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 Table of Contents  
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 49-52

Essential ergonomics to minimize work-related musculoskeletal disorders in echocardiography

1 Cardiac Centre, Bahrain Defence Force Hospital, Bahrain
2 Department of Medicine, Karolinska Institute; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden

Date of Web Publication9-Mar-2018

Correspondence Address:
Mr. Shantanu Deb
Cardiac Sonographer, RCS, Bahrain Defence Force Hospital, Cardiac Centre, West Riffa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_2_18

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Physicians and sonographers performing echocardiographic scans place themselves at risk of developing work-related musculoskeletal disorders (WRMSDs) owing to faulty posture and repetitive hand and arm movements. Poor ultrasound ergonomics plays a pivotal role in the development of WRMSD and can result in injury and sickness absence, impacting efficiency and work productivity. The aim of this article is to draw the attention to common considerations and corrective measures to reduce the risk of WRMSD among professionals actively performing echocardiographic scans.

Keywords: Echocardiography, ergonomics, work-related musculoskeletal disorders

How to cite this article:
Deb S, Venkateshvaran A. Essential ergonomics to minimize work-related musculoskeletal disorders in echocardiography. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:49-52

How to cite this URL:
Deb S, Venkateshvaran A. Essential ergonomics to minimize work-related musculoskeletal disorders in echocardiography. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2020 Aug 3];2:49-52. Available from: http://www.jiaecho.org/text.asp?2018/2/1/49/227029

  Introduction Top

The practice of echocardiography entails sitting for long hours, tiresome postures, and repetitive hand and arm movements. As an occupational group, both sonographers and practicing physicians are prone to developing work-related musculoskeletal disorders (WRMSDs), a range of conditions caused by forceful or awkward movements that cause injury to muscles, tendons, and ligaments. Common symptoms include aches and pains, joint stiffness, and muscle tingling or burning sensations.[1],[2] Studies conducted among sonographers in other parts of the world suggest that between 80% and 90.5% scan in pain, and sometimes, the onset of discomfort arrives within 5 years of entering the profession.[3],[4] In addition, WRMSD also results in sickness absence, surgical procedures, and in some cases, a premature end to a promising career.[1],[5] Preventive measures that are aimed at reducing the risk of WRMSD among the growing ultrasound community in India are essential.

Ergonomics, derived from the Greek word “ergon,” meaning work, refers to the applied science concerned with design and arrangement of physical spaces to facilitate better human–object interaction to promote work efficiency and safety. Poor ultrasound ergonomics has received attention in the last few decades as a common factor that can lead to WRMSD, in addition to other exacerbating psychosocial factors and workload management issues.

The aim of the current article is to provide a broad overview of common WRMSD-related health issues and to suggest corrective measures to reduce risk among scanning professionals using optimal ergonomic practices. Over the next few paragraphs, we intend to briefly cover (1) laboratory setting-related considerations, (2) equipment-related considerations, (3) position and posture-related considerations, and (4) process-related considerations.

Laboratory setting-related considerations

Before beginning an examination, it is important to pay attention to factors that may help reduce or prevent potential strain or injury. An adequately-sized room with ambient lighting to minimize screen glare and ambient temperatures as suggested by the installation plan of commercial ultrasound equipment providers is to be considered [Figure 1].[2],[6]
Figure 1: Excessive lighting (left) and optimal lighting (right) to reduce screen glare in an echocardiographic laboratory

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Equipment-related considerations

Most current ultrasound systems comply with industry standards for the prevention of WRMSD in sonography[7] and include a height-adjustable console [Figure 2], optimized control layout for use by both right-handed and left-handed operators, unobstructed transducer and external device access, and monitors with reduced flicker and adequate visual contrast. Several models provide a footrest designed to encourage a neutral ankle position [Figure 3] and lightweight transducers balanced to minimize torque on the wrist.
Figure 2: Inappropriate (left) and appropriate (right) console height during transport of ultrasound equipment

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Figure 3: Inappropriate (left) and appropriate (right) ankle positions employing available foot rests on ultrasound equipment

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When considering the patient couch, an easily maneuverable, height-adjustable couch with a drop away or cut-out section to facilitate easy access to apical windows without undue strain on the operator's wrist is advisable. Further, a chair that can be adjusted in keeping with the height of the operator is recommended such that shoulder abduction is limited to <30° while scanning, and the forearm of the non-scanning arm is approximately parallel to the floor.[8] Adequate lumbar support is necessary, and the seat design must support an upright posture. Swivels that permit the operator to easily switch from patient to the machine, while maintaining an aligned posture is are advantageous. Hyperextension of the shoulder for prolonged periods causes a strain on the rotator cuff muscles and glenohumeral joint and should be avoided [Figure 4].
Figure 4: Hyperextension of the shoulder (left) and more neutral shoulder positions (right) during scanning

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Position and postural-related considerations

The shoulders, neck, back, hands, wrist, and fingers are all prone to additional strain during scanning. These will be addressed in subsequent passages.

Shoulders, neck, and back

The shoulder corresponding to the scanning arm is impacted by excessive arm abduction that can result in potential injury.[2],[9] It is important to position the patient couch as close as possible to minimize arm abduction [Figure 5]. In addition, this also prevents overextension of the nonscanning arm as it reaches for the machine's controls. In the event an optimal positioning cannot be obtained, such as when performing bedside studies, requesting additional help with controls is advisable. Optimal bed height may also help support a neutral shoulder position while scanning [Figure 6].
Figure 5: Excessive arm abduction (left) and more optimal arm positioning (right) during scanning

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Figure 6: Inappropriate (left) and appropriate (right) bed height to maintain a neutral shoulder position while scanning

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Evans et al. have suggested that 65.8% of ultrasound practitioners have neck-related health issues,[3] making this another site of common injury.[2] The neck vertebrae are most mobile as compared to bones in the spine, and long periods of fixed position build up tension in the neck muscles, leading to fatigue. Optimal positioning of the monitor aligned with the line of operator eyesight minimizes neck extension and adjusting the angle of a tilting monitor to <20° is suggested[2] [Figure 7].
Figure 7: Inappropriate (Left) and appropriate (Right) monitor height and angle to prevent hyperextension

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Prolonged sitting is another relative disadvantage while scanning as it increases pressure on the intervertebral discs and trunk muscles, and this negative impact is exacerbated when leaning or sitting in a twisted position. Maintaining an upright posture while scanning minimizes twist on the back. Commercially available ergonomic chairs are worthwhile investments if scanning for prolonged periods of time. If using a height-adjustable patient couch, alternating between standing and sitting position is also beneficial.[2],[6] Other measures that minimize the need to twist the spine, such as positioning the patient closer to the operator or employing a slightly convex lumbar rest to enhance lower back support are desirable when scanning for long periods.

Hands, wrists, and fingers

A general rule while scanning is to adopt as neutral a hand and wrist position as possible. When switching from the long axis to short axis views, it is preferable to rotate the transducer in one's hand, rather than flex one's wrist [Figure 8]. When acquiring apical views, a palmar grip with the wrist in a neutral position, rather than a pinch grip, is always recommended [Figure 9]. In general, a palmar grip allows for even distribution of transducer weight across the whole hand, rather than localized points that may lead to injury in due course.[10] A common misconception among practitioners is that greater pressure on the probe results in better image quality. However, studies have suggested that this may play little role,[11] and other factors concerning optimal probe position and adequate awareness on image optimization such as altering probe frequency and employing harmonics may be useful. Wearing gloves may also be of value for better grip, provided they are textured and the right size.[12],[13]
Figure 8: A neutral wrist position is recommended while switching from the long axis (left) to short axis (right) views

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Figure 9: Illustration of the pinch grip (left) as compared to the palmar grip (right) while acquiring the apical views

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Process-related considerations

In addition to equipment and physical controls, certain process-related measures may also be of value to promote the long-term health and well-being of echocardiographers. Creating opportunity for frequent shift in positions either to perform image analysis or short walks between echo-stations and periodical micro-breaks is essential according to a number of studies.[1],[6],[10],[12],[14] Even during a study, taking the probe off a patient to perform a quick measurement provides a short period of relaxation to the shoulder and wrist. Engaging the hospital-based physiotherapist to provide short exercises to sonographer groups as part of their continuing education is advisable and should be discussed with section administrators and hospital management.

In summary, we provide a few suggestions that may minimize the risk of WRMSD among the echocardiography community.

  1. Adjust the height of the machine, chair, and patient bed depending on operator height before performing an examination
  2. Adjust the lighting in the echo laboratory to minimize glare and eye strain
  3. Schedule a discussion with the ultrasound application specialist to understand all machine-related ergonomic features to support healthy scanning practices
  4. Keep the monitor at eye level and console within easy reach during the scan
  5. Place the patient bed as close as possible to minimize shoulder abduction
  6. Maintain good and upright posture: Minimize reaching, straining, and twisting. Provide adequate support to the scanning hand
  7. Maintain a neutral wrist and shoulder position as far as possible while scanning and minimize excessive tension or twist
  8. Practice scanning with both hands for additional advantage
  9. Encourage micro-breaks during the hours spent scanning. Look away from the screen or get up and stretch. Even a few minutes, every few patients will provide a change in position and help relax upper body muscles
  10. Create a discussion forum to discuss improvements in physical environment with the management and engage assistance from the hospital-based physiotherapy department, if available.

Further studies are required to capture WRMSD-related data among the Indian sonographer community, in addition to the impact of corrective ergonomic-related measures on practitioner health and well-being.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Morton B, Delf P. The prevalence and causes of MSI amongst sonographers. Radiography 2008;14:195-200.  Back to cited text no. 1
Baker JP, Coffin CT. The importance of an ergonomic workstation to practicing sonographers. J Ultrasound Med 2013;32:1363-75.  Back to cited text no. 2
Evans K, Roll S, Baker J. Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists: A representative sample. J Diagn Med Sonogr 2009;25:287-99.  Back to cited text no. 3
Pike I, Russo A, Berkowitz J, Baker JP, Lessoway VA. The Prevalence of Musculoskeleta Disorders Among Diagnostic Medical Sonograhers. J Diagn Med Sonogr 1997;13:219-27.  Back to cited text no. 4
Janga D, Akinfenwa O. Work-related repetitive strain injuries amongst practitioners of obstetric and gynaecological ultrasound worldwide. Arch Gynecol Obstet 2012;286:353-6.  Back to cited text no. 5
Monnington SC, Dodd-Hughes K, Milnes E. Risk Management of Musculoskeletal Disorders in Sonography Work. Birmingham: Health and Safety Executive; 2012.  Back to cited text no. 6
Brown G, Gregory V, Habes DJ, Murphey S. Industry standards for the prevention of work-related musculoskeletal disorders in sonography. J Diagn Med Sonogr 2003;19:283-86.  Back to cited text no. 7
Salvendy G. Handbook of Human Factors and Ergonomics. Hoboken, New Jersey: John Wiley & Sons; 2012.  Back to cited text no. 8
Village J, Trask C. Ergonomic analysis of postural and muscular loads to diagnostic sonographers. Int J Ind Ergon 2007;37:781-9.  Back to cited text no. 9
Coffin C. Work-related musculoskeletal disorders in sonographers: A review of causes and types of injury and best practices for reducing injury risk. Rep Med Imaging 2014;7:15-26.  Back to cited text no. 10
Toomey C, McCreesh K, Leahy S, Jakeman P. Technical considerations for accurate measurement of subcutaneous adipose tissue thickness using B-mode ultrasound. Ultrasound 2011;19:91-6.  Back to cited text no. 11
Sunley K. Prevention of Work-Related Musculoskeletal Disorders in Sonography. London: Society of Radiographers; 2006.  Back to cited text no. 12
Bolton GC, Cox DL. Survey of UK sonographers on the prevention of work related muscular-skeletal disorder (WRMSD). J Clin Ultrasound 2015;43:145-52.  Back to cited text no. 13
Forrester C. The Osteopath's Role in the Diagnosis and Management of Patients with the Symptoms of Repetitive Strain Injury in the Upper Extremities. London: The British School of Osteopathy; 2012.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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