Carpal Tunnel Syndrome – The Vibration Puzzle
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There is a long established association between vibration exposure and carpal tunnel syndrome. Since 1992 carpal tunnel syndrome has been a prescribed industrial disease for which state benefit can be payable where the condition arises in association with the use of hand held vibrating tools.
Notwithstanding, in a civil claim for personal injury the task of proving that a client's carpal tunnel syndrome is related to vibration exposure at work can still be challenging. Why is this?
Part of the difficulty lies in the fact that the symptoms and signs of carpal tunnel syndrome tend to be similar whatever the cause. The method of diagnosis and clinical treatment tend to be the same. Nerve conduction studies do not reveal significant differences between workers with a history of vibration exposure and those without. Where electro diagnostic testing is positive the usual outcome is surgery in the form of carpal tunnel release.
As there are a range of occupational and constitutional risk factors for carpal tunnel syndrome the lack of distinguishable clinical features to differentiate the vibration induced condition creates a level of uncertainty. As a consequence claims for this condition are often a fertile ground for dispute between opposing medical experts.
However, there are other signs and history to look out for which might support a link to vibration.
In addition to symptoms of carpal tunnel syndrome clients may also report episodes of blanching in the thumb or finger/s on exposure to the cold indicating some vascular dysfunction consistent with Raynaud's phenomenon or Vibration White Finger.
Sometimes the symptoms of tingling and numbness may not be confined to the median nerve distribution - the whole of the fourth and fifth fingers may also be affected. This may indicate the involvement of the ulnar nerve or a digital neuropathy consistent with the sensori-neural component of HAVS (Hand –Arm Vibration Syndrome). It is not unusual for carpal tunnel and HAVS to co-exist.
Often the outcome of the carpal tunnel release operation for those with a history of vibration exposure is mixed. Clients report an improvement in symptoms whilst absent from work only for their symptoms to recur on their return.
There are a number of possible explanations for this: the existence of scar tissue as a result of the surgery itself or peripheral nerve damage due to vibration (caused by exposure either before the operation and/or after the client has returned to work and where the exposure has continued).
Medical research has shown that vibration can damage nerves. In their paper 'Structural nerve changes at wrist level in workers exposed to vibration' [Occup Environ Med. 1997 May; 54(5):307-11.] Stromberg et al took biopsies of the dorsal interosseus nerve just proximal to the wrist from male cadavers with known exposure to hand-arm vibration and from those without [controls]. Their findings were that vibration could induce structural change in the peripheral nerves in the form of demyelination and fibrosis. The paper concluded that their findings might explain the poor results often seen in clients following carpal tunnel release surgery.
In a civil claim you would not expect to take a biopsy from a client in order to try and prove your case! At best one can check the operation notes relating to the carpal tunnel release surgery to ascertain whether the hand surgeon has commented on the state of the median nerve but even this can be of limited value.
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