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Preventing Sonographer Musculoskeletal Injury

How to Avoid Carpal Tunnel, Tendonitis, and Disk Problems Among Sonographers

Egregious Ergonomics Create Olympic-sized problems for Australian Sonographers

SDMS Member's Testimony

American College of Cardiology Workshop on 2-D and Doppler Echocardiography

The British Columbia Ultrasonographers' Society

Recommendations for Quantitations of the Left Ventricle by Two-Dimensional Echocardiology

Sonographer Occupational Musculoskeletal Disorders: What Are They And How Can They Be Prevented

 


Excerpt from:

How to Avoid Carpal Tunnel, Tendonitis, and Disk Problems Among Sonographers
AuntMinnie.com Staff Writer

May 11, 2000

While sonographers take great pains to make sure their patients are comfortable, they may be sacrificing their own health in the process by not practicing good ergonomics, according to occupational health and safety experts.

As a result, long-term biomechanical problems such as carpal tunnel syndrome and tendonitis could plague ultrasound practitioners and cost employers up to $75,000 per employee for lost time and treatment.

Paula Woletz, a sonographer at the University of Medicine and Dentistry of New Jersey in Brunswick, spearheaded an ergonomics evaluation at her workplace in the hopes of quantifying the aches and pains that had, thus far, been anecdotal.

Specialists from the affiliated Robert Wood Johnson Medical School paid a visit to the department of gynecology, obstetrics, and reproductive services to observe and interview 11 sonographers and one physician.

"The findings from that small group showed that there was physical evidence of cervical disk disease in 4 out of 12 individuals. Two employees who had reported neck problems had shoulder abnormalities documented. Four employees had problems in the hands and wrists, including carpal tunnel syndrome."

"A breakdown by the hospital's risks and claims department put the cost of modifying each workstation with adjustable equipment at about $4,200 per exam room. In comparison, the costs of treating various injuries ranged from $10,000 to $75,000," Woletz said.

"In other words, maybe it makes sense to look at the big picture and stop being penny-wise and pound foolish," she added.


Excerpt from:

Egregious Ergonomics Create Olympic-sized Problems for Australian Sonographers
Bachelor, J, AuntMinnie.com Staff Writer

September 21, 2000

Approximately 78% of sonographers in Australia report musculoskeletal injuries (MSI) as a result of their employment, according to the results of a survey conducted by Val Gregory of the Royal Prince Alfred Hospital in Sydney. Gregory said that he sees MSI as a serious health problem for the profession, and he believes that its incidence is increasing.

"There are a number of sonographers who 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," he wrote in Sound Effects, the quarterly bulletin of the Australian Sonographers Association.

Of Australian sonographers surveyed, the incidence of musculoskeletal pain and discomfort experienced by sonographers since starting scanning was 95.4%.

Many sonographers experienced pain and discomfort in more than one area, with 91% reporting shoulder pain, neck 84%, upper back 73%, wrist 61%, lower back 61%, eyes 59%, hands and fingers 56%, upper arm 53%, middle back 43%, and forearm 41%. Hip and leg pain was also reported.

Classification of the symptoms include:

  • Nerve entrapment cubital, radial, and carpal tunnel syndromes
  • Tendon-related disorders - tendonitis, tenosynovitis, De Quervain's syndrome, ganglion cyst formation
  • Muscular disorders - fibronyositis, tension neck syndrome
  • Neurovascular disorders - thoracic outlet syndrome
  • Joint capsular disorders - bursitis, osteoarthritis, synovitis


Most sonographers suffer a combination of these symptoms. The injuries are caused or aggravated by the repetitive movement, forceful exertions, and unnatural posture adopted by sonographers during their jobs.

There are two main processes that cause MSI in sonographers:

  • Overuse or strain of the muscles may cause micro tears at the tendon insertions, resulting in ischemic and soft-tissue breakdown. If the micro tears continue, further abrasions and tears occur. An acute injury may result in a tear at an already-damaged tendon insertion.
  • Venous returns also can be obstructed, causing enlargement of tendon sheaths that results in scarring and compression of the nerves. Demyelination, slowing of nerve conduction, and loss of function occur with prolonged nerve compression.

The pain and discomfort occurred mainly at the end of the working day and after work. The mean average time that sonographers had suffered pain and discomfort was 52 months.

According to Gregory, the main factors that contribute to MSI in Australian sonographers are:

  • Poor equipment design: keyboard/screen height and position, equipment maneuverability, poor transducer grip, ill-adjusted or non-adjustable chairs and examinations couches.
  • Poor posture due to the type of work performed, especially with shoulder in sustained abduction and the spine in unnatural alignment.
  • Sustained pressure and force often used to optimize imaging.
  • Repetitive movements, particularly when performing sessions of similar examinations.
  • Awkward scanning techniques, especially when performing endocavity, cardiac, musculoskeletal, and vascular examinations.
  • Assisting with patient movement.
  • Body habits and gender - surveys have reported that taller, heavier sonographers and males have fewer incidences of MSI.
  • Inadequate work breaks, with insufficient recovery time.


Excerpt from:

SDMS Member's Testimony
www.SDMS.org

June 6, 2000

Hello, my name is Jane Doe.* I am a Diagnostic Medical Sonographer, and I have come to this hearing today in Oregon to share with you my experiences stemming from an occupational injury. This injury has taken from me my professional career and my dream. Even more sadly, it has limited my ability to use my training and experience to help people, the very reason that I was drawn to a health care career in the first place. Unfortunately, my experiences are all too common because the health care industry has failed to take a number of precautions to prevent the kinds of occupational injuries that I have suffered.

My occupational health problems have a long history spanning more than two years. Initially I experienced pain along my right forearm with difficulty holding the transducer during long or difficult ultrasound procedures. Eventually, I experienced pain during all my scanning procedures. Pain then became my constant companion during my waking and nighttime hours.

My career is over.

Other factors contributed to my injury and could have been prevented.

  • My employer could have purchased adjustable gurneys. Many times we were forced to scan in awkward positions using the old, non-adjustable gurneys.
  • My employer did not buy adjustable scanning chair even though they were requested many times. Often we were required to assume contorted positions due to chair height. Adjustable chairs are essential for a more comfortable and appropriate position.

All of these factors, and others, meant that my body was constantly in a tensed, strained and awkward position. My physicians have stated that my injuries are the inevitable result of those contortions and that constant strain. I hope that my experiences and my pain will demonstrate the need for real change in the way that ultrasound services are provided in this nation.

  • Name withheld upon request.


Excerpt from:

American College of Cardiology Workshop on 2-D and Doppler Echocardiography

January 10-14, 1994

EQUIPMENT

Most modern echocardiographic units have excellent image quality and are capable of defining myocardial endocardium in the majority of patients. The following list of equipment will be necessary to perform quality stress echocardiography.

Ultrasound unit with VCR
Echo bed for imaging
Treadmill
Cable connection to treadmill
Digital image acquisition unit
Review station for floppy disk (optional)


Excerpt from:

The British Columbia Ultrasonographers' Society

Approached Simon Fraser University's School of Kinesiology with a concern regarding the high prevalence of musculoskeletal injuries associated with ultrasonography.

Results from the task analyses were analyzed from a biochemical standpoint, based on information gathered from the personal interviews. Firstly, four main areas of the body were identified as being at risk of injury from ultrasonography. Secondly, injurious factors associated with each body area were identified. Thirdly, these body positions were analyzed in action to determine the presence of the injurious factors, and subsequently a relationship between injurious factors and observed body positions was represented as a degree of risk to the sonographer. Lastly, the causes leading to the assumed body positions and the resultant effects on the musculoskeletal system of the body, were identified.

Recommendations / Modifications to Design

Hydraulic bed/chair
Adjustability of the equipment is essential in producing a working position which is neutral, comfortable, and places low stress on the musculoskeletal system of the sonographer.


Excerpt from:

Recommendations for quantitation of the left ventricle by two dimensional echocardiography

American Society of Echocardiography Committee on standards, subcommittee on quantitation of two-dimensional echocardiograms.

Because the patient is often in a sleep lateral position, it is frequently difficult to transect the true apex unless there is a mattress with a scoop or excavation at the point where the apex impulse is generally located. An alternate technique is to use a narrow examination table that allows free access of the transducer to the apex impulse without mechanical interface. These approaches are especially important with large transducers. Lack of specialized examining tables makes quantitive measurements more difficult in the critical care setting where modifying the bed is not practical.


Sonographer Occupational Musculoskeletal Disorders:
What Are They And How Can They Be Prevented

Sound Ergonomics, L.L.C. and
Biodex Medical Systems, Inc.

ultrasoundgraphConclusions:

Musculoskeletal disorder, or MSD, refers to a group of disorders caused by or aggravated by workplace activities. These neuromusculoskeletal disorders are referred to by a number of names, such as musculoskeletal injury (MSI) and repetition repetitive strain injury (RSI), but the currently accepted term by OSHA is musculoskeletal disorder. Although MSD has been described for years in a number of other professions, it has only recently been identified in sonographers.

MSD accounts for between 40% and 60% of all recorded work-related illnesses. In the field of diagnostic medical sonography, 84% of sonographers surveyed suffer from some form of injury. It is the leading cause of long-term illness absence in health care workers. The incidence of MSD has increased ninefold over the last 10 years and may actually even be higher, since many cases remain unreported. The physical problems of MSD result from a combination of factors. There are biomechanical factors, which include inefficient scanning postures, frequent repetitive motions, exertion of excess force while performing these motions, wrist flexion or deviation, faulty work space and equipment design.

A second set of factors relates to work organization. Employees may work long hours without breaks, often enticed with bonuses and incentives. There is often a lack of training for employees in the proper ways to perform their duties or in the proper use of the equipment.

A third set of factors includes delayed reporting or diagnosis of injuries, and inappropriate injury management.

Some individual physical factors associated with MSD risk include age, gender, height & weight, body-mass index (BMI), systemic illnesses, level of physical fitness, and hand dominance.

The types of work activities known to cause MSD in sonographers include:

  • repetitive motion
  • forceful exertions or strain when pushing into a patient's abdomen or compressing leg veins
  • awkward postures or unnatural positions, commonly from reaching over patients during bedside exams
  • uncomfortable positioning of limbs, such as flexion, extension or deviation of the hand
  • overuse, generally the result of downsizing and an increase in the number of exams performed per day
  • frequent reaching above shoulder level
  • work activities to which the individual is unfamiliar

 

Advances in technologies, particularly automatic film developing and filmless storage devices have increased the time sonographers are actually scanning because these new devices have reduced the time needed between patients. Sonographers do not have sufficient "down time" to allow the muscles used during scanning to recover.

MSD causes pain, inflammation, swelling, and deterioration of tendons and ligaments. Muscles and joints become stressed once their support structures are weakened. The most commonly affected areas in sonographers are the shoulder and neck in those who scan right-handed and the wrist and elbows in left-handed cardiac sonographers.

ultrasoundgraph2Symptoms of MSD occur after months or years of overuse and usually occur away from the job, commonly at night. The symptoms most often reported are pain, loss of sensation, numbness, burning or tingling, tenderness, swelling, clumsiness, or muscle spasm. They range in severity from aching and fatigue that subside with overnight rest to constant pain that impacts work and leisure activities and may even be career-ending.

The injuries associated with MSD in sonographers include carpal and cubital tunnel, epicondylitis of the elbow, neck and back strains, shoulder capsulitis, tendonitis and tenosynovitis. Treatments for these injuries range from rest and analgesics to surgery. Alternative treatment methods, such as massage therapy, provide relief in some instances. However, the outcome for treatment of occupational MSD is poor – once treated it often recurs. The key, therefore, is to PREVENT the injury initially.

Prevention of MSD is multifactoral, involving sonographers, department managers, and equipment manufacturers.

  • Sonographers must be aware of what activities cause their pain and learn to modify those activities.
    - they must help educate their supervisors about occupational MS D
    - they should request ergonomic adaptable equipment
    - they should learn the proper use of all the exam room equipment
    - they should become familiar with and utilize adaptive equipment when scanning, such as support cushions, wrist braces
    - they should learn and perform some stretching and strengthening exercises designed to prevent injury.
    - they should report symptoms of MSD as soon as they occur

  • Department managers should be responsive to the requests of their staff.
    - work breaks must be built into the daily schedule and workloads should be modified
    - ergonomic designs should be implemented in the scanning rooms
    - they should supply ergonomically designed equipment
    - they should facilitate injury reporting and initiation of treatment

  • Equipment manufacturers should work closely with those using their products and solicit input as to the ergonomic impact of those products.
    - ultrasound equipment should have adjustable monitors and keyboards
    - transducers should be wide enough to allow for a comfortable grip
    - tranducer cables should be lightweight
    - chairs and stool should be height-adjustable with back supports and footrests
    - exam tables should be height adjustable with hand or foot controls.
    - tables should be the appropriate width and length
    - tables should have the capability to add stirrups, IV poles, and/or oxygen tank holders.
    - tables used for cardiac exams should have removable or drop-out sections to allow the sonographer to maintain comfortable arm and hand positions when scanning

  • Ergonomically-adaptable features of the exam room equipment and the sonographers awareness and proper use of those features are critical to the prevention of occupational MSD in this profession.

  • The economic impact of MSD includes lost wages, more numerous medical insurance claims and Worker's Compensation claims, increased sick and disability leave time, and ultimately compromised patient care as the profession loses the most experienced sonographers to injury. Injured sonographers can cost employers thousands of dollars each year. Loss of chargeable revenue can be as high as $520,000. Worker's compensation claims have been estimated to amount to

    Ultrasound Table
  • $29,000 -$32,000 per injury, or $2,700 per month. Medical bills for the average shoulder injury, excluding possible surgical treatment, can add up to $20,000 per year, or $1700 per month. The cost to an employer of hiring replacement staff for an injured sonographer can range between $60,000 to $80,000 per year, or from $5000 to $6500 per month. It has been estimated that the average cost to find and hire a sonographer is $10,000, which is strong motivation for providing an ergonomic environment that will help protect experienced sonographers from injury and allow them to continue providing quality patient services.

 

References:

Battevi N, Bergamasco R, Girola C; Criteria for the reintegration in the workforce of workers with musculoskeletal disorders of the upper limbs, based on preliminary practical experience; Ergonomics; Sept. 1998; 41(9):1384-97.

Browne C, Bernard M, Faithfull D; Occupational repetition strain injuries; Med J of Australia; Mar. 17, 1984:329-32.

Carson R; Reducing cumulative trauma disorders; AAOHN Journal; June 1994; 42(6):270-276.

Dammers J, Veering M, Vermuelen M; Injection with methylprednisolone proximal to the carpal tunnel: randomized double blind trial; Br Med J; Oct. 2, 1999; 319(7214): 884.

Field LD, Savoie FH; Common elbow injuries in sports; Sports Med; Sept. 26, 1998 (3): 193-205.

Fisher TF; Preventing upper extremity cumulative trauma disorders. An approach to employee wellness; AAOHN Journal; June 1998; 46(6): 296-301.

Franzblau A, Werner, RA; What is carpal tunnel syndrome?; JAMA; July 12, 1999; 282(2):186.

Guidotti TL; Occupational repetitive strain injury; Am Family Phys; Feb. 1992; 45(2): 585-92.

Grieco A, Molteni G, DeVito G, Sias N; Epidemiology of musculoskeletal disorders due to biomechanical overload; Ergonomics; Sept. 1998; 41(9): 1253-60.

Frost P, Andersen JH, Nielsen VK; Occurrence of carpal tunnel syndrome among slaughterhouse workers; Scand J Work Environ Health; Aug. 1998; 24(4):285-92.Melhorn JM; Cumulative trauma disorders and repetitive strain injuries. The future; Clin Orthop; June 1998 (351):107-26.Necas M; Musculoskeletal symptomatology and repetitive strain injury in diagnostic medical sonographers: A pilot study in Washington and Oregon; JDMS; 12(6); Nov.-Dec. 1996:266-273.

Pike I, Russo A, Berkowitz J, Baker J, Lessoway V; The prevalence of musculoskeletal disorders among diagnostic medical sonographers; JDMS; 13(5); Sept.-Oct. 1997:219-27.

Rempel DM, Harrison RJ, Bernhart S; Work-related cumulative trauma disorders of the upper extremity; JAMA; Feb. 12, 1992;267(6):838-42.

Silverstein B, Welp E, Nelson N, Kalat J; Claims incidence of work-related disorders of the upper extremities: Washington state, 1987 through 1995; Am J Public Health; Dec. 1998; 12:1827-33.
Thompson JS, Phelps TH; Repetitive strain injuries; Postgraduate Medicine; Dec. 1990; 88(8):143-9. 

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Keith Fox, RDCS, RCVT
Coordinator of Cardiology Services
University Mednet

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