Table 1.

Main features and results of the 12 studies included in the scoping review about the correlation between anti-X apron use and musculoskeletal disorders (MSDs) onset. Study conclusions, relating to the topic of this review, are highlighted in bold.

Author, year [Ref.no] Country	Study Design/Aims/Objectives	Setting/Population/Sample	Methods	Main Results
Alexandre et al., 2017 [9] France	Cross-sectional study To quantify the impact of the weight of radiation protection lead aprons on the discomfort and fatigue of HCWs.	In the field Four HCWs (2 F; 2 M) Interventional gastroenterology operating room with and without use of X-rays.	Muscular discomfort and fatigue Skin temperature measured by Infrared thermography Five muscle groups were investigated: deltoid, Pectoralis major, Trapezius, Lumbar spine, Hamstring muscles Three different situations: ▪ after the reference situation (T0), ▪ after 3 h spent in the classical endoscopy service (without apron) (T1), ▪ after 3 h spent in the operating room with apron (T2).	All the muscular groups studied, especially trapezoids and pectorals, had significant temperature increases, with discomfort and fatigue inducing back pain in medical staff. The apron weight is carried primarily by the shoulders, symmetrically, and the corresponding muscle groups may have a contraction threshold that is best suited for resisting this weight, even in static position.
Birnie et al., 2011 [10] Canada	Cross-sectional study To determine the prevalence of cervical and lumbar spondylosis in a group of interventional electrophysiologists, in comparison to a control group of non-interventional cardiologists. To examine the potential predictors of the development of disease. To investigate current practices of ergonomic planning of electrophysiology laboratory and ergonomic training of electrophysiologists.	By web survey 58 Interventional electrophysiologists - Mean age 45.66 ± 9.63 y; - 94.8% Male. 36 Non-interventional Cardiologists - Mean age 46.31 ± 7.74 y; - 94.4% Male.	Web-based Survey conducted with an online questionnairre, consisting of three sections: - The first section asked for baseline demographics, years of clinical practice, and details of electrophysiology laboratory practice (including the number of hours per week of wearing lead and type of lead). - The second section asked about symptoms of cervical or lumbar spondyolosis. - The last section contained questions about morbidity from and disease treatment.	There was a significantly higher prevalence of cervical spondylosis in the electrophysiologists (20.7% compared to 5.5%, p = 0.033). There was a trend for increased prevalence of lumbarspondylosis (25.9% compared to 16.7%, p = 0.298). No significant difference related to lead-wearing between HCWs affected or non-affected by cervical and lumbar spondylosis.
Elkoushy et al., 2011 [11] Canada	Cross-sectional study To assess the compliance of endourologists with radiation safety measures To determine the prevalence of orthopedic complaints.	By web survey 134 Endourologists Age - <40 y 33 (24.6%) - 40–60 y 85 (63.4%) - >60 y 16 (11.9%)	An Internet-based survey was sent to all members of the Endourological Society. Baseline characteristics of practice patterns, compliance with various radiation protection measures, and prevalence of various orthopedic compliants were assessed. Open-ended questions assessed specific orthopedic compliants and reasons for non-compliance with radiation safety measures.	64.2% (n = 86) reported muscoloskeletal problems: 38.1% (n = 51) back problems, 27.6% (n = 37) neck problems, and 17.2% (n = 23) hand problems. 26.5% of endourologists enrolled cited discomfort and heaviness of lead aprons as reason for non-compliance in wearing them.
Goldstein et al., 2004 [12] USA	Cross-sectional study To characterise the prevalence of orthopedic and radiation-related health problems among invasive cardiologists in contemporary practice.	By web survey 424 Interventional cardiologists	A Web-based Survey was sent to the Society for Cardiac Angiography and Interventions members. Health questions (yes/no) focused on orthopedic problems (spine, hips, knees, and ankles) and problems associated with chronic radiation exposure.	60% (n = 96) of physicians performing invasive procedures with more than 21 years experience reported spine problems (p < 0.05). Hip, knee, or ankle problems were noted in 28% of operators. Authors related spine problems, at least in part, to a greater number of hours bearing lead.
Johnson et al., 2011 [13] USA	Cross-sectional study The primary goal of this study was to test the hypothesis that wearing the 3.7 kg vest portion of a radiological shielding garment (a ‘lead’) significantly increases lower back and shoulder muscle activity in quasistatic erect and forward-flexed postures. Secondarily, the authors examined the effects of gender and forward-flexed posture, as well as their interactions with lead use.	Laboratory 19 young healthy adults (9 Female; 10 Male) Age range 21–30 y	sEMG recording of muscle activity of trapezius and back muscle groups. For each muscle group, a two-group (by gender) repeated measures study with two within-subject factors (erect or forward-flexed posture, presence or absence of the vest) was performed. Filling out a questionnaire on which participants described their perceived level of effort and discomfort in postures with and without the lead using graphic rating scales.	Use of the lead did not result in a significant increase in muscle activity in the lower back or shoulders, despite perceived increases in effort and discomfort. Posture proved to be the most significant secondary factor affecting activity in the lower back, while participant gender proved insignificant. Short-term use of the lead does not appear to contribute to the incidence of back pain or injury in interventionalists. Avoiding flexed postures could more directly reduce the likelihood of pain or injury.
Livingstone et al., 2018 [14] India	Cross-sectional study To evaluate the knowledge and practice of using radiation-protective aprons by interventionists in radiology.	Questionnaire 91 Vascular and Interventional Radiologists Age range - 30–40 y 44% - 40–50 y 29%	Paper-and-Pencil Self-Administered Simple Survey with demographic, occupational, and health questions about type and duration of interventions; model, material, type, and weight of apron used, and health problems	47% prevalence of body aches attributed to wearing single-sided aprons. Most of the interventionists who wore lead-free aprons did not complain of any physical strain.
Moore et al., 1991 [15] USA	Cross-sectional study To investigate the possibility that wearing lead aprons during interventional radiology procedures might be a vocational risk factor for back pain.	By e-mail survey 236 Radiologists (Gastrointestinal, cardiovascular, and interventional radiologists) respondend - 25 F; 211 M - Age range 30–67 y - 179 subjects finally enrolled	Four-part, 23-item questionnaire - 1st part: general information - 2nd part: use of lead aprons (average number of hours per week, total number per years) - 3rd part: experience of back pain and if its onset predated the use of lead aprons - 4th part: alleged association between onset and persistence of back pain and lead apron use.	52% prevalence of back pain in those who reported to use lead aprons frequently, compared with 46% in those who use infrequently; (ORM-H =1.18 [0.64–2.15]). Severe back pain was reported by 12% of frequent apron users and 8% of infrequent apron users (ORM-H = 1.61 with 95% confidence limits of 0.55 and 4.68). Back pain was reported by 49% of long-term apron users and 48% of non-long-term apron users (ORM-H = 0.83 with 95% confidence limits of 0.43 and 1.59). Severe back pain was reported by 12% of long-term apron users as opposed to 7% of non-long-term apron users (ORM-H = 2.29 with 95% confidence limits of 0.66 and 7.92). Of those respondents who first experienced back pain after they began to wear a lead apron, 43% (33/76) thought that the apron was at least partly responsible for their symptoms. Of all respondents with back pain, 49% (62/127) reported that their pain worsened when they used a lead apron. Back pain caused 24% (32/131) of all respondents with back pain to consciously limit the amount of time spent wearing a lead apron and led 7% (9/128) to consider a change in subspecialty. Authors concluded that, although many radiologists thought that lead aprons played a role in the development of their back pain, their study did not show a statistically significant association.
O’Sullivan et al., 2002 [16] Canada	Cross-sectional study To examine the practices of Endoscopic retrograde Cholangiopancreatography (ERCP) and the prevalence of musculoskeletal injuries.	By mail survey 114 endoscopist practising ERCP	Paper-and-Pencil Self-Administered Questionnaire on: - ERCP practices - -musculoskeletal conditions experienced and questions related to them - physical risk involved in performing ERCP, such as the type pf lead aprons worn, the type of endoscope used, and the frequency of breaks (defined by removing the lead apron between procedures).	57% prevalence of back pain and 46% prevalence of neck pain. The majority of respondents (61%) wore a one-piece lead apron while performing ERCP.
Orme et al., 2015 [17] USA	Case-control study To determine whether the prevalence of work-related musculoskeletal pain and other medical conditions is higher among physicians and allied staff who work in interventional laboratories (require wearing lead aprons and exposure to radiation), compared with employees who do not.	Employees of Mayo Clinic: - 1543 completed the survey (response rate of 57%), - 1042 involved with procedures utilising radiation. - Mean age 43 ± 11.3 y - 33% M	Web-based Survey	Clinical employees with occupational exposure to procedures involving radiation requiring lead apron use reported experiencing work-related pain more often than the control group (54.7% vs. 44.7%; p < 0.001) and after adjustment for age, sex, body mass index, pre-existing musculoskeletal conditions, years in profession, and job description (odds ratio: 1.67; 95% confidence interval: 1.32 to 2.11; p < 0.001).
Ross et al., 1997 [18] USA	Cross-sectional study To investigate the relationship between lead radiation shielding aprons and frequency of back pain, neck pain, and sciatica.	385 interventional cardiologists - Mean age 46 ± 8 y - 95.3% M 131 orthopedists - Mean age 49.9 ± 10.9 y - 93.9% Male 198 rheumatologists Mean age 45.4 ± 7.4 y 71.1% Male	Survey conducted by self-administered 16-item questionnaire, including: -age and gender -occurrence of back pain or sciatica before specialty training, years of practice, average number of procedures performed requiring X-ray per week -number of hours per day wearing lead aprons in an average week, use of 1- vs. 2-piece aprons -missed work days secondary to back or leg pain -number of days missed in the prior 12 months -use of conservative therapy including bed rest and/or support devices, analgesics and/or muscle relaxants for back or leg pain, surgical procedure for herniated disc, the type of procedure, and the intervertebral disc level.	6.5% prevalence of cervical disk herniation in the cardiology group, compared to 0.3% in the orthopedic surgeons and 0% in the rheumatologists (p < 0.001). Multiple level disc diseases: 3.4% prevalence in the cardiology group, compared to 0% in the orthopedic surgeons and 0% in the rheumatologists; (p < 0.03). The percentage of cardiologists, orthopedic surgeons, and rheumatologists who reported the use of aprons was 99.7%, 82.4%, and 5.0%, respectively (p < 0.001 cardiologists vs. the other two groups). One-piece aprons were worn by most physicians doing procedures in all groups, with 2-piece aprons worn by 22.9% of cardiologists, and none in orthopedic surgeons. The average number of reported radiologic procedures per week was 12.1 for cardiologists, 2.9 for orthopedic surgeons, and 0.6 for rheumatologists. The average reported hours per day aprons were worn were 8.4 by cardiologists, 2.0 for orthopedic surgeons, and 0.2 for rheumatologists (p < 0.0001). The authors observed that cardiologists who wore aprons for considerably longer periods of time had a substantially greater frequency of skeletal complaints and more missed days from work due to pain, compared with the control groups.
Rothmore et al., 2002 [19] Australia	Cross-sectional study To compare body part discomfort ratings, fatigue, and ease of movement among radiographers while wearing two-piece lead suits, one-piece suits, and one-piece suits with waist belts.	Five angiographers 3 F; 2 M full-time employed	Workers enrolled used three different lead apron types (two-piece suits, one-piece suits, one-piece suits with waist belts) on two occasions. They were asked to indicate their level of discomfort by compilating a visual analogue scale (VAS) on their perceived levels of discomfort and fatigue at the beginning (T1) and end (T2) of patient procedural lists.	While wearing a one-piece apron, significant differences were found in levels of discomfort between T1 and T2 in the neck/shoulders (p < 0.05) and lower back (p < 0.05). Wilcoxon tests showed that subjects experienced significantly greater levels of discomfort at T2 and a significant increase in fatigue levels between T1 and T2 for subjects while wearing a one-piece lead apron (p < 0.05). A Friedman’s test (p = 0.07), indicated a trend towards decreased ease of movement for subjects while wearing a one-piece lead apron.
Tetteh et al., 2020 [20] USA	Cross-sectional study To determine the effects of radiation personal protective equipment (rPPE) on the development of fatigue of the erector spinae and trapezius muscles while performing a simulated surgical procedure.		Surface EMG for recording muscle activity from trapezius and erector spinae muscles.	The results from the statistical analysis showed that the rPPE significantly accelerated fatigue development in several of the muscles sampled.

Ref. no = Reference number; MSDs = Musculoskeletal disorders; HCWs = healthcare workers; F = female; M = male; ERCP= Endoscopic retrograde Cholangiopancreatography.; OR_M-H= Odds ratio Mantel-Heanszel; sEMG = surface electromyography.