Certificate in HAVS Regulations

ELIGIBILITY

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.

EXAMINATION FORMAT

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.

ADVICE

A6. Any further advice on the Regulations may be obtained by writing to the Chief Examiner.

Certificate in HAVS Guidance

INTRODUCTION

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.

CERTIFICATE

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.

TRAINING

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.

EXAMINATION PAPER

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.

Certificate in HAVS Syllabus

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.

PRE-REQUISITE KNOWLEDGE

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.

CORE SYLLABUS

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

Epidemiology

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

Risk assessment

factors to consider
role of vibration measurement

Exposure Action and Limit Values

definitions
units, and implications of time weighted measurements
what the values are
limitations, not ‘safe’ values
short term exposures

Risk control

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)
acceleromoters
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)

Exposure-response relationship

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

Latency

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)

Vascular component

physiology of control of peripheral circulation
local versus central hypothesis
evidence of harm: larger vessels and capillaries
changes in blood components

Neurological

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

Musculoskeletal component

physiological effects of vibration on muscle
vibration tonic reflex
reduction in grip strength
aetiology, damage to nerve or muscle?

Skeletal system

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

Musculoskeletal symptoms

impaired grip strength
upper limb pain
osteoarthritis

Other conditions

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

Vascular

primary Raynaud’s and Secondary Raynaud’s disease including connective tissue disease eg scleroderma, trauma, occlusive vascular disease and hypersensitivity

Neurological

carpal tunnel syndrome, diabetes mellitus etc.

Other

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

Other approaches

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
pitfalls

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)

Referral methods

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

Clinical examination

inspection
tests

Standardised tests

vascular
neurological
musculoskeletal

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

Page last updated 20 June, 2022

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