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Application of cold intolerance symptom severity questionnaire among vibration-exposed workers as a screening tool for the early detection of hand-arm vibration syndrome: a cross-sectional study

Application of cold intolerance symptom severity questionnaire among vibration-exposed workers as... Background: The detection rate of hand-arm vibration syndrome (HAVS) is very low in South Korea compared with other countries. The absence of uniform consensus and guidelines for diagnosing HAVS has been presumed to be one of the reasons. The HAVS has various manifestations including cold intolerance and its severity can be measured using the cold intolerance symptom severity (CISS) questionnaire. This study aimed to determine whether the CISS questionnaire, being used as a screening tool, can aid in the early detection of HAVS. Methods: A total of 76 male workers with vibration-induced symptoms were enrolled as the final study participants. To compare the CISS score of healthy individuals, 41 men who had never been exposed to local vibration were included in the study. In addition to the former medical questionnaire, the participants answered the CISS questionnaire. A statistical analysis was conducted to identify the association of CISS scores with vibration induced symptom and to determine its cut off value. Results: The reliability of the CISS questionnaire was proven to be good, with a total Cronbach’s alpha of 0.922. The mean CISS score of the exposed group increased in every vascular stage [stage 0 = 42.6 (18.5); stage 1 = 59.4 (14.1); and over stage 2 = 60.2 (21.6)]. They were significantly higher than that of the non-exposed group. The result was fairly consistent with those in the sensorineural stage. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) of 30 were 88.5, 65.3, 76.1, 82.1 and 0.769, respectively. From the result of logistic regression, the adjusted odds ratio of both components increased by the CISS score grouped by 30s. Conclusions: The self-reported CISS questionnaire, used to measure the degree of cold intolerance, showed high agreement with the Stockholm classification of HAVS. Hence, we recommend the use of this questionnaire to assess the level of cold intolerance among vibration-exposed workers and detect individuals who are at risk of vibration-induced impairment with a cutoff value of 30. Trial registration: IRB No. 2018–07–040-001. Registered on 4 September 2018. Keywords: Hand-arm vibration syndrome, Cold intolerance, CISS questionnaire, Screening test * Correspondence: ciyoo62@hanmail.net Department of Occupational and Environmental Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, Republic of Korea Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 2 of 9 Background discomfort or avoidance of cold [16]. As it is a common Hand-arm vibration syndrome (HAVS) is a potentially dis- complaint following hand injuries including HAVS, cold abling condition comprising one or more specific neuro- intolerance had been frequently studied in conjunction logical, vascular, and musculoskeletal features, associated with hand injuries and vibration-induced impairments with exposure to hand-held vibrating tools such as grinders [17–19]. An interesting fact is that cold intolerance [1]. The typical manifestation of HAVS is cold-induced showed a high agreement with Stockholm workshop clas- vasospasm of the finger, which is often referred to as sification [20]. Various questionnaires have been used to vibration-induced white finger [2]. Other symptoms include detect cold intolerance. Among those, the self-reported hypersensitivity to cold exposure and sensorineural symp- cold intolerance symptom severity (CISS) question- toms such as tingling sensation, numbness, paresthesia, and naire proved to be a reliable, valid, and effective tool to sensory loss. These neurological features are known to pre- check the degree of cold intolerance [21, 22]. It is cede vascular symptoms, which result in decrease in work important to assess vibration-exposed workers for cold ability and debilitation of daily life [3]. intolerance since it may be an early neurological symptom As there is no internationally agreed gold standard, the of vibration-induced injury [18, 19]. Carlsson et al. re- diagnosisofHAVSisbased onthe typical clinical features, ported that the cold intolerance identified by the CISS history of exposure to vibration, and exclusion of other questionnaire was more apparent in patients with HAVS conditions [4]. Clinical assessment of vibration-induced than in healthy individuals, including the severity and oc- impairment is classified based on the Stockholm workshop currence of symptoms and influence on daily life, disabil- scale from 1986. According to the practical guidelines of ity, and health-related quality of life [18]. the Korean employee health management 2015, the follow- The current questionnaire administered to vibration-ex- ing initial tests should be conducted in vibration-exposed posed workers as part of their occupational health exam workers: work history investigation, peripheral circulation includes various questions on the risk factors of HAVS. exam, neurological test, and muscular function test [5]. Unfortunately, it merely has ancillary role in helping doc- Based on the results, the doctor decides who among the tors assess the vibration-exposed workers. As it cannot be workers needs further examination. This practical guideline quantified, these questionnaires could not be used as a published on 2015 reflects the actual condition of the screening tool nor act in consensus with the healthcare health management system in South Korea, which only lists providers of vibration-exposed workers. We hypothesized the exams without any organized or shared criteria that can that by applying the CISS questionnaire as part of the oc- be used to select workers requiring further evaluation. cupational health exam for vibration-exposed worker, we In fact, according to the Ministry of Employment and La- can quantify the degree of worker’s symptoms using the bor’s announcement in 2016, 32,217 workers were reported questionnaireand sort outpeoplewho need to take fur- to be exposed to hand-transmitted vibration and only 14 of ther objective exams to diagnose HAVS. Thus, it can them were diagnosed with HAVS and compensated [6, 7]. make up for the weak point of the current system used From the meta-analysis performed on vibration-exposed in diagnosing HAVS. Hence, this study aimed to evalu- workers in various countries, the incidence of vibration-in- ate whether the CISS questionnaire is a valid screening duced white finger ranged from 13.8 to 55.7%, which was tool that can be used for the early detection of HAVS higher than that in South Korea [8]. The incidence of vibra- and, if it is possible, to find out the appropriate cutoff tion-induced finger is dependent on the type of vibration value for vibration-exposed workers in South Korea. tool and duration of exposure, because the degree of dis- ability increases as the intensity and duration of vibration Methods exposure increases [9–12]. According to ISO 5349:2001, Study participants when exposed to a vibration velocity of 10 m/s per day, 1 The study was performed by obtaining the history and out of 10 workers whose working duration exceeds 6 years health exam results of vibration-exposed workers who vis- can eventually develop vibration-induced white finger ited Ulsan University Hospital and underwent occupational [8, 13, 14]. One of the most common tools used in a health exam or consulted an occupational-environmental typical industrial line in South Korea is grinders, and physician to evaluate the symptoms of HAVS from January its velocity is about 5–10 m/s [15]. Based on this theory, 2011 to December 2016. The exposure group was defined we hypothesized that the use of inappropriate diagnostic as symptomatic workers who had been exposed to vibra- systems or errors in occupational health exams conducted tion by using vibration-inducing tools. The medical records in vibration-exposed workers resulted in the underdiagno- of 91 individuals were reviewed. All participants were men sis of vibration-induced disabilities, leading to the low in- and aged over 18 years. Seven participants who were cidence of HAVS in South Korea. not able to complete the questionnaire and eight who Cold intolerance is defined as an abnormal or exagger- had a missing Stockholm stage were excluded. Finally, a ated reaction to cold exposure of an injured part, causing total of 76 workers comprised the exposure group. On Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 3 of 9 the contrary, the control group was composed of individ- for potential confounding variables such as age, smoking uals who had never been exposed to hand-transmitted vi- status, duration of using vibration tools, and past medical bration. The CISS questionnaire scores of the exposed history [17]. group and healthy individuals were compared. All partici- Several cutoff values for CISS questionnaire scores pants in the control group were men and aged 20–60 among normal population have been reported. Initially, years. Six of the total 40 compare group were excluded the CISS score classification system was subdivided into from the analysis due to history of hand trauma. mild (4–25), moderate (26–50), severe (51–75), and very severe (76–100) [21]. Recently, Sweden reported a cutoff Basic information survey and physical examination value of 50, while Netherlands reported a cutoff value of Variables associated with vibration included age, present 30 [18, 19, 21, 25]. Therefore, to find the appropriate cut- task, type of vibrating tool used, the duration of use, oc- off value for screening HAVS in South Korean workers, cupational posture, and safety equipment status [17]. we drew out three possible cutoff values: 20 and 30, which Data regarding the participants’ medical history (hyperten- were estimated from the means and standard deviations sion, heart disease, diabetes mellitus, musculoskeletal dis- of the exposure group, and 40 from the ROC curve. orders, trauma, etc.) and smoking history were collected Statistical analyses were performed using IBM SPSS because these variables may influence any current Statistics for Windows version 21.0 (IBM SPSS Inc., symptoms. After performing vascular and neurologic Chicago, IL, USA), and p-values less than 0.05 were tests, the staging was conducted by a physician based considered significant. on the Stockholm workshop scale. In addition to the former questionnaire, the CISS Results questionnaire was applied. The first form of CISS question- A total of 110 participants were enrolled in the study, of naire was cold sensitivity severity scale (CSS) invented by which 76 (69.1%) comprised the exposed group and 34 McCabe, which was updated 6 years later by Irwin into (30.9%) comprised the non-exposed group. Among the CISS questionnaire in Sweden. In 2006, Rujis et al. reported exposed group, 61 (80.3%) were diagnosed with HAVS. the modified version of CISS questionnaire [21, 23, 24]. The mean (SD) age of the non-exposed group was 40.7 The questionnaire is composed of six questions. The (10.3) years, which was significantly lower than that of first question asks about the type of symptom an indi- the exposed group. A significant difference in the dur- vidual is experiencing and is not included in the scor- ation of vibration tool use and daily exposed hour in the ing. The next five questions ask about the frequency of sensorineural and vascular stages was observed in the symptoms, time of occurrence, behavior change to ease exposed group. However, no trend was observed. Factors the symptom, degree of symptom aggravation when such as smoking status and past medical history had no performing certain activities, and how much the symp- significant difference in each stage (Table 1). toms affected their daily life. The internal consistency of the questionnaire expressed by Cronbach’s alpha was very good. The total Cronbach’s Statistical analysis alpha of all items in the translated questionnaires was First, an analysis was performed to check the reliability 0.922. The construct validity of the questionnaire tested and validity of the CISS questionnaire. The reliability using factor analysis showed that the items in the CISS was assessed using Cronbach’s alpha scale. Content val- questionnaire were valid. idity was assessed by the experts involved in the study, The median total CISS score of the vibration exposed via literature review and comments from the participants group was higher than that of the non-exposed group of this study. Construct validity was investigated through (Fig. 1). The CISS score pattern according to vascular factor analysis. Before performing the analysis, the exposed and sensorineural stage is presented in Table 2 and group was stratified using the Stockholm classification expressed as means and standard deviations (SD). It was scale. Due to the limited number of samples with stage 3 compared with that of the control group and their in- and stage 4 vascular HAVS and stage 3 sensorineural creasing pattern is depicted in a column graph (Fig. 2). HAVS, they were classified as over stage 2 group. In fact, In both components, the exposed group’s mean score each component was grouped into stage 0, 1, and over 2. was significantly higher than that of the non-exposed We conducted a descriptive analysis to characterize sam- group, which was 20.3 (11.0). The mean (SD) CISS score ples of the study. The CISS score trend of the non-exposed of the exposed group increased in every vascular stage group and the Stockholm stages of the exposed group were [stage 0 = 42.6 (18.5); stage 1 = 59.4 (14.1); and over stage analyzed using ANOVA. To assess the association between 2 = 60.2 (21.6)]. They were significantly higher than CISS score and HAVS, logistic regression was conducted to those of the non-exposed group (mean = 20.6; SD = 11.0). calculate the univariate and multiple adjusted odds ratios The post-hoc result revealed the significant difference be- (aORs) and 95% confidence intervals (CIs) while adjusting tween the non-exposed group and stage 0 of the exposed Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 4 of 9 Table 1 General characteristic between non-exposed and exposed group based on Stockholm workshop stage Non-exposed Exposed (n = 76) (n = 34) Vascular stage p value Sensorineural stage p value Stage 0 Stage 1 Stage 2 Stage 0 Stage 1 Stage 2 (n = 35) (n = 19) (n = 22) (n = 25) (n = 38) (n = 13) Age 40.7 ± 10.3 47.5 ± 8.8 49.3 ± 9.3 52.2 ± 6.8 < 0.01 47.1 ± 9.5 49.7 ± 7.7 52.5 ± 8.2 < 0.01 Total exposure 225.6 ± 112.8 242.4 ± 106.0 244.2 ± 87.4 < 0.01 197.1 ± 103.1 252.7 ± 98.4 257.4 ± 105.3 < 0.01 Daily exposure 5.2 ± 2.9 6.7 ± 2.2 4.8 ± 3.2 < 0.01 5.7 ± 2.9 5.1 ± 3.0 6.2 ± 2.5 < 0.01 Non-smoker 22 (64.7) 24 (68.6) 13 (68.4) 11 (50.0) 0.505 20 (80.0) 22 (57.9) 6 (46.2) 0.160 Smoker 12 (35.3) 11 (31.4) 6 (31.6) 11 (50.0) 5 (20.0) 16 (42.1) 7 (53.8) Diabetes No 30 (88.2) 35 (100) 19 (100) 22 (100) 0.037 25 (100) 38 (100) 13 (100) 0.032 Yes 4 (11.8) ––– –– – Hypertension No 31 (91.2) 31 (88.6) 16 (84.2) 20 (90.9) 0.864 23 (92.0) 32 (84.2) 12 (92.3) 0.771 Yes 3 (8.8) 4 (11.4) 3 (15.8) 2 (9.1) 2 (8.0) 6 (15.8) 1 (7.7) Dyslipidemia No 34 (100) 35 (100) 19 (100) 21 (95.5) 0.373 25 (100) 37 (97.4) 13 (100) 1.000 Yes–– – 1 (4.5) – 1 (2.6) – Unit: mean ± standard deviation, number (percentage) p-value was calculated by ANOVA for continuous variables p-value was calculated by chi-square test for categorical variables group and between stages 0 and 1 and over stage 2. However, unlike the vascular stage, no statistical signifi- The result was fairly consistent with those in the sen- cance was observed between stage 0 and stage 1. sorineural stage. The mean (SD) CISS score showed an Table 3 shows the sensitivity, specificity, positive pre- increasing trend, 47.0 (18.3), 49.0 (19.4), and 70.1 (16.7). dictive value (PPV), and negative predictive value (NPV) The post-hoc result, non-exposed group, and stage 1 of of each estimated cutoff value. The ROC curve for each the sensorineural component were significantly different. cutoff value is presented in Fig. 3. The area under the Fig. 1 Comparison of total CISS score between vibration-exposed group versus non-exposed group. The line in the box represents the median value of total CISS score and the top and bottom of the box is the upper and lower quartile range Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 5 of 9 Table 2 CISS score pattern according to the vascular and sensorineural stage Non-exposed Exposed (n = 76) p Post-hoc (n = 34) b c d value comparison Stage 0 Stage 1 ≥ Stage 2 Vascular stage 20.3 ± 11.0 42.6 ± 18.5 (n = 35) 59.4 ± 14.1 (n = 19) 60.2 ± 21.6 (n = 22) < 0.01 a < b < c,d Sensorineural stage 47.0 ± 18.3 (n = 25) 49.0 ± 19.4 (n = 38) 70.1 ± 16.7 (n = 13) < 0.01 a < b,c < d Unit: mean ± standard deviation, number (number of people included in each stage) p-value was calculated by ANOVA a,b,c,d Each presented for the Post-hoc comparison which represents Non-exposed, Stage 0, Stage 1, ≥ Stage 2, respectively curve (AUC) values for each cutoff value were 0.688, significant even after adjusting the possible confounding 0.769, and 0.759 respectively, where 30 was considered variables. as the best score but was not largely different from the Besides, the sensorineural component gained a differ- score of 40. ent result. When the score was categorized as 20s, there Table 4 shows increasing pattern of OR and aOR by the was no significant increase in the OR or aOR in any CISS score in each vascular and sensorineural component score group. However, when we assigned the under 30 of HAVS. We analyzed the vascular and sensorineural com- group as baseline, the OR of the 31–60 group and over ponents separately to determine the relevance of CISS score 61 group showed an increasing pattern [OR of 31–60 with each component. The CISS score was categorized into score group = 6.51 (95% CI = 2.39–17.73); OR of over 61 20s and 30s at each component of the Stockholm scale to group = 14.25 (95% CI = 4.53–44.82)] and remained sig- compare which scoring group is more appropriate to assess nificant even after adjustment of confounding variables. HAVS. For the vascular component, when the baseline was set as the score group under 20, the OR and aOR of the Discussion score group from 21 to 40 were not considered significant. The present study shows an association between CISS However, the OR and aOR of the 41–60 group [OR = 9.33 score and HAVS. The CISS score reflects the degree of (95% CI = 1.88–46.35); aOR = 6.54 (95% CI = 1.15–37.24)] cold intolerance, while the Stockholm stage reflects the and over 61 group [OR = 46 (95% CI = 8.41–251.66); severity of the disease. From the increasing pattern of aOR = 24.34 (95% CI = 3.84–154.20)] significantly in- the mean CISS score based on the Stockholm stage creased compared with the baseline, which indicates (Table 1), it can be inferred that cold intolerance is that the risk of HAVS increased as the CISS score in- related to disease severity in both vascular and sensori- creased. The result was more consistent when the neural components of HAVS. This also corresponds to baseline score was set to 30. The OR significantly in- the complex pathophysiology of cold intolerance. Cold creased as the CISS score increased [OR of the 31–60 intolerance, which is the mainstay of CISS questionnaire, group = 13.54 (95% CI = 2.90–63.28); OR of the over 61 is usually seen among the hand-injured patients. This group = 82.42 (95% CI = 15.38–441.54)] and remained debilitating symptom persists, causing a serious problem Fig. 2 Pattern of total CISS score by both vascular and sensorineural component. This column graph shows mean total CISS score of non- exposed group and of the stages of vascular and sensorineural component. The mean total CISS score of both component is higher than that of the non-exposed group Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 6 of 9 Table 3 Test characteristics of proposed cutoff value of the CISS patients with higher vascular stage may have the periph- questionnaire to detect HAVS eral neuropathic disorder already and thus experience Cut off value Sensitivity Specificity PPV NPV AUC more severe cold intolerance [3]. As there is no gold standard diagnostic tool for HAVS, 20 96.7 40.8 81.5 90.1 0.688 the physical exam by the experienced occupational doc- 30 88.5 65.3 76.1 82.1 0.769 tor and history of occupational exposure has an import- 40 72.1 79.6 67.0 69.6 0.759 ant role in diagnosing HAVS [4]. Testing for neurology and motor as well as vascular function is ancillary to as it affects an individual’s daily life and performance at that. The validity of testing tools had different values at work [16, 19, 21, 26, 27]. The mechanism of cold sensi- each study, and there are no specific standards to date tivity is still under debate, to identify whether it is [4, 31–35]. The cold provocation test is known to be the caused by a thermoregulatory dysfunction or by a neuro- objective test to assess for presence of vascular impair- logic condition that triggers neuropathic pain, which is ment in patients with HAVS, but there is variability again applicable to that of HAVS. Similar to the complex among the studies [34, 36, 37]. About the neurologic im- mechanism of cold intolerance, patients with HAVS may pairment, a previous study reported about the objective present with various organ dysfunctions. Moreover, its tests but no consensus has been established yet [31, 36, 38]. mechanism is known to be complex, with impairment of Thus, the diagnosis of HAVS is largely dependent on the the sympathetic nervous system and dysfunction of the patients’ subjective complaint and physical exam performed vascular system [16, 28–30]. Obviously, cold intolerance by an experienced occupational specialist. The ques- is an important manifestation of HAVS as in other hand tionnaires included in the recent occupational exams injuries, which many patients experience [31]. Addition- for vibration-induced workers contain various ques- ally, results showed that the association is more distinct tions that can help in diagnosing HAVS. However, each in the vascular component than in the sensorineural item cannot be quantified, which makes it difficult to component. This is because, generally, peripheral neuro- use as a screening questionnaire. pathic symptoms due to local vibration exposure are In this background, the need for developing consensus known to precede peripheral vascular symptoms. Thus, among the occupational specialist has emerged. We suggest Fig. 3 ROC curve of each estimated cutoff value. Blue line indicates the ROC curve of cutoff value 20. Green line indicates the ROC curve of cutoff value 30. Yellow line indicates the ROC curve of cutoff value 40. Purple line is the reference line Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 7 of 9 Table 4 Odds ratio and adjusted odds ratio of CISS score between non-exposed and exposed group CISS N Before adjustment After adjustment score a b OR 95% CI aOR 95% CI Vascular CISS score grouped by 20 Under 20 23 1.00 1.00 21–40 33 1.29 0.20–8.35 0.96 0.13–6.90 41–60 27 9.33 1.88–46.35 6.54 1.15–37.24 Over 61 27 46.00 8.41–251.66 24.34 3.84–154.20 CISS score grouped by 30 Under 30 41 1.00 1.00 31–60 42 13.54 2.90–63.28 10.47 2.08–52.70 Over 61 27 82.42 15.38–441.54 47.38 8.07–278.19 Sensorineural CISS score grouped by 20 Under 20 23 1.00 1.00 21–40 33 2.25 0.60–8.40 2.00 0.33–12.16 41–60 27 7.07 1.98–25.28 3.62 0.63–20.68 Over 61 26 14.44 3.78–55.19 4.47 0.76–26.36 CISS score grouped by 30 Under 30 41 1.00 1.00 31–60 42 6.51 2.39–17.73 4.96 1.32–18.71 Over 61 27 14.25 4.53–44.82 5.29 1.27–22.07 Odds ratio was calculated by logistic regression analysis Adjusted odds ratio was calculated by multiple logistic regression analysis after adjusting age, total period of using vibration-inducing tools, current smoking status, and past medical history using CISS questionnaire as a screening tool for HAVS. Additionally, as it is said above, we strongly doubt that the The CISS questionnaire can be used to quantify the incidence of HAVS has been underestimated in South subjective symptoms by computing the total score. Korea considering the prevalence of HAVS in other coun- Health care managers in the vibration-exposed industry try. In this sense, we suggest 30 as the proper cutoff value require all workers to fill out the questionnaires periodic- to avoid missing the detection of vibration-induced disor- ally to identify those who need further evaluation, which ders among the workers for now. enhances accessibility to diagnosis of vibration-induced This study has several limitations. First, this study is a impairments. In addition, occupational health manage- cross-sectional study, which makes it hard to determine ment organizations can use the questionnaire as an evi- the causal relationship between cold intolerance proven dence to conduct expensive tests to confirm HAVS and by the CISS questionnaire and HAVS. Second, there provide additional objective data in physical exams. More- could have been a recall bias since CISS questionnaire is over, the specific symptom of HAVS, also known as a self-reported questionnaire. Moreover, there is a limi- vibration-induced white finger, is rarely reported in warm tation within the questionnaire itself. The CISS ques- climate but neurologic symptoms such as tingling sensa- tionnaire used in this study is not the one recently tion and numbness have been reported even in warm modified. The recent version of the CISS questionnaire climate [39, 40]. While vibration induced white finger is has additional response options in questions number rarely observed during summer in South Korea, cold in- two and three, allowing the minimum total score of zero tolerance can be triggered by factors such as humidity, and making the symptoms of the unexposed group to be rain, and windy weather [18]. In this sense, the CISS ques- more clearly identified. Additionally, the contents of the tionnaire can be applied regardless of the season, making CISS questionnaire are mostly about the effects of cold it more useful. intolerance on daily life. To use it as a screening tool to To our knowledge, this is the first study conducted in evaluate the effects of cold intolerance on performance search for the cutoff value that can be used in a question- at work, it is advisable to add the items that focus more naire to screen for HAVS and test for its validity and reli- on identifying the discomforts experienced by the vibra- ability. By comparing the sensitivity, specificity, PPVs, and tion exposed group than focusing on the daily discom- NPVs among the three estimated cutoff values, scores fort. Definitely, future studies must be conducted using above 30 or 40 would indicate the need for further evalu- the revised CISS questionnaire to confirm its role as a ation. Supporting this suggestion, the risk of HAVS is well screening tool. Finally, there are no definite objective expressed when the CISS score is grouped by 30s than tools to compare the sensitivity and specificity of the 20s, which infers that a CISS score of 30 would be more questionnaire in diagnosing HAVS. There have been a appropriate to predict the people possibly having HAVS. number of studies in search of confirmative tests to Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 8 of 9 diagnose HAVS. However, the gold standard of diagnosis syndrome; NPV: Negative predictive value; OR: Odds ratio; PPV: Positive predictive value; PWES: Potential work exposure scale; SD: Standard deviation remains unknown. In the future, we hope to conduct a study that evaluates the correlation between the CISS Acknowledgements scores and other objective diagnosing tools used to iden- The authors would like to thank Occupational & Environmental Health Center, Ulsan University Hospital, University of Ulsan College of Medicine and tify the degree of vascular or sensorineural impairment the participants of the study. in vibration exposed workers. Nevertheless, the significance of this study is that this is Funding Not applicable. the first study to test the validity and reliability of the CISS questionnaire and to adopt the CISS questionnaire as a Availability of data and materials tool to screen individuals with HAVS in South Korea. As Not applicable. mentioned above, cold intolerance is one of the most de- Authors’ contributions bilitating complications of hand injuries experienced by ARK, as the first author of this article, designed the study, interpreted the several patients, including HAVS. Cold intolerance is a data, and drafted the manuscript. CY, as the corresponding author of this article, suggested the study design, interpreted the data, and revised the symptom that cannot be completely eliminated. Many manuscript. JHS and HL consulted the study method and revised the studies have reported the practice of lifestyle modification manuscript. DYK and JSK reviewed and revised the manuscript. All authors to improve symptoms and the study is still ongoing. Only read and have approved the final manuscript. early diagnosis can make early intervention possible, and Ethics approval and consent to participate only early intervention (e.g., stop vibration exposure) can This study was conducted with the approval of the institutional review stop the progression of the symptom. board of Ulsan University Hospital (ID: 2018–07–040-001). Future studies are needed to modify the questionnaire Consent for publication according to the purpose of using it as a screening tool Not applicable. for the early detection of patients with HAVS. Many Competing interests studies using the CISS questionnaire were conducted in The authors declare that they have no competing interests, either now or conjunction with the potential work exposure scale future. (PWES) [22]. The PWES includes questions about the exposure of hands to cold in the workplace. If it is used Publisher’sNote along with the CISS questionnaire in the workplace, it Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. will be more helpful in caring for vibration-exposed workers. Finally, other than using the CISS questionnaire Author details as a screening tool, it can also be used to detect people Department of Occupational and Environmental Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 who have cold intolerance as the symptom persists for a Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, Republic of Korea. long time, causing discomfort in their daily life as well as 2 Department of Occupational and Environmental Medicine, Gyeongsang in their working life and educate them how to manage National University College of Medicine, Gyeongsang National University Changwon Hospital, Institute of Health Science, 15, Jinju-daero 816beon-gil, the symptom and ways to relieve the symptom. Jinju-si, Gyeonsangnam-do 52727, Republic of Korea. Received: 27 September 2018 Accepted: 1 February 2019 Conclusion The prevalence of HAVS in South Korea is low compared References to other countries. As there is no gold standard, doctor’s 1. 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Patterns of thermoregulation associated with cold intolerance after digital replantation. Microsurgery. 1995;16(8): 556–65 PMID: 8538434. 29. Stoyneva Z, Lyapina M, Tzvetkov D, Vodenicharov E. Current pathophysiological views on vibration-induced Raynaud’s phenomenon. Cardiovasc Res. 2003;57(3):615–24 PMID: 12618223. 30. Ruijs AC, Jaquet JB, van Riel WG, Daanen HA, Hovius SE. Cold intolerance following median and ulnar nerve injuries: prognosis and predictors. J Hand Surg Eur Vol. 2007;32(4):434–9. https://doi.org/10.1016/J.JHSB.2007.02.012. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Occupational and Environmental Medicine Springer Journals

Application of cold intolerance symptom severity questionnaire among vibration-exposed workers as a screening tool for the early detection of hand-arm vibration syndrome: a cross-sectional study

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Springer Journals
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Copyright © 2019 by The Author(s).
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Medicine & Public Health; Public Health; Occupational Medicine/Industrial Medicine
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2052-4374
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10.1186/s40557-019-0284-x
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Abstract

Background: The detection rate of hand-arm vibration syndrome (HAVS) is very low in South Korea compared with other countries. The absence of uniform consensus and guidelines for diagnosing HAVS has been presumed to be one of the reasons. The HAVS has various manifestations including cold intolerance and its severity can be measured using the cold intolerance symptom severity (CISS) questionnaire. This study aimed to determine whether the CISS questionnaire, being used as a screening tool, can aid in the early detection of HAVS. Methods: A total of 76 male workers with vibration-induced symptoms were enrolled as the final study participants. To compare the CISS score of healthy individuals, 41 men who had never been exposed to local vibration were included in the study. In addition to the former medical questionnaire, the participants answered the CISS questionnaire. A statistical analysis was conducted to identify the association of CISS scores with vibration induced symptom and to determine its cut off value. Results: The reliability of the CISS questionnaire was proven to be good, with a total Cronbach’s alpha of 0.922. The mean CISS score of the exposed group increased in every vascular stage [stage 0 = 42.6 (18.5); stage 1 = 59.4 (14.1); and over stage 2 = 60.2 (21.6)]. They were significantly higher than that of the non-exposed group. The result was fairly consistent with those in the sensorineural stage. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) of 30 were 88.5, 65.3, 76.1, 82.1 and 0.769, respectively. From the result of logistic regression, the adjusted odds ratio of both components increased by the CISS score grouped by 30s. Conclusions: The self-reported CISS questionnaire, used to measure the degree of cold intolerance, showed high agreement with the Stockholm classification of HAVS. Hence, we recommend the use of this questionnaire to assess the level of cold intolerance among vibration-exposed workers and detect individuals who are at risk of vibration-induced impairment with a cutoff value of 30. Trial registration: IRB No. 2018–07–040-001. Registered on 4 September 2018. Keywords: Hand-arm vibration syndrome, Cold intolerance, CISS questionnaire, Screening test * Correspondence: ciyoo62@hanmail.net Department of Occupational and Environmental Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, Republic of Korea Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 2 of 9 Background discomfort or avoidance of cold [16]. As it is a common Hand-arm vibration syndrome (HAVS) is a potentially dis- complaint following hand injuries including HAVS, cold abling condition comprising one or more specific neuro- intolerance had been frequently studied in conjunction logical, vascular, and musculoskeletal features, associated with hand injuries and vibration-induced impairments with exposure to hand-held vibrating tools such as grinders [17–19]. An interesting fact is that cold intolerance [1]. The typical manifestation of HAVS is cold-induced showed a high agreement with Stockholm workshop clas- vasospasm of the finger, which is often referred to as sification [20]. Various questionnaires have been used to vibration-induced white finger [2]. Other symptoms include detect cold intolerance. Among those, the self-reported hypersensitivity to cold exposure and sensorineural symp- cold intolerance symptom severity (CISS) question- toms such as tingling sensation, numbness, paresthesia, and naire proved to be a reliable, valid, and effective tool to sensory loss. These neurological features are known to pre- check the degree of cold intolerance [21, 22]. It is cede vascular symptoms, which result in decrease in work important to assess vibration-exposed workers for cold ability and debilitation of daily life [3]. intolerance since it may be an early neurological symptom As there is no internationally agreed gold standard, the of vibration-induced injury [18, 19]. Carlsson et al. re- diagnosisofHAVSisbased onthe typical clinical features, ported that the cold intolerance identified by the CISS history of exposure to vibration, and exclusion of other questionnaire was more apparent in patients with HAVS conditions [4]. Clinical assessment of vibration-induced than in healthy individuals, including the severity and oc- impairment is classified based on the Stockholm workshop currence of symptoms and influence on daily life, disabil- scale from 1986. According to the practical guidelines of ity, and health-related quality of life [18]. the Korean employee health management 2015, the follow- The current questionnaire administered to vibration-ex- ing initial tests should be conducted in vibration-exposed posed workers as part of their occupational health exam workers: work history investigation, peripheral circulation includes various questions on the risk factors of HAVS. exam, neurological test, and muscular function test [5]. Unfortunately, it merely has ancillary role in helping doc- Based on the results, the doctor decides who among the tors assess the vibration-exposed workers. As it cannot be workers needs further examination. This practical guideline quantified, these questionnaires could not be used as a published on 2015 reflects the actual condition of the screening tool nor act in consensus with the healthcare health management system in South Korea, which only lists providers of vibration-exposed workers. We hypothesized the exams without any organized or shared criteria that can that by applying the CISS questionnaire as part of the oc- be used to select workers requiring further evaluation. cupational health exam for vibration-exposed worker, we In fact, according to the Ministry of Employment and La- can quantify the degree of worker’s symptoms using the bor’s announcement in 2016, 32,217 workers were reported questionnaireand sort outpeoplewho need to take fur- to be exposed to hand-transmitted vibration and only 14 of ther objective exams to diagnose HAVS. Thus, it can them were diagnosed with HAVS and compensated [6, 7]. make up for the weak point of the current system used From the meta-analysis performed on vibration-exposed in diagnosing HAVS. Hence, this study aimed to evalu- workers in various countries, the incidence of vibration-in- ate whether the CISS questionnaire is a valid screening duced white finger ranged from 13.8 to 55.7%, which was tool that can be used for the early detection of HAVS higher than that in South Korea [8]. The incidence of vibra- and, if it is possible, to find out the appropriate cutoff tion-induced finger is dependent on the type of vibration value for vibration-exposed workers in South Korea. tool and duration of exposure, because the degree of dis- ability increases as the intensity and duration of vibration Methods exposure increases [9–12]. According to ISO 5349:2001, Study participants when exposed to a vibration velocity of 10 m/s per day, 1 The study was performed by obtaining the history and out of 10 workers whose working duration exceeds 6 years health exam results of vibration-exposed workers who vis- can eventually develop vibration-induced white finger ited Ulsan University Hospital and underwent occupational [8, 13, 14]. One of the most common tools used in a health exam or consulted an occupational-environmental typical industrial line in South Korea is grinders, and physician to evaluate the symptoms of HAVS from January its velocity is about 5–10 m/s [15]. Based on this theory, 2011 to December 2016. The exposure group was defined we hypothesized that the use of inappropriate diagnostic as symptomatic workers who had been exposed to vibra- systems or errors in occupational health exams conducted tion by using vibration-inducing tools. The medical records in vibration-exposed workers resulted in the underdiagno- of 91 individuals were reviewed. All participants were men sis of vibration-induced disabilities, leading to the low in- and aged over 18 years. Seven participants who were cidence of HAVS in South Korea. not able to complete the questionnaire and eight who Cold intolerance is defined as an abnormal or exagger- had a missing Stockholm stage were excluded. Finally, a ated reaction to cold exposure of an injured part, causing total of 76 workers comprised the exposure group. On Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 3 of 9 the contrary, the control group was composed of individ- for potential confounding variables such as age, smoking uals who had never been exposed to hand-transmitted vi- status, duration of using vibration tools, and past medical bration. The CISS questionnaire scores of the exposed history [17]. group and healthy individuals were compared. All partici- Several cutoff values for CISS questionnaire scores pants in the control group were men and aged 20–60 among normal population have been reported. Initially, years. Six of the total 40 compare group were excluded the CISS score classification system was subdivided into from the analysis due to history of hand trauma. mild (4–25), moderate (26–50), severe (51–75), and very severe (76–100) [21]. Recently, Sweden reported a cutoff Basic information survey and physical examination value of 50, while Netherlands reported a cutoff value of Variables associated with vibration included age, present 30 [18, 19, 21, 25]. Therefore, to find the appropriate cut- task, type of vibrating tool used, the duration of use, oc- off value for screening HAVS in South Korean workers, cupational posture, and safety equipment status [17]. we drew out three possible cutoff values: 20 and 30, which Data regarding the participants’ medical history (hyperten- were estimated from the means and standard deviations sion, heart disease, diabetes mellitus, musculoskeletal dis- of the exposure group, and 40 from the ROC curve. orders, trauma, etc.) and smoking history were collected Statistical analyses were performed using IBM SPSS because these variables may influence any current Statistics for Windows version 21.0 (IBM SPSS Inc., symptoms. After performing vascular and neurologic Chicago, IL, USA), and p-values less than 0.05 were tests, the staging was conducted by a physician based considered significant. on the Stockholm workshop scale. In addition to the former questionnaire, the CISS Results questionnaire was applied. The first form of CISS question- A total of 110 participants were enrolled in the study, of naire was cold sensitivity severity scale (CSS) invented by which 76 (69.1%) comprised the exposed group and 34 McCabe, which was updated 6 years later by Irwin into (30.9%) comprised the non-exposed group. Among the CISS questionnaire in Sweden. In 2006, Rujis et al. reported exposed group, 61 (80.3%) were diagnosed with HAVS. the modified version of CISS questionnaire [21, 23, 24]. The mean (SD) age of the non-exposed group was 40.7 The questionnaire is composed of six questions. The (10.3) years, which was significantly lower than that of first question asks about the type of symptom an indi- the exposed group. A significant difference in the dur- vidual is experiencing and is not included in the scor- ation of vibration tool use and daily exposed hour in the ing. The next five questions ask about the frequency of sensorineural and vascular stages was observed in the symptoms, time of occurrence, behavior change to ease exposed group. However, no trend was observed. Factors the symptom, degree of symptom aggravation when such as smoking status and past medical history had no performing certain activities, and how much the symp- significant difference in each stage (Table 1). toms affected their daily life. The internal consistency of the questionnaire expressed by Cronbach’s alpha was very good. The total Cronbach’s Statistical analysis alpha of all items in the translated questionnaires was First, an analysis was performed to check the reliability 0.922. The construct validity of the questionnaire tested and validity of the CISS questionnaire. The reliability using factor analysis showed that the items in the CISS was assessed using Cronbach’s alpha scale. Content val- questionnaire were valid. idity was assessed by the experts involved in the study, The median total CISS score of the vibration exposed via literature review and comments from the participants group was higher than that of the non-exposed group of this study. Construct validity was investigated through (Fig. 1). The CISS score pattern according to vascular factor analysis. Before performing the analysis, the exposed and sensorineural stage is presented in Table 2 and group was stratified using the Stockholm classification expressed as means and standard deviations (SD). It was scale. Due to the limited number of samples with stage 3 compared with that of the control group and their in- and stage 4 vascular HAVS and stage 3 sensorineural creasing pattern is depicted in a column graph (Fig. 2). HAVS, they were classified as over stage 2 group. In fact, In both components, the exposed group’s mean score each component was grouped into stage 0, 1, and over 2. was significantly higher than that of the non-exposed We conducted a descriptive analysis to characterize sam- group, which was 20.3 (11.0). The mean (SD) CISS score ples of the study. The CISS score trend of the non-exposed of the exposed group increased in every vascular stage group and the Stockholm stages of the exposed group were [stage 0 = 42.6 (18.5); stage 1 = 59.4 (14.1); and over stage analyzed using ANOVA. To assess the association between 2 = 60.2 (21.6)]. They were significantly higher than CISS score and HAVS, logistic regression was conducted to those of the non-exposed group (mean = 20.6; SD = 11.0). calculate the univariate and multiple adjusted odds ratios The post-hoc result revealed the significant difference be- (aORs) and 95% confidence intervals (CIs) while adjusting tween the non-exposed group and stage 0 of the exposed Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 4 of 9 Table 1 General characteristic between non-exposed and exposed group based on Stockholm workshop stage Non-exposed Exposed (n = 76) (n = 34) Vascular stage p value Sensorineural stage p value Stage 0 Stage 1 Stage 2 Stage 0 Stage 1 Stage 2 (n = 35) (n = 19) (n = 22) (n = 25) (n = 38) (n = 13) Age 40.7 ± 10.3 47.5 ± 8.8 49.3 ± 9.3 52.2 ± 6.8 < 0.01 47.1 ± 9.5 49.7 ± 7.7 52.5 ± 8.2 < 0.01 Total exposure 225.6 ± 112.8 242.4 ± 106.0 244.2 ± 87.4 < 0.01 197.1 ± 103.1 252.7 ± 98.4 257.4 ± 105.3 < 0.01 Daily exposure 5.2 ± 2.9 6.7 ± 2.2 4.8 ± 3.2 < 0.01 5.7 ± 2.9 5.1 ± 3.0 6.2 ± 2.5 < 0.01 Non-smoker 22 (64.7) 24 (68.6) 13 (68.4) 11 (50.0) 0.505 20 (80.0) 22 (57.9) 6 (46.2) 0.160 Smoker 12 (35.3) 11 (31.4) 6 (31.6) 11 (50.0) 5 (20.0) 16 (42.1) 7 (53.8) Diabetes No 30 (88.2) 35 (100) 19 (100) 22 (100) 0.037 25 (100) 38 (100) 13 (100) 0.032 Yes 4 (11.8) ––– –– – Hypertension No 31 (91.2) 31 (88.6) 16 (84.2) 20 (90.9) 0.864 23 (92.0) 32 (84.2) 12 (92.3) 0.771 Yes 3 (8.8) 4 (11.4) 3 (15.8) 2 (9.1) 2 (8.0) 6 (15.8) 1 (7.7) Dyslipidemia No 34 (100) 35 (100) 19 (100) 21 (95.5) 0.373 25 (100) 37 (97.4) 13 (100) 1.000 Yes–– – 1 (4.5) – 1 (2.6) – Unit: mean ± standard deviation, number (percentage) p-value was calculated by ANOVA for continuous variables p-value was calculated by chi-square test for categorical variables group and between stages 0 and 1 and over stage 2. However, unlike the vascular stage, no statistical signifi- The result was fairly consistent with those in the sen- cance was observed between stage 0 and stage 1. sorineural stage. The mean (SD) CISS score showed an Table 3 shows the sensitivity, specificity, positive pre- increasing trend, 47.0 (18.3), 49.0 (19.4), and 70.1 (16.7). dictive value (PPV), and negative predictive value (NPV) The post-hoc result, non-exposed group, and stage 1 of of each estimated cutoff value. The ROC curve for each the sensorineural component were significantly different. cutoff value is presented in Fig. 3. The area under the Fig. 1 Comparison of total CISS score between vibration-exposed group versus non-exposed group. The line in the box represents the median value of total CISS score and the top and bottom of the box is the upper and lower quartile range Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 5 of 9 Table 2 CISS score pattern according to the vascular and sensorineural stage Non-exposed Exposed (n = 76) p Post-hoc (n = 34) b c d value comparison Stage 0 Stage 1 ≥ Stage 2 Vascular stage 20.3 ± 11.0 42.6 ± 18.5 (n = 35) 59.4 ± 14.1 (n = 19) 60.2 ± 21.6 (n = 22) < 0.01 a < b < c,d Sensorineural stage 47.0 ± 18.3 (n = 25) 49.0 ± 19.4 (n = 38) 70.1 ± 16.7 (n = 13) < 0.01 a < b,c < d Unit: mean ± standard deviation, number (number of people included in each stage) p-value was calculated by ANOVA a,b,c,d Each presented for the Post-hoc comparison which represents Non-exposed, Stage 0, Stage 1, ≥ Stage 2, respectively curve (AUC) values for each cutoff value were 0.688, significant even after adjusting the possible confounding 0.769, and 0.759 respectively, where 30 was considered variables. as the best score but was not largely different from the Besides, the sensorineural component gained a differ- score of 40. ent result. When the score was categorized as 20s, there Table 4 shows increasing pattern of OR and aOR by the was no significant increase in the OR or aOR in any CISS score in each vascular and sensorineural component score group. However, when we assigned the under 30 of HAVS. We analyzed the vascular and sensorineural com- group as baseline, the OR of the 31–60 group and over ponents separately to determine the relevance of CISS score 61 group showed an increasing pattern [OR of 31–60 with each component. The CISS score was categorized into score group = 6.51 (95% CI = 2.39–17.73); OR of over 61 20s and 30s at each component of the Stockholm scale to group = 14.25 (95% CI = 4.53–44.82)] and remained sig- compare which scoring group is more appropriate to assess nificant even after adjustment of confounding variables. HAVS. For the vascular component, when the baseline was set as the score group under 20, the OR and aOR of the Discussion score group from 21 to 40 were not considered significant. The present study shows an association between CISS However, the OR and aOR of the 41–60 group [OR = 9.33 score and HAVS. The CISS score reflects the degree of (95% CI = 1.88–46.35); aOR = 6.54 (95% CI = 1.15–37.24)] cold intolerance, while the Stockholm stage reflects the and over 61 group [OR = 46 (95% CI = 8.41–251.66); severity of the disease. From the increasing pattern of aOR = 24.34 (95% CI = 3.84–154.20)] significantly in- the mean CISS score based on the Stockholm stage creased compared with the baseline, which indicates (Table 1), it can be inferred that cold intolerance is that the risk of HAVS increased as the CISS score in- related to disease severity in both vascular and sensori- creased. The result was more consistent when the neural components of HAVS. This also corresponds to baseline score was set to 30. The OR significantly in- the complex pathophysiology of cold intolerance. Cold creased as the CISS score increased [OR of the 31–60 intolerance, which is the mainstay of CISS questionnaire, group = 13.54 (95% CI = 2.90–63.28); OR of the over 61 is usually seen among the hand-injured patients. This group = 82.42 (95% CI = 15.38–441.54)] and remained debilitating symptom persists, causing a serious problem Fig. 2 Pattern of total CISS score by both vascular and sensorineural component. This column graph shows mean total CISS score of non- exposed group and of the stages of vascular and sensorineural component. The mean total CISS score of both component is higher than that of the non-exposed group Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 6 of 9 Table 3 Test characteristics of proposed cutoff value of the CISS patients with higher vascular stage may have the periph- questionnaire to detect HAVS eral neuropathic disorder already and thus experience Cut off value Sensitivity Specificity PPV NPV AUC more severe cold intolerance [3]. As there is no gold standard diagnostic tool for HAVS, 20 96.7 40.8 81.5 90.1 0.688 the physical exam by the experienced occupational doc- 30 88.5 65.3 76.1 82.1 0.769 tor and history of occupational exposure has an import- 40 72.1 79.6 67.0 69.6 0.759 ant role in diagnosing HAVS [4]. Testing for neurology and motor as well as vascular function is ancillary to as it affects an individual’s daily life and performance at that. The validity of testing tools had different values at work [16, 19, 21, 26, 27]. The mechanism of cold sensi- each study, and there are no specific standards to date tivity is still under debate, to identify whether it is [4, 31–35]. The cold provocation test is known to be the caused by a thermoregulatory dysfunction or by a neuro- objective test to assess for presence of vascular impair- logic condition that triggers neuropathic pain, which is ment in patients with HAVS, but there is variability again applicable to that of HAVS. Similar to the complex among the studies [34, 36, 37]. About the neurologic im- mechanism of cold intolerance, patients with HAVS may pairment, a previous study reported about the objective present with various organ dysfunctions. Moreover, its tests but no consensus has been established yet [31, 36, 38]. mechanism is known to be complex, with impairment of Thus, the diagnosis of HAVS is largely dependent on the the sympathetic nervous system and dysfunction of the patients’ subjective complaint and physical exam performed vascular system [16, 28–30]. Obviously, cold intolerance by an experienced occupational specialist. The ques- is an important manifestation of HAVS as in other hand tionnaires included in the recent occupational exams injuries, which many patients experience [31]. Addition- for vibration-induced workers contain various ques- ally, results showed that the association is more distinct tions that can help in diagnosing HAVS. However, each in the vascular component than in the sensorineural item cannot be quantified, which makes it difficult to component. This is because, generally, peripheral neuro- use as a screening questionnaire. pathic symptoms due to local vibration exposure are In this background, the need for developing consensus known to precede peripheral vascular symptoms. Thus, among the occupational specialist has emerged. We suggest Fig. 3 ROC curve of each estimated cutoff value. Blue line indicates the ROC curve of cutoff value 20. Green line indicates the ROC curve of cutoff value 30. Yellow line indicates the ROC curve of cutoff value 40. Purple line is the reference line Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 7 of 9 Table 4 Odds ratio and adjusted odds ratio of CISS score between non-exposed and exposed group CISS N Before adjustment After adjustment score a b OR 95% CI aOR 95% CI Vascular CISS score grouped by 20 Under 20 23 1.00 1.00 21–40 33 1.29 0.20–8.35 0.96 0.13–6.90 41–60 27 9.33 1.88–46.35 6.54 1.15–37.24 Over 61 27 46.00 8.41–251.66 24.34 3.84–154.20 CISS score grouped by 30 Under 30 41 1.00 1.00 31–60 42 13.54 2.90–63.28 10.47 2.08–52.70 Over 61 27 82.42 15.38–441.54 47.38 8.07–278.19 Sensorineural CISS score grouped by 20 Under 20 23 1.00 1.00 21–40 33 2.25 0.60–8.40 2.00 0.33–12.16 41–60 27 7.07 1.98–25.28 3.62 0.63–20.68 Over 61 26 14.44 3.78–55.19 4.47 0.76–26.36 CISS score grouped by 30 Under 30 41 1.00 1.00 31–60 42 6.51 2.39–17.73 4.96 1.32–18.71 Over 61 27 14.25 4.53–44.82 5.29 1.27–22.07 Odds ratio was calculated by logistic regression analysis Adjusted odds ratio was calculated by multiple logistic regression analysis after adjusting age, total period of using vibration-inducing tools, current smoking status, and past medical history using CISS questionnaire as a screening tool for HAVS. Additionally, as it is said above, we strongly doubt that the The CISS questionnaire can be used to quantify the incidence of HAVS has been underestimated in South subjective symptoms by computing the total score. Korea considering the prevalence of HAVS in other coun- Health care managers in the vibration-exposed industry try. In this sense, we suggest 30 as the proper cutoff value require all workers to fill out the questionnaires periodic- to avoid missing the detection of vibration-induced disor- ally to identify those who need further evaluation, which ders among the workers for now. enhances accessibility to diagnosis of vibration-induced This study has several limitations. First, this study is a impairments. In addition, occupational health manage- cross-sectional study, which makes it hard to determine ment organizations can use the questionnaire as an evi- the causal relationship between cold intolerance proven dence to conduct expensive tests to confirm HAVS and by the CISS questionnaire and HAVS. Second, there provide additional objective data in physical exams. More- could have been a recall bias since CISS questionnaire is over, the specific symptom of HAVS, also known as a self-reported questionnaire. Moreover, there is a limi- vibration-induced white finger, is rarely reported in warm tation within the questionnaire itself. The CISS ques- climate but neurologic symptoms such as tingling sensa- tionnaire used in this study is not the one recently tion and numbness have been reported even in warm modified. The recent version of the CISS questionnaire climate [39, 40]. While vibration induced white finger is has additional response options in questions number rarely observed during summer in South Korea, cold in- two and three, allowing the minimum total score of zero tolerance can be triggered by factors such as humidity, and making the symptoms of the unexposed group to be rain, and windy weather [18]. In this sense, the CISS ques- more clearly identified. Additionally, the contents of the tionnaire can be applied regardless of the season, making CISS questionnaire are mostly about the effects of cold it more useful. intolerance on daily life. To use it as a screening tool to To our knowledge, this is the first study conducted in evaluate the effects of cold intolerance on performance search for the cutoff value that can be used in a question- at work, it is advisable to add the items that focus more naire to screen for HAVS and test for its validity and reli- on identifying the discomforts experienced by the vibra- ability. By comparing the sensitivity, specificity, PPVs, and tion exposed group than focusing on the daily discom- NPVs among the three estimated cutoff values, scores fort. Definitely, future studies must be conducted using above 30 or 40 would indicate the need for further evalu- the revised CISS questionnaire to confirm its role as a ation. Supporting this suggestion, the risk of HAVS is well screening tool. Finally, there are no definite objective expressed when the CISS score is grouped by 30s than tools to compare the sensitivity and specificity of the 20s, which infers that a CISS score of 30 would be more questionnaire in diagnosing HAVS. There have been a appropriate to predict the people possibly having HAVS. number of studies in search of confirmative tests to Kim et al. Annals of Occupational and Environmental Medicine (2019) 31:6 Page 8 of 9 diagnose HAVS. However, the gold standard of diagnosis syndrome; NPV: Negative predictive value; OR: Odds ratio; PPV: Positive predictive value; PWES: Potential work exposure scale; SD: Standard deviation remains unknown. In the future, we hope to conduct a study that evaluates the correlation between the CISS Acknowledgements scores and other objective diagnosing tools used to iden- The authors would like to thank Occupational & Environmental Health Center, Ulsan University Hospital, University of Ulsan College of Medicine and tify the degree of vascular or sensorineural impairment the participants of the study. in vibration exposed workers. Nevertheless, the significance of this study is that this is Funding Not applicable. the first study to test the validity and reliability of the CISS questionnaire and to adopt the CISS questionnaire as a Availability of data and materials tool to screen individuals with HAVS in South Korea. As Not applicable. mentioned above, cold intolerance is one of the most de- Authors’ contributions bilitating complications of hand injuries experienced by ARK, as the first author of this article, designed the study, interpreted the several patients, including HAVS. Cold intolerance is a data, and drafted the manuscript. CY, as the corresponding author of this article, suggested the study design, interpreted the data, and revised the symptom that cannot be completely eliminated. Many manuscript. JHS and HL consulted the study method and revised the studies have reported the practice of lifestyle modification manuscript. DYK and JSK reviewed and revised the manuscript. All authors to improve symptoms and the study is still ongoing. Only read and have approved the final manuscript. early diagnosis can make early intervention possible, and Ethics approval and consent to participate only early intervention (e.g., stop vibration exposure) can This study was conducted with the approval of the institutional review stop the progression of the symptom. board of Ulsan University Hospital (ID: 2018–07–040-001). Future studies are needed to modify the questionnaire Consent for publication according to the purpose of using it as a screening tool Not applicable. for the early detection of patients with HAVS. Many Competing interests studies using the CISS questionnaire were conducted in The authors declare that they have no competing interests, either now or conjunction with the potential work exposure scale future. (PWES) [22]. The PWES includes questions about the exposure of hands to cold in the workplace. If it is used Publisher’sNote along with the CISS questionnaire in the workplace, it Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. will be more helpful in caring for vibration-exposed workers. Finally, other than using the CISS questionnaire Author details as a screening tool, it can also be used to detect people Department of Occupational and Environmental Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 who have cold intolerance as the symptom persists for a Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, Republic of Korea. long time, causing discomfort in their daily life as well as 2 Department of Occupational and Environmental Medicine, Gyeongsang in their working life and educate them how to manage National University College of Medicine, Gyeongsang National University Changwon Hospital, Institute of Health Science, 15, Jinju-daero 816beon-gil, the symptom and ways to relieve the symptom. Jinju-si, Gyeonsangnam-do 52727, Republic of Korea. Received: 27 September 2018 Accepted: 1 February 2019 Conclusion The prevalence of HAVS in South Korea is low compared References to other countries. As there is no gold standard, doctor’s 1. 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Published: Mar 1, 2019

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