Vibration exposure (Vibration-induced white finger / Hand-arm vibration syndrome): clinical guidelines

List of Abbreviations

PS — pain syndrome

VAS – visual analogue scale

VID — vibration-induced disease

VS — vibration sensitivity

RRFP — rehabilitated injured person's rehabilitation program

QoL — quality of life

QST — quantitative sensory testing

MC — medical care

PNS — peripheral nervous system

PAS — peripheral angiodystonic syndrome

MPC — maximum permissible concentration / maximum permissible level

PMC — periodic medical examination

RVG — rheovasography

EVE — early vibration exposure

OHCRW — occupational hygiene characteristics of working conditions

PPE — personal protective equipment

CTS — carpal tunnel syndrome

SPA — sanatorium-resort treatment

COWC — special assessment of working conditions

NCV — nerve conduction velocity

T/TG — thermometry/thermography

LoE – level of evidence

USD/US — ultrasound Dopplerography / ultrasound examination

LER — level of evidence and recommendation

CST — cold stress test

ENMG – electroneuromyography

Terms and Definitions

Angiospasm (angiospasmus; Greek angeion - vessel and spasmus - spasm) - pathological narrowing of the lumen of terminal arteries (arterioles and capillaries) due to prolonged strong contraction of the muscular layer of their walls, with a sharp restriction or even cessation of blood flow in them, leading to tissue ischemia in the basin of the spastic artery with impaired blood circulation and tissue metabolism [1].

Acrocyanosis - a symptom of bluish skin discoloration of the distal extremities associated with circulatory pathology in arterioles and capillaries and an increased content of reduced hemoglobin in venous blood as a result of increased oxygen utilization by peripheral tissues and/or slowing of the linear blood flow velocity [1].

Pain - an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or resembling such an experience [2].

Harmful occupational factor (HOF) - an occupational factor whose exposure to an employee can lead to their disease [3,4,5].

Hypoalgesia - partial loss of pain sensitivity

Hypoesthesia - partial or complete impairment of certain or multiple types of sensitivity (tactile, temperature, proprioceptive, vibration).

Evidence-based medicine - the application of mathematical estimates of the probability of benefit and the risk of harm, obtained in high-quality scientific research on patient samples, to make clinical decisions regarding the diagnosis and treatment of specific patients [6].

Disease is a condition resulting from the action of pathogenic factors, characterized by impairment of bodily function, working capacity, and the ability to adapt to changing environmental conditions of the external and internal environment, accompanied by simultaneous alterations in the body's protective-compensatory and protective-adaptive reactions and mechanisms [7].

Instrumental diagnostics - diagnostics using various devices, apparatus, and instruments to examine a patient.

Conflict of interest - a situation in which a medical or pharmaceutical worker, in the exercise of their professional activities, has a personal interest in obtaining, personally or through a representative of a company, material gain or another advantage that affects or may affect the proper performance of their professional duties due to a contradiction between the personal interest of the medical worker or pharmaceutical worker and the interests of the patient.

Medicinal products - pharmacological agents in the form of dosage forms used for the prevention, diagnosis, treatment of a disease, rehabilitation, for the preservation, prevention, or termination of pregnancy.

Health impairment - physical, mental, or social distress associated with the loss, anomaly, disorder of a psychological, physiological, anatomical structure and (or) function of the human body [7].

Neuropathic pain - pain caused by a lesion or disease of the somatosensory nervous system [8].

Patient - an individual to whom medical care is provided or who has applied for medical care regardless of whether they have a disease and regardless of their condition [7].

Polyneuropathy (PNP) (Greek poly - many, neuro - nerve, pathos - disease) is a heterogeneous group of diseases having various etiologies and pathogenesis, the common sign of which is multiple diffuse damage to nerve fibers within peripheral nerves [9].

Maximum permissible level (MPL) of vibration - the level of vibration which, with daily work (except weekends), but no more than 40 hours per week throughout the entire work experience, should not cause vibration-induced disease or health deviations detectable by modern research methods during work or in the long-term lives of present and future generations [10,11].

Working group - two or more people of the same or different professions working together and in a coordinated manner for the purpose of creating clinical guidelines, and bearing joint responsibility for the results of this work.

Sanitary and hygienic characteristics of working conditions of an employee in case of suspected occupational disease (poisoning) (OHCRW) – qualitative and quantitative characteristics of the leading and all accompanying harmful factors of the production environment and labor process, labor regimes, with a conclusion on the degree of their compliance with hygienic requirements and standards provided for by sanitary legislation that could lead to an occupational disease (poisoning) [12].

Special assessment of working conditions (SAWC) is a unified set of sequentially implemented measures to identify harmful and (or) hazardous factors of the production environment and labor process (hereinafter also referred to as harmful and (or) hazardous production factors) and to assess the level of their impact on the employee, taking into account the deviation of their actual values from the standards (hygienic standards) of working conditions established by the federal executive body authorized by the Government of the Russian Federation, and the use of personal and collective protective equipment for employees [5].

Syndrome — a stable set of symptoms sharing common etiology and pathogenesis [7].

Carpal tunnel syndrome (CTS) is an alteration in the function and structure of the median nerve due to local compression/damage of the nerve as it passes through the carpal tunnel beneath the transverse carpal ligament [13].

Condition — changes in the organism arising from the impact of pathogenic and (or) physiological factors and requiring medical care [6].

Working conditions are a combination of factors of the production environment and labor process that influence the working capacity and health of the employee [3, 4, 5].

Level of evidence validity — reflects the degree of confidence that the observed effect of a medical intervention is true [6].

Level of убедительности рекомендаций (Grade of recommendation) — reflects not only the degree of certainty in the reliability of the intervention's effect, but also the degree of certainty that following the recommendations will bring more benefit than harm in a specific situation [5].

Raynaud's phenomenon (syndrome) is a paroxysmal change in skin color (pallor/cyanosis/erythema), starting with pallor of the distal phalanges of the fingers, caused by spasm of the digital terminal arteries, usually triggered by exposure to cold or emotional manifestations [1, 14].

Chronic pain is constant or recurring pain lasting for three months or longer in one or more anatomical regions, characterized by significant emotional distress (anxiety, depression) or impaired functioning (limitation of daily and social activities) [2].

Chronic occupational disease is a disease resulting from prolonged exposure of an employee to a harmful production factor (factors), causing temporary or permanent loss of occupational capacity [15].

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Vibration exposure (Vibration disease — VD) — a chronic occupational disease characterized by damage to the peripheral vascular, nervous, and musculoskeletal systems in the vibration exposure zone upon prolonged exposure to industrial vibration exceeding the maximum permissible level (MPL) [15, 16, 17, 18, 19].

Adverse effect of industrial vibration (Early signs of vibration exposure — ESVE) is the presence of deviations in the employee's health status based on the results of instrumental examination in the absence of clinical signs of the disease upon prolonged exposure to industrial vibration exceeding the MPL [18, 20].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The etiological factor of VD is industrial vibration exceeding the MPL, which, depending on the method of transmission to humans, is subdivided into two types [4, 21]:

• general vibration transmitted to the body through supporting surfaces: for a standing person — through the soles of the feet, for a sitting person — through the buttocks, for a lying person — through the back and head;

• local vibration transmitted through the hands, the soles of the feet of a sitting person, and the forearms contacting vibrating working surfaces.

Sources of local vibration include hand-held motorized tools (with engines), machine and equipment controls, hand-held non-motorized tools (without engines), fixtures, and processed parts or products held in the employee's hands.

Sources of general vibration, depending on the category, are vehicles (category 1), transport and technological equipment (category 2), and technological equipment (categories 3a, 3b, 3c).

Under production conditions, the simultaneous impact of local (regional) and general vibration often occurs, which was previously considered in our country as combined vibration [17, 18].

The normalized vibration parameter at the workplace is the equivalent corrected vibration acceleration for the work shift, A (8) <9>, m · s^-2 (equivalent corrected vibration acceleration level for the work shift, L_{A (8)}, dB). Requirements for quantitative parameters of maximum permissible values and levels of industrial vibration depending on the type of vibration, direction of its impact, and category in Russia are established by sanitary and epidemiological rules and regulations (SanPiN) [21].

For many years in Russia, based on the results of inspections of various enterprises, a significant proportion of workplaces not meeting SanPiN standards in terms of vibration exposure levels (general and local) has been noted, with a tendency toward a 2.3-fold decrease nationwide between 2013 and 2022 [22].

Vibration exposure is frequently combined with other harmful production factors [19, 23–28]:

• cooling microclimate,

• contact with neurotropic chemicals (lead, mercury, organic solvents, etc.),

• static-dynamic physical overloads involving muscles of the upper extremities and shoulder girdle (regional loads) during local vibration,

• general physical overloads (involving muscles of the limbs and trunk) during general vibration exposure,

• noise,

• predominantly fibrogenic aerosols.

Among the listed factors, low air temperature and physical overloads shorten the time to VD development and also determine certain specific features of the clinical manifestations of the disease [29–34].

There is a disparate sensitivity of human organs and tissues to damage by vibrations of different frequencies, due to resonance phenomena, in which a sharp increase in the vibration amplitude of a body or its parts occurs when the frequency of an external periodic action coincides with their natural frequency [23, 24, 27, 35]. The most significant damaging effect on the human body is exerted by vibration in the frequency range of 35–250 Hz [17, 18, 23, 24, 35].

The transfer of vibrational energy from the working tool/equipment to the body of the working person and its further propagation has an inversely proportional relationship to frequency: low-frequency vibration propagates through body structures over long distances; with increasing vibration frequency, its damping by soft tissues increases, with a reduction in the propagation zone while simultaneously increasing the density of the vibrational process due to reflection from dense bone structures located closest to the impact area [23, 35–38].

Knowledge of the characteristics of industrial vibration is necessary for clinicians to understand the pathogenetic mechanisms of its effect on the human body, the features of the development of clinical manifestations of VD during the expert assessment of the link between the disease and profession, and the selection of treatment tactics, rehabilitation, and the development of VD prevention measures.

The most important pathogenetic links in the formation and progression of VD are [35, 39–62]:

• irritation of skin receptors in the distal parts of the hands and the plantar surface of the feet;

• altered reactivity of adrenoceptors in the vibration exposure area, with the development of reflex vasoconstriction due to increased excitability of a-adrenoceptors initiating vasoconstriction (primarily as a thermoregulatory response) and depression or blockade of b-adrenoceptors providing vasodilation;

• increased excretion of adrenaline, noradrenaline, and their precursors — dopamine, dihydroxyphenylalanine;

• increased production of neurohumoral vasoconstrictor factors such as catecholamines, pressor prostaglandins, and endothelin-1, exerting vasopressor effects;

• decreased synthesis of endothelial prostacyclin, which has a vasodilating effect;

• damage to nerve endings and receptors at the site of exposure to a powerful stimulus, and subsequently to the peripheral nerve fibers themselves, among which the most sensitive to vibration are unmyelinated C-type fibers (C-type fibers of slow pain sensitivity, thermal warmth, and postganglionic fibers of the sympathetic nervous system (NS)), as well as thinly myelinated (A-ϭ-type fibers of thermal cold and fast pain sensitivity) and myelinated (A-β-type fibers of selective vibratory and tactile sensitivity) fibers;

• prolonged ischemia in the distal extremities caused by vibration contributes to axonal degeneration with metabolic disturbances in neurons, which may lead to asymmetric distal axonal decay (the degree of damage is more pronounced in the limb subject to greater vibration exposure);

• impaired blood supply to the nerve fibers of peripheral nerves due to angiospasm leads in turn to tissue hypersensitivity to neurotransmitters and may promote the additional release of prostaglandins that contribute to vasoconstriction;

• transcapillary oxygen exchange is disrupted, leading to tissue hypoxia in the zone of vibration exposure with subsequent impairment of oxidative processes in the ischemic zone as a result of angiospasm of the smallest vessels – precapillaries and capillaries;

• the rheological properties of peripheral blood change both due to alterations in plasma fibrinogen concentration and the morphometric parameters of erythrocytes and the state of their membranes; vibration causes a decrease in the deformability of erythrocyte membranes and a change in their characteristic spherical shape, which contributes to the further aggravation of microcirculatory disorders, primarily at the level of precapillaries and capillaries;

• a direct damaging effect of vibration significantly exceeding the maximum permissible level (MPL) on the endothelial lining of small vessels cannot be ruled out, as evidenced by histological changes in all layers of the peripheral vessel wall found in experimental studies on vibration exposure;

• development of local aseptic inflammation in tissues exposed to the mechanical impact of vibration (exogenous factor);

• disruption of the mechanisms of generation and conduction of nociceptive signals in the nerve fibers of peripheral nerves upon vibration exposure due to structural and functional transformations within them leads to the formation of chronic mixed pain syndrome (nociceptive and neuropathic) with an increasing neuropathic component as vibration disease (VD) progresses and pain severity increases, accompanied by anxiety-depressive emotional and volitional changes;

• prolonged trauma to intervertebral discs and lumbar vertebral bone tissue can lead to the occurrence and progression of spinal degenerative changes when exposed to low-frequency whole-body vibration, especially in the resonant range;

• the reactivity of the vestibular apparatus changes upon exposure to whole-body vibration due to mechanical oscillations occurring in various planes, depending on the worker's body position (standing individuals are more sensitive to vertical vibrations, lying down individuals to horizontal ones);

• the functional state of various parts of the brain changes due to the complex reflex influence of vibration on the central nervous system, disrupting its regulatory effects on vascular tone not only in the periphery but also on cerebral blood flow, manifesting as inadequate blood supply to the central parietal region and a decrease in the intensity of blood flow reactions against the background of a reduced overall level of cerebral blood flow.

1.3 Epidemiology of the Disease or Condition

There is no reliable epidemiological data on the incidence of vibration disease (VD) in the Russian Federation and globally due to the lack of a Unified Register of Occupational Diseases in our country and abroad. Data on occupational morbidity in Russia from 2013 to the present, based on reports from the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing (Rospotrebnadzor of the RF) regarding the registration and accounting of newly detected cases of occupational diseases, allow us to conclude that VD has stably occupied second place in the structure of occupational pathology caused by physical factors over the last 10 years (according to 2022 data – 42.64%) [22].

An increased risk of developing VD is observed among workers in mining enterprises, heavy, power, and transport engineering, and transportation, where mechanized tools, equipment, and machines serving as sources of vibration are widely used [16,18,22,23,24,26,31].

The highest risk of developing VD is borne by male mine sinkers, stoping miners, casting trimmers, emery grinders, forestry workers, sharpeners, grinders, assembly mechanics/fitters, truck drivers, excavator operators, bulldozer operators, agricultural machine operators, and mining excavation machine operators. Among women, crane operators are most at risk [22,63 - 66].

VD is newly registered more frequently in worker age groups over 50 years and with a work history in contact with vibration exceeding 20 years, with no reliable differences in gender distribution. There is a continuing decline in the proportion of victims resulting in disability as one of the indicators of the severity of the occupational disease and the degree of loss of professional fitness due to occupational VD.

For the first time in 2022, the main cause of chronic occupational pathology, including VD, was determined to be a long work history with the occupational factor (46.36%), less frequently imperfections in technological processes (22.03%), and design flaws in labor equipment (11.32%) [22].

1.4 Features of Coding the Disease or Condition

The algorithm for coding VD in accordance with ICD-10 and the international ILO document [67,68,69] consists of first indicating the code T75.2, followed by additional codes corresponding to the clinical symptom profile of the disease.

T75.2 - Effects of vibration (Vibration disease)

G56.0 - Carpal tunnel syndrome

I73.0 - Raynaud's syndrome (peripheral angiodistonic syndrome)

M19.8 - Other specified arthrosis (wrist and elbow joints)

G 62.8 - Specified polyneuropathy

М77.2 - Wrist periarteritis (periarthritis of the wrist joints)

М54.1 - Lumbosacral radiculopathy

Z57.7 - Adverse effect of occupational vibration (early signs of vibration effects - ESVE)

Examples of clinical diagnosis formulation for VD and ICD-10 coding:

• Vibration disease associated with local vibration exposure, initial manifestations (peripheral angiodistonic syndrome with rare Raynaud's syndrome; upper extremity polyneuropathy with sensory disturbances). ICD-10 code: T75.2, I73.0, G62.8.

• Vibration disease associated with local vibration exposure, moderate manifestations (upper extremity polyneuropathy with sensory and vegetative-trophic disorders; periarthritis of the wrist joints; arthrosis of the elbow joints, joint function impairment stage 1). ICD-10 code: T75.2, G62.8, М77.2, М 19.8.

• Vibration disease associated with whole-body vibration exposure, initial manifestations (peripheral angiodistonic syndrome; upper and lower extremity polyneuropathy with sensory disturbances). ICD-10 code: T75.2, I73.0, G62.8.

• Vibration disease associated with whole-body vibration exposure, moderate manifestations (lumbosacral radiculopathy). ICD-10 code: T75.2, М 54.1.

During periodic medical examinations, in the absence of a clear clinical picture of VD but in the presence of grounds, signs of the adverse effects of occupational vibration (ESVE) are indicated along with the ICD-10 code Z57.7.

1.5 Classification of the disease or condition

There is no universally accepted classification of VD worldwide or in Russia. Previously, various classification options for vibration disease were used in our country, always taking into account the mode of vibration transmission [17, 19, 23, 72-76].

The 'List of Occupational Diseases' proposed by the ILO lists diseases associated with vibration exposure without subdividing their occurrence by the mode of vibration transmission (local, whole-body, or a combination thereof), but lacks the term 'Vibration disease' [68,312]. At the same time, foreign practical medicine widely uses the terms: 1) hand-arm vibration (HAV), the manifestations of which include 'vibration-induced white fingers' (VWF), tingling and/or numbness of the fingers, upper extremity musculoskeletal disorders, carpal tunnel syndrome (CTS) symptoms, and neurosensory disorders [17, 77-99]; 2) whole-body vibration syndrome (WBV), the manifestations of which include the clinical effects of its impact on the lumbosacral spine [100 - 122]. In our country, the term 'Vibration disease' (VD) has been firmly established in domestic clinical practice since 1961, proving its validity and convenience for application.

In 2019, an international consensus on the criteria and stages of hand-arm vibration syndrome (HAVS) was published [76]. In addition to sensorineural disorders, it proposed criteria for vibration-induced Raynaud's phenomenon that do not fully correspond to the 2014 international consensus criteria for Raynaud's phenomenon (RP) [14], including secondary RP caused by local vibration exposure, which have long been used in national clinical practice [16, 20, 23, 71, 130–136].

In our country, in accordance with clause 2.6 "Diseases associated with exposure to occupational vibration" of the current "List of Occupational Diseases" [69] and years of clinical practice, three variants of clinical manifestations of vibration disease (VD) are distinguished depending on the mode of vibration transmission:

2.6.1 Vibration disease associated with exposure to local vibration (manifestations: upper limb polyneuropathy, including sensorineural and autonomic-trophic disorders; upper limb peripheral angiodystonic syndrome [including Raynaud's syndrome]; carpal tunnel syndrome [median nerve compression neuropathy]; forearm myofibrosis; wrist periarthrosis; wrist and elbow osteoarthritis);

2.6.2 Vibration disease associated with exposure to whole-body vibration (manifestations: peripheral angiodystonic syndrome [including Raynaud's syndrome]; upper and lower limb polyneuropathy, including sensorineural and autonomic-trophic disorders; lumbosacral radiculopathy);

2.6.3 Vibration disease associated with exposure to local and whole-body vibration (manifestations: see subitems 2.6.1 and 2.6.2).

Based on current clinical practice in our country, when assessing the severity of the clinical manifestations of the disease, the following grades of VD are currently distinguished (discussed on September 28, 2017, at the 6th All-Russian Congress of Occupational Physicians) [130, 132, 134]:

• Grade 0 (zero) — preclinical manifestations of VD (early signs of vibration exposure [ESVE]);

• Grade 1 (first) — initial manifestations of VD;

• Grade 2 (second) — moderate manifestations of VD.

The classification into three grades of VD severity is based on the involvement of major target systems (peripheral vascular system, peripheral nervous system, musculoskeletal system, etc.) and clinical practice. The introduction of preclinical manifestations of VD (grade 0) is driven by the need to bring the document into alignment with international practice [76] and to implement timely preventive measures. The absence of Grade 3 (severe manifestations of VD) is due to the fact that such forms do not develop in our country thanks to legislatively mandated preventive measures aimed at preventing the development and progression of severe forms of VD [3, 137, 138].

The clinical syndromes of Grade 1 vibration disease associated with exposure to local vibration are:

• upper limb peripheral angiodystonic syndrome, including infrequent Raynaud's syndrome;

• carpal tunnel syndrome (median nerve compression neuropathy);

• upper limb polyneuropathy with sensory disturbances.

The clinical syndromes of Grade 2 vibration disease associated with exposure to local vibration are:

• upper limb peripheral angiodystonic syndrome, including frequent Raynaud's syndrome;

• upper limb polyneuropathy with sensory and autonomic-trophic disorders;

• forearm myofibrosis;

• wrist periarthrosis, wrist and elbow osteoarthritis.

The clinical syndromes of Grade 1 vibration disease associated with exposure to whole-body vibration are:

• upper and lower limb peripheral angiodystonic syndrome;

• upper and lower limb polyneuropathy with sensory disturbances.

The clinical syndromes of Grade 2 vibration disease associated with exposure to whole-body vibration are:

• upper and lower limb peripheral angiodystonic syndrome, including upper limb Raynaud's syndrome;

• upper and lower limb polyneuropathy with sensory and autonomic-trophic disorders;

• lumbosacral radiculopathy.

Grade 1 vibration disease associated with exposure to local and whole-body vibration presents with the following clinical syndromes:

• upper and lower limb peripheral angiodystonic syndrome, including infrequent upper limb Raynaud's syndrome;

• upper and lower limb polyneuropathy with sensory disturbances;

Grade 2 vibration disease associated with exposure to local and whole-body vibration presents with the following clinical syndromes:

• upper and lower limb peripheral angiodystonic syndrome, including frequent upper limb Raynaud's syndrome;

• upper and lower limb polyneuropathy with sensory and autonomic-trophic disorders;

• wrist periarthrosis, wrist and elbow osteoarthritis.

• lumbosacral radiculopathy.

In individuals working in contact with vibration exceeding permissible levels for a prolonged period, isolated pathological changes pathognomonic to vibration exposure may be observed without the formation of a well-defined clinical syndrome, which is insufficient to establish a clinical diagnosis of VD [20, 134, 135]. Such presentations seeking medical care (periodic medical examinations, self-referral to a medical organization), in accordance with ICD-10 Chapter XXI, are recommended to be classified as "Early signs of vibration exposure (ESVE)" (corresponding to the ICD-10 code "Other specified harmful effects of occupational vibration") for the purpose of subsequent dynamic follow-up of the worker in the risk group along with therapeutic and preventive measures.

1.6 Clinical presentation of the disease or condition

Vibration disease is characterized by a chronic, prolonged, benign course with a gradual progression of clinical syndromes, featuring vascular, neuritic (sensory), and autonomic-trophic disorders, as well as musculoskeletal alterations at the site of vibration contact.

Currently, VD associated with local vibration exposure (local VD) presents with the following main clinical syndromes: upper limb angiodystonic syndrome (PAS); carpal tunnel syndrome (CTS); upper limb polyneuropathy syndrome with sensory and autonomic-trophic disorders.

Upper limb (u.l.) peripheral angiodystonic syndrome (PAS) develops with prolonged exposure to local vibration of various frequencies. The clinical picture is characterized by [1, 14, 18, 20, 23, 71, 130–133, 136, 139–149]:

• complaints of chilliness, hyperhidrosis, and paresthesias in the hands;

• complaints of intermittent, mild, aching pain in the hands occurring at rest;

• absence of sensory disturbances;

• finger hypothermia (≤27.0^°C) and bilateral thermal asymmetry (greater than 1^°C);

• cyanosis and marbled appearance of the hands;

• palmar hyperhidrosis (not an obligate symptom);

• pasty edema of the fingers and dorsum of the hands (not an obligate symptom);

• positive white spot test and Bogolepov test;

• u.l. rheovasography (RVG) changes: mild decrease in pulse blood filling and increased arteriolar tone in the fingers and hands;

• delayed recovery time of finger skin temperature to baseline values according to cold provocation tests (not an obligate sign).

A clinical variant of upper limb PAS is Raynaud's syndrome (phenomenon) of a paroxysmal nature (synonyms: dead fingers syndrome, white fingers syndrome, finger acroangiospasms, "vibration-induced white finger") manifesting as episodes of skin pallor (whitening) of the fingers, starting from the distal phalanges and having a clear demarcation. Raynaud's syndrome develops more frequently upon provocation. It is characteristic of high- and medium-frequency local vibration exposure.

Raynaud's syndrome in Grade 1 local VD:

• episodes of skin pallor (whitening) of the fingers occur infrequently (several times a year) in the presence of a triggering factor—local cooling of the hands or general chilling of the body, most commonly during the cold season;

• only the terminal phalanges of individual fingers on the hand subjected to greater local vibration exposure turn white;

• duration of the attack does not exceed a few minutes (max 5–10 minutes);

• pain reaction is not characteristic of short-term acroangiospasms.

Raynaud's syndrome in Grade 2 local VD:

• episodes of skin pallor (whitening) of the fingers become more frequent (several times a month, rarely daily) and occur not only upon local cooling of the hands or general chilling of the body, but also spontaneously;

• the area of finger whitening increases (terminal and middle phalanges, or the entire finger);

• duration of acroangiospasms increases to 20 minutes or more;

• pain in the fingers may occur during prolonged acroangiospastic attacks.

The attack ends with spontaneous restoration of skin coloration in the fingers. Outside of Raynaud's syndrome (acroangiospasm) attacks, the clinical picture does not differ from the manifestations of upper limb PAS not accompanied by these attacks [1, 14, 20, 71, 130–133, 136, 139–149].

Carpal tunnel syndrome (CTS) (synonyms: carpal tunnel syndrome; median nerve mononeuropathy, compression or entrapment neuropathy of the median nerve at the wrist, Schulze-Putnam neuropathy), being a multifactorial syndrome, can develop with prolonged exposure (recoil) of local vibration of various frequencies to the wrist area when holding a part or vibrating tool with one or both hands [84,88,90-92,95,97,98].

The clinical picture of CTS in the development of vibration disease is determined by local damage to the median nerve at the wrist level [84,88,90-92,95,97,98,150-155] and is characterized by:

• numbness and paresthesias in the 1st–3rd fingers and the palm of the hand (the area of median nerve innervation in the hand) in the hand holding the vibrating tool/part, occurring at rest;

• increased numbness and paresthesias in the 1st–3rd fingers and palm in the night and morning hours, and when raising the arm/arms up;

• decreased numbness and paresthesias in the 1st–3rd fingers and palm when lowering the arm/arms down, or with active movements;

• the onset of pain, predominantly neuropathic in nature, in the 1st–3rd fingers and palm;

• hypalgesia of the 1st–3rd fingers and the medial zone of the hand (palm);

• positive Tinel's and Phalen's signs.

It develops at an early stage of vibration disease manifestation and may be unilateral. With progression, CTS can lead to a decrease in working capacity, most often due to an increase in pain syndrome, predominantly neuropathic in nature. Motor disorders in the form of paresis of the 1st–3rd fingers and hypotrophy/atrophy of the thenar muscles in hand-arm vibration disease are usually not observed. As hand-arm vibration disease progresses, median nerve damage becomes more extensive and is part of the upper limb polyneuropathy syndrome, which is characterized by damage to the distal parts of all peripheral nerves of the upper limbs.

The main manifestation of vibration disease associated with exposure to local vibration is upper limb polyneuropathy syndrome with sensory and autonomic-trophic disorders [16-20,23,25,26,29-31,64,65,71,72,75,76,82,83,156-175].

The clinical picture is characterized by:

• aching, nagging pain in the hands and forearms, most often at rest;

• numbness and paresthesias in the hands and forearms at rest;

• sensory disturbances, especially pain and vibration sensitivity, in the distal upper extremities according to the polyneuritic type;

• hypothermia of the hands;

• marbling, cyanosis of the hands, and of the forearms as it progresses;

• palmar hyperhidrosis (non-obligate symptom), less commonly palmar hyperkeratosis (non-obligate symptom).

The clinical picture of forearm myofibrosis is characterized by [16,18,20,23,31,71,88,133,164,182-184]:

• a feeling of heaviness and fatigue in the arms;

• pain in the forearm muscles;

• attacks of tonic cramps in the hand and forearm muscles during work with a vibrating tool;

• tenderness and tension of the forearm muscles on palpation;

• increased mechanical excitability (positive "key sign") of the forearm muscles;

• loss of elasticity and resilience of muscles (loose, flabby) as the disease progresses;

• decreased strength in the distal parts of the arms (primarily reduced endurance to static effort).

The clinical picture of wrist periarthrosis, and wrist and elbow arthrosis as the disease progresses is characterized by [16,18,20,23,31,71,162,185,186]:

• pain in the wrist joints, less commonly in the elbow joints, when working with local vibration;

• appearance of pain upon movement in the specified joints;

• restricted range of motion and "crunching" during movements in the specified joints;

• tenderness upon palpation of periarticular soft tissues of the joints.

Musculoskeletal disorders as manifestations of hand-arm vibration disease develop gradually in the absence of an acute onset and only during the period of occupational activity involving local vibration. They are characterized by localization of joint damage, which must correspond to the direction of vibration exposure, and this must be taken into account when assessing the clinical manifestations of vibration disease. The role of static-dynamic physical overloads, frequently combined with local vibration exposure, in the genesis of musculoskeletal pathology in hand-arm vibration disease is being discussed, but there is no consensus to date [16,19,23,30,31].

Currently, vibration disease associated with whole-body vibration (WBV) presents with the following main clinical syndromes: peripheral angiodystonic syndrome of the upper and lower extremities, including with Raynaud's phenomenon; polyneuropathy of the upper and lower extremities with sensory and autonomic-trophic disorders; lumbosacral radiculopathy [18,23,70,123-128].

Peripheral angiodystonic syndrome of the upper and lower extremities (PAS of upper and lower extremities) develops with prolonged exposure to whole-body vibration, predominantly of high frequencies, at an early stage of WBV development.

The clinical picture is characterized by [18,23,70,123-128]:

• complaints of chilliness (cold sensitivity) of the hands and feet,

• complaints of sweating of the feet and hands (non-obligate sign);

• complaints of paresthesias and mild aching pain in the feet and hands occurring at rest;

• absence of sensory disturbances;

• hypothermia of the fingers and toes;

• side-to-side thermal asymmetry (greater than 1⁰C) (non-obligate symptom);

• change in color of the distal extremities in the form of marbling and cyanosis of the feet and hands;

• hyperhidrosis of the feet and palms (non-obligate symptom);

• puffiness of the dorsum of the feet and hands (non-obligate symptom);

• positive white spot and Bogolepov's test signs;

• mild decrease in the intensity of pulse blood filling, multidirectional changes in tone from increased tone of the extremity finger arterioles to decreased tone of the veins, predominantly of the lower extremities (according to rheovasography of upper and lower extremities);

• slowdown in the time (more than 30 minutes) for finger skin temperature to recover to baseline values according to cold testing (non-obligate sign) [16,18,70].

The clinical variant of PAS with upper limb Raynaud's syndrome of paroxysmal course develops rarely and only with combined exposure above the permissible levels of whole-body transport vibration and local high- and medium-frequency vibration on machine and mechanism controls due to the additive effect. The clinical symptoms of Raynaud's phenomenon are identical to those described in vibration disease associated with local vibration.

Polyneuropathy of the upper and lower extremities with sensory impairment - the most common clinical syndrome of VD associated with general vibration exposure, according to domestic studies [16,18,70,123-128].

• Clinical manifestations are characterized by: aching pain in the upper and lower extremities, often localized in the joint areas;

• numbness and paresthesias of the distal upper and lower extremities;

• sensory disturbances: polyneuritic-type hypalgesia in the distal extremities; impaired vibration sensitivity with the characteristic development of initial hyperesthesia followed by decreased vibration sensitivity;

• marbling of the distal extremities;

• hyperhidrosis of the hands and feet (non-obligate symptom);

• hypothermia of the hands and feet (only with WBV progression).

With simultaneous exposure to whole-body and local vibration above permissible levels, attacks of finger blanching (Raynaud's syndrome) may develop against the background of pre-existing polyneuritic disorders. The formation of this syndrome is observed in occupational groups such as industrial bulldozer drivers, agricultural machine operators, and others [70,123,126].

Prolonged exposure to whole-body vibration (predominantly transport, less often transport-technological) can lead to the development of lumbosacral radiculopathy (LSR). In many countries worldwide, the development of dorsopathy with low back pain (LBP) and LSR is considered the only adverse manifestation of whole-body vibration exposure on the worker's body, accompanied by the development of degenerative changes in the spine verified by spondylography, CT, and MRI [26,100-112,187-195]. No dependence of the affected side on the level of whole-body vibration has been established. An exposure-response relationship for the timing of lumbosacral dorsopathy development depending on the level of whole-body vibration has been determined [26,102,109,112,113,118,195].

Chronic lumbosacral radiculopathy, as a manifestation of WBV, is characterized by the gradual development of LBP and the onset of the first episode of lumbago or lumboischialgia during the period of work with whole-body vibration above permissible levels, and subsequently:

• recurrent pain syndrome in the lumbosacral spine both during whole-body vibration exposure and at rest;

• restricted range of motion in the lower back;

• positive tension signs (Lasegue's, Wasserman's, etc.);

• tension (defense) of the lumbosacral muscles;

• tenderness upon palpation of the muscles and lumbosacral vertebral points;

• impaired spinal kinematics with the development of kyphosis and scoliosis, and increased physiological lordosis of the lumbosacral level;

• decreased/absent tendon reflex corresponding to the affected nerve root (L4, L5, S1);

• sensory impairment in the zone of the affected nerve root (L4, L5, S1);

• muscle hypotonia/hypotrophy corresponding to the affected nerve root (L4, L5, S1);

• decreased strength in the lower extremity muscle group corresponding to the affected nerve root (L4, L5, S1).

The L4, L5, and S1 roots are most frequently affected, which determines the specific clinical symptoms of lumbosacral radiculopathy. The intensity of pain syndrome can vary from severe to mild depending on the stage of the process (exacerbation, subremission or incomplete remission, remission) [16,18,123,125]. The process is most often unilateral, although the development of bilateral symptoms is also possible.

The clinical presentation of vibration disease associated with exposure to local and whole-body vibration includes a combination of all the above syndromes characteristic of the damaging effects of these types of vibration [16,18,23,196].

Early signs of vibration exposure (ESVE) are characterized by [18,20,134,135]:

• absence of complaints regarding health status;

• absence of health abnormalities upon physical examination by a physician;

• increased vibratory perception thresholds upon pallesthesiometry;

• hypothermia of the fingers/toes (not an obligate sign);

• changes in nail fold capillaries of the fingers (according to capillaroscopy);

• changes in rheovasography (RVG) of the upper and/or lower extremities (not an obligate sign).

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of Vibration Disease is established based on characteristic complaints, anamnesis, physical and instrumental examination data, analysis of work activity, and sanitary and hygienic working conditions.

2.1 Complaints and Anamnesis

- a sensation of cold hands (for local vibration disease) and/or feet (for whole-body vibration disease),

- increased sensitivity of the hands (for local vibration disease) and/or feet (for whole-body vibration disease) to cold exposure,

- increased sweating of the palms and/or soles,

- episodes of blanching of the distal phalanges of the fingers (for local vibration, and combined local and whole-body vibration) (during contact with vibration, general body cooling, washing hands with cold water, spontaneously) and their frequency (rarely, periodically, frequently).

GPR CLEL 5Grade of Recommendation C (Level of Evidence - 5).

- numbness and/or tingling in the 1st–3rd fingers, medial part of the 4th finger of the hand(s), lasting for at least 1 month,

- pain in the wrist, hand, and 1st–3rd fingers of the hand(s) (when holding a vibrating tool/part with both hands during work,

- impairment of fine motor skills of the fingers and hand: when grasping small parts/objects during work, operating controls of vibrating tools/equipment, difficulties in daily life (buttoning clothes, etc.).

GOM CLoE 4Grade of Recommendation — C (Level of Evidence — 4).

- numbness and paresthesias of the distal upper extremities,

- pain in the hands and forearms,

- cramping of the fingers, especially during work,

- sensation of weakness in the hands.

GOM CLoE 4Grade of Recommendation — C (Level of Evidence — 4).

- numbness and paresthesias of the distal lower extremities, followed by the upper extremities,

- pain in the distal lower extremities, followed by the upper extremities,

GOM CLoE 4Grade of Recommendation — C (Level of Evidence — 4).

Comment: to assess the severity of pain syndrome, it is advisable to use pain intensity scales (visual analogue scale VAS, etc.) and the DN4 neuropathic pain questionnaire (Appendices G1, G2) [305,306,307].

- pain in the wrist joints, less commonly in the elbow joints, during work involving contact with local vibration;

- occurrence of pain upon movement in the wrist and/or elbow joints during work involving contact with local vibration.

GOM CLoE 4Grade of Recommendation — C (Level of Evidence — 4).

Comments: to assess the severity of pain syndrome, it is advisable to use pain intensity scales (visual analogue scale VAS, etc.) and the DN4 neuropathic pain questionnaire (Appendices G1, G2) [305,306,307].

- difficulties in self-care in daily life and walking due to lower back pain;

- difficulties in performing work operations due to lower back pain,

- occurrence of the first episode of lumbago or lumboischialgia during work with vibration exceeding maximum permissible levels,

- relapses of lumbago or lumboischialgia in the lumbosacral spine with continued work exposed to whole-body vibration exceeding maximum permissible levels.

GCR CLEL 3Grade of Recommendation — C (Level of Evidence — 3).

Comments: to assess the severity of pain syndrome, it is advisable to use pain intensity scales (visual analogue scale VAS, etc.) and the DN4 neuropathic pain questionnaire (Appendices G1, G2) [305, 306].

- the nature and conditions of their employment (contact with occupational vibration and other harmful occupational factors – work process strenuousness, cooling microclimate),

- the history of any diseases, injuries, or frostbite the patient has experienced;

- domestic workloads (use of vibrating tools, driving personal vehicles),

- participation in so-called "strength" sports in their free time from work.

GPR CLEL 5Grade of Recommendation C (Level of Evidence - 5).

Comments: it is necessary to clarify the correlation between the onset of the disease and the period of work in contact with vibration exceeding maximum permissible levels, the length of service in contact with vibration by the onset of the disease (typically at least 10 years), the nature of the disease course (absence of an acute onset), and the presence of clinical signs of the disease at the time of examination. Other factors that could have caused the symptoms of the disease must be excluded. For differential diagnosis, detailed data must be collected regarding other diseases and health disorders that may have similar clinical symptoms/syndromes and mimic the manifestations of vibration disease.

- establishing the fact of the patient seeking medical care at the medical organization at their workplace and/or place of residence/registration with symptoms/syndromes characteristic of vibration disease during the period of employment in contact with vibration exceeding the maximum permissible level (originals of outpatient medical records (if available), or extracts from outpatient medical records regarding visits for medical care);

- establishing the fact of seeking medical care with symptoms/syndromes characteristic of vibration disease during inpatient medical care in the period of work in contact with vibration exceeding maximum permissible levels (extracts from the inpatient medical record (if available);

- presentation of complaints and detection of health abnormalities typical of vibration disease during mandatory medical examinations of workers exposed to harmful working conditions (results of the preliminary medical examination upon employment involving vibration and periodic medical examinations – PMD during employment involving vibration);

- establishing the fact of employment in professions associated with exposure to industrial vibration and its duration (employment records according to a copy of the work record book, including in electronic format, and employment contracts);

- establishing the fact of work under conditions of local and/or general vibration exposure exceeding the maximum allowable levels (MAL) (employee's individual health risk assessment in case of suspected vibration disease; measurement protocols for local and overall vibration at the workplace based on the results of workplace hazard assessment and special labor conditions assessment for the entire period of exposure to vibration).

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: the procedure for establishing an occupational disease in our country is regulated by statutory legal documents. The issue of expert assessment regarding the causal link between the disease and the profession is handled by a specialized medical institution—the Center for Occupational Pathology (COP); a medical certificate in the established form is issued, and an investigation of the occupational disease case is conducted with the drawing up of an Occupational Disease Report in accordance with regulatory legal documents [15,276,277,278].

2.2 Physical Examination

- visual assessment of skin discoloration in the distal parts of the hands/ hands and feet (mottling, cyanosis, mottled-cyanotic coloration),

- visual assessment of the skin condition in the distal parts of the hands/ hands and feet (pastiness of the fingers and the back of the hands/feet) (non-obligate sign),

- assessment of moisture levels (hyperhidrosis) of the palms/soles (non-obligate sign),

- tactile assessment of skin temperature in the distal parts of the upper and/or lower extremities (cool, markedly cold),

- tests (blanching test ("white spot" sign) and Bogolyubov's test - positive),

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

- assessment of the skin of the hand: edema of the fingers and hand, trophic changes in the skin and nails, Raynaud's syndrome.

- assessment of the hand muscles: presence/absence of atrophy: flexor pollicis longus (M. flexor pollicis longus), abductor pollicis brevis (M. abductor pollicis brevis), opponens pollicis (M. opponens pollicis),

- assessment of all types of sensitivity (pain, temperature, vibration, discrimination) in the 1st - 3rd fingers,

- assessment of muscle strength (flexor pollicis longus (M. flexor pollicis longus), abductor pollicis brevis (M. abductor pollicis brevis), and opponens pollicis (M. opponens pollicis),

- performing the opposition test (the patient brings the thumb and little finger together—in case of marked weakness of the abductor pollicis brevis muscle (M. abductor pollicis brevis at a later stage of the disease), bringing the fingers together is difficult or the physician (investigator) easily separates the patient's closed fingers.

- performing provocative tests (Tinel's, Phalen's, Gillet's tests, etc.) that allow suspected median nerve compression [152,318-321].

GPP CGrade of Recommendation - C (Level of Evidence - 5).

- assessment of tendon and periosteal reflexes in the upper and lower extremities (brisk, equal; absence of pathological reflexes),

- assessment of all types of sensitivity in the upper and lower extremities (decreased pain and vibration sensitivity in the distal parts of the upper extremities only, followed by impaired temperature sensitivity in the upper extremities, absence of discrimination sensitivity disorders),

- assessment of muscle strength in the upper and lower extremities (preserved, absence of atrophy and hypotrophy),

- assessment of trophic changes in the skin and nails of the hands and feet (pastiness of the hands, normal feet).

GPP CGrade of Recommendation - C (Level of Evidence - 5).

- assessment of tendon and periosteal reflexes in the upper and lower extremities (brisk, equal; absence of pathological reflexes);

- assessment of all types of sensitivity in the upper and lower extremities (pain, vibration, temperature, discrimination) (decreased pain and vibration sensitivity of the distal parts first in the lower extremities, then in the lower and upper extremities, followed by impaired temperature sensitivity in the upper extremities, absence of discrimination sensitivity disorders);

- assessment of muscle strength in the upper and lower extremities (preserved, absence of atrophy and hypotrophy),

- assessment of trophic changes in the skin and nails of the hands and feet (pastiness of the fingers and the back of the hands and feet).

GPP CGrade of Recommendation - C (Level of Evidence - 5).

Comments: Evidence of polyneuritic disorders of vibratory etiology includes preserved tendon-periosteal reflexes, preserved muscle strength, absence of trophic and muscle tone disorders, pain hypesthesia (hypalgesia) within the innervation zone of all peripheral nerves in the distal parts of only the upper extremities (upon exposure to local vibration) and hypalgesia within the innervation zone of all peripheral nerves in the distal parts of the lower extremities or both upper and lower extremities (upon exposure to general vibration), vibration hypesthesia as the leading pathognomonic sign of vibration disease (obligate sign); temperature and tactile hypesthesia as vibration disease progresses.

Symptoms of hyperpathy, hyperalgesia, allodynia, and polyesthesia are not characteristic of vibration-induced polyneuropathy.

To assess muscle strength in vibration disease, handgrip strength measurement (A02.02.003) is used (reference values: 40 kg for men, 30 kg for women). Handgrip strength measurement may show a slight decrease in hand strength. According to the Medical Research Council scale for muscle strength grading, it is preserved (5 points) (see Appendix G3) [246-247].

- presence of pain and restricted range of motion in the wrist joints of the upper extremities,

- presence of pain and restricted range of motion in the elbow joints of the upper extremities,

- tenderness upon palpation of periarticular soft tissues and muscle attachment projection sites.

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: palpation of the wrist and/or elbow joints reveals tenderness upon palpation of the said joints, pain during movement in them, and a restricted range of motion in the joints due to pain. X-ray examination of these joints is recommended.

- changes in the soft tissues of the forearm muscles (supinator group) of the upper extremities in the form of cord-like indurations and tension of muscle fibers upon palpation;

- increased mechanical excitability of the forearm muscles – "key" sign.

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: in the presence and progression of lumbosacral radicular compression caused by whole-body vibration, patients may exhibit alterations in the physiological lumbar lordosis (most often its flattening), development of scoliosis (homo- or heterolateral), limited range of motion in the lumbar spine during forward and lateral trunk flexion, positive Lasègue's sign, less commonly Wassermann's (Wassermann-Mackevich) sign, back muscle defense and tenderness upon palpation of lumbosacral paraspinal points, hypotonia/hypotrophy of the lower leg/thigh muscles; decreased strength in the extensor hallucis longus, lower leg, and thigh muscles; sensory impairment in the corresponding dermatome, and decreased/absent Achilles or knee tendon reflexes corresponding to the affected nerve root [290].

2.3 Laboratory Diagnostics

There are currently no specific laboratory diagnostic methods for vibration-induced disease (VID). The scope of investigations is variable and depends on the suspected etiological factor.

Comments: laboratory evidence (parameters of the complete blood count, blood total protein level, blood albumin level, blood albumin/globulin ratio, protein fraction ratio, blood cholesterol level, blood lipoprotein level, low-density lipoprotein cholesterol level, blood triglyceride level, high-density lipoprotein cholesterol level, serum glucose, serum C-reactive protein (CRP) level, and blood creatine phosphokinase (CPK) activity) has no independent diagnostic value for confirming a VID diagnosis and is necessary to assess the patient's general condition and perform differential diagnosis.

During the development of pathological disorders in VID, local aseptic inflammation occurs in tissues exposed to vibration, which may result in upward shifts within reference ranges in the levels of nonspecific inflammatory markers (ESR, C-reactive protein, etc.), micro- and macroelement composition, as well as immunological and hormonal parameters.

2.4 Instrumental Diagnostics

Peripheral angiodystonic syndrome, including Raynaud's phenomenon

Comments: Capillaroscopy is a method of direct visual assessment of capillary circulation, but only locally at the transitional fold of the finger nailfold. When exposed to vibration, capillary circulation changes are obligate and follow a specific sequence of development. Initially, VID manifests as a spastic state of capillaries, especially under high-frequency vibration exposure. As VID progresses, a spastico-atonic and subsequently atonic state of the capillaries develops. A reduction in the number of capillaries per 1 mm is observed (normal is 12–15 per 1 mm) due to the so-called "capillary rarefaction" phenomenon. Spastic capillaries are shortened, and intermittent blood flow is observed. In atony, deformed capillaries are dilated, predominantly due to the venous limb, and blood flow is not visible.

It must be kept in mind that capillary alterations can be observed in many diseases accompanied by small vessel involvement.

Comments: Thermometryis performed using non-contact and contact thermometers in a room with a comfortable microclimate, following a mandatory adaptation period of at least 15–20 minutes indoors. Evidence of VID may include a decrease in skin temperature with asymmetrical readings on the terminal phalanges of the fingers (below 27^oC), the dorsal aspects of the hands and forearms (below 29.6^oC), and the toes (≤24.0^o). These indicators are considered the baseline skin temperature for the specified locations. Another informative parameter isthe baseline temperature recovery timemeasured by performing thermometry every 3–5 minutes after a cold provocation test (CPT). A diagnostic sign of VID is considered to bethe delayed recovery time of baseline skin temperatureon the fingers exceeding 20–25 minutes (Stage 1 VID – up to 30 minutes, Stage 2 VID – up to 40 minutes or more).

Comments: The CPT is a provocative test used to confirm the presence of Raynaud's syndrome (the development of a finger acroangiospasm attack). It is performed by immersing the patient's hands for a strictly defined period (exposure time) in a container with pre-cooled water. There are several methodological approaches for conducting the CPT: 1) water temperature +4 ^oC, exposure time 1 min; 2) water temperature from +8 ^oC to +10 ^oC, exposure time 3 min; 3) water temperature from +10 ^oC to +12 ^oC, exposure time 5 min. Next, the color of the skin of the hands is evaluated. If the distal phalanx of at least one finger turns white or shows sharp cyanosis with a clear boundary ("amputation type"), the test is considered positive. In other cases (hyperemia, mottling, mild generalized cyanosis of the hands), the CPT result is considered negative. Contraindications to the CPT include: cold allergy (cold urticaria), cardiovascular pathology (history of myocardial infarction, coronary artery disease, atherosclerosis of various vessels with heart failure, etc.), and poor prior tolerance to CPT (pronounced pain syndrome, headache attack, cardiac pain, etc.).

Comments: RVG (synonym: rheoplethysmography) determines the intensity and volume of blood flow in the arterial vessels of the extremities, as well as the tone parameters of vessels of various calibers (small, medium, and large). Local vibration exposure is characterized by a decrease in pulse blood volume intensity (PBVI) combined with an increase in tone, primarily in the arterioles of the distal upper extremities (fingers and hands). As vibration-induced disease progresses, changes in the arterial vessels of the forearms join in. Atony of the arterioles and arteries of the upper extremities is significantly less common. These changes are functional in nature, which is confirmed by positive dynamics (an increase in PBVI, normalization of arteriolar and medium-caliber artery tone) following a pharmacological (nitroglycerin) test.

VID associated with whole-body vibration is characterized by a decrease in PBVI in the distal upper and lower extremities (feet, hands) against the background of decreased venous tone, primarily in the lower extremities. These changes are functional, as confirmed by positive dynamics—an increase in PBVI upon administration of a pharmacological (nitroglycerin) test.

Comments: Signs of vibration-induced vascular disorders according to USDG may include angiospasm of the hand vessels due to a decreased diameter of arterioles and arteries, reduced systolic and volumetric blood flow velocities, and an elevated pulsatility index. Peripheral vessel USDG in VID is advisable to perform only when high-resolution diagnostic ultrasound systems are available.

Comments: The LDF method detects changes in the microcirculatory bed, including the capillaries of the soft tissues of the fingers and toes. Exposure to local vibration exceeding the permissible limits leads to a hyperemic type of microhemodynamics with spastic manifestations, a normocirculatory type with spastic manifestations, and a spastic type. At the same time, persistence of vascular disorders is noted.

Carpal tunnel syndrome (median nerve mononeuropathy)

Comments: electroneuromyography is the "gold standard" of instrumental diagnostics for nerve damage. It allows for the objectification of the topical diagnosis, as well as the assessment of the acuteness and severity of neural damage [152, 285-287, 257].

Comments: Ultrasound examination of the median nerve allows for the visualization of the nerve and surrounding structures, which helps identify the causes of compression, diagnose focal nerve constriction, and perform a differential diagnosis with neoplasms of the nerve or surrounding tissues.

Upper extremity polyneuropathy syndrome with sensory disorders

Comments: stimulation electroneuromyography is an objective method of instrumental diagnostics for damage to the peripheral nerves of the upper extremities (A05.02.001.004, A05.02.001.05, A05.02.001.06). It allows for the objectification of the topical diagnosis, as well as the assessment of the acuteness and severity of neural damage to the peripheral nerves of the upper extremities in vibration disease.

Comments: The algometry method is carried out using special devices—pressure algesimeters of various modifications, the operating principle of which consists in the quantitative measurement of the patient's sensitivity to pain (pain threshold) by exposing the skin to calibrated mechanical pain stimuli.

The development of vibration disease is accompanied by a decrease in pain sensitivity (hypoalgesia) of a polyneuritic type in the distal extremities. It is recommended to perform this during an in-depth examination at the Center for Occupational Pathology.

Comments: the formation of peripheral polyneuropathy as a manifestation of vibration disease reveals an increase in vibration sensitivity thresholds at various frequencies. The most frequent and pronounced changes in vibration sensitivity are observed at a frequency of 125 Hz, and somewhat less frequently at 63 Hz. When initially diagnosing vibration disease, it is recommended to study vibration sensitivity on the upper extremities (local vibration) and upper and lower extremities (if a special foot attachment is available) (general vibration) across an expanded spectrum of fixed frequencies (8, 16, 32, 63, 125, 250, and 500 Hz) during an examination in an inpatient setting at the Center for Occupational Pathology. During follow-up monitoring of a patient with an established diagnosis of vibration disease, one can limit the examination to a shortened version (at frequencies of 63, 125, and 250 Hz).

To assess vibration sensitivity, a number of portable and computerized domestic and foreign vibration biothesiometers (Vibrotest-M, Vibration Sensitivity Analyzer) have been developed—instruments designed to produce vibrations that act on a body part (usually the fingers of the upper/lower extremities) with varying intensity for the non-invasive measurement of the vibration sensitivity threshold. Vibration biothesiometers make it possible to assess vibration sensitivity at various fixed geometric mean frequencies from 8 to 1000 Hz.

Comments: QST (Quantitative sensory testing) allows for the objective assessment of quantitative parameters of various types of sensitivity: thresholds of temperature (differentially for cold and heat) and vibration sensitivity (A02.24.001 Pallesthesia testing) and pain. The method evaluates the functional state of various types of afferent fibers (lightly myelinated A-delta, Aβ, and unmyelinated C-fibers), as well as central sensitization, which, according to modern pain theory, forms the basis for the development of chronic pain syndromes. Patients with vibration disease associated with local vibration exposure exhibit elevated cold and warm temperature sensitivity thresholds, as well as cold pain thresholds, in both hands. Heat pain thresholds are elevated and exhibit high variability of indicators. Vibration sensitivity thresholds at a frequency of 100 Hz are elevated in vibration disease. QST is not an independent diagnostic method and is recommended for use only in conjunction with a neurological examination

Myofibrosis of the forearms

Comments: measurements of hand muscle strength and endurance are carried out using hand dynamometers of various modifications. Pathology of the forearm muscles is characterized by a decrease first in muscle endurance to static effort, and then in hand strength.

The method has low sensitivity and informativeness (dynamometers are not subject to metrological verification).

Comments: performed to visualize potential changes in the forearm muscles (tears, fiber splitting, edema of muscle fibers and sites of attachment of muscle fascia to bones).

Periarthrosis and arthrosis of the wrist and elbow joints

Comments: Prescribed to visualize potential changes in periarticular soft tissues and joints for the diagnosis of periarticular tissue pathology—wrist periarthrosis, which is characteristic of hand-arm vibration syndrome.

Comments: It is prescribed to visualize possible bone and joint changes in order to diagnose osteoarthritis (OA) of the radiocarpal joints and other small joints of the hands. Occupational vibration disease (OVD) is characterized by the clinical development of OA of the radiocarpal joints accompanied by joint function impairment (JFI).

Comments: It is prescribed to visualize possible bone and joint changes in order to diagnose osteoarthritis of the elbow joints. As OVD progresses, OA of the elbow joints with JFI may develop.

Lumbosacral radiculopathy

Comments: Standard X-ray of the lumbar and sacral spine in two projections (anteroposterior and lateral) is prescribed to visualize possible bone and joint changes in order to diagnose degenerative-dystrophic changes (DDC) in the lumbar and sacral spinal motion segments. There is no correlation between the severity of DDC and the clinical manifestations of generalized OVD.

Comments: It is prescribed to visualize changes in the lumbosacral spine.

2.5 Other Procedures

Peripheral angiodystonic syndrome, including Raynaud's phenomenon

None.

Carpal tunnel syndrome (Median nerve mononeuropathy)

Comments: Needle electromyography allows detection of an acute or chronic denervation-reinnervation process indicating axonal damage. If necessary, in addition to the 1st interosseous muscle, the abductor digiti minimi muscle, and the thenar muscles, paraspinal muscles at the C8 – Th1 levels, as well as muscles related to the middle and upper trunks of the brachial plexus, are examined. Needle EMG allows differential diagnosis with such conditions as motor neuron disease, plexopathy, spinal cord and root lesions at the C8 – Th1 levels, Hirayama disease, distal forms of spinal amyotrophy, and distal myopathies [152].

Upper extremity polyneuropathy with sensory disturbances

None.

Polyneuropathy of the upper and lower extremities with sensory disturbances

None.

Myofibrosis of the forearms

None.

Periarthrosis of the radiocarpal joints, osteoarthritis of the radiocarpal and elbow joints

None.

Lumbosacral radiculopathy

None.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Used in patients with a confirmed diagnosis of vibration disease depending on the syndromic manifestations of the disease

For peripheral angiodystonic syndrome, including Raynaud's syndrome

Comments: any single myotropic vasodilator drug is prescribed. Medicinal products are recommended for use in accordance with the indications and contraindications for use, routes of administration, and dosages contained in the instructions for medical use of the medicinal product.

Comments: The duration of treatment and dosing regimen of platelet aggregation inhibitors (ATC code B01AC), nicotinic acid and its derivatives (ATC code C10AC) are determined by the attending physician individually, depending on the clinical presentation of OVD as PAS, including Raynaud's syndrome, and the therapeutic effect achieved. Medicinal products are recommended for use in accordance with the indications and contraindications for use, routes of administration, and dosages contained in the instructions for medical use of the medicinal product:

Comments: Deproteinized calf blood hemoderivative, by stimulating oxygen consumption, leads to the stabilization of cell plasma membranes during ischemia and a decrease in lactate formation, thus exhibiting an antihypoxic effect. The medicinal product is recommended for use in accordance with the indications and contraindications for use, routes of administration, and dosages contained in the instructions for medical use of the medicinal product.

Comments: for PAS with Raynaud's syndrome, dry-air hand baths, diadynamic therapy for the hands and shoulder girdle, amplipulse therapy, and ultraviolet irradiation (UVI) of the collar zone with erythemal doses are indicated. Regimes, frequency, and duration are determined by the attending physician after consultation with a physical therapy physician.

In carpal tunnel syndrome (CTS)

Conservative treatment depends on the severity of symptoms and disease duration. [16,18,20, 152]. Conservative treatment includes medical treatment of mild to moderate CTS in order to achieve symptom regression within 2 weeks [152].

Comments: the efficacy of perineural administration of GCS in mild to moderate CTS has been proven [152].

Comments: adding a combination of B vitamins to pharmacotherapy may provide an additional analgesic effect. The efficacy of using a combination of B vitamins in CTS as a manifestation of localized OVD has been proven [13, 16, 18, 20, 235, 236, 251].

Comments: Opinions vary regarding the efficacy of physical therapy modalities in CTS as a manifestation of localized OVD [16,18,20,262-266,269-275].

Upper extremity polyneuropathy syndrome (in localized OVD) and/or polyneuropathy of the upper and lower extremities with sensory disturbances (in generalized OVD)

Comments: To optimize treatment, combined vitamin B preparations are used, such as pyridoxine + thiamine + cyanocobalamin + [lidocaine]. Medicinal products are recommended for use in accordance with the indications for use, contraindications, methods of administration, and doses contained in the instructions for use of the medicinal product.

Comments: the antioxidant properties of thioctic acid** preparations have been proven in the treatment of other polyneuropathies accompanied by microangiopathy, which justifies their use for treating vibration-induced PNP [308-312]. #Thioctic acid** (alpha-lipoic acid) is prescribed as intravenous infusion of 600 mg daily for 10 days.

Comments: For the treatment of non-specific inflammation and pain relief, NSAID therapy is recommended according to standard practice. NSAIDs are administered intramuscularly or orally; the lowest effective dose should be used for the shortest possible duration. After observing the response to initial therapy, the dose and frequency of administration should be adjusted according to the patient's individual needs. To reduce the risk of adverse gastrointestinal side effects, proton pump inhibitors are prescribed concurrently.

Comments: for the treatment of pain syndrome as a manifestation of vibration disease, antidepressants (non-selective monoamine reuptake inhibitors) are recommended as first-line drugs. Antidepressants with an analgesic effect are used in average therapeutic doses to reduce pain intensity and correct anxiety-depressive disorders. The duration of the treatment course is determined by the attending physician.

Comments: for the treatment of pain syndrome as a manifestation of vibration disease, other antiepileptic drugs are recommended as first-line therapy. Antiepileptic drugs (carbamazepine**, gabapentin, pregabalin**) are used only in cases of pain syndrome that is refractory to other medications and has a pronounced neuropathic component in grade 2 PNP resulting from exposure to both local and general vibration. The duration of the treatment course is determined by the attending physician.

Comments: prescribed as second-line drugs when NSAIDs, antidepressants (non-selective monoamine reuptake inhibitors), and other antiepileptic drugs are insufficiently effective. Tramadol and other non-opioid analgesics (ATC code N02AJ15) provide temporary relief, but tolerance develops (higher doses are required each time) along with drug dependence (the patient can no longer do without these drugs). Therefore, the use of opiates for more than 10 days is not recommended.

Comments: Regimens, frequency, and duration are determined by the attending physician after consultation with a physical therapy specialist.

Comments: the validity of this method in official medicine, including in the treatment of vibration disease, is actively debated. The use of acupuncture for pain relief in the development of vibration disease and hand-arm vibration syndrome deserves attention. There is no conclusive evidence regarding the efficacy of vibration disease treatment.

Myofibrosis of the forearms

Conservative treatment includes methods aimed at muscle rehabilitation [16-18, 20, 23].

Comments: all types of electrotherapy are used, including with medications (A17.13.001 Drug electrophoresis for microcirculation disorders, A17.29.003 Drug electrophoresis in unspecified diseases, A17.30.024 Electrophoresis with pulsed currents ), paraffin or ozokerite applications (A20.24.002.001 Paraffin application to hands or feet (paraffin bath), (A20.30.036 Paraffin-ozokerite application), mud therapy (A20.30.014 Mud baths); manual massage 1–12 sessions, starting from the hand muscles, then the forearms (A21.01.001 General medical massage); balneotherapy (A20.30.009 Local therapeutic baths (2-4 chamber)).

Comments: Acupuncture is a specific variant of reflexology—a system of methods for acting on areas of the human body using localized mechanical stimulation. The validity of this method in official medicine, including in the treatment of vibration disease, is actively debated. There is no conclusive evidence regarding the efficacy of vibration disease treatment.

Periarthrosis and arthrosis of the wrist and elbow joints

Conservative treatment includes methods aimed at restoring joint function, relieving or reducing pain syndrome [13,16-18, 20, 23, 235, 238].

Comments: for the treatment of non-specific inflammation and pain relief, NSAID therapy according to the standard regimen is recommended. NSAIDs are administered intramuscularly or orally; the lowest effective dose should be used for the shortest possible duration. After observing the response to initial therapy, the dosage and frequency of administration should be adjusted according to the individual needs of the patient. Topical NSAIDs in the form of gels/ointments are used as maintenance therapy when joint pain is incompletely relieved. To reduce the risk of adverse gastrointestinal side effects, proton pump inhibitors are co-prescribed.

Comments: all types of electrotherapy are recommended (A17.04.001 Drug electrophoresis in joint diseases, A17.30.024 Pulsed current electrophoresis), paraffin or ozokerite applications (A20.24.002.001 Paraffin therapy for hands or feet (paraffin bath), (A20.30.036 Paraffin-ozokerite application), peloidtherapy (A20.30.014 Mud baths); manual massage 1–12 sessions, starting from the hand muscles, then the forearms (A21.01.001 General medical massage); balneotherapy (A20.30.009 Local therapeutic baths (2–4 chamber)).

Lumbosacral radiculopathy

Conservative treatment includes methods aimed at relieving pain, improving the patient's quality of life, and restoring working capacity in patients with lumbosacral radiculopathy [13, 16, 18, 20, 23, 235, 238, 290].

Comments: it is recommended to prescribe NSAIDs in effective doses for the minimum necessary number of days to reduce the risk of side effects. Oral forms of NSAIDs are preferred. In the combination therapy of pain syndrome, a combination of selective serotonin reuptake inhibitors (SSRIs) and non-steroidal anti-inflammatory and antirheumatic drugs is used.

Comments: muscle relaxants are used in cases of lumbosacral radiculopathy with muscle-tonic pain syndrome in the clinical picture of vibration disease, associated with whole-body vibration exposure, to target the pathogenetic mechanisms of chronic pain, primarily back muscle spasm (defense).

Comments: for the treatment of pain syndrome as a manifestation of vibration disease, antidepressants (non-selective monoamine reuptake inhibitors) are recommended as first-line drugs. Antidepressants with an analgesic effect are used in average therapeutic doses to reduce the intensity of pain syndrome and correct anxiety-depressive changes. The duration of the treatment course is determined by the attending physician. Antiepileptic drugs (carbamazepine**, pregabalin**, gabapentin) are used as second-line drugs for the treatment of vibration disease pain syndrome.

3.2 Surgical Treatment

Comments: the goal of surgical treatment is decompression of the median nerve in the carpal tunnel, which is achieved by complete transection of the transverse carpal ligament. Indications for decompression include the absence of a sustained adequate effect from conservative therapy, shortening of remission periods, and progression of neurological symptoms [152].

Comments: surgical intervention is recommended upon the development of clinical symptoms of pelvic organ dysfunction (cito!), unsatisfactory results of conservative treatment for at least 6–8–12 months prior to the onset of permanent loss of mobility and impaired quality of life, as well as in persistent severe pain syndrome that is not relieved by other treatment methods.

Peripheral angiodystonic syndrome

No indications for surgical treatment

Upper limb polyneuropathy syndrome (in local vibration disease) and/or upper and lower limb polyneuropathy with sensory disturbances (in general vibration disease)

No indications for surgical treatment

Periarthrosis and arthrosis of the wrist and elbow joints

No indications for surgical treatment

Myofibrosis of the forearms

No indications for surgical treatment

3.3. Other treatment methods

Comments: physical therapy is prescribed in accordance with the recommendations of a specialist in physical therapy and sports medicine, taking into account the leading clinical syndrome of vibration disease.

Comments: immobilization is the first-line treatment for mild to moderate carpal tunnel syndrome due to its simplicity and good tolerability. There is insufficient evidence of the superiority of one immobilization device design over another [152]. Orthoses should be used in patients with vibration disease associated with local vibration exposure who are diagnosed with carpal tunnel syndrome.

Comments: orthopedic devices should be used in patients with vibration disease associated with whole-body vibration exposure who are diagnosed with lumbosacral radiculopathy.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

An employee with an established or confirmed diagnosis of vibration disease is referred for medical and social examination (MSE) to a bureau, where an individual rehabilitation/habilitation program (IRHP) is drawn up for the victim of an occupational disease – vibration disease. Patient management is carried out in accordance with the rehabilitation plan and in accordance with the recommendations and decisions of a specialized occupational pathology medical organization regarding the examination of the causal relationship between the disease and the profession, the examination of occupational fitness, and dynamic examination and treatment for vibration disease.

Medical rehabilitation for vibration disease can be carried out under the following conditions: outpatient (in settings that do not provide round-the-clock medical observation and treatment); inpatient (in settings that provide round-the-clock medical observation and treatment) [276, 314–317].

Comments: Rehabilitation of patients with VD includes annual repeated courses of conservative complex treatment in accordance with the individual rehabilitation and habilitation program (IRHP) approved by the ITU (Medical and Social Expertise). The frequency of treatment courses is at least 1–2 times per calendar year, provided there is dynamic follow-up by an occupational health physician and other specialist physicians (neurologists, surgeons, traumatologists-orthopedists, physiotherapists, general practitioners) with an evaluation of the treatment outcomes.

Rehabilitation may include therapeutic exercise for peripheral vascular diseases (A19.13.001), peripheral nervous system diseases (A19.24.001), spine diseases (A19.03.002), joint diseases and injuries (A19.04.001), manual therapy for peripheral nervous system diseases (A21.24.001), spine diseases (A21.23.006), joint diseases (A21.04.001), and psychological methods (A21.23.005 Neuropsychological rehabilitation).

The effectiveness of rehabilitation is determined by the adequacy of the treatment provided depending on the main clinical syndrome of VD, proper job placement, and the absence of comorbid general somatic pathology, which can significantly hinder rehabilitation. With regular treatment courses after cessation of work involving vibration exposure, regression of symptoms is possible, up to the complete disappearance of the clinical manifestations of VD, which is considered full rehabilitation or recovery.

Comments: sanatorium-resort treatment for patients with VD and individuals with early signs of vibration exposure (ESVE) is carried out only in the absence of medical contraindications. The scope of therapeutic measures within sanatorium-resort treatment is determined by the leading clinical symptoms of VD, the presence of concomitant diseases/conditions in a specific patient, and the equipment and location of Russian sanatorium-resort organizations using natural therapeutic factors. The frequency of sanatorium-resort treatment is once per calendar year, year-round, and, if possible, in the patient's native climatic and geographical zone. Sanatorium-resort treatment may include therapeutic mineral baths (A20.30.001), peloidotherapy (A20.24.001 mud therapy for peripheral nervous system diseases), and other modalities in the absence of contraindications [314-317].

Comments: Job placement must be rational and exclude work in contact with vibration exceeding or within the maximum allowable levels (MAL), as well as significant static-dynamic physical loads exceeding permissible parameters and exposure to adverse microclimatic factors, primarily cooling.

A temporary transfer by decision of the medical commission (MC) of a medical organization is recommended for individuals with early signs of vibration exposure (ESVE) and working patients with grade 1 VD, which in practice is hindered by the enforcement of Article 73 of the Labour Code of the Russian Federation.

Permanent transfer to work not associated with vibration exposure, significant static-dynamic physical loads exceeding permissible parameters, and an adverse microclimate is recommended for all patients with grade 2 VD severity. Permanent transfer to work not associated with vibration exposure is recommended for patients with grade 1 VD severity if the clinical picture includes angiospastic syndrome (PAS) with Raynaud's phenomenon.

Regardless of the severity of VD, the presence of other diseases/conditions in the patient that prevent the performance of work associated with harmful production factors, including industrial vibration, serves as the basis for declaring them permanently unfit to perform the specified types of work in accordance with Appendix No. 2 to Order of the Russian Ministry of Health No. 29n dated January 28, 2021.

5. Prevention and Dispensary Observation

Comments: The employer is responsible for organizing the PME, and the medical organization conducting it is responsible for its quality. Paragraphs 4.3.1 (local vibration) and 4.3.2 (whole-body vibration) of the appendix to the Procedure for conducting mandatory preliminary and periodic medical examinations of workers provided for in part four of Article 213 of the Labor Code of the Russian Federation under Order of the Ministry of Health of the Russian Federation No. 29n dated January 29, 2021, regulate the frequency of medical examinations (annually for ages 18 to 21, once every 2 years for ages over 21), the list of specialist doctors, and the scope of examination during PME. In addition to the main types of examinations carried out for all individuals working in hazardous working conditions, it mandatorily includes examinations by the following specialists: surgeon, ophthalmologist, otolaryngologist, and dermatovenereologist. The mandatory set of diagnostic research methods includes: local vibration — pallesthesiometry (measurement of vibration sensitivity), refractometry (or skiascopy), vestibular function test (without medical service code), eye biomicroscopy (A03.26.001), visometry (A02.26.004); whole-body vibration — pallesthesiometry (A02.24.001), refractometry (or skiascopy) (A03.26.008), vestibular function test (without medical service code), pure-tone audiometry (A12.25.001). Additionally, upon the recommendation of medical specialists during the examination of the causal relationship between the disease and the profession, the worker may be mandatorily examined with: cold test (without medical service code), rheovasography (A05.12.001) or ultrasound dopplerography of upper limb vessels (arteries and veins) and lower limbs (A04.12.002.001), stimulation electroneuromyography (A05.02.001.003), and upon exposure to local vibration — capillaroscopy (A03.13.002) and hand radiography (A06.03.032). Both at the stage of the preliminary medical examination (upon hiring for work associated with vibration exposure) and during PME for individuals working in contact with occupational vibration, when granting clearance for work (occupational fitness assessment), specialists must mandatory take into account the presence of diseases in the worker that are contraindications for working with vibration, the list of which is defined in the List of medical contraindications to work with hazardous and (or) dangerous production factors, as well as work during which mandatory preliminary and periodic medical examinations are carried out according to Appendix No. 2 to Order of the Ministry of Health of the Russian Federation No. 29n dated January 29, 2021.

Comments: To prevent the development of VD, therapeutic exercises for peripheral vascular diseases (A19.13.001), peripheral nervous system diseases (A19.24.001), spine diseases (A19.03.002), joint diseases and injuries (A19.04.001), manual therapy for peripheral nervous system diseases (A21.24.001), spine diseases (A21.23.006), and joint diseases (A21.04.001) are used.

6. Organization of Medical Care

Medical care for Vibration Disease (VD), which is a chronic occupational disease, is provided to patients in accordance with the Procedure for Providing Medical Care for Chronic Occupational Diseases [276].

Medical care can be provided at the outpatient stage (occupational physician's office, preliminary and periodic medical examination - PME) and the inpatient stage (center for occupational pathology, occupational pathology department).

At the outpatient stage (medical organizations of any ownership form, including occupational physician offices), an occupational physician, upon identifying characteristic complaints, a typical clinical picture, and information on occupational history and working conditions, may establish the diagnosis of "suspected vibration disease associated with local and/or general vibration exposure" with mandatory indication of the leading clinical syndrome(s) in two cases: 1) during a preliminary and/or periodic medical examination; 2) upon the patient's independent seeking of medical care at a medical organization. In both cases, the occupational physician issues and sends in the prescribed manner a notification of the establishment of a preliminary diagnosis of chronic occupational disease VD (ICD-10 code: T75.2) using the established form in accordance with Appendix No. 1 to the Order of the Ministry of Health of the Russian Federation dated May 28, 2001, No. 176, for the compilation of the sanitary-hygienic characteristic of working conditions (SHC WC). This notification is sent to the territorial body of the federal executive authorities authorized to exercise state control and supervision in the field of ensuring sanitary and epidemiological welfare, which exercises supervision over the facility where the chronic occupational disease VD originated.

After the compilation of the SHC WC, the patient with suspected VD is referred by the occupational physician of the medical organization at the place of residence or stay (taking into account the right to choose a medical organization) to the territorial center for occupational pathology, submitting the following patient documents: a copy of the work record book or other documents confirming employment relations between the citizen and the employer; SHC WC; information on the results of the special assessment of working conditions (SAWC) of the employee's workstation regarding the assessment of local and general vibration (if available); information on the results of mandatory preliminary (upon employment) and periodic (during employment) medical examinations with specialist physician examination data and pallesthesiometry results; an extract from the citizen's medical documentation containing clinical data on the citizen's health status (an extract from the medical chart of a patient receiving outpatient medical care; extract(s) from the medical chart of a patient receiving inpatient medical care - if available); radiography of the hands involving the wrist joints and elbow joints (performed strictly according to indications).

At the center for occupational pathology, additional examination of the patient is performed (pallesthesiometry at 3 frequencies, skin thermometry, cold test), initially on an outpatient basis, and subsequently in an inpatient setting (if an occupational pathology department is available). Based on the results of the detailed examination, if a diagnosis of VD is established, a Notification of the Establishment of the Final Diagnosis of an Occupational Disease – VD is compiled.

Subsequently, the patient with VD requires outpatient dispensary monitoring by an occupational physician and a neurologist, and, if necessary, consultation with other specialist physicians: a traumatologist-orthopedist (in the absence thereof, a surgeon), a general practitioner, an otorhinolaryngologist, a physiotherapist, and others. Courses of outpatient treatment for VD are carried out at least once a year for grade 1 VD, and twice a year for grade 2 VD.

At least once a year, patients with vibration disease must undergo dynamic follow-up and treatment at an occupational pathology center, occupational pathology department, or other medical organization authorized to provide specialized medical care in occupational pathology on an outpatient or inpatient basis.

Each level of medical care delivery for vibration disease must include collecting complaints and anamnesis, reviewing (partially for the first level) documentation (profession, work experience, data from sanitary-hygienic characteristics of working conditions and/or special assessment of working conditions), standard physical neurological and therapeutic examination, and instrumental methods (the range of methods applied is determined by the level of medical care provided).

After establishing the final diagnosis of vibration disease, the specialized medical organization conducting the examination of the disease's causal relationship with the profession shall draw up a «Medical certificate on the presence or absence of an occupational disease in a patient» in the approved form [277], as well as a «Notice of the establishment of the final diagnosis of a chronic occupational disease — vibration disease, its modification, clarification, or cancellation» in the approved form [278].

Subsequently, a patient diagnosed with an occupational disease of vibration disease is referred by the medical organization where they are under permanent follow-up for an examination at the ITU bureau to assess the degree of disability and approve the rehabilitation program for the victim of an occupational disease.

Issues of disability evaluation in vibration disease are resolved taking into account the leading clinical syndrome, severity of the disease, features of the disease course, presence of comorbid conditions, the effect of ongoing treatment, and the patient's rehabilitation potential.

As a rule, the main causes of decreased working capacity in patients with vibration disease are persistent pain syndrome, sensory disorders of various modalities (primarily vibration sensitivity), impaired mobility, as well as frequent, prolonged attacks of finger blanching (Raynaud's syndrome), and pronounced peripheral vascular and trophic changes.

Issues of fitness-for-work evaluations for workers with a confirmed diagnosis of vibration disease are resolved taking into account a number of factors.

In accordance with clause 52 of the List of Medical Contraindications to Work with Harmful and (or) Hazardous Production Factors, as well as Work Requiring Mandatory Preliminary and Periodic Medical Examinations (Appendix No. 2 to Order No. 29n of the Russian Ministry of Health dated January 29, 2021), the presence of vibration disease is a contraindication to work involving vibration (local and general).

When grade 1 vibration disease develops, workers need dynamic medical follow-up and annual courses of treatment aimed at correcting the developed vibration-induced disorders, at least once a year.

When vibration disease progresses to grade 2 (moderate severity), patients need follow-up care by an occupational pathologist and a neurologist with treatment courses administered at least twice a year. Subsequently, returning to work involving industrial vibration for individuals who have previously suffered from vibration disease is not advisable.

Medical indications for hospitalization in a medical organization:

1. Ineffectiveness of the outpatient stage of medical care for vibration disease.

2. Increasing severity of clinical symptoms of vibration disease despite adequately administered treatment at the outpatient stage of medical care.

3. Implementation of treatment and rehabilitation measures as part of fulfilling the individual rehabilitation program for the victim of vibration disease.

4. Conducting an examination of the disease's causal relationship with the profession and/or a fitness-for-work evaluation.

Criteria for discharging a patient from a medical organization:

For patients referred for hospitalization for the purpose of examining the disease's causal relationship with the profession and/or evaluating fitness for work:

1. Completion of the procedure for examining the causal relationship between the disease and the profession and/or evaluating fitness for work.

2. Violation by the patient of the internal regulations of the medical organization (the patient is discharged prematurely and/or with an appropriate note in the disability certificate) [7].

For patients referred for hospitalization for examination and treatment, as well as treatment and rehabilitation measures:

1. Improvement in condition, regression of symptoms following a course of inpatient examination and treatment.

2. Violation by the patient of the internal regulations of the medical organization (the patient is discharged prematurely and/or with an appropriate note in the disability certificate) [7].

7. Additional Information

The timeline for the development of vibration disease is influenced by a number of factors. The most significant are levels of vibration exposure and duration of contact with it (work experience, exposure time per work shift, levels exceeding the permissible limits). The frequency spectrum of the acting vibration determines the predominant clinical symptoms during the formation of vibration disease. Exposure to other harmful occupational factors, such as an unfavorable cooling microclimate, wetting and contamination of the hands, contact with neurotoxic substances, regional static-dynamic loads involving the muscles of the hands and shoulder girdle (under local vibration exposure) and general static-dynamic loads involving the trunk and leg muscles (under general vibration exposure), as well as noise, enhance the effects of vibration exposure and shorten the development time of vibration disease, while also determining certain specific features of the clinical manifestations of the disease.

The progression of vibration disease is slow over several years and is observed in individuals with initial manifestations of the disease who continue to work in contact with vibration.

The prognosis for life is favorable, as the development of vibration disease does not lead to death. The prognosis for recovery is also favorable. After cessation of work in contact with industrial vibration (the post-contact period), the variants of the disease course are determined by the leading clinical syndrome and the degree of its severity. Provided there is dispensary follow-up and systematic courses of treatment 3-5-7 years after cessation of contact with vibration, there is usually a decrease (regression) in the clinical symptoms of vibration disease, primarily sensorineural polyneuropathy with Raynaud's syndrome. Peripheral neurosensory disorders in the form of polyneuropathy and carpal/cubital radicular syndromes are torpid to the therapy [16,18,20,279-281].

In case of improper job placement of vibration disease patients and the presence or addition of comorbid diseases that hinder rehabilitation—primarily disorders of the nervous, endocrine, cardiovascular, and musculoskeletal systems—reverse development of vibration disease is not observed.

Criteria for Evaluating the Quality of Medical Care

Criteria for assessing the quality of specialized occupational pathology medical care during inpatient examination and treatment of patients with suspected or established vibration disease during the examination of the disease's causal relationship with the profession, as well as during their dynamic follow-up according to documents [282-284], are presented in the table.

References

Appendix A1. Working Group Composition

Igor V. Bukhtiyarov (working group lead) ^1,4 – President of the Association of Occupational Health Physicians and Specialists (AOHPS), member of the International Commission on Occupational Health (ICOH), Chief freelance specialist in occupational health of the Russian Ministry of Health, Honored Worker of Science of the Russian Federation, Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Sciences

Galina N. Lagutina (lead developer) ¹ – Honored Physician of the Russian Federation, Candidate of Medical Sciences, Associate Professor

Sergey A. Babanov ⁹ – - member of the Association of Occupational Health Physicians and Specialists (AOHPS), Chief freelance specialist in occupational health of the Ministry of Health of Samara Region, Doctor of Medical Sciences, Professor

Elena V. Bakhtereva ³ – Doctor of Medical Sciences

Alla V. Zheglova ¹ - member of the Association of Occupational Health Physicians and Specialists (AOHPS), Doctor of Medical Sciences, Professor

Lyudmila P. Kuzmina ^1,4 – Member of the Association of Occupational Health Physicians and Specialists (AMT), Member of the International Commission on Occupational Health (ICOH), Honored Worker of Science of the Russian Federation, Doctor of Biological Sciences, Professor

Oleg L. Lakhman ² – Doctor of Medical Sciences, Professor of the RAS, Professor

Olga P. Nepershina ¹ – Candidate of Medical Sciences

Elena L. Poteryaeva ⁸ – Member of the Presidium of the Association of Occupational Health Physicians and Specialists (AMT), Member of the International Commission on Occupational Health (ICOH), Chief Freelance Specialist Occupational Pathologist of the Siberian Federal District and the Ministry of Health of the Novosibirsk Region, Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Professor

Lyudmila M. Saarkoppel ^1,6 – Member of the Association of Occupational Health Physicians and Specialists (AMT), Member of the International Commission on Occupational Health (ICOH), Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Professor

Viktor A. Semenikhin ⁷ – Member of the Presidium of the Association of Occupational Health Physicians and Specialists (AMT), Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Professor

Leonid A. Strizhakov ^1,4 - Member of the Association of Occupational Health Physicians and Specialists (AMT), Member of the International Commission on Occupational Health (ICOH), Chief Freelance Specialist Occupational Pathologist of the Moscow Healthcare Department, Doctor of Medical Sciences

Evgeny E. Shigan ^1,5 – Executive Director of the Association of Occupational Health Physicians and Specialists (AMT), National Secretary of the International Commission on Occupational Health (ICOH) in the Russian Federation, Doctor of

Medical Sciences

Lyubov A. Shpagina ⁸ – Member of the Presidium of the Association of Occupational Health Physicians and Specialists (AMT), Member of the Interregional Public Organization "Russian Respiratory Society", Member of the International Commission on Occupational Health (ICOH), Member of the European Respiratory Society (ERS), Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Professor, Academician of the RANS

¹ FSBSI "Izmerov Research Institute of Occupational Health"

² FSBSI "East-Siberian Institute of Medical and Ecological Research"

³ FSBFSI "Yekaterinburg Medical Research Center for Prophylaxis and Health Protection of Industrial Workers" of the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing (Rospotrebnadzor)

⁴ FSAEI HE "I.M. Sechenov First Moscow State Medical University" of the Ministry of Health of the Russian Federation (Sechenov University)

⁵ FSAEI HE "Pirogov Russian National Research Medical University" of the Ministry of Health of the Russian Federation

⁶ FSBEI FPE "Russian Medical Academy of Continuous Professional Education" of the Ministry of Health of the Russian Federation

⁷ FSBEI HE "Kemerovo State Medical University" of the Ministry of Health of the Russian Federation

⁸ FSBEI HE "Novosibirsk State Medical University" of the Ministry of Health of the Russian Federation

⁹ FSBEI HE "Samara State Medical University" of the Ministry of Health of the Russian Federation

No conflict of interest is declared.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Occupational pathologists (31.08.44).

2. Neurologists (31.08.42).

3. General practitioners (31.08.54)

4. General practitioners / Internal medicine physicians (31.08.49).

5. Traumatologists and orthopedists (31.08.66).

6. Surgeons (31.08.67).

1. Scale for assessing levels of reliability of evidence (LRE) for diagnostic methods (diagnostic interventions)

2. Levels of Evidence (LoE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

7.       

3. Scale for evaluating levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitation interventions)

Procedure for updating clinical guidelines: review once every 3 years.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

• Federal Law No. 323-FZ dated November 21, 2011 "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" (as amended on December 25, 2023);

• Federal Law No. 61-FZ dated April 12, 2010 "On Circulation of Medicines" (as amended on January 30, 2024);

• Order of the Ministry of Health of the Russian Federation No. 926n dated November 15, 2012 "Approval of the Procedure for Providing Medical Care to the Adult Population for Nervous System Diseases";

• Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017 "On Approval of Criteria for Assessing the Quality of Medical Care";

• Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017 (as amended on September 24, 2020, with rev. dated October 26, 2022) "On Approval of the Nomenclature of Medical Services" (Registered with the Ministry of Justice of Russia on November 7, 2017, No. 48808).

• International Classification of Functioning, Disability and Health, approved at the Fifty-fourth World Health Assembly on May 22, 2001.

• Order of the Ministry of Health of the Russian Federation No. 901n dated November 12, 2012 "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Traumatology and Orthopedics'" (registered by the Ministry of Justice of the Russian Federation on December 25, 2012, registration No. 26374), as amended by Order of the Ministry of Health of the Russian Federation No. 114n dated February 21, 2020 (registered by the Ministry of Justice of the Russian Federation on July 28, 2020, registration No. 59083).

These clinical guidelines were developed taking into account the following methodological materials and interdisciplinary specialist consensuses:

• Nasonov E.L., Yakhno N.N., Karateev A.E., et al. General principles of treatment of musculoskeletal pain: interdisciplinary consensus. Scientific and Practical Rheumatology. 2016;54(3):247-265.

• Karateev A.E., Nasonov E.L., Ivashkin V.T., et al. Rational use of non-steroidal anti-inflammatory drugs. Clinical guidelines. Scientific and Practical Rheumatology. 2018; 56: 1-29.

• Davydov O.S., Yakhno N.N., Kukushkin M.L., Churyukanov M.V., et al. Neuropathic pain. Clinical guidelines for diagnosis and treatment. Russian Journal of Pain. 2018;4(57):5-41.

• Clinical Guidelines ID: 400. Chronic pain syndrome (CPS) in adult patients requiring palliative medical care. – 2023-2024-2025 (02/15/2023) – Approved by the Ministry of Health of the Russian Federation.

• Clinical Guidelines ID: 777 Discogenic lumbosacral radiculopathy. 2023-2024-2025 (12/08/2023) – Approved by the Ministry of Health of the Russian Federation.

• Clinical Guidelines ID: 778 Musculoskeletal (non-specific) lower back pain – 2023-2024-2025 (12/08/2023) – Approved by the Ministry of Health of the Russian Federation.

These clinical guidelines have been developed taking into account the indications and contraindications, routes of administration, and dosages of medicinal products in accordance with the instructions for medical use contained in the State Register of Medicinal Products – www.grls.rosminzdrav.ru__ Revision March 15, 2024.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Vibration disease (VD) is an occupational disease caused by prolonged exposure to vibration exceeding the maximum permissible level and characterized by a chronic course.

Main symptoms of the disease that a patient with a developing condition may observe:

• pain in the hands and forearms;

• numbness in the hands;

• coldness of the hands;

• "tingling", "burning", "prickling", "itching" sensations in the hands and forearms;

• episodes of blanching or sudden cyanosis of the fingertips;

• palmar hyperhidrosis;

• cramping of the fingers;

• feeling of weakness in the hands;

• sleep disturbances (difficulty falling asleep, night awakenings) due to pain and other sensations in the hands;

• pain in the elbow and wrist joints;

The developing pain syndrome and other symptoms can lead to anxiety and lowered mood, loss of working capacity, and deterioration in overall quality of life. If these symptoms are present, it is recommended to consult a neurologist or general practitioner, as timely detection and preventive measures will allow the worker to maintain working capacity and prevent the progression of a disease that impairs quality of life and causes suffering to the patient.

As a prevention of VD, a set of measures is used, the basis of which is the improvement of working conditions, compliance with all production safety requirements, and the improvement of existing technological processes. To prevent the development of VD, a worker must follow the established work and rest schedule, use personal protective equipment (antivibration mittens, antivibration gloves; special footwear; earmuffs or earplugs; warm special clothing; in case of water exposure and cooling effects of water – waterproof clothing, mittens, and footwear).

A mandatory preventive measure is undergoing preliminary and periodic medical examinations (PME), the procedure for which is regulated by Order of the Ministry of Health of the Russian Federation No. 29n dated January 28, 2021 (as amended on February 1, 2022). For workers exposed to occupational vibration, PME is conducted once every 2 years. It mandatorily includes examinations by the following medical specialists: neurologist, otolaryngologist, ophthalmologist, and surgeon, and, upon recommendation, dermatovenereologist for individuals working in contact with local vibration. The mandatory set of diagnostic research methods includes: pallesthesiometry (measurement of vibration sensitivity) and visual acuity. Additionally, upon the recommendation of specialists participating in the PME, the worker may undergo: skin thermometry with a cold test, rheovasography or ultrasound examination of peripheral vessels, electroneuromyography, vestibular analyzer examination, and, upon exposure to local vibration, capillaroscopy and hand radiography, oraudiometry upon exposure to whole-body vibration.

As prevention of vibration disease development, a number of methods are used: self-massage, dry-air hand baths, therapeutic exercise, physiotherapeutic treatment (electrical procedures, two-chamber hand and foot baths, mud therapy, etc.) and reflexotherapy methods (massage, acupuncture, laser magnetotherapy).

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Pain intensity assessment scales

Russian name: Visual analog scale (VAS), numeric rating scale (NRS), verbal rating scale (VRS)

Original name: Visual Analog Scale (VAS), Numeric Rating Scale (NRS), Verbal Rating Scale (VRS)

Sources:

• Williamson A., Hoggart B.: Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing. 14:798-804 2005.

• Pain: a guide for students and doctors: study guide / ed. by Academician of the RAMS N. N. Yakhno. – M.: MEDpress-inform, 2010. – 304 p.

Type — assessment scale

Purpose: assessment of pain intensity

Content (template): The VAS is a 10 cm straight line segment (Fig. G.1). Its beginning corresponds to the absence of pain sensation – "no pain", and the endpoint reflects agonizing unbearable pain – "unbearable pain". The line can be either horizontal or vertical. The patient is asked to make a mark on it corresponding to the intensity of pain they are currently experiencing. The distance between the beginning of the segment ("no pain") and the made mark is measured in centimeters and rounded to the nearest whole number. Each centimeter on the line corresponds to 1 point. With a mark up to 2 cm, pain is classified as mild, from 2 to 4 cm as moderate, from 4 to 6 cm as severe, from 6 to 8 cm as very severe, and up to 10 cm as unbearable.

NRS is analogous to VAS and is its modification. The patient marks one of 11 (sometimes a gradation from 0 to 10 is used) scale points corresponding to the current intensity of their pain.

VRS consists of adjectives describing pain, arranged in order of increasing intensity. Sometimes a scale containing adjectives and numerical designations is used (0 – "no pain", 1 – "mild", 2 – "moderate", 3 – "severe", 4 – "very severe", 5 – "unbearable"). The algorithm of use is the same as for VAS.

Figure G.1 Visual Analog Scale (VAS), Numeric Rating Scale (NRS), Verbal Rating Scale (VRS)

Key (interpretation): If the scale length is 10 cm, then

Notes: The scale allows assessing the severity of subjective pain sensations.

Appendix G2. Douleur Neuropathique 4 (DN4) questionnaire for neuropathic pain component

Russian name: Neuropathic Pain Symptom Inventory

Original name: Douleur Neuropathique 4 (DN4)

Sources:

• Bouhassira D., Attal N., Alchaar H., Boureau F., Brochet B., Bruxelle J., Cunin G., Fermanian J., Ginies P., Grun-Overdyking A., Jafari-Schluep H., Lanteri-Minet M., Laurent B., Mick G., Serrie A., Valade D., Vicaut E. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4)// Pain: March 2005 - Volume 114 - Issue 1 - p 29-36 doi: 10.1016/j.pain.2004.12.010.

• Timmerman H., Steegers MAH, Huygen FJPM, Goeman JJ, van Dasselaar NT, Schenkels MJ, Wilder-Smith OHG, Wolff AP, Vissers KCP. Investigating the validity of the DN4 in a consecutive population of patients with chronic pain. PLoS One. 2017 Nov 30;12(11): e0187961. doi: 10.1371/journal.pone.0187961.

• Davydov O. S., Yakhno N. N., Kukushkin M. L. et al. Neuropathic pain: clinical guidelines for diagnosis and treatment of the Russian Association for the Study of Pain // Russian Journal of Pain. 2018. No. 4. P. 5–41. DOI: 10.25731/RASP.2018.04.025.

Type — questionnaire

Purpose: identification of neuropathic pain or the neuropathic component of pain in mixed nociceptive-neuropathic pain syndromes

Content (template): The questionnaire consists of two parts. The first is filled out based on patient interview, the second based on clinical examination. The first part evaluates positive sensory symptoms, the second part identifies allodynia and negative sensory symptoms.

Appendix G3. Muscle strength assessment scale

Russian name: Medical Research Council Muscle Scale

medical research

Original name: Medical Research Council (MRC) Weakness Scale

Sources:

• Medical Research Council. Aids to the examination of the peripheral nervous system, Memorandum no. 45, Her Majesty’s Stationery Office, London, 1981. https://mrc.ukri.org/research/facilities-and-resources-for-researchers/mrc-scales/mrc-usclescale/

• van der Ploeg RJ, Osterhuis HJ, Reuvekamp J. Measuring muscle strength. J Neurol. 1984;231(4):200‐203.

• A.N. Belova. Scales, Tests, and Questionnaires in Neurology and Neurosurgery. Moscow: Prakticheskaya Meditsina, 2018. — 696 p.

Type — assessment scale

Purpose: assessment of muscle strength in points

Muscle strength according to the Medical Research Council scale

Key (interpretation): the higher the score, the greater the muscle strength

Note: to assess the muscle strength of individual muscles and muscle groups, a

six-point scale is used — from 5 to 0. A comparative assessment of the affected and healthy

sides is performed. A score of 5 indicates no paresis. Paresis is defined as mild if

strength corresponds to 4 points, moderate — 3 points, pronounced — 2 points, severe —

1 point, and paralysis — 0 points. It can be used dynamically; a modified scale allows calculating the ratio of muscle strength between the healthy and affected sides as a percentage.

Appendix G4. Roland-Morris questionnaire

Russian name: Roland-Morris Questionnaire

Original name: Roland-Morris Disability Questionnaire, RDQ

Sources:

• Roland M.O., Morris R.W. A study of the natural history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low back pain //Spine. – 1983. – Vol. 8. – P. 141–144.

• Tarakanov A.A., Efremov V.V. Instrumental validation of the "Low Back Pain and Disability (Roland-Morris)" questionnaire. Russian Journal of Pain: 2 (56); 2018. pp. 96-97.

Type — questionnaire

Purpose: assessment of the impact of lower back pain on daily functioning. Check only those statements that characterize your condition today.

Note: the Roland-Morris questionnaire consists of 24 items answered by the patient. The total number of items checked by the patient is calculated, so the possible result ranges from 0 to 24. The higher the number of checked items, the more pronounced the patient's functional impairment. To monitor treatment dynamics, the questionnaire can be refilled, and the number of items showing improvement can be converted into percentages.