American Osteopathic College of Occupational and Preventive … · 2012-10-06 · American...

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012

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Ergonomic Injuries in Ultrasonographers

Pierce Sherrill, DOAurora Medical GroupGtreen Bay, Wisconsin

Ergonomic Injuries in Ultrasonographers

Description:

Technical contact:

Content contact:

This course describes risk factors for, andappropriate responses to, ergonomic injuries inultrasonographers.

Objectives:

-Participants should be able to identify risk factors, injuries, andtreatments for injuries in ultrasonographers;-Participants should be able to name at least three effectivestrategies for prevention of ergonomic injuries in this group ofworkers;-Participants should be able to teach effective postural andworkstation adjustments to minimize risk of injury in this group.

Objectives

• How and Why Injuries Occur

• Common Musculoskeletal Disorders (MSD’s)

• Correct Postural Alignment

• The Ergonomic Workstation

• Adaptive Equipment

• The Importance of Exercise

How Injuries Occur

• Musculoskeletal Disorders (MSD’s) is a term used to describecumulative trauma disorders to the soft tissues of the body

• Work related MSD’s (WMSD’s) are well documented andrecognized as an occupational hazard for sonographers

• 80% of sonographers are scanning in pain and 20% of theseeventually have a career ending injury¹

• “On average, within 5 years of entering the profession,sonographers experience pain while scanning.”²

- ¹David S,: Importance of sonographers reporting work-related musculoskeletal injury: a qualitative view. J Diagn Med Sonography2005;21:234-237

- ²Industry standards for the prevention of work-related musculoskeletal disorders in sonography: consensus conference on work-relatedmusculoskeletal disorders in sonography. J Diag Med Sonography 19:281 Sep_oct 2003, 281-286.

Why Injuries Occur

Physical demands include:

• Lifting, carrying, pushing and pulling more than 35 lbs.

• Long reaches away from the base of support

• Standing continuously

• Forceful gripping

• Squatting, crouching, stooping

Musculoskeletal Disorders

Risk Factors in Sonography:

• Repetition

• Forceful movement

• Static positions

• Prolonged exertion

• Awkward postures

• Heavy lifting or pushing /pulling

• “One study suggested that sonographers who perform more than100 scans a month are at risk for WRMSD… the majority ofsonographers perform at least three times that figure.”¹

- ¹Gibbs V and Young P,Methods to prevent work-related musculoskeletaldisorders amongst sonographers. Synergy July 2011.


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Risk Factors - Repetition

• Doing the same scanrepeatedly throughout the day

• Moving the arm and hand inthe same way during a scan

Risk Factors – Forceful Movements

• Sonographers can place up to40 lbs. of pressure during ascan

• Static positioning with thisamount of pressure rapidlycauses muscle fatigue

Risk Factors – Awkward Postures Risk factors – Heavy Lifting

• Moving beds duringbedside exams, movingand transferring patientsand lifting laundry are allexamples of heavy lifting

Conditions

Sonographers are particularly vulnerable tothe following injuries:

Conditions

Carpal Tunnel Syndrome

• Compression of the median nerve in the volar aspect of wrist

• Produces numbness and radiating pain in the radial-palmar aspectof hand

• Produces sensory deficit in the palmar aspect of the first 3 digitsand/or weakness of thumb opposition

• “…63% of all the respondents [in a survey of sonographers] hadsymptoms of CTS at some point in their careers.”

- Mercer, R, Occupational health hazards to the ultrasonographer and theirpossible prevention. J Am Soc Echocardiography 10;4 May 1997


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Carpal Tunnel Syndrome - Treatment

• Rest

• Rigid splinting at night and rest periods

• Soft neoprene splinting while at work

• Postural Education – shoulders down and back and neck retraction

• Daily nerve glides

• Stretching

• Occupational therapy, corticosteroid injection, surgery

Conditions

Tendonitis/Tenosynovitis

• Inflammation of the lining of the tendon sheath and enclosed tendon

• Tendons are painful with motion with localized pain along the

tendon

• May be mild to severe; may occur at rest or with movement

Tendonitis-Treatment

• Rest

• Splinting at night and during rest periods

• Alternate heat/ice (heat before shift and ice after shift or difficultexam)

• Stretching program

• When pain is resolved, strengthening is indicated

• Corticosteroid injection; surgical release in extreme cases

Epicondylitis

• Caused by a strain of the forearm muscles and their tendinousattachments to the humeral epicondyle

• Lateral Epicondylitis (tennis elbow)- Pain with resisted wrist extension

- Usually associated with palm-down lifting; occasionally with forceful supination

• Medial Epicondylitis (golfers elbow)- Pain with resisted wrist flexion

- Usually associated with palm-up lifting; occasionally with forceful pronation

• Pain is directly over the epicondyle and may cause weakness

Epicondylitis Treatment

• Rest

• Postural education – position arms close to the body while scanningor during heavy lifting

• Heat

• Forearm band/wrist splinting

• Nerve glides

• Stretching

• Injection; occasionally, surgical repair of tendon origin

Conditions

Trigger Finger

• Inability to fully flex or extend a finger; sometimes movement isassociated with a clicking sound

• Caused by the thickening of a tendon; it catches on the sheath as itglides in and out of the sheath’


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Trigger Finger Treatment

• Rest

• Sometimes, placing a band aid over the PIP joint will prevent thefinger from triggering

• Heat

• Corticosteroid injection; occasionally, surgical release of the tendonsheath

Conditions

DeQuervain’s Disease

• Thumb pain involving the abductor pollicis longus and extensorpollicis brevis muscle of the forearm

• Finkelstein’s test is usually diagnostic

• As with other forms of tenosynovitis, exclude other medicalexplanations:

- Poorly-controlled diabetes

- Rheumatic and other autoimmune disorders

- Athletic injury

- Reiter’s syndrome, systemic sclerosis, amyloidosis, type II hyperlipoproteinemia,disseminated gonococcal infection

DeQuervain’s Disease Treatment

• Rest

• Neoprene thumb spica splint while working

• Alternate heat and ice before and after shift or difficult scan

• Build up the handle of the transducer with foam or use a larger oneif possible

• Use the least amount of pressure possible while scanning; alternatedifficult scans that require a lot of pressure with easier exams

• Injections and/or tendon release if needed

Conditions

Shoulder Impingement

• Inflammation of the soft tissues in the shoulder girdle including therotator cuff tendons

• Produces localized or radiating pain in the shoulder or radiatingdown the arm

• Most prominent with the humerus horizontal (flexed or abducted)

Shoulder Pain Treatment

• Rest

• No overhead work at work and at home

• Postural education – shoulders down and back with neck retraction

• Keep shoulder in 30 – 60 degrees of abduction when scanning asoften as possible

• Alternate heat and ice

• Stretching

• Strengthening is indicated when pain subsides

Conditions

Thoracic Outlet Syndrome

• Pain and numbness/tingling in the hand, neck, shoulder or arms

• Caused by compression of the subclavian vessels and/or thebrachial plexus against a cervical rib or the scalene muscles

• Conservative treatment is similar to the recommendations undershoulder impingement

• Surgery (first rib resection) as a (very) last resort


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Postural Alignment – Shoulder/Neck

1. Shoulder blades backward,together and down

2. Tuck the chin in slightly;pull the head backward(make a double chin)

3. Hinge from the hips whenleaning or stooping over apatient during a scan

4. This position provides themost strength with the leasteffort while scanning

Posture

• Neck slightly retracted

• Shoulders down and back

• Ears over shoulders, overhips, with feet supported

• Should be a relaxed, uprightposition

Neutral Posture

Wrist Neutral Posture

• Wrist flexion causes nervecompression

• Wrist extension reducesstrength

• Neutral wrist positions provide

the best strength and comfort

Wrist Neutral Posture

• Sonographer should changebody position to get the wrist ina neutral position; or

• rest the wrist in a neutralposition after the scan

Posture

• Power Zone: the areabetween shoulders and hips

• This is the area where wehave the most power with theleast effort

• Work in the your power zoneas much as possible

• Adjust the table height as wellas change body position

Postural Alignment

• When you hold your arm in 90degrees of abduction yourmuscles will be fatigued in 10

minutes

• When you have to hold yourarm in this position – giveyourself frequent rest breaksand get out of this position assoon as possible


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Postural Alignment

• When you hold your arm in 60degrees of abduction you willhave 20 – 30 minutes beforeyour muscles will fatigue

Postural Alignment

• When you hold your arm in 30degrees of abduction you willhave approximately 60minutes before your musclesfatigue

• It is best for sonographers toscan with the arm in 30 -60degrees of abduction

• Resting or neutral position ofthe shoulder: less than 30degrees abduction

The Ergonomic Workstation

• Workstation set-up is very important --even if it helps for just part of the scan


• Position the ultrasound equipment parallel to the exam table and asclose to the nearest side of the table as possible


• Lower the table to its lowestposition

• Ambulatory patients shouldbe able to sit on the tablewith no help


• Position the patient toward theedge of the table so the patienttouches the sonographer’s hip

• If the patient cannot assist; usea Patran sheet to slide thepatient over.


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• Adjust the table height so thatthe sonographer’s forearm isparallel to the floor; or have thesonographer stand to do thescan


• Place towels or supportcushions to help support theforearm while scanning


• Position the monitor directly in front so that there is less twisting ofthe neck

• Sonographer’s eyes should be level with the top 2 inches of themonitor

• The monitor should be about arm’s length away

• Controls should be easily accessible. Central locking is preferable

The Ergonomic Workstation-Chair

• There is no universal chair.The idea of a chair is onlypresent in examples.

-Aristotle, 384-322 B.C.

• There is no perfect chair

• What is important isadjustability

The Ergonomic Workstation - Chair

• Adjust the chair so that legs are comfortable and parallel to the floorand so that the scanning arm is held as close as possible

• This may require adjusting the chair height and the control panel ofthe equipment

• If using the chair that is in these photos, the back of the chair canbe used to support the forearm



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• Place feet on footrests that areon the machine or the chair

The Computer Workstation-Chair Summary

• Place feet on the footrests in aneutral position

• Adjust the chair so that thelegs are comfortable andparallel to the floor

• Scanning arm – no more than30 degrees of abduction

Ergonomic Workstation - Gripping

• Avoid excessive force whengripping the transducer

• Only use the amount of forceneeded for the scan

• If a sonographer pushes downfor 5 seconds to obtain acertain view – he/she shouldrelease and recover for 15seconds before proceeding

• Develop “ambidextrous”scanning ability to use bothhands

Ergonomic Workstation - Gripping

• Wearing non textured glovesthat are too large increaseseffort up to 40%

• Wear gloves that fit

Correct Sitting Posture Correct Standing Posture


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Quick Tips for Postural Alignment

• Face Forward

• Keep spine in neutral

• Feet well supported

• Stabilize core muscles

• Keep hands/arms in front ofthe body

• Elbows at the side

• No reaching

• Wrists straight and level withelbows

• Forearms parallel to floor

• If sitting, thighs parallel to floor

• Movement is a MUST!

Adaptive Equipment

• Adaptive equipment can be used to remove or reduce the riskfactors in the workplace

• The following pieces of adaptive equipment are available throughvarious vendors:

Adaptive Equipment

• Place support cushions or abath blanket on the edge ofthe table betweensonographer and patient

• Support cushions areavailable throughwww.soundergonomics.com

Adaptive Equipment

• Gel Bottles should have large openings to reduce the strengthneeded to squeeze the bottle and a larger diameter to avoidextended grip position

Adaptive Equipment

Cable Brace

• Place the cable brace on theforearm of the scanning arm,just below the elbow to reducedrag from the cable

• This reduces the drag of thecord on the arm

• Cables should be long enoughto permit unrestricted use

Adaptive Equipment

The following options mayimprove patient positioningand reduce scan time and/orthe need for a 2nd caregiver:

• Slings are available to retractthe pannus(www.KanguruWeb.com)

• Breast slings and arm supportsare available(www.soundergonomics.com)

• For cardiac imaging a dropaway or cut out section willallow unhindered access to theapical region

• For endovaginal scanning –adjustable footboards andstirrups should be available

• Other options are placing thepatient in Trendelenberg orreverse Trendelenbergposition, upright table back.arm extensions and patientrestraints


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Safe Patient Handling – Patran Sheet

• The Patran Sheet to reducesfriction when moving a patienttoward the edge of the bed ortable

• There are other brands thatmay be available at your localhospital.

Safe Patient Handling

• Push the Patran sheetunderneath the patients hips,shoulders and legs

• Push the green Patran sheetunderneath the draw sheetwith your hands


• Pull the patient as close to theedge of the bed or table aspossible making sure it is safefor the patient


• Caregiver then pulls the Patransheet from under the patientso they don’t begin to slidedown

• Begin pulling it out fromunderneath the far leg andgently pull the Patran sheetfrom under the patient


• Simple and easy!

Safe Patient Handling Tips

• Use a gait belt to assist anambulatory patient to the table

• Always ask the patient toassist

• If more than one person isneeded for assistance – use alift instead

• Use a lift if the patient cannotbear weight or cannot followdirections

• Never boost or reposition apatient without a Patran Sheet


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The Reading Room Workstation

• Position the monitor directly infront of operator

• Eyes are level with the top 2inches of monitor

• Monitor should beapproximately an arm’s lengthaway

The Reading Room Workstation

• Lower the light level in theroom to eliminate glare

• Should be able to seecomfortably without straining

• Blue light is easiest on theeyes

Administrative Controls

Schedule and workload

• The same type of exams should not be scheduled together toprevent repetitive motion

• Bedside exams – do portable exams only when absolutelynecessary, not because it is more convenient

• Encourage exam rotation as much as possible


Breaks

• Enforce lunch breaks – do not give this up in order to take onmore patients or to leave on time at the end of the day

• Encourage mini breaks about every 8 minutes if possible. Putthe transducer down to relax the scanning arm


• Workload Distribution – Share all exams with other workers in thedepartment

• Certain exams may need two persons to do the procedure safely

• On call – Limit after-hours call to only one institution; try avoid on-call more than 24 hours at a time


• Do not insist on “textbook-perfect’ images if it is notneeded for the diagnosis.Communication with theordering physician is oftenhelpful.


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The Importance of Exercise

• Sonographers tend to overuse certain muscle groups. Thesemuscles become hypertrophied and the opposing muscle groupsbecome atrophied

• When opposing muscles groups are unbalanced, the risk of injuryincreases

• A complete fitness program will allow those opposing musclegroups to maintain their integrity to be able to provide the balanceneeded to support the overused muscles


Stretching before activity increases circulation, promotes the elasticityof the muscle and increases range of motion.

Sample Stretching Schedule

• Warm up:

• Patient 1

• Patient 2

• Rest Break

• Patient 3

• Patient 4

• Patient 5

• Lunch (Rest)

• Warm up

• Patient 6

• Patient 7 – Stretch

• Patient 8

• Rest

• Patient 9

• Stretch


• Regular strengthening of all muscle groups help to keep the bodyworking together as a functional unit

• Strengthening the shoulder girdle also provides stability for thenecessary movements of the hand and forearm

• Shoulder stability is necessary in order to meet the physicaldemands of Sonography

Self Care

• It is important that sonographers take responsibility for how they managestress

• Stress contributes to musculoskeletal injury through muscle tightnessand spasm.

• An act as simple of closing the eyes for 5 minutes can increase energylevel and reduce pain. Muscle recovery can be improved through restand relaxation on and off the job

Self Care

Some simple stress busters :

• Cut “to do” lists in half

• Collaborate and cooperate – share the work load

• Exercise

• Laugh – do something fun

• Prioritize the big projects

• Give away “the cape” – remind workers to accept their ownlimitations and conditions that they cannot control

• Focus on one activity at a time

• Close the eyes; breathe


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Self Care

• Remind the injured worker to limit leisure activities that use theupper extremity such as gardening, needlework, knitting, playingmusical instruments and racket spots

Self Care

After a strain or a painful exam the RICE treatment can be effective inreducing symptoms:

• Rest

• Ice

• Compression

• Elevation

NSAIDS are also effective for short term use to reduce inflammation

Self Care

• Encourage sonographers to develop a regular self care routineincluding body awareness, exercise, fitness and nutrition.

Summary

To minimize strain and fatigue during scanning and to prevent longterm pain and disability, the following best practices arerecommended:

• Organize by moving equipment so that controls are within easyreach

• Adjust the chair and bed so that the back and feet are supportedby the chair; shoulders and elbows are relaxed and supported onboth sides or stand

• Position the monitor screen to suit individual height

Summary

During Scanning:

• Ask your patient to assist by moving close or rolling to their side. Ifthe patient cannot assist, use a Patran sheet or lift equipment

• Face the work; avoid twisting or leaning to one side

• Use a loose power grip around the transducer and avoid a pinchgrip

Summary

Organize the list:

• Rotate tasks to change positions frequently

• Enforce breaks and lunch – 2 breaks of 10 minutes are better thatone break of 20 minutes

• Encourage mini breaks: bring the arm back to the side, wrist inneutral and relax the fingers. Shake arms, roll shoulders andstretch the neck.


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Summary

Equipment

• Use adjustable equipment and adaptive devices including bathblankets, support cushions, Patran sheet and patient handlingdevices

• Ergonomically adjustable equipment and flexible cables should be ahigh priority

References

• Sound Ergonomics (2005) Ergonomic Guidelines for Sonography.Kenmore, WA: Sound Ergonomics

• Industry Standards for the Prevention of Work RelatedMusculoskeletal Disorders in Sonography:www.sdms.org/msi/default.asp andhttp://www.sdms.org/pdf/wrmsd2003.pdf

•

• http://www.sdms.org/OSHA/etool.asp. “A very comprehensive androbust source of information for helping sonographers reduce theirrisk of WRMSD”.

• http://www.sdms.org/pdf/preventinginjury.pdf JCAHO article onprevention of injury among sonographers

American Osteopathic College of Occupational and Preventive … · 2012-10-06 · American...

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