Repetitive Stress Symptoms Among Radiology Technologists: Prevalence and Major Causative Factors

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1 Repetitive Stress Symptoms Among Radiology Technologists: Prevalence and Major Causative Factors Daniel S. Siegal, MD a, Deborah Levine, MD a, Bettina Siewert, MD a, Dana Lagrotteria, RDMS a, Dieter Affeln, MD b, Jack Dennerlein, PhD c, Phillip M. Boiselle, MD a Purpose: The aims of this study were to determine the prevalence of repetitive stress symptoms among radiology technologists working in a fully digital radiology department and to ascertain which work-related factors contribute most to their symptoms. Methods: A survey instrument was designed by occupational health specialists and administered to 5 technologists working in a large academic medical center radiology department. Data gathered included the presence of repetitive stress symptoms and prior diagnoses of repetitive stress syndrome. Respondents were also asked whether they spent hours per day in an awkward posture (a screening question to identify individuals at risk for ergonomic injuries). Additionally, respondents were asked to identify which factors among a list of items contributed most to their symptoms. Results: A total of 4 responses were received (response rate 46%). Repetitive stress symptoms were reported by 7 respondents (7%), and prior diagnoses of repetitive stress syndrome were reported by 44 (4%). Seventy-one respondents (68%) reported spending hours per day in an awkward posture. Regarding the factors that were perceived to contribute most to repetitive stress symptoms, items related to patients and imaging equipment were cited much more frequently than those related to computers. The most commonly cited factors were patient transfer (%), ultrasound probes (%), heavy imaging equipment (%), nonergonomic chairs (9%), and lead aprons (%). Conclusion: Repetitive stress symptoms are highly prevalent among radiology technologists working in a fully digital department but are primarily perceived to be related to tasks unrelated to computers. Thus, efforts to reduce the risk for injury should be focused primarily on improved ergonomics of patient transfer and imaging equipment. Key Words: Radiology technologists, ergonomics, interventions J Am Coll Radiol ;7: Copyright American College of Radiology INTRODUCTION Radiology technologists (RTs) have traditionally performed a variety of physical tasks related to imaging equipment and patient transfer that place them at increased risk for musculoskeletal complaints and injuries a Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts. b Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. c Harvard School of Public Health, Boston, Massachusetts. Corresponding author and reprints: Phillip M. Boiselle, MD, Beth Israel Deaconess Medical Center, Department of Radiology, Brookline Avenue, Boston, MA 5; pboisell@bidmc.harvard.edu. 956 []. With the recent transformation of many radiology departments into fully digital environments, technologists now also perform an increased number and variety of computer-related tasks. It is known that fully digital departments are associated with a high rate of repetitive stress symptoms and injuries among radiologists [-6], but the perceived impact of the digital environment on technologists is unknown. In particular, knowledge regarding the relative perceived impact of traditional work-related tasks in comparison with more recent computer-related tasks on symptoms would be helpful for guiding preventive measures to reduce work-related injuries among technologists. Thus, the purposes of this study were to determine American College of Radiology 9-8//$6. DOI.6/j.jacr..5.4

2 Siegal et al/repetitive Stress Among Radiology Technologists 957 the prevalence of repetitive stress symptoms among technologists working in a fully digital department and to ascertain which work-related factors contribute most to their symptoms. METHODS Background Information on Our Departmental Environment Our department is located within a large urban academic medical center. At the time of this survey, 5 technologists were working in the department. Among all technologists in our department, approximately % work in diagnostic x-ray, % in CT, % in MRI, % in ultrasound, and the remainder in interventional radiology, mammography, or nuclear medicine. In 999, our department transitioned from hard-copy interpretation to soft-copy interpretation using a PACS. We use soft-copy images for all studies, with the exception of our mammography division, which uses a combination of hard-copy and soft-copy images. In 8, the total annual examination volume of our practice was approximately 4,. Description of Technologist Ergonomics In 5, in response to growing concerns about repetitive stress injuries, our department teamed with occupational health specialists in our hospital to promote awareness of ergonomics among our radiologists and technologists. This initiative included grand rounds presentations devoted to ergonomic awareness and training, which focused primarily on postural training related to computer use. Additionally, new ergonomic tables and chairs were distributed in some areas of the department, primarily in radiology reading rooms and, to a lesser extent, in technologist work areas. Although technologists in our department are subspecialized by modality (general diagnostics, ultrasound, MRI, CT, mammography, and interventional radiology), their work profiles share many similar potential stressors, such as use of imaging equipment, patient transfer, data entry, and interaction with our PACS. Considering these common factors, our survey was designed to be administered collectively to all technologists in the department. Survey Instrument and Dissemination A survey instrument (Appendix) was designed by occupational health specialists and administered in June 8 to 5 technologists working in the radiology department at our large academic medical center. A hard-copy version of the survey was distributed to our RTs during the ergonomics-focused grand rounds. An identical electronic copy of the survey was sent to all technologists, and reminders were sent to further enhance participation. Data gathered included the presence of repetitive stress symptoms and prior diagnoses of repetitive stress syndrome. Respondents were also asked whether they spent hours per day in an awkward posture (a screening question to identify those at risk for repetitive stress symptoms and injuries) and whether they spent multiple hours at a personal computer or PACS (a risk factor for computer-related repetitive stress symptoms and injuries). Respondents were also asked to identify which factors among a list of workstation and imaging equipment items contributed most to their symptoms. It was possible to list more than one item. Additionally, a free-text area was provided for narrative comments at the end of the survey. Respondents were asked if they had received ergonomic chairs and tables in their work areas in the past 8 months, whether they had received any ergonomic training, and if these interventions had an effect on any pain, stiffness, or soreness they experienced in the workplace. Respondents who replied positively to these questions were also asked to rank the impact of their repetitive stress symptoms using a 7-point, Likert-type scale ranging from ( markedly worse ) to ( markedly better ). Our hospital s institutional review board approved an exemption of informed consent for the retrospective anonymous analysis of the survey data. The anonymity of all individual responses has been preserved. To comply with the preservation of anonymity of subspecialty groups of technologists, our survey intentionally did not request information regarding a respondent s area of subspecialization. RESULTS A total of 4 responses were received (response rate 46%). Repetitive stress symptoms were reported by 7 respondents (7%), and prior diagnoses of repetitive stress syndrome were reported by 44 (4%). Seventy-one respondents (68%) reported spending hours per day in an awkward posture. Although a majority (n 66 [64%]) reported spending 6 hours a day working at a PACS workstation or personal computer, 9 respondents (8%) reported working 8 hours per day at such a workstation. Regarding the factors that were perceived to contribute most to repetitive stress symptoms, items related to imaging and equipment were cited much more frequently than those related to computer workstations. The most commonly cited factors are represented in Figure and included patient transfer (n 4 [%]), ultrasound probes (n 4 [%]), heavy imaging equip-

3 958 Journal of the American College of Radiology/ Vol. 7. December Fig. Major causative factors of repetitive stress symptoms as reported by technologists. US ultrasound. ment (n [%]), nonergonomic chairs (n [9%]), and lead aprons (n [%]). Only respondents (%) indicated that they had received new ergonomic chairs, and of that group, a majority (n [6%]) indicated little or no improvement (a Likert scale score of or ). Only 8 (7%) reported receiving new ergonomic tables, with a majority (n [6%]) also reporting little or no improvement in symptoms (a Likert scale score of or ). Fourteen respondents (%) provided narrative comments. Seven narrative responses (5%) addressed issues specific to sonography, with most of these comments addressing the difficulty of performing repetitive examinations in an awkward position. For example, in their narrative comments, technologists reported specific symptoms related to the awkward positions required to perform ultrasound examinations, such as experiencing shoulder symptoms when holding an ultrasound probe with an extended arm while simultaneously pressing the probe on the area of interest on the patient s body. DISCUSSION Our survey of technologists working at a large academic medical center found that a majority of respondents have experienced repetitive stress symptoms and that nearly half have either previously confirmed or suspected repetitive stress injuries. Importantly, we also found that traditional aspects of technologists daily work tasks such as patient transfer and the use of imaging equipment are perceived to contribute more to their symptoms than computer-related activities, which are a major factor for radiologists. Thus, our results suggest that ergonomic interventions in radiology departments should be tailored differently for radiologists and RTs. Although previous studies have indicated a high prevalence of symptoms or injuries among RTs [7-9], there are conflicting results in the literature regarding causative factors, which have only been addressed by a few studies. For example, patient transfer and demanding physical workload have been identified as sources of injury for technologists, but lead apron use has not been shown to be significantly linked to low back pain [,8,].To our knowledge, this is the first study to survey a diverse variety of RTs across all subspecialty areas and also the first to incorporate assessment of the potential impact of ergonomic interventions for technologists working in a fully digital PACS environment. We are aware of only one similar study among radiologists [], which reported a high prevalence of repetitive stress symptoms and injuries among radiologists working in a fully digital environment. A major difference between radiologists and technologists in these two studies, however, is their response to computer-related ergonomic interventions. Indeed, whereas improvements in repetitive stress symptoms were observed in 7% to 8% of radiologists who received ergonomic chairs, workstations, and postural training [], only a minority of technologists reported improvement after these same interventions in our study. We anticipate that this difference may be explained largely by the different amount of time spent using computers between radiologists and technologists. For example, whereas 8% of responding technologists in this survey reported spending 8 hours per day working at a PACS workstation or personal computer, a prior study of radiologists at our hospital found that 68% of respondents reported spending 8 hours per day at a PACS workstation or personal computer []. The lower frequency of prolonged ( 8 hours per day) computer use by technologists in our survey may also help explain why computer-related factors were not included among the top factors that were perceived to contribute most to technologists symptoms. Rather, the most commonly reported responses related to patient transfer, ultrasound probes, and the use of heavy imaging equipment. These results emphasize the importance of tailoring ergonomic interventions to address these aspects of technologists work. We recognize that many of these ergonomic factors may be difficult to address and emphasize that optimal solutions are beyond the scope of this study. However, the types of issues that we have identified will require efforts beyond the departmental level to fully address. For example, although ergonomic training related to optimal patient transfer and handling of heavy equipment may be addressed locally, issues such as the design of ultrasound probes and weight of equipment will require larger, collaborative efforts between radiologists, technologists, and industry. A particular area in need of such

4 Siegal et al/repetitive Stress Among Radiology Technologists 959 collaboration is ultrasound. Although proper body position and comfortable chairs have been reported to reduce neck and back symptoms, other factors not amenable to ergonomic training or basic equipment modification, such as transducer design, have been identified as predictors of hand and wrist pain in sonographers []. We acknowledge several limitations of our study. First, because our survey focused on the prevalence of subjective, self-reported symptoms, we cannot provide data for specific injuries. Second, because of the anonymous nature of our survey design, we cannot compare symptom prevalence between different age groups, genders, or technologist modality. Third, because of the voluntary nature of our survey, there is potential for selection bias among our respondents. It is possible that those with repetitive stress symptoms or injuries may have been more likely to respond than those without symptoms. It is also possible that technologists working in certain modalities at increased risk were more likely to respond for the same reasons. For example, the high prevalence of responses about ultrasound probes in comparison with the relative proportion of ultrasound technologists in our department suggests that this subgroup may have been relatively overrepresented among our respondents. Conversely, the possibility of underreporting of symptoms should be considered for fear of possible repercussions due to inability or difficulty performing one s job duty. Fourth, although our survey was designed in conjunction with occupational health specialists with experience in assessing ergonomic issues, we acknowledge that the individual survey questions were not evaluated for their reliability and psychometric properties. Finally, because we did not obtain information regarding other medical, social, or recreational histories from our technologists that may have contributed to their selfreported symptoms, it is possible that we have overestimated the prevalence of symptoms that are truly secondary to work-related tasks. In summary, our survey demonstrates that RTs report a relatively high prevalence of repetitive stress symptoms. Although the precise contribution of work-related tasks to these symptoms has not been fully delineated, responding technologists perceive that factors related to patient transfer and the use of imaging equipment are the major contributing work-related factors. To provide a safer working environment for technologists, radiology departments and radiology equipment manufacturers should work collaboratively to address these issues. APPENDIX Ergonomics Survey. How many hours per day do you work at a personal computer or PACS? Do you spend more than hours per day in an awkward posture?. Do you frequently experience pain, stiffness, soreness, or cramping in either extremity, or the back or neck area, that you feel may be related to your work tasks? 4. In the past, have you been diagnosed with or treated for a repetitive strain/overuse syndrome, or do you think you may have suffered from such condition? 5. Which ONE of the following items contributes MOST to symptoms of pain, stiffness, or soreness that you may experience in the workplace (circle ONE from either category)? Workstation Factors: Chair Keyboard Mouse Dictaphone Fixed table height Other t applicable (no symptoms) Imaging Equipment Factors: Patient transfer Moving heavy equipment Ultrasound probe System control panel Lead apron Other t applicable (no symptoms) 6. Has your work area received new adjustable chairs in the past 8 months? 6a. Please rank impact of new chairs on any pain stiffness or soreness that you may have experienced in the workplace

5 96 Journal of the American College of Radiology/ Vol. 7. December 7. Has your work area received new PACS workstation tables in the past 8 months? 7a. Please rank impact of new tables on any pain stiffness or soreness that you may have experienced in the workplace 8. Have you participated in an ergonomic training session in the past 8 months? 8a. Please rank impact of new training on any pain stiffness or soreness that you may have experienced in the workplace 9. Demographics please check your position in the department. Resident Radiologist This same survey was administered to all members of the radiology department as part of a formal ergonomic assessment of our department. Fellow Radiologists Staff Radiologist Nurse or PA Technologist Administrative Assistant n-physician Administrator. Narrative comments REFERENCES. Kumar S, Moro L, Narayan Y. Perceived physical stress at work and musculoskeletal discomfort in X-ray technologists. Ergonomics 4;47: Boiselle PM, Levine D, Horwich PJ, et al. Repetitive stress symptoms in radiology: prevalence and response to ergonomic interventions. J Am Coll Radiol 8;5:99-.. Bransetter BF IV. Basics of imaging informatics. Part. Radiology 7; 44: Harisinghani MG, Blake MA, Saksena M, et al. Importance and effects of altered workplace ergonomics in modern radiology suites. Radiographics 4;4: Ruess L, O Connor SC, Cho KH, et al. Carpal tunnel syndrome and cubital tunnel syndrome: work-related musculoskeletal disorders in four symptomatic radiologists. AJR Am J Roentgenol ;8: Rumreich LL, Johnson AJ. From traditional reading rooms to a soft copy environment: radiologist satisfaction survey. J Digit Imaging ;6: Wright DL, Witt PL. Initial study of back pain among radiographers. Radiol Technol 99;64: Lorusso A, Bruno S, L Abbate N. Musculoskeletal complaints among Italian X-ray technologists. Ind Health 7;45: Kumar S. Musculoskeletal morbidity of x-ray technologists. Int J Ind Ergon 4;:9-4.. Moore B, van Sonnenberg E, Casola G, velline RA. The relationship between back pain and lead apron use in radiologists. AJR Am J Roentgenol 99;58:9-.. Magnavita N, Bevilacqua L, Mirk P, Fileni A, Castellino N. Work-related musculoskeletal complaints in sonologists. J Occup Environ Med 999; 4:98-8.