NIOSH releases report on Preventing Work-Related Musculoskeletal Disorders in
Sonographers are at risk for developing work-related musculoskeletal disorders such
as inflammation of the tendons (tendonitis) or tendon sheaths (tenosynovitis), bursitis,
muscle strains, and pathology of the nerves in the upper extremities, neck, and
NIOSH recommends appropriate engineering controls, work practices, hazard communication,
and training to prevent these work-related musculoskeletal disorders.
report as .pdf file
Ergonomics is the study of the human body at work. As a science, it has its roots in the Industrial Revolution. It has only been recently that designers could benefit from new databases and statistics, and it is only recently that the results of bad designs are showing up in large segments of the population as Work-related Musculoskeletal Disorders (WRMSD’s) or Repetitive Stress Injuries (RSI’s).
One of the key elements of Ergonomics is environmental design. How workers lay out their work space and how they interface with it (i.e. sit, stand, move around, view a monitor screen, address a CPU, etc.) has an immediate impact on both productivity and worker health. This is true both for healthy workers, physically-challenged workers and people already suffering from cumulative trauma disorders or RSI’s.
Awareness of pain and discomfort associated with the occupation of Sonography surfaced around 1980 just prior to the widespread use of real time scanners. The most common complaint was pain in the shoulder of the sonographer’s scanning arm. This syndrome soon became known as Sonographer’s Shoulder. The number of complaints reached the attention of Marveen Craig, a well-known sonographer, educator and author. Craig published an article in the Journal of Diagnostic Medical Sonographers (JDMS) in May/June 1985 titled "Sonography: An Occupational Health Hazard"? This article polled approximately 100 veteran sonographers with 5-20 years experience in the profession. The results were very interesting. When questioned, these veterans complained of stress and burnout, vision problems that were improved when display of ultrasound images was switched from black on white to white on black; infections (this was prior to universal precautions and the widespread availability of sinks for hand washing in scanning rooms) and allergies (some sonographers were allergic to the coupling gel).
Electric shock was not uncommon, especially when doing bedside studies and when removing transducers from the articulated arm. Muscle strain involving the wrist, base of the thumb and shoulder was also reported. Sonographers using the early real-time systems complained of heavy transducers and cables.
As more real-time systems came into use complaints of sonographer’s shoulder almost disappeared. However, this lasted only 10 years and by 1994 complaints started to pour in to the Canadian Society of Diagnostic Medical Sonographers (CSDMS) and they started to track these complaints. Vicky Lessoway, 1994 President of the British Columbia Ultrasound Society (BCUS) made it her goal to address this issue in the Province. The Society of Diagnostic Medical Sonography (SDMS) was also starting to hear complaints and they were increasing in number and variety. The BCUS and the SDMS joined forces to address the issue of occupational injury in Sonography. In 1997 a large questionnaire was developed by the SDMS and the Health Care Benefit Trust of Vancouver Canada (HBT) in collaboration with the local ultrasound society (BCUS), the labor union representing Canadian Sonographers. Some of the data from that questionnaire will be shared in this column in the coming months.
The 1997 questionnaire and many subsequent studies show that musculoskeletal disorders among sonographers and physicians who scan patients full-time is a serious health problem and the incidence appears to be increasing as work loads increase. Some individuals have had to seek alternative employment as they can no longer perform ultrasound. Others have had to reduce their hours of work or change work practices to continue to work.
The incidence of WRMSD identified as pain or chronic discomfort that the respondents believe to be work related is now being tracked in sonographer populations by various organizations. These self-reported incidence rates are consistently high:
WRMSD may appear as one or more of the following conditions, depending on the nature and intensity of work activities.
There is also a family of symptoms associated with WRMSD; some are a result of cumulative effects, while others relate to specific causes.
WRMSD symptoms have been grouped into 3 stages to help sonographers recognize what they are experiencing and hopefully encourage and empower them to seek medical help as soon as possible.
Stage 1: aching, fatigue that subside with overnight rest; work performance not affectedStage 2: aching, fatigue that does not subside with overnight rest; symptoms occur earlier in the day; may affect job performanceStage 3: aching, fatigue, weakness result in reduced performance in work & leisure activities; symptoms disturb sleep & may last for months or years
These stages were described by Browne, C.D., Nolan, B.M. and Faithfull, D.K., in their article `Occupational repetition strain injuries: Guidelines for diagnosis and management', Medical Journal of Australia, 140, March 1984, pp. 329-32, The stages refer to all types of occupational injury and are not specific to Sonography.
In future articles in this series we will explore what the sonographer or scanning physician can do to reduce their vulnerability to WRMSD, the role of equipment design and equipment manufacturers, and how individuals can take a proactive approach to treating and preventing WRMSD.
Next Month: The American Experience-Statistical Evidence of the Risk Factors
Work-related musculoskeletal injury (WRMSI) has been studied and documented extensively
in many professions over the past two decades. This study intensified in the early
1990’s as downsizing and rightsizing became a popular way for corporations to improve
their profitability. The resulting intensification of work demands with resultant
increases in incidence of WRMSI stimulated efforts to better define the relationship
between work activities and WRMSI incidence. Numerous surveys by different authors
were sent out to collect data on occupational injury. These were typically research
oriented, local in scope and tended to be small in terms of the number of surveyed
participants. What was interesting about these surveys was that many reported a
very high incidence of occupational injury in diagnostic medical sonographers.
The Society of Diagnostic Medical Sonography (SDMS) was also receiving reports of
WRMSI in sonographers and this prompted them to pay for a large survey. In late
1996 through early 1997 a survey was conducted using 3000 sonographers randomly
selected from the American Registry Diagnostic Medical Sonographers (ARDMS) data
base. The survey was funded by the SDMS, Canadian Society of Diagnostic Medical
Sonographers (CSDMS), and the British Columbia Ultrasound Society (BCUS).
The data indicated that the majority of injuries were in the neck and shoulder,
closely followed by the wrist and back. It is important to also note the amount
of eyestrain since this leads to compensatory bad posture and further injury. Many
of those responding to the survey stated that they suffered from headaches and blurred
vision due to inadequate lighting. As might be expected from the nature of the work
sonographers perform, the occurrence of reported pain is highest for the neck, shoulders
and upper back (Figure 1).
The goals of this survey were to:
The survey was a 21-page questionnaire divided into 5 sections.
The questionnaire was returned from 983 out of 3000 sonographers from the United
States, for a 33% return rate. Two hundred and eleven out of 232 sonographers from
British Columbia returned the survey for an outstanding return rate of 92%. The
questionnaire was piloted in British Columbia but was not changed making it possible
to include the data in the final statistics. The survey was also mailed to all Canadian
sonographers except those living in British Columbia and 427 out of 1088 were returned
for a 39% response rate. The grand total of returned questionnaires was 1,621. The
data was published in a paper published in JDMS 13:219-227 Sept/Oct, 1997, authored
by Pike, Russo, Berkowitz, Baker, and Lessoway.
RESULTS OF THE SURVEY:
The average time of actual scanning is 17.8 days per month and 6.8 hours per day.
The average length of a work day, not including “on-call” was 8.3 hours. Fifty-seven
percent of sonographers scanned while seated. Risk factors for injury are related
not only to how much time is spent holding a transducer and exerting force but also
to the time spent in a static position. The survey showed that 30 % of respondents
typically maintained static posture during scanning for less than 10 minutes, 31.4%
for 10-15 minutes and 29.1% for 15-30 minutes. Over 30 minutes accounted for 9.5%.
When asked to describe the pain they experienced:
Of those reporting pain
Of those receiving treatment
In general, sonographers have a positive perception of their work environment and
corporate culture. However, respondents indicated they had some concerns over work
schedule, work tasks and lack of support services.
Work environment concerns included:
Eighty-four percent of respondents reported they had experienced pain or discomfort
since starting work as a sonographer
Of these, 96.5% thought it was related to scanning, 88.9% still experience pain
or discomfort and had done so for an average of 5 years (58.068 months). The average
length of time the respondents had been in the profession was 11 years.
Data from the same survey showed that the average age of practicing sonographers
who responded to the study is 42 years and that 80% of respondents were between
the ages of 30 and 50, and 11.5% were under 30 years of age (Figure 2). Sonography
is typically not a first career for most sonographers and the average length of
time that the respondents had been in the field was 11 years. There is a higher
incidence of musculoskeletal complaints in the chronologically older population
which may account for part of the problem found. However, force, duration, static
position, equipment design, lack of education on risk factors by the end user and
workstation design are more likely to be the cause of the international problem.
Research on WRMSI in other professions has shown a direct correlation between the
length of time that work activity associated with MSI is sustained and both the
incidence and severity of WRMSI. Many types of WRMSI can be greatly reduced by introducing
interruptions to sustained activity, in the form of rest breaks or by modifying
the work flow to incorporate activities which use different muscles and joints,
thus giving the body time to recover from potentially injurious activity. The number
of breaks which sonographers are able to take during the work day thus becomes a
critical factor. The survey highlighted this as a major problem (Figure 4).
Figure 4 shows the number of breaks of 10 minutes or more per day on average that
the respondent sonographers reported. Over half reported receiving no breaks during
the work day. This is important because breaks provide opportunity for the muscles
and tendons to recover from sustained use.
Respondents were asked to identify those activities that they felt were causative
of the pain they reported experiencing and to rate these activities on a scale of
1-5 with 5 being most likely to cause pain or exacerbation of pain and 1 being least
likely. The most commonly reported activities are graphed in Figure 5.
The impact of WRMSI is not limited to the workplace. Injury to muscles, tendons
and joints can affect the individual’s ability to participate in recreation, household
tasks, and ultimately in the ability to sustain work. Respondents were asked to
indicate where they experienced pain (the top three bars of Figure 6) and whether
the pain compromised their ability to engage in specified activities (the bottom
4 bars of Figure 6). It is interesting that the number of responses indicating absent
from work was quite low compared with similar surveys in other professions. This
most likely reflects the overall positive attitude that sonographers have about
their work and that they choose to continue working even when experiencing significant
pain. Contributing to this is also concern for ones co-workers who will have to
pick up the work-load for the absent staff member. This causes many to work beyond
the point where they should stop and get medical treatment; this may lead to an
increase in the number of career ending injuries. Sonographers may also be aware
of others in their department who are also suffering from similar injuries and may
feel that it is inappropriate for them to seek relief by staying off work. Finally
there is a significant amount of denial until pain and discomfort reaches an intolerable
The data graphed in Figure 7 was consolidated from three different sources and represents
the volume of procedures per sonographer over a period of 8 years. The numbers for
1992 come from data collected by the AHRA to study manpower in radiology departments.
The AHRA repeated this study in 1995. The data for 2000 came from the Sonographer
Benchmark study by the SDMS and the SDMS Foundation. Figure 7 demonstrates a dramatic
increase in work load for sonographers between 1995 and 2000. This is the most likely
explanation for the parallel increase in the complaints about occupational injury
as manpower shortages take their toll on the profession.
The data above was presented as part of written testimony to Elaine Chao the Labor
Secretary under the Bush administration. Two representatives from the SDMS testified
during the Clinton administration regarding occupational injury in sonographers
in 1999. You may view this testimony at www.sdms.org under workzone. After the OSHA
standard signed into law by Clinton was rescinded by Bush the Labor Secretary took
further public testimony and the same two representatives responded on behalf of
the SDMS and the sonography community.
The high incidence of occupational injury in the field of Sonography is truly alarming.
While meat cutters and bar code scanners in grocery stores are considered high-risk
occupations their incidence of injury is substantially less than that for sonographers.
The British Columbia survey has been repeated in Australia, Canada, and New Zealand
and recently in the United Kingdom. The results of all of these surveys (Figure
8) show an equal or higher incidence rate than the United States.
Although sonographers in these countries perform ultrasound slightly differently
and the type of studies they perform also differ, they are all performing procedures
using essentially the same equipment, and technique. This means that something very
fundamental to the process of performing ultrasound scans must be at root of this
In the next article we will explore how sonographers can reduce their vulnerability
to WRMSI and future articles will provide advice on taking positive action to reduce
the incidence of WRMSI in the ultrasound workplace.
Sonographers and physicians who scan can reduce their vulnerability to WRMSD through
education. It is imperative to know the risk factors for occupational injury if
you are going to be able to reduce your risk or prevent these conditions.
One of the main risk factors is reaching. This can occur with either or both arms
and can cause pain and discomfort in the shoulder and neck. To reduce reaching of
the non-scanning arm pull the equipment as close as possible towards you. You should
attempt to reduce the reach to no more than 30 centimeters. This requires there
to be enough leg room under the scanner console to accommodate your legs. If this
is not possible you need to stand to scan. Avoid keeping your arm extended over
the control panel or freeze button. Reaching with your scanning arm can be avoided
by positioning the patient correctly. The patient’s body should be close to the
operator and the part of the patient’s body to be scanned should be in line with
your shoulder. Do not scan with you arm extended behind you as this produces torque
on the shoulder and requires the neck to be twisted in the opposite direction to
view the monitor.
Twisting of the trunk and neck was one of the main complaints from sonographers.
This is avoided by putting your weight evenly on both feet when standing and using
your abdominal muscles to support your trunk when sitting. To avoid twisting of
the neck position the monitor directly in front of you by bringing the equipment
parallel and touching the table the patient is lying on. Do not tilt the monitor
to share the image with your patient. If the patient is to be allowed to watch the
study a monitor needs to be provided on the wall for their viewing.
Wrist flexion and extension is another risk factor and is often seen when sonographers
do not take the time to support their wrist. Keep your wrist in a neutral position.
Do not leave your wrist on the edge of the keyboard. When moving equipment push
with straight wrists and avoid twisting motion of the trunk while trying to control
the direction of movement of the equipment. If the equipment has wheels that can
be locked in one direction, always lock the leading wheels so that you can more
easily steer the equipment. If you have difficulty moving heavy equipment do not
hesitate to ask for assistance and advocate for lighter equipment in future purchases.
To reduce abduction of the arm the table must be lowered and the chair raised. The
goal is to reduce the angle of abduction to 30 degrees or less. To accomplish this
the patient must be positioned near the edge of the table such that the patient’s
side is touching the sonographer’s side.
Many sonographers grip the transducer unnecessarily tight. The use of well fitting
textured-finger gloves can also assist with this. Do not wear gloves that are too
large, as this also requires more grip once the gel is applied. How tight you grip
the transducer is more a result of habit than necessity. Your grip needs to be only
tight enough to avoid dropping the transducer and to maintain control.
Cables should not be draped around your neck or allowed to just hang freely. A cable
brace works well to prevent torque on the wrist. Select transducers with flexible,
light-weight cables whenever possible.
Scan head design is very important as well as how you hold the transducer. Experiment
with various ways of holding the scan head to learn how to minimize stress on structures
of the hand. Avoid a pinch grip and try as much as possible to use a power grip.
This will take getting used to and you will have less fine motor skill for a while
but eventually you will find ways to use this grip for at least part of the study.
Explore changing your grip for various parts of the scan in order to distribute
stress across different muscle groups.
Make ergonomics part of the buying decision for the next piece of equipment for
your lab and look for equipment features that compliment the types of scanning you
most often perform.
Avoid static positions and make sure there is variety in the types of scans you
do. Avoid scheduling the same type of procedures back to back whenever possible.
Take mini breaks to relax your arm, hand, fingers, and neck. Take a few seconds
every 8 minutes to relax before continuing the study. Do not schedule add on patients
during your lunch breaks, this time is needed to reduce the stress on your muscles
and tendons. Do not go from scanning to PACS and back to scanning without allowing
for muscle recovery time. Take many brief breaks during the day rather than long
breaks only once or twice.
By being aware of the potential for WRMSI you can make optimal choices in scheduling
studies, setting a reasonable work pace, while still managing the heavy demands
that all of us face in the workplace today.
In 2001 Labor Secretary Elaine Chao formed an advisory committee to address occupational injury in healthcare workers. Those working in Nursing Homes were selected as the first to be studied. As a result of the efforts of this advisory committee, OSHA has recently published Ergonomic Guidelines for Nursing Homes. The URL below will give you direct access to the complete report on the OSHA website.
Although specific to Nursing Home workers, the new Guidelines are important for sonographers and physicians who scan because they represent a model for how to constructively approach this problem without seeking legislative restrictions. The core recommendations of the guidelines focus on “engineering-out” the risk factors for nursing home workers. The highest risk is associated with manual lifting, repositioning and moving of residents. OSHA’s guidelines recommend an approach to eliminate all manual lifting of nursing home residents. The guidelines go on to provide extensive examples of how this can be done by using appropriate equipment and facilities. To address the remaining sources of work-related musculoskeletal disorder (WRMSD) in the nursing home workplace, OSHA recommends that a WRMSD reduction program should include the following elements:
This report represents a landmark in OSHA’s efforts to reduce WRMSD in American workers. Guidelines such as those published for the Nursing Home industry do not carry the force of law and cannot be used in civil lawsuits, but they will exert a powerful force to increase awareness of best practices for reduction of WRMSD. Publication of these guidelines represents the first major initiative in OSHA’s new coaching and counseling approach. Having set the standard for this approach, OSHA hopes to stimulate professional and industry groups to begin developing their own standards for reduction of WRMSD.
The Society of Diagnostic Medical Sonography (SDMS) has taken a leading role in preventing and reducing WRMSD and will be holding a consensus conference in May 2003 to address occupational injuries in the diagnostic ultrasound profession. It is the objective of this conference to generate a set of standards and guidelines for the field. The conference will be attended by representatives from Australia, the United Kingdom, Canada, and the United States. The conference will also be attended by representatives from professional societies, ultrasound scanner and accessory equipment manufactures, as well as the accrediting and credentialing bodies relevant to our field. This broad representation should result in robust and practical guidelines that will enjoy strong support through all levels of the community.
Elimination of WRMSD from the ultrasound workplace is an objective that we should all seek to achieve. WRMSD can be eliminated through a broad-based initiative which includes employee awareness and training, appropriate procedures, use of assist devices and tools, and maintenance of a work pace that respects the needs of sonographers and physicians who scan. The consensus conference guidelines should be a strong first step on the path to an injury-free workplace for sonographers!
I am often asked by sonographers how they should approach trying to get
ergonomic scanners and accessories in their hospital or clinic. Using the cost
of not addressing ergonomics presents a compelling argument.
Here are some points that serve as introduction to this subject
There is a critical shortage of health care professionals that is expected to worsen
through the remainder of this decade. Results of a survey on the magnitude of
this shortage were published in a consulting report entitled The Healthcare
Workforce Shortage and Its Implications for American Hospitals. You can
download the report as a .pdf file from this link:
While most of the attention has been focused on the
nursing shortage, ultrasound is one of the most seriously affected areas, with
projected shortages continuing through the end of this decade. This means that
it is difficult to recruit and retain sonographers, and this is likely to
become even more difficult in the future.
John Hawkins, vice president of Allied Consulting, a
national health care staffing firm based in Irving,Texas states: a single
ultrasound sonographer with a moderate caseload will generate about $4,550 in
charges per day (1). It is difficult to arrive at a single number for the
revenue potential of a sonographer since sonographers practice in a wide range
of settings and perform a wide range of procedures with varying revenue
potential.The number given by Mr. Hawkins is based on his experience as a
recruiter and probably represents the high end of the range. To establish the
bottom end of the range we can use an average Medicare payment rate ($120) and
10 procedures per day resulting in $288,000 in revenue per year. The midpoint
of this range is about $400,000 and this is probably a realistic number to use
in our calculations. Of course, each setting will be different and an
administrator responsible for ultrasound services should know precisely how
much revenue each sonographer is generating. For the remainder of this article
we will use a conservative estimate of $400,000 per year or $33,000 per month
as the average revenue generation capacity of one sonographer.
OSHA has identified the following workplace risk
factors for WRMSD for any type of employment. It is interesting to note that
they all might apply to all ultrasound except vibration.
repetitive motions forceful or awkward movements duration of pressure overuse
poor posture/ improper positioning excessive force and strain vibrations
Costs of Injuries
There are direct and indirect costs related to an occupation injury, including
the medical cost of treating the injury; the cost of replacement staff, as well
as the loss of revenue secondary to decreased productivity during time loss.
Direct Medical costs: $20,000
Medical Care for the Employee: Medical
bills for the average shoulder injury (this does not include the possibility of
surgical treatment) $20,000 per year. Most of this cost is usually covered by
the employee's health insurance.
Workman's Comp: $29,000-32,000 per year per injured employee
compensation data is collected by National Council on Compensation Insurance in
40 states including the District of Columbia. This data is published in a
report "Workers Compensation Detailed Claim Characteristics" a copy of which
can be obtained at http://www.ncci.com
Loss of Revenue: at least $33,000 per month lost revenue if a vacant position
not filled .This is a direct loss to the bottom line of the employer.
Addressing the potential for work-related musculoskeletal injury (WRMSI) must
be a multidimensional effort. First, the employer must provide appropriate
ergonomic equipment for the work environment. Second, the sonographer must be
educated in ergonomics and trained to properly use ergonomics in the workplace.
Third, the employer and the sonographer must mutually seek to establish and
maintain a reasonable work load for the sonographer. Finally, the
sonographer must take personal responsibility for aggressively applying good
ergonomic work practices at all times.
Many work-related musculoskeletal injuries can be prevented by use of
appropriate ergonomic equipment.
The basic support equipment (stool, ergonomic aids, exam table) are relatively
inexpensive and should be implemented immediately in any ergonomic program.
Acquiring a ultrasound scanner specifically designed to address ergonomic
issues may take a bit longer, but any administrator who does the math on the
cost of losing a sonographer to WRMSI should be budgeting for replacement
scanners as soon as possible. It is simply shortsighted management to ignore
the WRMSI problem.
Priceless: a healthy competent sonographer
It is obvious from the above figures that it simply makes good sense to address
ergonomics rather than to ignore it until you have an injured employee.
Addressing ergonomics does not mean there will be no injuries since this is a
multifaceted problem and involves sonographers as well as equipment and
employers. However, what is manifestly true is that you cannot reduce injures
in the workplace unless you make the effort to get the right equipment and you
train and motivate staff to use it correctly.