SonoWorld Ergonomics

Occupational Injury

OCCUPATIONAL INJURY

Ergonomics is the study of the human body at work. As a science, it has its roots in the Industrial Revolution. It has only been recently that designers could benefit from new databases and statistics, and it is only recently that the results of bad designs are showing up in large segments of the population as Work-related Musculoskeletal Disorders (WRMSDs) or Repetitive Stress Injuries (RSIs).

One of the key elements of Ergonomics is environmental design. How workers lay out their work space and how they interface with it (i.e. sit, stand, move around, view a monitor screen, address a CPU, etc.) has an immediate impact on both productivity and worker health. This is true both for healthy workers, physically-challenged workers and people already suffering from cumulative trauma disorders or RSIs.

Awareness of pain and discomfort associated with the occupation of Sonography surfaced around 1980 just prior to the widespread use of real time scanners. The most common complaint was pain in the shoulder of the sonographers scanning arm. This syndrome soon became known as Sonographers Shoulder. The number of complaints reached the attention of Marveen Craig, a well-known sonographer, educator and author. Craig published an article in the Journal of Diagnostic Medical Sonographers (JDMS) in May/June 1985 titled Sonography: An Occupational Health Hazard? This article polled approximately 100 veteran sonographers with 5-20 years experience in the profession. The results were very interesting. When questioned, these veterans complained of stress and burnout, vision problems that were improved when display of ultrasound images was switched from black on white to white on black; infections (this was prior to universal precautions and the widespread availability of sinks for hand washing in scanning rooms) and allergies (some sonographers were allergic to the coupling gel).

Electric shock was not uncommon, especially when doing bedside studies and when removing transducers from the articulated arm. Muscle strain involving the wrist, base of the thumb and shoulder was also reported. Sonographers using the early real-time systems complained of heavy transducers and cables.

As more real-time systems came into use complaints of sonographers shoulder almost disappeared. However, this lasted only 10 years and by 1994 complaints started to pour in to the Canadian Society of Diagnostic Medical Sonographers (CSDMS) and they started to track these complaints. Vicky Lessoway, 1994 President of the British Columbia Ultrasound Society (BCUS) made it her goal to address this issue in the Province. The Society of Diagnostic Medical Sonography (SDMS) was also starting to hear complaints and they were increasing in number and variety. The BCUS and the SDMS joined forces to address the issue of occupational injury in Sonography. In 1997 a large questionnaire was developed by the SDMS and the Health Care Benefit Trust of Vancouver Canada (HBT) in collaboration with the local ultrasound society (BCUS), the labor union representing Canadian Sonographers. Some of the data from that questionnaire will be shared in this column in the coming months.

The 1997 questionnaire and many subsequent studies show that musculoskeletal disorders among sonographers and physicians who scan patients full-time is a serious health problem and the incidence appears to be increasing as work loads increase. Some individuals have had to seek alternative employment as they can no longer perform ultrasound. Others have had to reduce their hours of work or change work practices to continue to work.

The incidence of WRMSD identified as pain or chronic discomfort that the respondents believe to be work related is now being tracked in sonographer populations by various organizations. These self-reported incidence rates are consistently high:
USA= 81%
Canada=87%
Australia=80%
Italy=80%
UK=89%

WRMSD may appear as one or more of the following conditions, depending on the nature and intensity of work activities.
Carpal Tunnel Syndrome
Tenosynovitis
Shoulder bursitis
Tennis/Golfers elbow
Thoracic Outlet Syndrome
Bursitis (shoulder)

There is also a family of symptoms associated with WRMSD; some are a result of cumulative effects, while others relate to specific causes.
Paindull ache
Altered sensation
Numbness
Tingling
Weakness
Clumsiness
Visualheadaches, blurred vision

WRMSD symptoms have been grouped into 3 stages to help sonographers recognize what they are experiencing and hopefully encourage and empower them to seek medical help as soon as possible.

Stage 1: aching, fatigue that subside with overnight rest; work performance not affected
Stage 2: aching, fatigue that does not subside with overnight rest; symptoms occur earlier in the day; may affect job performance
Stage 3: aching, fatigue, weakness result in reduced performance in work & leisure activities; symptoms disturb sleep & may last for months or years

These stages were described by Browne, C.D., Nolan, B.M. and Faithfull, D.K., in their article `Occupational repetition strain injuries: Guidelines for diagnosis and management', Medical Journal of Australia, 140, March 1984, pp. 329-32, The stages refer to all types of occupational injury and are not specific to Sonography.

In future articles in this series we will explore what the sonographer or scanning physician can do to reduce their vulnerability to WRMSD, the role of equipment design and equipment manufacturers, and how individuals can take a proactive approach to treating and preventing WRMSD.

Next Month: The American Experience-Statistical Evidence of the Risk Factors

The American Experience Statistical Evidence of Risk Factors

Musculoskeletal Injury and Sonography: The American Experience Statistical Evidence of Risk Factors

Work-related musculoskeletal injury (WRMSI) has been studied and documented extensively in many professions over the past two decades. This study intensified in the early 1990s as downsizing and rightsizing became a popular way for corporations to improve their profitability. The resulting intensification of work demands with resultant increases in incidence of WRMSI stimulated efforts to better define the relationship between work activities and WRMSI incidence. Numerous surveys by different authors were sent out to collect data on occupational injury. These were typically research oriented, local in scope and tended to be small in terms of the number of surveyed participants. What was interesting about these surveys was that many reported a very high incidence of occupational injury in diagnostic medical sonographers.

The Society of Diagnostic Medical Sonography (SDMS) was also receiving reports of WRMSI in sonographers and this prompted them to pay for a large survey. In late 1996 through early 1997 a survey was conducted using 3000 sonographers randomly selected from the American Registry Diagnostic Medical Sonographers (ARDMS) data base. The survey was funded by the SDMS, Canadian Society of Diagnostic Medical Sonographers (CSDMS), and the British Columbia Ultrasound Society (BCUS).

The data indicated that the majority of injuries were in the neck and shoulder, closely followed by the wrist and back. It is important to also note the amount of eyestrain since this leads to compensatory bad posture and further injury. Many of those responding to the survey stated that they suffered from headaches and blurred vision due to inadequate lighting. As might be expected from the nature of the work sonographers perform, the occurrence of reported pain is highest for the neck, shoulders and upper back (Figure 1).

Figure 1: Distribution of complaints by body region

The goals of this survey were to:
    Determine prevalence of MSI and correlate known work and personal factors.
    Develop instruments, protocols and methods to quantify risks.
    Design and test interventions
    Recommend work load/procedural changes.
    Recommend modification or redesign of equipment and/or environment.

The survey was a 21-page questionnaire divided into 5 sections.
* Section 1
     Work experience
     General Health
     Background Information
         Questions on age, gender,
         smoking, wearing of lenses
         state of health, exercise habits,
         hobbies

* Section 2
     Work schedule and tasks
* Section 3
     Work equipment
* Section 4
     Problems, pain and discomfort
* Section 5
     Work environment and corporate culture

The questionnaire was returned from 983 out of 3000 sonographers from the United States, for a 33% return rate. Two hundred and eleven out of 232 sonographers from British Columbia returned the survey for an outstanding return rate of 92%. The questionnaire was piloted in British Columbia but was not changed making it possible to include the data in the final statistics. The survey was also mailed to all Canadian sonographers except those living in British Columbia and 427 out of 1088 were returned for a 39% response rate. The grand total of returned questionnaires was 1,621. The data was published in a paper published in JDMS 13:219-227 Sept/Oct, 1997, authored by Pike, Russo, Berkowitz, Baker, and Lessoway.

RESULTS OF THE SURVEY:
The average time of actual scanning is 17.8 days per month and 6.8 hours per day. The average length of a work day, not including on-call was 8.3 hours. Fifty-seven percent of sonographers scanned while seated. Risk factors for injury are related not only to how much time is spent holding a transducer and exerting force but also to the time spent in a static position. The survey showed that 30 % of respondents typically maintained static posture during scanning for less than 10 minutes, 31.4% for 10-15 minutes and 29.1% for 15-30 minutes. Over 30 minutes accounted for 9.5%.

When asked to describe the pain they experienced:
     90% reported an aching feeling
     56% experienced stiffness
     40% reported sharp pain or cramping
     33% had weakness, numbness or burning

Of those reporting pain
55% saw a physician / medical professional
Of these, 81.7% received diagnosis, however only 45.8% received any kind of treatment

Of those receiving treatment
     67.7% said it had been moderately or very effective
     28.3% said the treatment had been slightly effective
     4.0% reported no treatment effect

In general, sonographers have a positive perception of their work environment and corporate culture. However, respondents indicated they had some concerns over work schedule, work tasks and lack of support services.

Work environment concerns included:
    Inability to schedule overtime or extra work in advance (61%)
    Inability to take scheduled breaks (56%)
    Lack of control over work (54%)
    Repetitive work tasks (61%)
    Lack of work schedule support (40%)
    Lack of helpful personal development support services (40%)

Eighty-four percent of respondents reported they had experienced pain or discomfort since starting work as a sonographer
         81% from the SDMS study
         87.2% from the CSDMS study
         91% from the BCUS study

Of these, 96.5% thought it was related to scanning, 88.9% still experience pain or discomfort and had done so for an average of 5 years (58.068 months). The average length of time the respondents had been in the profession was 11 years.

Figure 2: Age distribution of respondents

Data from the same survey showed that the average age of practicing sonographers who responded to the study is 42 years and that 80% of respondents were between the ages of 30 and 50, and 11.5% were under 30 years of age (Figure 2). Sonography is typically not a first career for most sonographers and the average length of time that the respondents had been in the field was 11 years. There is a higher incidence of musculoskeletal complaints in the chronologically older population which may account for part of the problem found. However, force, duration, static position, equipment design, lack of education on risk factors by the end user and workstation design are more likely to be the cause of the international problem.

Figure 3: Incidence of "severe" pain as a subset of those reporting pain.

Research on WRMSI in other professions has shown a direct correlation between the length of time that work activity associated with MSI is sustained and both the incidence and severity of WRMSI. Many types of WRMSI can be greatly reduced by introducing interruptions to sustained activity, in the form of rest breaks or by modifying the work flow to incorporate activities which use different muscles and joints, thus giving the body time to recover from potentially injurious activity. The number of breaks which sonographers are able to take during the work day thus becomes a critical factor. The survey highlighted this as a major problem (Figure 4).

Figure 4: Number of breaks during the work day.

Figure 4 shows the number of breaks of 10 minutes or more per day on average that the respondent sonographers reported. Over half reported receiving no breaks during the work day. This is important because breaks provide opportunity for the muscles and tendons to recover from sustained use.

Figure 5: Activities associated with pain.

Respondents were asked to identify those activities that they felt were causative of the pain they reported experiencing and to rate these activities on a scale of 1-5 with 5 being most likely to cause pain or exacerbation of pain and 1 being least likely. The most commonly reported activities are graphed in Figure 5.

Figure 6: Impact of WRMSI

The impact of WRMSI is not limited to the workplace. Injury to muscles, tendons and joints can affect the individuals ability to participate in recreation, household tasks, and ultimately in the ability to sustain work. Respondents were asked to indicate where they experienced pain (the top three bars of Figure 6) and whether the pain compromised their ability to engage in specified activities (the bottom 4 bars of Figure 6). It is interesting that the number of responses indicating absent from work was quite low compared with similar surveys in other professions. This most likely reflects the overall positive attitude that sonographers have about their work and that they choose to continue working even when experiencing significant pain. Contributing to this is also concern for ones co-workers who will have to pick up the work-load for the absent staff member. This causes many to work beyond the point where they should stop and get medical treatment; this may lead to an increase in the number of career ending injuries. Sonographers may also be aware of others in their department who are also suffering from similar injuries and may feel that it is inappropriate for them to seek relief by staying off work. Finally there is a significant amount of denial until pain and discomfort reaches an intolerable level.

OTHER DATA, OTHER FINDINGS:

Figure 7: Volume of procedures performed per sonographer per year

The data graphed in Figure 7 was consolidated from three different sources and represents the volume of procedures per sonographer over a period of 8 years. The numbers for 1992 come from data collected by the AHRA to study manpower in radiology departments. The AHRA repeated this study in 1995. The data for 2000 came from the Sonographer Benchmark study by the SDMS and the SDMS Foundation. Figure 7 demonstrates a dramatic increase in work load for sonographers between 1995 and 2000. This is the most likely explanation for the parallel increase in the complaints about occupational injury as manpower shortages take their toll on the profession.

The data above was presented as part of written testimony to Elaine Chao the Labor Secretary under the Bush administration. Two representatives from the SDMS testified during the Clinton administration regarding occupational injury in sonographers in 1999. You may view this testimony at www.sdms.org under workzone. After the OSHA standard signed into law by Clinton was rescinded by Bush the Labor Secretary took further public testimony and the same two representatives responded on behalf of the SDMS and the sonography community.

DISCUSSION:
The high incidence of occupational injury in the field of Sonography is truly alarming. While meat cutters and bar code scanners in grocery stores are considered high-risk occupations their incidence of injury is substantially less than that for sonographers. The British Columbia survey has been repeated in Australia, Canada, and New Zealand and recently in the United Kingdom. The results of all of these surveys (Figure 8) show an equal or higher incidence rate than the United States.

Figure 8: Incidence of reported pain among sonographers by country.

Although sonographers in these countries perform ultrasound slightly differently and the type of studies they perform also differ, they are all performing procedures using essentially the same equipment, and technique. This means that something very fundamental to the process of performing ultrasound scans must be at root of this problem.

In the next article we will explore how sonographers can reduce their vulnerability to WRMSI and future articles will provide advice on taking positive action to reduce the incidence of WRMSI in the ultrasound workplace.

Vulnerability to work-related musculoskeletal disorders

Sonographers and physicians who scan can reduce their vulnerability to WRMSD through education. It is imperative to know the risk factors for occupational injury if you are going to be able to reduce your risk or prevent these conditions.

One of the main risk factors is reaching. This can occur with either or both arms and can cause pain and discomfort in the shoulder and neck. To reduce reaching of the non-scanning arm pull the equipment as close as possible towards you. You should attempt to reduce the reach to no more than 30 centimeters. This requires there to be enough leg room under the scanner console to accommodate your legs. If this is not possible you need to stand to scan. Avoid keeping your arm extended over the control panel or freeze button. Reaching with your scanning arm can be avoided by positioning the patient correctly. The patients body should be close to the operator and the part of the patients body to be scanned should be in line with your shoulder. Do not scan with you arm extended behind you as this produces torque on the shoulder and requires the neck to be twisted in the opposite direction to view the monitor.

Twisting of the trunk and neck was one of the main complaints from sonographers. This is avoided by putting your weight evenly on both feet when standing and using your abdominal muscles to support your trunk when sitting. To avoid twisting of the neck position the monitor directly in front of you by bringing the equipment parallel and touching the table the patient is lying on. Do not tilt the monitor to share the image with your patient. If the patient is to be allowed to watch the study a monitor needs to be provided on the wall for their viewing.

Wrist flexion and extension is another risk factor and is often seen when sonographers do not take the time to support their wrist. Keep your wrist in a neutral position. Do not leave your wrist on the edge of the keyboard. When moving equipment push with straight wrists and avoid twisting motion of the trunk while trying to control the direction of movement of the equipment. If the equipment has wheels that can be locked in one direction, always lock the leading wheels so that you can more easily steer the equipment. If you have difficulty moving heavy equipment do not hesitate to ask for assistance and advocate for lighter equipment in future purchases.

To reduce abduction of the arm the table must be lowered and the chair raised. The goal is to reduce the angle of abduction to 30 degrees or less. To accomplish this the patient must be positioned near the edge of the table such that the patients side is touching the sonographers side.

Dont scan like this. The table is too high and the chair too low. See how many other elements of poor ergonomics you can spot in this picture.

Do scan like this. With the table lower and the chair higher the angle of abduction is now les than 30 degrees. The patient and the machine have also been repositioned to further improve the ergonomics of the scanning process.

Many sonographers grip the transducer unnecessarily tight. The use of well fitting textured-finger gloves can also assist with this. Do not wear gloves that are too large, as this also requires more grip once the gel is applied. How tight you grip the transducer is more a result of habit than necessity. Your grip needs to be only tight enough to avoid dropping the transducer and to maintain control.

Cables should not be draped around your neck or allowed to just hang freely. A cable brace works well to prevent torque on the wrist. Select transducers with flexible, light-weight cables whenever possible.

Scan head design is very important as well as how you hold the transducer. Experiment with various ways of holding the scan head to learn how to minimize stress on structures of the hand. Avoid a pinch grip and try as much as possible to use a power grip. This will take getting used to and you will have less fine motor skill for a while but eventually you will find ways to use this grip for at least part of the study. Explore changing your grip for various parts of the scan in order to distribute stress across different muscle groups.

Make ergonomics part of the buying decision for the next piece of equipment for your lab and look for equipment features that compliment the types of scanning you most often perform.

Avoid static positions and make sure there is variety in the types of scans you do. Avoid scheduling the same type of procedures back to back whenever possible. Take mini breaks to relax your arm, hand, fingers, and neck. Take a few seconds every 8 minutes to relax before continuing the study. Do not schedule add on patients during your lunch breaks, this time is needed to reduce the stress on your muscles and tendons. Do not go from scanning to PACS and back to scanning without allowing for muscle recovery time. Take many brief breaks during the day rather than long breaks only once or twice.

By being aware of the potential for WRMSI you can make optimal choices in scheduling studies, setting a reasonable work pace, while still managing the heavy demands that all of us face in the workplace today.

OSHA Publishes Ergonomic Guidelines for Nursing Homes

In 2001 Labor Secretary Elaine Chao formed an advisory committee to address occupational injury in healthcare workers. Those working in Nursing Homes were selected as the first to be studied. As a result of the efforts of this advisory committee, OSHA has recently published Ergonomic Guidelines for Nursing Homes. The URL below will give you direct access to the complete report on the OSHA website.

http://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html

Although specific to Nursing Home workers, the new Guidelines are important for sonographers and physicians who scan because they represent a model for how to constructively approach this problem without seeking legislative restrictions. The core recommendations of the guidelines focus on engineering-out the risk factors for nursing home workers. The highest risk is associated with manual lifting, repositioning and moving of residents. OSHAs guidelines recommend an approach to eliminate all manual lifting of nursing home residents. The guidelines go on to provide extensive examples of how this can be done by using appropriate equipment and facilities. To address the remaining sources of work-related musculoskeletal disorder (WRMSD) in the nursing home workplace, OSHA recommends that a WRMSD reduction program should include the following elements:

         provide management support;
         involve employees;
         identify problems;
         implement solutions;
         address reports of injuries;
         provide training; and
         evaluate ergonomics efforts.

This report represents a landmark in OSHAs efforts to reduce WRMSD in American workers. Guidelines such as those published for the Nursing Home industry do not carry the force of law and cannot be used in civil lawsuits, but they will exert a powerful force to increase awareness of best practices for reduction of WRMSD. Publication of these guidelines represents the first major initiative in OSHAs new coaching and counseling approach. Having set the standard for this approach, OSHA hopes to stimulate professional and industry groups to begin developing their own standards for reduction of WRMSD.

The Society of Diagnostic Medical Sonography (SDMS) has taken a leading role in preventing and reducing WRMSD and will be holding a consensus conference in May 2003 to address occupational injuries in the diagnostic ultrasound profession. It is the objective of this conference to generate a set of standards and guidelines for the field. The conference will be attended by representatives from Australia, the United Kingdom, Canada, and the United States. The conference will also be attended by representatives from professional societies, ultrasound scanner and accessory equipment manufactures, as well as the accrediting and credentialing bodies relevant to our field. This broad representation should result in robust and practical guidelines that will enjoy strong support through all levels of the community.

Elimination of WRMSD from the ultrasound workplace is an objective that we should all seek to achieve. WRMSD can be eliminated through a broad-based initiative which includes employee awareness and training, appropriate procedures, use of assist devices and tools, and maintenance of a work pace that respects the needs of sonographers and physicians who scan. The consensus conference guidelines should be a strong first step on the path to an injury-free workplace for sonographers!

The Economics of Ergonomics

The Economics of Ergonomics.

I am often asked by sonographers how they should approach trying to get ergonomic scanners and accessories in their hospital or clinic. Using the cost of not addressing ergonomics presents a compelling argument.

Here are some points that serve as introduction to this subject

Over 80% of sonographers experience work related pain
Of those who experience work-related musculoskeletal pain (WRMSD), 20% will eventually suffer career-ending injuries. That means that without improved ergonomics, about 16% of sonographers will be lost to the work force due to musculoskeletal injury.
There is a critical shortage of health care professionals that is expected to worsen through the remainder of this decade. Results of a survey on the magnitude of this shortage were published in a consulting report entitled The Healthcare Workforce Shortage and Its Implications for American Hospitals You can download the report as a .pdf file from this link: http://www.hospitalconnect.com/aha/key_issues/workforce/resources/Content/FcgWorkforceReport.pdf While most of the attention has been focused on the nursing shortage, ultrasound is one of the most seriously affected areas, with projected shortages continuing through the end of this decade. This means that it is difficult to recruit and retain sonographers, and this is likely to become even more difficult in the future.
John Hawkins, vice president of Allied Consulting, a national health care staffing firm based in Irving , Texas states: a single ultrasound sonographer with a moderate caseload will generate about $4,550 in charges per day (1). It is difficult to arrive at a single number for the revenue potential of a sonographer since sonographers practice in a wide range of settings and perform a wide range of procedures with varying revenue potential. The number given by Mr. Hawkins is based on his experience as a recruiter and probably represents the high end of the range. To establish the bottom end of the range we can use an average Medicare payment rate ($120) and 10 procedures per day resulting in $288,000 in revenue per year. The midpoint of this range is about $400,000 and this is probably a realistic number to use in our calculations. Of course, each setting will be different and an administrator responsible for ultrasound services should know precisely how much revenue each sonographer is generating. For the remainder of this article we will use a conservative estimate of $400,000 per year or $33,000 per month as the average revenue generation capacity of one sonographer.
OSHA has identified the following workplace risk factors for WRMSD for any type of employment. It is interesting to note that they all might apply to all ultrasound except vibration.

repetitive motions

forceful or awkward movements

duration of pressure

overuse

poor posture/ improper positioning

excessive force and strain

vibrations

Costs of Injuries

There are direct and indirect costs related to an occupation injury, including the medical cost of treating the injury; the cost of replacement staff, as well as the loss of revenue secondary to decreased productivity during time loss.

Direct Medical costs: $20,000

Medical Care for the Employee: Medical bills for the average shoulder injury (this does not include the possibility of surgical treatment) $20,000 per year. Most of this cost is usually covered by the employees health insurance.

Workmans Comp: $29,000-32,000 per year per injured employee

Workers compensation data is collected by National Council on Compensation Insurance in 40 states including the District of Columbia . This data is published in a report Workers Compensation Detailed Claim Characteristics a copy of which can be obtained at http://www.ncci.com

Loss of Revenue: at least $33,000 per month lost revenue if a vacant position not filled . This is a direct loss to the bottom line of the employer.

The Alternative

Addressing the potential for work-related musculoskeletal injury (WRMSI) must be a multidimensional effort. First, the employer must provide appropriate ergonomic equipment for the work environment. Second, the sonographer must be educated in ergonomics and trained to properly use ergonomics in the workplace. Third, the employer and the sonographer must mutually seek to establish and maintain a reasonable work load for the sonographer. Finally, the sonographer must take personal responsibility for aggressively applying good ergonomic work practices at all times.

Many work-related musculoskeletal injuries can be prevented by use of appropriate ergonomic equipment.

Height adjustable stool: $755

Set of support cushions: $250

Ergonomic exam table: $7,400

Ergonomic Ultrasound Scanner: $120,000 $180,000

The basic support equipment (stool, ergonomic aids, exam table) are relatively inexpensive and should be implemented immediately in any ergonomic program. Acquiring a ultrasound scanner specifically designed to address ergonomic issues may take a bit longer, but any administrator who does the math on the cost of losing a sonographer to WRMSI should be budgeting for replacement scanners as soon as possible. It is simply shortsighted management to ignore the WRMSI problem.

Priceless: a healthy competent sonographer

It is obvious from the above figures that it simply makes good sense to address ergonomics rather than to ignore it until you have an injured employee. Addressing ergonomics does not mean there will be no injuries since this is a multifaceted problem and involves sonographers as well as equipment and employers. However, what is manifestly true is that you cannot reduce injures in the workplace unless you make the effort to get the right equipment and you train and motivate staff to use it correctly.

References:

1. Hawkins, J Technologist in the House? Advance for Imaging and Oncology Administrators. Vol 13, Issue 8, Page 38, August 1, 2003

Suggested reading:

Schneider M. Franz. Why ergonomics makes a lot of sense from a dollar-and-cents standpoint and why it may be inevitable because of legislation. On line:

http://www.soundergonomics.com/PDF%20Files/ErgSonWellBeing.pdf

Ergoweb. On line: http: http://www.ergoweb.com

Brown E. Ergonomics and repetitive strain injuries. On line: htpp://dea.human.cornell.edu

Good ergonomics is good economics. On line: http://www.aflcio.org/safety/

Workplace Injury and Cost Data from Liberty Mutual August 2001 http://www.ergoweb.com/news/detail.cfm?id=395

Relating Health Care Cost Savings to Ergo Intervention Nov 23, 2001 http://www.ergoweb.com/news/detail.cfm?id=442

Pike I, Russo A, Berkowitz J, Baker J, Lessoway V. The prevalence of musculoskeletal disorders among diagnostic medical sonographers; JDMS; 13(5); Sept.-Oct. 1997: 219-27.

Occupational Safety and Health Administration. http://www.osha-slc.gov

Grieco A, Molteni G, DeVito G, Sias N. Epidemiology of musculoskeletal disorders due to biomechanical overload; Ergonomics; Sept. 1998; 41(9): 1253-60.

Melhorn JM. Cumulative trauma disorders and repetitive strain injuries: The future; Clin Orthop; June 1998 (351): 107-26.

Evanoff B. Testimony submitted to the United States Senate Committee on Appropriations Subcommittee on Labor, Health and Human Services, and Education Special Hearing on Ergonomics, April 2001. On line: http://www.senate.gov/appropriations/labor/

Hawkins, J. Survey Seeks to Quantify Technologists Worth; Advance for Imaging and Radiation Therapy Professional; July 28, 2003; 11.