Up to 90% of sonographers and other operators of diagnostic medical sonography report having painful work-related injuries affecting the muscles, nerves, ligaments, or tendons.¹ These work-related musculoskeletal disorders (WRMSDs) result from the multiple times a day the operators repeatedly make the same movements and maneuvers while performing ultrasound examinations.² For the ultrasound operator, the most common locations of WRMSDs include the shoulder, neck, wrist, and hands, and the results of WRMSDs can lead to serious health issues, absenteeism, presenteeism, and even leaving the field of ultrasound altogether.³

The following are some of the critical factors that can lead to the development of WRMSDs:

• Poor ergonomics, including poor posture and machines with poor ergonomic design.³
• Poor workflow, including the positions of the machine, bed, and workstation, leads to unnecessary arm abduction and overreaching.³
• Lengthy exams with an increasing workload and number of exams to be performed during the workday.⁴
• Inadequate breaks between examinations in addition to an increasing workload.⁵
• Psychological stress and psychosocial factors in the workplace.⁶
• Unsupportive or inflexible environments that fail to account for the diverse abilities and experiences of individual operators.⁷

The Occupational Safety and Health Administration has placed the primary responsibility for protecting workers on the employer.^8,9 So, when developing WRMSD prevention protocols, administrators should collaborate with ultrasound operators to create policies that support their safety.¹⁰ Such policies should take into account scheduling to limit overtime work and provide breaks, staffing levels to optimize patient care, proper ergonomic equipment and adjustable equipment, and room designs that facilitate proper ergonomics, such as adequate space for patients and equipment. The workplace culture should support wellness and also have transparent policies regarding reporting and tracking of WRMSDs.

The operator also needs to ensure their working space is set up in the best manner possible for preventing WRMSDs during their workday. They can do so by customizing their ultrasound environment to promote proper ergonomic technique.

1. At the beginning of each examination, the operator should properly position and make adjustments depending upon the body habitus of each patient.¹¹ Reaching movements should be avoided by keeping the operator, machine, bed, and patient as close together as possible and at appropriate heights.
2. The operator’s head and the screen/monitor should be on the same axis, and the eye-screen distance should be at least 60 cm. The top of the screen should be aligned with the level of the operator’s eyes; then, the top of the screen should be tilted back slightly to encourage proper neck posture.^11,12
3. The operator’s neck should be straight, and neck extension should be avoided.⁶
4. The operator should be positioned in order to allow the arm to be in a relaxed position with the upper arm close to the body (minimal flexion, ideally abduction <30 degrees) and the elbow at a 90-degree angle, ie, the forearm should be horizontal to the floor allowing the shoulder to remain in a neutral positionwhenever possible.
5. A “wearable transducer cable support device,”¹³ such as a cable brace, can be utilized to reduce arm strain during scanning. Also, the ultrasound transducer cable should not be passed around the operator’s neck as any traction force could result in a poor neck position.^11,12
6. A scanning chair should be equipped with a backrest for lumbar support and adjustable height to mold the lumbar lordosis. Moreover, a seatback inclined between 10° and 20° is recommended. The back should be well supported on the seat. A slight gap should remain between the edge of the seat and the back of the knee, and the body should be on the axis of the screen. The chair should be height adjustable so the operator can be properly positioned relative to the patient and ultrasound system. Exam chairs should not have armrests as they may restrict access to the patient.
7. Exam tables should be height adjustable to encourage proper positioning by minimizing extended reaching, elevated arms, and wrist deviation, and allowing operators to stand and/or sit while performing procedures.
8. The ultrasound machine keyboard should be easy to move and adjust.
9. Removing the transducer from the patient and relaxing the hand to allow for brief micro-breaks during the examination can help reduce muscle strain.
10. With the exception of point-of-care imaging, portable diagnostic exams should be limited to critically ill patients and those patients who are unable to come to the ultrasound department.

Specific types of ultrasound examinations also bring unique challenges. Some of these challenges are addressed, by specialty, in the AIUM Practice Principles for Work-Related Musculoskeletal Disorder.¹⁴

Increased awareness of the magnitude of the problem and local quality improvement (QI) efforts are necessary to ensure that these standards are translated into the successful reduction of WRMSDs among ultrasound operators.

A QI program should include ongoing tracking or logging of the following:

• Ergonomic education for employees
• Safety and resource utilization
• Equipment updates
• The numbers and types of reported symptoms and/or injuries, and
• Organizational (ie, policies and practices) changes or updates made to improve employee safety and well-being.

A review of these data, along with a status check on overall workplace culture and worker well-being, should be conducted annually. To do so, a QI team composed of individuals from all levels of the organization (eg, administration, management, staff) should review aggregated data from tracking logs and any annual workplace environment reports to identify and prioritize areas for improvement.

The protection of our frontline workforce is paramount in retaining individuals with valuable skills. This protection requires a change in industry mindset that acknowledges the shared responsibility among both employers and ultrasound operators.

This post was created from the AIUM Practice Principles for Work-Related Musculoskeletal Disorder, which was developed by the American Institute of Ultrasound in Medicine in collaboration and with the expressed support of the American College of Emergency Physicians (ACEP), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR), American Registry for Diagnostic Medical Sonography (ARDMS), American Society of Echocardiography (ASE), Australasian Society for Ultrasound in Medicine (ASUM), Fetal Heart Society (FHS), Intersocietal Accreditation Commission (IAC), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), Perinatal Quality Foundation (PQF), Society of Diagnostic Medical Sonography (SDMS), and Society for Maternal-Fetal Medicine (SMFM). The Practice Principle was developed to expand on the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography”¹³ to include safety practices for all health care professionals who utilize ultrasound.

References

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8. United States Department of Labor, Occupational Safety and Health Administration. Ergonomics website. https://www.osha.gov/ergonomics. Accessed November 12, 2021.
9. United States Department of Labor, Occupational Safety and Health Administration. Solutions to control hazards website. https://www.osha.gov/ergonomics/control-hazards. Accessed November 12, 2021.
10. United States Department of Labor, Occupational Safety and Health Administration. Identity problems website. https://www.osha.gov/ergonomics/identify-problems. Accessed November 12, 2021.
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12. BP Bernard (ed). Musculoskeletal Disorders and Workplace Factors; A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. U.S. Department of Health and Human Services July; 1997 DHHS (NIOSH) Publication No. 97B141.
13. Industry standards for the prevention of work related musculoskeletal disorders in sonography. J Diagn Med Sonogr 2017; 33:370–391.
14. AIUM practice principles for work-related musculoskeletal disorder [published online ahead of print January 24, 2023]. J Ultrasound Med. https://doi.org/10.1002/jum.16124.