Ergonomics for the Breast Center
Kenneth B. Zaparinuk, PT, DPT, OCS, BSPE
Eisenhower Medical Center
La Quinta Physical & Occupational Therapy
La Quinta, CA
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This ergonomics article was created based on Original Question: NCBC is pleased to announce that we have an expert physical therapist, board certified as an orthopedic specialist, who has agreed to write an article about Ergonomics for the Breast Center. In order to write the most meaningful article, the author is requesting feedback from the breast center membership. What would you like the author to address in the article? Do you have any orthopedic challenges that make it difficult to perform your duties? Do any of the procedures you perform at the breast center that cause you physical discomfort or pain? Are there any procedures that you perform that cause physical discomfort or pain to the client? (Think of positioning issues) Thank you to those who responded to make this article job specific rather than generic. The responses have been edited to address the main ergonomic issue and how it relates to working at a breast center. |
Concepts to understand before addressing the Responses
Human beings are habitual when it comes to accomplishing daily tasks either in the work place, at home or in recreation. For example how many people return from the grocery store, grab all 17 bags in the LEFT hand so the door can be opened with the key in the RIGHT hand?
Have you considered that maybe a 30-45 lbs. load in one hand puts a significant stress on your tendons? Have you felt the burning in your forearm and strain in your fingers as you lug those bags to the door, waiting for that moment when you can place them on the table to feel the relief that you made it? How many grocery trips will you make per year and do the same thing? What does this do to those tendons over time? If you do this at home and repetitively use your wrist extensors performing breast ultrasounds during the day, does it makes sense how you can develop lateral epicondylitis?
We know that you are a super person capable of incredible feats, but there is a limit that your tendons can handle.
Maybe your head is writing checks that your body can’t cash?
So what can be done about this?
Common responses from orthopedic patients include the following:
- Well if I don’t do it, who will?
- Why make multiple trips, if I can do it one trip?
- I have always done it this way.
- Why does my arm still hurt after taking medication, getting injections and having Physical Therapy?
Welcome to Ergonomics 101!
er·go·nom·ics definition:
- A science that deals with designing and arranging things so that people can use them easilyand safely
- The parts or qualities of something's design that make it easy to use
What this means is that the work area should be arranged and designed for the person that works in the area. In short, your work area should be arranged to cater to your size with tools and work behaviors that make your work less stressful on your body. Adapt the work to the worker. Sounds simple enough, but somehow ergonomics has become a health issue.
Ergonomics is not really a health issue.
BAD ergonomics is a health issue.
Typically, by the time a medical provider is seen, there is usually already an injury. If a person has developed carpal tunnel syndrome, impingement syndrome, lateral epicondylitis, shoulder bursitis, back pain, active trigger points, etc., she may have been habitually performing poor body positioning, poor lifting practices, repetitive motion, etc. At this point, the focus is on recovery rather than taking preventive measures to avoid these diagnoses.
This approach is very reactive. The problem with reactive methods is that the person has already become injured. Wouldn’t it be far better to prevent the injury from occurring? This article discusses the opportunity to become proactive. The goal is to increase awareness of how to prevent injury to one’s self.
Below are the specific responses to the NCBC original question posed by technologists from breast centers:
Question #1
How many scans are appropriate for a Sonographer to perform in one hour?
Using an OSHA screening tool for risk factors that contribute to MSDs (musculoskeletal disorders) states:
- Repeating the same motion every few seconds or repeating a cycle of motions involving the affected body part more than twice per minute for more than 2 consecutive hours in a workday.
- Working with the back, neck or wrists bent or twisted for more than 2 hours total per day
One way to interpret this is reactive: WHAT? I perform ultrasounds ALL DAY for 8 hours! I would be fired if I only did ultrasounds for 2 hours!
Another way to interpret this issue is to be proactive:
- Am I setting up the table so I can position the patient in an optimal position for both their comfort and my proper body positioning?
- Am I positioning the US unit and screen in a position so that I am not straining my neck or reaching awkwardly with my arm?
- Can I perform the US without putting my wrist in an awkward position?
- If the only way I can get a proper image is to position my wrist awkwardly, how much time am I in that position and does it exceed 2 hours per day? For example, if your wrist is in an awkward position for 4 minutes per US and you perform 15 USs per day, your wrist is in an awkward position for only 60 minutes per day. Because there are breaks between patients, the awkward positioning is not consecutive for 2 hours.
- Short answer: you should be able to tolerate 1 US every 30 minutes. The goal, of course, is to eliminate as much awkward positioning as possible in the 10-20 minutes you are actually performing the US.
Question #2
How long of a break should a Sonographer have to rest and stretch between exams?
Breast US takes approximately 10 minutes per average case and can be up to 20 minutes with difficult cases. If you have 30 minutes per US, this leaves you 10-20 minutes of rest per case. Stretching can be performed before the work day to prepare the body for the tasks about to be performed. It can also be performed after the work day as recovery. Stretching during the work day can be beneficial for short periods but should not be excessive. Overstretching can cause irritation.
Stretching that is beneficial will be unique to the individuals’ specific needs based on their orthopedic issues. There are general guidelines for stretching to address carpal tunnel, elbow and shoulder issues that can be helpful and preventative. If a condition is beyond preventative measures, an evaluation by a Physical Therapist will be helpful in recognizing and addressing issues that are specific to the individual.
Question #3
How can tall people use an US machine that is immovable?
It is difficult to answer some questions without being able to assess the exact scenario you are experiencing. You want to avoid poor posturing so if the machine is older and not on a movable/adjustable cart you will want to place the unit in a position where you can sit on a stool with good posture while operating the machine. You may have to fabricate a solution based on what you have available in the room and the unit you have. In other words, if the screen is too low, raise it. If you can’t raise it any further, lower yourself to the screen while using a good posture.
Question #4
“For larger breasts you have to push harder on the probe to penetrate to get better images. Some sonographers will use two hands which can be uncomfortable for the patient.”
Having had introductory experience with Musculoskeletal US, images that are deep within the hip can be obtained by adjusting settings on the unit. Pushing harder for deep structures was not recommended secondary to the risk factors of developing MSD. I asked a Breast US technologist with 29 years of experience. She also reported never having to use 2 hands as she would adjust the setting on the unit. I would put this question out to the instructors of Breast US. You can also refer to the references at the end of the article. If you are having to push this hard it may be a question of technique.
Question #5
“During Breast Biopsies occasionally the Radiologist has us hold the probe. This can be very taxing on the shoulder, specifically if we are on the opposite side of the cart as the Radiologist. It's a long stretch to hold the probe in air without arm support.”
We tried to recreate this at the breast center. Here is a possible solution.
Which is the best position for the US technololgist? (Pick 2)
Picture A
Picture B
Picture C
Picture D
Picture E
Answer: B and E
Thoughts:
- Posture: standing or sitting with a straight back and neck
- Elbow and wrist below shoulder height
- In C & D shoulder flexion is approaching or past 90⁰ (contributes to impingement syndrome or arm fatigue)
- In A the back is excessively forward bent
Question #6
“The thumb wears out or you get carpal tunnel with using the “C” formation to hold the breast during the mammogram.”
You will have to look at the position of the rest of your body while performing the mammogram. You may be performing the “C” but if your wrist is hyperextended or your thumb is trapped by the compression plate, you will have to evaluate your technique. Consider these photos below:
Proper Biomechanics for Mammogram
- The back and neck are in good alignment for both patient. and technologist
- The elbow is below shoulder height
- The wrist is not excessively flexed or extended
- See the next 2 photos and look at the biomechanics described above as the technologist completes the positioning
- Note the neutral thumb and the index finger alignment
- Note the small amount of forearm pronation as the technologists completes the positioning.
Can you pick out the poor body mechanics?
- The technologist’s shoulder is abducted
- The wrist is extended and radially deviated at an awkward angle
- The thumb is excessively abducted and is being compressed by the compression paddle
- The technologist’s hand is trapped
Proper body mechanics for shorter tech with taller patient
Poor body mechanics tall tech with shorter patient
- The patient’s neck is excessively extended
- The technologist is forward flexed with a forward head posture
- Correct posture (not displayed)
This particular technologist corrects her neck and back posture and bends her knees to lower herself as needed to complete the exam. Partial squatting is a common solution for tall workers.
Poor body mechanics tall tech with shorter patient
- The technologist’s neck is forward and rotated
- The Left shoulder is elevated and abducted
- The Right shoulder is abducted
- The Left wrist is flexed and radially deviated
Poor body mechanics….period!
Question #7
“After 3 decades of using my thumb to press on buttons for exposures I have extreme arthritis in my thumb and will require surgery”.
Thank you for sharing this one. This a perfect example of the importance of ergonomics. This is a reactive approach to the problem, i.e. injury has already occurred. Ergonomic intervention would have been important 30 years ago for this situation.
The proactive approach would involve the issues addressed in the conclusion of this article. An assessment and modification of the frequency, intensity and duration of activity would have been the appropriate intervention to avoid advancement of degenerative changes.
Question #8
“I am having knee surgery because I have a habit of moving too fast. I twist my knee when I turn. As we age we cannot move like we used to.”
Ergonomic studies also involve mapping out the trail a person follows to move about a room during a day. To minimize steps, equipment is placed in strategic positions. Procedures are logically planned to minimize unnecessary moving back and forth.. Practicing a turn without a rapid pivot is very helpful in avoiding meniscal injuries. This is not a sport, you are a health care industrial athlete. The season is year-long and lasts decades over a sport career. We have to be smart with our bodies.
Conclusions:
Think of work activities in terms of 3 parameters:
- Frequency: How often do I do an activity?
- Intensity: How hard am I performing the activity?
- Duration: How long am I performing the activity?
If you are performing an activity that is high intensity for a long duration repeatedly throughout the day, you are most likely going to develop MSDs.
By making reasonable changes to minimize the above parameters, you take excessive stresses off the body and will be able to work more efficiently.
Thank you for the opportunity to present ergonomic issues that occur at the breast center. I hope the suggestions are helpful. Additionally, I hope the discussion has empowered you to consult with an ergonomics specialist or Physical Therapist to seek out solutions for your specific needs.
References
https://www.osha.gov/SLTC/etools/hospital/sonography/sonography.html
Baker and Coffin. “The Importance of an Ergonomic Work Station to Practicing Sonographers”, Journal of Ultrasound Medicine, 2013; 32: 1363-1375
Ann E Barr and Mary F Barbe. “Pathophysiological Tissue Changes Associated With Repetitive Movement: A Review of the Evidence”, PHYS THER. 2002; 82:173-187.
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Breast centers choosing to participate in the NQMBC will join a national quality documentation program based on clearly defined measures with a decade of experience, hundreds of participants and millions of data points. Participants possess the ability to confidentially compare themselves to all other program users with immediate feedback using user-specified filters to enhance relevance to one's own breast center. In addition, the program allows participants to track their own performance over time. Participants may select any number of measures for submission---from one to the entire complement of measures.The NQMBC is the only breast care-specific quality management program of its type, offering performance monitoring of service delivery, professional performance and clinical outcomes across the patient's journey from screening through diagnostics, surgery and adjuvant therapies. The NQMBC measures will soon incorporate all of Medicare's PQRS breast care measures so that programs will be able to immediately assess their performance compared to peers for all patients in addition to Medicare beneficiaries. NQMBC is working with industry to automate the data collection process to reduce the time and resources necessary to develop a quality management program. Through participation in NQMBC, data reporting requirements of accrediting agencies and payors can be met.The NQMBC envisions and intends to facilitate a concise national breast care dataset based on performance measures with standardized definitions.
