Introduction to Musculoskeletal Disorders (MSKD) - USA

Congratulations! You have completed the Introduction to Musculoskeletal Disorders course. Listed below are the key points presented in this course. Take time to review the material before you try the final assessment. Download and print a copy of the detailed Course Review In this course you have learned: Discuss risk factors in the development of muscular injury   Identify symptoms of progressive MSK injury   List suggested solutions for decreasing injury while moving patients   Explain environmental adjustments that help decrease MSKD. Upon completion of this course you will be able to:   Discuss risk factors in the development of muscular injury. Identify symptoms of progressive MSK (musculoskeletal) injury. List suggested solutions for decreasing injury while moving patients.   Explain environmental adjustments that help decrease MSKD.    View these instructions for information on navigating through the self-evaluation tools we call ‘Your Turns’. Click the icon below to view the self-evaluation instructions. Note: This is not part of the final Assessment. Learn How to Navigate the Your Turns Learn how to navigate the Your Turns. Instructions:Flash File:HTML5 File:/content/generator/Course_90024586/navigation_instruct/index.htmlPDF File: The healthcare professional often begins their training with the goal of providing care to diagnose and ease patient pain, whether human or animal, due to trauma or disease. In the past, very few professionals thought that their work tasks would result in daily pain affecting their personal and professional lives.   Many aspects of our work life have the potential to influence our overall health. These include shift work, chemical exposure, and musculoskeletal disorders (MSKD). This condition encompasses the overuse of muscles, nerves, tendons, due to body postures, and repeated tasks. The result is either transient or permanent injury and disability.     This sonographer and patient position result in bending and twisting from improper equipment setup and patient position. This course provides an introduction to the prevalence of overuse related musculoskeletal (MSK) injury.   The physical symptoms of MSK disorders begin to occur when the mechanical demands exceed our muscles, tendons ligaments, and even bone. The resulting strains, ruptures, microfractures, and degenerative changes result in either acute or chronic problems. An acute injury, due to a short-term damage, often occurs suddenly. An example would be a muscle tear when moving heavy equipment or a broken bone occurring during a fall. The chronic injury occurs with a repeated musculoskeletal (MSK) damage. Among the most frequently reported cause of restricted or lost work time, this type of injury develops gradually. Due to continued exposure to risk factors, MSK disorders extracts a substantial personal toll due to the inability to work or perform simple tasks and activities of daily living.1 Everyone has the potential to develop WRMSDs (work-related musculoskeletal disorder), however, this course focuses on the medical professions. Research shows that all medical specialties have a high instance, 80 percent or higher, of injury’s underscoring the importance of proper ergonomics during the working day and in our personal life.1-5   Keep in mind, an ergonomic risk factor is any imbalance between you and your environment.6 Usually associated with the work environment, many activities outside of work contribute to musculoskeletal disorders.   The type of musculoskeletal injury depends on the body part, such as the shoulder, arm or back. They key is the continued repetition, static positions, force and often vibration occurring during an activity. These factors become interdependent and difficult to separate; however, the lack of rest periods, and the continual stretching to strengthen muscles and tendons increases the likelihood of developing musculoskeletal problems.   Click on the icon below for examples of risk factors. Learn More about Risk Factors Learn more about risk factors.7, 8 Tab TitleTextBody Position Maintaining a body position for an extended period of time contributes to injury.    This can be an activity done with our family such as a long bike ride. Extended sitting in front of a computer lower than eye level adds to back and neck problems. Repeated Movements   The use of the same muscle groups or joints to perform the same motion defines a repeated movement. An example is when we use a computer mouse to duplicate the same series of motions: position the mouse, click.   Force   Force is the work we do to lift, grasp, or move an item.  As we increase force, we also increase the effort of our muscles. Since we often perform the same task multiple times during the day, we decrease the benefits of rest due to force. An example of force is the effort used in pinching or grasping motions used to perform a biopsy.   VibrationFast movement, either up and down, back and forth, or rotational defines vibration. Symptoms of vibrational damage include finger numbness, grip deficiencies, decrease in touch, and, as with other risk factors, pain.   Bike riders often experience numbness in the wrists and hands due to pressure on nerves and vibration (ring and little finger). Vibration of imaging systems occurring during transport to the patient room is another contributing factor.   Musculoskeletal injury provides symptoms to alert us to the severity of the injury. As with many physiologic problems, early symptoms are often ignored. The onset of damage may be no more than a mild discomfort associated with specific job tasks or activity. Due to rapid resolution of our symptoms, we may think we have either fully recovered or be unable to target the activity causing the problem. As injury continues, so do the persistence of our symptoms. What once resolved with a long weekend or a good night’s rest, continues until we are unable to complete our work or daily living activities.   Use the links below to learn about how life activities, both personal and professional, add up to injury.  Learn More about MSK Damage Learn more about MSK damage.7 Tab TitleTextEarly Stage  During the early stages you will feel aching, fatigue, stiffness or discomfort of the injured area. Your arm, back or leg may feel uncomfortable but stretching, a good night's rest or a long weekend resolves your symptoms.    During this phase you won’t see any reduction of your ability to perform work tasks or enjoy life in your free time.     At this stage, stretching and rest (teal blocks) balance tiredness and aching (black blocks) without restrictions. Intermediate Stage As injury progresses, pain accompanies aching and fatigue. Symptoms persist during the day while working and in your leisure time. The advantages of stretching decrease.   Pain interrupts sleep reducing benefits of rest.   Repetitive activities become restricted by pain, stiffness, and swelling. This decreases the ability to perform tasks such as typing, playing the piano, or knitting.    At this stage, the benefits stretching and rest (teal blocks) decease while tiredness and aching, with added pain (black blocks) begin to restrict activities.  Late Stage Long standing, chronic injury adds weakness or, in the case of grasping activities, unintentional dropping of objects. Sleeping becomes difficult due to constant pain. Even light activities become difficult. At this stage you may not be able to work or participate in activities previously enjoyed.   Resolution of symptoms and healing may be helped by surgery, physical therapy, and anti-inflammatory medication; however, you may not regain full use of the injured area (i.e., arm, back).     At this stage, the benefits stretching and rest (teal blocks) decease while tiredness and aching, with added pain (black blocks) begin to restrict activities.  Wrist and Shoulder MSKD Signs and Symptoms Learn more about wrist and shoulder MSKD signs and symptoms.7, 9, 10 Tab TitleTextWristWorking with computers increases our risk of developing wrist problems due to repetitive motions. The table below provides a few causes of symptoms, possible causes, and the end results.   Symptom Behavior Complications Pain, weakness, swelling ache or burning, cramping Repetitive wrist motions Tendinitis and / or tenosynovitis Pain at the base of the thumb Hand twisting De Quervain’s tenosynovitis Forceful gripping Night tingling, burning pain on the radial side of the wrist Repeated compression of the median nerve Carpal tunnel syndrome ShoulderRepetitive motions also damage shoulder structures. The table below provides a few causes of symptoms, possible causes, and the end results. Symptom Behavior Complications Pain, weakness, swelling ache or burning, muscle atrophy Repetitive shoulder motions Tendinitis and / or tenosynovitis, Rotator cuff damage Hand swelling, pain, numbness Extended flexion Thoracic outlet syndrome Transport of loads on shoulder Arm extension at or above shoulder height Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90024586/fw-intro-your-turn-01/index.htmlPDF File: Ergonomics, the science of fitting a task to both the limitations and capabilities of an individual, is an important part of our day. We know now that MSK injury is the result of repetition, the amount of force, awkward motions, and positions. The goal, to reduce stress, injuries and associated problems, are why we study human factors or ergonomic methods. In our busy day we often neglect or ignore the importance of positioning of tools used (i.e., monitors) and neglect to perform stretches to help counteract physical stress. This includes establishing ‘best practices’ when moving patients during our work day and the changes needed to compensate for life events such as pregnancy. Click on the icon below to learn how you can help reduce the incidence of musculoskeletal disorders.   Learn More about Reducing MSKD Learn more about reducing MSKD.7 Tab TitleTextMonitor The optimal distance of a monitor or digital device is a distance of 20 – 40 inches / 50 – 100 centimeters.   Adjust the font visibility to accompany the distance.    Adjust the height to minimize neck flexion or extension. Position the monitor top at or below eye level. Keep the chin parallel to the ground. Additionally, low or non-glare surfaces reduce eye strain.  Body Position Any time we maintain a static or awkward position, our muscles remain contracted. This includes either sitting or standing with unbalanced distribution of our weight. When changing positions take the time to adjust your tools.     Alternate your position from sitting to standing to use different muscle groups. Chairs Adjust chairs and stools to allow for placement of your feet either on the foot rest or floor at a 90-degree angle (parallel to the floor).   Place the lumbar support at the low back.  Keyboard / Mouse Maintain a neutral position of the wrist and hand when using a keyboard or mouse. Ensure relaxed fingers and straight wrists.   In this example, the wrist (double arrowheads) shows a dorsal flexion. To adjust, simply level the wrist. The mouse hand position (double down arrows) is in a pinch-type grip. Move the hand into an open placement.  Breaks Do you take a break from your keyboard, mouse, imaging equipment or monitor?    How often do you stretch during the day?   Are there breaks in your work and personal schedule for rest or social activities?   If you answer never, seldom, or ‘I don’t have time’, remember that musculoskeletal damage cumulates. Performing our tasks using ergonomic principles increases the quality of or work and life tasks while decreasing fatigue and pain.  Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90024586/fw-intro-your-turn-02/index.htmlPDF File: MSKD is a multifactorial process as many things contribute to injury of our musculoskeletal health. In the ideal world, everything would be in continuous balance; however, changes in our lifestyle and overall health also alter our risk for MSK damage.    In addition to body position, force, repeated movements, and vibration, we must consider the influence of pregnancy and drugs, prescription, over the counter, and recreational, in our efforts to avoid harm.  One of the most common life events, pregnancy, results in physical changes such as weight gain and the increasing size of the growing fetus. Less evident are the changes due to the hormones relaxin, estrogen, and progesterone which result in an increase in laxity of joint structures (i.e., tendons, ligaments) .11 Though beneficial during labor and delivery, this process increases the risk for knee injuries and pelvic pain.12, 13   Hand swelling due to edema increases the incidence of carpal tunnel syndrome11-13 due to nerve compression. The same swelling raises the risk of de Quervian’s tenosynovitis that extends into the post delivery period.11, 13 Learn More about Ergonomics and Pregnancy Learn more about ergonomics and pregnancy. Tab TitleTextPregnancy Outcome6, 14 A pregnant woman has the same risk factors, high force (lifting), lack of rest, awkward body position, and repetitive work. Ignoring the impact of the physical risk factors shows an increase in the possibility of preterm labor and the need for a caesarian section. The risk of preterm birth increases with prolonged standing or sitting (>3 hours), heavy lifting, and repetitive tasks. Another concern, maternal obesity (defined as a body mass index [BMI] of greater than 25), not only increases MSKD, but also a negative pregnancy outcome.Postural changes13, 15, 16 Changes in posture increase as the pregnancy progresses. These include: Anterior angling of the neck and pelvis. Flattening of the feet due to ligament relaxation increasing hyperextension of the thoracic spine and knees. Posterior extension of the head. ​Increased lordosis.  Many common lifestyle practices, such as smoking, as well as medication can cause muscle and tendon weakness. This increases our risk for injury when twisting, both balanced or off-balance lifting.   Click on the link below to learn how smoking, over the counter and prescription medication change our MSK health Learn More about Changes in MSK Health Learn more about changes in MSK health. Tab TitleTextSmoking17-18 We are all familiar with the effects of tobacco use on the cardiovascular and pulmonary systems. Though we associate smoking with arterial disease, there is also a decrease in contractibility of muscle tissue and muscle strength. Additionally, there is a strong correlation between bone loss and an increased risk of fracture. Other findings show rotator cuff tear damage increases in smokers.   A final consideration is post-operative outcomes. Smokers tend to show delayed fracture healing, increased complications with joint replacement, rotator cuff reconstruction, and poor anterior cruciate reconstruction stability. Prescription Drugs19-23Many of us use statins to reduce our cholesterol, and thus, our risk for heart disease. Studies have shown that statin effects on tendons include tendinopathy with a high incidence of rupture. The loss of striated muscle cells due to rhabdomyolysis has the potential to lead to weakness and thus, increase injury risk.   Fluoroquinolone (aka Cipro) is a type of antibiotic used to treat bacterial infections such as urinary tract infections, pneumonia or staphylococcus infections.  One known side effect is the development of tendinopathy that may lead to rupture. Individual factors increasing the risk of tendon degeneration include increasing age, diabetes mellitus, rheumatic arthritis, gout, and sports.   These are two examples of prescription medications that may increase the risk of musculoskeletal injury. Keep in mind that many drugs have side effect and your risk may increase further if using a combination of medications (i.e., antibiotics, anti-inflammatories, analgesics, hormone treatment, high blood pressure medication). We now know that ergonomics is the process of fitting skills to our environment, tools, and activities in both our work and personal life. Global standards to help us understand the responsibilities of each individual, employer, and equipment manufacture agree on a holistic approach to work related musculoskeletal disorders (WRMSKD) prevention.7, 24-26    Ergonomics in children’s ‘workplace’ includes the postural changes seen with heavy backpacks.2 Click on the link below to learn how you, your employer, and human factors experts can help reduce MSK disorders.   *Note: This a partial list. Learn More about Ergonomic Safety in the Workplace Learn more about ergonomic safety in the workplace.24 Tab TitleTextPersonal Work Habits Maintain a neutral posture (i.e., minimize reaching, bending, awkward / static postures). Organized your workspace to your postural needs. Relax and stretch during the workday. Take frequent small breaks and have meals away from your work station. Vary positions and work tasks when available. Practice safe patient transfer.  Find solutions to identified ergonomic problems.   This sonographer has rotated an ergonomic chair allowing for placement of support (orange) for her arm. A brace helps reduce transducer cable weight. Organizational Responsibilities  Ergonomic training / evaluation (i.e. physical and occupational therapy). Process to report ergonomic improvement. Monitor work schedules (i.e. patient load) Ensure adequate time for breaks and meals. Variation of imaging exam types and tasks. Limit portable exams. Confirm adequate room size for both imaging and workstation tasks. Verify adjustability of exam tables, mobile computer workstations, chairs, monitor and light levels. Adhere to industry standards supplied by occupational safety groups. Eliminate any retaliation fears (whistleblower) for filing a complaint. Human Factors Engineering design of medical equipment applies both psychological and physical principles by specialists in human factors. This area of study merges occupational health and safety to aid in reducing repetitive strain injuries and other WRMSD. A few considerations in designing ergonomic medical imaging systems include: Reduction of keystrokes on the control panel. Determination of force required to move portable systems and the need for motorized assistance. System height to accommodate height differences of technologists. Power cord and ethernet length allowing for access to outlets or ports. Adjustable system consoles. Design of the user interface to accommodate for right- or left-hand use. The addition of a foot switch to allow adjustment of system height or to initiate an image capture, is a consideration in imaging equipment design. Musculoskeletal problems occur in healthcare workers at a greater incidence than other labor-intensive careers such as manufacturing or construction.27 One task, moving patients, is a major contributor due to an inability to maintain ergonomic positions and the increase in patient obesity.28 It is no surprise that among healthcare workers, those employed within an extended care facility or hospital have the highest rate of injury.27 Repeated reaching, lifting, and transferring of patients within the diagnostic imaging department increases the possibility of injury to the back, shoulder and upper extremities.29 A partial solution to the incidence of becoming harmed while caring for our patients, is the use of appropriate lifting techniques.30, 31  Click on the link below to view suggested procedures to decrease injury while transferring a patient. Learn More about Moving Patients Learn more about moving patients. 1. Lock the wheelchair or stretcher wheels. 2. Perform examination on the stretcher or in the wheelchair. 3. Lift close to your body. 4. During patient transfers, lift with your legs rather than the back. 5. Refrain from twisting and unnatural positions while lifting. 6. Avoid extending arms above shoulder height. 7. Utilize mechanical lifts, transfer belts, and lateral sliding aids when possible. 8. Request help. 9. Move equipment during transfer. 10. Adjust exam table or bed to lowest level for chair transfer or level with the stretcher. 11. Encourage the patient to aid in transfer process. Your Turn Your Turn. Instructions:Flash File:HTML5 File:/content/generator/Course_90024586/fw-intro-your-turn-03/index.htmlPDF File: Globally, MSKD is one of the biggest causes of disability occurring during working years predominately in women.33 We are often told that we should use ‘best practices’ during our work day. What exactly does that mean?   Best practices for decreasing or preventing MSK disorders include evidence-based behaviors and clinical practice guidelines. Often the focus for prevention of work-related musculoskeletal injury centers on the physical result of improper completion of work tasks. Another aspect, how our perception of our work factors into our overall health, is often neglected.    Click on the link below to learn more about the physical and psychosocial components of WRMSK. Learn More about Best Practices for WRMSKD Learn more about best practices.2, 14, 34, 35 Tab TitleTextPhysical Move patients in a safe manner using either manual or mechanical (recommended) assistance. Use personal work habits that minimize physical stress. Stretch during the workday. Adjust work tasks to compensate for temporary conditions (i.e., pregnancy, injury). Vary job duties through the day.  Psychosocial Use stress-reduction techniques (i.e., yoga, meditation, massage). Take breaks during your workday away from your work area. Identify risk factors. Attend / complete ergonomic training. Participate in the employee feedback process. Report WRMSD. Maintain realistic expectations for recovery when developing MSKD. Injuries to the muscles, tendons, nerves, joints, and spine due to risk factors experienced during our work day defines work-related musculoskeletal disorders. As our workload increases so does the repetitive stress on our bodies. The medical professions enjoy a predominately female workforce in their mid-40’s.36   WRMSKD’s are a relatively common malady with 54 percent of working adults over 18 reporting symptoms. The economic cost is in the billions due to associated expenses such as medical care, lost wages, and legal fees. Though reduced in retired populations (>65 years), there is approximately a 40 percent incidence of muscular injury. 37   Percentage of workers with pain.   86% Sonographers29, 31 45% Non-scanning peers36, 38 85% Obstetricians and midwives3 88% Nurses4 70% Pregnancy without previous pain11 Explore the links below for the Glossary, References, and Further Reading opportunities. Glossary Glossary. Anterior – Towards the front   Edema – Swelling due to inflammation or accumulation of fluid within tissues.   Hyperextension – Movement beyond the normal range of a joint.   Lordosis – Excessive anterior curvature of the spine.   Organization – A facility or department with a particular purpose i.e., clinic, hospital, diagnostic imaging department.   Posterior – Towards the back.   Posture – The position of our bodies.   Risk factor – Any behavior that increases the chances of developing MSKD.   Static – Fixed or unchanging position.  References / Further Reading References / Further Reading. Tab TitleText1-81. Society of Diagnostic Medical Sonographers. (2017). Industry standards for the prevention of work related musculoskeletal disorders in sonography. Journal of Diagnostic Medical Sonography. 33(5): 370-391.   2. Murphey, S. (2017). Work related musculoskeletal disorders in sonography. Journal of Diagnostic Medical Sonography. 33(5): 354-369.   3. Wang, J., Cui, Y., He, L., Xu, X., Yuan, Z., Jin, X., and Li, Z. (2017). Work-related musculoskeletal disorders and risk factors among Chinese medical staff of obstetrics and gynecology. International Journal of Environmental Research and Public Health. 14(6): 562. 4. Yan, P., Li, F., Zhang, L., Yang, Y., Huang, A., Wang, Y., and Yao, H. (2017). Prevalence of work-related musculoskeletal disorders in the nurses working in hospitals of Xinjiang Uygur autonomous region. Pain Research & Management: 5757108-5757108.   5. Shokati, B., YektaKooshali, M.H., Zareiyan, S., AkbariNezhad, A., and Soroush, A. (2018). The prevalence of work-related musculoskeletal disorders among X-ray radiographers those working in radiology centers of the hospitals affiliated in AJA University of Medical Sciences: a cross-sectional study. Military Caring Sciences. 4: 190-200.   6. OHCOW. (2020). Ergonomics & pregnancy, Occupational Health Clinics for Ontario Workers Inc.: Ontario. 7. Work-related musculoskeletal disorders (WMSDs). (2019). Safety, C.C.f.O.H.a., Editor, CCOHS: Hamilton, ON.   8. Harrison, G. and Harris, A. (2015). Work-related musculoskeletal disorders in ultrasound: Can you reduce risk? Ultrasound. 23(4): 224-230.  9-169. Coombs, P. and Ptasnik, R. (2016). Sonography of the shoulder and upper arm. In van Holsbeeck, M. and Introcaso, J.H., (Eds.), Musculoskeletal Ultrasound (pp. 737-811). Philadelphia: Jaypee.   10. van Holsbeeck, M., Ditmars, D., and Introcaso, J. (2016). Sonography of the wrist and hand. In van Holsbeeck, M. and Introcaso, J.H., (Eds.), Musculoskeletal Ultrasound (pp. 870-945). Philadelphia: Jaypee.   11. Kesikburun, S., Güzelküçük, Ü., Fidan, U., Demir, Y., Ergün, A., and Tan, A.K. (2018). Musculoskeletal pain and symptoms in pregnancy: a descriptive study. Therapeutic Advances in Musculoskeletal Disease. 10(12): 229-234.   12. Gross, G.A. and George, J.W. (2016). Orthopedic injury in pregnancy. Clinical Obstetrics and Gynecology. 59(3): 629-638. 13. Thabah, M. and Ravindran, V. (2015). Musculoskeletal problems in pregnancy. Rheumatology International. 35(4): 581-587.   14. Guendelman, S., Gemmil, A., Hosang, N., and Macdonald, L. (2017). Physical and organizational work stressors and associations with cesarean deliveries. Journal of Occupational and Environmental Medicine. 59(6): 571-577.   15. Almeida, H.A. (2016). Pregnancy and ergonomics, in BioMedWomen: Clincical and bioengineering for women's health, Jorge, R.N., Mascarenhas, T., Durante, J.A., et al., Editors, Taylor & Francis Group: Porto, Portugal 11-18. 16. Ireland, M.L. and Ott, S.M. (2000). The effects of pregnancy on the musculoskeletal system. Clinical Orthopaedics and Related Research®. 372: 169-179.  17-2417. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. (2014). The health consequences of smoking—50 years of progress: A report of the surgeon general., Services, U.S.D.o.H.a.H., Editor, U.S. Department of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA.   18. Al-Bashaireh, A.M., Haddad, L.G., Weaver, M., Kelly, D.L., Chengguo, X., and Yoon, S. (2018). The effect of tobacco smoking on musculoskeletal health: A systematic review. Journal of Environmental and Public Health. 2018: 4184190-4184190.   19. Auer, J., Sinzinger, H., Franklin, B., and Berent, R. (2016). Muscle- and skeletal-related side-effects of statins: tip of the iceberg? European Journal of Preventive Cardiology. 23(1): 88-110.   20. Shimatsu, K., Subramaniam, S., Sim, H., and Aronowitz, P. (2014). Ciprofloxacin-induced tendinopathy of the gluteal tendons. Journal of general internal medicine. 29(11): 1559-1562. 21. Khaliq, Y. and Zhanel, G.G. (2005). Musculoskeletal injury associated with fluoroquinolone antibiotics. Clinics in Plastic Surgery. 32(4): 495-502.   22. Stinner, D.J., Orr, J.D., and Hsu, J.R. (2010). Fluoroquinolone-associated bilateral patellar tendon rupture: A case report and review of the literature. Military Medicine. 175(6): 457-459.   23. Nyyssönen, T., Lantto, I., Lüthje, P., Selander, T., and Kröger, H. (2018). Drug treatments associated with Achilles tendon rupture. A case-control study involving 1118 Achilles tendon ruptures. Scandinavian Journal of Medicine & Science in Sports. 28(12): 2625-2629. 24. Industry standards for the prevention of work related musculoskeletal disorders in sonography. (2017). Journal of Diagnostic Medical Sonography. 33(5): 370-391.  25-3225. EU-OSHA. Perspective 2: Ergonomics - with a policy dimension. in Give musculoskeletal health to children and young workers. 2019. Bilbao: European Agency for Safety and Health at Work.   26. CCOHS. (2019). Work-related Musculoskeletal Disorders (WMSDs). 2019 2019 [cited 2020 3 April]; Available from: https://www.ccohs.ca/oshanswers/diseases/rmirsi.html.   27. Bureau of Labor Statistics. (2015). Incidence rates for nonfatal occupational injuries and illnesses involving days away from work per 10,000 full-time workers by industry and selected events or exposures leading to injury or illness, 2014., U.S. Department of Labor: Washington DC.   28. Organization, W.H. (2016). Prevalence of obesity among adults, BMI ≥ 30, age-standardized estimates by country. 2016 2017-09-22 [cited 2020 06 February]; Available from: http://apps.who.int/gho/data/node.main.A900A?lang=en.   29. United States Department of Labor Occupational Safety & Health Administration. (2020). Clinical services: Radiology. 30. U.S. Department of Labor Occupational Safety and Health Administration OSHA 3182. (2009). Ergonomics for the prevention of musculoskeletal disorders, OSHA, Editor: Washington, DC.   31. The National Institute for Occupational Safety and Health (NIOSH). (2008). Patient handling techniques to prevent MSDs in healthcare. CDC. Washington, DC. [Cited 2020 3 April]; Available from https://www.cdc.gov/niosh/topics/safepatient/#National%20Safe%20Patient%20Handling%20Standards.   32. Pullen, R.L.J. (2008). Transferring a patient from bed to wheelchair. Nursing2020. 38(2): 46-48.  33-3833. Vos, T., Abajobir, A.A, and Abate, K.H. (2017). Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 390(10100): 1211-1259.   34. Al-Rammah, T.Y., Aloufi, A.S., Algaeed, S.K., and Alogail, N.S. (2017). The prevalence of work-related musculoskeletal disorders among sonographers. Work. 57(2): 211-219.   35. Dear, J.A. (1993). Ergonomics program management guidelines for meatpacking plants, OSHA., Editor, U.S. Department of Labor: Washington, DC. [Cited 2020 3 April]; Available from https://www.osha.gov/Publications/OSHA3123/3123.html   36. Barros-Gomes, S., Orme, N., Nhola, L.F., Scott, C., Helfinstine, K., Pislaru, S.V., . . . Pellikka, P.A. (2019). Characteristics and consequences of work-related musculoskeletal pain among cardiac sonographers compared with peer employees: A multisite cross-sectional study. Journal of the American Society of Echocardiography. 32(9): 1138-1146. 37. Malik, K.M., Beckerly, R., and Imani, F. (2018). Musculoskeletal disorders a universal source of pain and disability misunderstood and mismanaged: A critical analysis based on the U.S. model of care. Anesthesiology and Pain Medicine. 8(6): e85532-e85532.   38. Orme, N.M., Geske, J.B., Pislaru, S.V., Askew, J.W., Lennon, R.J., Lewis, B.R., . . . Singh, M. (2016). Occupational musculoskeletal pain in cardiac sonographers compared to peer employees: a multisite cross-sectional study. Echocardiography. 33(11): 1642-1647.   The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages.   All names and data of patients, parameters and configuration dependent designations are fictional and examples only.   All rights, including rights created by patent grant or registration of a utility model or design, are reserved.   Please note that the learning material is for training purposes only!   For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. 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