Author's reply: Cold provocation testing and hand-arm vibration syndrome – an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners (<i>Br J Surg</i> 2003; 90: 1076 – 1079)

Abstract

Sir Coughlin raises several points, most of which we feel are dealt with in the article. This was not a research paper, but an audit of the findings in a large number of miners being assessed. The conditions of the clinical process were defined by the Institute of Sound and Vibration Research (ISVR) and referred to in the paper. Claimants would have been in a controlled environment for 2 h. Gloves were applied for the cold provocation test (CPT) and the patient stabilised for a further 2 min. The paper reports we found no seasonal variation. Thermocouples were applied lightly to the pulp skin over the terminal phalanges using micropore and air was excluded. The recommended temperature was 15 °C (ISVR); 5 °C runs the risk of reactive hyperaemia occurring. Coughlin refers to his own findings stating that the test gave a 95 per cent sensitivity and a 100 per cent positive predictive value for HAVS (based on an experimental study of 21 patients) yet some months later wrote ‘there is a need for a sensitive objective investigation to confirm the diagnosis (of HAVS) and that the diagnosis and assessment of disease severity are subjective at present’1. We drew this to the attention of the Editor of Occupational Medicine—but Coughlin and his colleagues did not respond to our enquiry. This later test was neurological based on two-point aesthesiometry. The response from Coughlin also ignores the findings of Mason who studied the CPT in a cohort of 1000 miners and found it of limited value2.