Abstract
Introduction
Sonographers in the Western New South Wales Local Health District (WNSWLHD) reported a musculoskeletal pain prevalence rate of 95%. Participatory ergonomics, where workers are consulted about improving work conditions, was utilised to identify work-related musculoskeletal disorder (WMSD) risks and potential solutions. The aim of this study was to compare the prevalence of WMSD in a cohort of sonographers before and after implementation of ergonomic changes that were driven by recommendations from a participatory ergonomics approach.
Methods
This observational mixed methods study analysed the impact of participatory ergonomic-driven interventions on changes on musculoskeletal pain in a cohort of sonographers employed within the WNSWLHD. A retrospective analysis of 10 sonographer WMSD pain surveys over five sites was completed, along with semi-structured interviews regarding which interventions were perceived as useful, which interventions were not implemented and any barriers to implementation.
Results
Installation of patient monitors, use of ergonomic scanning techniques and job rotation were perceived as responsible for decreased musculoskeletal pain. Taking lunch breaks and microbreaks, use of antifatigue mats and having two sonographers perform mobile exams were not fully implemented. No interventions were perceived as responsible for increased pain.
Conclusion
This small study provides preliminary evidence that a participatory ergonomics approach facilitated identification of occupation and site-specific risks for WMSD in the WNSWLHD, allowing implementation of ergonomic changes to be tailored to the workplace, resulting in a safer work environment for sonographers.
Keywords: Ergonomics intervention, sonographer, participatory ergonomics, work-related musculoskeletal disease
Introduction
The prevalence of work-related musculoskeletal disorders (WMSD) amongst sonographers is high globally. Prevalence rates of sonographers scanning in pain range between 75 and 98% in countries including Australia, Belgium, China, United States of America, Pakistan and Saudi Arabia.1–6 One in five sonographers are estimated to experience a career ending musculoskeletal injury. 7 Supporting these findings, a risk management survey conducted in response to several career ending injuries amongst sonographers in the Western New South Wales Local Health District (WNSWLHD), Australia, reported a pain prevalence rate of 95%. Minimizing ergonomic risk factors related to scan techniques appears to be a key recommendation for reducing WMSD in sonographers. However, despite the availability of such guidelines,8–10 the prevalence of pain whilst scanning remains high.
During ultrasound examinations, poor ergonomic positioning of equipment, patient and sonographer have been indicated as factors contributing to injury. 11 Poorly adjusted or non-adjustable chairs, examination tables and ultrasound machines do not allow a sonographer to adopt an optimal ergonomic position for scanning. Risk of sonographer WMSD is increased with frequent and prolonged scans and undertaking more than 100 scans per month. 12 In addition, scanning the same types of examinations consecutively has been identified as a risk factor for neck and upper limb WMSD due to repetitive motion. 13
Ergonomically correct scanning technique requires an interaction between the sonographer and the work environment to achieve good postural alignment and reduce the risk of WMSD. 14 The availability and correct use of scanning equipment that facilitates adjustment to achieve optimal ergonomic practices is a key factor in reducing WMSD. 15 Even with this knowledge, there are limited studies in sonographers that have reported on the effectiveness of ergonomic interventions. 16
Participatory ergonomics is a strategy that involves consulting workers about improving their work practices and perceived injury risks. Workers are considered to have expert knowledge in their own tasks and can actively contribute to the process of risk assessment and control. 17 Participatory ergonomics has been utilised across a spectrum of industries, has been the subject of several systematic reviews and large trials, 18 and has been found to be an effective strategy for decreasing injury risks in manual task workers. 17 Despite the high prevalence of work-related pain, very few participatory ergonomic studies in sonographers have been reported.16,19
Therefore, the primary aim of this study was to determine the change in prevalence of musculoskeletal pain in sonographers following implementation of ergonomic changes driven by a participatory ergonomic approach. Additionally, the feasibility and usefulness of implementation of participatory ergonomic changes were explored.
Methods
Study design
This longitudinal observational study used a mixed methods approach comprising both quantitative and qualitative data.
Procedure summary
All sonographers employed in five WNSWLHD hospital sites completed a pain survey as part of a risk management report in 2015.
Consultant ergonomists were engaged to discuss risks and potential solutions in each hospital ultrasound department.
Participatory ergonomics was utilised via round table discussion at quarterly sonographer meetings to design interventions specific to the risks identified in each hospital department (Table 1).
Ergonomic interventions were implemented over an 18-month period.
A post implementation pain survey was completed by sonographers employed at the five sites three months after implementation of participatory ergonomic interventions.
A semi-structured interview was conducted with all sonographers who had completed both pain surveys to ascertain which interventions were implemented and which interventions they believed were responsible for any pain changes.
Table 1.
Implemented strategies to reduce WMSD by work site.
| Site number | Work practices thought to be responsible for increasing WMSD | Solutions implemented |
|---|---|---|
| 1 | Mobile examinations | Two sonographers to perform mobile examinations |
| Returning beds to central collection area | Beds collected from outside scanning room | |
| Seat type | Saddle and flat seat chair types are available | |
| Transvaginal scanning | Triangle pad available to reduce wrist flexion and deviation | |
| Reaching for left side of patient in bed | Turning beds around to facilitate left side of patient being closer to sonographer | |
| 2 | Standing on hard floors | Anti-fatigue mats |
| Seat type | Saddle and flat seat chair types are available | |
| Pushing beds by sonographer only | 2 people required to move beds | |
| Poor ergonomic practices | Conscious effort to reset posture during scan and consider swapping between standing and sitting | |
| Neck rotation when sharing ultrasound monitor with patient for obstetric scanning | Installation of patient monitor | |
| 3 | Pushing of beds by sonographer only | 2 people required to move beds |
| Reaching for left side of patient in bed | 2 person scanning practice | |
| Scanning multiple obstetric patients consecutively | Change in booking procedure | |
| Poor ergonomic practices | Conscious effort to reset posture during scan and consider swapping between standing and sitting | |
| Standing on hard floors | Anti-fatigue mats | |
| 4 | Neck rotation when sharing ultrasound monitor with patient for obstetric scanning | Installation of patient monitor |
| Standing on hard floors | Anti-fatigue mats | |
| Poor ergonomic practices | Conscious effort to reset posture during scan and consider swapping between standing and sitting. Use of microbreaks. | |
| 5 | Standing on hard floors | Anti-fatigue mats |
| Increased patient scheduling | Enforced morning tea and lunch breaks. Use of microbreaks. | |
| Poor ergonomic practices | Conscious effort to reset posture during scan and consider swapping between standing and sitting |
Pain survey
All sonographers employed in five WNSWLHD hospital sites completed a SafeWork Australia discomfort survey 20 (Appendix 1) as part of a risk management report in 2015. This survey measured pain intensity using a visual analogue scale from 0 to 5, with 0 being no pain, 3 being moderate pain and 5 being unbearable pain, for various anatomical body regions. Sonographers were invited to again complete the SafeWork Australia discomfort survey, 21 months after implementation of the participatory ergonomic interventions.
Participatory ergonomics
A participatory ergonomic approach was utilised by the WNSWLHD sonography group, Risk Management Unit and Medical Imaging Business Unit to identify potential solutions to workplace factors regarded as high risk with the aim of decreasing and/or preventing WMSD in the sonographers. Sonographers at each site identified several environmental and administrative work practices they thought were associated with increased pain prevalence during scanning. The sonographers held several round table discussions and recommended changes in the scanning environment and in sonographer scanning practices to try to address each identified risk factor (Table 1). The interventions were based on recommendations from the Australasian Sonographers Association and Australian Society for Ultrasound in Medicine guidelines. 8 The recommended changes to the scanning environment were funded by the WNSWLHD Medical Imaging Business Unit and implemented over the subsequent 18 months.
Data collection and analysis
Dichotomous and continuous pain data from the pre-post surveys were analysed descriptively to determine the prevalence and intensity of pain in each body region at each measurement timepoint. The primary outcome was change in musculoskeletal pain after the ergonomics intervention as measured by the SafeWork Australia discomfort survey. 20
In addition, participants responded by telephone to semi-structured interview questions from a study author following the post-intervention survey. The questions explored which recommended ergonomics interventions were actually implemented; which interventions were not implemented and reasons for this; barriers and facilitators to implementing the interventions; the interventions the sonographers thought were most responsible for any changes in musculoskeletal pain; and any other changes implemented which were not part of the planned intervention. Audio-recordings of participant responses to the semi-structured interview questions were transcribed verbatim and thematically analysed using Nvivo 12. 21
Due to the small sample size of sonographers completing both surveys and telephone interviews, statistical analysis was not possible. Quantitative data were represented descriptively using numbers, percentages and means. Analysis was performed using Microsoft Excel software. 22
Ethics and informed consent
Ethical approval was granted by the Greater Western Human Research Ethics Committee (HREC) in February 2019 to retrospectively analyse the quantitative musculoskeletal pain pre-post-survey data and to interview the sonographers who participated in both surveys. Participating sonographers provided written informed consent. Site-specific approval was also sought and granted by the Greater Western HREC.
Results
Participants
A total of 20 sonographers were employed by the WNSWLHD at the time of the original risk management survey and each completed the initial SafeWork Australia discomfort survey. Of these, 15 sonographers completed the second SafeWork Australia discomfort survey. Only 10 completed both surveys, primarily due to staff turnover and extended leave, and therefore, were eligible for inclusion in the analyses. Demographic characteristics of these participants are included in Table 2.
Table 2.
Sonographer characteristics (n = 10).
| n | % | |
|---|---|---|
| Sex | ||
| Male | 3 | 30 |
| Female | 7 | 70 |
| Age (years) | ||
| <50 | 5 | 50 |
| >50 | 5 | 50 |
| Scans per day | ||
| <10 | 3 | 30 |
| >10 | 7 | 70 |
All sonographers scanned with the right hand and used the left hand for ultrasound machine console operation. Seven of the 10 participants performed only sonographic examinations. The other three participant sonographers also performed managerial or general radiographic duties. The number of scans per day varied between individual sonographers but all who did not perform other duties scanned more than 10 examinations per day (Table 2). All sites were regional and rural sites, the ultrasound equipment is all variations of one manufacturer with similar adjustability features. The types of scans performed were mixed between general, obstetrics, vascular and musculoskeletal.
Pain survey – Option 1
Sonographer participants reported multiple areas of musculoskeletal pain (Tables 3 and 4). The most reported body parts where sonographers experienced pain were neck, right shoulder and right wrist/hand both before and after introduction of ergonomic workplace changes (Table 3). Post-intervention, there was a decrease in both prevalence and intensity of pain in the neck and right shoulder. There was a decrease in prevalence in right elbow, right wrist/hand and lower back pain; however, the intensity of pain was increased. Left shoulder and right hip pain prevalence remained stable, but there was a decrease in left shoulder pain intensity. Left wrist/hand pain prevalence and intensity increased post-intervention.
Table 3.
Pre and post intervention intensity and aggregate pain score per body part.
| Pre intervention |
Post intervention |
|||||
|---|---|---|---|---|---|---|
| Body region | n = 10 | Mean intensity ± SD | Aggregate pain scores per body part | n = 10 | Mean intensity ± SD | Aggregate pain scores per body part |
| Neck | 5 | 2.8 ± 1.3 | 14 | 3 | 1.6 ± 1.5 | 8 |
| Right shoulder | 7 | 2.6 ± 1.3 | 18 | 6 | 1.9 ± 1.3 | 13 |
| Right elbow | 3 | 1.6 ± 1.2 | 5 | 1 | 2 ± 0 | 2 |
| Right wrist/hand | 6 | 2 ± 1.3 | 12 | 5 | 3 ± 0.7 | 15 |
| Left shoulder | 1 | 4 ± 0 | 4 | 1 | 3 ± 0 | 3 |
| Left wrist/hand | 0 | 0 | 0 | 2 | 3 ± 0 | 3 |
| Lower back | 3 | 2.5 ± 0.7 | 9 | 2 | 3 ± 0 | 6 |
| Right hip | 2 | 3 ± 0 | 6 | 2 | 3 ± 0 | 6 |
Table 4.
Responses to ergonomic interventions by site and sonographer.
| Interventions implemented by sonographer | Change in pain | Safework Australia discomfort score (0-5, 0 = no pain, 3 = moderate pain, 5 = unbearable pain) | Interventions implemented which sonographer feels attributed to pain changes | Sonographer perception of pain changes | |
|---|---|---|---|---|---|
| Site 1 | |||||
| Sonographer 1 | Turning bed around to scan left side of patients. Two sonographers for mobile examinations | Decrease in right shoulder pain | 4–3 | Turning bed around to scan left side of patients | Current pain levels are thought to be due to immobile and obese patients and obstetric scanning. Although two sonographers for mobile scans were useful, workload limits availability of second sonographer most of the time. |
| Decrease in left shoulder pain | 4–0 | Turning bed around to scan left side of patients | |||
| Decrease in right wrist/hand pain | 4–3 | Turning bed around to scan left side of patients | |||
| Decrease in neck pain | 4–3 | Turning bed around to scan left side of patients | |||
| Increase in left wrist/hand pain | 0–3 | ||||
| Sonographer 2 | Two types of chairs available. Regular chair used. Two sonographers for mobile examinations. Turning bed around to scan left side of patients | Decrease in lower back pain | 2–0 | Option of two chairs, sonographer uses a regular chair. Turning bed around to scan left side of patients | Saddle chair thought responsible for initial back pain score. Although two sonographers for mobile scans were useful, workload limits availability of second sonographer most of the time. |
| Decrease in right wrist/hand pain | 2–0 | Turning bed around to scan left side of patients | |||
| Sonographer 3 | Two types of chairs available. Regular chair used. Two sonographers for mobile examinations. Use triangle pad for transvaginal studies. Turning bed around to scan left side of patients | Right shoulder pain unchanged | 2–2 | Option of two chairs, sonographer uses a regular chair. | More recently right wrist pain has improved, sonographer thought this was due to using a cable brace and scheduling changes so longer examinations are not performed back to back. Increase in pain thought due to increase in obese patients. Regular chair thought to be responsible for stable right shoulder and right hip pain |
| Decrease in lower back pain | 4–3 | ||||
| Right hip pain unchanged | 3–3 | Option of two chairs, sonographer uses a regular chair. | |||
| Increase in right wrist/ hand pain | 0–4 | ||||
| Site 2 | |||||
| Sonographer 1 | Different scanning chairs available. Wardsmen helping with hospital beds. Patient monitor for obstetric scans. Making conscious effort to scan ergonomically | Decrease in neck pain | 3–0 | Patient monitor for obstetric scans | Increase in shoulder pain thought due to increasing workload, obese patients and mobile, scans. Decrease in neck pain thought due to using less probe pressure and stopping scan earlier rather than persevering in an attempt to improve image quality. Sonographer believes left hand scanning decreased upper limb pain, but time to readjust room was not possible due to workload. Sonographer strongly advocates left hand scanning be taught to students. |
| Increase in right shoulder pain | 3–4 | ||||
| Decrease in right elbow pain | 3–0 | ||||
| Right wrist/hand pain unchanged | 3–3 | ||||
| Lower back pain unchanged | 3–3 | ||||
| Right hip pain unchanged | 3–3 | ||||
| Left wrist/hand pain increased | 0–3 | ||||
| Site 3 | |||||
| Sonographer 1 | Making conscious effort to scan ergonomically | No pain reported by sonographer in either survey | Making conscious effort to scan ergonomically | ||
| Sonographer 2 | Change third trimester bookings, assistance to push beds from waiting room, assistance with machine for left side of patient, conscious effort to scan ergonomically | Neck | 2–0 | Making conscious effort to scan ergonomically | Ensuring monitor was always directly in front of sonographer was thought responsible for decrease in neck pain |
| Right shoulder | 1–1 | ||||
| Right wrist | 1–0 | Making conscious effort to scan ergonomically | Standing and using gravity for more probe pressure was thought responsible for decrease in wrist pain. | ||
| Site 4 | |||||
| Sonographer 1 | Install new patient monitor, rotate through modalities, alternate sitting and standing | Right shoulder | 1–1 | Thought use of a saddle chair also contributed to decrease in pain | |
| Right elbow | 1–0 | Rotating in modalities, alternate sitting and standing | |||
| Right wrist | 1–0 | Rotating in modalities, alternate sitting and standing | |||
| Sonographer 2 | Use of cable brace, microbreaks, install new patient monitor, alternate sitting and standing | Neck | 4–3 | Installation of patient monitor | Sonographer has modified scanning technique to keep right shoulder closer to body which is thought to have improved right shoulder pain |
| Right shoulder | 4–0 | ||||
| Left shoulder | 0–3 | ||||
| Right wrist | 0–3 | ||||
| Site 5 | |||||
| Sonographer 1 | Enforcing breaks, alternate sitting and standing and being more conscious of ergonomic scanning position | Right shoulder | 3–2 | Alternate sitting and standing | A hospital physiotherapist was tasked to give the sonographers an ergonomic assessment and has given them exercises, therabands and instructions on best ergonomic positioning. Sonographer feels that this has also been responsible for decrease in pain |
| Sonographer 2 | Enforcing breaks, being more conscious of ergonomic scanning position | Right elbow | 1–2 | Sonographer has no real insight into increase in pain | |
| Right hand | 1–2 | ||||
| Neck | 1–2 |
Post intervention questionnaire
The thematic analysis of qualitative responses from the 10 participant sonographers is reported in Table 4. Themes elicited by the analysis included the ergonomic interventions perceived to be responsible for pain changes, and barriers and enablers to implementation of interventions. Table 4 also describes the ergonomic interventions which were implemented by each individual sonographer at each site, the body part area pain changes and any perceptions of pain changes.
Interventions thought responsible for pain changes
Sonographers perceived the reduction in neck pain to be related to installation of a patient monitor, which allowed the ultrasound machine monitor to be positioned directly in front of the sonographer. Before installation of a patient monitor, sonographers would turn the ultrasound monitor towards the patient so they could view the images, resulting in repetitive sustained neck rotation of the sonographer during scanning. One sonographer perceived neck pain was reduced by applying less transducer pressure and ceasing the scan earlier if pain was experienced, rather than prolonging the scan to try improving image quality. In addition, another sonographer reported repositioning the bed to scan the left side of the patient more easily also decreased neck pain.
The reduction in right shoulder pain reported by sonographers was attributed to turning the bed to scan the left side of patients, instructions on best ergonomic scanning, alternating between sitting and standing and modification of technique to keep the sonographer’s scanning arm close to the body. A reduction in right elbow and wrist pain was attributed to work rotation schedules into other scanning modalities, such as computed tomography and radiography.
Change of chair design used while scanning was an intervention considered useful by some sonographers, but the preferred chair designs differed. One sonographer attributed use of the saddle chair as a reason for a decrease in pain, while two others who changed to a flat stool with back support thought ceasing use of the saddle chair decreased pain or kept pain levels stable.
Multiple sonographers perceived an increase in the number of obese patients scanned was responsible for increasing pain levels in the right upper limb. Immobile patients, obstetric scans, performing mobile scans and increasing workload were also flagged as perceived reasons for individual increases in pain levels.
Barriers to implementation of ergonomic changes
Several of the original interventions suggested by the hospital sonographers were only implemented for a short period of time. For example, antifatigue mats ceased to be used relatively quickly due to the difficulty of rolling the chair onto the mats for examinations that were completed with the sonographer seated. Other interventions were considered useful but could not be fully implemented due to time or workforce constraints, such as having two sonographers rostered to perform mobile examinations, scanning with the left hand and patient scheduling which precluded sonographers taking lunch breaks and microbreaks.
Discussion
This study explored the occurrence of WMSD in a small cohort of sonographers before and after local implementation of various ergonomic interventions that were trialled following a participatory ergonomics approach to identify and ameliorate injury risk factors. After interviewing sonographers, trends were identified regarding interventions which were perceived as useful in reducing musculoskeletal pain. Barriers preventing implementation of some ergonomic interventions were identified following the participatory ergonomic process and the perceived reasons for increases in musculoskeletal pain, despite implementation of agreed ergonomic interventions, were also identified.
Multiple sonographers reported a reduction in neck and upper limb pain following implementation of several of the agreed ergonomic interventions. Turning the bed to place the body part being scanned closer to the sonographer was perceived to be responsible for a decrease in both neck and right upper limb pain. In addition, neck pain was perceived to be decreased by the installation of patient monitors, and right upper limb pain by alternating work postures between sitting and standing and by employing ergonomic scan techniques such as keeping the scanning arm close to the body.
Reduction in muscular load has been associated with less musculoskeletal pain and discomfort in the upper limb and neck 23 and it is likely that each of these interventions decreased neck and shoulder muscle activation levels by employing more neutral neck and shoulder postures and/or by reducing the time spent in a static work posture. Static contraction of trapezius is increased when the neck is flexed or rotated 3 and, an electromyography study in sonographers, reported a decrease in trapezius activation levels of nearly 90% when arm abduction was reduced from 75° to 30° with the forearm supported. 24 Installation of a patient monitor reduced the repetitive and sustained neck rotation required by sonographers as sharing the ultrasound machine monitor so patients could view the scan images was not required. Reduced shoulder abduction range is facilitated by turning the bed around so that the body area to be scanned is as close to the sonographer as possible, 11 by alternating work postures between sitting and standing 14 and by keeping the scanning arm as close to the sonographers body as possible. Employing postures during scanning that require decreased trapezius activation would have reduced the mechanical load on the spine and the shoulder resulting in the decreased neck and right shoulder pain reported by these sonographers.
A decrease in work activity, i.e. number of patients scanned, was also perceived to be responsible for decreasing musculoskeletal pain. Periodic job rotation between scanning and another imaging modality, such as computed tomography, reduced the total number of sonographic examinations and was perceived to result in a reduction of elbow and wrist pain by one sonographer. In addition, one sonographer who did not report any musculoskeletal pain associated with their work, scanned fewer patients than other sonographers in the study, due to greater administrative responsibilities. However, sonographers reported that high scan workloads and patient scheduling made it difficult to find the time for tea, lunch and microbreaks to manage their clinical workload. This was either due to booking schedules which did not account for scanning breaks, to choices made by the sonographers who felt it was their duty to accept urgent scans or because sonographers felt a special allegiance toward patients in the small communities in which they worked. This type of work stress to accommodate more patients has been identified in other rural communities. 11
Change of chair design used for scanning was an intervention perceived to decrease pain by some sonographers, but the preferred chair designs differed between operators. One sonographer perceived their use of a saddle chair was responsible for a decrease in their pain, while two others who changed from a saddle chair to a flat stool with back support reported ceasing use of the saddle chair decreased their pain. A study in surgeons utilising different chair types showed no significant difference between chair types in body discomfort scores or postural load. 25 Similarly, more surgeons preferred a flat seat with a back over the saddle chair which we also found was a trend in this study albeit on a smaller scale.
Half the sonographers in this study reported increased pain at some body sites at the post intervention measurement. No implemented interventions were perceived to be responsible for this pain increase. Sonographers who reported increased pain at the post-test measure attributed it to factors influencing scanning such as patient obesity and immobility, obstetric scans and high scanning workloads.
The use of antifatigue mats to address the issue of standing on hard floors as a contributing factor to increased musculoskeletal pain was reported as not useful by sonographers in all four departments that implemented them as it was time consuming to move them. The mat was removed when sonographers scanned in the seated position as the chair did not roll easily over it. In addition, the mats were required to be moved if seated or standing techniques varied between sonographers. Sonographers also felt that the movements required to remove the mats from the floor probably represented another risk factor for WMSD due to the bending and awkward positions required.
Although sonographers in this study reported that the strategy of performing mobile examinations, i.e. scans requiring the ultrasound machine to be taken to the patient’s room, with two staff to reduce WMSD was useful, they reported that it was not feasible to implement consistently due to lack of staff availability. Full booking schedules usually meant all the sonographers on shift were otherwise engaged in other examinations.
An intervention not identified for implementation as part of the participatory ergonomics process, but which was trialled and reported by one sonographer to be potentially useful in reducing pain, was left-handed scanning. Alternating between right and left handed scanning is commonly recommended in the ergonomic sonography literature as a strategy to reduce exposure to awkward and prolonged body positions by half. 26 However, as this required regular changing of the position of equipment in the scanning room throughout the day, this intervention was perceived by the sonographer as not feasible due to time constraints.
Decreasing sonographer workload is a potential solution to most of these identified barriers. Scanning fewer patients per day would allow sonographers greater availability to assist each other with mobile examinations, ensure that microbreaks and lunch breaks were implemented and allow time for left-handed scanning. Improved scheduling and increasing staff would require organizational/management support, which may provide access to resources to obtain staff or space to implement these interventions; however, a key barrier to implementation of participatory ergonomic interventions is lack of resources. 27 Other solutions to the identified barriers to implementation of ergonomic interventions to reduce sonographer WMSD can be instigated individually, such as alternating between sitting and standing scanning and being more ergonomically aware while scanning. 27
Although representing 50% of the sonographer staff in the WNSWLHD, this study was limited in size to 10 sonographers. Future studies involving larger cohorts are required to be able to conduct statistical analyses to reach firm conclusions about the effectiveness of the ergonomic interventions trialled in this study. A regular ergonomic education refresher course would remind sonographers to utilise the adaptable equipment for ergonomic best practice. This has been suggested in previous studies on ergonomics in sonographers.28,29
Conclusion
The pre and post implementation pain surveys noted an overall decrease in prevalence of neck and right upper limb pain. The ergonomic changes in this study which were perceived to have the most effect on pain prevalence were patient monitors, interventions which kept the scanning arm close to the sonographer’s body, alternating between sitting and standing and making a conscious effort to scan ergonomically, in addition to interventions which decreased workload such as job rotation.
Many of these interventions were feasible to implement in the sonography departments and were implemented individually by sonographers. Some interventions required organisational support and funding such as job rotation and patient monitors and may not be as easily implemented in the future, depending on available resources.
Sonographers, managers and Work Health and Safety (WHS) advisors should continue to use a participatory ergonomics approach at group meetings as part of a continual WHS improvement strategy to identify WMSD injury risks and prevention strategies to be implemented in each department. Further well-designed trials are needed to examine the effectiveness of promising interventions to prevent WMSD in sonographer populations.
Acknowledgments
N/A.
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Guarantor: KS.
Contributorship: All authors: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. Drafting the article or revising it critically for important intellectual content. Final approval of the version to be published.
ORCID iDs: Kristie Sweeney 
https://orcid.org/0000-0002-7507-1941
Martin Mackey
https://orcid.org/0000-0002-1591-3991
Ethics Approval
Greater Western Human Research Ethics Committee.
Western NSW Local Health District 29 Hawthorn Street PO Box 4061 Dubbo NSW 2830.
Reference number: LNR/19/GWAHS/8 (GWAHS 2019-007), February 2019.
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