later integrated

circuits, these instruments were very expensive, fairly large, and few in

Hs


Table 38. Number and percentage (column) of workers in tobacco smoking
categories, by VWF stages

VWF Stage
Smoking 00 00 oT ON TN ol 02 03
Categories (control) (exposed)
Nonsmoker 23 il 6 3 iL 10 9 1
(36%) (24%) (30%) (15%) = (28%) (29%) (25%) (102)
Ex-smoker 20 uit 4 3 7 iz 4 3
(32%) (24%) (20%) (15%) (18%) (64) (114) (304)
Moderate
cigarette 6 1l 1 6 4 i 12 1
smoker (9%) (24%) (54) (30%) (10%) = (21%) ~— (33%) = (10%)
Heavy
cigarette 13 12 9 6 16 14 9 4
smoker (21%) (264) (45%) (30%) (41%) (41%) = (25%) = (40%)
Moderate
pipe or cigar 1 0 0 2 ie L 1 0
smoker (24) (104) (3%) (34) (34)
Heavy pipe
or cigar
smoker 0 0 0 0 0 0 0 0
Missing or
invalid data 0 1 0 0 0 0 1 1
for smoking (2%) (34) (10%)
history
TOTAL 63 46 20 20 Bo 34 36 10
(COLUMN) (100%) = (100%) (100%) (100%) (1004) (1004) (1004) (1004)

88


Table 42. Ages of exposed group and control
group (industries combined).

Exposed Control
Mean age 30 years 31 years
Median age 27 years 28 years
Range of ages 20-66 years 21-63 years
(Number of Workers) (205) (63)

Table 43. Mean ages of workers in medical exclusion

groups (all exposure groups combined).

Mean ages

Medical exclusion groups Foundries Shipyard
Hand/digit trauma 36 49
(22-55) (26-60)
High blood pressure 36 49
(23-49) (30-58)
Special diseases 38 56
(25-59) ((52=59)
Mixed diseases (except 44 59
Primary Raynaud's Disease) (24-59) (55-63)
Primary Raynaud's Disease 34 40
(22-50) (32-53)
All medical exclusion 37 = Mean 52 = Mean
groups 42 = Median 56 = Median
(22-59) (26-63)

93


Table 64. Classification of VWF stages by temperature

and pain sensory tests on the basis of a VWF

symptom classification rule.

Classes of VWF Symptoms Using Rule*

Total
Actual One or More Actually
VWF Stage No Symptoms Symptoms in Stage
00(control)
00(exposed) 91 12 103

(false
positives)
OT, ON, TN 38 106 144
Ol, 02 and 03 (false
negatives)

Total in VWF
symptom classes 129 118 247

Percent of VWF

symptom classes

in actual VWF

stage 714 90%

*VWF Symptom Classification Rule

Temperature Pain test
test result result
N N = no symptoms

one or more symptoms

rPre
rap

Note: Twenty-one workers were excluded because of abnormal skin

temperatures.

109

Percent
Correctly
Classified

88%

74%

80%


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Decision diagram and selection criteria for exposure groups (expgrp).
56

Figure 3.


Table 14. White Finger (WF) staging of workers in medical exclusion groups
(MEDGRP ).
WF Stage
Stage 00 Stages OT, ON, and IN Stages Ol, 02, and 03*

Exposure Medgrps Primary Medgrps Primary Medgrps Primary
Groups 1 Through 4 Raynaud's 1 Through 4 Raynaud's 1 Through 4 Raynaud's

Exposed 6 0 13 0 8 2)

Control 4 0 1 1 i 2

Exposure

groups

3 through 8 o! 0 1 0 3 4

* These gr

oups had no stage 04 cases


Le A series of laboratory studies were performed to confirm two
proposed objective clinical tests photocell plethysmography (40)

and aesthesiometry (41).
Qe Associated, new, and patentable instruments (41, 42) were

developed for both laboratory and field use.

3. Additional engineering work (recommendation 8 above) and better
methodology were developed to obtain accurate vibration
measurements from pneumatic chipping tools.

4. For the field study, a 45-foot trailer was obtained and outfitted
in-house to carry on the medical-clinical and objective diagnostic
testing.

Si. A customized engineering truck (43) was modified in-house to meet
the study needs for engineering testing.

In October 1977, a "dry run" of the entire field study procedure was done
using 16 NIOSH volunteer employees. The total testing time per subject
averaged 2 hours and 15 minutes.

In January 1978, the Vibration Study Team began onsite field testing of
chipper and grinder workers, which represents the content of this report.
Data were collected for 8 weeks and 385 volunteer workers were tested. The
field examinations were made at two large, gray-iron foundries and one
shipyard. Data collection ended with the additional examination of 50
stone cutters in Bedford, Indiana--the exact location where 60 years
earlier Dr. Alice Hamilton first described VWF in the United States (the
results of the Bedford study are presented in a separate paper (44)).


EXAMINATION OF LOWER EXTREMITIES

Card 18, Col.

Subject ID L=''5'
Palpation
RIGHT LEFT
Dorsalis pedis beats/min. beats/min. G7 11
Tibialis ant. beats/min. beats/min. a2 i= 7,
Popliteal art. beats/min. beats/min. 18 - 23

Test Measurements

a) Skin thickness

RIGHT LEFT
Calf mm Calf mm 24 - 29
Thigh mm Thigh ‘um 30 - 35
Preliminary State Assessment
States of Raynaud's Phenomenon (VWF)
Stages Condition of Digits Work and Social
Interference
to) No blanching ot digits No complaints 36
Or Intermittent tingling No interference with
activities 37
oy Intermittent numbness No interference with
activities 38
1 Blanching of one or No interference with
more fingertips with activities 39
or without tingling
and numbness
2 Blanching of one or Slight interference
more fingers with with home and social
numbness, Usually activities. No inter-
confined to Winter ference at work 40
3 Extensive blanching. Definite interference
Fe-quent episodes at work, at home and
Summer as well as with social activities.
Winter Restriction of hobbies. 41
4 Extensive blanching. Occupation changes to
Most fingers; fre- avoid further vibration
quent episodes exposure because of
Summer and Winter severity of signs and
symptoms 42
(Note: Complications are not used in this grading.)
COMMENTS :
Examining Physician Date
First 3 Characters of Last Name | | 75 - 77

151


Table 39. Alcoholic beverage consumption.

00

(controls) (exposed)

Number of workers who

never drink or were

not drinking at the

time of the survey. 9

Number of workers
who drank at the
time of the survey. 54

Mean ounces of
alcoholic beverages
drank monthly.* 45

* Calculated from the number of cans or bottles of beer usually drank

00

12

34

51

oT

18

51

VWF Stage
ON TN
5 8
15 31
60 59

oL

26

75

02

31

41

weekly, bottles of wine drank monthly, and cocktails or other Liquor

drinks consumed weekly.

90

03

37


STUDY OBJECTIVES AND PROTOCOL

The following study objectives and protocol were established at the January
1977 meeting (see Present Study Development).

STUDY OBJECTIVES

1. Determine if VWF exists in certain U.S. worker populations by
comparing the prevalence of VWF in control groups and
vibration-exposed groups of workers operating selected pneumatic
hand tools in certain work situations.

2. If VWF does exist, relate its occurrence to vibration exposure time
and vibration characteristics of hand-held tools.

3. Establish preliminary vibration guidelines for preventing VWF in
the occupational groups studied.

4. Investigate the validity of certain physiological and clinically
obiective tests for early detection of VWF.

5. Based on the results of 2 and 3 above, provide preliminary
technical guidelines to tool manufacturers for reducing vibration
in the tool types studied.

PROTOCOL

A comprehensive survey of workers would be performed. Those using
pneumatic hand-held chipping and grinding tools would be _ studied.
Voluntary participation in the study was asked of companies with large
numbers of pneumatic chipping and grinding workers. These companies had
been identified during previous NIOSH surveys (37,38). All shifts would be
examined. All study participants would be volunteers who would be
subjected once to:

1. An interviewer-administered questionaire consisting of a non-
medical (especially occupational history) and medical portion.

2. A general medical examination to detect medical problems that may
confound a diagnosis of VWF.

3. The following clinical tests: skin temperature, light-touch
sensing, pain (via pin prick) sensing, and temperature sensing.

4. A special medical history and finger examination to diagnose the
presence of white finger or VWF.

5 Is


As.

SUMMARY AND CONCLUSIONS

A field survey of 385 workers at two foundries and a shipyard was
carried out to study the health effects of workers using chipping
and grinding tools on the job.

A decision model and selection criteria were designed to assign
workers to exposure groups based on the use of vibrating hand tools
on past and present jobs. Workers in the exposed group used
pneumatic chipping and grinding tools on their present jobs and did
not have confounding past exposures. Workers in the control group
had never used vibrating hand tools on any jobs and did not have
confounding hobby tool exposures.

Extensive medical histories and examination data from the survey
were used to determine if workers had medical conditions that would
confound a diagnosis of VWF (Vibration White Finger Disease).
Thirteen percent of the exposed group and 12% of the control group
had confounding medical conditions. Only 2.6% of the entire survey
population had Primary Raynaud's Disease. Workers with confounding
medical conditions were excluded from further analysis.

The prevalence of VWF in the exposed group was 474 at the foundries
and 19% at the shipyard. None of the workers in the control group
had symptoms of Raynaud's Phenomenon or white finger; control
workers who had confounding medical conditions were excluded from
the group.

The VWF diagnoses made by the survey physicians were compared for
consistency with the VWF stages derived from the questionnaire data
. Only seven inconsistencies were found, all of which were
explicable according to medical or questionnaire information.

Surveys were made of the finger segments affected by the VWF
symptoms of tingling, numbness, and blanching. The tip of the
middle finger on each hand was affected in the highest proportion of
workers, while the proximal segment of the thumb was least affected
by all three symptoms.

The proportion of workers reporting tingling, numbness, or blanching
in warm weather increased significantly with an increase in the
severity of VWF stages. Also, the proportion of workers who had
trouble sleeping because of numbness and tingling increased
significantly with the increased severity of VWF stages.

=41=


AF

PH

WPA

EPA

SPA

DFW

DFB

DHC

DDHC.

Table 35. Percentage of yes answers to questions about pain and
aching in parts of the arm and nand. (see Taole 32 tor
legend of row symbols).

VWF Stage

00 (control) 00 (exposed) oT ON TN ol 02 03
N=63 N=46 N=20 N=20 N=39 N=34 N=36 N=L0

0% 26% 60% 35% 69% 56% 674% 604

0% 9% 404 15% 54% 41z 47% 004

8% 13% 204% 25% 59% 41% 504 60%

8% 9% 254% 10% 44% 18% 47h 604

8% 33% 20% 454 26% 32% 28% 404
Table 36. Percentage of yes answers to questions about ditficulty

performing activities (see Table 32 for legend of
row symbols).

VWF Stage
00 (control) 00 (exposed) OT ON TN ol 02 03
N=63 N=46 N=20 N=20 N=39 N=34 N=36 N=LO
3% 9% 20% 15% 214 21% 504% 604
2% 4h 54 0% 234% 9% 33% 504
0% 9% 10% 20% 264 23h 42% 50%
2% 24h 20% 104 15% 214 19% 304

86


individual health histories, length of exposure, type of exposure, length of
time since last exposure, etc. These factors complicate the analysis of
risk of VWF in the ex-chippers group. It was not within the design of this
study to attempt to answer questions about ex-chippers and VWF. The number
of ex-chippers tested was relatively small (30 workers) and ideally would
have been nonexistent, but the circumstances of field studies require that
some workers be tested who may not be included in the data analysis.

MIXED PAST EXPOSED - EXPOSURE GROUP 4

Workers who did not use any vibrating hand tool on their current job but
used a tool in category B or C on at least one past job were placed in
exposure group 4. Most of these workers were brought to the testing station
as potential control subjects, but their occupational histories revealed
past hand-arm vibration exposure.

MIXED CURRENT EXPOSED - EXPOSURE GROUP 5

Workers who did not have a job title as a current chipper, but used any type
of vibrating hand tool on their current job and had not used a chipping
hammer on any past jobs were placed in exposure group 5. Some of the
workers in exposure group 5 were potential exposed subjects who did not have
a job title as a current chipper (some of the workers in Table 6) or were
potential control subjects such as mechanics and electricians who currently
used vibrating hand tools.

CHIPPERS WITH CONFOUNDING EXPOSURES - EXPOSURE GROUP 6

The selection criteria for exposure group 6 was explained above under the
exposed group. Nineteen current chippers had conflicting exposures that
caused them to be excluded from the exposed group. On past jobs that had
not included a chipping hammer, 1 worker had used a gasoline~powered chain
saw, 1 worker a riveting hammer, 1 worker an air tamper and 15 workers a
jackhammer. One worker had used a jack hammer on both his current and a
past job.

EXPOSED WITH SIGNIFICANT HOBBY EXPOSURE - EXPOSURE GROUP 7

Five workers were excluded from the exposed group for significant hobby tool
use. Four workers had used gasoline-powered chain saws for at least 2 years
and as long as 12 years; one worker reported using "pneumatic tools",
including pneumatic grinders in auto bodywork.

CONTROL WITH SIGNIFICANT HOBBY EXPOSURE - EXPOSURE GROUP 8

Two workers who had used gasoline-powered chain saws as hobby tools for two
years were excluded from the control group.

Table 9 summarizes the number of workers in each exposure group totally and
by industry.

==


Case Number |

Mobility
Flex. Ext.

Wrist

Fingers

Tendonitis

LI |

Carpal Tunnel Syndrome

Dupuytren's

Arthritis

CARD NO.

= Yes

Normal

Preliminary Stage Assessment

|

Stage Assessment

z2H

ovr osoc
=z

Hand on Chisel

1 =Left 2 = Right 3 = Both

Card No. 11

11

Abnormal

Card Columns
1-4

11
12

13

14 - 16

Code Entered Into Blocks

=159-

Fwnroooeo

HAaH

uy)

79 - sf


*4. What about numbness in your fingers?

RESPONSE LOCATION OCCURENCE ONSET
1__YES 1_REPORTED 1 WARM 19
2__No 8__DK 2 COOL/COLD = 8_DK
8 DK 8_ DK ~—
5. Have you had trouble sleeping because of numbness or tingling in your
hands or fingers?.....ssseseeseeeoeeeele YES 2. 8 DK

IF YES ASK:

6. On the average, how long
does the tingling/numbness last?

L LESS THAN 5 MIN.
P) LESS THAN 15 MIN.
(IF THE RESPONDENT CANNOT GIVE 3 LESS THAN 30 MIN.
AN ESTIMATED TIME, READ THE 4 LESS THAN 1 HOUR
CODING CATEGORIES. ) 5 MORE THAN 1 HOUR
8 DK
ibs What do you usually do to get rid of the tingling/numbness?
VERBATIM RESPONSE
*8. Do you ever have aching
in your fingers?
RESPONSE LOCATION OCCURENCE ONSET
1 YES 1__ REPORTED 1 WARM 19
27 No 8 DK 2 COOL/COLD = 8_DK
8 DK 8 DK
*9. What about pain in your hands?
RESPONSE LOCATION OCCURENCE ONSET
1 YES i__ REPORTED 1 WARM 19
2 NO 8 DK 2__CooL/ COLD 8__DK
8 DK 8_ DK
*10. Did you ever have frost- RESPONSE LOCATION OCCURENCE ONSET
bite or painful, swollen, 1 YES 1 REPORTED 1 WARM 19
redish-blue fingers? 2 NO 8 DK 2__COOL/COLD 8__ DK
8 DK 8_DK

124


RAYNAUD'S PHENOMENON OF OCCUPATIONAL ORIGIN

MEDICAL-CLINICAL CRITERIA

It is essential that Primary Raynaud's Disease as originally described by
Raynaud (and sometimes known as "Constitutional Cold Fingers") be
distinguished from Raynaud's Phenomenon of Occupational Origin (also called
Vibration White Fingers or VWF).

The physiological cause of Raynaud's Phenomenon of Occupational Origin and
of Primary Raynaud's Disease is not known (45). Vibration may directly
injure the peripheral nerves, thereby causing numbing of the fingers and
hands or the paresthesia of the hands may be secondary to the vascular
constriction of the blood vessels causing ischemia of the peripheral
nerves. Likewise the physiological or chemical changes occurring in the
blood vessels or blood due to vibration can only be speculated upon at this
time (46). Whatever the etiology, it is necessary to distinguish all
individuals with medical conditions giving rise to impaired circulation of
the fingers or sensory changes in the hands. Individuals having these
medical conditions are classified as either cases of Primary Raynaud's
Disease or as cases of Secondary Raynaud's Phenomenon due to causes other
than vibration.

For individuals with a history of vibration exposure, the time of disease
onset differentiates cases of Primary Raynaud's Disease from those with
Raynaud's Phenomenon due to vibration. Primary Raynaud's Disease can be
established by the onset of blanched digits and greater sensitivity to cold
stimulus (than in normal subjects) prior to exposure to vibration and
entrance into industry. There may also be a strong family history of white,
cold hands.

Secondary Raynaud's Phenomenon due to causes other than vibration may be
attributed to numerous medical conditions (see Table 1). Individuals with
collagen diseases (connective tissue diseases) who have a history of white
finger attacks due to cold and such diseases as systemic lupus
erythematosus, scleroderma, and rheumatoid arthritis must be separated from
cases of VWF. Cases with interference of the blood vessels leaving the
thoracic cage, such as costo-clavicular and hyper-abduction syndromes,
confound a diagnosis of VWF as do neurogenic disorders such as poliomylitis
and syringomyelia. Cases with vascular disorders such as Buerger's disease,
generalized atherosclerosis, and a long history of raised blood pressure
present symptoms similar to VWF and must be considered separately. Other
cases are distinguished who have abnormal configuration and distribution of
the radial and ulnar arteries in the forearm and palms, as revealed by
clinical examination of the pulses. Trauma of the hands and fingers from

Aas


Figure 2. Foundry Worker Operating a Chipping Hammer.

52


PREVIOUS EMPLOYMENT

(REPEAT Q. 2-9 FOR EACH JOB. REPEAT Q. 1 UNTIL YOU ASCERTAIN THAT YOU HAVE
RECORDED ALL RELEVANT JOBS, INCLUDING PART TIME EMPLOYMENT AND MILITARY
SERVICE. * ON Q. 9, IF NO HAND TOOLS WERE USED ON A JOB WRITE "NONE" UNDER
“HAND TOOLS". )

1. Now, where did you work before you started working for 2
2. What kind of a company is it; what do they do there?
3. In what month and year did you start working there?
4. And, in what month and year did you stop working there?
Se Did you work full-time or part-time?
6. What was your occupation or job title?
7. On this job did you work with vinyl chloride?
8. Did you use any vibrating hand tools?
IF YES ASK: 9. What kind of vibratory hand tool?
10. Did you use any other vibratory nand tools?
TYPE OF DATE FULL TIME JOB VINYL HAND
EMPLOYER COMPANY STARTED/ENDED PART TIME TITLE CHLORIDE TOOLS
as 1_YES 2_NO
8 DK
2. 1_YES 2_NO
8 DK
3. 1_ YES 2_NO
8 DK
4. 1_ YES 2_NO
8 DK
5. 1 YES 2_NO
8 DK
6. 1 YES 2_NO
38 DK
7. i YES 2 NO
8 DK
8. 1_YES 2_NO
8 DK

121


Table 59. Wrist and finger mobility for exposed and
control groups (row percents).

Wrist flexion

Normal Abnormal
Control 94% 6%
Exposed 97% 3%
Wrist extension
Normal Abnormal
Control 95% 5%
Exposed 98% 24
Finger flexion
Normal Abnormal
Control 87% 13%
Exposed 86% 14%
Finger extension
Normal Abnormal
Control 92% 8%
Exposed 88% 12%

105


Table 61. Combined responses of workers to the three
sensory tests.

Sensory Tests
Temp- Light- VWF Stage
erature Pain Touch 00 00 oT ON TN ol 02 03
(control) (exposed)

N N N 60 28 1 8 iL & 4 0
N N A 0 3 0 1 0 0 0 0
N A N 0 1 2 0 1 Qs 3 0
A N N 1 4 1 0 3 7 1 0
N A A 0 1 0 0 4 0 0 0
A N A 0 L 0 0 1 ‘Z 4 dE:
A A N 0 1 2 8) 10 il 5 2
A A A (0) g 2 4 6 7 14 6

61 42 18 18 36 32 Bd: 9

Note: Twenty-one workers were excluded because of abnormal skin temperatures.

107


VIBRATION STUDY TEAM*

D. E. Wasserman, MSEE (Project

MEDICAL-CLINICAL TESTING CLINICAL-OBJECTIVE

Director)

TESTING ENGINEERING TESTING

Team Leader: Team Leader:

W. Taylor, M.D., Ph.D., D.Sc.

:
R. Miday, M.D.2 W. Carlson, B.

R. James, M.S.

EPIDEMIOLOGY RADIOLOGY

S. Samueloff, M.D.3

Team Leader:

D. Reynolds, Ph.b.4

Si D. Wasserman, MSEE
R. Basel, M.S.4
T. Doyle
W. Asburry

STATISTICS & DATA PROCESSING

Team Leader: Team Leader:

G. Howie, M.D.°

M. Rappaport, M.D.
S. Langenbrunner
D. Nurre
W. Parr,

V. Behrens, M.S.
S. Spaeth, B.S.
C. Cottrill, M.S.

Ph.D.

Team Leader:

J. Burg, Ph.D.

J. Morrison, B.S.
N. Lalich, M.s.
R. Smith, B.S.
K. Hicks

6

* 7 . .
The report contained herein represents only one portion of a large multi-
disciplined vibration study. This report is complete in itself,
however, the reader is advised to consult the other volumes comprising
the entire study effort in order to gain a complete understanding of the
scope of the project.

1 Visiting Scientist, University of Dundee Medical School, Dundee, Scotland

2 Kettering Institute, University of Cincinnati Medical School,
Cincinnati,Ohio

3 Visiting Scientist, Hebrew University, Hadassah Medical School,
Jerusalem, Israel

4 Mechanical Engineering Department, University of Pittsburgh,
Pittsburgh, Pennsylvania

5 Consultant Radiologist, University of Dundee Medical School,
Dundee, Scotland

6 Consultant Radiologist, University of Cincinnati Medical School,

Cincinnati, Ohio


Table 33.

Tingling

No
Yes
No
Yes
No
Yes
No
Yes
No
yes
No
Yes
No
Yes
No
Yes

Distribution of exposed workers by tingling, numbness, and
blanching symptoms combined (from study questionnaire; exposed
group only).*

Blanching VWE

Numbness Blanching Stage Stage Number &
No No 00 00 46 23
No No 00 oT 21 10
Yes No 00 ON 20 10
Yes No 00 TN Sy] 13
No Yes ol OL 7 3
No Yes ol ol il 3:
Yes Yes ol ol 2 1
Yes Yes ol ol 14 i)
No Yes 02 02 3 A
No Yes 02 02 5 3
yes Yes 02 02 5 3
Yes Yes 02 02 23 Le
No Yes 03 03 0 10)
No Yes 03 03 0 0
Yes Yes 03 03 1 0.5
Yes Yes 03 03 9 4

*Data was missing for one worker

84


to choose between cold or warm weather, it is safe to assume that those
answering yes to warm weather also experienced symptoms in cold weather.
Respondents who said they had symptoms in both warm and cold weather were
combined with those answering yes to occurrence in warm weather. Table 23
gives the number and percent with symptoms in cold or warm weather by stage
of VWF for the exposed group. As the VWF stage increases in severity for
all three symptoms the proportion having symptoms in warm weather increases.
This relationship of cold and warm weather to VWF staging was found to be
statistically significant for all three symptoms by Kendall's Tau-B measure
of association (69). Kendall's Tau-B measure was 0.161 for tingling

(p = 0.025), 0.176 for numbness (p = 0.021) and 0.291 for blanching
(p = 0.005). Because the populations for these three tests are not distinct
Gi.se., they partially overlap), the probability levels given are gross
estimates.

Workers were also asked if they had trouble sleeping because of tingling or
numbness in their hands or fingers. Table 24 gives the proportions answer—
ing positively to this question by VWF stages. This table also shows an
increasing proportion of workers having trouble sleeping because of numbness
and tingling with increasing stages of VWF. A trend test for proportions
(70) was used to determine if a significant linear trend is present in these
proportions. The chi-square statistic for trend was significant
(p = 0.0039) and did not depart significantly from linearity (p = 0.73).

An important characteristic of the VWF problem in a population is the
latency of the disease. Latency is determined as the time period from the
beginning of exposure to hand-arm vibration to the onset of the symptoms of
VWF. The onset year of tingling, numbness, and blanching was recorded on
the study questionnaire for workers reporting these symptoms. For this
study, the starting date for the earliest job using a pneumatic chipping
hammer was designated the beginning of hand-arm vibration exposure. For all
exposed workers, the current job was considered a chipping hammer job.

The month and year were identified for the starting and ending dates of
jobs. For latency calculations, the 15th of the month was assigned to each
of these dates as the starting or ending day. Both days and months had to
be assigned to the onset date of symptoms. These were assigned by the
following criteria:

1. June 30 (year of onset for tingling, numbness or blanching) was
used as the onset date except when the year of the survey was the
same as the onset year, or the starting date for the earliest job
using a chipping hammer was later than June 30 of the onset year.

2. When the onset year of the symptom was the same as the year of the
survey, the onset date was set in the month of the survey and 15
days before the middle date of the survey (the surveys extended
over a number of weeks and occurred in January, February, April,
and May).

9 =


Subject ID

A
RFT {1
RFL td
RFF {1

First 3 Characters of Last Name

B
1)
01
0)

c
(oy
J
Cay

INSPECTION OF LOWER EXTREMITIES

Inspection Criteria

Code Condition
A Amputations
B Deformities
c Scars
a (Golor) Blanching
K (Color) Cyanosis
RIGHT FRONT BACK
RES + RBT
REL..
+ RBL
RFF... har
J K A B
{1 01 1 :) a Oe i
LO: RL ef ] (1)
(1 01 RFF 6f)] (1)

17
149

Card 16, Col.

LS:

6-15
16 - 25

26 - 35

is - 77


ATTACHMENT A

Project Title and Number: Prevalence of Raynaud's Disease

in Chippers and Grinder Operator's Using Vibrating Hand
Tools (G-21, 7-9277328).

Procedures and tests which involve human subjects in conduct
of subject project are as follows:

A study questionnaire consisting of a non-medical and medical
portions will be completed. The non-medical portion consisting
of: (1) demographic data, (2) work history data, (3) information
on the types and usage of vibrating tools. The medical portion
consisting of: (1) occupational history and (2) specific medical
history designed to detect Raynaud's Phenomenon and its complica-
tions.

A specific medical examination of the arms and legs designed to
detect Raynaud's Phenomenon.

A noninvasive series of medical tests (i.e. tests which do not
pierce the skin): x-rays of the hands; tests which determine touch
sensitivity of the fingers (aesthesiometry, two point discrimination,
touch, mild heat and pin prick); measurement of finger diameters;
measurement of finger blood flow (plethysmography).

A series of engineering tests (mechanical impedance and acceleration)
designed to determine the amount and characteristics of the vibration
getting to the hands.

Rights under the Privacy Act of 1974 Title 5 United States Code,
Section 552(a) (e) (3)

The information required to be given to me under the Privacy Act
of 1974 is as follows:

1) Authority for collecting information is the Occupational
Safety and Health Act of 1970

2) The principal purposes are as stated in Section I, Item 3.

3) Routine use of this information is in developing criteria
and programs for a safe and healthful place of employment
as published on October 1, 1975 CDC-NIOSH-0121.00,Feleal Reysler-.

4) I do not have to furnish any information I do not wish to.
Nothing happens to me as a result of my not providing
information, whether all or in part of that requested,
except that I may be terminated from the project.

116


Table 40. Mean, median, and range of ages by

exposure group and industry.

Exposure group and industry

Exposed-foundries
Exposed-shipyard

Control-foundries
Control-shipyard

Ex-chippers~foundries
Ex-chippers-shipyard

Mixed past exposed-foundries
Mixed past exposed-shipyard

Mixed current exposed-shipyard

Confounded chipper-foundries
Confounded chipper-shipyard

Exposed w/hobby-foundries

Control w/hobby-foundries

Mean

26
41

34
25

30
43

37
28

Bi

26
51

25

28

91

Median

24
42

30
25

28
43

38
28

26

23
52

24

28

Range

20-49
22-66

21-63
21-30

21-43
29-59

20-62
28

23-53

20-42
30-63

22-29

28


HEALTH-RELATED VARIABLES AND VWF STAGING

Certain symptoms of pain and aching in the arms and hands, off-the-job
disability and social impairment have been thought to be related to VWF.
Seventeen questions (see Table 32) were asked on the study questionnaire
about these symptoms and types of impairment. The relationship of both the
occurrence of tingling, numbness and blanching and VWF staging to the
responses to these questions was investigated.

The workers in the exposed group were grouped in Table 33 by combinations of
the occurrence of tingling, numbness, blanching and stage of blanching.
None of these groups overlap. Because the number of workers in some of
these groups was very small they were recombined into symptom categories as
shown in Table 34.

Table 34 gives the percentage of workers in each symptom category who
answered yes to each of the 17 questions listed in Table 32. The following
observations can be made baseed on the data in Table 34:

1. The proportion of workers in the control group (CO) answering yes
to all of the questions was less than or equal to the proportion in
the exposed group at stage 00 (EO).

2. The proportion of workers in the exposed group at stage 00 (KO)
answering yes to all of the questions was less than or equal to the
proportion with tingling, numbness, or blanching. This was the
case except for the question concerning pain and aching in the
shoulder, trouble sleeping because of tingling and numbness (SL
group only), and difficulty distinguishing between hot and cold
objects (BL and NB groups only).

3 A higher percentage of workers experiencing only tingling (T) or
only tingling and blanching (TB) reported aching in the fingers
than did those in all of the other symptom categories.

4. Workers experiencing tingling only (T) had a higher or equal
percentage of yes answers to 12 of the 17 questions compared with
those with numbness only (N).

5. Workers with tingling and numbness only (IN) had unexpectedly high
percentages of yes answers compared with some of the workers with
stages 01 and 02 blanching (BL, TB, NB, and 1B). Workers with
tingling and numbness only (IN) exceeded at least one of these
blanching groups (BL, TB, NB and 1B) for every question and
exceeded all four blanching groups for 7 of the 17 questions.
Workers with tingling, numbness, and stage 01 blanching had a lower

=39=