Musculoskeletal disorders in interventional radiology workers: an integrative review

This integrative review analyzed scientific production on musculoskeletal disorders related to personal protective equipment used by interventional radiology teams. The PubMed, Embase, and SciELO databases were searched using a strategy developed with the help of a librarian. The double-blind selection process involved the Rayyan online tool. A total of 12 articles were included, which were organized according to year of publication, country research subjects, study type, and main outcomes. Five thematic categories emerged from the analysis: “personal protective equipment”; “ergonomics in the interventional radiology environment”; “the composition of personal protective equipment”; “radiation protection for interventional teams” and “the prevalence of musculoskeletal symptoms in interventional teams”. Outcomes associated with musculoskeletal disorders among interventional teams predominated in the studies, and advances in radiological protection were reported, especially in shielding technologies, as well as continuing efforts toward more ergonomic protective equipment to reduce the risk of musculoskeletal disorders.


INTRODUCTION
The widespread use of X-ray radiation requires investigation into the safety and protection of health professionals.The risks involved in its use, especially in interventional procedures, has stimulated the evolution and diversification of personal radiation protection equipment. 1nterventional radiology, a unique specialty involving diagnostic, therapeutic, vascular, and non-vascular procedures, is aimed at virtually all patient populations.Currently, most interventional professionals perform several hours-long procedures per day, and units operate 24 hours a day, 7 days a week.The physical demands are different from those of diagnostic radiology in that interventional radiology requires upright posture, heavy personal protective apparel, performing technically complex procedures, and moving equipment and changing positions to perform these procedures. 2 Lead aprons are one of the most important garments for health professionals who may be exposed to ionizing radiation.Thyroid protectors, gloves, and lead glass goggles further reduce exposure.To shield against ionizing radiation, lead has historically been the most common material due to its great attenuation potential.The use of other materials, such as barium, bismuth, and antimony, is increasing and lead-free or low-lead alloys are now available.Higher lead equivalency increases protection, but makes the equipment heavier. 3ue to musculoskeletal injuries, manufacturers of radiological protection equipment have investigated ways of reducing its burden to ensure an adequate balance between comfort and protection, ie, reducing overload without compromising safety.Unfortunately, this is not always achievable.Generally, lead aprons do not achieve the double objective of excellent radiation protection while avoiding ergonomic hazards, since the lighter they are, the farther they fall below acceptable protection standards. 2nternational Electrotechnical Commission standard 61331 4 addresses general requirements for medical protective equipment in terms of design and the attenuation properties of the materials, but not ergonomics.Although protective apparel can effectively reduce exposure to X-rays, it can cause mechanical overload in users, which could result in negative effects on the musculoskeletal system, especially the spine. 4iven the above, it is important to study knowledge production about musculoskeletal disorders related to personal protective apparel among interventional radiology team members.Thus, the aim of this study was to conduct an integrative review on the topic to raise awareness about these disturbances, alternatives for resolving them, and to promote new solutions.

METHODS
This integrative literature review addressed the following research question: "What is the ergonomic influence of personal protective equipment on interventional radiology workers?"The review's methodology followed a protocol by Forte et al. 5 involving the following stages: identifying the theme and formulating the research question, defining the inclusion and exclusion criteria, categorizing studies according to the inclusion and exclusion criteria, evaluating and critically analyzing the findings, and presenting the findings.
The descriptors and keywords, as well as the search strategies, were defined through consultation with a librarian and are detailed in Table 1.The Boolean operators AND and OR were used to maximize the number of results.The SciELO search strategy differed from the PubMed and Embase strategies in that Portuguese and Spanish descriptors and keywords were used, in addition to deleting the theme "occupational health", to improve the results.
The inclusion criteria were complete scientific articles published in English or Portuguese that contained the relevant descriptors/keywords in the abstract and/or title and whose general and/ or specific objectives explicitly referred to the research question.The time frame, 1990 to 2020, was based on the creation of the National Center for Cardiovascular Interventions (CENIC) in 1991.This body created an official database to document the performance and development of interventional radiology in Brazil.We expected there to be an increase in related publications after this milestone.
The exclusion criteria were any other publication format (ie, letters, reviews, theses, dissertations, editorials, books, book chapters, government documents, and newsletters), studies unavailable in full online, publications prior to 1990, and duplicate records.
The PubMed, Embase, and SciELO databases were searched in September 2020.The search was performed using the Federated Academic Community/Federal Institute of Santa Catarina network (CAFe/IFSC).These databases were selected due to being open access (for greater online access to full texts) and conducive to Brazilian and international publications on the theme.
Article selection was performed by 2 researchers (OBF and CNM) who were blinded using Rayyan, an online tool developed by the Qatar Computing Research Institute.The categories of analysis emerged from the content of the included articles.
Of special note was the scarcity of Brazilian studies.A single study was found within the scope of this review.Flôr    Rothmore 15 Interventional physicians

Crosslongitudinal study
To compare discomfort, fatigue, and ease of movement in interventional physicians when using different lead garments.

DISCUSSION
Five thematic categories emerged from the analysis: "personal protective equipment"; "ergonomics in the interventional radiology environment"; "the composition of personal protective equipment"; "radiological protection for interventional teams"; and "the prevalence of musculoskeletal symptoms in interventional teams".

PERSONAL PROTECTIVE EQUIPMENT
The primary purpose of radiation protection is to reduce or prevent exposure to ionizing radiation.The use of protective equipment is mandatory in the interventional environment to control exposure. 11ince it is not optional, in addition to shielding effectiveness, investigations about the equipment's dimensions and user adaptability are important.Such equipment is worn an average of 5 hours a day, 2-5 days a week. 15Rothmore 15 points out that the correct apparel must be selected and recommends segmented pieces (vest/skirt) due to better mobility.If this is not an option, whole aprons with adjustable waists should be used.Benjamin & Meisinger 8 report that, in addition to lead shielding, correct apparel types must also be used to maximize effectiveness and provide adequate protection.An inadequate relationship between users and equipment can lead to radiation exposure, injuries, and musculoskeletal pain. 8espite the importance this subject is given in the literature, inattention to personal protective equipment is still frequent.According to Chen et al., 16 usage of lead aprons is low, around 70%, and almost 10% of the staff in their sample did not know the correct position for the dosimeter.According to Wilson-Stewart et al., 17 non-use or incorrect use of radiation protective equipment could result in exceeding the recommended dose.A 2016 Algerian survey indicated that correct clothing can reduce the annual effective dose to < 10% in interventional cardiologists, while the apron and thyroid protector set further reduces exposure to < 4%. 18The authors pointed out that the main error among workers is underuse of protective glasses, which leads to excessive annual doses.They highlighted training and awareness about personal protective equipment, even for professionals outside the radiology department.

ERGONOMICS IN THE INTERVENTIONAL RADIOLOGY ENVIRONMENT
Although the risks of cumulative exposure to radiation have been studied for decades, some important points have been overlooked.The balance between ergonomics and protection should be improved.Safety equipment must keep pace with the dramatic evolution of imaging technology.As a metaphor for this relationship, Klein et al. 13 described how technological innovation led to airbags, which have made driving far safer than seat belts alone, with current protective equipment being like seat belts.Although they concede that lead protection is efficient, an ideal equipment design has yet to be commercialized, resulting in widespread user discomfort from the burden.Soares et al. 19 analyzed anthropometric characteristics and hand grip strength, finding a significant relationship between these two variables, concluding that ergonomic concerns directly influence work quality and the impact of work activities.
However, ergonomics also positively affects the radiological environment.The proper positioning of monitors in fluoroscopy, for example, prevents neck pain.Setting the procedure tables to the correct height alleviates the impact on elbows, reducing overload on the brachialis muscles. 8Benjamin & Meisinger highlight strategies for minimizing musculoskeletal damage in very long routines, including keeping physically fit, maintaining good posture at work, alternating foot support using a support bench, and regular stretching. 8In a study on nursing staff attitudes about protective measures in interventional radiology procedures, Flôr & Gelbcke 10 observed complaints of discomfort related to protective apparel use.Corroborating this, Pereira 20 reported that the location of materials and the weight of lead aprons were ergonomic difficulties in the interventionist environment.

THE COMPOSITION OF RADIATION PROTECTION EQUIPMENT
Traditionally, lead has been used in radiation protective equipment due to its high attenuation level. 3,6However, barium, bismuth, and other materials have been increasingly studied as alternatives to lead.Kang et al. 21concluded that personal protective apparel based on urethane resin and bismuth nanopowder provides excellent performance, mainly due to its flexibility. 21Schlattl et al. 22 compared lead alternatives in 3 different X-ray beams (60, 75, and 120 kV), finding that the a minimum effective dose increases 6% for tin and 3% for a combination of tin and bismuth. 22Cetin et al. 23 concluded that, despite being cheap and easily accessible, lead is toxic and heavy.Lead alternatives, including bismuth, tin, antimony, and tungsten, can be used in protective apparel, providing better protection than a 0.25-mm lead garment, while being 85% lighter.

RADIATION PROTECTION FOR INTERVENTIONAL TEAMS
The interventional radiology environment involves high occupational risk due to long exposure times to ionizing radiation. 24Thus, protection against occupational exposure is required for everyone working in the unit.This includes not only radiology technicians, physicians, and nurses, but others who may be there only occasionally, such as anesthesiologists. 24These workers require proper monitoring and protective equipment. 14Flôr & Gelbcke 10 reiterate that interventional teams suffer the impact of ionizing radiation without being prepared to minimize it.
Radiation safety measures, such as dosimeters and adherence to the time, distance, and shielding principles, should be encouraged in the work environment, striving toward the "as low as reasonably achievable" concept.Klein et al. 13 point out that if ergonomics can accompany technological advances in interventional practice, workers will have safer and more comfortable careers.Radiological protection, especially in interventional radiology, requires alignment between ergonomics and hightech environments. 14Attention to occupational health is lacking in interventional medicine.
According to Chen et al., interventional radiology teams have a weak understanding of radiation protection. 16König et al. reported that the consequences of prolonged low-dose X-ray exposure are still being studied and remain controversial. 25hile some current studies report that radiology workers are not at increased risk of malignant diseases, 26,27 others state that their risk of brain tumors is doubled, in addition to a moderate risk of melanoma and breast cancer. 28

PREVALENCE OF MUSCULOSKELETAL SYMPTOMS IN INTERVENTIONAL TEAMS
Concern for the health of interventionists led to the creation of the Multi-Specialty Occupational Health Group in 2005 in the United States.The central objective of this group is to improve the occupational health of interventional teams, determine the impact of occupational conditions, risks on an epidemiological scale, and the dangers mitigated in the laboratory to better direct efforts to minimize exposure. 13ccording to Klein et al., 13 there is an association between the use of lead clothing and the back, hip, knee, and ankle pain experienced by a quarter of interventional workers.Another relationship was the association between work hours and back problems among interventional laboratory staff. 18Benjamin & Meisinger 8 pointed out that spine-related complaints exceed 40% among workers with more than 10 years of experience.This number increases to 60% among those with > 20 years of experience.A further 28% report hip, knee, and ankle problems.Approximately 33% of those who reported back pain said they missed work due to symptoms in this region. 8ack pain accompanies interventional workers to such a degree that "interventional disc disease" was proposed in the late 1990s. 8Benjamin & Meisinger also compared rheumatologists, orthopedists, liver surgeons, and cardiac interventionists, with the latter having a higher incidence of musculoskeletal pain complaints and longer periods of missed work.Another important fact is that most workers who used lead protective apparel had herniated discs. 8In contrast, Monaco et al. 6 failed to find a correlation between protective apparel and musculoskeletal disorders in interventional radiology workers.Despite the more evident discomfort in users, this relationship has not yet been fully established. 6

FINAL CONSIDERATIONS
The present review found that shielding power against ionizing radiation has improved in radiation protective equipment between 1990 and 2020.Outcomes related to the development of musculoskeletal disorders predominated in the studies.The manufacture of lighter and more ergonomic apparel has been investigated to reduce the risk of these disorders.The included studies also called for better education about radiation protection.
Machado CN et al.
Although this integrative review revealed a scarcity of Brazilian publications on musculoskeletal disorders in interventional radiology, promising advances were also identified in radiation protection and interventional radiology, mainly in shielding technologies.
The present study can alert health professionals, especially teams that work with ionizing radiation and personal protective equipment, to consider their methods and seek alternative strategies of improving occupational health.

2023
Associação Nacional de Medicina do Trabalho This is an open access article distributed under the terms of the Creative Commons license.
& Gelbcke 10 reviewed radiological nursing studies in important national journals, including Revista Texto e Contexto, Revista Brasileira de Enfermagem, Revista de Enfermagem da Universidade de Pernambuco, and Revista de Enfermagem da Universidade do Estado do Rio de Janeiro, regarding the effects of ionizing radiation and physical load.