The importance of an ergonomic workstation to practicing sonographers

AIUM Practice Principles for Work-Related Musculoskeletal Disorder

The prevalence of Work-Related Musculoskeletal Disorders (WRMSDs) among ultrasound professionals has been significant. National and international efforts to create industry standards have focused primarily on injuries in sonographers. In addition, the Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety & Health (NIOSH) have published documents related to this occupational exposure. There has also been significant attention on equipment utilization and design to help reduce the prevalence of WRMSDs. The American Institute of Ultrasound in Medicine (AIUM) developed the AIUM Practice Principles for Work-Related Musculoskeletal Disorder in collaboration with other organizations whose members use ultrasound [see Collaborating Societies and Representatives]. This document supports the "Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography" and aims to expand on these Standards to include safety practices for all health care professionals who utilize ultrasound. These professionals include members of the scientific community, a wide variety of medical professionals, and dental professionals. These ultrasound users and operators will collectively be referred to in this document as "operator(s)" except in those instances where data addressed those holding a specific job title, such as sonographer. In addition, this document will support guidance for quality improvement specific to preventing and reducing injury rates.

Does participatory ergonomics reduce musculoskeletal pain in sonographers? A mixed methods study

Introduction

Sonographers in the Western New South Wales Local Health District (WNSWLHD) reported a musculoskeletal pain prevalence rate of 95%. Participatory ergonomics, where workers are consulted about improving work conditions, was utilised to identify work-related musculoskeletal disorder (WMSD) risks and potential solutions. The aim of this study was to compare the prevalence of WMSD in a cohort of sonographers before and after implementation of ergonomic changes that were driven by recommendations from a participatory ergonomics approach.

Methods

This observational mixed methods study analysed the impact of participatory ergonomic-driven interventions on changes on musculoskeletal pain in a cohort of sonographers employed within the WNSWLHD. A retrospective analysis of 10 sonographer WMSD pain surveys over five sites was completed, along with semi-structured interviews regarding which interventions were perceived as useful, which interventions were not implemented and any barriers to implementation.

Results

Installation of patient monitors, use of ergonomic scanning techniques and job rotation were perceived as responsible for decreased musculoskeletal pain. Taking lunch breaks and microbreaks, use of antifatigue mats and having two sonographers perform mobile exams were not fully implemented. No interventions were perceived as responsible for increased pain.

Conclusion

This small study provides preliminary evidence that a participatory ergonomics approach facilitated identification of occupation and site-specific risks for WMSD in the WNSWLHD, allowing implementation of ergonomic changes to be tailored to the workplace, resulting in a safer work environment for sonographers.

Quantification of physical stress experienced by obstetrics and gynecology sonographers: A comparative study of two ultrasound devices

This study aims to quantify the stresses of sonographers using two different ultrasound devices, one of conventional and one of ergonomic design. A total of 20 obstetricians and gynecologists participated in this study, and two types of tasks (scanning and positioning) were evaluated while using the two different devices. To quantify workload, four dependent variables (muscle activity, estimated grip force, subjective comfort rating, and task time) were measured. The muscular activity required while using the conventional device was 14.4% MVC (Maximum voluntary contraction) for the scanning task, which was significantly higher than that of the ergonomic device. The subjective comfort rating for the conventional design was lower than that of the ergonomic design. For the positioning task, the ergonomic device (33.2% MVC) resulted in significantly higher muscle activity in the extensor digitorum (ED) and flexor digitorum superficialis (FDS) than the conventional design (22.2% MVC), whereas the deltoid muscle showed significantly lower activity than in users of conventional design (4.5% MVC). Ergonomically-designed ultrasound devices improve ease of moving and the probe's supporters, reduce physical load and increase ease of use for sonographers. Our results may be used as guidelines for usability testing of ultrasound devices.

A unified representation of control logic in human-ultrasound machine interaction

Advances in human-computer interaction (HCI) technologies have granted sonographers and radiologists a much improved user experience when operating different ultrasound (US) machines. Continued HCI improvements in US would benefit from a systematic study of the HCI control logic used in this domain. Such a study has not been presented previously and is the subject of this paper. We surveyed sonographers to determine the most frequently used controls in US machines. We standardized the representation of the US machine HCI control logic by using the unified modelling language (UML). We used UML diagrams to analyze the HCI control logic of 10 different cart-based US machines from several major manufacturers, and we discovered that the control logic for the most frequently used functions are identical. While this control logic does not follow an established standard, it has been commonly adopted. Using the UML for the visualization and formulation of control logic, we can target logically optimal interactions (whose operation steps cannot be further reduced), e.g., adjustment of B-mode gain, frequency and depth, and can derive methods to simplify logically sub-optimal interactions, e.g., the pointing and selecting operation, as well as image measurements. Our study provides insights into existing HCI approaches used in US machines and establishes a rigorous UML-based framework for future US machine design to improve interoperability, efficiency and ease-of-use.

Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion

Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.

Ergonomics in IR

Ergonomic research in the field of interventional radiology remains limited. Existing literature suggests that operators are at increased risk for work-related musculoskeletal disorders related to the use of lead garments and incomplete knowledge of ergonomic principles. Data from existing surgical literature suggest that musculoskeletal disorders may contribute to physician burnout and female operators are at a higher risk of developing musculoskeletal disorders. This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas, including burnout and gender.

Following the Principles of Ergonomics and Musculoskeletal Disorders in Ultrasonographers

Background/Aim. It has been noticed that doctors who regularly perform ultrasound examinations have different clinical manifestations of musculoskeletal disorders. The aim of this research is to examine the level of knowledge of ultrasonographers regarding preventative measures and health consequences of the forced body positions during work.

Subjects and methods. The total of 75 doctors of both genders, aged 31-50 years, who use ultrasound diagnostics participated in the research. The research was conducted throughout 2016, as a cross-sectional study, with the aid of a structured questionaire.

Results. The total of 60% subjects either rarely use the break during working hours or do not have a break at all. The participants most commonly use the movable monitor and the ability to wrap the cable around their arm (73,3%). This percentage is similar in all age groups. The respondents most often stated that they walk daily (41,3%), with no differences among age groups. 25% of the respondents negate any spine related pains, while over a half said that they experience pain in one segment of the spinal column (cervical, thoracic or lumbar), regardless of the age group. 52% said that they serch for information on their own accord, while 36% stated that they are not at all informed. Only in less than 10% of cases is information provided by the authorities in the institution where the participants are employed, and during regular health examinations, information is given by the designated doctor in 2,7% of cases.

Conclusion. The respondents implement the recommendations regarding safe work and other preventative measures to a very small extent, regardless of gender and age. Most of the respondents experience pain in the spine and joints, which can be related to the work in ultrasound diagnostics. Additionally, doctors are not well-informed regarding the preventative measures.

Musculoskeletal pain amongst Australian sonography students and recent graduates and an evaluation of the use of ergonomic education for prevention

Introduction/Purpose

Sonographers develop pain whilst scanning and may not consistently adhere to ergonomic recommendations. The aim was to quantify this within Australian sonography students and recent graduates and to determine whether a relationship exists between: (i) pain and failure to adhere to ergonomic recommendations; and (ii) theoretical and practical ergonomic education during university and clinical placement, and the adherence to recommendations.

Methods

Online questionnaire distributed to Australian student sonographers and sonographers until two years post-graduation.

Results

During scanning, 33/39(84.62%) experienced musculoskeletal pain, and 21/33 (63.64%) experienced pain less than 1.76 full-time equivalent (FTE) days during the two FTE week period. The majority, 37/39 (94.87%), were not consistently adhering to recommendations, with 25/37 (67.57%) only doing so for less than 2.1 FTE days during two FTE weeks. Failure to adhere to ergonomic recommendations and development of musculoskeletal scanning pain was positively correlated (r = 0.7 (P = 0.01)).All participants had received some form of ergonomic education. This education was theoretical and practical during university and clinical placement for 24/39 (61.54%); however, receiving this resulted in no difference for adherence to ergonomic recommendations. Qualitative data demonstrated high workloads, scanning patients with increased body habitus or limited mobility were potential barriers to adherence to ergonomic recommendations.

Discussion

Ergonomic education occurs, yet a lack of knowledge and adherence to recommendations continues. Considerations for other potential barriers are required.

Conclusion

Ensuring students adhere to ergonomic recommendations post-graduation and identifying relevant barriers within the clinical environment are important. Future research to investigate potential barriers around ergonomic adherence is suggested.

Optimizing Ergonomics in Breast Imaging

Breast imaging radiologists spend many hours seated at workstations and are therefore at high risk for repetitive strain injuries and computer vision syndrome. In addition, many perform hand-held sonography and image-guided procedures, which may present additional ergonomic challenges. In this article, we describe optimal ergonomics for breast imaging radiologists and discuss additional strategies to mitigate risks from work-related injury and improve overall physical well-being.

Prevention of Shoulder Injuries in Sonographers: A Systematic Review

Shoulder injury and pain are the most commonly reported work-related musculoskeletal disorders (WRMSDs) among sonographers. Shoulder injury can affect the sonographer’s performance, which may lead to a reduction in the quality of services to patients. Therefore, sonographers must protect themselves from shoulder injury to provide high-quality services, work efficiently, conserve their future career, and improve their quality of life. A review of literature was conducted, revealing evidence to suggest ways to prevent various injuries to sonographers, but only a few studies in the past 10 years have focused specifically on shoulder injury. Good posture, ergonomics, and suitable workspace design play important roles in reducing the rates of shoulder injury. In addition, increasing the sonographer’s awareness of how to prevent shoulder injury and the supervisor’s knowledge about the protection from WRMSDs can decrease the rates of shoulder injury among sonographers.

A Usability Study of 3 Radiotherapy Systems: A Comparative Evaluation Based on Expert Evaluation and User Experience

BACKGROUND The complex user interface design of radiotherapy treatment delivery systems can lead to use error and patient harm. In this study, we present the results of a comparison of 3 radiotherapy treatment delivery systems now used in China. MATERIAL AND METHODS We conducted a comprehensive usability study of 3 radiotherapy treatment delivery systems. Expert evaluation was performed through heuristic evaluation with 3 human-factors experts and 1 experienced radiation therapist for each system. User experience was assessed through perceived system usability and workload, using the National Aeronautics and Space Administration Task Load Index and the Post-Study System Usability Questionnaire. RESULTS For the expert evaluation, 47 usability problems were identified for Varian Trilogy, 75 for Elekta Precise, and 37 for Shinva XHA600E. Most problems were classified as major and minor usability problems, and were found in the process of patient setup and setup verification. For the user experience, radiation therapists presented a lower workload for Varian Trilogy compared to Elekta Precise (P<0.01) and Shinva XHA600E (P<0.01), and a lower workload for Elekta Precise compared to Shinva XHA600E (P=0.020). Radiation therapists perceived a higher system usability for Varian Trilogy compared to Shinva XHA600E (P<0.01), and a higher system usability for Elekta Precise compared to Shinva XHA600E (P<0.01). CONCLUSIONS This research provides valuable data on how 3 radiotherapy treatment delivery systems compare. The results of this study may be useful for hospital equipment procurement decisions, and designing next-generation products to improve patient safety.

Assessments of Physical Workload in Sonography Tasks Using Inclinometry, Goniometry, and Electromyography

Background

Echocardiography involves strenuous postures of the upper limbs. This study explored the physical workload in the neck and upper limbs in sonographers performing echocardiography, and the extent to which the workload differs from than in other work tasks (other sonographic examinations, and nonsonographic tasks).

Methods

The physical load was assessed by inclinometry, goniometry, and electromyography methods in 33 female sonographers during authentic work using three different echocardiography techniques and other work tasks.

Results

Echocardiography was characterized by low velocities of the head, arms, and wrists, and a low proportion of muscular resting time in the forearms, in the transducer limb, and the computer limb. The transducer limb was more elevated in one of the techniques, but this technique also involved a higher proportion of muscular resting time of the trapezius muscle. We also found a high proportion of awkward wrist postures in the transducer wrist in all three techniques; in one due to prolonged flexion, and in the others due to prolonged extension. Other work tasks were less static, and were performed with higher upper arm and wrist velocities.

Conclusion

None of the three echocardiography techniques was optimal concerning physical workload. Thus, to achieve more variation in physical load we recommend that the equipment be arranged so that the sonographer can alternate between two different techniques during the workday. We also propose alternation between echocardiography and nonsonographic tasks, in order to introduce variation in the physical workload. Clinical expertise should be used to achieve further improvements.

Can Teaching Ultrasound Ergonomics to Ultrasound Practitioners Reduce White Knuckles and Transducer Grip Force?

Ergonomic training is necessary to help reduce work-related upper limb disorders (WRULD) in sonographers. This study provided an ergonomic training session for sonographers, to determine whether a teaching intervention changed the grip force used to hold a transducer. Thirteen practitioners participated and were placed into two groups (intervention group n = 7). Participants were asked to scan the same simulated transabdominal early pregnancy case. An ergometer was used, which enabled all participants to hear the effect of holding the transducer tightly. Their matched grip force was measured before and after the intervention using a dynamometer. The intervention group reviewed videos and photographs taken during the scan to see if this affected the matched grip force further. Study findings showed that the short ergonomic training session with the use of an ergometer significantly reduced the matched grip force applied to a transducer ( P < .05) for all participants. The video/photo review did not result in any further significant changes.

Barriers to Performing Ergonomic Scanning Techniques for Sonographers

This study aimed to identify the barriers that prevent currently practicing credentialed sonographers from using industry standard ergonomic scanning techniques. A quantitative descriptive design was used with data collected through an anonymous online survey of members of the Society of Diagnostic Medical Sonography. A total of 1234 members participated in the survey. The results confirmed previous reports that a high percentage (85.5%) of sonographers scan in pain, with the shoulder most commonly affected. Four barriers to ergonomic scanning practice were identified by more than 25% of the respondents, including being too busy, patient obesity, portable exams, and patients who are unable to cooperate. Some barriers are not within the control of the sonographer, such as patient obesity and patient condition, while other barriers are within moderate control, such as scheduling and lack of equipment. The focus should be placed on correcting and improving those barriers that can be controlled, thereby reducing the risk of work-related musculoskeletal injuries in sonographers.

Musculoskeletal Pain Relief in Sonographers: A Systematic Review of the Effects of Therapeutic Techniques

Musculoskeletal pain and resulting injury is a growing concern for sonographers. Statistics substantiate the rising trend of sonographers in pain, but prevention methods are not currently established as part of the education process or in the clinical environment. A systematic review of the literature was performed to determine whether sonographers taught to use proper body mechanics, stretching, and/or therapeutic techniques experience less pain. The results suggest that education workshops and stretching techniques have the potential to benefit sonographers. Sonographers who incorporate stretching into the work day may experience a reduction in pain. Education workshops may improve the long-term outcomes for sonographers. Additional research is necessary to determine the outcomes of the various therapeutic methods. Those methods that are proven valuable should be adopted into the sonography profession by educators and clinical sites. Managers, supervisors, physicians, and sonographers should be provided information regarding research outcomes in order to advocate for evidence-based practice changes.

Ultrasound probe grip: the afternoon tea technique

Background

Globally, ultrasound is being used to assist in central venous and difficult peripheral intravenous access in a variety of emergency and non-emergency clinical settings.

Context

After reading Flood's paper on safe central venous access and noting the difficulties clinicians find in probe stabilisation whilst performing dynamic intravenous access, we decided to share our teaching technique.

Innovation

The purpose of this correspondence is to highlight the 'afternoon tea technique' as a potential teaching method for probe stabilisation.

Implications

It is hoped that this technique will improve the image quality in dynamic procedures and increase the success rate of ultrasound-guided intravenous access in clinical practice.

Neck and upper extremity pain in sonographers - Associations with occupational factors

Sonographers have a high risk of musculoskeletal disorders. This study explores the associations between working conditions and musculoskeletal pain based on the frequency and intensity of pain in the neck and upper extremities. A questionnaire was answered by 291 female sonographers. High prevalence of neck/shoulder pain was associated with eye complaints and headache related to work on the computer, dissatisfaction with the computer workstation, high mechanical exposure index (MEI) and high demands. The possibility to adjust the keyboard and chair, and adequately corrected eyesight were positive factors. High prevalence of elbow/hand pain was associated with performing echocardiography, computer-related eye complaints, high MEI and high job and sensory demands. In echocardiography, working with a straight wrist and holding the transducer with a two-handed grip or alternating hands was associated with a low prevalence of elbow/hand pain. Thus, further improvements in the working conditions are possible and are recommended.

The Prevalence of and Risk Factors Associated with Musculoskeletal Disorders among Sonographers in Central China: A Cross-Sectional Study

Objective

Studies from industrialized countries show that musculoskeletal disorders (MSD) occur commonly in sonographers. However, little is known about sonographers in China, where the awareness of ergonomics and MSD, workload, and available equipment/facilities may differ. We aimed to investigate the prevalence of MSD and associated risk factors in sonographers in central China.

Methods

A cross-sectional survey was conducted with 381 sonographers from 14 randomly selected tertiary hospitals in Hubei province, central China. Musculoskeletal symptoms (using the Nordic Questionnaire) and risk factors (mostly derived from the Health Benefit Trust survey instrument and the Dutch Musculoskeletal Questionnaire) were recorded. Multivariate logistic regression was used to quantify associations between risk factors and MSD.

Results

The 12-month period prevalence of MSD was 98.3%, being highest in the neck (93.5%) and shoulder (92.2%), followed by the lower back (83.2%), wrist/hand, upper back, and elbow. Factors contributing to neck pain were psychological fatigue, shoulder abduction and trunk bend-and-twist posture. Height-adjustable tables and chairs were protective factors. Shoulder pain was associated with female sex, health status, mental stress, shoulder abduction, and trunk bend-and-twist posture. Height-adjustable chairs and the awareness of adjusting the workstation before scanning were protective factors. Elbow pain was associated with health status and height-adjustable tables. Wrist/hand pain was associated with female sex, bending the wrist, and working with obese patients. Upper back pain was associated with shoulder abduction, height-adjustable chairs, and device location. Lower back pain was associated with the number of scans performed per day, awkward postures, bending the trunk, twisting or bending the neck forward, and using a footrest.

Conclusions

This study suggests a high prevalence of MSD in sonographers in central China. Hence, it is necessary to improve the awareness of MSD by training, and the ergonomics of their current work environment by addressing physical workload, and psychological and equipment/facility-related factors.

Swedish Sonographers' perceptions of ergonomic problems at work and their suggestions for improvement

BACKGROUND

Sonographers' perceptions of ergonomic and work-related pain problems at work have so far mostly been researched in quantitative studies by questionnaires. There is a need of experience-based research to deepen the knowledge about how sonographers perceive ergonomic problems at work. Therefore, the aim of this qualitative study was to describe sonographers' perceptions of ergonomic problems at work, and their suggestions for improvement strategies.

METHODS

Twenty-two female sonographers were individually interviewed regarding different aspects of their physical working environment. Content analysis was applied.

RESULTS

The sonographers perceived different ergonomic problems in their working environment, but to offer patient comfort and to obtain the best possible images were often prioritized over working posture. Echocardiography was considered demanding as the examination is performed with little variation in posture. Ergonomic improvements included reducing the manual handling of the transducer, optimizing the adjustability of equipment, and taking the patient's physique and health into account. As some examinations were perceived to be more ergonomically demanding, variation between examinations was suggested, however, this requires broader skills.

CONCLUSION

Sonography, especially echocardiography is ergonomically demanding but the improvement strategies suggested were perceived useful and applicable.

Ultrasound Transducers

Diagnostic medical ultrasound transducers have evolved through the years and have contributed significantly to improved patient care. This article discusses the history and types of transducers and the elements that have changed over time. There has been a sharp transition from natural to human-made elements and from one to many in a single transducer. Ergonomics also now plays a role in transducer design and will continue to do so; the grip, weight, and size of transducers are in the forefront of design considerations. The evolution of transducers has changed not only how well we visualize anatomy and what anatomy we see but also how the patient’s care is managed. Different, new, and emerging technologies certainly will continue to be identified within the sonography community.

Work-related musculoskeletal disorders in ultrasound: Can you reduce risk?

Work-related musculoskeletal disorders are a common cause of pain and sickness absence for ultrasound practitioners. This article aims to provide background information about factors increasing the chance of developing work-related musculoskeletal disorders and potential ways to reduce risk. Factors influencing ultrasound professionals' likelihood of developing work-related musculoskeletal disorders include poor posture, repetitive movements, transducer pressure and poor grip, stress, workload, limited support or sense of control and other psychosocial factors. The impact of these risk factors on the health and well being of ultrasound practitioners can be reduced by following recommendations published by professional bodies and the Health and Safety Executive. Ultrasound practitioners should remember that optimising the examination should not be at the detriment of their health. Some hints and tips to reduce the chance of developing work-related musculoskeletal disorders are provided.