Raynauds phenomenon among men and women with

noiseinduced hearing loss in relation to vibration exposure

Hans Pettersson1, Lage Burstrm1, Tohr Nilsson1,2
Ume University, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Ume, 2Sundsvall
Hospital, Department of Occupational and Environmental Medicine, Sundsvall, Sweden
1

Abstract
Raynauds phenomenon is characterized by constriction in blood supply to the fingers causing finger blanching, of white
fingers(WF) and is triggered by cold. Earlier studies found that workers using vibrating handheld tools and who had
vibrationinduced white fingers(VWF) had an increased risk for hearing loss compared with workers without VWF.
This study examined the occurrence of Raynauds phenomenon among men and women with noiseinduced hearing
loss in relation to vibration exposure. All 342 participants had a confirmed noiseinduced hearing loss medico legally
accepted as workrelated by AFA Insurance . Each subject answered a questionnaire concerning their health status
and the kinds of exposures they had at the time when their hearing loss was first discovered. The questionnaire covered
types of exposures, discomforts in the hands or fingers, diseases and medications affecting the blood circulation, the use
of alcohol and tobacco and for women, the use of hormones and whether they had been pregnant. The participation
rate was 41%(n=133) with 38%(n=94) for men and 50%(n=39) for women. 84 men and 36 women specified if
they had Raynauds phenomenon and also if they had used handheld vibrating machines. Nearly 41% of them had
used handheld vibrating machines and 18% had used vibrating machines at least 2h each workday. There were 23
men/6 women with Raynauds phenomenon. 37% reported WF among those participants who were exposed to handarm
vibration(HAV) and 15% among those not exposed to HAV. Among the participants with hearing loss with daily use of
vibrating handheld tools more than twice as many reports WF compared with participants that did not use vibrating
handheld tools. This could be interpreted as Raynauds phenomenon could be associated with an increased risk for
noiseinduced hearing loss. However, the low participation rate limits the generalization of the results from this study.
Keywords: Handarm vibration, hearing loss, noise, Raynauds phenomenon, white fingers

Introduction
Hearing loss relates to age and the rate at which hearing is lost
increases with exposure to noise. The risk of noiseinduced
hearing loss can be modified by genetic, chemical, or medical
factors.[1,4]Another interacting factor for the risk of noiseinduced
hearing loss might be exposure to vibrations. Workers using
vibrating handheld tools are exposed to hazardous levels of
noise and to handarm vibrations(HAV). Longterm exposure
to HAV could cause workers to develop white fingers(WF).
WF or Raynauds phenomenon is characterized by episodic
constriction in the blood supply to the fingers causing finger
blanching. When the vasospasm is believed to be secondary to
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vibration it is called vibrationsinduced white fingers(VWF).

Workers using vibrating handheld tools who have VWF have
an increased risk for noiseinduced hearing loss compared with
workers without VWF but of similar age and with similar noise
exposures.[1,5-9]
Episodes of WF among those with WF or Raynauds
phenomenon are primarily triggered by cold or emotional
stress.[10] Primary Raynauds phenomenon has no related
disease of external identified cause but could have a genetic
component. Secondary Raynauds phenomenon comprises cases
of WF that is linked to an underlying disease or is caused by an
external factor. VWF is one example of secondary Raynauds
a phenomenon that causes finger blanching as a vasospastic
overreaction to cold.
A crosssectional study by Palmer etal.[11] found an association
between finger blanching and hearing loss in people who
had never worked with handheld vibrating tools or in noisy
environments. Both men and women in the study had an
increased risk of hearing loss if they had finger blanching.
Noise & Health, March-April 2014, Volume 16:69, 89-94

Pettersson, etal.: Raynauds phenomenon and noise-induced hearing loss

A study based on a postal questionnaire was used to further

explore the occurrence of Raynauds phenomenon among
men and women with noiseinduced hearing loss in relation
to vibration exposure.

the hands or fingers, illnesses and medications affecting

the blood circulation, if they used tobacco(smoked or used
snuff) daily or used alcohol weekly and for women, the use of
hormones and whether they had been pregnant.

Methods

Exposures

Participants
The study sample consisted of men and women who had
a confirmed noiseinduced hearing loss accepted by the
insurance company AFA Insurance as workrelated and as
such had received financial benefits from AFA Insurance in
Sweden between 1995 and 2004. AFA Insurance is owned
by Swedens labour market parties and they insure employees
within the private sector, municipalities and county councils
in Sweden. The participants noiseinduced hearing loss had
been graded from 1% to 15% disability depending on the
severity of the noiseinduced hearing loss. The definition of
1% disability is a combined mean hearing threshold level
at 2000 and 3000 Hz that is equal to or more than 35 dB
and also that the combined mean hearing level at 4000 and
6000Hz is equal to or more than 45dB. The worker must
also have been exposed to noise for at least 10years at noise
exposure levels of more than 8590 dB (A). For shorter
noise exposure durations the noise exposure must have been
above 90dB(A). Hearing loss from impulse noise exposures
must have been from noise exposures above 135dB(C) or
115dB(A). For 15% disability the hearing threshold is more
than 40dB at 1000Hz and above 60dB at 2000Hz. Also,
the combined mean hearing threshold level at 3000, 4000 and
5000 must be above 50dB. The noise exposure criteria are
the same as for 1% disability.
The men and women had to be between the ages of 18 and 55
when their noiseinduced hearing loss was confirmed to be
included in the study. The men were randomly chosen and 86
men were from the northern region of Sweden, 85 men were
from the middle region and 90 men were from the southern
region. Because there were only a few women who had a
confirmed workrelated noiseinduced hearing loss, we chose
to invite all such women to participate in the study. The study
sample consisted of 261 men and 81 women. After excluding
participants for whom a current address was unavailable,
the final sample consisted of 246 men and 78 women who
received the questionnaire. Areminder was sent if the
participants had not responded the 1sttime. The questionnaire
study was approved by the Regional Board of Ethics for
Medical Research in Ume, Sweden(Dnr 08151 M).
Questionnaire
The men and women in the study sample were invited to
answer a questionnaire covering their health status and
the kinds of exposures they had at the time when their
noiseinduced hearing loss was first discovered. The
questionnaire included types of exposures, discomforts in
Noise & Health, March-April 2014, Volume 16

If the participants stated that they had used handheld

vibrating machines when they first discovered their
noiseinduced hearing loss, they were classified as being
exposed to HAV. Participants who did not use any handheld
vibrating machines were classified as not exposed to HAV.
The participants were then asked to subjectively estimate
how many minutes per working day and for how many years
they had been working with vibrating machines until they
first discovered their hearing impairment. Noise exposure
was addressed in the questionnaire by asking the participants
to subjectively estimate their daily noise exposure. They
were also asked to estimate how many minutes per working
day they had a noise level where the participant could not
talk to another person 1m away without raising their voice.
The participants were also asked for how many years they
had worked in their occupation at the time they discovered
they had noiseinduced hearing loss. Their cold exposure was
estimated by questions on how much of a working day they
were outside.
Classification of Raynauds phenomenon
Participants were classified as having WF based on their
response to the question Do you have white(pale) fingers
of the type that appear when exposed to damp and cold
weather (see picture)? If they answered yes to this
question they were classified as having WF and were asked
for how many years they had WF symptoms.
The subsequent classification of WF as primary Raynauds
phenomenon, or secondary Raynauds phenomenon was
based on information on the subjects exposures, injuries and
diseases.
Participants were classified as having possible primary
Raynauds phenomenon if they had no HAV exposure and
if they had WF with no other apparent cause(WFPR). Such
causes were frostbite on any hand, surgery for carpal tunnel
syndrome, hospitalization due to injury, disease or illness
with influence on the vascular circulation such as diabetes,
hypertension, heart diseases, or rheumatic diseases such
as scleroderma, joint or muscle disease, thyroid disease,
asthma, bronchitis, migraine, or arm or wrist fractures. Use of
medications for migraines, vascular spasms, cardiovascular
disease or hypertension was also categorized as other cause.
For a participant to be classified with possible secondary
Raynauds phenomenon, due to vibration (VWFSR), the
participant had to be exposed to HAV and not fulfilling the
criteria of other causes of WF.
90

Pettersson, etal.: Raynauds phenomenon and noise-induced hearing loss

Statistics
All statistical analysis was performed with IBM SPSS Statistics
version20(IBM Corporation. Software Group. Somer. NY.
USA) The prevalence of use of handheld vibrating machines,
WF and WFPR and VWFSR were calculated. The noise
exposure duration in hours was calculated by multiplying the
number of years at the current occupation multiplied by 220
workdays/year and then by the number of minutes per day
in a noisy environment. The HAV exposure was calculated
by multiplying the number of minutes per day working with
handheld vibrating machines by 220 workdays/year and
then by the total number of years working with handheld
vibrating machines. The mean(standard deviation[SD]) ages
for all participants who answered the questionnaire were
calculated at the time when the participants noiseinduced
hearing loss was confirmed. The relative risk(RR) and 95%
confidence intervals(95% CI) was calculated for WF among
participants who were exposed to HAV were compared with
a reference group of participants who were not exposed to
HAV. Also, the RR with 95% CI of WF was calculated as
the prevalence of WF among those exposed to HAV divided
by the prevalence of WF among those not exposed to HAV.
The RR of WF among participants in the Northern Region
compared with WF in the southern region.

Results
The participation rate was 41%(n=133) with 38%(n=94)
for men and 50% (n = 39) for women with noiseinduced
hearing loss. In the northern, middle and southern regions
of Sweden, the participation rates for men were 42%, 39%
and 35%, respectively. The mean(SD) age of the participants
who answered the questionnaire was 41 (9) years [39 (10)
for men and 46 (8) for women] and for those who did not
answer the mean age(SD) was 41(9) years[40 (9) for men
and 44 (7) for women]. The average age was almost the
same for those men and women who answered or did not
answer the questionnaire. The most common occupations
among the participants were teachers(n = 15), military
personnel(n=13) and welders(n=4).
Totally 84 men and 36 women reported information on
WF and also specified if they had used handheld vibrating
machines. The most commonly used handheld vibrating
machines were grinders, drillers and screwdrivers. Nearly
41% (n = 49) of the 84 men and 36 women had used
handheld vibrating machines and 18% (n = 21) had used
vibrating machines for at least 2 h each workday. Nearly
37% had reported WF among participants exposed to HAV
compared with 15% among those who were not exposed to
HAV[Table1].
In our study, there were a total of 23 men and six women
who had cases of WF. The mean age, average noise exposure
duration and the use of tobacco and alcohol were about
91

the same for those with WF compared with those without

WF[Table2]. There was a RR of 2.4(95% CI: 1.24.6) for
WF among participants who were exposed to HAV compared
with participants not exposed to HAV.
Among the 29 participants with WF, there were 8(20%) men
with WF who were not exposed to HAV and five had WFPR.
Of the men exposed to HAV, there were 15 with WF(34%)
and eight of them had VWFSR[Table3]. Among the women
exposed to HAV, three women had WF and among women
who were not exposed to HAV two women had WFPR and
one had VWFSR[Table3]. The prevalence of WF among men
was 27% compared with 17% among women.
There were four participants not classified as having WFPR
but who had WF and were not exposed to HAV. These four
participants had either frostbite in the hand(two men), took
medication for cardiac or hypertension problems(one man)
or had an operation for carpal tunnel syndrome(one woman).
Among the participants not classified as having VWFSR,
nine had either taken medication for cardiac or hypertension
problems or vascular spasms (three men and two women),
been hospitalized following an accident (one man), or had
frostbite in their hands(two men) and one man had both
frostbite in his hands and had been operated on for carpal
tunnel syndrome.
The average noise exposure durations until the discovery of
noiseinduced hearing loss were shorter among men with
WFPR and for men with WF and not exposed to HAV compared
with men without WF[Table4]. Participants with or without
WF and who were exposed to HAV had about the same noise
exposure duration except for women[Table4]. The average
exposure to HAV was about the same for all participants with
WF compared to those without WF[Table4].
Table1: The prevalence(%) of WF among participants
exposed and not exposed to HAV, the mean(SD) age, number
of years of WF symptoms, duration of noise exposure and the
prevalence(%) of tobacco and alcohol use
Exposure No.
HAV

Yes
No

Age
WF
WF
Tobacco Alcohol Noise
years no. (%) duration no. (%) no. (%) duration
mean
mean
mean
(SD)
(SD)*
(SD)**
49 41(10) 18(37)
6(8)
31(63) 40(82) 10(13)
71 41(9) 11(15) 12(14) 21(30) 54(76) 10(11)

*In years, **In 1000 h. WF = White fingers, HAV = Handarm vibration,

SD = Standard deviation

Table2: The mean(SD) age, WF symptoms in years, duration

of noise exposure among participants with or without WF and
the prevalence(%) of tobacco and alcohol use
WF No. Age years WF duration Tobacco Alcohol Noise duration
mean (SD) mean (SD)* no. (%) no. (%) mean (SD)**
Yes 29
43(11)
11(11)
14(48) 22(76)
12(15)
No 91
40(9)

38(42) 72(79)
9.4(11)
*In years, **In 1000 h. WF = White fingers, SD = Standard deviation

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Pettersson, etal.: Raynauds phenomenon and noise-induced hearing loss

Table3: The prevalence(%) of WF among men and women who had or had not been exposed to HAV, the mean(SD) number of
years of WF symptoms and the prevalence(%) of possible primary and secondary Raynauds phenomenon
Gender
Men
Women
Both

Total no.
44
5
49

Men
Women
Both

44
5
49

HAV exposure
WF no.(%)
WF duration mean(SD)*
15(34)
7.5(9.0)
3(60)
8()
18(37)
7.5(8.5)
Only secondary
Secondary Raynaud
8(20)
4.3(3.9)
1(20)

9(18)
4.3(3.9)

No HAV exposure
Total no.
WF no.(%)
40
8(20)
31
3(10)
71
11(15)
Only primary
40
5(13)
31
2(6)
71
7(10)

WF duration
mean(SD)*
15(15)
20()
16(13)
Primary Raynaud
19(17)
20()
19(15)

*In years. WF = White fingers, HAV = Handarm vibration, SD = Standard deviation

Table4: The mean(SD) duration of noise and HAV exposure

and the average(range) use of hearing protectors during noise
exposure among men and women with or without WF, possible
primary or secondary Raynauds phenomenon
Exposure WF
HAV

Yes

No

Gender Total Noise

no. duration
mean
(SD)*
WF and no WF Both
49 10(13)
WF
Men
15 11(16)
Women 3
26(19)
Both
18 13(17)
Only
Men
8
11(13)
secondary
Women 1
13()
Rayanud
Both
9
12(13)
No WF
Men
29 9.3(12)
Women 2
4()
Both
31 9.1(11)
WF and no WF Both
71 10(11)
WF
Men
8 1.4(2.1)
Women 3
26(90)
Both
11 9.5(13)
Only primary Men
5 1.6(2.3)
Raynaud
Women 2
28(11)
Both
7
10(15)
No WF
Men
32 7.3(9.8)
Women 28 12(12)
Both
60 9.6(11)

Hearing
protection
mean
(range)
74(0100)
88(30100)
62(0100)
83(0100)
75(30100)
85(0)
76(30100)
72(0100)
30(1050)
69(0100)
46(0100)
38(0100)
33(0100)
37(0100)
91(0100)
0(0)
61(0100)
58(0100)
35(0100)
47(0100)

HAV
duration
mean
(SD)*
9.9(14)
4.4()
9.5(13)
6.9(6.0)

6.9(6.0)
7.5(9.7)
15()
7.8(9.6)

*In 1000 h, Percentage of noise exposure. WF = White fingers, HAV = Handarm

vibration, SD = Standard deviation

There was, on average, less use of hearing protection among

participants who were not exposed to HAV compared to those
participants who were exposed to HAV when the participants
discovered they had hearing loss[Table4].

Discussion
The low participant rate limits the possibilities for
generalization of the results from this study. Furthermore, all
the participants answered a questionnaire about their working
conditions and health status. However, the classification of
suffering from WF or not was based on information from
the questionnaire and this selfreported symptoms has not
been verified by medical investigations and could, therefore,
include both primary and secondary Raynauds phenomenon.
Noise & Health, March-April 2014, Volume 16

Moreover, the used question is not specifically related to

primary or secondary Raynauds phenomenon and could
have generated false classification of primary Raynauds
phenomenon being a secondary Raynauds phenomenon.
All men and women in this study had a medicolegally confirmed
workrelated, noiseinduced hearing loss. The participants
hearing impairment had been graded from 1% to 15% disability
depending on the severity of noiseinduced hearing loss. The
mean level of disability was about the same for men and women
with or without WF who used or did not use handheld vibrating
machines.
Among the participants, 41% had used handheld vibrating
tools and 18% used these types of tools for at least 2h and
each workday. This is higher numbers than the corresponding
numbers among all Swedish workers using handheld were
9% use handheld vibrating tools for at least 2 h and each
workday.[12] The noise exposure from these handheld vibrating
tools could be one explanation for the higher prevalence of
noiseinduced hearing loss among the participants. One could
also speculate that the higher prevalence is due to simulations
exposure to HAV. One earlier longitudinal study suggested
an increased risk of hearing loss from HAV in a noisy
environment,[9] but this conclusion is not supported by other
longitudinal studies.[1,13]
There were 29 cases of WF among the participants in this
study. For male construction workers in Sweden exposed to
HAV, prevalence of WF of 13.4% has been reported.[14] In the
present study there was prevalence of WF of 34% among men
with noiseinduced hearing loss who were exposed to HAV
and the prevalence of VWFSR was 20%. There was a RR of
2.4(95% CI; 1.24.6) for WF among participants who were
exposed to HAV compared with participants not exposed to
HAV. Earlier longitudinal and crosssectional studies have
found an increased risk of hearing loss among workers with
VWF compared to workers without VWF who have similar
noise exposure and are of similar age.[1,59] Therefore, WF
from exposure to HAV might be a factor that increases the
risk of noiseinduced hearing loss.
In this study the prevalence of WF among men with
noiseinduced hearing loss who were not exposed to HAV
92

Pettersson, etal.: Raynauds phenomenon and noise-induced hearing loss

was 20% and 13% of the men had WFPR. Among Swedish
male office workers not exposed to HAV prevalence of 8.4%
for WF has been reported.[14] An earlier crosssectional study
on finger blanching found that there was an increased risk
of hearing loss for men and women with finger blanching
who were not extensively exposed to HAV or noise.[11] One
could therefore speculate if WF is a trigger for noiseinduced
hearing loss. In the present study men with WF and no
exposure to HAV had shorter noise exposure durations until
the discovery of hearing loss compared to men without WF
and no HAV exposure and to men with or without WF who
were exposed to HAV.
Participating women who were both exposed and not
exposed to HAV had prevalence of WF of 17%. An earlier
crosssectional study among women in Sweden reported a
similar prevalence of Raynauds phenomenon of 16%.[15]
Pyykk etal. suggested that the same mechanism that causes
restriction of the blood supply to the fingers could also restrict
blood supply to the cochlea. HAV could possibly trigger an
overactivation of the sympathetic nervous system(SNS)
causing a restriction in blood supply to the fingers and cochlea
that would lead to finger blanching and ischemia in the
cochlea.[5,16] HAV might reduce the blood supply in the fingers
by stimulating the SNS in the fingers causing VWF.[1719] Noise
exposure might reduce the blood supply to the cochlea.[2023]
If HAV also reduce the blood circulation in the cochlea then
combined noise and HAV exposure might increase the blood
circulation in the cochlea and increase the risk for hair cell loss
and hearing loss. The function of the SNS in the cochlea is not
fully understood. It is believed that the SNS controlled the blood
supply to the cochlea.[20,22,24] During noise exposure the systolic
blood pressure will rise and also the cochlear blood flow, but
when the blood pressure is too high then the autonomic nervous
system could reduce the cochlear blood flow.[24] The SNS might
have a protective effect on the cochlea, but there are studies
that also suggest a harmful effect.[2528] Palmer et al.,[11] found
an increased risk of hearing loss among men and women not
extensively exposed to HAV or noise and further studies on the
mechanism causing a possible increased risk of hearing loss for
men and women with finger blanching are recommended.
Among those participant who were exposed to HAV there
were 37% who had WF and 63% stated that they used
tobacco. Smoking may increase the risk of noiseinduced
hearing loss and of VWF.[29]
Earlier crosssectional studies have found that workers
using handheld vibrating tools in tropical regions have a
lower prevalence of Raynauds phenomenon than those in
colder regions.[30,31] A cohort study found that HAVexposed
workers in the northern region of Sweden were at a higher
risk of WF than workers in the southern region.[14] The effect
of HAV on WF might be increased in cold environments.[14]
Among participants in our study there was no increased risk
93

of WF in the northern region compared with the southern

region of Sweden.
Other diseases and injuries that could cause peripheral circulation
disturbances are frostbite in the hands operations for carpal tunnel
syndrome, hospitalization following an accident and taking
medication for cardiac or hypertension problems or vascular
spasms. These factors could disturb the blood circulation and be
a factor for VWFSR that is not from HAV exposure.
There are some possible limitations in this study. The main
limitation was that the participant rate was low at 41% with
less men(38%) answering than women(50%). The selection
of participants for this study could be biased because all
participants were selected due to confirmed noiseinduced
hearing loss. This selection makes it difficult to compare the
prevalence of WF in other groups of workers. The participants
in the present study stated when they first discovered that
they had hearing loss. Aproblem with discovering hearing
loss is that it comes gradually over time. It can be difficult
to exactly know when the hearing loss occur. Some of the
different groups of workers in the present study might have a
clear understanding when the hearing loss occurred. Military
personal might have notice at once if they lost hearing when
firing a gun. Also, teachers might be more aware of their
hearing since it is so important to use when teaching. The
participation rate was highest in the northern and lowest in
the southern region but still very low. There were 13 military
personnel in this study and six had WF. Military personnel often
have impulse noise exposure from firing weapons during their
work and this could cause hearing problems. Impulse noise
exposure causes noiseinduced hearing loss from mechanical
injury to the hair cells in the cochlea while continuous noise
exposure causes metabolic changes that cause hair cell death
and noiseinduced hearing loss.[23] The suggested possible
increased risk of noiseinduced hearing loss from HAV or
VWF comes from studies on workers exposed to continuous
and not impulse noise, thus the military personnel could
have affected the results if they had acquired noiseinduced
hearing loss from impulse noise and not from continuous noise
exposure. There could be some participants who developed
WFPR who then began working with HAV and were, therefore,
classified with VWFSR. It is possible that this study has some
misclassification of WFPR and VWFSR even after excluding
other causes of WF such as frostbites, carpal tunnel syndrome,
hospitalization following an accident and medication for
cardiac and hypertension problems or vascular spasms. This
study has no information as to when the participants developed
frostbite or carpal tunnel syndrome or were hospitalized for
an accident. It could have been before or after they developed
WF. The noise exposure at the participants current work was
used in this study and we have no information on the level of
noise exposure or HAV exposure before the current job. Noise
exposure and HAV exposure as minutes per day may vary over
time and among machines. The usage of hearing protection is
the percentage of noise exposure time during the current job at
Noise & Health, March-April 2014, Volume 16

Pettersson, etal.: Raynauds phenomenon and noise-induced hearing loss

the time when they discovered noiseinduced hearing loss and

there is lack of information on earlier use of hearing protectors.

Conclusion
Among the participants with hearing loss with daily use of
vibrating handheld tools more than twice as many reports
WF compared with participants that did not use vibrating
handheld tools. This could be interpreted as Raynauds
phenomenon could be associated with an increased risk for
noiseinduced hearing loss. However, the low participation
rate limits the generalization of the results from this study.

Acknowledgments
The authors would like to acknowledge the financial support of AFA
Insurance (Project 20070104). We also thank Michel Normark,
Elisabeth Molander and Tezic Kerem for their support in selecting
participants and administering the questionnaire.

Address for correspondence:

Hans Pettersson
Ume University, Occupational and Environmental
Medicine, Department of Public Health & Clinical
Medicine, SE-901 87 Ume, Sweden
E-mail: hans.pettersson@umu.se

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How to cite this article: Pettersson H, Burstrm L, Nilsson T. Raynaud's
phenomenon among men and women with noise-induced hearing loss in
relation to vibration exposure. Noise Health 2014;16:89-94.
Source of Support: AFA Insurance (Project 2007-0104). Conflict of
Interest: None declared.

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