The Deep Abdominal Transducer (DAX): See deeper with less force
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White paper The Deep Abdominal transducer (DAX): See deeper with less force Balancing the scale between image quality and injury risk when scanning high BMI patients Carolyn T. Coffin, MPH, RDMS, RDCS, RVT Ergonomics consultant, Sound Ergonomics, LLC Anthony Tardi, RDMS, RVT; Michele Baillie, B. Sc, RDMS, RDCS Siemens Medical Solutions USA, Inc., Ultrasound siemens-healthineers.com/ultrasound SIEMENS Healthineers White paper · DAX The Deep Abdominal transducer (DAX): See deeper with less force Balancing the scale between image quality and injury risk when scanning high BMI patients Contents Introduction 3 By the numbers: Sonography and Work Related Musculoskeletal Disorders 4 DAX (Deep Abdominal Transducer): Innovation and injury prevention 6 Conclusion 7 2 siemens-healthineers.com/ultrasound DAX · White paper Introduction All medical imaging is a balance – a balance between transducer pressure tend to increase. The increased obtaining a high-quality, diagnostic image, with that transducer push force, coupled with long periods of of safe technology usage so as not to produce any static arm or body positions, can contribute to increased biological effects on the body during the imaging operator injury risk. With obesity on the rise, high body process. Ultrasound adds yet another layer to this mass index (BMI) exam conditions are being encountered delicate equilibrium in the form of operator safety. more and more often in ultrasound on a daily basis, thus It is no secret that the world obesity rate is increasing. propagating an injury-ripe environment [Fig 1]. Studies According to the World Health Organization (WHO), have shown that work related musculoskeletal disorders 1.9 billion adults 18 years and older, are overweight. (WRMSDs) develop gradually over a period of time from Of this number, 650 million people are considered repeated exposure; WRMSDs are the most frequently obese – a number that has tripled since 19751. Large reported causes of restricted or lost work time.2 body habitus patients affect image quality and present To combat these risks, Siemens Healthineers has looked a challenge to all imaging modalities; ultrasound, toward innovation as the key to improving and/or however, is the most affected. The increased subcuta- customizing the main tool that ultrasound imaging neous fat and adipose tissue encountered with these uses for every exam – the transducer. Redefining patients attenuates and scatters the ultrasound beam, this tool at an imaging and ergonomic level to better resulting in image degradation. This loss of image accommodate the difficulties encountered with quality is further impacted with increasing depth. As high-BMI patient scanning, will ultimately benefit the ultrasound users struggle to obtain diagnostic images end-user by reducing the risk of injury during these on overweight and obese patients, exam time and exams. 650 million IL . world-wide1 Image quality Risk of injury Obesity trend Figure 1: As the obesity trend continues to climb on a global scale, the impact to ultrasound is two-fold. Not only is the sonographic image quality decreased in overweight and obese patients, the ultrasound workforce is at an increased risk of injury while obtaining these images. siemens-healthineers.com/ultrasound 3 White paper · DAX Force is the exertion of Awkward postures physical effort applied by a body occur when body parts are part to perform a specific task positioned away from their such as the arm or shoulder neutral position. These pressing downward to perform postures can put stress on an abdominal scan2 associated joints and muscles.2 Repetition is performing Contact pressure Exessive reaching and/or the same or similar tasks is sustained contact between abduction of the arm along with repeatedly, either continually a body part and an external neck extension and rotation should or frequently for an extended object, such as a bed or be avoided during scanning. period of time without stretcher2 Longer times spent in non-neutral adequate recovery time2 positions increase risk potential.2 Figure 2: The primary physical risk types that can be encountered in sonography practice – force (transducer push), repetition, contact pressure, awkward posture/positions, and excessive reaching or rotation.2 Sonographers experience some or all of these risks on a daily basis in an effort to visualize the region of interest (ROI) or due to the inability to adjust equipment. By the numbers: Sonography and Work Related Musculoskeletal Disorders Work related musculoskeletal disorders (WRMSDs) than 30°, intramuscular pressure on the blood vessels are conditions that are caused and/or aggravated by of the rotator cuff muscles and the deltoid muscle workplace activities. These types of injuries affect the can reduce flow to these muscles and their tendons. muscles, nerves, ligaments, and tendons and can result Prolonged muscle contractions caused by static arm in (but are not limited) to strains, sprains, tears, and positions, whether from overreaching or arm abduction, localized body pain, such as in the back or neck. In the can overload the muscles fibers leading to fatigue and diagnostic medical sonography world, there is a high injury 4, 5 . Excessive reaching can be reduced by moving incidence of WRMSDs among sonographers due to the patient closer and having the ultrasound system prolonged static postures of the arm, such as excessive control panel close to the sonographer. Arm abduction abduction and extended reaching3, during the scanning while scanning can be reduced by lowering the exam process. Contact pressure with an external object, table and/or raising the exam room chair. awkward and sustained postures coupled with repetition during the Sonographer’s workday can all contribute to Although equipment position changes and modifications an WRMSD [Fig 2]. of work postures can lead to a reduction in injury risk, one factor over which sonographers have no control The shoulder is a very flexible joint that allows us to is patient obesity. In an effort to provide images of achieve many different positions with our arms, however diagnostic quality for the obese patient, sonographers the price for this flexibility is a joint that is fairly unstable. feel compelled to exert excessive transducer pressure Overreaching and excessive arm abduction force the while scanning. This pressure, added to a shoulder that shoulder muscles to support the arm while it is in these is already compromised by static posture, can result in a non-neutral postures. When the arm is abducted more rapid onset of pain and muscle fatigue. This additional 4 siemens-healthineers.com/ultrasound DAX · White paper 39% 90% of sonographers report of sonographers experience patient obesity as the symptoms of Work-Related 90% most significant barrier Muscoloskeletal Disorders reported to practicing ergonomic (WRMSDs) 1 shoulder pain7 scanning techniques3 69% 20% reported low of symptomatic back pain7 sonographers suffer career-ending injuries6 54% reported hand and wrist symptoms7 10 years 72% 3 years 45% 6 months 15% Sonographers with WRMSD symptoms8 Figure 3: Sonography is a physically challenging imaging modality made even more so with the increase in patient size seen globally. In an analysis of occupational factors related to shoulder discomfort, 39% of sonographers cite patient obesity as the most significant barrier for ergonomic scanning. Shoulder pain, back pain and wrist symptoms can all result from poor ergonomic scanning. Sonographers have reported WRMSDs as early as 6 months into their career, and for some, these injuries can be career-ending. The impact of these occupational hazards can not only affect the user physically, it can also intensity workforce shortages and ultimately challenge patient care delivery resources. force required by a traditional transducer, perpetuated • 20% of those who were symptomatic suffered throughout a sonographer’s career, will have a career-ending injuries.6 cumulative negative impact on the arm and shoulder • muscles. When this force is added to the muscle firing 90% of sonographers reported shoulder pain, with required to maintain arm abduction or excessive 69% reporting low back pain and 54% reporting reach to the patient, the risk for injury could increase work-related symptoms of the hand and wrist.7 significantly. As the obese population continues to • WRMSD symptoms caused by performing ultrasound grow, injuries related to transducer pressure will also exams occur as early as six months from the start of continue to grow. employment (15% incidence) to 45% after three years, Aside from the lasting personal toll of an WRMSD and as high as 72% after ten years of employment.8 injury, an injured sonographer can intensify workforce According to a 2017 study on ergonomic scanning shortages, which can cause unexpected operational techniques for sonographers, 39.3% of sonographers and financial challenges for an ultrasound department interviewed reported that patient obesity was the most or medical institution. significant barrier to practicing ergonomic scanning Recent studies have shown some troubling numbers techniques.9 With approximately 650 million people that should be of concern to both sonographers and worldwide being considered overweight or obese, the employers [Fig 3]: problem of large BMI patients is not going away, and it is clear that a new and intelligent solution is needed • 90% of clinical sonographers experience symptoms to help combat these WRMSDs. of WRMSD.2 siemens-healthineers.com/ultrasound 5 White paper · DAX 5C1 DAX Abdomen Abdomen TIB:0.55 TIB:0.59 TIC:3.39 TIC:2.91 TIS:0.55 TIS:0.59 MI:1.07 MI:1.14 21fps 19fps 98% 95% 2D H POR H Low 2dB/DR60 5dB/DR60 DAX 17cm 15cm Figure 4: Abdominal aorta with conventional transducer exerting Figure 5: Abdominal aorta with DAX transducer exerting an average an average of 1.01 pounds of force. of 0.3 pounds of force, 70% less than conventional transducer technology. DAX (Deep Abdominal Transducer): Innovation and injury prevention Transducer development focuses mainly on two of transducer pressure exerted while scanning a large parameters: optimizing image quality and reducing the person. Similar images of the abdominal aorta were risk for work-related musculoskeletal disorders (WRMSD) obtained with a conventional transducer and with the in sonographers. An innovative solution for reducing DAX. The force exerted with the conventional transducer the need to exert excessive transducer pressure is was an average of 4.5N or 1.01 pound-force (pounds of the Deep Abdominal Transducer (DAX) developed for force) [Fig 4]. The force exerted with the DAX transducer the ACUSON Sequoia with BioAcoustic technology was an average of 1.3N or 0.3 pound-force (pound of by Siemens Healthineers. DAX has the capability to force) [Fig 5]. When compared, the DAX transducer image at diagnostic depths of up to 40 cm, whilst also resulted in a 70% reduction in push force over that of reducing the need for excessive transducer pressure. the conventional ultrasound transducer [Fig 6]. Since To demonstrate the penetrability of this new transducer, WRMSDs develop over time, this additional force spread an analog pull-push force gauge by M&A Instruments, over the span of a sonographer’s career, will have a Inc., was used to provide a close estimate of the amount cumulative negative impact on the arm and shoulder muscles. 6 siemens-healthineers.com/ultrasound DAX · White paper DAXACUSON Image quality Risk of injury Figure 7: DAX helps balance the scale between image quality and injury prevention when scanning the high BMI patient. Conclusion The incidence of WRMSD in ultrasound is on the rise along with an increase in the overweight and obese population. The causes of WRMSD in sonographers are multifactorial, necessitating a variety of solutions to reduce the risks. These solutions include changes in the individual’s work postures and patient scheduling, as 70% less well as replacing older equipment with those with the downward force most current ergonomic features. The ACUSON Sequoia system and the innovative DAX transducer have these desired ergonomic features. DAXACUSON Designed for superior usability, the ACUSON Sequoia system has incorporated the latest industrial design and imaging architecture ideals along with industry recommendations and best practices to optimize the Figure 6: When compared to a conventional transducer, entire ergonomic experience. This intuitive design goes the DAX showed a 70% reduction in push-force when even further with the addition of the DAX transducer, imaging a high BMI patient.10 an industry-exclusive solution, thereby giving the user a more innovative tool for imaging obese or high BMI patients [Fig 7]. With its improved penetrability and reduced scanning force, the DAX transducer helps to improve diagnostic confidence whist simultaneously mitigating the risk of injury to the user. siemens-healthineers.com/ultrasound 7 Standalone clinical images may have been cropped References to better visualize pathology. The products/features mentioned in this document may not be commercially 1 World Health Organization statistics on obesity and overweight available in all countries. Due to regulatory reasons, https://www.who.int/news-room/fact-sheets/detail/obesity-and- overweight their future availability cannot be guaranteed. 2 Murphey, Susan. Work Related Musculoskeletal Disorders in Please contact your local Siemens Healthineers Sonography. Society of Diagnostic Medical Sonography organization for further details. Whitepaper 2018 3 ACUSON Sequoia is a trademark of Siemens Medical Roll SC, Evans KD, Hutmire CD, Baker JP. An analysis of occupational factors related to shoulder discomfort in diagnostic Solutions USA, Inc. medical sonographers and vascular technologists. Work. 012;42(3):355-365. 4 Garg A,Hegmann K, Kapellusch J. Short-Cycle overhead work At Siemens Healthineers, our mission is to enable and shoulder girdle muscle fatigue. Int. J. Ind. Ergon. 2006; healthcare providers to increase value by empowering 36:581-597. them on their journey towards expanding precision 5 Village J,Trask C. Ergonomic analysis of postural and muscular medicine, transforming care delivery, and improving loads to diagnostic sonographers. Int. J. Ind. Ergono. 2007; patient experience, all enabled by digitalizing healthcare. 37:781-789. 6 An estimated five million patients worldwide everyday Pike I, Russo A, Berokwitz J, Baker J, Lessoway V. The Prevalence of Musculoskeletal Disorders Among Diagnostic Medical benefit from our innovative technologies and services Sonography. Available at http://www.sdms.org/?ID=19. Accessed in the areas of diagnostic and therapeutic imaging, Aug 2017. laboratory diagnostics and molecular medicine as well 7 Evans K, Roll S, Baker J. Work-Related Musculoskeletal Disorders as digital health and enterprise services. (WRMSD) Among Registered Diagnostic Medical Sonographers We’re a leading medical technology company with over and Vascular Technologists: A Representative Sample. J. Diagnostic Med. Sonogr. 2009;25(6):287-299. 120 years of experience and 18,500 patents globally. 8 With over 50,000 employees in more than 70 countries, Muir M, Hrynkow P, Chase R, Boyce D, Mclean D. The Nature, Cause, and Extent of Occupational Musculoskeletal Injuries we’ll continue to innovate and shape the future of among Sonographers: Recommendations for Treatment and healthcare. Prevention. J. Diagnostic Med. Sonogr. 2004;20(5):317-325 9 Scholl, C., and Salisbury, H. (2017). Barriers to Performing Ergonomic Scanning Techniques for Sonographers. J. Diagnostic Med. Sonogr. 33, 406–411. 10 Data on file with Siemens Healthineers. Study performed by Sound Ergonomics, LLC Siemens Healthineers Headquarters Legal Manufacturer Siemens Healthcare GmbH Siemens Medical Solutions USA, Inc. Henkestr. 127 Ultrasound 91052 Erlangen, Germany 22010 S.E. 51st Street Phone: +49 9131 84-0 Issaquah, WA 98029, USA siemens-healthineers.com Phone: 1-888-826-9702 siemens-healthineers.com/ultrasound Published by Siemens Medical Solutions USA, Inc. · HOOD05162003153882 · 9283 0121 online © Siemens Medical Solutions USA, Inc., 2021