A1. Candidates for the Faculty of Occupational Medicine approved certificate in Hand Arm Vibration Syndrome (HAVS) are required EITHER
(a) to provide full or limited registration with the General Medical Council of the United Kingdom
(b) to provide evidence of full or limited registration with the Nursing and Midwifery Council of the United Kingdom
(c) to possess a medical or nursing qualification acceptable to the Director of Assessment of the Faculty. These candidates must produce their original registration certificates, or diplomas of qualification, and official translation of their diplomas if not in English.
A2. Candidates who do not meet the criteria may still attend the course. They are not eligible to obtain the certificate in Hand Arm Vibration Syndrome but the course provider may at their discretion provide a certificate of attendance. This certificate should not in any way imply competence to assess or diagnose HAVS.
A3. Candidates are required to provide evidence of having completed a Faculty approved HAVS Training Course by the date of the examination.
A4. The question papers are divided into two sections. Candidates who are doctors are required to pass section A on law and pathophysiology and section B on staging, management, testing and examination. Nurses are required to pass section A only.
AWARD OF THE CERTIFICATE
A5. Candidates who have successfully completed the requirements specified in A4 will be awarded the Certificate in Hand Arm Vibration Syndrome.
A6. Any further advice on the Regulations may be obtained by writing to the Chief Examiner.
1. The Faculty of Occupational Medicine of the Royal College of Physicians of London introduced this qualification in 2005 for doctors and nurses who wish to demonstrate a level of proficiency in Hand Arm Vibration Syndrome.
2. Regulations governing the Certificate in Hand Arm Vibration Syndrome have been published by the Faculty. It is the responsibility of candidates to ensure that they obtain the latest edition of the Regulations. These notes do not form part of the Regulations but are intended to provide guidance for candidates and those running courses to prepare candidates for this qualification.
3. This qualification is intended to meet the needs of registered medical and nursing practitioners who wish to demonstrate by a combination of training and examination, a level of knowledge and competence in Hand Arm Vibration Syndrome.
4. The qualification reflects the satisfactory completion of two main elements: training and the examination paper.
5. A number of institutions offer training courses for the Certificate in HAVS covering the core syllabus. The core syllabus guides the training of occupational health professionals (nurses and doctors) in the requirements for health surveillance for a workforce exposed to hand-transmitted vibration and in the diagnoses and management of an individual with HAVS. The syllabus is published by the Faculty and is in Annex A.
6. Certificate courses are approved on behalf of the Faculty by the Director of Assessment to whom applications must be made in writing at least 6 weeks before the course is due to start. Approval is valid for three years only and it is the responsibility of training courses to reapply for approval.
7. Successful completion of a Faculty approved Certificate training course is mandatory. It is required for confirmation of completion of training, that candidates should attend at least 90% of the course, or other confirmation as approved by the Faculty.
8. The purpose of the examination is to test factual knowledge.
9. The question papers are divided into two sections. Section A on law and pathophysiology, consists of approximately 30 questions, and is taken by all candidates. Section B on staging, management, testing and examination, consists of approximately 30 questions, and is taken by doctors. It is optional for nurses. Additional questions may be included for trial purposes and will not be used when calculating scores. Candidates should be aware that these questions may appear anywhere on the paper.
10. Section A and Section B both last for 30 minutes each. At the end of 30 minutes, Section A is collected and those nurses not wishing to sit Section B are invited to leave the examination room. The examination paper for Section B is then distributed. Nurses need to pass Section A only. Doctors need to pass Section A and B.
11. A candidate’s performance in each section will be assessed relative to an external standard set by examiners. Questions are reviewed after each sitting for quality assurance purposes and the pass mark may be adjusted slightly at each examination. The pass mark for the examination is normally around 75%.
12. Doctors will be required to pass Sections A and B at one sitting, there is no provision to roll-over or ‘bank’ passes from one sitting to another.
MAINTENANCE OF THE QUESTION BANK
13. All examination scripts are returned to the Faculty at the end of each examination in order to maintain the integrity of the examination question bank.
14. All Faculty approved course centres contribute questions to the question bank.
RE-ATTEMPTS AT THE CERTIFICATE IN HAND-ARM VIBRATION
15. Candidates are eligible for up to six attempts to obtain a pass in the Certificate of Hand Arm Vibration Syndrome.
16. Candidates must declare to the course centre whether or not they are re- attempting the examination and the Faculty should be informed of this for monitoring purposes.
17. Candidates must re-attempt their examination at a pre-scheduled examination diet, following completion of the course. Candidates are not permitted to make private arrangements with the Faculty approved course centres to re-attempt their examination on an individual basis outside of a scheduled examination.
18. Candidates choosing to re-attempt the examination at a course centre they have not previously attended are required to provide evidence of their previous course completion to the respective course centre. When re-attempting the examination, it is recommended that candidates attend at least the final day of the HAVS course again.
This syllabus is intended to guide the training of occupational health care professionals in the requirements for health surveillance for a workforce exposed to hand-transmitted vibration, and in the diagnosis and management of an individual with HAVS. It is aimed at health professionals working in the UK occupational health setting, rather than in a medicolegal one.
A general understanding of occupational health is required. No specific knowledge of HAVS is assumed or necessary.
FORMAT OF TEACHING
To allow for student interaction, this subject best lends itself to small group teaching, using a combination of formal presentations and practical sessions. An appropriately designed distance learning course would also be suitable.
METHODS OF ASSESSMENT
Attendance at all sessions (or completion of all sections for distance learning) is required. Suitable formal assessment, for example by MCQs or short answers, is required. This should include problem-based assessments, such as examining the ability to provide management advice based upon a clinical scenario or for a given Stockholm grading.
Introduction (30 minutes)
Background to HAVS
- definition of HAVS
- brief history of development of knowledge
- Faculty reports 1993, 2004
- prescribed disease
- RIDDOR reportable
- Vibration Regulations and HSE guidance 2001 and 2004
- number of people exposed in UK
- prevalence of symptoms in UK
- ubiquity of exposures in UK
- examples of significantly exposed occupational groups
Overview of Health Surveillance (HSG61)
- why health surveillance is needed
- purpose of statutory health surveillance
- general criteria to be met for statutory health surveillance
Indications for health surveillance, when it is likely to be needed, and also when it may not be appropriate
Context of health surveillance, as a part of the overall control measures
Legal (45 minutes)
Relevant legislation and regulations
- HSWA 1974
- Management HSW Regulations 1999
- Control of Vibration at Work Regulations
Overall requirements of the Regulations
- assess the risk
- avoid or reduce the risk
- inform, train and consult workers
- provide health surveillance
- factors to consider
- role of vibration measurement
Exposure Action and Limit Values
- units, and implications of time weighted measurements
- what the values are
- limitations, not ‘safe’ values
- short term exposures
- approaches to avoidance of exposure
- risk reduction measures
Information and training of workers
- lay information sheet from Faculty
- role of health professionals in consultation with workers
Health surveillance; statutory requirements
- purpose of health surveillance in HAVS
- record keeping
- confidentiality and communication with management
- provision of group data to management
Workplace vibration exposure (45 minutes)
Exposures and their measurement and reporting
- practicalities of vibration measurement
- terminology relating to vibration/acceleration (see legal section)
- single axis versus tri axial measurements
Relevant International/British Standards
- ISO 5349
- Machinery safety Regulations and vibration declaration
- considerations relating to standard testing of vibration emissions
Illustrations of different types of tool causing hand transmitted vibration
- hand held tools
- hand fed machinery
- hand guided machinery
- examples of vibration measurements for different tools, including beneficial effects of maintenance
Ergonomics of tool use
- importance of grip strength/ feed force as a factor in disease
- weight of tools and how to reduce/overcome this
- postural aspects of tool use
- manual handling aspects of jobs
Aetiology (30 minutes)
- the exposure response model in BS 6842 and the effects of duration of exposure and acceleration magnitude
- the ISO exposure response model, and the background to its derivation.
- limitations of the ISO model
- other general information on exposure response contained in the Annexes to ISO
- lack of detailed information on exposure-response relationship for the sensorineural and musculoskeletal components of HAVS
- the concept of latency in relation to the onset of the vascular component
- the relationship between vibration magnitude and latent period for vascular effects, with examples
Pathophysiology (30 minutes)
- physiology of control of peripheral circulation
- local versus central hypothesis
- evidence of harm: larger vessels and capillaries
- changes in blood components
- skin receptor types
- innervation of receptors
- evidence of local damage to nerve fibres
- effects of pressure on larger nerve trunks
- carpal tunnel syndrome, ulnar nerve damage at the wrist
- differences between ‘classical’ entrapment carpal tunnel and CTS associated with HAVS
- physiological effects of vibration on muscle
- vibration tonic reflex
- reduction in grip strength
- aetiology, damage to nerve or muscle?
- bony outgrowths, bone vacuoles, osteoarthritis
Evidence of reversibility, progress and prognosis
Health effects of hand-transmitted vibration (60 minutes)
Vascular: secondary Raynaud’s phemomena
- blanching of finger tips
- progression of symptoms with continuing exposure
- phases of a ‘typical‘ episode of vasospasm
- triggers for vasospasm
Sensorineural including nerve entrapment
- initial onset often neurological
- altered thermal sensitivity
- effects on dexterity
- impaired grip strength
- upper limb pain
- Dupuytren’s disease, sensorineural hearing loss
Overall impact of symptoms on functional ability and work/social life
Differential diagnosis (30 minutes)
Prevalence of symptoms in non-exposed population
- primary Raynaud’s and Secondary Raynaud’s disease including connective tissue disease eg scleroderma, trauma, occlusive vascular disease and hypersensitivity
- carpal tunnel syndrome, diabetes mellitus etc.
- hypothenar hammer syndrome, thoracic outlet syndrome etc.
Classification (45 minutes)
General uses of classification
Consistency; longitudinal follow up; decisions on deployment; clinical audit; research
Stockholm Workshop Scale
- vascular. Limitations of the scale
- neurological. Limitations of the scale
The scales in practice
- pen pictures of typical symptoms at stages 2 and 3, Vascular and Neurological
- repeatability & agreement between observers
- Griffin scoring
Details of health surveillance programme (45 minutes)
Setting up the programme
- overview of the programme
- roles of the varying parties
- training of the various parties
- communication with employer and workers, information and education for workers
- health records
Pre employment assessment: evidence of pre existing vulnerability
- Level 1 questionnaire, possible individual risk factors
Screening assessment, including frequency of assessment
- Level 2, short questionnaire, (responsible person)
- Level 3, occupational health nurse, (qualified person)
- Level 4, occupational physician, (medical officer)
- Level 5, standardised testing
Clinical assessment (60 minutes)
Value of information recorded at lower tiers
Approach to the patient
- overview of symptoms
- free text record of symptoms
- questioning from standardised questionnaire
- the sections in the questionnaire
How to synthesis the information obtained to reach an overall classification
Management of cases of HAVS (60 minutes)
Advice to employees and employers, including confidentiality issues
Prognosis and reversibility
- available options for therapeutic interventions
Measures to reduce ongoing vibration exposure
General advice on reducing the impact of the condition eg keeping warm, avoiding smoking, noise exposure
Accepted guidance on deployment action at Stage 2 and Stage 3
- special consideration for cases with rapid progression or other individual factors
Individual functional assessment, disability and judging fitness for work, including safety issues
Possible application of DDA
Medicolegal and regulatory considerations
- reporting under RIDDOR with consent
- prescribed disease & industrial injuries benefit issues
- compensation / civil claim