Work-Related Musculoskeletal Disorders among the Female Cath Lab Population By Kristen Detton Carter, BS, ATC Deborah Weber, MBA A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 Female WMSDs 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Kristen Detton Carter Deborah Weber This thesis has been read by each member of the following supervisory committee and, by majority vote, found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist Female WMSDs 3 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Kristen Detton Carter Deborah Weber This thesis has been read by each member of the student research agenda committee and, by majority vote, found to be satisfactory. Date December 16, 2022 ____________________________________ Kristen Detton Carter December 16, 2022 ____________________________________ Deborah Weber Female WMSDs 4 Abstract The current body of literature has found a high correlation between work-related musculoskeletal disorders (WMSDs) and time spent in the cardiac catheterization lab (cath lab); however, there is a meager amount of research directed at the female population.1 It has been shown that in other work environments, there is a difference in female orthopedic injuries vs. male orthopedic injuries. 1, 2, 3 This quantitative study aimed to determine the prevalence of musculoskeletal disorders among cath lab professionals and further identify the variability in WMSDs among male and female professionals. The Nordic Musculoskeletal Questionnaire is a self-reported work-related musculoskeletal injury questionnaire. The survey was distributed through social media to reach a representative sample of US cath lab professionals. 531 individuals responded to the questionnaire, and 394 participants were eligible to participate in the study. Musculoskeletal symptoms were experienced by 99% percent of the participants at least once in the last twelve months. 84% of the total participants were female and reported that their most common area of pain was the lower back and cervical regions. The remaining 15 % were male and reported that their most common pain area was the lower back and lower extremity regions. The largest group, 322 (82%), stated they’d experienced lower back pain in the last 12 months. Several gender-based differences exist among cath lab professionals. Differentiation between gender disorders can be related to size, ergonomics of the individuals in the cath lab, positioning of the equipment, and ergonomic training and education. Further research is needed to address the ergonomic hurdles female cath lab professionals face and future directions cath labs can take to educate and train female/all professionals to decrease musculoskeletal disorders, retain a healthy workforce, and attract new professionals. Female WMSDs 5 Acknowledgments We want to thank the men and women who participated in this study and Professor Chris Steelman for his help in conducting the research and compiling data. Female WMSDs 6 Table of Contents Chapter 1: Introduction ............................................................................................................... 10 Background ........................................................................................................................................... 11 Statement of the Problem ..................................................................................................................... 12 Purpose of the Study ............................................................................................................................. 13 Research Questions ............................................................................................................................... 14 Significance of the Study ...................................................................................................................... 15 Definition of Key Terms ....................................................................................................................... 15 Summary ................................................................................................................................................ 17 Chapter 2: Literature Review ...................................................................................................... 19 Documentation ...................................................................................................................................... 19 Work-Related Musculoskeletal Disorders (WMSD) Prevalence and Risk Factors ........................ 21 Females in the Cath Lab ....................................................................................................................... 23 Ergonomics ............................................................................................................................................ 26 Future Directions and Recommendations .......................................................................................... 29 Summary ................................................................................................................................................ 32 Chapter 3: Research Methods ..................................................................................................... 33 Research Methods and Design(s) ......................................................................................................... 33 Population .............................................................................................................................................. 34 Sample .................................................................................................................................................... 35 Materials/Instruments/Data Collection, Processing, and Analysis ................................................... 35 Operational Definition of Variables .................................................................................................... 37 Assumptions........................................................................................................................................... 38 Limitations ............................................................................................................................................. 38 Delimitations .......................................................................................................................................... 39 Ethical Assurances ................................................................................................................................ 39 Summary ................................................................................................................................................ 39 Chapter 4: Findings ..................................................................................................................... 41 Results .................................................................................................................................................... 41 Participant Characteristics .................................................................................................................................. 41 Prevalence of Musculoskeletal Injury ................................................................................................................. 45 Physical Factors Influencing WMSDs ................................................................................................................ 48 Manifestation of WMSDs by Gender ................................................................................................................. 51 Evaluation of Findings .......................................................................................................................... 52 Summary ................................................................................................................................................ 53 Female WMSDs 7 Chapter 5: Implications, Recommendations, and Conclusions ................................................. 54 Implications ........................................................................................................................................... 54 Prevalence of Musculoskeletal Injury ................................................................................................................. 54 Physical Factors Influencing WMSDs ................................................................................................................ 54 Manifestation of WMSDs by Gender ................................................................................................................. 55 Recommendations ................................................................................................................................. 55 Conclusions ............................................................................................................................................ 56 References .................................................................................................................................... 58 Appendices .................................................................................................................................... 62 Appendix A: Informed Consent .......................................................................................................... 62 Female WMSDs 8 List of Tables Table 1: Demographic Information ............................................................................................................. 42 Table 2: Specialty Within the Cath Lab ...................................................................................................... 43 Table 3: Credentials .................................................................................................................................... 44 Table 4: WMSDs Prevalence Reported in the Last 12 Months .................................................................. 46 Table 5: WMSDs Prevalence Reported in the Last 12 Months Preventing Normal Work (at home or away from home).................................................................................................................................................. 47 Table 6: WMSDs Prevalence Reported in the Last 7 Days ........................................................................ 48 Table 7: Years Working in the Cath Lab .................................................................................................... 48 Table 8: Working Hours per Week ............................................................................................................. 49 Table 9: Hours a Week Wearing Protective Garments (Lead) ................................................................... 50 Table 10: Type of Protective Garment (Lead) ............................................................................................ 51 Table 11: Customization of Protective Garments (Lead) Available in the Cath Lab ................................. 51 Female WMSDs 9 List of Figures Figure 1: Nordic Musculoskeletal Questionnaire 37 .................................... Error! Bookmark not defined. Figure 2: Participant’s Age Ranges ............................................................................................................ 42 Figure 3: Participant's Heights and Weights ............................................................................................... 43 Figure 4: Specialty within the Cath Lab ..................................................................................................... 44 Figure 5: Credentials ................................................................................................................................... 45 Figure 6: Total Number of Positive Responses to WMSDs in the Last 12 Months ................................... 46 Figure 7: WMSDs Prevalence Reported in the Last 12 Months ................................................................. 47 Figure 8: Years Working in the Cath Lab ................................................................................................... 49 Figure 9: Working Hours per Week ............................................................................................................ 50 Figure 10: Hours Wearing Protective Garment (Lead) per Week .............................................................. 51 Female WMSDs 10 Chapter 1: Introduction The current body of literature has found a high correlation between work-related musculoskeletal disorders and time spent in the cath lab; however, there is a meager amount of research directed at the female population. 1 The disparities in gender-based injuries remain grossly under-researched. Gender-based research is an increasingly important topic in the medical field. Most research focuses on the generic, non-gendered cath lab professional. The gender research gap affects female practitioners' professional and personal lives. 4 It has been shown in other professional research areas that there is a difference in female orthopedic injuries vs. male orthopedic injuries. 1, 2, 3, 5 Correlating work-related musculoskeletal disorders analysis into the cath lab is logical in furthering the data directed at the female healthcare professional. The CDC defines work-related musculoskeletal disorders (WMSDs) as conditions in which the work environment and the individual’s work performance contribute significantly to the state of injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs. These conditions are made worse or persist longer due to work conditions. In 2020, the Bureau of Labor Statistics reported that the injury rate among healthcare workers increased by 40.1 percent; however, the overall injury and illness rate in all other industries has remained the same or decreased. 6 Within the healthcare field, nurses and technologists reported the most injuries and diseases within the healthcare field. 7 In addition to this data, women are particularly plagued by injury. In 2020, the bureau reported that days away from work cases for women in private industry increased by 68.0 percent. 6 Combining this data, we can conclude that the overall debilitating rate of injury and illness for women in the healthcare industry continues to Female WMSDs 11 grow. Yet, the literature and research directed at women in the workplace lag far behind the data of their male counterparts. 1 The prevalence of WMSDs and ergonomic hurdles female cath lab professionals face vary from their male counterparts. 1 We expect our findings to be consistent with prior research, indicating work-related musculoskeletal disorders are pervasive in the cath lab. 1, 2, 3, 5 We hope our results further identify the variability in WMSDs among male and female professionals. Work ergonomics and contributing environmental factors affecting the prevalence of orthopedic pain for professionals are also addressed. By identifying risk factors and common WMSDs among female cath lab professionals, future directions can address ways to minimize WMSDs, retain current female professionals by keeping them healthy, and attract new female professionals to the field. Background In 2019 the Association of American Colleges (AAMC) reported that more women (50.5%) were enrolled in medical school than men (49.5%), and this continues to be a trend. 8, 9 Professionals in the healthcare industry are highly predisposed to work-related musculoskeletal disorders. 7 The professionals working in the cath lab are particularly interesting as this field continues to grow, and data show a disparity in recruiting females to the cath lab. 10 Hence, the authors propose a need for safety standards directed toward females to help minimize the risk of such injuries. Barnard et al. identified only 11 articles written before 2022 addressing female WMSDs in the interventional laboratory. Of those articles, few women participated in the research, with a representation of female interventionists at an average of 25.7% of total respondents. Minimal Female WMSDs 12 data was collected on the effects of WRMD on females; however, they did recognize that 72% of female interventionalists had WRMD, and most reported upper extremity pain. 1 This article highlights the importance of conducting further analysis of the female conditions in the cath lab as a practical responsibility of researchers in the future. Statement of the Problem Working in a Cath lab entails many occupational risk factors. Radiation exposure and wearing protective lead aprons have been the focus of most research related to occupational risk factors of personnel in the cath lab; however, the WMSDs are a recent emphasis. 3, 11, 12 When radiation exposure, wearing protective lead aprons, and WMSDs risk factors are combined, the injury rate is higher than when each risk factor is isolated. 2 Orme et al.’s research surveyed 1,543 employees at various locations, where 67% reported working with radiation. The employees who worked with radiation were more likely to report musculoskeletal pain than other healthcare employees. When researchers adjusted for age, sex, BMI, pre-existing musculoskeletal injuries, years in the profession, and job description, technicians reported the highest rates of musculoskeletal pain, followed by nurses and physicians. 2, 3 The CDC defines WMSD as injuries including muscle pain, nerves, joints, spinal disc, back, and neck. 2 The increase in orthopedic injuries and musculoskeletal disorders has become a concern for researchers and health professionals. 9 Work conditions in the cath lab can contribute to severe musculoskeletal disorders. Asghari et al. investigated musculoskeletal pain related to work conditions and postures. 13 The study found a high prevalence of musculoskeletal pain, particularly in the low back, neck, and ankle pain. In a recent study, Evans et al. surveyed 635 AART-credentialed radiographers about Female WMSDs 13 musculoskeletal symptoms. The findings revealed that most (81%) survey participants reported orthopedic injuries or musculoskeletal pain during procedures. 14 Scheidt et al. further explored the effects of wearing lead aprons in relation to WMSDs. They found that wearing lead aprons were correlated with back pain, even among seemingly young and healthy doctors, and attributed to a shorter career. 15 The current discussion on the issue of WMSD has not addressed risk factors and symptoms related to female professionals in the Cath lab. The lack of female representation in such studies necessitates further research. For instance, A meta-analysis by Barnard et al. discovered only 11 studies on PubMed and EBSCOhost databases addressing female WMSD.1 The representation of female interventionists is only at an average of 25.7% of respondents.1 This under-representation of females in relevant research yields a lack of understanding of female workers’ risk factors contributing to WMSM. This also leads to a lack of knowledge of musculoskeletal symptoms and orthopedic pain that females working in the Cath lab encounter. This research aims to address this problem by conducting a study that specifically examines the prevalence of WMSD for female cath lab professionals. The following research question guides this study to handle such a problem facing female Cath lab workers. Purpose of the Study This quantitative study explores self-reported musculoskeletal symptoms in female cath lab professionals. The information gathered from anonymized demographics and responses from the Nordic Musculoskeletal Questionnaire (NMQ) was designed to capture several critical dimensions of females in the cath lab and additional comparative analysis of males in the cath Female WMSDs 14 lab. One of the key questions was what physical factors influence self-reported work-related musculoskeletal injuries among a representative sample of US female cath lab professionals. A request for participation was sent out via social media to cath lab professionals. It linked an online Qualtrics survey that included demographic questions and used the NMQ to inquire about their musculoskeletal symptoms and levels of exposure to risk factors. The target population was female cath lab professionals 18 and older, with additional male responses used for comparison purposes. The Weber State University Institutional Review Board approved this research project. Dependent variables include: • Musculoskeletal disorders • Fit and customization of lead aprons • Hours a day spent wearing lead aprons • Size and body type of patient. Independent variables include: • Gender • Ergonomics of working postures • Need for radiation protection and wearing lead aprons while working in a cath lab Research Questions Q1. What are the most common work-related musculoskeletal disorders (WMSDs) in female cath lab professionals? Q2. What are work-related musculoskeletal disorders (WMSDs) commonly found in the cath lab among female cath lab professionals? Female WMSDs 15 Q3. What physical factors influence self-reported work-related musculoskeletal injuries (WMSDs) among a representative sample of US female cath lab professionals? Q4. How do work-related musculoskeletal disorders (WMSDs) manifest differently in males vs. females? Hypothesis: H1 We hypothesize varying musculoskeletal disorders associated with working in the cath lab between females and males. Significance of the Study Identifying common work-related musculoskeletal disorders (WMSDs) among female cath lab professionals can further our understanding of the risk factors and the variability in WMSDs among male and female cath lab professionals. 2, 12 The differentiation between gender disorders can be related to size, ergonomics of the individuals in the cath lab, positioning of the equipment, and ergonomic training and education. 4, 13 Understanding initial mechanisms of injury can lead to evidence-based interventions to decrease WMSDs. This research further identifies the relationship between working conditions and risk factors leading to WMSDs to aid policymakers in establishing safety protocols within the cath lab. Preventing WMSDs from occurring will enable female cath lab professionals to enter and stay healthy throughout their careers. Definition of Key Terms Allied Health Professional. A “non-nurse” or “non-physician” healthcare professional is involved in diagnostic and operational healthcare.18 Female WMSDs 16 Cardiac Catheterization Laboratory/Cath Lab/ CCL. A procedure room, usually within a hospital, where cardiac professionals perform minimally invasive percutaneous procedures. Procedures utilize catheters, imaging equipment, and medication to obtain diagnostic cardiac information or repair blocked arteries and structural abnormalities without surgery. 16 Cath Lab Professional. For this study, “cath lab professionals,” “interventionalists,” “technologists,” “allied health professionals,” and “nurses” include anyone wearing protective gear (lead), operating fluoroscopy equipment such as tables and c-arms and administering radiopaque contrast media for purposes of minimally invasive interventional procedures. Electrophysiology Specialty. Electrophysiology is the branch of physiology that studies the electrical properties of biological cells and tissues. It involves measurements of voltage changes, electric current, or manipulations on various scales, from single ion channel proteins to whole organs like the heart. Ergonomics. The science of fitting workplace conditions and job demands to the capability of the working population.2,14 Interventionalists. Doctors specialize in treating cardiovascular disease via catheters to provide minimally invasive interventional procedures.15 Nurse. Assists the physician in the performance of cardiac interventional procedures.17 Neurology Specialty. A specialty focused on cranial and spinal procedures, including aneurysms, arteriovenous malformations, emergency stroke, and carotid artery issues. 17 Female WMSDs 17 Pediatric Specialty. A specialty focused on treating children’s congenital, interventional, or diagnostic procedures, including valve stenosis, septal defects, patent ductus arteriosus, pulmonary atresia, coarctation of the aorta, and arrhythmias. 18 Peripheral Specialty. A specialty focused on blood flow to the legs or arms. 17 Protective Garment (Lead Apron). The primary protective garment is worn during fluoroscopy procedures. 19 Structural Heart Specialty. A specialty focused on valves, walls, chambers, or muscles. These may include procedures related to cardiomyopathies, congenital heart disorders, and heart valve diseases. 20 Technologist. Assists the physician in the performance of cardiac interventional procedures.16 Work-Related Musculoskeletal Disorders (WMSD). Musculoskeletal disorders are injuries or disorders involving the muscles, nerves, tendons, joints, cartilage, and spinal discs caused by conditions where work contributes to the injury significantly through the environment or performance (of tasks).2 Summary More information is needed on WMSDs directed at the female cath lab professional population, even though female radiographers and interventionists have well-documented WMSDs. 21 The purpose of this study, through examining work ergonomics, prior literature, past survey responses, and the use of an inclusive, quantitative survey aimed at obtaining relevant Female WMSDs 18 information from affected professionals in the cath lab environment, we hope to identify risk factors and common WMSD’s of female cath lab professionals, and assist future directions which minimize WMSD’s, retain current professionals, and attract new female professionals to the field. For this study, “cath lab professionals,” “interventionalists,” “technologists,” “allied health professionals,” and “nurses” include anyone wearing protective gear (lead), operating fluoroscopy equipment such as tables and c-arms and administering radiopaque contrast media for purposes of minimally invasive interventional procedures. Female WMSDs 19 Chapter 2: Literature Review The current body of literature has found a high correlation between work-related musculoskeletal disorders and time spent in the cath lab; however, there is a meager amount of research directed at the female population.1 The prevalence of WMSDs and ergonomic hurdles female cath lab professionals face vary from their male counterparts. By identifying ergonomic risk factors and common WMSDs among female cath lab professionals, future directions can address minimizing WMSDs. Documentation Initially, the research began with an interest in the known adverse effects of work-related musculoskeletal disorders in the cardiac catheterization laboratory. “Orthopedic,” “injury,” “interventional laboratory/cath lab,” and “healthcare” were our primary search terms used. Most articles focused on lead aprons, decreasing radiation exposure, and the orthopedic repercussions of current safety procedures. The search produced high-quality reports documenting general safety protocols and efforts to minimize orthopedic disorders. We expanded the search to include similar vocabulary on our four basic search terms and retrieved identical results. The expanded search produced one article by Barnard et al., which found a gap in the research. Their paper, Ergonomics and Work-Related Musculoskeletal Disorders: Characteristics Among Female Interventionalists, reported a surprising lack of research focused on the challenges of female interventionalists. Barnard et al. found only 11 articles mentioning female interventionalists; of those articles, there was poor female representation.1 Female WMSDs 20 Poor female representation inspired our secondary search criteria focusing on “female,” “interventional laboratory/cath lab,” and “WMSDs.” The additional research revealed the lack of pertinent areas of current research and significant knowledge gaps. Scholarly databases searched: (i.e., PubMed, Google Scholar, Science Direct, NCBI, MEDLINE, Biomed Central, Research Gate, One Search powered by Stewart Library) from November 2021 through Fall 2022. The nature and sources of references met the following inclusion criteria. Our search was limited to published peer-reviewed articles and abstracts. In addition to searching for relevant articles in databases, the exploration of bibliographies of relevant articles and websites of relevant organizations was also incorporated. Only publications written in English were included in the investigation and subsequent review, and articles published after 2004 were included. Our study population is adults (over 18 years of age) who have worked in the cath laboratory. The population includes women working as cath lab professionals and males for comparison purposes. Several related questions drove the review of the literature: ● What are work-related musculoskeletal disorders (WMSD) commonly found in the cath lab? ● How are WMSDs manifested differently in males vs. females? ● How are current safety protocols affecting WMSDs? ● What are the most common WMSDs in females and the most common mechanism of injury? Female WMSDs 21 ● How are the ergonomics of females affected by the equipment set-up in the cath lab, typically adjusted for male coworkers? ● How can the work environment be adapted for female cath lab professionals? ● What improvements can be made in the cath lab to prevent female WMSDs? Work-Related Musculoskeletal Disorders (WMSD) Prevalence and Risk Factors Researchers have examined work-related factors for developing musculoskeletal disorders and orthopedic injuries for years from different perspectives. In 1999, Carayon et al.’s study proposed several theories linking job stress to WMSDs. They focused on physiological, psychological, and behavioral factors influencing injuries and disorders in the work environment. Psychosocial work factors, including anxiety and pressure, can affect physical symptoms and must be considered when discussing physical pain. 22 Carayon referenced Smith and Carayon-Sainfort’s work in 1989 as a model for analyzing multiple work-related factors that contribute to WMSDs. Their framework incorporates job balance by including psychosocial triggers for stress and anxiety; it encourages a holistic approach to work satisfaction and safety when designing work environments. 23 Another early investigation of this issue was carried out by Wright and Witt, who found out that about 77% of the American Society Radiologic Technologists (ASRT) sample reported back pain. 24 Examining this issue developed over decades, researchers employed mixed methods to investigate work-related musculoskeletal disorders, including surveys, observations, and biomechanical assessment. Anderson et al. conducted a systematic review of all the articles on allied health professionals’ WMSDs in 2016. Their analysis of research for allied health professionals was an overall assessment of low-quality studies. They found a significant variation in outcomes, with Female WMSDs 22 prevalence rates of injury anywhere from 28% to 96% in one year. Follow-up and further quality research were highly recommended for all allied health professionals exhibiting WMSDs. 25 Currently, the CDC has linked numerous work factors to musculoskeletal disorders. 26 Work-related Musculoskeletal Disorders are among the most reported injuries for interventionists working in Cath Labs. 14, 27, 25, 28 A cross-section study by Yizengaw et al. involving 934 participants showed that WMSDs constitute a significant problem affecting healthcare providers. Many participants confirmed lower back pains. 12 Asghari et al. examined musculoskeletal pain related to job characteristics and working postures of interventional nurses. 29 In their study, nurses, completed multiple surveys: the Nordic Musculoskeletal Questionnaire (NMQ), the QWL questionnaire, and direct observations of working postures. The study found a high prevalence of musculoskeletal pain and upper back, neck, and ankle pain. Reed et al. also surveyed nurses over nine weeks. Most musculoskeletal disorders were compiled by body region. This study found that MSDs affecting the foot/ankle region were common among nurses, resulting in limited physical activity. 30 Smilowitz et al. highlighted the occupational hazards of interventional cardiologist’s procedures. It was found that cardiologists reported more back and neck pain than other groups of physicians. 31 They highlighted the posture required for long hours with the rising volume of interventional cases. Evans et al. explored musculoskeletal symptoms in radiographers in the United States. In this study, 635 AART-credentialed radiographers completed an online survey that included questions about their musculoskeletal pain and exposure to risk factors associated with pain symptoms. The results showed that 81% of the respondents reported pain or discomfort while performing cases. 14 Female WMSDs 23 Musculoskeletal disorders for all surgical/procedural personnel in fluoroscopy treatment labs are complicated by the requirement to wear heavy lead aprons during procedures leading to discomfort and fatigue. An article titled “Wearing Lead Aprons in Surgical Operating Rooms: Ergonomic Injuries Evidenced by Infrared Thermography,” published in 2017, shows, via infrared imaging, the body temperature of specific muscle groups, trapezoids and pectorals increases while wearing protective lead. Overall, provider fatigue was quantified by analyzing participants' rise in heart rate, blood pressure, and cutaneous temperature between lead-required and lead-free procedures. Results noted a significant temperature increase in participants in lead-required methods, identifying the impact of load bearing on the body and the recruitment of muscles in the body’s attempt to adapt to the additional weight. 32 Females in the Cath Lab In 2000 Grossi et al. painted a generally negative picture of female pain tolerance and coping strategies compared to their male counterparts. Using the Coping Strategies Questionnaire, the Swedish-based research team highlighted patients seeking care for their pain. 72% of the 446 patients were female. Their final assessments were that females had a poorer capacity to cope with musculoskeletal pain leading to higher emotional distress, more significant disability, and required more treatments for their pain than males. 33 This research has provided a little groundwork for females’ musculoskeletal pain and tolerance in the workforce. The complex relationship between biological factors and the surgical environment creates a complex equation in creating an ergonomically efficient and safe environment for female professionals. 34 Tsekoura et al. identified a statistically significant pain difference between male and female nurses in Greece. The females reported more lumbar spine, thoracic spine, shoulder, and Female WMSDs 24 neck pain than their male counterparts. 5 This further confirms Hooftman et al.’s statement that females tend to have more neck and shoulder disorders than their male counterparts. 35 Most of these nurses did not receive physiotherapy for their injuries. They attributed their pain to staff shortages, lack of ergonomic training for prolonged standing periods, and the manual lifting required by nursing duties. While 84% of the nurses believed manual handling of patients led to WMSDs, only one-third had participated in any manual handling course. 5 Strazdin and Bammer explored why employed women in any field are more prone to upper-extremity musculoskeletal disorders. Their research found that women’s increased risk factors can be attributed to additional home and work demands. Women tended to spend more time using computers, more repetitive movements, and used poorer and less comfortable ergonomic equipment at work. Outside the work environment, women reported doing more unpaid housework than their male counterparts, including most parenting tasks. This time restriction led women to accommodate by decreasing exercise and relaxation time, which presumably accounts for the loss of upper body musculoskeletal strength, which could protect them from injuries. The authors concluded that this time restriction would likely continue increasing with the western economies’ response to globalized labor markets and work pace. 36 The lack of current research supporting the female cath lab professional WMSDs is a general gap in the literature. Barnard et al.’s foundational work for female physicians in interventional radiation found only eleven articles mentioning gender-related musculoskeletal disorders research. Of those articles, most mentioned gender differences as females being shorter, having smaller glove sizes, and generally being younger than their male counterparts; however, 72% of these females reported WMSDs versus only 46% of the males. Most of the women reported upper extremity pain, possibly related to their ergonomic positions during Female WMSDs 25 procedures and the size and design of equipment, while the males reported lumbar pain. Barnard et al. found that six of the eleven articles identified being female as a risk factor for WMSDs. 1 One of the eleven articles mentioning gender variability addressed the instrument ergonomics for females versus their male colleagues. Females were likelier to report WMSDs attributed to procedure instruments and have a negative opinion of the devices. They labeled the tools as difficult and uncomfortable to use. Fram et al. recommended further ergonomic instrument design research to allow all orthopedic surgeons to practice in a safe and comfortable environment. 37 Sutton et al. found similar results in their survey of ergonomic challenges and WMSDs, noting that minimally invasive operating rooms and instrument design favor taller surgeons with larger, stronger hands. Female surgeons were more likely to receive treatment for hand, wrist, and finger pain. Females who wore smaller gloves, sizes 5.5 to 6.5, reported more incidences of the neck, shoulder, and upper back pain than men who wore similar gloves. Sutton et al. recommended instrument redesign and table height adjustment to begin the ergonomic adaptation of laparoscopic surgical operating rooms. 1, 38 Another critical article cited in Barnard et al.’s work included all employees in Mayo Clinic’s interventional cardiology and interventional radiology labs. Orme et al. found that not only were females more likely to report WMSDs, but technicians and nurses reported the highest rates of WMSDs (62%), followed by attending physicians (44%) and then trainees (19%). 2 Wearing ill-fitting lead can lead to more than just orthopedic impairments. A recent study found that breast cancer rates among female orthopedic surgeons are higher than in U.S. women. The upper outer quadrant is the most common breast cancer site, and it remains relatively unprotected from radiation while wearing lead aprons. When tested with dosimeters, the upper outer breast Female WMSDs 26 received 0.40 mrem/hr, while the lower inner quadrant received only 0.06 mrem/hr. Another factor for increased breast radiation dose was wearing ill-fitting lead. 39 There is an overall lack of adaptation in the cardiac cath lab to the growing number of female interventionalists. The top concerns are the lack of education in radiation safety and re-entrance into the cath lab after pregnancy. Professional development opportunities for female cardiologists in all stages of their profession are necessary steps to decrease both the perceived and actual gender-based differences in the cath lab. 4 Cultural and social disparities among males and females make it difficult for females to speak up about their ergonomic challenges. Female proceduralists often fail to voice concerns or challenges, fearing their needs will be perceived as complaints or high maintenance. 34 The disparity in the ergonomic needs of female professionals can be attributed to a lack of awareness on all levels. Females need to continue speaking up for the environment to change. The Society for Surgical Ergonomics is a non-profit society led predominantly by females addressing the “professional needs of surgeons and proceduralists in their interactions with their procedural environments (ergonomics) to improve their well-being, quality of life, and career longevity.” 40 Among other focuses, society addresses the lack of ergonomic education in the resident curriculum. Ergonomics Ergonomics is the science of adjusting the work environment using administrative or engineering designs to fit the capabilities and demands of the working population. Ergonomics aims to reduce the risk of injury and the development of disorders. 26 Ergonomic challenges in procedural rooms are multi-factorial, and solutions must be addressed similarly. 34 Cath lab workplace injuries are often associated with poor motor movement and body control, inadequate Female WMSDs 27 working posture, and awkward positions held for long periods. These risk factors are complicated by using lead garments during procedures. The average lead apron weighs about ten pounds. Depending on the movement, a ten-pound apron can add fifteen to fifty pounds of extra force per movement. 41 The Society of Interventional Radiology estimated that a fifteen-pound lead apron could exert a pressure of 300 pounds per square inch on the intervertebral discs. 42 Ross et al. compared axial skeletal disorders among interventional radiologists, who wore lead all day during procedures, orthopedic surgeons, who stood all day but did not wear lead, and rheumatologists, who stood briefly during the day. The interventional radiologists reported pain more often than their counterparts. Ross et al. postulated the lead weight and the ceiling-mounted monitors requiring repeated head movement by interventional radiologists as a possible cause for the increased incidences of cervical disc disease. 28, 42 In addition to standing for long periods and wearing lead garments, Benjamin and Meisinger reported further ergonomic strains in the interventional radiology lab. The lab’s low lighting causes eye strain. The room set-up and design often limit the staff’s maneuverability and ease of reaching the patient through all the equipment. Limited table height adjustments for shorter surgeons force them to stand in ergonomically challenging positions for long periods, leading to additional strain and positional pain. 34 The limited adjustability of the monitors often leads staff to work in one position while viewing in another, causing other neck and back strain. They noted that the beginning of the procedures is incredibly taxing as the physicians and staff reach to use the ultrasound system. Benjamin and Meisinger stated that the lack of “intuitive usability and standardization of devices” exacerbates the strained posture of those working in the interventional lab. 43 Female WMSDs 28 Benjamin and Meisinger identified the elements necessary for an ideal procedure set up. The monitors should be placed directly in front of the physician at approximately fifteen degrees below their horizon to limit axial rotation. The optimal table height should be a factor of 0.07-0.08 of the surgeon’s neutrally positioned elbow. A small stool should be placed by the surgeon’s feet for intermittent resting on each leg throughout the procedure. These suggestions include properly fitting lead aprons, proper posture, and good health practices outside the work environment. 43 A scoping study reviewing factors of WMSDs in allied health professionals published in 2016 identified a gap in understanding the potential causal factors of WMSDs and risk management strategy.21 The authors suggest identifying various causal factors relevant to a population group. This information is the foundation for an effective risk reduction strategy in WMSDs.21 Three hundred nurses who participated in a Greek Nordic Musculoskeletal Questionnaire study identified the most critical perceived risk factors for WMSDs were lack of ergonomic training and being short-staffed. 5 In a 2020 article, the Congress of Neurologic Surgeons was surveyed, revealing that 73% of experienced WMSD out of 417 replies.30 In this group, 90% identified ergonomics as an “underexposed” aspect of neurosurgery.30 An article that first appeared in the 2015 Journal of the American College of Cardiology mentions a revealing study by Orme et al., which determined by a 1500+ employee response survey that WMSDs are more common in those participating in interventional procedures versus those who are not. WMSDs were present in nearly half of physicians surveyed and increased prevalence in nurses and technicians.31 Female WMSDs 29 Future Directions and Recommendations In 2019 the Association of American Colleges (AAMC) reported that more women (50.5%) were enrolled in medical school than men (49.5%). 8 Professionals in the cath lab are highly predisposed to work-related musculoskeletal disorders. Hence, safety standards are needed for females and males to help minimize the risk of such injuries. Many research articles highlight the dangers of damage to the musculoskeletal system with theoretical and practical recommendations for future intervention. The Centers for Disease Control has proposed recommendations to help reduce the risks of work-related injuries by developing and implementing workplace controls. 26 They recommend a three-tiered hierarchy of rules as an intervention strategy for decreasing workplace hazards. Engineering controls, the first tier, include moderating the way materials, including patients, are moved. Using mechanical assist devices to reduce strain on the professional's body is the first defense against injuries. The first tier also includes moderating the workstation to be more ergonomically correct for the cath lab healthcare providers. The second tier comprises administrative controls. Although less effective than engineering controls, implementing protocols and procedures can decrease workplace injuries. The third tier encourages using personal protective devices (PPE) as final protection against injuries. This would include wearing lead, gloves, masks, and eyewear for cath lab employees. 26 Barnard et al. recommend early ergonomic training to medical students during their IR rotation to reduce the resident’s physical workload. 1 Adopting training criteria, including the best positions, postures, and self-care techniques, can significantly decrease the possibilities of WMSDs in the future and improve quality of life, rates of burnout, and overall professional satisfaction. 11 Female WMSDs 30 Reduced stress in the workplace, including decompression time, meditation training, deep breathing exercises, and simple yoga postures, can allow professionals to relax and increase their work satisfaction. Klatt et al. explored the benefits of mindfulness-based stress reduction (MBSD) by implementing a mindfulness in motion (MIM) program for ICU staff. The staff participated in mindfulness training during work for one hour a week for eight weeks. The program teaches mindfulness-awareness principles, group mindfulness practices, light yoga, and relaxing music. The retention rate and benefits for MIM were highly successful and showed signs of being successfully implemented in various high-stress work environments. 44 Cath lab personnel would benefit significantly from this or similar programs. Sommerich et al. found ergonomically challenging workspaces for mammographers with procedural buttons positioned at the knee and hip height while hands were at shoulder height, helping patients to remain in the correct position. The main concerns of the mammographers were the challenging room layouts, equipment layouts, and the physical demand on their musculoskeletal system. Sommerich et al. engaged a focus group of mammographers, asking for their feedback and suggestions. In collaboration with the research team, they determined an “A” list for mammography interventions in workplace effectiveness and efficiency. 45 Similar focus groups and task workforces can be implemented for cath lab professionals. Allowing cath lab professionals to voice their concerns and receive validated feedback, with efforts to implement their ideas, can move the problem of musculoskeletal injuries toward a solution. Limiting or rotating work tasks while working in fluoroscopy has been cited as a possible intervention to prevent WMSDs by Evans et al. Their study focused on self-reported risk factors for physical and physiological leading to work-related musculoskeletal injuries. They concluded Female WMSDs 31 that 81% of survey participants reported experiencing pain while working, and further investigation into interventional processes must be studied further. 14 Wearing lead aprons has long been associated with work-related musculoskeletal injuries and fatigue. This topic has been further researched by Alexandre et al. using infrared thermography. Their study aimed to quantify the impact of wearing lead aprons leading to discomfort and fatigue on professionals in the gastroenterology field. They found significant differences in muscle recruitment and fatigue between professionals wearing lead aprons and those who did not. Their research will continue to analyze the difference in body posture and use strength training to improve core musculature and posture, hoping it can make a difference in decreasing muscular fatigue while working with a lead apron. 32 Investments in procedural room equipment are a necessary step in minimizing injuries. The companies developing equipment and tool designs for procedural rooms need to include many proceduralists in the design process. The stereotypical tall male with size eight gloves is not an appropriate example of all proceduralists’ size. 34 Equipment assisting in transferring patients to the procedure table and hospital bed is another possible intervention and future direction to increase safety among cath lab personnel. The expense may have a significant upfront cost. However, the long-term consequences to healthcare professionals are a significant risk for any organization. Hwang et al. found a substantial reduction in pulling forces, shoulder movements, and muscle activity when equipment, such as slide sheets, slide boards, and inflatable air-assist devices, were used to maneuver patients compared to just pulling with draw sheets. 46 Female WMSDs 32 Summary The problem of WMSDs in the cath lab has been well documented, but the current literature is significantly limited in data relating to female professionals in these fields. Addressing the ergonomics of the cath lab environment and future directions to protect these professionals must be further explored. There needs to be a change in the healthcare culture by adapting to a medical environment that doesn’t fall into the typical tall, strong, and male stereotypes. Creating a more inclusive environment, these efforts will improve work satisfaction and the health of every healthcare provider in the cath lab. Further addressing the lack of female-related literature must be further explored as well. There is a need for more current and inclusive surveys of female cath lab professionals’ challenges and work-related musculoskeletal disorders. Once current information has been gathered, further research and protocols can be established to protect females in the cath lab. 1 Female WMSDs 33 Chapter 3: Research Methods The prevalence of WMSDs and ergonomic hurdles female cath lab professionals face vary from their male counterparts.1 We expect our findings to be consistent with prior research, indicating work-related musculoskeletal disorders are pervasive in the cath lab. We hope our results further identify the variability in WMSDs among male and female professionals. Work ergonomics and contributing environmental factors affecting the prevalence of orthopedic pain for professionals are also addressed. By identifying risk factors and common WMSDs among female cath lab professionals, future directions can address ways to minimize WMSDs, retain current female professionals by keeping them healthy, and attract new female professionals to the field. Q1. What are the most common work-related musculoskeletal disorders (WMSDs) in female cath lab professionals? Q2. What are work-related musculoskeletal disorders (WMSDs) commonly found in the cath lab among female cath lab professionals? Q3. What physical factors influence self-reported work-related musculoskeletal injuries (WMSDs) among a representative sample of US female cath lab professionals? Q4. How do work-related musculoskeletal disorders (WMSDs) manifest differently in males vs. females? Research Methods and Design(s) This quantitative study explores self-reported musculoskeletal symptoms in female cath lab professionals. There is a gap in the literature focusing on female work-related musculoskeletal symptoms in the cath lab.1 Female WMSDs 34 This research was aimed at what physical factors influence self-reported work-related musculoskeletal injuries among a representative sample of US female cath lab professionals. The target population was female cath lab professionals 18 and older, with additional male responses used for a comparison value. A request for participation was sent out via social media to cath lab professionals who are part of LinkedIn, Facebook, and Twitter cath lab-related groups. It linked an online survey that included the existing validated Nordic Musculoskeletal Questionnaire was used in conjunction with personal data (e.g., age, height, weight, gender, clinical licensure, department) and work environment (hours wearing lead each day, number of hours worked in a week, years the individual has worn protective garments, commonly called lead, in their career.) We examined other sources and questionnaires but found the Nordic Musculoskeletal Questionnaire to be the most straightforward and appropriate tool. The NMQ has a high internal consistency and constructs validity.37 The NMQ is easily administered and highly applicable to our research questions. The Weber State University Institutional Review Board approved this research project. Population The population targeted in this study includes women 18 years of age and older working as female cath lab professionals. The males were also included for comparison purposes. Specifically, the data is obtained from only those who work in the cath lab environment. No protected populations were included, and participants from this population were asked to volunteer. This study aims to explore self-reported musculoskeletal symptoms in female Cath lab professionals. Female WMSDs 35 Sample Questions were delivered via convenience sampling through a link sent to professional groups and hospital systems and posted on social media groups such as Facebook, Twitter, and LinkedIn to request participation in an anonymous and voluntary online survey. Any imaging professional could participate. However, data will be extracted for purposes of this study to include only those currently working in one of six categories (cardiac catheterization, electrophysiology, structural heart, neurology, interventional radiology, pediatric cardiac catheterization) who are female and male (for comparison purposes), 18 years of age and older, to explore levels of exposure to risk factors and musculoskeletal symptoms. Because of the social media component, it’s understood that the number of responses could be far-reaching across the globe, not strictly in the United States. This data was compared to existing data to determine the significance of responses. Materials/Instruments/Data Collection, Processing, and Analysis Upon receiving IRB approval, the Nordic Musculoskeletal Questionnaire and additional demographic information were sent out via social media sources (Facebook, Twitter, LinkedIn). Data was collected through the electronic transmission of a Qualtrics survey. The existing validated Nordic Musculoskeletal Questionnaire was used in conjunction with personal data (e.g., age, height, weight, gender, clinical licensure, department) and work environment (hours wearing lead each day, number of hours worked in a week, years the individual has worn protective garments, commonly called lead, in their career.) Developed in 1987, the questionnaire has been used for musculoskeletal surveys for over thirty years.36 The Nordic Musculoskeletal Questionnaire is a published, validated, and reliable survey. The NMQ uses a test-retest methodology, with the reliability of different answers ranging between 0%- and Female WMSDs 36 23%.37 The questionnaire structure is designed for statistical analysis by computer software. All research data were collected through the electronic transmission of a Qualtrics survey. The NMQ10 is in two well-differentiated structures. The first part, the general one, refers to symptoms in 9 parts of the body (neck, shoulders, elbows, wrists/hands, upper back, lower back, hip/thighs, knees, and ankles/feet) during the last 12 months/7 days. The second part, the specific one, refers to symptoms in three body parts (neck, shoulders, and lower back) throughout the subject's working life/7 days beforehand. To answer this questionnaire, the subjects were asked to respond "yes" or "no" to the following question: "Have you any time during the last 12 months had trouble (ache, pain, discomfort)— followed by a list and body diagram of the nine different anatomical areas. If the respondent marked "yes,” then the respondent was asked to answer the question "Have you at any time during the last 12 months been prevented from doing your normal work (at home or away from home) because of the trouble?" and "Have you any trouble at any time during the last seven days?" Data was collected and summarized using Qualtrics data analysis and SPSS. Analysis showed that 530 individuals consented to participate in the survey. 137 responses either did not complete the study or resided outside the United States. Thus, they were omitted from the final data set. Ultimately, 394 participants completed the survey and were included in the last data set used for analysis. To analyze information about musculoskeletal injuries in females, data can be compared to males utilizing a scattergram to indicate the time in the cath lab and the number of injuries for each population. After the regression line is applied to both data sets, the working hypothesis will show support. Multiple regression analysis will be used since more than one variable will be used to predict the WMSD variable.38 Female WMSDs 37 Figure 1: Nordic Musculoskeletal Questionnaire 37 Operational Definition of Variables The dependent working variable is work-related musculoskeletal disorders (WMSD). WMSDs are the muscles, nerves, tendons, joints, cartilage, and spinal discs caused by conditions where work contributed to the injury significantly through the environment or performance (of tasks).2 The WMSDs of the cath lab are suspected to be caused by protective gear worn, particularly lead aprons, and the implementation of physical duties. The purpose of this study was to answer the question of identifying what risk factors are for WMSDs in the female cath lab population. Female WMSDs 38 Assumptions Participation was never 100%, and male responses were lower than female responses. For this research, it is assumed that participants will not reach 100% of sent copies of the survey. It is assumed that responses will include those working in the cath lab specifically and be a mixture of physicians, allied health professionals, and nurses; the information specific to females and the cath lab will be pulled from this entire response. WMSDs are presumed to increase with years of experience in the cath lab. Participant responses are assumed to be subjective and utilize the honor system to self-identify WMSDs and perceived pain. Limitations The amount of literature directed at the causes of female WMSDs is limited; responses were sorted to pull out information specific to both the cath lab and female WMSDs. The research was limited to English publications and could omit potentially valuable foreign language studies and unpublished theses. 47 The information related to individual WMSDs is self-reported and thus subjective. Voluntary response bias may provide evidence that deviates from the general population in the cath lab. The degree to which this data is representative of the general cath lab population is unknown. Gendered responses may not be representational of the larger population. The response rate of females was satisfactory and disproportionate to the male response rate presenting another possible bias in the data set. 4 Data from this survey will be compared with previous Nordic Musculoskeletal Questionnaire results to identify statistically unusable data and documents. Female WMSDs 39 Delimitations The scope of data used in this study contains previously published study material and validated survey material directed at identifying the prevalence and types of work-related musculoskeletal disorders; the Nordic Musculoskeletal Questionnaire is the most straightforward standardized and validated survey to administer and highly applicable to this research2. Survey links were posted via Facebook, Twitter, and LinkedIn, and sent only to those with potential or known cath lab duties. To limit error, the sample is restricted to those currently working a minimum of 12 hours per week in the cath lab. Information was extracted from the data to compare male to female responses. Ethical Assurances Before data collection, IRB approval was sought and obtained from the Weber State University Institutional Review Board. IRB approval ensures that ethical considerations are observed and that conducting the study will not harm the participants. No protected populations are included, and participation in the study was voluntary. All participants who agreed to participate in this study signed the informed consent form (Appendix A). Contact information of the researchers was included so participants could contact the researchers with any concerns or questions related to the study. The collected data will be stored in a secured hard drive for three years. Only researchers have the right to access the study data. Summary This study aims to identify female cath lab professionals’ prevalence, location, and possible causes of WMSDs to compare with prior research results.37 Questions were sent as a Female WMSDs 40 convenience sample model. Relevant information was gathered from as many participants as possible by posting the link in social media, radiology, and cardiology groups. The researchers aim to strengthen future directions of laboratory improvements related to WMSD prevention by identifying common risk factors, especially in the female population. Data was analyzed to retrieve pertinent information directed at female respondents in the cath lab using multiple regression statistical analysis models.38 Female WMSDs 41 Chapter 4: Findings Understanding WMSDs in the cath lab, gender differentiation, and identifying risk factors will aid policymakers in developing safety protocols and recommended policies in the cath lab. Utilizing the Nordic Musculoskeletal Questionnaire, a previously validated quantitative survey, this study explores self-reported musculoskeletal symptoms in cath lab professionals. Results Participant Characteristics The female response rate was very high (333, 85%), while the male response rate was lower (61,15%). The small male sample size may not be representative of the larger cath lab population. The cath lab professionals’ sample in this survey had an age range of 18-65+. The average age group for females and males was 35-44. 47% of females and 51% of males weighed between 150-200 pounds. Most females were between 5’5” and -6’0” (154, 46%) followed closely by 5’1”-5’5” (151, 45%), while most males were between 5’1” and -5’5” (30, 49%) followed by 5’5”-6’0” (20, 38%). (Table 1) Interventional cardiology 347 (88%) was the most prevalent department within the cath lab, followed by electrophysiology 20 (5%) and structural heart 14 (4%). The other participants worked in neurology, pediatric, and peripheral. (Table 2) Participants with a nursing credential had the highest response rate, 166 (42%), followed by radiologic technologists at 156 (39%), and 81 (19%) participants held an RCIS or RCES credential. (Table 3) Female WMSDs 42 Table 1: Demographic Information Personal Variables Female N=333 Males N=61 Total N= 394 Gender 85% 15% 100% Age 35-44 years = 31% 35-44 years = 34% Weight 150-200 lbs = 47% 100-150 lbs = 26% 150-200 lbs = 51% 100-150 lbs = 28% Height 5’1-5’5” = 45% 5’5”-6’0” = 46% 5’1-5’5” = 49% 5’5”-6’0” = 38% Figure 2: Participant’s Age Ranges 0% 5% 10% 15% 20% 25% 30% 35% 40% Female Male 18-24 25-34 35-44 45-54 55-64 65+Female WMSDs 43 Figure 3: Participant's Heights and Weights Table 2: Specialty Within the Cath Lab Females N= 331 Male N= 61 Total N=394 Electrophysiology 16 (5%) 4 (7%) 20 (5%) Interventional 296 (89%) 51 (84%) 347 (88%) Neurology 1 (<1%) 0 (0%) 1 (<1%) Pediatric 5 (2%) 1 (2%) 6 (2%) Peripheral 5 (2%) 1 (2%) 6 (2%) Structural Heart 10 (3%) 4 (7%) 14 (4%) 0% 10% 20% 30% 40% 50% 60% 5'1"-5" 5'5"-6'0" 100-150 lbs 150-200 lbs Female MaleFemale WMSDs 44 Figure 4: Specialty within the Cath Lab Table 3: Credentials Female N=333 Male N=61 Total N= 394 Cardiologist 4 (1%) 0 (0%) 4 (1%) Nurse 133 (40%) 20 (33%) 166 (39%) Paramedic 2 (<1%) 0 (0%) 2 (<1%) Radiologic Technologist 116 (35%) 24 (39%) 156 (37%) RCES 0 (0%) 1 (<1%) 2 (<1%) RCIS 67 (20%) 13 (21%) 81 (19%) Respiratory Therapist 1 (<1%) 1 (1%) 2 (<1%) Other 10 (3%) 0 (0%) 13 (3%) 0 50 100 150 200 250 300 350 EP Interventional Neurology Pediatric Peripheral Structural Heart Specialty/Department # Female MaleFemale WMSDs 45 Figure 5: Credentials Prevalence of Musculoskeletal Injury 388 (99%) of participants experienced at least one WMSD in the last 12 months; females experienced 85% of these injuries. The prevalence of MSWDs in the previous 12 months was highest in the low back (322, 82%), neck (306, 77%), upper back (262, 66%), and shoulders (277,70 %) regions for both genders. Low prevalence rates were seen for elbow pain (42, 11%) (Table 7). (Table 4) Female participants' most frequent areas of ache, pain, or discomfort in the last 12 months that prevented them from normal work (at home or work) were in the low back area (25%), which was the same as males (11%) (Table 5). The highest weekly prevalence of pain was low back pain for both females (159, 48%) and males (29, 48%) followed by neck 306 (78%) and shoulder pain 277 (70%) (Table 6). 0 20 40 60 80 100 120 140 Cardiologist Nurse Other Paramedic Radiologic Technologist RCES RCIS Respiratory Therapist Credential # Female MaleFemale WMSDs 46 Table 4: WMSDs Prevalence Reported in the Last 12 Months Body Region Female N=333 Males N=61 Total N= 394 Neck 255 (77%) 51 (85%) 306 (78%) Shoulders 232 (70%) 45 (74%) 277 (70%) Elbows 39 (12%) 6 (10%) 45 (11%) Wrist/Hands 136 (41%) 19 (31%) 155 (39%) Thoracic/Upper Back 220 (69%) 42 (69%) 262 (66%) Low Back Area 275 (83%) 47 (77%) 322 (82%) Hips 191 (57%) 29 (48%) 220 (56%) Knees 161 (48%) 30 (49%) 191 (48%) Foot/Ankles 189 (57%) 35 (57%) 224 (57%) Figure 6: Total Number of Positive Responses to WMSDs in the Last 12 Months 0 50 100 150 200 250 300 350 400 450 Yes NoFemale WMSDs 47 Figure 7: WMSDs Prevalence Reported in the Last 12 Months Table 5: WMSDs Prevalence Reported in the Last 12 Months Preventing Normal Work (at home or away from home) Body Region Female N=333 Males N=61 Total N=394 Neck 43 (13%) 4 (7%) 48 (12%) Shoulders 40 (12%) 5 (8%) 45 (11%) Elbows 3 (<1%) 2 (3%) 5 (1%) Wrist/Hands 20 (6%) 4 (7%) 24 (6%) Thoracic/Upper Back 30 (9%) 6 (10%) 36 (9%) Low Back Area 83 (25%) 7 (11%) 90 (23%) Hips 33 (10%) 5 (8%) 38 (10%) Knees 33 (10%) 2 (3%) 35 (9%) Foot/Ankles 27 (8%) 4 (7%) 31 (7%) Total Prevalence 313 (94%) 39 (64%) 352 (88%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Low Back Neck Shoulders Female MaleFemale WMSDs 48 Table 6: WMSDs Prevalence Reported in the Last 7 Days Body Region Female N=333 Males N=61 Total N=394 Neck 123 (37%) 29 (48%) 152 (39%) Shoulders 107 (32%) 25 (41%) 132 (34%) Elbows 10 (3%) 4 (7%) 14 (4%) Wrist/Hands 57 (17%) 11 (18%) 68 (17%) Thoracic/Upper Back 90 (27%) 23 (38%) 113 (28%) Low Back Area 159 (48%) 29 (48%) 189 (48%) Hips 87 (26%) 16 (26%) 102 (26%) Knees 70 (21%) 18 (30%) 88 (22%) Foot/Ankles 103 (31%) 19 (31%) 122 (31%) Total Prevalence 806 (242%) 175 (287%) 981 (249%) Physical Factors Influencing WMSDs The prevalence of WMSDs could correlate with years of working in a cath lab (Table 7). Most participants worked 40+ hours a week (265, 67%) (Table 8) and 20+ hours a week wearing protective garments (lead aprons) (212, 53%) (Table 9). Most of the cath lab professionals in this study wear two-piece garments (329, 83%) (Table 10) and 306 (78%) participants have customized protective garments (lead) (Table 11). Table 7: Years Working in the Cath Lab Female N=333 Male N=61 Total N= 426 1-5 years 105 (32%) 29 (48%) 145 (35%) 5-10 years 77 (23%) 11 (18%) 98 (23%)_ 10-15 years 44 (13%) 4 (7%) 50 (12%) 15+ years 107 (32%) 17(28%) 130 (31%) Female WMSDs 49 Figure 8: Years Working in the Cath Lab Table 8: Working Hours per Week Female N= 333 Males N= 61 Total N=394 < 10 hours 3 (1%) 1 (2%) 4 (1%) 10-20 hours 7 (2%) 1 (2%) 8 (2%) 20-30 hours 12 (4%) 2 (3%) 14 (4%) 30-40 hours 89 (27%) 14 (23%) 103 (36%) 40+ hours 222 (67%) 43 (70%) 265 (67%) 0 10 20 30 40 50 60 Female Male Years Working In Cath Lab 1 to 5 5 to 10 10 to 15 15+Female WMSDs 50 Figure 9: Working Hours per Week Table 9: Hours a Week Wearing Protective Garments (Lead) Female N= 333 Males N= 61 Total N= 394 < 5 hours 8 (2%) 0 (0%) 8 (2%) 5-10 hours 30 (9%) 5 (8%) 35 (9%) 10-15 hours 35 (11%) 10 (16%) 45 (11%) 15-20 hours 78 (23%) 16 (26%) 94 (24%) 20-30 hours 112 (34%) 20 (33%) 132 (34%) 40+ hours 70 (21%) 10 (16%) 80 (20%) 0% 10% 20% 30% 40% 50% 60% 70% 80% <10 10 to 20 20-30 30-40 40+ Working Hours Per Week Female MaleFemale WMSDs 51 Figure 10: Hours Wearing Protective Garment (Lead) per Week Table 10: Type of Protective Garment (Lead) Female N= 332 Males N= 61 Total N= 393 1 piece 53 (16%) 11 (18%) 64 (16%) 2 piece 279 (84%) 50 (82%) 329 (84%) Table 11: Customization of Protective Garments (Lead) Available in the Cath Lab Female N= 333 Males N=61 Total N= 394 Yes 265 (80%) 41 (67%) 306 (78%) No 68 (20%) 20 (33%) 88 (22%) Manifestation of WMSDs by Gender Female participants' most frequent areas of ache, pain, or discomfort for females in the last 12 months were low back pain 275 (83%), while males were most affected by neck pain 51 (85%). The area of most ache, pain, or discomfort that prevented the participants from doing normal work (at home or work) in the last 12 months was low back pain (83, 25%) for females and neck pain (7, 11%) for males. The highest weekly prevalence of pain was in the low back area (159, 48%) for females and (29, 48%) for males. 0 5 10 15 20 25 30 35 40 45 Female Male 10-20 Lead Hours 20-30 Lead Hours 30+ Lead HoursFemale WMSDs 52 Evaluation of Findings The female response rate was 85% of the survey population, while the males were only 15%. The male sample size is smaller, and harder to come to definitive conclusions about a larger male population; however, the female response rate was high with 333 women voicing their pain. This is a positive indication that women are looking for a voice and opportunity to be recognized in the cath lab. Note that the height results variable confounds the gender assumption of pain and height because most male participants were 5’5” or less. This indicates that height variation and lab ergonomic modification applies to the individual, not gender-based generalizations. 14 On another note, this may be due to the small sample size and may not be representative of the larger population. Interventional cardiology was the most frequently reported specialty. This specialty may correlate with high WMSDs as these procedures require protective garments (lead aprons) to be worn throughout the length of the procedure with high radiation doses. Electrophysiology cases, by comparison, tend to use less fluoroscopy and parts of these cases can be done without wearing lead aprons, like mid-case mapping and during closure. These details may correlate with the amount of WMSDs varying by specialty. 99% of participants in this study experienced aches, pain, or discomfort in at least one region of the body in the last 12 months. Only six individuals participating in this research study felt well enough to mark “no ache, pain, or discomfort” in any of the nine major body regions. 85% of these participants were female. This is the first study discussing the prevalence of WMSDs in the cath lab, differentiating gender disorders. WMSDs are common in the cath lab, with the majority (99%) of professionals in this survey suffering from various aches, pain, or Female WMSDs 53 discomfort in the last 12 months. Previous studies identified female WMSDs as more common in the neck and upper extremities. 48, 49, 50 This study confirmed discomfort in the neck and upper extremities; however, low back pain was reported by females as the most prevalent WMSD in the previous 12 months. This finding is similar to previous studies with results of low back pain pervasive in the cath lab. 14, 51 With both female and male prevalence of low back pain, the research suggests further inclusive research on low back pain prevention for both genders. Most participants in this survey worked over 40 hours a week and wore customized, two-piece lead aprons over 20 hours a week. As previous studies have concluded, working more than full-time hours (40 hours per week) while wearing lead aprons more than half of that time correlates with WMSDs. 2, 3, 5, 11, 12, 14, 15 Summary The prevalence of musculoskeletal injuries continues to be well documented in the cath lab. Physical factors affecting WMSDs are influenced by years and hours worked, hours wearing lead aprons and the design of lead aprons. Manifestations of female WMSDs were well documented in this study. Female WMSDs 54 Chapter 5: Implications, Recommendations, and Conclusions Female musculoskeletal injuries have not been well documented in the cath lab. This study has evaluated the prevalence of musculoskeletal injuries in the cath lab by adding gender variabilities to their injuries. The Nordic Musculoskeletal Questionnaire was used as a research tool. Additional demographic information was added before being distributed through social media. Subjective and voluntary response bias was a limitation of this study. This study will add to the research confirming musculoskeletal injuries in the cath lab. Various physical factors influence injury presentation, including gender. Implications Prevalence of Musculoskeletal Injury With 99% of participants exhibiting a WMSD in the last 12 months, further ergonomic training early in cath lab careers, for both women and men, could provide insight into ways of implementing strategies for prevention and rehabilitation programs in the cath lab. Multiple-component ergonomic training for all cath lab personnel is recommended. 13 WMSDs lead to diminished productivity at work and may lead to psychological symptoms. 5, 36 Implementing these programs could significantly decrease the number of WMSDs in the future, improving the professional quality of life and retaining professionals for extended periods. Physical Factors Influencing WMSDs Years working in the cath lab wearing lead aprons have been correlated with WMSDs. One significant finding in this research showed an increase in low back pain once a professional has worked more than five years in an EP/Cath lab setting. 52 A relationship between years in the cath lab, hours worked every week, and the amount of time wearing lead aprons leads to an Female WMSDs 55 increase in WMSDs. 2, 3, 5, 11, 12, 14, 15 Exercise programs have benefited professionals, but the lack of compliance is often attributed to a lack of free time and ergonomic education. 14 To address these issues, support is needed from the administration of cath labs, and further research is required. Manifestation of WMSDs by Gender In past studies on WMSDs in IR or the cath lab, there has been a poor female representation in the participants. 1 One of the most vital statistics of this research is the number of female participants (333, 84%) who voluntarily responded through social media to the questionnaire. Male participation was significantly less (61, 15%). The high response rate from females may be related to more females entering the cath lab setting or excitement for further research and interventions focused on females. Barnard et al. recommended further research through a comprehensive survey to gather more information on female interventionalists prevalence, location, severity, and causes of WMSDs. This research focused on the prevalence and area of female cath lab professionals' WMSDs and found that low back (275, 83%), neck (255, 77%), shoulders (232, 70%), and thoracic/upper back pain (220, 66%) to be the most significant areas of pain in the last 12 months. These results further confirm females’ tendency for upper body symptoms. 1, 36 Further research is required to understand the severity and causes of females’ upper body WMSDs. The study focused on female ergonomics, and training to prevent injuries is also recommended. Recommendations Studies have notable suggestions and programs, but despite the increased awareness and knowledge of the benefits of ergonomic training and preventative measures, few cath labs Female WMSDs 56 incorporate daily practices for injury prevention. 53 The Centers for Disease Control has recommended a three-tiered hierarchy of rules as an intervention strategy for decreasing workplace hazards. The three tiers address ergonomic, administrative, and PPE interventions to create healthier environments for healthcare personnel. 26 Creating customized workstations can alleviate functional and ergonomically unsafe environments for everyone working in the cath lab. 14 The ergonomic risks are exacerbated by using protective lead garments leading to increased musculoskeletal injuries inhibiting daily functions and leading to long-term consequences. Currently available strategies for injury prevention need to be practically implemented in the cath lab, and future interventions should be further explored for additional injury prevention resources. Further recommendations include implementing preventative programs with education in ergonomics and procedure room equipment setup. Barnard et al. recommend early ergonomic training for medical students to improve and relieve the resident’s physical workloads. 1 This would provide practical ways for both genders to improve ergonomic movement and to track possible enhancements that can be made to the programs. Adopting training criteria, exercise programs, and stressing daily adoption of preventative techniques, can significantly decrease the possibilities of WMSDs in the future and improve quality of life, rates of burnout, and overall professional satisfaction. 11, 51 Conclusions The purpose of this study through examining work ergonomics, prior literature, past survey responses, and the use of an inclusive, quantitative survey aimed at obtaining relevant information from affected professionals in the cath lab environment. WMSDs are pervasive in the cath lab and can be further differentiated by gender variabilities. Treatment and prevention Female WMSDs 57 strategies cannot remain generalized but must begin individualizing various strategies for WMSDs. The female population in the cath lab continues to grow, and so should prevention strategies and research studies addressing this population. Research gaps exist in understanding and adapting to the change in cath lab demographics. 1, 4 This subset of professionals deserves to be studied. Utilizing standardized testing to improve validity and searching for causal relationships can further enhance the knowledge about gender differentiation within the cath lab. Information gathered from these future studies can enhance cath lab safety and prevent or minimize WMSDs. 47 Promoting gender equity and further exploring the variabilities in gender WMSDs are required to retain current professionals and attract new female professionals to the field. Female WMSDs 58 References 1. Barnard E, Sheaffer K, Hampton S, Measel ML, Farag A, Shaw C. Ergonomics and Work-Related Musculoskeletal Disorders: Characteristics Among Female Interventionists. Cureus. 13(9):e18226. doi:10.7759/cureus.18226 2. Orme NM, Rihal CS, Gulati R, et al. Occupational Health Hazards of Working in the Interventional Laboratory. 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Commercially Available Friction-Reducing Patient-Transfer Devices Reduce Biomechanical Stresses on Caregivers’ Upper Extremities and Low Back. Hum Factors. 2019;61(7):1125-1140. doi:10.1177/0018720819827208 47. Long MH, Johnston V, Bogossian F. Work-related upper quadrant musculoskeletal disorders in midwives, nurses and physicians: A systematic review of risk factors and functional consequences. Appl Ergon. 2012;43(3):455. 48. Hooftman WE, van Poppel MN, van der Beek AJ, Bongers PM, van Mechelen W. Gender differences in the relations between work-related physical and psychosocial risk factors and musculoskeletal complaints. Scand J Work Environ Health. 2004;30(4):261-278. doi:10.5271/sjweh.794 49. Strazdins L, Bammer G. Women, work and musculoskeletal health. Soc Sci Med. 2004;58(6):997-1005. doi:10.1016/S0277-9536(03)00260-0 50. de Zwart BCH, Frings-Dresen MHW, Kilbom Å. Gender differences in upper extremity musculoskeletal complaints in the working population. Int Arch Occup Environ Health. 2000;74(1):21-30. doi:10.1007/s004200000188 51. Sawalha K, Beresic N, Khan S, Kamoga GR. The Prevalence of Low Back Pain and Evaluation of Prevention Strategies among the Electrophysiology and Catheterization Laboratory Community (Physicians, Nurses, Technicians) in Rural Hospitals. IntechOpen; 2021. doi:10.5772/intechopen.95740 52. Worker Safety in Hospitals | Occupational Safety and Health Administration. Accessed November 22, 2022. https://www.osha.gov/hospitals 53. Cornelis FH, Razakamanantsoa L, Ben Ammar M, et al. Ergonomics in Interventional Radiology: Awareness Is Mandatory. Medicina (Mex). 2021;57(5):500. doi:10.3390/medicina57050500 Female WMSDs 62 Appendices Appendix A: Informed Consent Welcome to the Nordic Musculoskeletal Questionnaire! Thank you for participating in our research study exploring Work-Related Musculoskeletal Injuries in Female Cath Lab Professionals. This survey is open online to all individuals employed in the cardiac catheterization laboratory (CCL) as administrators, registered nurses, radiologic technologists, cardiovascular technologists, and interventional cardiologists in the United States are invited to participate. The purpose of this study is to observe and correlate work-related musculoskeletal disorders within the female gender in the CCL. This research will provide a better understanding of female musculoskeletal disorders and injuries, differentiation of orthopedic injuries by gender, perceived pain associated with working conditions, and future directions interventional laboratories can adjust to the female population. It may provide additional knowledge for garment design, case scheduling, reduction of hours for injured populations, preventative measures, and a baseline for longitudinal research designs. This research has been approved by the Weber State University Institutional Review Board. The information obtained would be used solely for academic and educational purposes. Participation in this study is on the basis of consent and is completely voluntary and anonymous. You may decline to take part or withdraw from the study without providing explanation at any time by simply closing the browser page. If you choose to withdraw, the data you have provided prior to withdrawal will be destroyed and not be included in our analyses. Please note that once you have completed and submitted your survey responses, we are unable to remove your anonymized responses from the study. All data will be stored in a password protected electronic format. The survey should not take more than 10 minutes to complete. Your comments, ideas, impressions, and views are very much appreciated. The researchers will greatly appreciate if you are able to kindly share this survey with colleagues! Research Team Contacts: You can contact the research team to address any concerns or for a full copy of the Informed Consent. Research team members contact information: 1. Kristen Detton Weber State University Cardiac Specialist Program Email: Kristendetton@mail.weber.edu Female WMSDs 63 2. Deborah Weber Weber State University Cardiac Specialist Program Email: Deborahweber@mail.weber.edu 3. Christopher Steelman, MS, R.T., (R) (CI) (ARRT), RCIS, FACVP Assistant Professor Weber State University Director - Cardiac Specialist Program Email: Csteelman@weber.edu By clicking the button below, you acknowledge that your participation in the study is voluntary. You are 18 years of age. You are aware that you may choose to terminate your participation in the research for any reason.