Around the 1970s, in the early days of the application of ultrasound in clinical medicine, physicians and allied health professionals from a wide variety of medical specialties and backgrounds performed a small number of tests. Patient volumes were small and studies were targeted to specific diagnostic medical questions. Examples of these were: “Is the midline of the brain shift caused by a tumor or hematoma?”

As the equipment developed, there was a significant increase in the type of studies that could be performed. Many more practitioners entered the field, and more patients were referred for ultrasound procedures. By the mid 1980s, peerreviewed articles appeared in the literature about allied health personnel performing ultrasound exams starting to experience pain and discomfort. Most were complaining of the shoulder of their scanning arm, which became known as sonographer’s shoulder.

Early Articles, Studies & Conferences

One of the earliest articles published in the 2003 issue of Journal of Occupational Health by Vanderpool et al. addressed the incidence of carpal tunnel syndrome among echocardiographers. As patient volumes increased and equipment improved, the use of ultrasound in medicine experienced a “sonic boom.”

In 1995, the Heath Care Benefit Trust (HCBT) of British Columbia, Canada, decided to fund a study on the prevalence of musculoskeletal disorders among diagnostic medical sonographers. The surprise in the results was not that there was occupational injury, but that the study documented a significant 84% incidence in North America. The findings of the HCBT were published in the Journal of Diagnostic Medical Sonography in 1997.

Joan P Baker, president and founder of Sound Ergonomics, was the liaison member representing sonographers of the United States for the HCBT and this study. Sonographers scanning in pain and some experiencing career-ending injuries continued to be reported not only among North American sonographers, but also among many others using ultrasound around the world.

The Society of Diagnostic Medical Sonography (SDMS) hosted a consensus conference on work-related musculoskeletal disorders (WRMSD) in sonography on May 13-14, 2003, in Dallas, Texas. The conference was chaired by Joan P. Baker, MSR, RDMS, RDCS, FSDMS, founder of the SDMS and internationally recognized advocate for prevention of WRMSD in sonography. Baker has been a sonographer for over 45 years and served on the faculty of Bellevue College.

The goal of the conference was to develop risk-reducing industry standards that serve to address the multifaceted problem of WRMSD in sonography. The industry standards address the role of employees, employers, educators, medical facilities and equipment manufacturers in reducing the incidence and impact of these injuries on the workforce. These industry standards are intended to assist all stakeholders in making informed decisions. Adoption of these industry standards has improved the well-being of sonographers and sonologists, and has addressed the workforce shortage in the profession. The industry standards were approved by OSHA and became part of the alliance between SDMS and OSHA.

Twenty-seven participating organizations were invited and attended the one-and-a-half day consensus conference. They represented stakeholder groups, professional organizations, and credentialing, accreditation and governmental agencies.

The 27 conference attendees unanimously approved the outcome of the conference, which was the publication of Industry Standards for the Prevention of WRMSD in Sonography. The following year this document was adopted by OSHA. This was part of the alliance between SDMS and OSHA, which was signed by Edwin Foulke, the assistant secretary of OSHA.

Musculoskeletal Disorders

Musculoskeletal disorders (MSD) have been described in a number of professions over the years. MSDs are defined as injuries that are caused by or aggravated by workplace activities. They account for up to 60% of all workplace illnesses and are known by different names.

• Musculoskeletal disorder (MSD)
• Repetitive strain injury (RSI)
• Cumulative trauma disorder (CTD)
• Repetitive motion injury (RMI)
• Work-related musculoskeletal disorder (WRMSD)

MSDs have only been identified in sonographers since 1997, but are increasing in incidence. Surveys done among American and Canadian sonographers in 1997 showed an 84% incidence. However, this incidence had increased to 90% by 2008. Possible explanations for this increased incidence are many:

• Aging workforce: In 1997, 8.3% of sonographers were 50 years of age or older. By 2008, 30% of sonographers were 50 years of age or older, and 46.9% of vascular technologists were over 50.
• Increased patient volumes: Reimbursements have decreased over the past 15 years, causing managers to increase through-put in order to maintain economic stability.
• Employee awareness: Publications, word of mouth and lectures on this subject have permeated the field, essentially making sonographers worldwide aware of this problem.
• Intolerance to working in pain: Employees feel exploited. There is increased pressure to handle unscheduled studies on a STAT basis, as well as a significant volume of non-emergency studies. In the past eight years, there has been a 55.5% increase in the number of studies performed per sonographer every year. In addition, there are staff shortages with no replacement staff or temporary staff hired to cover the ultrasound department. This, in turn, causes longer working hours with busier schedules.
• Job dissatisfaction: Stress in the workplace has been increasing due to a volatile and unpredictable economy, accompanied by little job security and increased litigation. Of the 90% that are experiencing pain, 20% have been forced to give up their profession as a result of their injury.

Preventing Injury

With more and more patients being scanned using ultrasound, mounting evidence of the worldwide increase in occupational injury within this profession has caused everyone involved to take a look at how this might be prevented in the new generation of sonographers and vascular technologists, and how such incidences can be mitigated or at least addressed in those with more years of experience.

The original equipment manufacturers (OEM) now look carefully at their design of new equipment to make sure it is ergonomic and will not cause injury to the operator. A study on the relationship between ergonomic work environments and productivity from a broad cross-section across North America found that absenteeism fell from 4% to 1% after workstation design changes were implemented, and employee productivity was subjectively judged as “much improved.” Blue Cross Blue Shield found that after implementing ergonomic designs in employee workstations, there was a 4.4% improvement in productivity.

A comprehensive ergonomics program at Johns Hopkins Hospital resulted in an 80% reduction in MSDs over a six-year period. Intel reported a 72% reduction in MSDs over a four-year period after implementing an ergonomics program. One high-tech manufacturer had a 5% improvement in productivity using ergonomic improvements in the employees’ workstations. This increased productivity resulted in a net reduction in staff. Taking into consideration inflation, taxes and cost of invested capital, the difference between ergonomic and non-ergonomic furnishings for a first-time purchaser would be recovered in less than eight months. It may also be possible to modify existing equipment to make it more ergonomic.

The Sonographer Symptom Survey

The response to the Sonographer Symptom Survey was excellent, with 3,024 completing the survey. These results were consistent with surveys over the past five years, which have unequivocally demonstrated that work-related injury among sonographers and vascular technologists is a serious problem. The incidence has risen from 84% to 90% between 1995 and 2008. Occupational injuries among sonographers are reaching record numbers, and we are losing the most experienced in the profession due to the long-term effects of cumulative trauma.

The reasons given for pain were:

1. Sustained shoulder abduction
2. Applying pressure
3. Twisting of neck and trunk

The types of studies causing the pain:

1. Venous reflux studies
2. Bedside exams
3. Endovaginal exams

Also of importance:

• 68.1% of sonographers are age 40 and above
• 52.1% have been scanning more than 16 years
• 88.2% female
• 59.6% perform nine or more scans per day

Only 54.5% were actually shown how to use the ergonomic features of new equipment.

It is of note that if an ultrasound system is shut down for one week for any reason, including worker injury, the loss of revenue exceeds the amount needed to fully equip a lab with ergonomic equipment.

The number one study that causes injury in sonography is reflux procedures. This study is also the most challenging to mitigate. Most equipment does not go low enough to allow for using the control panel ergonomically. The need to use augmentation while the patient is standing adds to the difficulty, especially if the patient becomes unstable on their feet or faints while in this position. Sound ergonomics is committed to educating those that perform a lot of these procedures in how to protect themselves from injury while obtaining the necessary images to make a diagnosis.