American Osteopathic College of Occupational and Preventive Medicine OMED 2012, San Diego, Wednesday, October 10, 2012
Ergonomic Injuries in Ultrasonographers Ergonomic Injuries in Ultrasonographers
Description: Pierce Sherrill, DO This course describes risk factors for, and Aurora Medical Group appropriate responses to, ergonomic injuries in Gtreen Bay, Wisconsin ultrasonographers. Technical contact:
Objectives:
-Participants should be able to identify risk factors, injuries, and treatments for injuries in ultrasonographers; -Participants should be able to name at least three effective strategies for prevention of ergonomic injuries in this groupContent of contact: workers; -Participants should be able to teach effective postural and workstation adjustments to minimize risk of injury in this group.
Objectives How Injuries Occur
• How and Why Injuries Occur • Musculoskeletal Disorders (MSD’s) is a term used to describe cumulative trauma disorders to the soft tissues of the body • Common Musculoskeletal Disorders (MSD’s) • Work related MSD’s (WMSD’s) are well documented and • Correct Postural Alignment recognized as an occupational hazard for sonographers
• The Ergonomic Workstation • 80% of sonographers are scanning in pain and 20% of these eventually have a career ending injury¹ • Adaptive Equipment • “On average, within 5 years of entering the profession, sonographers experience pain while scanning.”² • The Importance of Exercise
- ¹David S,: Importance of sonographers reporting work-related musculoskeletal injury: a qualitative view. J Diagn Med Sonography 2005;21:234-237 - ²Industry standards for the prevention of work-related musculoskeletal disorders in sonography: consensus conference on work-related musculoskeletal disorders in sonography. J Diag Med Sonography 19:281 Sep_oct 2003, 281-286.
Why Injuries Occur Musculoskeletal Disorders
Risk Factors in Sonography: Physical demands include: • Repetition • Lifting, carrying, pushing and pulling more than 35 lbs. • Forceful movement • Static positions • Long reaches away from the base of support • Prolonged exertion • Awkward postures • Standing continuously • Heavy lifting or pushing /pulling
• Forceful gripping • “One study suggested that sonographers who perform more than 100 scans a month are at risk for WRMSD… the majority of • Squatting, crouching, stooping sonographers perform at least three times that figure.”¹
- ¹Gibbs V and Young P,Methods to prevent work-related musculoskeletal disorders amongst sonographers. Synergy July 2011.
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Risk Factors - Repetition Risk Factors – Forceful Movements
• Doing the same scan • Sonographers can place up to repeatedly throughout the day 40 lbs. of pressure during a scan
• Static positioning with this amount of pressure rapidly causes muscle fatigue
• Moving the arm and hand in the same way during a scan
Risk Factors – Awkward Postures Risk factors – Heavy Lifting
• Moving beds during bedside exams, moving and transferring patients and lifting laundry are all examples of heavy lifting
Conditions Conditions
Carpal Tunnel Syndrome
• Compression of the median nerve in the volar aspect of wrist Sonographers are particularly vulnerable to • Produces numbness and radiating pain in the radial-palmar aspect the following injuries: of hand
• Produces sensory deficit in the palmar aspect of the first 3 digits and/or weakness of thumb opposition
• “…63% of all the respondents [in a survey of sonographers] had symptoms of CTS at some point in their careers.” - Mercer, R, Occupational health hazards to the ultrasonographer and their possible prevention. J Am Soc Echocardiography 10;4 May 1997
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Carpal Tunnel Syndrome - Treatment Conditions
• Rest Tendonitis/Tenosynovitis
• Rigid splinting at night and rest periods • Inflammation of the lining of the tendon sheath and enclosed tendon
• Soft neoprene splinting while at work • Tendons are painful with motion with localized pain along the tendon • Postural Education – shoulders down and back and neck retraction • May be mild to severe; may occur at rest or with movement • Daily nerve glides
• Occupational therapy, corticosteroid injection, surgery
Tendonitis-Treatment Epicondylitis
• Rest • Caused by a strain of the forearm muscles and their tendinous • Splinting at night and during rest periods attachments to the humeral epicondyle
• Alternate heat/ice (heat before shift and ice after shift or difficult • Lateral Epicondylitis (tennis elbow) exam) - Pain with resisted wrist extension - Usually associated with palm-down lifting; occasionally with forceful supination • Stretching program • Medial Epicondylitis (golfers elbow) - Pain with resisted wrist flexion • When pain is resolved, strengthening is indicated - Usually associated with palm-up lifting; occasionally with forceful pronation
• Corticosteroid injection; surgical release in extreme cases • Pain is directly over the epicondyle and may cause weakness
Epicondylitis Treatment Conditions
• Rest Trigger Finger
• Postural education – position arms close to the body while scanning • Inability to fully flex or extend a finger; sometimes movement is or during heavy lifting associated with a clicking sound
• Heat • Caused by the thickening of a tendon; it catches on the sheath as it glides in and out of the sheath’ • Forearm band/wrist splinting
• Nerve glides
• Stretching
• Injection; occasionally, surgical repair of tendon origin
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Trigger Finger Treatment Conditions
• Rest DeQuervain’s Disease
• Sometimes, placing a band aid over the PIP joint will prevent the finger from triggering • Thumb pain involving the abductor pollicis longus and extensor pollicis brevis muscle of the forearm • Heat • Finkelstein’s test is usually diagnostic • Corticosteroid injection; occasionally, surgical release of the tendon sheath • As with other forms of tenosynovitis, exclude other medical explanations: - 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 Conditions
Shoulder Impingement • Rest
• Neoprene thumb spica splint while working • Inflammation of the soft tissues in the shoulder girdle including the rotator cuff tendons • Alternate heat and ice before and after shift or difficult scan • Produces localized or radiating pain in the shoulder or radiating • Build up the handle of the transducer with foam or use a larger one down the arm if possible • Most prominent with the humerus horizontal (flexed or abducted) • Use the least amount of pressure possible while scanning; alternate difficult scans that require a lot of pressure with easier exams
• Injections and/or tendon release if needed
Shoulder Pain Treatment Conditions
• Rest Thoracic Outlet Syndrome
• No overhead work at work and at home • Pain and numbness/tingling in the hand, neck, shoulder or arms
• Postural education – shoulders down and back with neck retraction • Caused by compression of the subclavian vessels and/or the brachial plexus against a cervical rib or the scalene muscles • Keep shoulder in 30 – 60 degrees of abduction when scanning as often as possible • Conservative treatment is similar to the recommendations under shoulder impingement • Alternate heat and ice • Surgery (first rib resection) as a (very) last resort • Stretching
• Strengthening is indicated when pain subsides
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Postural Alignment – Shoulder/Neck Posture
Neutral Posture
1. Shoulder blades backward, 3. Hinge from the hips when together and down leaning or stooping over a patient during a scan • Neck slightly retracted • Shoulders down and back 2. Tuck the chin in slightly; 4. This position provides the • Ears over shoulders, over pull the head backward most strength with the least hips, with feet supported (make a double chin) effort while scanning • Should be a relaxed, upright position
Wrist Neutral Posture Wrist Neutral Posture
• Sonographer should change body position to get the wrist in a neutral position; or
• rest the wrist in a neutral • Wrist flexion causes nerve position after the scan compression • Wrist extension reduces strength • Neutral wrist positions provide the best strength and comfort
Posture Postural Alignment
• Power Zone: the area • Work in the your power zone • When you hold your arm in 90 between shoulders and hips as much as possible degrees of abduction your muscles will be fatigued in 10 • This is the area where we • Adjust the table height as well minutes have the most power with the as change body position least effort • When you have to hold your arm in this position – give yourself frequent rest breaks and get out of this position as soon as possible
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Postural Alignment Postural Alignment
• When you hold your arm in 30 degrees of abduction you will • When you hold your arm in 60 have approximately 60 degrees of abduction you will minutes before your muscles have 20 – 30 minutes before fatigue your muscles will fatigue • It is best for sonographers to scan with the arm in 30 -60 degrees of abduction
• Resting or neutral position of the shoulder: less than 30 degrees abduction
The Ergonomic Workstation The Ergonomic Workstation
• Workstation set-up is very important -- • Position the ultrasound equipment parallel to the exam table and as even if it helps for just part of the scan close to the nearest side of the table as possible
The Ergonomic Workstation The Ergonomic Workstation
• Lower the table to its lowest • Position the patient toward the position edge of the table so the patient touches the sonographer’s hip
• Ambulatory patients should be able to sit on the table with no help • If the patient cannot assist; use a Patran sheet to slide the patient over.
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The Ergonomic Workstation The Ergonomic Workstation
• Adjust the table height so that the sonographer’s forearm is • Place towels or support parallel to the floor; or have the cushions to help support the sonographer stand to do the forearm while scanning scan
The Ergonomic Workstation The Ergonomic Workstation-Chair
• Position the monitor directly in front so that there is less twisting of • There is no universal chair. the neck The idea of a chair is only present in examples. -Aristotle, 384-322 B.C. • Sonographer’s eyes should be level with the top 2 inches of the monitor • There is no perfect chair
• The monitor should be about arm’s length away • What is important is adjustability
• Controls should be easily accessible. Central locking is preferable
The Ergonomic Workstation - Chair The Ergonomic Workstation - Chair
• Adjust the chair so that legs are comfortable and parallel to the floor and so that the scanning arm is held as close as possible
• This may require adjusting the chair height and the control panel of the equipment
• If using the chair that is in these photos, the back of the chair can be used to support the forearm
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The Ergonomic Workstation - Chair The Computer Workstation-Chair Summary
• Place feet on the footrests in a neutral position
• Adjust the chair so that the • Place feet on footrests that are legs are comfortable and on the machine or the chair parallel to the floor
• Scanning arm – no more than 30 degrees of abduction
Ergonomic Workstation - Gripping Ergonomic Workstation - Gripping
• Avoid excessive force when gripping the transducer • Wearing non textured gloves that are too large increases • Only use the amount of force effort up to 40% needed for the scan
• If a sonographer pushes down for 5 seconds to obtain a • Wear gloves that fit certain view – he/she should release and recover for 15 seconds before proceeding
• Develop “ambidextrous” scanning ability to use both hands
Correct Sitting Posture Correct Standing Posture
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Quick Tips for Postural Alignment Adaptive Equipment
• Adaptive equipment can be used to remove or reduce the risk • Face Forward • No reaching factors in the workplace • Keep spine in neutral • Wrists straight and level with • Feet well supported elbows • Stabilize core muscles • Forearms parallel to floor • The following pieces of adaptive equipment are available through • Keep hands/arms in front of • If sitting, thighs parallel to floor various vendors: the body • Movement is a MUST! • Elbows at the side
Adaptive Equipment Adaptive Equipment
• Place support cushions or a bath blanket on the edge of the table between sonographer and patient • Gel Bottles should have large openings to reduce the strength needed to squeeze the bottle and a larger diameter to avoid extended grip position • Support cushions are available through www.soundergonomics.com
Adaptive Equipment Adaptive Equipment
Cable Brace The following options may • For cardiac imaging a drop • Place the cable brace on the improve patient positioning away or cut out section will forearm of the scanning arm, and reduce scan time and/or allow unhindered access to the just below the elbow to reduce the need for a 2nd caregiver: apical region drag from the cable • Slings are available to retract • For endovaginal scanning – the pannus adjustable footboards and (www.KanguruWeb.com) • This reduces the drag of the stirrups should be available cord on the arm • Other options are placing the • Breast slings and arm supports • Cables should be long enough patient in Trendelenberg or are available to permit unrestricted use reverse Trendelenberg (www.soundergonomics.com) position, upright table back. arm extensions and patient restraints
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Safe Patient Handling – Patran Sheet Safe Patient Handling
• Push the Patran sheet underneath the patients hips, • The Patran Sheet to reduces shoulders and legs friction when moving a patient toward the edge of the bed or table
• There are other brands that • Push the green Patran sheet may be available at your local underneath the draw sheet hospital. with your hands
Safe Patient Handling Safe Patient Handling
• Caregiver then pulls the Patran sheet from under the patient so they don’t begin to slide down
• Pull the patient as close to the edge of the bed or table as • Begin pulling it out from possible making sure it is safe underneath the far leg and for the patient gently pull the Patran sheet from under the patient
Safe Patient Handling Safe Patient Handling Tips
• Simple and easy! • Use a gait belt to assist an • Use a lift if the patient cannot ambulatory patient to the table bear weight or cannot follow directions • Always ask the patient to assist • Never boost or reposition a patient without a Patran Sheet • If more than one person is needed for assistance – use a lift instead
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The Reading Room Workstation The Reading Room Workstation
• Position the monitor directly in • Lower the light level in the front of operator room to eliminate glare
• Eyes are level with the top 2 • Should be able to see inches of monitor comfortably without straining
• Monitor should be • Blue light is easiest on the approximately an arm’s length eyes away
Administrative Controls Administrative Controls
Schedule and workload Breaks
• The same type of exams should not be scheduled together to • Enforce lunch breaks – do not give this up in order to take on prevent repetitive motion more patients or to leave on time at the end of the day
• Bedside exams – do portable exams only when absolutely • Encourage mini breaks about every 8 minutes if possible. Put necessary, not because it is more convenient the transducer down to relax the scanning arm
• Encourage exam rotation as much as possible
Administrative Controls Administrative Controls
• Workload Distribution – Share all exams with other workers in the department
• Certain exams may need two persons to do the procedure safely • Do not insist on “textbook- perfect’ images if it is not needed for the diagnosis. Communication with the ordering physician is often • On call – Limit after-hours call to only one institution; try avoid on- helpful. call more than 24 hours at a time
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The Importance of Exercise The Importance of Exercise
• Sonographers tend to overuse certain muscle groups. These Stretching before activity increases circulation, promotes the elasticity muscles become hypertrophied and the opposing muscle groups of the muscle and increases range of motion. become atrophied
• When opposing muscles groups are unbalanced, the risk of injury increases
• A complete fitness program will allow those opposing muscle groups to maintain their integrity to be able to provide the balance needed to support the overused muscles
Sample Stretching Schedule The Importance of Exercise
• Warm up: • Warm up • Regular strengthening of all muscle groups help to keep the body working together as a functional unit • Patient 1 • Patient 6 • Patient 2 • Patient 7 – Stretch • Patient 8 • Strengthening the shoulder girdle also provides stability for the • Rest Break necessary movements of the hand and forearm • Rest • Patient 3 • Patient 4 • Patient 9 • Shoulder stability is necessary in order to meet the physical demands of Sonography • Patient 5 • Stretch • Lunch (Rest)
Self Care Self Care
• It is important that sonographers take responsibility for how they manage Some simple stress busters : stress • Cut “to do” lists in half • Stress contributes to musculoskeletal injury through muscle tightness • Collaborate and cooperate – share the work load and spasm. • Exercise • Laugh – do something fun • An act as simple of closing the eyes for 5 minutes can increase energy • Prioritize the big projects level and reduce pain. Muscle recovery can be improved through rest and relaxation on and off the job • Give away “the cape” – remind workers to accept their own limitations and conditions that they cannot control • Focus on one activity at a time • Close the eyes; breathe
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Self Care Self Care
• Remind the injured worker to limit leisure activities that use the After a strain or a painful exam the RICE treatment can be effective in upper extremity such as gardening, needlework, knitting, playing reducing symptoms: musical instruments and racket spots • Rest
• Ice
• Compression
• Elevation
NSAIDS are also effective for short term use to reduce inflammation
Self Care Summary
To minimize strain and fatigue during scanning and to prevent long • Encourage sonographers to develop a regular self care routine term pain and disability, the following best practices are including body awareness, exercise, fitness and nutrition. recommended:
• Organize by moving equipment so that controls are within easy reach • Adjust the chair and bed so that the back and feet are supported by the chair; shoulders and elbows are relaxed and supported on both sides or stand • Position the monitor screen to suit individual height
Summary Summary
During Scanning: Organize the list:
• Ask your patient to assist by moving close or rolling to their side. If • Rotate tasks to change positions frequently the patient cannot assist, use a Patran sheet or lift equipment • Enforce breaks and lunch – 2 breaks of 10 minutes are better that • Face the work; avoid twisting or leaning to one side one break of 20 minutes
• Use a loose power grip around the transducer and avoid a pinch • Encourage mini breaks: bring the arm back to the side, wrist in grip neutral and relax the fingers. Shake arms, roll shoulders and stretch the neck.
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Summary References
Equipment • Sound Ergonomics (2005) Ergonomic Guidelines for Sonography. • Use adjustable equipment and adaptive devices including bath Kenmore, WA: Sound Ergonomics blankets, support cushions, Patran sheet and patient handling devices • Industry Standards for the Prevention of Work Related Musculoskeletal Disorders in Sonography: • Ergonomically adjustable equipment and flexible cables should be a www.sdms.org/msi/default.asp and high priority http://www.sdms.org/pdf/wrmsd2003.pdf • • http://www.sdms.org/OSHA/etool.asp. “A very comprehensive and robust source of information for helping sonographers reduce their risk of WRMSD”.
• http://www.sdms.org/pdf/preventinginjury.pdf JCAHO article on prevention of injury among sonographers
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