Ergonomic Evaluation of Musculoskeletal Risk in Sonographers
This paper presents a cross-sectional ergonomic evaluation of ultrasound sonographers working in an obstetric and gynecological scanning department. Using the Rapid Upper Limb Assessment (RULA) tool and an adapted Nordic Musculoskeletal Questionnaire (NMQ), the study assessed fourteen sonographers for postural risk, static muscle loading, and self-reported musculoskeletal symptoms. RULA analysis identified patient scanning as the highest-risk task element, occupying 31–39% of a typical 26-hour working week. Questionnaire results revealed that 93% of participants reported at least one musculoskeletal symptom, with the shoulder (57%), cervical spine (50%), and wrist/hands (50%) most frequently affected. The paper discusses contributing factors including equipment design, non-adjustable seating, and prolonged static postures, and proposes recommendations to reduce workplace injury risk among sonographers.
- Introduction: History of diagnostic ultrasound and prior injury research
- Methodology: RULA assessment and Nordic Questionnaire design
- Results: RULA scores, time-on-task data, and symptom prevalence
- Discussion: Risk factors, equipment design, and workplace limitations
- Conclusion: Summary of findings and recommendations for practice
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What makes this paper effective
- Combines two validated instruments — the RULA postural assessment tool and the Nordic Musculoskeletal Questionnaire — to triangulate findings from both observational and self-reported data sources, strengthening the credibility of conclusions despite a small sample.
- Grounds the study in a well-structured literature review that situates findings within comparable occupational groups, including cardiac sonographers, breast screening radiographers, and general radiographers, giving the reader comparative context.
- Presents quantitative data clearly through task-element tables and percentage time-on-task figures, making abstract risk scores concrete and interpretable for a clinical audience.
Key academic technique demonstrated
The paper demonstrates effective mixed-method convergence: observational workplace assessment (RULA) is paired with structured self-report interviews (NMQ) so that objectively measured postural risk scores can be directly compared with participant-reported symptom prevalence. This convergence validates each method's findings and compensates for the limitations inherent in each approach used in isolation.
Structure breakdown
The paper follows a conventional research report structure: an introduction that reviews the historical development of diagnostic ultrasound and prior injury literature; a methodology section explaining participant selection, RULA protocol, and questionnaire design; a results section presenting RULA grand scores by task element alongside NMQ prevalence tables; a discussion that contextualizes findings, acknowledges the small sample, and addresses equipment and workplace design factors; and a brief conclusion that synthesizes findings and outlines practical recommendations.
Introduction
Diagnostic ultrasound (DU) was first introduced to the medical world in 1942 by Austrian physician Dr. Karl Dussik (Levi, 2007). It was initially used to detect gallstones in 1950 by Ludwig and Stutler, but was subsequently developed for use in gynecology, where there was a profound need for safer imaging techniques (Levi, 2007). DU was first used in an applied clinical setting in 1958 by Professor Ian Donald from Glasgow, who used ultrasound to examine gynecological patients for pelvic lesions (Levi, 2007). It was used on a more regular basis within the clinical environment during the 1960s, gaining recognition by the American Medical Association in 1974 (Vanderpool, 1993).
In modern medicine, the use of ultrasound in both gynecology and obstetrics has become a normal part of the diagnostic and fetal assessment process. However, the increased use of ultrasound equipment has been identified as a source of workplace pain and discomfort in sonographers. Craig (2005) surveyed 100 sonographers with 5–20 years of experience. The results showed that the majority of respondents had experienced symptoms of musculoskeletal problems, including wrist and shoulder problems. The study, however, did not document exact figures concerning work-related problems, nor did it provide details pertaining to the methodology or response rate.
A study by Vanderpool (1993) surveyed 225 cardiac sonographers. A 47% response rate was achieved, with 72% of respondents female. Results found that 63% of respondents had experienced wrist problems during their career and 3% had been diagnosed specifically with Carpal Tunnel Syndrome.
Wihlidal and Kumar (2008) surveyed 156 sonographers in a postal survey in Alberta. A 61.5% (N=96) response rate was achieved, and 88.5% of respondents reported work-related symptoms either historically or on an ongoing basis. Clusters of symptoms included neck and intrascapular pain (54%), shoulder or upper arm pain (53%), low back pain (37.5%), and elbow pain (23.5%). Respondents were also asked about absence from work, and 16% reported that they had been forced to take time off due to symptoms (Wihlidal and Kumar, 2008).
In comparison with others involved in radiography work, May et al. (1994) surveyed breast screening radiographers in a UK national survey of 800 participants, receiving 320 responses. This study used two control groups: clerical staff (N=400) and general radiographers not involved in screening (N=400). Preliminary results found that those involved in general radiography reported the most muscular complaints (94.4%), while 76% of those involved in breast screening reported pain and 70% of clerical staff reported muscular discomfort. Although only descriptive data were reported, the study highlights the level of complaints within general and breast screening radiography.
Habes and Baron (2000) presented a case study of an ergonomic evaluation of ultrasound testing. The study highlighted the postural extremes sonographers had to adopt while using ultrasound equipment, the static loading from holding the scan heads, and the biomechanical loading on sonographers. Several recommendations from this study included the use of adjustable chairs including sit/stand seats and beds, the provision of elbow support, customizing one room for specific scanning types, and a secondary monitor positioned in the line of sight of the sonographer.
The results of these previous studies suggest that the use of ultrasonography equipment is accompanied by physical musculoskeletal problems. The following study was carried out following an initial ergonomics evaluation of work carried out in the radiography department of a hospital. The aim of the study was to identify the prevalence of musculoskeletal pain and discomfort, to identify postural risk factors when carrying out scanning tasks, and to evaluate the workplace and equipment design.
Methodology
The participants in the study all worked at one hospital specializing in gynecology and obstetrics. To become familiar with the working environment and the scanning process, a period of observation was conducted at the Neonatal unit. To further identify the principal components of the scanning process, a talk-through was carried out based on the method described in Kirwan and Ainsworth (2007).
The Rapid Upper Limb Assessment (RULA) methodology, developed by McAtamney and Corlett (2003), was used to identify whether the postures adopted when carrying out sonography tasks were high risk. The RULA analysis was carried out with six participants scanning obstetric patients and six participants scanning gynecological patients, including transvaginal scanning, during 90-minute observation periods.
A modified version of the standardized Musculoskeletal Questionnaire (NMQ) was used in the form of a structured interview during the initial stages of the study. The structured interview was based on the standardized and validated questionnaire developed by the Nordic Group (Kuorinka et al., 2010).
Results
A total of 14 sonographers took part in the study; 11 were registered radiographers and three were medical doctors. The age range of the participants was 35 to 52 years, with time working with ultrasound equipment ranging from 6 months to 23 years. The time spent using equipment ranged from 6 hours per week to 35 hours per week, with a mean of 26 hours per week scanning patients.
Observation data identified the different types of scans carried out within the department and allowed familiarization with the working environment and scanning process. Two main types of scans were identified: the obstetric scan and the gynecological scan. Nine rooms were routinely used for scanning, each fitted out with relevant equipment including computers for record keeping. Four different types of ultrasound equipment were used within the department. Eight of the consulting rooms contained non-adjustable stools of varying heights.
The talk-through process identified the task elements involved in scanning patients. Table 1 identifies the task elements from A to H that the sonographer carries out.
Postural observations made during the RULA analysis identified that when scanning a patient, the sonographer is required to twist the neck and trunk in order to view the monitor while simultaneously maintaining probe contact with the patient. The cervical spine is also held in moderate side flexion, typically when the sonographer is pointing out features on the display screen. Table 1 presents the data for the RULA analysis and indicates that, although the majority of tasks are scored at action level 2, the scanning of patients for both scan types analyzed was scored at action level 3, requiring investigation and change in the near future. The degree of static loading during the scanning element was also analyzed visually; it was approximated that when carrying out an obstetric scan, maintenance of static posture was required for 84% of the time, and for a gynecological scan, 74% of the scanning time.
Table 1. Task Elements and RULA Scores of the Scanning Process
Task Element A — Reading the patient's notes: Obstetric Mean Grand Score 3, Action Level 2; Gynae. Mean Grand Score 3, Action Level 2.
Task Element B — Walking: Obstetric Mean Grand Score 2, Action Level 1; Gynae. Mean Grand Score 2, Action Level 1.
Task Element C — Computer work: Obstetric Mean Grand Score 4, Action Level 2; Gynae. Mean Grand Score 4, Action Level 2.
Task Element D — Setting up the patient/equipment: Obstetric Mean Grand Score 4, Action Level 2; Gynae. Mean Grand Score 3, Action Level 2.
Task Element E — Performing the scan: Obstetric Mean Grand Score 5, Action Level 3; Gynae. Mean Grand Score 6, Action Level 3.
Task Element F — Talking to the patient/relatives: Obstetric Mean Grand Score 3, Action Level 2; Gynae. Mean Grand Score 3, Action Level 2.
Task Element G — Clearing the plinth: Obstetric Mean Grand Score 3, Action Level 2; Gynae. Mean Grand Score 3, Action Level 2.
Task Element H — Communicating with colleagues: Obstetric Mean Grand Score 3, Action Level 2; Gynae. Mean Grand Score 3, Action Level 2.
The percentage of time spent on each of the task elements was also calculated. The data highlight that the individuals surveyed spent between 31% and 39% of their time with patients carrying out the task with the highest RULA grand score.
The NMQ identified that 13 (93%) of respondents had previously or were currently experiencing at least one or more physical symptoms. Table 2 presents the summary results of the prevalence of musculoskeletal pain and discomfort. The data show that pain and discomfort are most commonly reported for the neck, shoulder, wrist/hands, upper back, and lower back. Two of the respondents felt that the symptoms they experienced encroached upon their leisure time, but none felt that their work activities had been reduced. Of those who complained of shoulder problems, 60% attributed this to sonography work, including working with the arm elevated for long periods. Moving patients and heavy equipment were also implicated to a lesser degree.
Table 2. Incidence of Musculoskeletal Problems in the Past 7 Days or 12 Months
Neck: Last 7 days — 5 (36%); Last 12 months — 7 (50%).
Shoulders: Last 7 days — 3 (21%); Last 12 months — 8 (57%).
Elbows: Last 7 days — 0 (0%); Last 12 months — 1 (7%).
Wrists/Hands: Last 7 days — 3 (21%); Last 12 months — 7 (50%).
Upper back/Thoracic Spine: Last 7 days — 5 (36%); Last 12 months — 5 (36%).
Lower back: Last 7 days — 5 (36%); Last 12 months — 7 (50%).
One or both hips, thighs, or buttocks: Last 7 days — 0 (0%); Last 12 months — 1 (7%).
One or both knees: Last 7 days — 1 (7%); Last 12 months — 2 (14%).
One or both ankles or feet: Last 7 days — 0 (0%); Last 12 months — 0 (0%).
Conclusion
Sonography is a relatively young profession that became prominent in the 1960s. Its characteristic scanning technique involves a great deal of static muscle work in the upper body. A consequence of this rapid growth is beginning to emerge, and research over the past decade has associated sonography with a number of musculoskeletal problems. Implicated in the symptom profile of this study were the postures adopted when using ultrasound equipment, the non-adjustability of workplace seating, and ultrasound equipment design.
The percentage of time spent on each of the task elements was also calculated. The data highlight that the individuals surveyed spent between 31% and 39% of their time with patients carrying out the task with the highest RULA grand score. These findings underscore the need for targeted interventions including adjustable work equipment, staff education on proper use of that equipment, changes to work organization, and the provision of arm supports to reduce the burden of musculoskeletal injury among sonographers.
Bibliography
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