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).
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Figure 1: Distribution of complaints by body region
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The goals of this survey were to:
- Determine prevalence of MSI and correlate known work and personal factors.
- Develop instruments, protocols and methods to quantify risks.
- Design and test interventions
- Recommend work load/procedural changes.
- Recommend modification or redesign of equipment and/or environment.
The survey was a 21-page questionnaire divided into 5 sections.
- Section 1
- Work experience
- General Health
- Background Information
- Questions on age, gender,
- smoking, wearing of lenses
- state of health, exercise habits,
- hobbies
- Section 2
- Section 3
- Section 4
- Problems, pain and discomfort
- Section 5
- Work environment and corporate culture
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:
- 90% reported an aching feeling
- 56% experienced stiffness
- 40% reported sharp pain or cramping
- 33% had weakness, numbness or burning
Of those reporting pain
- 55% saw a physician / medical professional
- Of these, 81.7% received diagnosis, however only 45.8% received any kind of treatment
Of those receiving treatment
- 67.7% said it had been moderately or very effective
- 28.3% said the treatment had been slightly effective
- 4.0% reported no treatment effect
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:
- Inability to schedule overtime or extra work in advance (61%)
- Inability to take scheduled breaks (56%)
- Lack of control over work (54%)
- Repetitive work tasks (61%)
- Lack of work schedule support (40%)
- Lack of helpful personal development support services (40%)
Eighty-four percent of respondents reported they had experienced pain or discomfort
since starting work as a sonographer
- 81% from the SDMS study
- 87.2% from the CSDMS study
- 91% from the BCUS study
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.
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Figure 2: Age distribution of respondents
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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.
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Figure 3: Incidence of "severe" pain as a subset of those reporting pain.
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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).
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Figure 4: Number of breaks during the work day.
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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.
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Figure 5: Activities associated with pain.
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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.
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Figure 6: Impact of WRMSI
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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
level.
OTHER DATA, OTHER FINDINGS:
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Figure 7: Volume of procedures performed per sonographer per year
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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.
DISCUSSION:
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.
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Figure 8: Incidence of reported pain among sonographers by country.
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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
problem.
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.