Direct Measures of Physical Factors Contributing to Work ... · completing four portable neonatal...

Direct Measures of Physical Factors Contributing to Work-Related Musculoskeletal Pain among

Diagnostic Medical Sonographers: A Pilot Study

Lauren Selhorst, RDMS

Radiologic Sciences and Therapy Division

Presented in Partial Fulfillment of the Requirements for Graduation With Distinction from

The School of Allied Medical Professions

Graduation with Distinction Committee Members Kevin D. Evans, PhD Shawn C. Roll, MS Terri Bruckner, MA

The Ohio State University

2011

1

Abstract

Diagnostic medical sonographers are very often exposed to factors that contribute to

workplace injury which have been categorized as work-related musculoskeletal

disorders (or WRMSD). This problem has become increasingly common as the number

of sonographic exams increases. A study to determine the height of the sonographers,

dimensions of the workspace, and other factors would be helpful to obtain a better

understanding of the potential for work-related injuries among sonographers. Survey

research has only provided indirect information and these reports need to be directly

verified. This undergraduate research project is an effort to better understand workplace

injury risk by directly observing sonographers while scanning and evaluated their

postures and positions. The measurements of posture and position are based on a

Rapid Upper Limb Assessment (RULA) scoring form. Direct measures were taken of the

sonographers' heights, exam table heights, and the dimensions of the machine. An

analysis will be completed to determine a potential relationship between the direct

measures (independent variables) and the individual sonographers' pain scores at the

beginning and end of each day. It is predicted that the pain scores will be in some way

related to the RULA scores, the sonographer heights, and the exam table heights. This

study begins to capture workplace factors that may plague sonographers and contribute

to WRMSD. Future work should be directed to modify these factors in order to prevent

these injuries from occurring.

2

Acknowledgements

I would like to thank my advisor, Dr. Kevin Evans, for all the work and support he has provided during the research process. He spent many hours meeting with me, editing my writing, applying for IRB approval, and supplying me with many helpful tips and advice. Without his guidance, this project would not have been possible.

I would also like to thank Shawn Roll for providing education on the RULA tool and advice on how to analyze the data.

A thank you is also extended to The Ohio State University East Hospital and all the sonographers in the Non-Invasive Vascular Lab and to Barbara Montgomery, RDMS, for allowing me to evaluate their scanning techniques.

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Table of Contents

Abstract.. . .. . ... . .. ... ... . .. . . . . .. . .. . .. . .. ... ... . .. .. . .. ............................................ . .......... Page 2

Acknowledgements .......................................................................................... Page 3

Chapter 1

a. Problem Statement.. ...................................................................................... Page 5

b. Related Research .......................................................................................... Page 6

c. Objectives of the Study ................................................................................. Page 13

Chapter 2

a. Procedures ................................................................................................. Page 14

b. Design ....................................................................................................... Page 14

Chapter 3

a. Results ....................................................................................................... Page 17

Chapter 4

a. Discussion .................................................................................................. Page 20

References .................................................................................................... Page 27

Appendices

a. Appendix A... .. . .. .. . . .. . . . . .. . .. .. . ....................................................................... Page 28

b. Appendix 8 .................................................................................................. Page 30

c. Appendix C ................................................................................................. Page 33

d. Appendix D ................................................................................................. Page 34

e. Appendix E ................................................................................................. Page 34

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Chapter 1

Problem Statement

Diagnostic medical sonographers are very often exposed to factors that contribute to workplace

injury which have been categorized as work-related musculoskeletal disorders (WRMSD).

WRMSD have become increasingly common in the field of sonography as a 2000 survey found

that "more than 80% of sonographers are scanning in pain during a study and 20% of these

professionals eventually experience a career-ending injury".' Even more recently, another

survey was conducted yielding the greatest participant sample to date with 2963 respondents.

This new survey revealed a 9% increase in the number of sonographers scanning in pain since

the 2000 survey, which implies that WRMSD are increasingly being reported in the field. 2

Obtaining a quality sonographic image can sometimes prove to be challenging and demands

odd angles and increased pressure on the hand and wrist. This can lead to scanning practices

that can contribute to WRMSD. Some scanning practices in the sonography field that have

been linked to WRMSD include: tightly gripping the transducer, sustained shoulder abduction,

twisting and bending of the wrist, maintaining poor posture for long periods of time, and

increased workload.' Other factors that have been linked to WRMSD include height, age, and

gender differences among sonographers. 3 Certain risk factors, such as level of personal

stress, the number of examinations performed per day, the length of time each examination

requires, the sonographer's physical and mental status, behavior such as work/rest cycles,

awkward postures, and physiological factors, have also been identified as contributing to

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WRMSO. 3 The increased risk ofWRMSO has necessitated extensive research in the work

habits and environments of sonographers internationally.

Related Research

WRMSO are increasing among diagnostic medical sonographers (OMS) and previous research

efforts have been executed to better understand the burden attached to the delivery of this

diagnostic service. This literature reviewed is organized in a chronologic manner to capture the

work that has evolved over time.

One of the earlier studies was conducted by Brown et al. to address the problem of

musculoskeletal disorders as a broad topic over a time span of three hundred years.

Throughout history, scribes, clerks, and telegraphers have all been documented as having

musculoskeletal disorders related to their occupations. Phrases such as writer's cramp and

scrivener's palsy were coined to refer to these disorders. The increased prevalence of these

disorders in the last several years, not only in diagnostic medical sonography, is described as

an epidemic and a 20th century health disaster' There is currently a lack of consensus on what

to call these musculoskeletal disorders because these disorders can arise as a result of a

variety of activities. Research is made difficult by the variety of the disorders. Because the

cause of the disorders can be ambiguous, the authors preferred that the disorders not be called

injuries. The term injury applies only if the cause of the tissue damage is known. 2

Brown et al.'s work takes a biopsychosocial approach to determining the cause of

musculoskeletal disorders. Physical factors were combined with psychological and social

factors in an attempt to find a link to the disorders. Factors were categorized as predisposing

factors, precipitating factors, and perpetuating factors. Predisposing physical factors include

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poor posture and short arms, while predisposing psychosocial factors include history of anxiety,

depression, job dissatisfaction, and emotional or physical trauma 2 Precipitating physical factors

include minor trauma, change of routine, and long hours of work, while precipitating

psychosocial factors include personal problems or current negative life events 2 Perpetuating

physical factors include poor ergonomics, abduction of the arm, tool design, poor health, and

deficiency conditions (i.e. iron, thyroid, vitamin 812), while perpetuating psychosocial factors

include chronic anxiety or depression, fatigue, financial issues, and attitudes 2

PHYSICAL PSYCHOSOCIAL

Predisposing Factors Poor posture History of anxiety or depression Short arms Job dissatisfaction

Emotional or physical trauma

Precipitating Factors Minor trauma Personal problems Change of routine Current negative life events LonQ work hours

Perpetuating Factors Poor ergonomics Chronic anxiety or depression Abduction of the arm Fatigue Tool design Financial issues Poor health Attitudes Deficiency problems

Sonographers with chronic regional pain were specifically interviewed by researchers; spinal

segmental dysfunction, active myofascial trigger pOints (a hyperirritable spot in skeletal muscle)

on the transducer side, subacromial rotator cuff impingement, and dysfunctional movement of

the scapulothoracic joint were consistently found on the transducer side 2

Electromyography was used to demonstrate the amount of time it takes to fatigue muscles

during arm abduction-"30 degrees of abduction is 60 minutes, 20 minutes when held at 60

degrees, 10 minutes when held at 90 degrees, and 5 minutes when held at 120 degrees.,,2

When scanning, sonographers are sometimes forced to use a variety of these angles, but it is

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important for them to understand that the greater the angle of abduction the shorter the time to

muscle fatigue and to avoid the greater angles as much as possible to prevent dysfunction.

Primary, secondary, and tertiary prevention methods need to be incorporated into the practice of

all DMS to reduce the risk ofWRMSD.

In a study by Muir et aI., a questionnaire was developed by an occupational health physician, an

occupational health nurse, an ergonomic engineer, an athletic therapist, and a

sonographer/nurse to record indirect incidence of WRMSD and related factors to the practice of

sonography. Sixty-seven members of the Canadian Society of Diagnostic Medical

Sonographers completed the Sonographers Work Health and Ergonomics Survey. Most DMS

worked in general clinical settings, performing a variety of 20 to 45 minute ultrasound exams

respondents had an average work experience of 9.82 years.3

When asked to rate present health status, 62% of DMS answered good, 34% excellent, and 3%

fair. 64% of DMS exercised for a minimum of 20 minutes three times a week, and 63%

exercised their shoulders, back, neck, or arms. Pain was reported in 15% of sonographers

within six months of employment, 45% after three years, and 72% after ten years. Several DMS

experienced changes in home life, work responsibilities, sleep patterns, and psychosocial well

being due to their pain. Shoulders, neck and upper back were found to be the most common

sites of pain. Treatment of WRSMD, either currently or in the past, was obtained by 85% of

DMS. 67% of DMS scaned five to seven hours per day and only 45% took breaks of ten

minutes or longer more than three times per day. Ergonomic education was received by only

66% of DMS within the previous two years at work. Workers responded that they would like to

have adjustable ultrasound equipment and increased exam room space, which they believed

would assist them to perform their work. A mean score of 4 (agree) was found when DMS were

asked if they felt like their own health is compromised because of their profession. 3

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A survey conducted by David concentrated on the importance of DMS self-reporting WRMSD,

and provided descriptive data during the time frame that the disorders are reported.

Respondents also provided information about barriers that prevent reporting injuries and

administrative responses to WRMSD. Many times, DMS believe that WRMSD is part of their

job and that they need to deal with the situation on their own instead of reporting it. David cited

a 2002 international conference which was held to discuss prevention and corrections that could

combat the increasing prevalence of WRMSD. "Steps that were recommended included

incorporating musculoskeletal injury prevention in sonography educational curricula, including

question related to prevention on credentialing examinations, and requiring prevention

processes for laboratory accreditation.'" Prevention is not only important for the well-being of

the individual DMS, but also for the well-being of the institution. Financially, the loss of one full

time DMS resulted in $21,153 lost in revenue for only one week'it also amounts to more stress

on co-workers and longer wait times for patients'

Additional indirect information was collected using open-ended questions focusing on the

reporting of WRMSD. Some qualitative responses included:

The administrators skeptically sent the sonographer for an examination and testing,' 'the

administrators refused to believe that the injury could occur on the job and forced the

sonographer to scan with the opposite hand the sonographer was using,' 'the workers'

compensation process is daunting,' and 'WRMSD is just part of the job.""

The study by David has limited ability to be generalized, due to its qualitative nature and that the

participants were all from the University of Oklahoma Health Sciences Center. However, it

uncovered some of the reasons that WRMSDs may go unreported.

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A pilot study was conducted in 2009 that recorded direct measurements on five DMS after

completing four portable neonatal neurosonographic scans in a NICU. Researchers proposed

that specific risk factors involved in performing neonatal neurosonography examinations

contributed to musculoskeletal distress of the wrist and hands. While conducting a portable

neonatal scan, sonographers were forced to maneuver through lines and tubes while wearing

protective gloves and scanning in compromised positions because these premature infants

must remain inside their isolettes at all times. The Rapid Upper Limb Assessment (RULA) tool,

a scoring system that analyzes musculoskeletal postures and positions, was used to evaluate

the sonographers' positions during each exam. Immediately following each examination, a

musculoskeletal sonogram of the DMS' elbows and wrists was also taken in order to evaluate

physiologic changes. Anterior-posterior and length measurements were made of the median

nerve while Power and Spectral Doppler were utilized to record hypervascularization. Lastly,

each DMS was given a visual analog scale (VAS) to self report the level of discomfort in the

neck, shoulder, and wristS

The mean age of the DMS in this study was 43 and mean work experience was 16.7 years.

RULA scores ranged from 1 to 7 with a "1" indicating a low strain posture and a "7" being a

hazardous position. Total RULA scores on the first session were 4.0 and 3.8 at the end of the

fourth session; these results were minimal. The researchers suggested that "comparative

studies using other gold standards are necessary to make any claim for the use of Doppler in

studying WRMSD and CTS more credible."s

Additional indirect information was recorded using a survey of a random and convenient sample

of 5200 registered DMS which returned 2963 respondents. This survey indicated that 90.4% of

DMS were scanning in pain. Shoulder pain was the most common in all groups, while finger,

hand, and wrist pain occurred most often in the older, more experienced groups. Cross-

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tabulation and Chi-square analysis involving age, gender, height, experience, and full-time or

part-time status were used to analyze the data. These data analyses found that location of pain

varied across the groups. "Aching" was the most common word to describe pain in all groups,

anti-inflammatory medicine was the most common prescribed treatment to treat injuries. There

was no difference in discomfort levels between full-time and part-time employees B

This survey was voluntary, therefore it produced a skewed response population, with most

respondents being over the age of 50 with 20 or more years of experience, a majority under 5'4"

in height, and a majority performing 9 to 11 sonographic examinations per day. Nearly all

participants indicated that they were able to adjust the positions of the examination table and

chair, but few were able to adjust their PACS workstations. Of all respondents, 48% have been

diagnosed with a musculoskeletal injury. The researchers suggested that OMS be followed

over longer periods of time to look at acute verses chronic pain. They recommended that future

studies be performed, and that education be offered to OMS about ergonomic practices to break

bad scanning habits and possibly decrease the prevalence of WRMSOB

In a study on comparing anthropometric measurements and the prevalence of musculoskeletal

injuries, research involved distributing another questionnaire focusing on job strain, obtaining

anthropometric measurements (including height, weight, waist circumference, functional forward

reach, hand breadth, hand length, hand spread), performing grip strength testing, and

evaluating occupational health records. The results indicated that shoulder pain was most

common, occurring in 73% of OMS reporting injury. The lower back followed with 69%, and

pain in the wrist and hand occurred in 54% of OMS. The researchers found that differences in

hand strength did not significantly affect the wrist and hands, but OMS who hold two or more

credentials have an increased risk of having injury in the wrist and hands. Musculoskeletal

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disorders were less likely to occur in those OMS who were physically larger, had more favorable

job strain scores, and spent less time standing 7

The authors of the article concluded that these results were only descriptive due to the small

sample size. It is suggested that transducers be made customized to different body types of

individual OMS. The authors also provided equipment design changes that could potentially

decrease the risk of musculoskeletal disorders. Height adjustable keyboards, monitors, chairs,

and examination tables, lightweight transducers, and voice-activated controls may improve the

ergonomic risk within sonography.7 A study to determine the relationship of the height of OMS,

dimensions of the workspace, and other factors would be helpful in better understanding the

potential for work-related injuries among OMS.

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Objectives of the Study

A gap in the literature exists with recording direct measurements of many of the factors that may

be contributory to WRMSO among OMS. Survey research has only provided indirect

information and these reports need to be directly verified. This research project proposed to

better understand these workplace issues by addressing this research question: What direct

measures taken among DMS and the work station and equipment contribute to their level of

discomfort upon completing their daily work?

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Chapter 2

Procedures

A direct observation of DMS in the work place was used to better investigate factors that may

increase their individual risk of WRMSD. To accomplish this direct observation of DMS at work,

the student researcher obtained consent during clinical rotations in Franklin County area

imaging centers. The researcher was in the site for a ten week period and was able to monitor

conditions over time. Exams were selected for observation based on the competency of the

researcher. The posture and position of the DMS was observed and recorded.

This study is an extension of research being conducted to evaluate equipment modifications to

prevent WRMSD in DMS. The protocol for this portion of the research was approved by the

Institutional Review Board.

Design

This descriptive research project was conducted over a period of five months. Direct

measurements of the following variables were collected:

Independent- Height of the DMS, Dimension of the ultrasound machine, Exam table heights,

and RULA scores for common ultrasound exams. (See attached images and sample RULA

worksheet in Appendix B).

Oependent- VAS pain scores taken before and after each work shift. (See attached VAS pain

scale in Appendix C).

The Rapid Upper Limb Assessment tool (RULA) was used to score the posture and position of

the DMS, for each scan. The RULA provides the opportunity to gather data and compute both a

sub-score and a total score for each subject evaluated. Sub-scores are computed for the

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following parts of the worker's body: upper arm position, lower arm position, wrist position, wrist

twist, neck position, trunk position, legs, and muscle and force/load scores for both the upper

and lower limbs. The values for these sub-scores are referenced to a chart and combined to

form scores for the arm and wrist position and the neck, trunk, and leg position. These two

scores are again referenced in another chart and combined to form an overall RULA score for

the exam. Referencing the RULA, an acceptable score for an exam is a 1 or a 2, a score of a 3

or a 4 requires further investigation, a 5 or 6 should be further investigated and changed soon,

and a 7 should be investigated and changed immediately· The process of conducting a RULA

evaluation was rigorously practiced.

The visual analog scale (VAS) is a self-rated score provided to the DMS, allowing them indicate

their level of pain, at the beginning and the end of each work shift. Descriptive statistics were

used to analyze the data set. The DMS were asked to provide a VAS score at the beginning of

their work shift and at the end of their work shift, for each day that was evaluated. The VAS

scoring chart is rated from 0 to 10-0 being "no pain" and 10 being "agonizing." An

occupational therapist provided periodic checks for scoring to insure reliability of the data with

both the RULA and the VAS.

The height of each sonographer in centimeters was self-reported. The height of the exam table

that was selected by the sonographer for each individual exam was measured in centimeters by

the researcher. A height ratio was calculated by taking the exam table height and dividing it by

the sonographer height.

The RULA and VAS both have published reliability measures that make them the best choice

for this kind of data collection. The researcher received training on how to obtain data with

these instruments. The anticipated statistics are reported as both frequencies and means for

the group of 5 DMS. Although statistical power was not achieved due to a lower than

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anticipated N, the hope had been to perform a statistical correlation to determine which of the

variables might be the most contributory to OMS's self-reported pain scores.

Variable Level of Measurement

RULA score (independent) Ordinal

OMS height (independent) Ratio

Table height (independent) Ratio

VAS score (dependent) Ordinal

Preliminary data was collected to determine feasibility of this project (See Appendix 0).

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Chapter 3

Results

Work-related musculoskeletal disorders have been identified as a problem among Diagnostic

Medical Sonographers (OMS). The objective of this study was to obtain direct measures of OMS

in an attempt to find a comparison between their posture and position during each exam and their

level of pain for each day. A total of five OMS were involved in this study, and a total of twenty-

five scores were obtained during a variety of ultrasound examinations.

Descriptive Statistics

The most frequently observed ultrasound observed examinations, in this study, were a carotid

duplex, obstetrical ultrasound (OBITVS), and a lower extremity venous Doppler (Right, Left, or

Bilateral LEV). Table 1 includes mean RULA sub-scores and overall scores and is provided

below. A table of all the RULA scores for ultrasound examinations can be found in the appendix

(Appendix D).

Table 1. Mean RULA sub-scores and overall scores for frequently observed exams.

Expected Sub-score for Sub-score for Neck, Trunk, Overall Score ArmlWrist & Legs RULA Score

RLEV 1-2 4.33 2.33 3.33 BLEV 1-2 3.86 3.29 3.43 Carotid 1-2 4.00 4.17 . 4.50 OBITVS 1-2 3.83 4.83 4.83

The height of each OMS was collected and compared with the height of an adjustable

examination table used for the patient's ultrasound examination (Note: OMS 10 #5's exam table

was not adjustable). Table 2 includes the examination table heights, OMS height, and overall

RULA scores and is provided below:

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Table 2. Comparison of the DMS heights, exam table heights, and RULA scores.

DMS Height Exam Table Height Height Ratio RULA Score (in cm) (in cm)

1 170 BLEV 94 1.81 3 BLEV 96 1.77 3 BLEV 90 1.89 3 LUEV 64 2.66 7

2 158 RLEV 64 2.47 3 BLEV 64 2.47 3

CAROTID 132 1.20 4 3 161 RLEV 76 2.12 3

BLEV 75 2.15 3 BLEV 72 2.24 3 BLEV 70 2.3 6

CAROTID 64 2.52 3 CAROTID 92 1.75 3

RUEV 72 2.24 3 4 173 RLEV 70 2.47 4

CAROTID 90 1.92 3 CAROTID 60 2.9 7 CAROTID 60 2.9 7

LUEV 70 2.47 5 5 175 OBITVS 81 2.16 3

OBITVS 81 2.16 5 OBITVS 81 2.16 7 OBITVS 81 2.16 4 OBITVS 81 2.16 4 OBITVS 81 2.16 6

The VAS scores for all the DMS are provided in Table 3.

Table 3. VAS scores taken daily among all DMS evaluated in the study.

Sonographer Exam Pre Score Post Score Difference

1 0 1 1

0 1 1

0 2 2

0 3 3

18

2 01/25/11 RLEV o o o o 1 1

3 2

1

3

3 02/19/11

3 03/10/11 4 4 02/15/11 CAROTID 0 0

4 02/18/11 CAROTID 0 3 3 4 02/25/11 RLEV 0 2 2

4 02/28/11 LUEV 0 0 0

4 03/01/11 CAROTID 0 2 2

5 04/05/11 OBITVS 2 4 2

5 04/07/11 OBITVS 2 4 2

5 04/08/11 OBITVS 2 4 2

A table is provided that lists some of the more frequently evaluated sonographic examinations and

the associated sub-scores, overall scores, and height ratios of the DMS.

Table 4. Most frequently evaluated sonographic exams and associated DMS data.

DMS Exam Location Trunk Score Leg Score RULA Height

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Chapter 4

Discussion

The prevalence of work-related musculoskeletal disorders (WRMSD) among diagnostic medical

sonographers (DMS) and vascular technologists (VT) is increasing. A recent study reported a 9%

increase in the amount of sonographers scanning in pain, raising the total to 89% experiencing a

WRMSD B The challenging nature of obtaining a quality sonographic examination is responsible

for this high rate of injury; awkward posture, shoulder abduction, and bending and twisting of the

wrist are only a few contributing factors. The objective of this study was to obtain direct measures

of DMS in an attempt to find a comparison between their posture and position during each exam

and their level of pain for each day. The RULA tool and the VAS scale were used to score

scanning technique and rate the daily pain level. Unfortunately, none of the sample sonographers

achieved an acceptable score of 1 or 2 on the RULA. Therefore, this pilot study illuminates the

need for further investigation.

Oescriptive Statistics

The obstetrical transvaginal (OBITVS) exam yielded the highest mean overall RULA score. This

exam requires using a long transducer with a handle and scanning transvaginally. Most

sonographers reach over the patient's leg in the stirrup causing the shoulder of the scanning hand

to abduct; the sonographer must then reach toward the machine with their free hand to work the

controls. The sonographer must angle the probe up, down, and side to side to get the proper

images causing bending and twisting of the hand and wrist. (See Fig.1)

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Figure 1. Demonstration of scanning on a phantom, illustrating the angulation of the DMS wrist.

The carotid exam yielded the second highest mean overall RULA score. This exam requires

using a linear transducer with a footprint of approximately 3 to 4 centimeters. This small footprint

forces the sonographer to use a pinch grip to hold the transducer. Most sonographers stand on

the right side of the patient when scanning, so he or she must reach over the patient in order to

scan the left carotid artery. This places the shoulder of the scanning hand in abduction.

Sometimes sonographers have to reach so far to the side of the cart that it causes the DMS feet

to become unbalanced. The DMS tends to bend the trunk and twist the neck. (See Fig. 2)

Figure 2. Demonstration of carotid scanning, illustrating the unbalanced posture, bent trunk and

twisted neck.

The lower extremity venous (LEV) exams yielded the lowest mean overall RULA score, averaging

1-1 Y, points lower than the osrrvs and the carotid. The LEV exam requires the sonographer to

compress the vein to check for thrombus causing the sonographer to apply a lot of force and put

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stress on the scanning arm. Like the carotid exam, the sonographer is forced to reach over the

patient to scan the left leg causing the same issues as mentioned above. (See Fig. 3)

Figure 3. An illustration of a sonographer pushing downward with the transducer, which causes a pinch grip.

Exams done portably at the patient's bedside consistently had a higher overall RULA score than

comparable exams done in the department, as all three portable exams evaluated scored a 6 or 7

on the RULA. Three exams done in the department also scored a 6 or a 7, but nineteen other

exams done in the department did not score as high. A study by Patel et al. evaluated the

efficiency of portable ultrasound examinations. Overall exam time for portable exams is 17.7

minutes longer than exams done in the department, exposing sonographers to prolonged

scanning'" Typically, portable patients are unstable and unable to travel to the department. These

examinations require a greater amount of physical work by the DMS. During a portable

examination, the DMS is required to push an ultrasound machine (>300 Ibs) from the department,

to the patient's bedside, and back. The Patel study also reported sub-optimal images obtained in

less-than-ideal environments. 9 While at the patient's bedside, the DMS is expected to work around

various medical equipment, which doesn't promote proper ergonomics during the ultrasound

scanning process.

22

A study by Pawaskar et al. compared the workflow and efficiency of conventional mobile

ultrasound scanners (full-size ultrasound machine on wheels) and the fairly new portable

ultrasound scanners (compact, lightweight, laptop-style ultrasound scanners). This study reported

that "portable testing represents 18% of the total volume of studies in large vascular labs."'° This

means that sonographers are exposed to less than ideal conditions that produce higher RULA

scores approximately one-fifth of the work shift. Researchers saw no significant difference in the

overall exam time required to perform a bedside exam with either machine. It may be beneficial

to look further into the ergonomic advantages, if any, of using laptop ultrasound equipment rather

than the larger versions. Patel et al. advocated the use of portable ultrasound scanners being

used to increase efficiency and reduce OMS exposure to WRMSO.

Bedside exams have been proven to decrease efficiency of ultrasound labs and have been

attributed to an increase in WRMSO. Reasons to avoid such exams include a performance trade

off, repetitive stress injuries, and the wear and tear of equipment. 9 These portable exams should

only be utilized when the patient is incapable of travel (i.e. a patient that is on a ventilator).

Anthropometric Data

The heights of sonographers were obtained along with the heights of exam tables selected for the

patient having a sonographic exam. The ratio of sonographer height to exam table height was

calculated, but no trends in the data could be visualized. Given this sample, however, it was

feasible to collect this information in the clinical site.

A 2009 study by Hill et al. gathered anthropometric data as well as the prevalence of WRMSO.

They reported that "larger" females "may be protected against the development of overuse

syndromes of the shoulder, low back, and hand/wrist," while also suggesting that larger hand size

may also be protective?

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Visual Analog Scale

The VAS tool provided a means of self-reported pain scores from the sonographers. Many exams

scoring high on the RULA also showed an increase in the pre and post VAS scores. This could

suggest that exams yielding high RULA scores could contribute to a increase in pain levels.

Although, the pilot data obtained could indicate that a high score on RULA could contribute to a

painful day for the sonographer, more data is needed in order to determine if the association does

exist.

The Evans et al. study demonstrated no significant difference in the experience of pain from

different age groups. Most sonographers described their pain as "aching" in their study.6

Additional work reported by Evans analyzed pain in the wrist, hand, and fingers specificaliy. The

researchers reported that sonographers experiencing wrist, hand, or finger pain had "similar

descriptions of symptoms regardless of the area of practice or years of experience.,,11

A major problem is that most injuries go either unreported or underreported; forty-three percent of

respondents in the Evans study related their pain to their occupation, but only twenty-six percent

put in a formal report. " When pain is allowed to go unrecognized it is more likely to progress to an

even more serious injury. Again, an indirect report is valuable, but has increased credibility when

compared to direct measures of sonographers in the workplace.

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Limitations

The main limitation of this study is attributed to the fact that data was obtained during the student

researcher's clinical rotation. The student researcher had other obligations to complete during the

rotation in addition to data collection for this study so she was unable to follow each sonographer

through the entire workday to better determine which exams contributed most to their level of

pain. The student researcher was scanning patients as well, so the patient workload was less

than that of a regular workday for the sonographer, possibly skewing the VAS scores. It could be

expected that the VAS scores would be higher if the sonographer had taken on the full patient

workload.

The VAS was taken at the beginning and at the end of the workday instead of the beginning and

the end of each exam, so it cannot be implied that a single exam score contributed to a certain

level of pain. It is difficult to say how reliable the VAS tool itself is, because it involves self

reported pain levels; however, the face to face self-reporting obtained in this study is thought to be

more accurate than that of online submissions to report pain utilized in past research.

This study had an N of only 5 DMS, and only 25 ultrasound exams evaluated in total. The N was

too low to make any statistically significant conclusions. Sonographers from only two facilities

were used, and only eight different exams were evaluated. The clinical examinations were

evaluated based on the prevalence for certain types of examination that were requested of these

laboratories. The data reported represents only those DMS observed for those examinations

preformed in these specific clinical sites. This data is only representative of these workers in the

context of these examinations.

If the proper time and resources were available, a more controlled study could be completed. The

student researcher could have repeatedly followed several sonographers for entire work shifts

25

until a statistically significant number of exams were evaluated. Sonographers from a variety of

scanning environments should be recruited (i.e. various vascular labs, obstetrical settings, and

radiology departments). A greater variety of exams should be evaluated in addition to those

included for this study, such as abdominal exams, renal exams, thyroid exams, and arterial

exams.

During each shift, every exam ordered should be evaluated. VAS scores should be recorded

before and after each exam as well as an overall VAS score at the beginning and end of each

work shift. If this were done, each RULA score and VAS score could be compared with each

other, and a correlation of problematic exams could possibly be made. The pushing and the

pulling of the ultrasound machine to and from the patient's bedside on portable exams would have

been included in the evaluation. A two person team of evaluators would have been utilized, and

the RULA scores would have been averaged to acquire a more accurate score.

Conclusions

This pilot study has objectively measured some of possible factors that contribute to WRMSD that

have been subjectively reported through past research. WRMSD among DMS and vascular

technologists are a serious issue that requires direct evaluation. The methods used in this pilot

study have been proven feasible; Future research that is executed on a larger scale may help to

truly pinpoint the risks related to WRMSD among sonographers.

26

References

1. SDMS speaks out for sonographers at OSHA hearings on ergonomic injury rules. 2000-2001. http://www.sdms.org/msilosha.asp.

2. Evans KD, Roll SC, Baker J: Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists: a representative sample. J Diagn Med Sonography 2009; 25:287-299.

3. Evans KD, Roll SC, Li X, Sammet S: A holistic evaluation of risk factors for work-related musculoskeletal disorders among asymptomatic sonographers performing neurosonology. J Diagn Med Sonography 2009.

4. Brown G, Fhgi A, Baker J: Work-related musculoskeletal disorders in sonographers. J Diagn Med Sonography 2004; 20:85-93.

5. David S: Importance of sonographers reporting work-related musculoskeletal injury: a qualitative view. J Diagn Med Sonography 2005; 21 :234-237.

6. Muir M, Hrynkow P,. Chase R, Boyce D, McLean D: The nature, cause, and extent of occupational musculoskeletal injuries among sonographers: recommendations for treatment and prevention. J Diagn Med Sonography 2004; 20:317-325.

7. Hill JJ, Slade MD, Russi MB: Anthropometric measurements, job strain, and prevalence of musculoskeletal symptoms in female medical sonographers. Work 2009; 33:181-189.

8. McAtamney C, Corlett N: RULA: rapid upper limb assessment tool. http://www.rula.co.uk/brief.html. Accessed March 2, 2010.

9. Patel D, Satiani B, Mong R, Baetz L, Spiezio K: Appropriate resource utilization in portable noninvasive vascular studies: the role of disruptive technology. J Vasc Ultrasound 2006; 30(1):35-38.

10. Pawaskar M, Balkrishnan R, Kiser D, Gray M, Satiani B: Work flow analysis: evaluation of conventional mobile versus portable ultrasound scanners in the noninvasive vascular laboratory. J Vasc Ultrasound 2008; 32(2):85-88.

11. Evans KE, Roll SC, Hutmire C, Baker JP: Factors that contribute to wrist-hand-finger discomfort in diagnostic medical sonographers and vascular technologists. J Diag Med Sonographer 2010.

27

Appendix A. Ultrasound equipment in the clinical sites.

Zonare

Length: 76 em Width: 60 em Cord Length: 404 em Height (lowest): 80 em Height (highest): 99 em

28

Length: 107 em

Philips HD 11

Height: 56em Cord Length: 337.5em

29

Length: 87 em

GE Logiq 9

Height: 61 em Cord Length: 332.5 em

30

Appendix B. Rapid Upper Limb Assessment tool

Client:

Right Side:

E .:e

RAPID UPPER LIMB ASSESSMENT

Date/time:

100"+

Assessor:

o Working across the

midline of the body or out

tothe side

==9')) ~ ~~1 bent'lway from midH..,e

SELECT ONLY ONE OF THESE: v

'" ~ .E o No resistance ~ less than 2kg intermittent load or force TI TI . ~ 'l

'" ~ o 2-lOkg intermittent load or force

~ ~

"

D Shoulder is raised

D Upper arm is abducted

D Leaning or supporting

the weight of the arm

o Wrist is bent away

from midline

~ o 2-lOkg static load' 2-lOkg repeated loads or forces + lOkg or more intermittent load or force

Muscle Use

Left Side:

E .:e

o Posture is mainly static, e.g. held for longer than 1 minute or repeated more than 4 times per minute

4S"-90"

o Working across the

midline of the body or out

to the side

o Shoulder is raised

o Upper arm is abducted

o Leaning or supporting

the weight of the arm

31

Muscle Use

~ u . Z

] ~ u . Z

fj . .8

~ .. " ~ 3 ~

" :e . ." " oc

"

SELECT ONLY ONE OF THESE:

o No resistance + less than 2kg intermittent load or force

o 2-10kg intermittent load or force

o Wrist is bent away

from midline

o 2-10kg static load. 2-lOkg repeated loads or forces· lOkg or more intermittent load or force


I!"___... ..... 20·

-'" '~.'.".'.".".".'." ••.. ' .•. ' .. " .•.. ' .. '.' ()~

© 2001

till" ..

)1

32

, ,

t ,

" (l \'1

~ ~

Force & Load forthe neck, trunk

and legs

Muscle Use

~ '(;

Legs and feet are well Legs and feet are

supported and in an NOT evenly balanced and

evenly balanced posture.

v (". supported.

SELECT ONLY ONE OF THESE:

o No resistance. less than 2kg intermittent load Of force

o 2-10kg intermittent load or force

o 2-1Qkg static load· 2-10kg repeated loads or forces. lOkg or more intermittent load or force

o lOkg static load' lOkg repeated loads or forces • Shock or forces with rapid buildup


Whilst COPE Occupational Health and Ergonomic Services Ltd (COPE) and Osmond Group Limited (Osmond) have taken every care in preparing this resource, it must be used according to the guidelines based on the original article~ by Prof E.N. Corlett and Dr L. McAtamney.

No responsjbility will be taken by COPE or Osmond in the use of this resource.

RULA provides a score of a snapshot of the activity as part of a rapid screening tool. The user should refer to the original article* to check the detail of the scoring and correct use of RULA scores. Further investigation and actions may be required.

For further information on methodology, please refer to our on-line guidance at www.ergonomics.co.uk or: McAtamney, Land Conel!. EN. Reducing the risks of work related upper limb disorders - A guide and methods. Published by: Institute for Occupational Ergonomics, University of Nottingham, Nottingham NG7 2RD, UK. (1992). Tel: +44 (0)115 9514005 for details

*McAtamney, L. and Corlett, EN. "RULA -: A survey method for investigation of work-related upper limb disorders Applied Ergonomics 1993, 24(2), 91-99

Appendix C. The Visual Analog Pain Scale

!?' -?y .!f!

~@ c:: ,g (j '< :t'

Unbearable Distress

Task

;S § &

r:'f

.!f! til

1::: </2

! §

'" .f;; if '" ff §

'< <:

No Distress

Date ______ Start ___ End __ _

Osmond® Ergonomic Office Solutions

33

Appendix D. RULA Assessment Data

Appendix E. Pilot data collected for Drs. Sommerich and Evans in one clinical site.

Pelvis-Transabdominal

Sonographer A (65 inches)

• Table height: 26 inches, 66 em

• Thigh height to sonographer

• Sat while scanning

• Chair height: 26 in, 66 em

Sonographer B (63.5 in)

• Table height: 27 in, 68.5 em

• Thigh height



Pelvis-Transvaginal

Sonographer A


• Hip height to sonographer

34



• Rests elbow on foot stool with handle

• Stool handle height: 35 in, 89 em

Sonographer B


• Hip height to sonographer

• Stood while scanning

RUQ

Sonographer A

• Table height: 26 in, 66 em




Thyroid

Sonographer C (63 in)

• Table height: 26 in, 66 em



• Chair height: 20.5 in, 52 em

Lower Extremity

Sonographer D (70 in)

• Table height: 28.5 in, 72 em

35


Lower Extremity (portable)

Sonographer D

• Table height: 36.5 in, 92 cm

• Stood while scanning

36

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