ABSTRACT

Background/Purpose: Medical sonography has become a vital diagnostic and therapeutic modality in modern-day healthcare practice, particularly in the fields of obstetrics and gynaecology. However, sonographers often have to work in situations which necessitate their carrying out repetitive movements, adopting awkward, misaligned positions and maintaining significant amounts of pressure on transducers for long periods of time. As a result, symptoms such as muscle and joint pain are common amongst practitioners. With up to 80–85% of sonographers working in pain, there is a need to develop suitable prevention programmes, which will require an in-depth knowledge of the factors causing and/or predisposing sonographers to the development of work-related musculoskeletal disorders (WRMSDs). This study focussed on identifying these factors.

Methodology: MEDLINE, PubMed, CINAHL, EBSCO, PEDro, PsycINFO, AMED and the Glasgow Caledonian University (GCU) online library via GCU’s ‘DISCOVER IT’ engine were electronically searched. The study was conducted as a structured literature review, adopting the PIO approach to guide the development of a research question and the database search. The use of carefully defined search terms and Reference Manager, the separation of grey literature and publications which were not in the English language and the application of specific inclusion and exclusion criteria resulted in the selection of six relevant articles, those that meet the inclusion criteria. These were subsequently assessed for quality using the CASP tool and subjected to a standardised data extraction form.

Main Results: This review highlighted the fact that there is a relatively high prevalence of WRMSDs amongst sonographers. Work-related risk factors include high patient loads, long working hours and repetitive muscle movements in repetitive work done by specialised sonographers such as cardiac and obstetric sonographers. Other factors include ergonomically poor equipment, poor workspace organisation and poor work scheduling. The increasing obesity of present-day populations causes increased stress and strain amongst sonographers and augments the possibility of developing WRMSDs.

Conclusion: The development of WRMSDs amongst modern-day sonographers is the result of interactions between different individual, workplace, administrative and biomechanical factors. Poor work scheduling, high patient loads (resulting in part from low staffing levels) and little or no practitioner rest between patients are additional influencing factors. This points to the need for modern, ergonomically safe equipment; proper workplace organisation; and the development of good work environments for sonographers. It is recommended that future research should identify the degree of influence of each factor on the development of WRMSDs. Finally, qualitative examination of influences on employee well-being, satisfaction and commitment can help to provide insights into the creation of ergonomically and psychologically healthy environments.

Table of Contents

ACKNOWLEDGMENTS. 2

ABSTRACT.. 3

LIST OF ABBREVIATIONS. 7

CHAPTER ONE: INTRODUCTION.. 8

1.0 Overview.. 8

1.1 Statement of the Problem.. 9

1.2 Research Question. 9

1.3 Aims and Objectives. 10

1.4 Importance of this Review.. 10

1.5 Summary. 10

CHAPTER TWO: LITERATURE REVIEW… 12

2.0 Overview.. 12

2.1 Ultrasonography: A Major Advance in Healthcare Practice. 12

2.2 The Prevalence of WRMSDs in Sonographers. 13

2.2.1 Signs and Symptoms of WRMSDs in Sonographers. 14

2.2.2 Factors Predisposing Sonographers to WRMSD.. 15

2.2.3 Preventing the Onset and Reducing the Severity of WRMSDs in Sonographers. 18

2.2.3.1 Risk Assessments. 18

2.2.3.2 Ultrasound Equipment 18

2.2.3.3 Education. 18

2.2.3.4 The Work Environment 19

2.3 Summary. 19

CHAPTER THREE: METHODOLOGY.. 20

3.0 Overview.. 20

3.1 Criteria for Formulating the Research Question. 20

3.2 Study Design. 22

3.3 The Search Strategy and Study Selection. 25

3.4 Inclusion and Exclusion Criteria. 26

3.5 Final Study Selection. 27

3.6 Data Extraction. 27

3.7 Quality of the Chosen Studies. 28

3.8 Summary. 29

CHAPTER FOUR: RESULTS. 30

4.0 Overview.. 30

4.1 Study Selection. 30

4.2 Quality Assessment of the Chosen Studies. 33

4.3 Characteristics of the Selected Studies. 33

4.4 Prevalence and Development of WRMSDs in Sonographers. 37

4.4.1 Techniques and Protocols. 38

4.4.2 Sample Size and Correlations. 38

4.5 Factors Influencing WRMSDs in Sonographers. 40

4.6 Summary. 43

CHAPTER FIVE: DISCUSSION.. 44

5.0 Overview.. 44

5.1 Summary of the Evidence. 44

5.2 Limitations. 46

5.3 Findings within the Context of the Current Evidence. 47

5.4 Research Recommendations. 48

CHAPTER SIX: CONCLUSION.. 50

References. 51

Appendices. 57

List of Tables
22 Defined Elements of the PIO Framework Used for this Research Study……. 3.1
32 Examples of Reasons for Exclusion of Studies……………………………… 4.1
35 Characteristics of the Selected Studies……………………………………… 4.2

List of Figures
31 The Study Selection Process using the PRISMA Statement………………. 4.1
40 Total Sample Size and Distribution Across and Within All Six Papers…… 4.2

List of Appendices

Critical Appraisal Skills Programme (CASP)….………………………….…… 57

Allied and Complementary Database AMED
American Occupational Therapy Association AOTA
American Society of Echocardiography ASE
Critical Appraisal Skills Programme CASP
Cumulative Index to Nursing & Allied Health Literature CINAHL
It’s an online database that hosting wide range of research studies EBSCO
Medical Literature Analysis and Retrieval System Online MEDLINE
Physiotherapy Evidence Database PEDro
Population, Intervention, Comparison, Outcome PICO
Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA
A database of the U.S. National Institutes of Health Pubmed
Randomised Controlled Trials RCTs
Ultrasound Imaging US
Work Related Musculoskeletal Disorders WRMSDs

1.0 Overview

The past few decades have been characterised by major advances in the field of medicine. Such advances have led to improvements in health and well-being, as well as the life expectancy of local, national and international populations. One of the factors facilitating these improvements in healthcare provision is the range of advances in medical diagnostic practice. In addition to biochemical, haematological and microbiological laboratory investigative science, radiology has also advanced significantly over the past few decades.

In the field of radiology, the introduction of ultrasound (US) scanning in particular has facilitated non-invasive investigations which expose patients to little or no risk (Engen et al, 2010; Oke & Adeyekun, 2013). It is therefore of immense value as a useful diagnostic and therapeutic modality (Hackmon et al, 2006). Medical diagnostic sonography in particular is a mode of diagnosis that has been of huge relevance to the healthcare industry since its introduction decades ago. All health professionals have begun to use it in their practice (McKiernan et al, 2010), making it an essential modern-day healthcare diagnostic modality (Hackmon et al, 2006). It is of particular value for obstetrics and gynaecological practice, and is often considered an integral segment of the physical examination (Schoenfeld, 1998; Engen et al, 2010).

While the activities of US technicians and practitioners are of vital importance in all fields of healthcare practice, however, there is a marked prevalence of work-related musculoskeletal disorders (WRMSDs) amongst US technicians and sonographers (Schoenfeld, 1998; Christenssen, 2001; Engen et al, 2010).

WRMSDs are conditions affecting muscles and tendons in the body which are typically due to an individual’s performance of numerous forceful and/or awkward movements (Morton & Delf, 2008; Oke & Adeyekun, 2013). Moreover, Adegoke (2008) described WRMSDs as the most common causes of severe long-term pain and physical disability, affecting hundreds of millions of people across the world. Sonographers typically work in situations that require them to sit or stand for long periods. Holding the transducer in a suitable position for scanning requires both static and dynamic loading of the muscles of the neck, back, shoulders and the upper extremities (Pike et al, 1997; Engen et al, 2010). In addition, sonographers usually have to carry out repetitive movements, often in misaligned positions, with the result that many have symptoms such as myalgia, or muscle pain, which is an indicator of various diseases and disorders. The most common reasons for such pain are the overuse or over-stretching of a muscle or group of muscles, or arthralgia, which is a symptom of infection, injury and illnesses in particular, osteoarthritis; (Hackmon et al, 2006). As a result, this group of practitioners is often prone to developing one form of WRMSD or another. These are often referred to interchangeably as musculoskeletal injuries (MSIs), repetitive strain injuries (RSIs) and WRMSDs.
1.1 Statement of the Problem

In 1997, a study for the Society of Radiographers revealed that up to 71% of radiographers have work-related pain and discomfort. Similar findings were observed in a 2000 study, which demonstrated that 70% of radiographers and 79% of sonographers have WRMSDs (Morton & Delf, 2008). Furthermore, a 2008 study showed that up to 90% of North American sonographers were suffering from some form of WRMSD (Coffin, 2014). An estimated 80–85% of sonographers work in some degree of pain, while up to 20% have pain and injuries which result in the end of their careers (Bastian et al, 2009). These patterns are higher in sonographers who have higher workloads, as well as those who have been practicing for long periods of time (Engen et al, 2010).

The extent of these problems, as well as the general level of disability associated with the conditions (Village & Trask, 2007), means that it is important to implement well-developed strategies for the prevention of and reduction of the severity of WRMSDs in the sonographer population. However, the development of suitable strategies will be facilitated by in-depth insight into the prevalence of these work-related disorders, as well as the factors that contribute to or reduce their incidence.
1.2 Research Question

What factors affect the prevalence and development of work-related musculoskeletal disorders in sonographers?
1.3 Aims and Objectives

The aim of this study was to examine whether there was evidence to support the factors that affect and result in the prevalence and development of WRMSDs amongst sonographers. The objectives were as follows:

To assess the incidence of such work-related disorders and injuries among sonographers.
To identify the factors influencing such work-related injuries in sonographers.
To identify the available evidence supporting such factors.
To assess the gaps in knowledge and practice in the existing literature.

1.4 Importance of this Review

Musculoskeletal disorders occur in 63–90% of sonographers, in contrast to about 13–22% of the general population (Village & Trask, 2007). Furthermore, the associated levels of debility mean that up to 20% of sonographers are forced to leave their profession, which emphasises the degree of this problem in this particular population. According to Roll et al (2012), while this is an acknowledged industry problem which has resulted in a number of professional guidelines, these studies suggest that the risk of injury has increased in this population since Pike et al’s 1997 study. It is therefore evident that there is a need to design, develop and implement methods of reducing the incidence and severity of existing musculoskeletal disorders. Nevertheless, it is not possible to develop such interventions successfully without an in-depth understanding of the factors responsible for this pattern. This study therefore examines existing literature to determine the predisposing factors, as well as the evidence which supports their relevance. It is anticipated that a good understanding of these factors will help in the development of interventions suited to different contexts.
1.5 Summary

The incidence of WRMSDs in sonographer populations means that such disorders pose a challenge for the modern-day sonographer. It is therefore vital to generate an in-depth understanding of the factors resulting in and predisposing to the development of these disorders in this population. The following chapters describe the literature review on work-related MSIs/musculoskeletal disorders in sonographers, the methodology of this research study, the results of the study and finally, give a discussion and analysis of the results.

Work-Related Musculoskeletal Disorders (WRMSDs) In Sonographers
2.0 Overview

Ultrasonography is a mode of diagnosis which has been of huge relevance to health care service society since its introduction decades ago. This is particularly so in the field of obstetrics and gynaecology (Schoenfeld, 1998), and it is now an essential modern-day healthcare diagnostic modality (Engen et al, 2010). However, the activities of US technicians and practitioners often result in a number of WRMSD conditions categorised by varying levels of soft and/or bony tissue discomfort (Pike et al, 1997; Schoenfeld, 1998; Engen et al, 2010). This chapter examines the field of ultrasonography, WRMSDs and the factors predisposing individuals to the development of such conditions.
2.1 Ultrasonography: A Major Advance in Healthcare Practice

The past few decades have been characterised by major advances in medical diagnostic practice, including US scanning, which has become a significant therapeutic and diagnostic tool in modern healthcare professions (Hackmon et al, 2006; Engen et al, 2010). The increasing relevance of sonography in all areas of medical practice means that there has been the development of sub-specialities devoted to it. Initially, diagnostic US was mainly the province of radiologists and sonographers who used the equipment within radiology departments (McKiernan et al, 2010). However, over time, it has become a relevant part of healthcare practice, particularly in obstetrics and gynaecology, where it is now assumed to be an essential element of the physical examination (Schoenfeld, 1998; Hackmon et al, 2006; McKiernan et al, 2010).

In sonography, the relative cost-effectiveness, non-invasiveness and minimal exposure of both patients and practitioners to harmful sound waves means that it is often used as the first mode of action before a move to alternative diagnostic and/or therapeutic modalities. This means that US practitioners must often carry out the procedure on numerous patients on a daily basis (Village & Trask, 2007).

The importance of this tool in modern-day clinical practice means that there is a need to identify any negative side effects which exist amongst its practitioners. Moreover, an examination of the causative and/or predisposing factors will help organisations and professional bodies to develop and implement guidelines of action which will help to secure the health, safety and well-being of their practitioners. This leads to questions about the occurrence of musculoskeletal disorders or injuries in the modern-day sonographer.
2.2 The Prevalence of WRMSDs in Sonographers

In the process of carryout out US examination, sonographers frequently perform numerous repetitive movements which often mean that their bodies are misaligned or placed in awkward positions. In addition, body positioning for many of the different scans puts operators at risk of sustained body strain (Hackmon et al, 2006). While the activities of US technicians and practitioners are of vital importance in all fields of healthcare practice, the development of WRMSDs among US technicians and sonographers shows a marked prevalence (Schoenfeld, 1998; Christenssen, 2001; Village & Trask, 2007; Engen et al, 2010). Such patterns of occurrence have led groups of researchers to describe US scanning as posing an occupational risk to medical practitioners and technicians conducting frequent, routine US examinations in any field of medical endeavour (Hackmon et al, 2006).

WRMSDs are soft and bony tissue disorders affecting bones, muscles, joints, tendons and ligaments; they cause the sufferer varying degrees of discomfort and either result from or are aggravated by workplace exposures (Pocratsky et al, 2013). In 2001, there were 333 800 new reports of WRMSDs in the United States (US), and 65% of these cases occurred due to repeated trauma (Barr et al, 2004).

First identified in 1985 with the description of ‘sonographers’ shoulder’ by Craig (1985), WRMSDs account for about 60% of all workplace conditions (Baker & Coffin, 2013; Bassey et al, 2013; Pocratsky et al, 2013; Coffin, 2014). The first major study of MSIs and musculoskeletal disorders in sonographers, conducted by Pike and his colleagues under the guidance of the Society of Radiographers, was carried out in 1997. This study revealed that up to 81% of radiographers have work-related pain and discomfort. Similar findings were reported in a 2000 study conducted as a reprise of the 1997 study, which demonstrated that 70% of radiographers and 79% of sonographers have WRMSD conditions (Morton & Delf, 2008; Roll et al, 2012). Furthermore, studies in 2008 showed that up to 90% of North American sonographers suffered from some form of WRMSD (Pocratsky et al, 2013; Coffin, 2014). An estimated 80–85% of sonographers work in some degree of pain, while up to 20% have severe enough pain and injuries to result in the end of their careers (Bastian et al, 2009; Bassey et al, 2013). These patterns are clearer in sonographers who have higher workloads, as well as those who have been practicing for a number of years (Engen et al, 2010).

The extent of the problem is further emphasised by the fact that up to 80% of sonographers receive treatment for WRMSDs: Forty-six per cent use physiotherapy and/or medication to alleviate pain, while 16.7% miss work as a direct result of symptoms. Moreover, 14.6% reduce their work duties, 9.4% reduce their work hours, 21.2% take sick leave and 11.75% take vacation days or leave (Village & Trask, 2007).

The patterns of occurrence of WRMSDs in sonographers are due in part to poor work postures and positioning, as well as sustained muscle exertion during repeated US examinations (Morton & Delf, 2008). Although it could be argued that technological advances should have facilitated the development of ergonomically US scanning machines, a lot of these problems are potentiated by organisational characteristics, such as poor job, worktable and workspace organisation, as well as equipment design (Village & Trask, 2007). Additionally, in the search for wide and freer ranges of operator movements, the use of new US scanners means that sonographers often have to support the weight of the transducers while also leaning across their patients. This contrasts significantly with older ?-scanners, whose arms were attached directly to the unit in a manner that facilitated the adoption of stable and naturally aligned positions by the operators (Morton & Delf, 2008).
2.2.1 Signs and Symptoms of WRMSDs in Sonographers

Common symptomatic areas include the neck, shoulder, upper, middle and lower back, upper arm, forearm, wrist, hands/fingers, elbows and legs (Morton & Delf, 2008; Ugwu et al, 2009; Baker & Coffin, 2013). Symptoms include inflammation and swelling, numbness, muscle spasms, burning and/or tingling, loss of sensation and loss of muscle strength (Coffin, 2014). Moreover, clumsiness and occasional visual symptoms such as eye strain, headaches and blurred vision have been reported (Ugwu et al, 2009; Baker & Coffin, 2013).
2.2.2 Factors Predisposing Sonographers to WRMSD

Coffin (2014) describes the work activities placing workers at high risk of developing WRMSDs as those involving forceful and/or awkward movements requiring the practitioner to perform frequent repetitive motions; this situation is worsened when the procedures go on for long periods of time. Other risk factors include maintaining poor posture or improper body positioning persistently, as well as the need to apply excessive, sustained force or to have regular exposure to strains and vibrations (Barr et al, 2004; Coffin, 2014). Apart from vibrations, sonographers experience all of the activities highlighted above in the course of carrying out their work roles.

WRMSDs in sonographers occur from or are aggravated by long, sustained or short, intensive periods of repetitive muscular movements. Technological advancements have reduced the time spent on each patient, and as a result, sonographers see more patients during an average work day, taking few or no rest breaks. In their 2008 study, Morton and Delf discovered that up to two-thirds of the participants had fewer than 10 minutes of rest in a workday. This is important because the guidelines for interventions recommended by professional bodies/societies such as the Society of Diagnostic Medical Sonography and various government agencies advocate that sonographers should take breaks at regular intervals throughout the day (Morton & Delf, 2008; Sommerich et al, 2011; Pocratsky et al, 2013; Coffin, 2014).

According to Village and Trask (2007), increasing incidence of musculoskeletal problems occurs when sonographers spend long periods of time scanning patients and maintain scans at higher number of patients than usual which has been defined in a guideline. In addition, certain US scans are more strenuous than others, including obstetric scans (Village & Trask, 2007) as well as echocardiography (Swinker & Randall, 2003). The existence of such risk factors in the workplace and practitioners’ exposure to these factors in this setting often result in injuries to their muscles, tendons, joints, cartilage and spinal discs (Irurhe et al, 2013).

There is a greater risk in sonographers who perform the same type of examination on a daily basis with little or no variation. This is common in more specialised examinations, such as obstetric scans, as mentioned above, and cardiac sonography (Coffin, 2014). This means that these workers carry out the same kind of muscular activities on a daily basis, repeatedly using the same muscle groups; often, there is little or no recovery time between scans (Barr et al, 2004; Baker & Coffin, 2013; Coffin, 2014). In an American Society of Echocardiography survey, it was discovered that up to 80% of respondents had back/neck and shoulder pain. This pain was associated with the performance of over 100 scans per month or regularly carrying out individual scans lasting for more than 25 minutes (Swinker & Randall, 2003; Pocratsky et al, 2013).

In 2000, a Sonography Benchmark Survey by the Society of Diagnostic Medical Sonography showed that on average, sonographers conducted about 10.4 scans per work day. This translates to 2704 patients per sonographer per year based on an annual figure of 260 working days; this represents a 55.7% increase in patient volume from the levels in 1992 (Baker & Coffin, 2013). On average, echocardiographers acknowledged performing an average of 22.5 scans per week, with each scan lasting up to 35.9 minutes (Swinker & Randall, 2003). This is a vital point, keeping in mind that the duration of pressure applied by the sonographer depends in part on the amount of time spent with each patient, as well as the amount of pressure exerted on the transducer during this time (Coffin, 2014). This points to the importance of a good allocation of work, including patient numbers and spacing, where practitioners are allowed sufficient time to rest between patients.

The repeated movements sonographers make are often carried out in misaligned positions (Hackmon et al, 2006). This can be due to the need to twist their torso and neck to view the monitor while scanning the patients (Ugwu et al, 2009; Pocratsky et al, 2013). Echocardiography scans, for example, frequently require the practitioners to perform repeated, often sustained twisting of the trunk during the procedures (Swinker & Randall, 2003). Poor limb positioning and frequent stretching above the shoulder level are also contributing factors (Swinker & Randall, 2003; Village & Trask, 2007; Morton & Delf, 2008).

People whose jobs are characterised by such high levels of ergonomic stress are more prone to developing WRMSDs (Moraes et al, 2009; Ugwu et al, 2009; Shiri & Viikari-Juntura, 2011). As a result, there is often pain in the shoulders, neck, wrist, hands and back (Bastian et al, 2009; Ugwu et al, 2009; Pocratsky et al, 2013). In addition, symptoms such as pain are reported more frequently by US technicians than physicians. Because US technicians carry out investigations on a daily basis, often seeing a very large number of patients, this pattern probably reflects the greater number of scans carried out by this population.

Another contributing factor is increasing age (especially when practitioners are over 40 years), which appears to leave practitioners more at risk of developing severe musculoskeletal symptoms. Older practitioners are also more likely to have been working in full-time US work for over five years, another factor which is associated with increased incidence of musculoskeletal complaints (Swinker & Randall, 2003; Baker & Coffin, 2013).

Further factors include patterns of obesity in present-day populations. The scanning of obese patients represents unique challenges to sonographers, who have to exert increased pressure and/or use higher scan frequencies on their patients to be able to achieve images of sufficient quality to make a diagnosis (Bastian et al, 2009; Baker & Coffin, 2013). One of the leading causes of WRMSDs in sonographers is sustained grip pressure on the transducer; this means that sonographers who have a relatively high proportion of obese patients are working in a situation where they need to maintain their grip consistently for prolonged periods of time (Bastian et al, 2009). The increasing population obesity means that up to 1 in 50 children and 1 in 400 adults are obese; these numbers are expected to increase even further over the next few years (Flegal et al, 2010; Agyemang et al, 2014). It is therefore obvious that this is a factor that must be considered in the design of equipment, as well as the arrangement of sonographers’ work spaces.

Other factors affecting the occurrence of WRMSDs are the characteristics of the healthcare organisation. According to Coffin (2014), health care staffing shortages mean that many organisations are faced with the challenge of providing high-quality US services to an increasing number of patients with a relatively small or dwindling staff population. In addition to making it difficult for sonographers to rest sufficiently between their appointments, such increased patient volumes also mean that these practitioners might not have the opportunity to ensure that they are optimising their use of available work spaces in a manner that is ergonomically safe. Moreover, there are both implicit and explicit pressures for employees to work beyond their normal working hours (Baker & Coffin, 2013). These factors are both physical and psychological stressors for workers and place them at even more risk of developing these disorders.
2.2.3 Preventing the Onset and Reducing the Severity of WRMSDs in Sonographers

The multiple causative factors of workplace WRMSDs means that there are many different opportunities to reduce or prevent them (Coffin, 2014). Some useful methods are described below.
2.2.3.1 Risk Assessments

Risk assessments are ‘an essential part of the process of identifying risks to employees’ (Morton & Delf, 2008, p. 198). It is mandatory for organisations to ensure that they carry out regular assessments of ergonomics and practices and processes of US scanning in the workplace. In the event that these assessments reveal deficiencies and problems, steps should be taken to address those issues (Baker & Coffin, 2013).

Actions which could be of use include the provision of adjustable chairs and tables, careful patient care and/or patient positioning and large, well-equipped rooms with sufficient space for the production of reports (Baker & Coffin, 2013). Furthermore, proactive management attitudes to risk assessment should encourage sonographers to report their difficulties and/or symptoms. This will facilitate changes in workstations or their rearrangement to increase sonographers’ comfort (Morton & Delf, 2008).
2.2.3.2 Ultrasound Equipment

US equipment must be ergonomically suitable; this is the responsibility of both equipment manufacturers and the organisation and department management. In addition to the nature of the equipment in the exam room, it is essential for the workstation, exam room and the type of US system to be carefully arranged (Baker & Coffin, 2013; Coffin, 2014).
2.2.3.3 Education

It is paramount for sonographers to be educated and provided with information about the correct use and adjustment of available equipment, self-care and risk prevention (Morton & Delf, 2008; Coffin, 2014). The number of publications and lectures on this aspect of sonography is increasing. These measures, in addition to word-of-mouth communication between members of the same professional bodies, mean that there is more practitioner awareness about the risks and outcomes of WRMSDs (Baker & Coffin, 2013).
2.2.3.4 The Work Environment

Managers are responsible for the selection, purchasing and maintenance of ergonomically designed equipment. Manager perceptions and actions are therefore vital in the development of ergonomically suitable work environments for sonographers. This is of particular relevance considering that the severity of symptoms and disability can increase when employee work environments are categorised by low levels of social support or poor levels of control of their job or work conditions (Shiri & Viikari-Juntura, 2011; Coffin, 2014).
2.3 Summary

Since the introduction of ultrasonography in healthcare practice, it has become a major modern-day diagnostic and therapeutic tool. However, although the activities of sonographers are vital in all fields of medicine, there is a marked prevalence of WRMSDs in technicians and practitioners, representing 63–91% of these employees in contrast to 13–22% in the general population.

Individuals WRMSDs commonly present with numbness, muscle spasms, inflammation and swelling, burning and/or tingling, loss of sensation and/or muscle strength, as well as occasional visual symptoms. They develop because sonographers regularly engage in repetitive motion, forceful or awkward movements and positioning and repeated strains. Increased patient loads and longer working days with fewer rest breaks further exacerbate these symptoms.

In view of the significance of these disorders, it is recommended that organisations carry out regular risk assessments to identify and rectify any deficiencies; install ergonomically suitable US equipment; educate employees about the correct posture and use of equipment; and maintain positive work environments. The following chapter details the methodology used to examine the factors affecting the prevalence and development of WRMSDs in sonographers.

3.0 Overview

Sonographers and radiographers are healthcare practitioners involved in conducting non-invasive diagnostic investigations covering all groups of patients. The extent of the problem of WRMSDs, as well as the general level of disability associated with the condi