Morbidity among X-ray technologists

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International Journal of Industrial Ergonomics 33 (2004) 29–40

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doi:10.1016/j.erg

Morbidity among X-ray technologists

Shrawan Kumar*, Lil Moro, Yogesh Narayan

Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 3-75 Corbett Hall, Edmonton,

Alberta, Canada T6G 2G4

Received 19 July 2002; received in revised form 22 April 2003; accepted 16 June 2003

Abstract

X-ray technologists were surveyed using structured questionnaire and face-to-face interviews for their personal,

recreational, occupational and occupational health variable. The questionnaire was piloted for clarity and validity prior

to execution. A random sample of 20 volunteer participants from two University hospitals were used. The responses

were analyzed for magnitude, duration and frequency analysis of activities; and, severity, duration and recurrence of

morbidity. The X-ray technologists were a young group of professionals ranging from 20 to 53 years of age. Eighty-nine

percent of the samples were physically active. Despite the young age and active life style, the X-ray technologists had

significant and diverse musculoskeletal problems. Eighty three percent of the sample had backache, 39% of female

sample had neck pain and 28% shoulder pain. The pain among the sample was aggravated by work activities and

relieved by rest, massage, heat/ice and exercise. Majority of technologists suffered multiple episodes of pain. Fifty

percent of the female sample suffered from upper extremity pain.

Relevance to industry

Healthcare sector is plagued with musculoskeletal injuries. X-ray technologists perform an essential and important

part in healthcare sector. Understanding the magnitude of their problem may be able to play an instrumental role in

their alleviation likely impacting on X-ray technologist’s performance.

r 2003 Elsevier B.V. All rights reserved.

Keywords: X-ray technologists; Musculoskeletal injury; Morbidity; Low-back pain; Upper extremity pain

1. Introduction

Diagnostic imaging using X-ray technology is anessential service in the healthcare field. It is one ofthe primary methods for recognizing trauma andpathology. In addition to handling routine casesamong inpatients and outpatients, it is urgentlyneeded in emergency, operating room and intensive

ng author. Tel.: +1-780-492-5979; fax: +1-

ss: [email protected] (S. Kumar).

front matter r 2003 Elsevier B.V. All rights reserve

on.2003.06.002

care units. Despite performing such a vital functionon the healthcare scene, the Diagnostic ImagingDepartments in hospitals tend to be relatively small.These small number of technologists work shiftsand weekends to provide uninterrupted service yearround. Each of the technologists works in everypart of the hospital from outpatients to emergencyand intensive care unit by rotation. Frequently,their activities assume a frantic pace due to back-logs and mounting caseloads. Given this impor-tance, complexity and demands of the job, it issurprising that very little has been published on

d.

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S. Kumar et al. / International Journal of Industrial Ergonomics 33 (2004) 29–4030

these jobs. A comprehensive review of literatureproduced five studies. Among the diagnosticimaging personnel studied, the X-ray technologistshad been largely ignored.All of the five studies (Rossi et al., 1999; Wright

and Witt, 1993; Miller and O’Brien, 1991; Mooreet al., 1992; May et al., 1994), were retrospectivestudies investigating either risk of low-back painor musculoskeletal disorder among the radio-graphers/X-ray technologists. May et al. (1994)have also videotaped two radiographers duringradiographic screening of several women forbreast cancer. All retrospective studies used ques-tionnaires. Rossi et al. (1999) investigated nurses,nursing aides, therapists and X-ray technicians.This was an age matched case control study. Theauthors concluded work relatedness of the backinjuries in the experimental sample. They reportedthat the risk of injury was not uniformly dis-tributed. It was more prevalent in orthopedicwards, in the plaster operating blocks andsterilization plants.With a response rate of 49% from 15% of the

target sample, Wright and Witt (1993) concludedthe tasks performed by radiographers increasetheir risk of back injuries. They further stated thatthe successive injuries tend to be more severe,eventually resulting in financial losses from med-ical costs, decreased productivity and increasedabsenteeism. They found that the prevalence ratefor low-back pain among male radiographers was72% whereas among female sample it was 77%.The authors did not find a statistically significantassociation between age, height, body weight andlow-back pain. However, in the Miller and O’Brien(1991) study, a positive association between bodyweight on one hand and low-back pain on theother was reported.Similarly in their preliminary results, May et al.

(1994) found a statistically significant difference inlow-back pain between radiographers aged 30–39years (34% prevalence) and 40–49 years (50%prevalence). The authors also reported that theprevalence of low-back pain among radiographerswas significantly higher even when they wereconsiderably younger compared to the clericalstaff with age range 50–59 years who had only20% prevalence rate for low-back pain.

Miller and O’Brien reported a positive associa-tion between length of employment, perceivedstress levels and low-back pain. They also reporteda somewhat protective effect of higher activitylevels on advanced low-back pain. While thecommon practice of wearing heavy lead apronhas been suspected to play a role in developmentof low-back pain in X-ray technologists, Mooreet al. (1992) did not find a significant statisticallink between the two.To assess the magnitude, nature and causes of

the musculoskeletal problems in X-ray technolo-gists, a review of Worker’s Compensation Board(WCB) records was undertaken. Unfortunately,from the information available one could notdiscern X-ray technologists related statistics. TheWCB Alberta data, however, provides valuableinformation for the healthcare as a whole.From the foregoing review of literature on

musculoskeletal disorders of diagnostic imagingtechnologists, it is clear that musculoskeletalmorbidity is a major problem in this population.However, a morbidity profile of this occupation isfar from clear. Therefore, the aim of this study wasto determine this musculoskeletal morbidity pro-file of the X-ray technologists from a randomsample of X-ray technologists working in twolarge teaching hospitals.

2. Methods

2.1. Site selection

In order to get a multiple task environment withcharacteristic demanding roles for X-ray technol-ogists, two large teaching hospitals were chosen.Administrative cooperation from these institutionswas obtained.

2.2. Sample, demographic and occupational health

variables

Demographic and occupational health profile ofall X-ray technologists was obtained from the twohospitals. The number of technologists, their ages,gender and length of employment in the job wasextracted from the record. The departments, job

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S. Kumar et al. / International Journal of Industrial Ergonomics 33 (2004) 29–40 31

classification, nature of injury, body part injured,type of injury, lost time and total costs were alsoextracted. Information on daily and monthlyprocedures was also obtained. Of the 109 technol-ogists, a random sample of 20 technologistsobtained release time for questionnaire/interview.A random sample of 20 X-ray technologists whoparticipated in interview/questionnaire study hada mean age of 37.9 years (standard deviation 10.1years). These subjects were assembled in Groups of2–3 at their work site as arranged by theiremployers. The informed consent from the parti-cipating technologists was obtained.

2.3. Questionnaire/interview

In order to obtain personal demographic data(i.e., information on physical and recreationalactivity, smoking habit, musculoskeletal injuriesor disorders and time loss as a result, physicalstresses at their jobs), the questionnaire developedand validated by Kumar (1990) was used modifiedto include profession-specific questions. Thisquestionnaire was piloted with five technologistsfor clarity and validity. Once a satisfactory formwas developed it was employed in the study.

2.4. Data analysis

2.4.1. Qualitative, frequency and magnitude

Questionnaire parts for personal demographicinformation and activities performed were qualita-tively analyzed to obtain a baseline of the life styleof the technologists who participated in thissurvey. For the activities and smoking, a frequencyand magnitude analysis was also done.Parts of the questionnaire which explored the

back pain and upper extremity pain were alsoqualitatively analyzed for presence/absence ofpain, aggravating and relieving factors, the natureof pain, severity–time distribution of pain, and if itwas a recurrent problem. In the latter case, thefrequency of recurrence was also obtained.

2.4.2. Current job

The information regarding the job title, the mostdifficult tasks in their jobs, and rank ordering ofwork areas in terms of tiresomeness and difficulty

of tasks were obtained. Further, the adequacy ofworkspace for doing the jobs, the nature, magni-tude, duration and frequency of the tasks per-formed during the work day was obtained for bothback and upper extremity.

3. Results

3.1. WCB profile of the healthcare industry

Table 1 provides a WCB profile of the health-care industry in general. Moving patients, acommon activity performed by the X-ray technol-ogists, was the source of injury in 49.8% of allclaims costing $12.97 million. Body movement andmoving materials were responsible for another28.8% and 5.95% of injuries, respectively. Thesecost an additional $5.42 and $1.55 millionsapproximately. These activities are the major partof X-ray technologist’s jobs in healthcare facilities.

3.2. X-ray technologist’s workforce in the hospitals

The two hospitals employed 50 and 59 X-raytechnologists, respectively. Of these in one hospital76% were females and 24% males. In the otherhospital, 69% were female and 31% male employ-ees. The age range of technologist was from 20 to60 years. The majority of technologists werebetween 30 and 40 years old (Table 2) and nextbiggest group was between 41 and 50 years old(Table 2). The majority of technologists hadworked on the job 5 years or under (Table 2).The majority of injuries sustained were sprain andstrain and were caused by overexertion and bodilyreaction. Back, neck/shoulder, upper extremities,elbow and wrist were all affected by injuries.

3.3. Body parts with pain among technologists

Approximately 39% of female technologists hadneck pain, 28% shoulder pain, 11% upper-backpain, 11% mid-back pain, 66% lower-back pain,22% buttocks pain, 5% lower-arm pain, 5% thighpain and 11% with leg pain. One of the two menhad upper-back pain and lower-back pain. By far,the maximum number of female technologist

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Table 2

Age distribution and work experience of X-ray technologists in

two studied hospitals

Age distribution Work experience

Age range Number of

technologists

Experience

range

Number of

technologists

20–30 28 0–10 47

31–40 33 11–20 37

41–50 31 21–30 14

51+ 17 30+ 2

Table 1

WCB industry profile health care centers 82,100; top 10 nature of injury (1994–1998)

Nature of injury Total costs Total costs (%) Rank Number of claims Cost/claim ($) Rank

Sprains/strains 21,109,615.00 68.42 1 6417 3289.64 7

Inflamed joints 2,159,977.00 7.00 2 539 4007.38 6

Occup inj, uns 1,753,204.00 5.68 3 658 2664.44 8

Occup inj, nec 1,667,143.00 5.40 4 369 4518.00 5

Fracture 1,439,858.00 4.67 5 315 4570.98 4

Disease—nervous system 860,351.00 2.79 6 156 5515.07 2

Contusion/bruise 834,822.00 2.71 7 803 1039.63 9

Multiple injuries 568,700.00 1.84 8 75 7582.67 1

Lacertion/puncture 237,104.00 0.77 9 831 285.32 10

Hernia/rupture 224,153.00 0.73 10 42 5336.98 3

Total 30,854,927.00 100.00 10205 3023.51

Ergonomics related (1, 2, 6 l 10) 24,354,096.00 78.93 1 7154 3404.26 2

Safety related (5, 7, 9) 2,511,784.00 8.14 3 1949 1288.76 3

Other (3, 4, 8) 3,989,047.00 12.93 2 1102 3619.82 1

Total 30,854,927.00 100.00 10205 3023.51


suffered dull pain (89%) followed by sharp pain(33%), tingling and burning pain (22%) andcutting pain by 11%. Only one male subjectsuffered from dull and sharp pain. Of the sevenfemale technologists who experienced neck pain,all of them experienced dull pain, two experiencedsharp pain and tingling and one experiencedburning pain. Similarly, dull pain in shoulderwas experienced by all five female subjects report-ing shoulder pain. Two of them had sharp andburning pain in shoulder and one of them hadcutting pain. Upper-back pain was experienced bytwo women and one man and they all experienceddull pain. One male and one female subjectsexperienced sharp pain and one female experi-enced burning and cutting pain. Two femaletechnologists had dull and burning pains in their

mid-back and one had sharp and cutting pain. Outof all the female technologists who suffered low-back pain, 92% had dull pain, 42% had sharppain, 25% had tingling pain and 33% of them hadburning pain. The male technologist sufferingfrom low-back pain had dull and sharp pain atdifferent stages. Buttocks pain was reported onlyin female technologists. Among those reportingsuch pain 75% had dull and sharp pain, 50% hadtingling and 25% had burning pain. Only onefemale technologist had lower-arm dull, tinglingand cutting pain. Similarly, one female technolo-gist had pain in her thighs which was dull, sharp,tingling and burning. Finally, two female technol-ogists had pain in their legs which was dull andsharp, and one had tingling and burning.

3.4. Current back pain profile

Eighty-three percent of the female technologistshad back pain at the time of data collection. Theirback pain was aggravated by lifting, pace of work,and heavy workload in addition to bending,twisting, and overexertion (Table 3). In themajority of cases relief was obtained by resting,massage, heating/ice and exercise (Table 3).Among the subjects who currently suffered fromlow-back pain three of them had suffered only oneepisode, nine had suffered two episodes, three had

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Table 3

Back pain profile: aggravating and relieving factors

Subcode Pain from Pain relieved with

F1 Lifting Physio manipulation, anti-inflammatory drugs

F10 Working areas where there is a lot of pulling, lifting Stretches and a night of sleep

F11 Bending over the wrong way Back exercises

F12 Physical activity Rest, stretching

F13 Lifting wrong, sneezing, standing up too fast, stress Ibuprofen, MEP (medication)

F14 Lifting wrong, or no cause Time

F15

F16 Standing in the same position, sitting too long Walking, changing positions

F17 Strain, overwork Ice, rest and exercise

F18 Overworking, under staffed Resting

F2 At the end of a busy day—no particular activity seems to

aggravate it, high frequency of activity

Rest, lying on back knees bent, heat on affected area, anti-

inflammatory drugs

F3 Fatigue, stiffness Heat, stretching exercises, anti-inflammatory drugs

F4 Lifting head of stretcher to sit patients up, Golfing Rest

F5 Heavy workload Rest

F6 Working in certain areas; being on feet for long periods of

time; moving and/or lifting/holding patients

Rest

F7 A day of work Exercise, proper body mechanics

F8 Sitting in one spot for extended periods of time. After

continuous days of lifting and moving X-ray film when its

under a patient

Rest, massage, stretching

F9 Too much reaching up and pushing or pulling heavy

weights

Anti-inflammatory drugs and stretching exercises

M1 Stress, lifting at work Relaxation, hot bath, stretching

M2


suffered three episodes and two technologists hadsuffered four episodes. Only one of the technolo-gists had pain problems a year later than injury,another had unpleasant pain, four unpleasant lightor intense pain in 6 months after suffering theinjury, five at 3 months and nine at 1 month afterthe injury. Fifteen of the episodes were resolved in2 weeks and another six episodes resolved in 1week. The intensity of pain gradually declinedbetween 1 and 3 months but in some cases it stayedat a very intense level. No subject in the sample hashad any back surgery. However, four subjects hadreported time loss injury ranging between 0.14 to 3weeks due to back injury and back pain.

3.5. Current upper extremity pain profile

Fifty percent of the female sample and bothmale sample suffered from the upper extremitypain. Their pain was, in general, aggravated by theuse of upper extremity at work by lifting, excessive

use, pushing/pulling trauma-bay and mobile ma-chines, and in general requiring static contraction(Table 4). A relief was obtained by rest, relaxation,stretching, heat/ice, splint and medication. In twocases the pain continued even at 1-year mark.Thirty-nine percent of the female sample and

both males had dull pain. Twenty-two percent ofthe female sample had sharp pain. One of the twomales and 11% of the female sample had tinglingpain, and one male and 6% of female sample hadburning pain. Cutting pain was present in 11% ofthe female sample. Due to the upper extremitypain up to 8 weeks were taken off work.

3.6. Current job profile

3.6.1. Stressful tasks in the current job

Out of 25 tasks listed as task activities for theX-ray technologists, 21 were reported as stressfulfor the back and upper extremities by the femalesample. Similarly, other than three tasks all other

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Table 4

Upper extremity pain: aggravation and relief

Subcode Pain from Pain relieved with

F1 Pregnancy—anything requiring grasping and lifting was

extremely painful

Wearing custom splints mostly at night

F10

F11

F12 Static muscle activity

F13

F14 A specific lifting motion Rest

F15 Excessive physical use and or strenuous use Rest

F16

F17 Some machines used (Trauma Bay) Not using arm above shoulder height or abduction

F18 Lifting Cortisone injections, rest, physiotherapy

F2

F3

F4

F5

F6 Driving mobile machine; lifting/processing cassettes typing

(teach tech students 2.5 days/week) therefore, do a lot of work

on the computer

Relaxation

F7 Working Exercise, rest, proper body mechanics

F8 Sports related (overuse) Stretching

F9

M1 Sometimes from work, sometimes from home Relaxation, hot bath, stretching activities

M2 Excessive use of the right arm Tylenol, Ice


tasks performed by the male sample was foundstressful for back and upper extremity (Table 7).However, it is worth pointing out that the taskswhich were not stressful for the back were stressfulfor the upper extremity, and the reverse was true aswell. Thus, there were no tasks which were notstressful. Manually lifting patients from wheel-chair, transferring patient using spine board andrepositioning cassette under patients were assessedto be stressful for back by 78%, 67% and 50% ofthe female subjects, respectively. Carrying cas-settes in one hand, loading/unloading multi-loaderusing hand and repositioning cassettes were foundto be stressful for upper extremity by 50%, 39%and 44% of female technologists, respectively(Table 5). Similar responses were also obtainedfor male sample, with the addition of pushing orpulling the X-ray tubes.In rank ordering, the female sample selected

carrying cassettes in one hand, holding patient inone position, and lifting patient and positioningcassette under the patients at the same time mostdifficult tasks for their back (Table 6). For the

upper extremity they found lifting and positioningcassette under patients at the same time, manuallylifting patients from the wheelchair, manuallytransferring spine board, pushing/pulling wheel-chair with one hand and holding intravenous dripin the other, raising stretcher head into a sittingposition, repositioning the patients in horizontalposition, repositioning patients in bed to uprightposition, and transferring patients to/from X-raytable as most stressful tasks. The male samplefound repositioning cassettes under patients andwearing lead aprons as the most stressful tasks.Out of the six work areas (emergency, fluoro-

scopy, general radiography, mobile radiography,operating room, outpatients and trauma theatre),most people spent 3–5 days in each area byrotation. Emergency room, general radiographyand mobile radiography were ranked as hardestfor the back and upper extremity (Table 7).The physical workspace available to technolo-

gists was deemed adequate for the task at hand‘‘mostly’’ by 28% and ‘‘sometimes’’ by 62% of thefemale sample. Only 22% of the technologists felt

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Table 5

Stressful tasks at work for back and upper extremity

Back

(yes)

% Back

(yes)

% Back

(no)

Upper ext

(yes)

% Upper ext

(yes)

% Upper ext

(no)

Female

Carrying cassettes one hand 2 11.1 88.9 9 50.0 50.0

Holding lower extremities of pediatric pts 1 5.6 94.4 0 0.0 100.0

Holding patient in position 2 11.1 88.9 3 16.7 83.3

Lifting pt and positioning cassette under pt at the

same time

1 5.6 94.4 1 5.6 94.4

Loading or unloading cassette bucky 0 0.0 100.0 3 16.7 83.3

Loading or unloading multi-loader one hand 0 0.0 100.0 7 38.9 61.1

Manually lifting patients from wheelchair 14 77.8 22.2 4 22.2 77.8

Manually lowering patient to wheelchair 2 11.1 88.9 0 0.0 100.0

Manually transferring spine board patient (stretcher

to/from X-ray table)

12 66.7 33.3 4 22.2 77.8

Moving furniture 0 0.0 100.0 1 5.6 94.4

Moving lead screens in OR 0 0.0 100.0 1 5.6 94.4

Pushing or pulling a bed 1 5.6 94.4 0 0.0 100.0

Pushing or pulling mobile radiography machine 5 27.8 72.2 5 27.8 72.2

Pushing or pulling stretcher one hand; IV/med line

one hand

4 22.2 77.8 6 33.3 66.7

Pushing or pulling wheelchair one hand; IV/med

line one hand

5 27.8 72.2 5 27.8 72.2

Pushing or pulling X-ray tube 5 27.8 72.2 6 33.3 66.7

Raising head of stretcher into sitting position 0 0.0 100.0 1 5.6 94.4

Repositioning cassette under patient 9 50.0 50.0 8 44.4 55.6

Repositioning patient in bed horizontally 4 22.2 77.8 2 11.1 88.9

Repositioning patient in bed to upright position 7 38.9 61.1 5 27.8 72.2

Repositioning patient on side in bed or stretcher 4 22.2 77.8 3 16.7 83.3

Transferring patient (stretcher to/from X-ray table)

using sheet

3 16.7 83.3 0 0.0 100.0


using slide board

4 22.2 77.8 1 5.6 94.4

Trauma Bay changing cassettes 1 5.6 94.4 1 5.6 94.4

Wearing lead aprons 4 22.2 77.8 3 16.7 83.3

Male

Carrying cassettes one hand 0 0.0 100.0 2 100.0 0.0

Manually lifting patients from wheelchair 2 100.0 0.0 1 50.0 50.0

Manually lowering patient to wheelchair 1 50.0 50.0 1 50.0 50.0



1 50.0 50.0 0 0.0 100.0


one hand

1 50.0 50.0 1 50.0 50.0

Pushing or pulling X-ray tube 0 0.0 100.0 2 100.0 0.0

Repositioning cassette under patient 2 100.0 0.0 1 50.0 50.0

Repositioning patient in bed horizontally 0 0.0 100.0 1 50.0 50.0

Repositioning patient in bed to upright position 1 50.0 50.0 0 0.0 100.0


using slide board

1 50.0 50.0 0 0.0 100.0

Wearing lead aprons 1 50.0 50.0 1 50.0 50.0


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Table 6

Work tasks—rankings

Back rank Upper ext rank

Mean Std. dev. Min. Max. Mean Std. dev. Min. Max.

Female

Carrying cassettes one hand 1 2 0 5 2 2 0 5

Holding lower extremities of pediatric pts 3 — 3 3 0 — 0 0

Holding patient in position 1 2 0 4 3 2 0 5

Lifting pt and positioning cassette under pt at the

same time

1 — 1 1 1 — 1 1

Loading or unloading cassette bucky 0 0 0 0 4 2 2 5

Loading or unloading multi-loader one hand 0 0 0 0 3 1 1 4

Manually lifting patients from wheelchair 2 1 0 5 1 2 0 5

Manually lowering patient to wheelchair 3 1 2 3 0 0 0 0



2 2 1 5 1 1 0 3

Moving furniture 0 — 0 0 4 — 4 4

Moving lead screens in OR 0 — 0 0 5 — 5 5

Pushing or pulling a bed 5 — 5 5 0 — 0 0

Pushing or pulling mobile radiography machine 2 2 0 5 2 2 0 5


one hand

2 2 0 5 3 2 0 5

Pushing or pulling wheelchair one hand; IV/med

line one hand

2 2 0 4 1 1 0 4

Pushing or pulling X-ray tube 3 2 0 5 3 2 0 5

Raising head of stretcher into sitting position 0 — 0 0 1 — 1 1

Repositioning cassette under patient 2 2 0 5 2 2 0 5

Repositioning patient in bed horizontally 3 1 2 4 1 2 0 3

Repositioning patient in bed to upright position 3 2 0 5 1 1 0 3

Repositioning patient on side in bed or stretcher 3 2 1 5 3 2 0 5


using sheet

3 1 2 4 0 0 0 0


using slide board

3 1 2 4 1 2 0 4

Trauma Bay changing cassettes 2 — 2 2 3 — 3 3

Wearing lead aprons 2 2 0 5 2 2 0 5

Male

Carrying cassettes one hand 0 0 0 0 3 0 3 3

Manually lifting patients from wheelchair 3 3 1 5 2 3 0 4

Manually lowering patient to wheelchair 2 — 2 2 5 — 5 5



5 — 5 5 0 — 0 0

Pushing or pulling stretcher

one hand; IV/med line one hand

1 — 1 1 5 — 5 5

Pushing or pulling X-ray tube 0 0 0 0 2 0 2 2

Repositioning cassette under patient 3 1 2 4 1 1 0 1

Repositioning patient in bed horizontally 0 — 0 0 4 — 4 4

Repositioning patient in bed to upright position 3 — 3 3 0 — 0 0


using sl

4 — 4 4 0 — 0 0

Wearing lead aprons 2 2 0 3 1 1 0 1


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Table 7

Work areas

Duration (days) Back Rank Upper Ext Rank

Mean Std. dev. Max. Min. Mean Std. dev. Max. Min. Mean Std. dev. Max. Min.

Female

Emergency room 4 2 7 0 2 1 6 1 2 1 4 0

Fluoroscopy 5 2 5 0 4 1 5 2 3 3 7 0

General radiography 4 2 7 0 2 1 4 1 2 1 3 0

Mobile radiography 5 2 7 0 2 1 5 1 2 1 5 0

Operating room 4 2 5 0 4 1 6 1 3 2 6 0

Outpatients 4 3 7 0 5 3 7 0 5 3 7 0

Trauma theatre 3 3 7 0 4 2 6 0 3 3 6 0

Male

Emergency room 5 0 5 5 3 0 3 3 4 1 5 3

Fluoroscopy 4 1 5 3 2 0 2 2 2 0 2 2

General radiography 4 1 5 3 3 2 4 1 3 2 4 1

Mobile radiography 5 0 5 5 3 2 4 1 2 1 3 1

Operating room 4 1 5 3 6 1 6 5 5 1 5 4

Outpatients 3 — 3 3 7 — 7 7 7 — 7 7

Trauma theatre 4 4 7 1 6 1 6 5 6 0 6 6


that they were ‘‘always’’ able to ask for help fromtheir coworkers, while 56% felt that they could‘‘mostly’’ ask and 17% could ask for help ‘‘some-times’’. Twenty-eight percent never found theirshift work difficult while other 28% found itsometimes, 17% always and 11% mostly difficult.Among the female technologists 11% of subjectsfelt that they had information only sometimes toperform their tasks safely. Other 44% and 39%felt that they had this knowledge ‘‘always’’ and‘‘mostly’’, respectively. Fifty percent of the tech-nologists felt that they were able to control thepace of their work only ‘‘sometimes’’ and 39% feltthat they could ‘‘never’’ control the pace.Of the female sample 67% of the technologists

mostly, 17% always, and 11% sometimes likedtheir jobs. The small sample of male subjectsmostly liked their jobs. Fifty percent of the femalesample and one of the two males felt that they onlysometimes have the right equipment to do theirjobs safely. The other 44% of the female samplefelt that they mostly have the equipments, whichallowed them to do their jobs safely. The time linesto complete their tasks was thought realistic byone of the two males and 44% of the femalesamples; and, the other male and 44% of the

female samples believed it to be only sometimes.Both males and 78% of the female sample thoughtthey were able to take their scheduled breaks. Inthe female sample 11% and 6% thought that theywere able to take their scheduled breaks alwaysand sometimes, respectively. Interestingly bothmales and 28% of the female samples, found theirjobs repetitive. Six percent and 44% of the femalesample found that their jobs were always andmostly repetitive, respectively. The flow of thework was felt to be well planned sometimes by oneof the two males, 56% of the female sample. Theother 50% of the male sample and 17% of thefemale sample felt that workflow was never wellplanned. Twenty-two percent of the female sub-jects believed that the work was mostly wellplanned. Fifty percent of the females found theirjobs to be always stressful. The jobs wereestimated to be sometimes stressful by one of thetwo males and 33% of the female sample.

4. Discussion

The survey results as well as personnel dataobtained from the two hospitals revealed that the

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entire workforce of X-ray technologists was arelatively young group of people ranging in agebetween 21 and 58 years. Furthermore, 89% of thetechnologists led a physically active life. The mostcommon physical activity performed by them waswalking. In addition, 44% indulged in recreationalactivities. One would normally expect youngpeople leading physically and recreationally activelife style to be healthy and free from morbidity.However, 83% of the female sample suffered fromback pain. Two of the subjects had had fourepisodes of back pain, another three had threeepisodes, nine more had two episodes and the lastthree had their first episode. A high frequency ofincidence and frequent recurrence of back pain isindicative of unusually high morbidity and riskfactors in the occupation. This observation getsfurther support from the fact that at one of thehospitals more than one-third of the sample wasunder 30 years of age and had a work exposure ofonly 5 years or less. Similarly, two-thirds of thesample was under 40 years of age with workexperience of 10 years or less. In a 4 year periodfrom 1996 to 1999, the Diagnostic ImagingTechnologists at Site A had reported 55 injuries.The bulk of those injuries were reported to beoverexertion and manifested themselves as sprainand strain. Back, neck, shoulder and upperextremities were mostly the organs affected andtogether they accounted for 55% of all injuries. AtSite B, technologists reported 94 cases in a periodof 2 years (1998–2000), 53% of these claims werethought to result from the musculoskeletal stres-sors, and 56% of the claims were sprain and strainwith the back most frequently affected (28%).These data demonstrate unambiguously that theprofession of technologists is hazardous and theorgans affected are those which are subjectedto overexertion. Furthermore, at Site B itelucidates that older workers have moreproblems of musculoskeletal nature. This couldbe mediated through either age (42 out of 50between 31 and 55 years) or due to much longerexposure to work stress (86% had worked for upto 20 years). It is also likely that an interactionbetween these two factors resulted in significantlyhigher incidence rate in the workplace at the otherhospital.

However, the only study which has reported aquantitative assessment of biomechanical load onX-ray technologists characterizes it as quitedemanding (Kumar et al., 2003). They reportedthat the tasks such as repositioning patientshorizontally and lifting patients from wheelchaircaused a lumbosacral compression of 7936 and8335N, respectively. Both these values exceed themaximum permissible limits as set out by NIOSH.Out of 16 tasks studied by Kumar et al. (2003),another four tasks exceeded the action limit by asignificant margin. In addition, another five tasks,though below action limit, were quite close to it.These and other several activities were notsporadic but rather repetitive. Given the muscu-loskeletal morbidity reported among X-ray tech-nologists here and biomechanical demands of thetasks they perform elsewhere (Kumar et al., 2003),it is arguable that the occupational loads are likelycausally associated with the morbidity observed.Such an assertion is based on temporal relation-ship, biological and mechanical plausibility andhigh level of morbidity outcome reported here. Alimitation of this study is that it had only a smallsample. Moveover, every effort was made that thesample selected was a random one. Hence general-izability of the findings is highly likely. However,given face-to-face questionnaire/interview with arandomly selected sample, the authors haveconfidence in the results presented to represent ageneral picture.While the foregoing evidence is convincing and

more than circumstantial, it is noted that it doesnot necessarily illustrate cause and effect inclassical sense of the term. The latter can bedemonstrated only if rigidly controlled experimen-tal manipulation of human subjects with incre-mental doses of exposures were administered andoutcome measured. However, such an approachwill be unacceptable due to ethical reasons. Due tothis limitation in extending rigorous experimentaldesign to human related issues, some deny anycausalty. For instance, Hadler (2000) alleges that,‘‘because a patient of angina suffers pain whenclimbing a flight of stairs, the musculoskeletalscientists may assign angina to stair climbing andpropose an escalator as a solution to the pro-blem’’. This analogy is fundamentally flawed. It’s

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inappropriateness and dissimilarities with muscu-loskeletal disorders can be argued at length but itwill suffice to say that an inability to provethrough a rigidly controlled experimental regimedoes not mean that a compelling empiricalevidence is only incidental. Particularly when suchevidence is abundant around us in scores of studiespublished in scientific literature (Kumar, 1990;Kumar et al., 2003; Frost and Anderson, 1999;Alund et al., 1994; Nordander et al., 1999;Fredricksson et al., 1999; Gorsche et al., 1999;Latko et al., 1999; Latza et al., 2000; Smedley et al.,1997 and many more).Other authors (Videman and Battie, 1999) claim

that if usages were altered over the course of alifetime, it will make no difference on the like-lihood and pattern of degenerative joint disease.These conclusions were drawn on the basis ofevidence obtained from the twin registry ofFinland. The authors ascribe less than 2% effecton the degeneration of spinal intervertebral discsto biomechanical loads. It is important to notethat the lifetime exposure to biomechanical loadwas determined by a 15-min interview in thisstudy. Such an approach and methodology is atbest questionable for the conclusions drawn.It needs to be stated here that biological tissues

which suffer degradation, insult or injury arephysical materials and respond to biomechanicalloads undergoing deformation. The deformationin turn for the duration of strain does also changephysiological homeostasis creating a biomechani-cal stress resulting from biomechanical load.Application of biomechanical load, by inducingstrain in the tissue, also changes the configurationof load distribution compounding the situation(Kumar, 2001).There is extensive scientific literature document-

ing that physical job demands are causallyassociated with musculoskeletal problems. Arecent review of these was captured in a two-partpaper by Keyserling (2000a, b). The scientificevidence for work relatedness of musculoskeletalinjuries includes epidemiological and biomechani-cal studies. Such a concurrence of evidence fromtwo directions clearly indicates biological andmechanical plausibility. Injuries, clearly, are me-chanical phenomena. For injuries to precipitate, a

structural basis is a prerequisite. Structural insultcan be caused to structures of any genetic makeupfor any psychosocial milieu through mechanicalmeans. Thus injury is a mechanical perturbation(Kumar, 2001). The odds of finding so manystudies which link occupational factors to injuriesin so many different experimental design andmethods in so many countries would be extremelysmall if ergonomic stressors were not trulyhazardous to the musculoskeletal system (Punnett,2000).

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Morbidity among X-ray technologists

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