Knowledge and use of work‐related musculoskeletal disorder (WRMSD) prevention techniques in the daily practice of final‐year Australian sonography students: A cross‐sectional study

Work‐related musculoskeletal disorders (WRMSD) commonly occur among student and qualified sonographers. While students may be educated about preventative techniques, transfer of this knowledge to practice may not occur. The aim of this study was to investigate the association between the theoretical knowledge final‐year students had of some common WRMSD prevention techniques, and the use of these techniques on clinical placement.


| INTRODUCTION
Work-related musculoskeletal disorders (WRMSD) are painful softtissue conditions caused by the repetitive and often awkward nature of some workplace activities. 1,2 The poor posture and prolonged static body positions sonographers adopt whilst scanning mean they are at risk of developing WRMSD of the shoulders, neck, back and upper extremities with the associated consequences ranging from mild pain to a career ending injury. [2][3][4][5][6][7][8][9][10][11] Despite significant improvements to the ergonomics of ultrasound equipment over the previous two decades, the prevalence of work-related pain among sonographers is currently reported at a rate above 90%. [3][4][5]11,12 A high prevalence rate has similarly been reported among sonography students, which is of concern, given they are just beginning their professional career. 13,14 Ergonomic interventions involve the adjustment of a users' workspace and environment for the prevention of WRMSD, however, these can only be effective if utilised. 15 Recommendations for WRMSD interventions, and for improvements in education of preventative measures are ample in the literature. 8,9,[16][17][18][19] Nevertheless, there is limited evidence to support the habitual use and lasting effectiveness of individual WRMSD prevention techniques, including ergonomically friendly scanning practices. Previous research found students did not make injury prevention a priority in their daily practice, but instead prioritised diagnostic image production above posture and ergonomics. 2 Similarly, WRMSD prevention workshops and multimedia presentations were reported as effective short-term interventions; however, participants often returned to previous detrimental habits within months. 16,17 These findings emphasise the importance of sonographer-specific ergonomics education, the formation of safe scanning behaviours, and the need for the constant reinforcement of ergonomic practices within the student population. 12,14,16,17 Although sonography students may learn some WRMSD prevention techniques during their education, the nature of their work means they are at greater risk of developing a future WRMSD if they do not use these techniques effectively. 12,16,17 The aim of this research was to investigate the theoretical knowledge of a subset of WRMSD prevention techniques that final-year sonography students possess, to investigate the students use of these techniques to prevent future WRMSD. This research will inform on how the injury prevention techniques selected for this study were implemented among this cohort of sonography students. It will also inform on the current ergonomics education students receive, with the aim to increase the use of WRMSD prevention techniques in the clinical practice of future sonography students.

| Study design
An original 10 question survey instrument (Figure 1) was formulated for this quantitative cross-sectional study, and checked for appropriateness and clarity by an academic sonographer. The target population were final-year Australian sonography students. All participants had completed a minimum of 1360 h of clinical placement. They also received generalised WRMSD education during the initial stages of their 4-year university course, however rather F I G U R E 1 Mixed method survey design (quantitative data and opened ended questions) developed for the identified target population than a dedicated theoretical unit to the topic, education was provided as part of multiple units. Sample size was calculated from a population of 81 students, as n = 67, using a confidence level of 95%. 20 CQUniversity Human Research Ethics Committee approval was obtained prior to data collection (approval number 2021-073).
An invitation containing a link to the survey was posted on the university online learning platform and was made available over a 4-week period during the participants' final year of clinical placement. Participation was voluntary, with anonymous data collected via the Qualtrics survey platform. 21 Electronic informed consent was obtained prior to commencement of the survey, with an estimated completion time of less than 10 min. Survey questions reviewed participants' WRMSD education either from their university or on clinical placement. Some common WRMSD prevention techniques and interventions were collated from the literature for investigation; however this list was not exhaustive. 8,9,[16][17][18][19] Participants were asked about their knowledge and use of these techniques, with recall limited to 30 days, and the aim to reduce the level of recall bias. 22 A combination of multiple-choice and checkbox responses were used to generate categorical data with optional open-ended questions. Two openended questions were used to support the categorical data, but due to a low response rate were not used for the development of themes.
Demographic characteristics including the participants' university enrolment status, gender and age were collected. Participants not matching the inclusion criteria were unable to proceed with the survey.   Figure 3. Almost all participants (93.6%, n = 29) reported awareness of the need to adjust both equipment and posture. No association was indicated between the knowledge and use of stretching and exercises either prior to (p = .56), or between scans (p = .10).

| Analysis
No association was indicated between the knowledge and use of an ergonomic aid, such as a cable brace (p = .59). Risk reduction of WRMSD relies on the habitual use of ergonomic scanning practices by both students and qualified sonographers. 10,25 The role initial ergonomics education plays in the development of these habitual practices is significant. 7 In contrast, Bonnuto et al. 13 reported participants had been sufficiently educated on sonographer ergonomics whilst at university however, up to 95% did not consistently adhere to ergonomic recommendations. In addition, the individual ergonomic recommendations were not specified, rather an overall adherence was investigated. 13 Thus, the failure to adhere to guidelines was not linked to any one prevention technique. 13 A similar lack of focus on the specific prevention techniques routinely implemented by sonography students has been demonstrated in other studies. [15][16][17]26 The use of a specialist for personal risk assessment and Pilates may be techniques workplaces could support to reduce WRMSD. Further education around the use of scanning with the alternative hand at university and support of this preventative measure in the workplace may be needed.

| DISCUSSION
Ergonomic aids such as a cable brace or vertical arm support device have previously been recommended for use by sonographers. 10,27 Although participants in this study recognised the use of ergonomic aids as WRMSD prevention techniques, very few (6.5%) incorporated them into their daily practice. Low response to this question may have been partly due to the wording, which specifically asked about use of a cable brace, and did not mention other aids such as an arm support cushion. Previous studies obtained similar results, indicating they are not regularly used despite being widely available and relatively cost effective. 2,15 Although used to lessen the burden on the arm due to a heavy transducer cable, these aids are more useful during certain scans; for example, breast work, which involves the sonographer sitting in one position for an extended period. The survey did not explore the scan types performed by the participants, so it is unknown whether they were performing scans that would have benefited more from use of these aids. Additionally, as some sonographers work out of multiple different examination rooms depending on room availability, they may not have their own aid available at all times. 15 Our study demonstrates a significant association between ergonomic education and knowledge of prevention techniques; however, three widely reported prevention techniques were not well recognised by the participants of this study. 1,3,7,16,18,30 These included varying the scans performed, taking sufficient breaks between patients, and the use of assistance when moving patients. Only 39%-55% of participants reported they were aware of these techniques, and only 23%-45% reported to used them regularly. Scholl and Salisbury 2 linked a busy environment where the culture was to forgo breaks, as well as patient limitations such as obesity and patients who were immobile to a failure to use these techniques. The results from our study may have been impacted by the participants limited ability to control the scans they performed, or the breaks they took, however, this does not explain the poor recognition of these techniques.

Mind-body techniques including meditation, stretches, yoga and
Pilates have previously been explored for the prevention or alleviation of musculoskeletal pain. 16,18,19,26 Although 84%-90% of participants demonstrated familiarity with stretches before and following scanning, no association was established between their knowledge and use. Although a significant association was suggested between the knowledge and use of Pilates, the numbers were small and may not be representative. Mind-body techniques often increase in usage following participation in awareness workshops, but generally decrease again within months. [16][17][18] This highlights the ongoing need to reinforce the benefits of techniques through professional development.
Although the use of risk assessments by professionals such as occupational therapists have previously been suggested, no participant in this study recognised this technique. 16 Risk assessments may not be considered by students, who are instead focused on scanning skills. Alternatively, until injury occurs, this technique is not considered. Research on early intervention by providing professional risk assessments on long term outcomes for students would be worthwhile.

| Limitations
The response rate was greater than 40%, which remains consistent with other similarly related survey studies; however, as the desired sample size of 67 was not attained in this study, the overall reliability and validity of the research is impacted. 13,15,20 Future studies could also include cardiac sonography students in order to achieve the sample size. Almost 90% of participants in this study were female, which is not unexpected given 80% of registered sonographers in Australia are female. 31 Another limitation of this research is the survey questions created for this research had not been previously validated, and therefore the clarity of the questions had not been tested. The potential for responder bias exists due to participants who may have been motivated to participate by a personal history of work-related pain or injury. 22 This may have led to the overrepresentation of participants who knew of and used these prevention techniques. 22 Survey data is limited by the risk of over-or under-reporting the knowl-

| CONCLUSION
This study has demonstrated students educated around injury prevention will retain knowledge of some key WRMSD prevention techniques.
Further to this, they will implement some of those techniques during practical scanning at the commencement of their career. Select prevention techniques consistently used by most participants surveyed included the adjustment of both ergonomic equipment and posture, including the examination couch, keyboard, screen monitor and chair, as well as the reduction of arm abduction angle. Other prevention techniques recognised, but not consistently used by students included the use of ergonomic aids and stretching or exercises before and after scanning.
Through exploration of sonography students' use of WRMSD prevention techniques on clinical placement, both university academic staff and clinical educators can assess whether the education they provide is likely to be successful in the formation of long-term healthy scanning habits. Clinical supervisors should also be encouraged to provide regular feedback on the students' ergonomic habits whilst on clinical placement.
This study may form the basis for future longitudinal research into the effectiveness of specific prevention techniques among students, as well as research into the WRMSD prevention practices routinely used by newly qualified sonographers. Future research is encouraged to focus on the effectiveness of specific preventative techniques, and to investigate if students are more likely to make ergonomic adjustments for specific ultrasound examination types to reduce the high prevalence of WRMSD among sonographers and prevent injury to students.