Ergonomics and Musculoskeletal Issues in Sonography

History of Work-Related Musculoskeletal Disorders in Sonography

Awareness of pain and discomfort associated with the occupation of sonography surfaced around 1980, just before the widespread use of real-time scanners. The most common complaint was shoulder pain in the sonographer’s scanning arm. The increasing number of complaints reached the attention of Marveen Craig, a well-known sonographer, educator, and author. Craig published an article in 1985 summarizing the results of a survey done of 100 sonographers who had between 5 and 20 years of scanning experience. The survey respondents complained of stress and burnout, vision problems that improved when images switched from black on white to white on black, infections, and allergies. Electric shock was not uncommon, especially when doing bedside studies and removing transducers from static scanners' articulated arms. Muscle strain involving the wrist, base of the thumb, and shoulder was also reported. Sonographers complained of heavy transducers and cables, and carpal tunnel syndrome claimed its first victim. The term sonographer’s shoulder came into use.

In the early 1980s, ultrasound systems underwent a complete redesign to real-time two-dimensional scanners, and although articulated arm scanners were used for many more years, real-time scanners were slowly introduced to most facilities.

As more real-time systems came into use, the sonographer’s shoulder appeared to diminish. However, this decline lasted only 10 years, and by 1995 the Society of Diagnostic Medical Sonography (SDMS) started receiving increasingly more and varied complaints. In 1997 an extensive 125-question survey was developed by the Health Care Benefit Trust of Vancouver Canada (HBT), in collaboration with the SDMS, the Canadian Society of Diagnostic Medical Sonography (CSDMS), and the British Columbia Ultrasound Society (BCUS). Through this survey, the incidence of work-related musculoskeletal disorder (WRMSD) was found to be 81% in the United States and 87% in Canada, for a combined average incidence in North America of 84%.

In 2008 a follow-up survey was conducted, and the incidence increased from 81% to 90% in the United States. Several variables may account for this increase: an aging workforce, increased awareness of WRMSD among sonographers, and increased willingness by sonographers to report an injury.

History of the Occupational Safety and Health Administration’s Involvement in Sonography

In 1970 Congress passed the federal Occupational Safety and Health (OSH) Act . The purpose of the OSH Act is to ensure, as far as possible, that every working man and woman in the nation has safe and healthful working conditions. Employers may be subjected to civil and sometimes criminal penalties if they violate this act.

The OSH Act is administered by the Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor, although individual states could create their own agency to enforce the act. Approximately 50% of the states opted to be regulated by the federal OSHA. The other states created their own agencies, which operate under a “state plan.” For example, California has a state plan and created its own agency, Cal/OSHA, to enforce safety regulations within that state.

Where industry-specific guidelines do not exist within the OSH Act, the general duty clause can be used. Lawyers representing injured sonographers seeking legal recourse refer to this clause. The criteria for applying the general duty clause are as follows:

• No acceptable standard for an industry

• Exposure to hazard that causes serious physical harm

• Hazard is recognized by the industry

• Feasible abatement method exists to correct the hazard

Section 5B of the general duty clause states that each employee shall comply with occupational safety and health standards and all rules, regulations, and orders issued pursuant to this act that are applicable to his or her own actions and conduct.

It is under the provisions of paragraph 5 A (1) that the OSH Act addresses ergonomic disorders. The language in paragraph 5B gives the impression that the employee holds significant responsibility for complying with health and safety standards; however, the employer bears most of the responsibility for compliance in the eyes of OSHA.

Over the years, OSHA has used many different labels for occupational injury:

• Cumulative trauma disorder (CTD)

• Repetitive motion injury (RMI)

• Overuse syndrome

• Repetitive strain injury (RSI)

• Musculoskeletal strain injury (MSI)

The term work-related musculoskeletal disorder (WRMSD) is currently in use. WRMSD incidents are defined as injuries that result in (1) restricted work, (2) days away from work, (3) symptoms of musculoskeletal disorder (MSD) that remain for 7 or more days, and (4) MSD requiring medical treatment beyond first aid.

According to Liberty Mutual, which collects data on WRMSD and the associated costs, repetitive motion injuries cost U.S. industries $2.3 billion per year. Ultrasound examination specialties such as echocardiography, high-risk obstetrics, and to a lesser extent, vascular sonography involve repetitive motion.

Liberty Mutual also reports that 95% of chief executive officers support workplace safety. Benefits include improved employee health. Indirect costs such as morale, productivity, and hiring of replacement staff are significantly reduced, whereas direct costs such as wage replacement and medical expenses are avoided.

Over the years, the Department of Labor received numerous requests from workers’ unions to create a way for employees to deal with their WRMSDs. This resulted in an Alliance Program, which enables organizations to work with OSHA to prevent workplace injuries by educating and leading employers and their employees in advancing workplace safety and health.

In May 2003, an International Ultrasound Industry Consensus Conference was hosted by the SDMS to develop injury risk-reducing standards to address the problem of WRMSDs in sonography. Twenty-six organizations represented by 32 participants attended the conference to discuss designing new platforms and procedures that incorporate better ergonomics. The industry standards address the role of employees and employers, educators, medical facilities, and equipment manufacturers in reducing the impact of these injuries on the workforce and are intended to assist all stakeholders in making informed decisions.

Separately, but at the same time, administrators addressed the issues of workload, scheduling, and room size, while sonographers discussed best practices, education, and training. The need for accredited programs to include curricula related to ergonomics and injury prevention and certifying bodies testing knowledge of risk factors was covered.

Definitions

WRMSDs are injuries of muscles, tendons, and joints caused by or aggravated by workplace activities. These injuries are the main reason for long-term absence among health care workers, accounting for up to 60% of all workplace illnesses. Survey data have shown that more than 80% of sonographers have some form of MSD that can be attributed to their work activities.

Surveys

Table 3.1 outlines the numerous surveys that have been conducted on the incidence of this injury in sonography. These surveys have produced other data relevant to the study of occupational injury in ultrasound, and their results support the presence of risk factors in the sonography profession. Several other factors contribute to reported injury rates, including worker awareness, unwillingness to work in pain, busier patient schedules, job dissatisfaction, an aging workforce, and workplace computerization.

A positive relationship has been demonstrated between the severity of WRMSDs and the performance of repetitive work tasks or tasks that require forceful movements, with or without repetitive motion. Increased use of technology has resulted in workers’ accomplishing the same work tasks with fewer movements. Thus the relationship between the user and the workstation equipment has become “frozen,” and the worker is often forced into a static posture. This combination of repetitive motions and prolonged static postures results in musculoskeletal discomfort and eventually injury.