Taking Care of the Caregiver: Ergonomics in the Reading Room

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Sit up straight. It may have been nagging advice from your Mom, but it’s good advice for the radiologist who sits in a digital reading room often for hours at a time. So is putting your feet flat on the floor and maintaining the proper angle of your elbows and hands on the keyboard and eyes to the monitor. Read on. Heeding good advice can ward off musculoskeletal problems that plague the profession.

Several studies have emerged over the past few years that acknowledge the risks of poor ergonomics on radiologists, and offer solutions on the proper way to read to avoid injury.

Clinically documented damage

“Paying close attention to the basics of workplace ergonomics can go a long way in increasing productivity and reducing fatigue, thus allowing full realization of the potential benefits of a PACS,” according to the recommendations of Mukesh G. Harisinghami, MD, from the division of radiology and director of abdominal MRI at Massachusetts General Hospital in Boston, and colleagues (Radiographics 2004; 24:615-627).

Cornell University PhD candidate Hrönn Brynjarsdóttir created the Cornell Digital Reading Room Ergonomics Checklist (CDRREC) for radiology reading room designers or PACS administrators, specifically due to the high rates of work-related injuries among radiologists. Ruess et el reported that radiologists at Tripler Army Medical Center developed a carpal tunnel incidence rate of 8.3 over a three-year period (Am J Roentgenol 2003;181:37-42).

Adjustability is key

Due to the long segments of time that the radiologists are sitting, adjustability is very important, says Dennis Garcia, operations manager of imaging informatics for UCLA Health System in Los Angeles. The health system uses the Anthro Carl’s Table throughout its facilities. “The chairs should be adjustable, including the back of the chair and its armrests. The desk also must be adjustable because we have radiologists of varying heights and weights.” 

Chairs and arm rests are required to be adjustable in height, and adjustable in a way that the radiologist’s feet are able to be placed flat on the floor with the knees at a right angle, according to David Hirschorn, MD, director of radiology informatics at Staten Island University Hospital in Staten Island, N.Y. Brynjarsdóttir adds that there should be a little more than a 90 degree angle at the hip joint, and the arms need to be supported.

It is recommended that the top edge of the PACS monitor be 15° to 50° below eye level, as shown here.
Constantly lowering the neck to look at the keyboard will result in undue strain and cumulative trauma to the neck.
Proper adjustment of arm rest.
Most often, the furniture usually needs to accommodate more than one body type and size. “We have to make sure that the workspace is customizable to each individual,” Garcia says. “The Anthro tables aren’t just adjustable for height, but also for tilt and lighting. Once we deployed these types of desks and chairs, most of the physical complaints pretty much dissipated.”

Any PACS monitor, which should rest 15 to 50 degrees below eye level, can now be tweaked with the hardware, due to adjustable monitor arms, according to Garcia.

Hirschorn concurs that adjustable height tables are particularly beneficial, so that the arms and forearms are parallel to the floor. “The wrists should not be lower or higher than the elbows, and vice versa—they should be level. Without an adjustable height, the countertops are almost always too high,” he explains.

Hirschorn also notes the benefits of a two-tiered table, as Staten Island uses AFC Industries’ two-tier units that have a front section, which holds the keyboards, and a back section, where the monitors are positioned. Each of the sections can move independently. “Your natural resting gaze spans from straight ahead to downward, and once your eyes go above horizontal, you naturally tilt your head upward, which not ergonomically safe for the neck,” he says.

Harisinghani et al write that users often “twist the neck to look at documents, bend it down to type, and tilt it upward or sideways to look at improperly placed monitors,” leading to tension in the neck muscles, which can cause neck and shoulder pain, and headaches.

Brynjarsdóttir adds that any paper document should be aligned with the top of the monitor screen to avoid unnecessary head and neck movements and refocusing of the eyes.  She adds that “having a monitor that is adjustable in height is essential for visual display terminals to ensure a non-static posture.”

The U.S. optimal viewing angle ranges between ±20° in the horizontal and vertical planes with respect to the display screen based, whereas the Canadian Standards Association Guideline on Office Ergonomics (2000) recommends the range to be 30° from the horizontal and vertical line of sight (0°). Yet, Brynjarsdóttir ackowledges that it is “virtually impossible to get one setting of monitor height that will be beneficial for both the musculoskeletal and visual systems of the body.”

Avoiding the mouse trap

When it comes to input devices, Brynjarsdóttir maintains it’s a reader’s preference—as long as it doesn’t cramp the hand, or bend the wrist too drastically.

Harisinghani et al suggest that an “awkward hand angle causes the nerves running through the wrist to rub against the surrounding ligaments and bone, leading to repetitive stress injuries or trauma disorders, such as carpal tunnel syndrome, and various kinds of tendon inflammation.”

Hirschorn says that devices, such as Countour Design’s RollerMouse Pro, can alleviate some wrist stress via its left-click lock button. “Also, its cylindrical shape allows the radiologist to roll it one direction or another using any of his or her 10 fingers, but not requiring wrist movement.” He adds that this design allows the user to switch hands.

Equipment + the user

Hirschorn notes that depending on specialty or modality images being read, the human interaction varies, and in many ways, the reader can adapt to a particular environment.

Ruess et al conclude that “emphasis must be placed not only on the physical workspace, but also on attempts to modify personnel behavior. Education and training regarding risk factors and preventive measure must be performed to effectively minimize the impact of these disorders on our specialty.”


Is Virtual the Future of the Reading Room?
Brigham and Women’s Hospital (BWH) in Boston is working with IBM to create a virtual Radiology Theatre, where teams of experts can simultaneously review patients’ medical data using a secure web browser.

Data such as CT and MRI scans, EKGs and other exams can be posted on the website and analyzed by a team in real-time. Each physician can talk and be seen through live audio/video web streaming, and have the ability to whiteboard virtually and input information to the patient’s record.  

Francine Jacobson, MD, a thoracic radiologist at BWH, who is spearheading the project, foresees that the technology could be used within a health system and also for physicians outside of their health system’s network. “If I place an image up on the site, I can discuss that image in real-time with a colleague next door with the same ease that I could discuss the study with a physician who resides outside of the U.S.,” she says.

“The software can record what we bring to the theatre, and then help us pull different images from varying modalities—automatically data-mining through the disparate systems, which is typically a manual process. The Theatre brings together both visual and non-visual data to help us make decisions for patient care, present a scene for a patient’s illness—all of which will increase patient safety when that patient’s care is transferred from one provider to one another,” Jacobson says.