Introduction
Mammography is the main imaging modality used in breast cancer screening and for that reason it is used frequently. To perform this exam, radiographers need to repeat movements and need to assume awkward postures to position the breast for standard views: craniocaudal (CC) and mediolateral oblique (MLO). The repetition of movements using extreme postures, the equipment manipulation requirements, the long working hours, heavier patient loads, less staff coverage, fewer opportunities for downtime and working in an environment with low temperatures can promote the development of work-related musculoskeletal disorders (WRMSDs) [
1‐
3].
Regarding an occupational health perspective, WRMSDs should be prevented as opposed to treated because primary prevention is more effective than treatment [
2,
4,
5].
Considering radiographers’ work scenarios, it is possible to identify several risk factors that should be evaluated (risk assessment) and mitigated (risk management) to prevent occupational diseases. The work environment and the equipment interface and its manipulation are highlighted as promoters of musculoskeletal discomfort during the patient positioning and examination by previous studies in the field of radiology [
6‐
8]. Most of the studies are focused on the radiologists’ work, mainly in those situations related to interaction with the information systems, performing ultrasound exams, analysing and reporting exams [
6‐
8]. Regarding radiographers’ work, very few references focused specifically on mammography activities were found in national or international contexts [
1]. For that reason, the optimisation of radiographers’ work to prevent musculoskeletal symptoms and pain, as well as WRMSDs, is hard and not supported by strong evidence. In a mammography room, radiographers need to respond to multiple demands, adapting their attitudes and behaviours to the equipment layout and to the patient’s characteristics when performing the exam. In a recent study [
1], problems related to postures inside mammography rooms were highlighted mainly when the radiographer and patient have different statures. The breast positioning for the acquisition of standard views—craniocaudal (CC) and mediolateral-oblique (MLO)—can be very demanding, requiring awkward postures classified as risk non-acceptable for WRMSDs. Designers and medical equipment designers, in Europe should consider patients’ and workers’ anthropometry characteristics to design interfaces (man-machine) to prevent WRMSDs (EN-1005-4: 2005).
The identification of strategies based on the ergonomic principals is essential to improve work interfaces related to equipment manoeuvring and patient positioning. Those strategies can contribute to preventing WRMSDs, reducing the health costs associated with healthcare professionals and patient safety [
2,
4,
5,
7].
The aim of this study is to identify new strategies to improve the radiographer’s posture during the performance of mammography exams, to reduce the risk of WRMSD occurrence and to contribute to improving the quality of mammography exams.
Methodology
The study was performed in two phases, using a mammography device from Siemens (Mammomat 1000; Siemens Medical Solutions, Erlangen, Germany) installed in the mammography laboratory at Lisbon School of Health Technology (ESTeSL).
In the first phase, the simulation of breast positioning in CC and MLO views using volunteers was carried out without any intervention in radiographer posture. Photographs and videos recorded were acquired (equipment Canon SX270 HS) in three different scenarios:
-
The radiographer is taller than the patient (anthropometric stature radiographer/patient combination 180 cm/153 cm)
-
The radiographer and patient have the same stature approximately (anthropometric stature radiographer/patient combination 171 cm/173 cm)
-
The radiographer is smaller than the patient (anthropometric stature radiographer/patient combination 153 cm/173 cm)
Three observers visualised the video and the frames showing the most demanding postures were selected via consensus (1.103, 1.221 and 1.213) for the three scenarios previously presented [
1]. Those frames were then introduced in specific software, kinovea 0.8.15, to measure the main body angles twice (head/neck, trunk and arms) according to the methodology proposed by Kapitaniac. The measured angles were classified in agreement with EN1005–4: 2005 [
9,
10] in three different levels: “acceptable”, “conditionally acceptable” and “not acceptable” (Table
1).
Table 1
Reference values for postural assessment (Standard BS EN 1005–4: 2005)
Trunk forward bending | 0–20° | 20–60° | >60° |
Upper arm flexion | 0–20° | 20–60° | >60° |
Upper arm abduction | 0–20° | 20–60° | |
Head/neck upward/downward bending | −40 to 0° | - | 0–40° |
The European Standard used as reference in the study was selected because it specified the requirements for postures and movements at three levels with minimal external force. The requirements are intended to reduce the health risks for nearly all healthy adults.
In the second phase, alternative postures for the three scenarios were simulated using different strategies such as: (1) sit on a stool (height variable between 50 and 80 cm), (2) stand-up on a step (10 cm high) or (3) stand-up on another step (15 cm high), both 68.5 cm × 28 cm (Table
2). The simulations were also recorded (photographs and video) and the same methodology applied in the first phase was followed.
Table 2
Simulated contexts during the breast positioning in craniocaudal (CC) and mediolateral oblique (MLO), without and with postural alternatives considering the radiographer and the patient
Anthropometric combination radiographer/ patient: 171 cm/173 cm (similar statures) | None | Patient on a step (10 cm) | CC |
None | Patient seated on a stool | CC |
None | Patient on a step (10 cm)
| MLO |
Radiographer seated on a stool | None | MLO |
Anthropometric combination radiographer/ patient: 180 cm/153 cm (radiographer taller than the patient) | None | Patient on a step (10 cm) | CC |
None | Patient on a step (15 cm) | MLO |
Radiographer seated on a stool | None | MLO |
Anthropometric combination radiographer/ patient: 153 cm/173 cm (radiographer smaller than the patient) | Radiographer on a step (10 cm) | None | CC |
None | Patient seated on a stool | CC |
None | Patient on a step (10 cm) | MLO |
Radiographer seated on a stool | Patient seated on a stool | MLO |
Discussion
This study aimed to identify the most demanding postures for radiographers while performing mammography exams and to suggest
postural alternatives to reduce the risk of WRMSDs based on evidence. In the previously performed study [
1] about mammography activities, the repetition of the movements associated with breast positioning was shown. The risk of WRMSDs, mainly while performing the MLO projection, was verified. In the first phase of this study, similar results were found in all scenarios simulated. The most awkward postures were classified as “non-acceptable” according to the European standard (BS EN 1005–4: 2005).
Postural alternatives adjusted to the anthropometric characteristics of the radiographers and patients were simulated, in the second phase of the study, and improvements were observed. The most obvious were perceived in the most extreme situations, the radiographer taller or shorter than the patient.
In the second scenario simulated (radiographer shorter than patient) for breast CC positioning, postural alternatives with the radiographer on the step, a reduction of 35.9% and 40.0% on the angle of the arm flexed and abducted was observed. On the other hand, the angle of the trunk increased 14.3% and the angle of head/neck increased 19.0%. However, this increase did not raise the risk of WRMSDs as the classification of “acceptable” was kept. During the postural alternatives for MLO breast positioning, asking the patient to be on a step was enough to promote an improvement of radiographers’ posture. A reduction of 50.0% in the angle of the trunk and 100% in the flexion of the head/neck was verified. Nevertheless, the risk of WRMSDs still exists because the classification of the angles as “non-acceptable” was kept. For this specific situation, other strategies to improve the radiographers’ posture are necessary to prevent the occurrence of WRMSDs.
In the third situation (radiographer taller than patient),
postural alternatives for positioning the patient on a step to perform breast CC views allowed also a reduction of 25.0% in the angle of the radiographer’s trunk and 43.8% in the angle of the neck/head. The angles of flexion and abduction of the arm were increased in 22.2% and 36.1% respectively but the classification of “conditionally acceptable” obtained without any intervention was preserved. For MLO position in the same
postural alternative scenario, seating the radiographer, allowed a reduction of 100% of head/neck angle, 80.6% in the trunk angle, 56.8% and 17.5% in the angles of the arm during the flexion and abduction, respectively. These improvements in radiographers’
postural alternatives during mammography performance can reduce the risk of WRMSDs and for that reason should be implemented in a clinical context. Several authors [
2,
4‐
6] showed in previous studies that the prevention should be prioritised, introducing changes that allow maintenance or even promotion of the workers’ health. WRMSDs sometimes are difficult to treat, being preferable to act at the level of the prevention, introducing protective equipment, hazard information, communication and right-to-know training, ergonomic consultation and assistance [
4].
Other radiographer activities should be analysed, focused on the manipulation of other medical imaging devices and workstations but also evaluating the noise, temperature, impact of monitors in visual performance and patient handling. General studies have already analysed some of those topics but not targeting specifically the radiographers’ activities, health and safety promotion and prevention [
2‐
12]. The analysis of the workflow and workload impacts should be also explored, mainly due to the introduction of new digital systems. The use of digital technologies brought new challenges and demands for radiographers’ activities as already shown in some studies [
13‐
19]. The effects on radiographers’ health and safety needs to be identified, to prevent occupational disorders and the associated costs. The training and education has also a major role to help healthcare professionals be aware and apply safe strategies at work, as showed in other studies [
2,
4,
6].
The main limitation of this study is related to the simulation of clinical practice. The images were not collected during mammography exam acquisitions to not disturb the patients and also to not affect the workload and workflow of mammography departments. The other limitation is related to the simulation of only three stature combinations. The methodology used in a previous study was followed, focusing mainly the extremes, as they were considered as the most challenging.
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