By Dr. David Sawatzky
I was recently consulted on the case of a commercial diver who presented with cold, white, painful fingers after walking outside on a cold windy day. When the diver was questioned it was discovered that they often experienced similar symptoms while diving and that the fingers sometimes took up to an hour to rewarm.
Maurice Raynaud was a French physician (1834-1881) who noted in his thesis for a medical degree in 1862 that some people had “intermittent attacks of severe pallor of the fingers or toes and sometimes of the ears and nose, brought on characteristically by cold and sometimes emotion”. Almost 150 years later, we still do not understand this problem well and a current medical definition is not much different from Raynaud’s original description, “a circulatory disorder that affects the hands and feet, caused by insufficient blood supply to these parts and resulting in cyanosis, numbness, pain and in extreme cases, gangrene”. Fortunately, extreme cases are extremely rare. People with Raynaud’s frequently present when the weather turns cold. I frequently see cases in September and October in Canada.
Raynaud’s symptoms occur in two ‘forms’. If the person has an underlying disease and the Raynaud’s symptoms are a result of that disease, the symptoms are called Raynaud’s Phenomenon or secondary Raynaud’s. If no underlying disease can be identified, the symptoms are called Raynaud’s Disease or primary Raynaud’s. The problem is that people often develop Raynaud’s symptoms years before other manifestations of the underlying disease. In addition, just because we cannot identify and diagnose an underlying disease does not mean one does not exist.
The distinction is useful, however, as Raynaud’s symptoms tend to be more severe and to progress if there is an underlying disease. If there is no underlying disease, the symptoms tend to be less serious and either stay relatively stable over time or actually disappear. In people with Raynaud’s symptoms, an underlying disease is eventually diagnosed about 40 per cent of the time.
In an attack of Raynaud’s symptoms, the small arteries (usually in one or more fingers but sometimes in a toe, the nose, ears, nipples, or lips) go into spasm and cut off the flow of blood to the body part. It turns white and/or blue, is cold, and can be very painful although numbness is more common. The spasm lasts from a few minutes to a few hours and can occur daily or less frequently.
When the arteries relax and dilate (usually when the part is warmed), the part turns red and becomes warm due to an abnormally increased blood flow. It can throb, tingle, burn or feel numb. If the constriction is prolonged and/or severe, the part can ulcerate and fissure (the cells die). In 60 per cent of cases only the fingers are involved. In 40 per cent of cases the toes are involved and rarely the ears, nose, nipples or lips are affected. Even a brief, mild exposure to cold can trigger an attack of Raynaud’s, such as taking something out of the freezer. The adjacent picture from the National Institute of Health website shows normal flow in figure A and active Raynaud’s in figures B and C.
Raynaud’s symptoms can be caused by diseases and conditions or repetitive actions that damage the arteries or nerves of the hands and feet, injuries to the hands and feet, exposure to some chemicals, and taking some medications.
Diseases that can cause Raynaud’s symptoms include Scleroderma (90 percent have Raynaud’s), Lupus (33 per cent have Raynaud’s), Sjogren’s syndrome, Rheumatoid arthritis, atherosclerosis, cryoglobulinemia, polycythemia, dermatomyositis, polymyositis, Buerger’s disease, pulmonary hypertension and sometimes thyroid problems.
Raynaud’s symptoms are the first sign of scleroderma 30 per cent of the time and may be the only symptom for many years. As a general guideline, Raynaud’s symptoms have to be present for more than three years with no signs of underlying disease before the diagnosis of Raynaud’s ‘disease’ can be made. If Raynaud’s symptoms start after age 40, an underlying disease is almost always present. In men over 50, peripheral vascular disease may cause Raynaud’s symptoms.
Repetitive actions (playing the piano, typing) and using vibrating tools (jackhammers, drills) may cause Raynaud’s symptoms. Some workplace chemicals (vinyl chloride – plastics industry) and some drugs (Ergotamine – used to control migraines, cisplatin and vinblastine – used to treat cancer, some over-the-counter medicines for colds, allergies and diet aids, and β-adrenergic blockers – used to control blood pressure) and nicotine (cigarettes) can cause Raynaud’s symptoms.
Raynaud’s symptoms with no underlying disease typically start in young adults (age 20 to 40) and are five times more common in women than in men. Relatives of someone with Raynaud’s symptoms are five times more likely to have symptoms than the general population so there appears to be a genetic component. Living in a cold climate will trigger symptoms (if these people lived in a warm climate they would not have symptoms). Approximately 5 per cent of Americans will have Raynaud’s symptoms. In approximately 15 per cent of cases the symptoms resolve completely.
Raynaud’s symptoms as a result of an underlying disease tend to develop after age 30 and are equally common in men and women. Over time they become more severe and frequent in 30 per cent of cases. The distal branches of the radial and ulnar arteries are often blocked.
Allen’s test involves clenching the fist and blocking both the radial and ulnar arteries at the wrist. The hand is opened and remains white. Pressure is released from one of the arteries and if the hand immediately fills with blood, the distal branches of that artery are open. The test is then repeated for the other artery, and finally the other hand. You can try this at home! The radial artery is located at the base of the thumb on the palmer side of the wrist while the ulnar artery is located at the base of the little finger, also on the palmer side of the wrist.
There is no cure for Raynaud’s symptoms but treatment often reduces or eliminates the frequency or severity of attacks. If the person smokes, they must stop. If the attacks are related to repetitive actions or vibration, the actions must be stopped or altered so that they do not trigger an attack. If stress is a factor, stress management should help reduce attacks. If the person is on any drugs that might be making the problem worse, they need to be stopped. Caffeine and alcohol can trigger attacks and should be avoided. Physical activity increases blood flow and might be helpful.
If the above measures are not effective, vasodilating drugs (calcium channel blockers, alpha blockers) sometimes work. As a last resort, surgery might help. If the person has occlusion of the large arteries, this can sometimes be addressed by surgery. Sympathectomy (cutting the sympathetic nerves) is sometimes effective but for reasons that are not completely understood, the effect only lasts for a few years.
Raynaud’s symptoms are relatively common and therefore many divers or people who want to be divers will have them. Can or should they dive? The two primary questions are whether diving will make their symptoms worse or cause damage, and whether their symptoms will interfere with their ability to dive safely.
Repeated exposure to stimuli that cause Raynaud’s symptoms can cause permanent damage in the affected part. Therefore, if diving is causing the person to experience attacks of Raynaud’s, they should not dive. Ways to dive that might reduce the risk of triggering an attack include diving in warm water, wearing excellent thermal hand protection (dry gloves) and avoiding tight wrist seals.
Core temperature is important for all divers and a drop in core temperature of only 33C (0.5C) will cause a dramatic reduction in blood flow to the hands. Divers with Raynaud’s might avoid triggering an attack if they keep their core temperature up. The rest of us should try to maintain our core temperature to keep our hands warm.
If a person who wants to become a diver has recently developed Raynaud’s symptoms, they might want to wait three years or so to see how serious the symptoms become and to see if an underlying disease is diagnosed. If they are already a diver, they can continue to dive as long as diving is not triggering an attack, and as long as the underlying disease is not interfering with their ability to dive safely. The underlying disease will often make the person unfit diving.
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