1

Incidence of Work-Related Musculoskeletal Disorders in Medical Dosimetry.

Alicia Wilson, BS, RT(T); John Keefe, BS, RT(T); Hanaan Habibulla, BS RT(MR); Nishele
Lenards, PhD, CMD, RT(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Matt Tobler, CMD,
RT(T); Sabrina Zeiler, MS, CMD, RT(T); Ashley Fellows, MS, CMD, RT(T)

Medical Dosimetry Program at University of Wisconsin, La Crosse, WI

Abstract
Musculoskeletal disorders (MSDs) account for almost 70 million physician office visits
per year in the United States and are the most common workplace injuries. These are conditions
involving the nerves, tendons, muscles, and supporting structures of the body. Previous studies
have concluded that computer users are at high risk of developing work-related musculoskeletal
disorders (WRMSDs). As computer users, medical dosimetrists are at risk of developing
WRMSDs, yet there is a lack of information regarding the incidence of WRMSDs among
medical dosimetrists. The purpose of this study was to determine the incidence of WRMSDs and
variables of workstation ergonomics that contribute to the increased risk of WRMSDs in medical
dosimetrists. A Qualtrics survey was created to support the 3 research questions guiding this
study. The survey was distributed to 2,646 full members of the American Association of Medical
Dosimetrists (AAMD), which included only certified medical dosimetrists (CMDs), via email.
The distribution of email surveys sent through the AAMD email distribution list resulted in 988
emails opened, for a contact rate of 37% (988/2646). One hundred sixty-four responses were
recorded yielding a response rate of 17% (164/988). Fifty-five percent (90/163) of participants
responded that they have experienced WRMSDs. Forty-four percent (289/652) of responses
indicated WRMSDs have a slight or moderate interference on work. Sixty-two percent (94/152)
of participants felt that their workstations were not ergonomically designed; even greater 68%
(104/153) did not feel their workstations were designed for their individually needs. Of those
respondents 64% (98/152) would like to see further adaptations made to their workspaces.
Keywords: Musculoskeletal disorders, medical dosimetrist, workplace injuries, risk factors,
workplace ergonomics
Introduction
Musculoskeletal disorders (MSDs) account for almost 70 million physician office visits
per year in the United States and are the most common workplace injuries.1,2 The Centers for
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Disease Control and Prevention defines work-related musculoskeletal disorders (WRMSDs) as

conditions that involve the nerves, tendons, muscles, and supporting structures of the body.3 Due
to the frequency, WRMSDs are reported to be a leading contributor for absenteeism and
disability, resulting in significant costs to employers.4,5 Researchers world-wide have emphasized
the prevalence of WRMSDs in professions including healthcare workers and computer users and
have determined the most common risk factors.6,7
The most documented risk factors of MSDs include age, gender, stress, and computing
skills. Environmental factors such as repetitive motion, inappropriate postures, poor ergonomics,
and duration of computer work with infrequent breaks also contribute to higher risk.8 These
environmental risk factors are prevalent among computer users, increasing the frequency of
reported WRMSDs. Computer users most commonly report WRMSDs as pain in the neck, back,
wrist, and headache.6 Furthermore, risk increases when workstations are not ergonomically
designed.6,9,10 As long-term computer users, medical dosimetrists are susceptible to WRMSDs
due to repetitive motion, inappropriate posture, poor ergonomics, and duration of computer work
limiting regular breaks.
Repetitive motion is a leading factor that has been shown to increase the risk of
WRMSDs. Long-term frequent mouse use has been linked to inflammation and tearing of the
ligaments and muscles in the shoulder which can lead to pain and weakness in the neck,
shoulder, and lower arm, especially when the position of the arm is elevated or abducted.11 While
performing daily tasks such as contouring and planning, medical dosimetrists are often executing
repetitive motions with the keyboard and mouse. Although a prominent risk factor, repetitive
motions are one of many risk factors medical dosimetrists are susceptible to.
Inappropriate posture, poor ergonomics, and duration of computer work with infrequent
breaks are also collectively linked to WRMSDs. Rehman et al7 revealed that computer work
involving significant attentiveness and concentration limits the opportunity for computer workers
to change positions and move. The lack of movement and breaks results in lengthy durations in
incorrect posture, therefore, increasing risk of MSDs.7 Medical dosimetrists’ work requires
significant attentiveness, concentration, and hours at a computer-station. The work environments
of medical dosimetrists pose the potential for awkward postures due to poor ergonomics such as
inappropriate computer screen height, desk height, and/or chair height and support. When
combined, the aforementioned factors suggest that medical dosimetrists are susceptible to
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WRMSDs of the upper and lower back, neck, and eye strain due to incorrect posture, poor
ergonomics, and inadequate breaks from both computer screens and sitting.
The research problem is that medical dosimetrists are at increased risk of developing
diagnosed WRMSDs due to repetitive motion, inappropriate posture, poor ergonomics, and
duration of computer work with limited breaks. The U.S. Bureau of Labor and Statistics12
reported over 270,000 MSD injuries for 2018 with some insurance companies estimating the cost
of repetitive motion injuries and other exertions to be over $5 billion annually.13 The increased
risk of WRMSDs for medical dosimetrists may account for considerable work time loss and even
disability.4 In a profession that could be greatly impacted by work time loss, it is important to
raise awareness of the incidence of WRMSDs, common risk factors, and appropriately designed
ergonomic workstations that can decrease the incidence of WRMSDs in medical dosimetry.
There is a paucity of literature on WRMSDs in the medical dosimetry profession, therefore, the
purpose of this study was to determine the incidence of WRMSDs and variables of workstation
ergonomics that contribute to the increased risk of WRMSDs in medical dosimetrists. Research
questions used to guide the study included: (Q1) what work-related musculoskeletal disorders are
observed amongst medical dosimetrists, (Q2) what alterations or adaptations have medical
dosimetrists done to create an individualized ergonomic workspace, and (Q3) since
implementing ergonomic alterations or adaptations, have medical dosimetrist musculoskeletal
disorders improved?
Methods and Materials 
Instrumentation
To gain insight into the incidence of MSDs in medical dosimetrists, an 18 question
survey, using Qualtrics XM, was derived and modified from 2 validated musculoskeletal
disorder questionnaires: the Standardized Nordic Questionnaire for the Analysis of
Musculoskeletal Systems (NMQ)14 and the Cornell Musculoskeletal Discomfort Questionnaire
(CMDQ).15 The NMQ is a standardized questionnaire that was developed to help quantify
musculoskeletal problems in 9 areas of the body that commonly experience MSDs including the
neck, shoulders, upper and lower back, elbows, wrists/hands, hips/thighs, knees, ankles/feet.16
The NMQ questionnaire is a frequently used screening tool for the identification MSDs in a wide
range of occupations.16 Developed at Cornell University, the CMDQ rated the frequency and
severity of discomfort for sedentary or standing office workers using a similar matrix structure as
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the NMQ, but separating the body into 11 areas.15 The structure of these surveys were combined
and modified to develop a survey specific to medical dosimetrists.
The first group of survey questions (Category 1) collected demographic information to
assess the length of time in the profession, incidence, frequency, and severity of MSDs, as well
as any associated medical care and non-work-related injuries. The goal of Category 1 questions
was to quantify the number of medical dosimetrists with diagnosed MSDs related to work who
also fall into the risk categories. The second group of questions (Category 2) helped identify
commonalities in workstation design, ergonomic adaptations put in place, and the ability to make
changes to workstations. The rationale for these questions was to assess the awareness,
implementation, and effectiveness of individualized ergonomic design. The third category of
questions (Category 3) helped determine the need for further adaptations.
Study Validation
While the NMQ and CMDQ surveys were tested for validity, the current researchers
modified those surveys for a specific group of individuals; therefore, no measures of reliability
of validity had been documented. To ensure that every attempt was made to validate the survey
instrument, the survey questions were subjected to a pre-test and pilot study to justify the
question and study format. A 17-question pilot study was distributed amongst 28 medical
dosimetrist interns. Twelve study responses were sought for validation, 17 were received. Based
on results of the pilot study, questions 15 and 16 regarding the implementation of ergonomic
adaptations were reformatted to improve clarity and result accuracy, resulting in 18 questions for
the distributed survey. The final survey was prepared for distribution to a larger population.
Participant Selection & Description
The participant selection was composed of certified medical dosimetrists (CMDs) in the
United States. To ensure participants included only CMDs, all full members of the American
Association of Medical Dosimetrists (AAMD) membership database were selected to receive the
survey. Full members are medical dosimetrists who have been certified by the Medical
Dosimetrist Certification Board. The study was limited to these members, excluding any CMDs
working outside of the United States and other radiation oncology professionals. The selection
was only a sample of the medical dosimetry population as AAMD membership does not include
all CMDs from the entire United States.
Data Collection
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Certified medical dosimetrists (n = 2,642) were emailed a description of the research and
provided an electronic survey hyperlink. There was a statement of implied consent which
informed the participants that participation in the survey was voluntary and consent implied
when they proceeded with the survey. All participant information was anonymous and
confidential. Medical dosimetrists were asked to include only MSDs related to work
environment. The survey was distributed on September 24, 2020 by the AAMD member services
manager. In addition, a request to complete the survey was posted to the AAMD Facebook page
on September 27, 2020 to help increase the response rate. The survey was closed on October 2,
2020. The Qualtrics survey tool was used to store responses and extract information for data
analysis.
The survey used a mixed-method approach that combined closed-ended and open-ended
questions. The closed-ended part of the survey used multiple choice and polar questions to gather
information on demographics of the population, awareness of workstation ergonomics, and
ergonomic adaptations. A yes response to the polar questions was considered positive, while a
no response was considered negative. The open-ended part of the survey asked questions about
the frequency, severity, and work interference from experienced WRMSDs and implemented
ergonomic adjustments. Using the mixed-method approach in the collection of data allowed for
confirmation of responses which provided better feedback for the researchers.
Statistical Analysis
Quantitative analysis of the study consisted of the researchers using descriptive analyses
to compile and characterize demographic information and the incidence of MSDs in the medical
dosimetry profession. Qualtrics’ reporting algorithm was used to check for statistical
relationships between questions. The algorithm was used to check for cause and effect
relationships between questions. Qualitative analysis of the study consisted of using content
analysis procedures. The researchers sorted through the open-ended responses and identified
themes that characterize the commonalities in workspace design and ergonomic adjustments
implemented, the impact of these adjustments, and need for further ergonomic intervention.
Results
In total, 2,646 email surveys were distributed through the AAMD email contact list. Of
that distribution, 988 emails were opened for a contact rate of 37% (988/2646). One hundred
sixty-four responses were recorded yielding a participation rate of 17% (164/988).
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The first group of questions gathered demographic information from our population.
Nearly 69% (112/163) of respondents were female. The most common age range was 51-60
years old, with over half of respondents falling between 41-60 (Table 1). Fifty-four percent of
respondents (89/164) had over 15 years of medical dosimetry experience with 63% (104/164)
working more than an average of 40 hours per week (Table 1). The majority of respondents
reported that they work from a clinic or hospital setting. When questioned whether medical
dosimetrists stood from their computer stations at least once per hour during the workday, or
looked away from their computer screens at least once every 20 minutes throughout the
workday; the consensus was predominantly “no”. Fifty-seven percent of respondents (94/164)
answered that they do not stand up from their workstation every hour, and 71% (117/164)
answered that they do not look away from their computer screen every 20 minutes.
The second group of questions answered research question (Q1), what WRMSDs are
seen amongst medical dosimetrists. Of the 164 participants, 55% (90/164) answered “yes” to
whether they had experienced MSDs as a medical dosimetrist. The most commonly experienced
MSDs were headache, neck pain/fixation, nerve pain/damage, tension neck syndrome, and eye
strain/fatigue (Figure 1). When all WRMSDs were considered, 29% (188/652) of respondents
described work interference from individual MSDs as slight, nearly 16% (101/652) described
interference as moderate, and 3% (21/652) stated their work interference was severe. The other
respondents chose not applicable (N/A) as their response (Figure 2). Nearly 78% (70/90) of the
participants who had experienced WRMSDs sought medical care for their injuries; including
physician, chiropractic, or other therapies.
The next group of questions answered research question (Q2) and (Q3), what alterations
or adaptations have medical dosimetrists done to create an individualized ergonomic workspace,
and have these alterations or adaptations improved MSDs. Forty-seven percent (72/153) of
respondents had received training on the subject. Still, roughly 62% (94/152) of respondents
believe their employer had not designed their workstation ergonomically and more importantly,
nearly 68% (104/153) believe their workstation design did not fit their individual needs.
Furthermore, about 75% of respondents (114/153) had made ergonomic adaptations, yet 65%
(98/152) would like to see further adaptations made. Of the 75% (114/153) of respondents who
made ergonomic adaptations, the most frequently implemented equipment were sit/stand desks,
ergonomic chairs, and ergonomic wrist pads (Figure 3). The majority of ergonomic equipment
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was purchased by the employer; however, approximately 35% (99/283) of ergonomic equipment
implemented was purchased by the medical dosimetrists themselves. Seventy-nine percent
(210/265) ergonomic adaptations implemented improved MSDs.
Discussion
Due to the voluntary participation in this survey, researchers were unable to conclude
whether the demographics represent the field of medical dosimetry as a whole. Results from this
study showed that 69% (112/163) of respondents were female, 73% (119/164) ≥ 40 years of age,
and 54% (89/164) have worked as a medical dosimetrist for >15 years. These demographics
only reflect the survey’s participants who were members of the AAMD, and may not represent
the true demographic population of medical dosimetry.
In response to research question (Q1) what WRMSDs are seen amongst medical
dosimetrists; headache, neck pain/fixation, nerve pain/damage, tension neck syndrome, and eye
strain/fatigue were the most commonly experienced MSDs amongst the respondents who have
experienced WRMSDs. Although the response rate was small, results showed that > 55%
(90/163) of participants have experienced WRMSDs as medical dosimetrists. The results of this
study corroborate the research of Borhany et al6 who found pain in the neck, back, wrist, and
headache to be commonly reported for other computer users. Forty-four percent (289/652) of
responses indicated that the individually described WRMSDs had a slight or moderate impact on
medical dosimetrists’ work, which could impact productivity and time away from work leading
to increased costs to employers. Furthermore, research may be needed to verify statistical
relationships existing between years of experience, gender, standing/visual breaks, and incidence
of musculoskeletal disorders.
In response to research (Q2) and (Q3) what alterations or adaptations have medical
dosimetrists made to create an individualized workspace, and did these adaptations improve
MSDs; the most striking result of the current study was the number (>60%, 104/153) of medical
dosimetrists who thought their workstations were not ergonomically designed nor designed to fit
their individual needs. The length of time spent at a computer workstation in significant
concentration, without taking breaks from sitting or looking at their computer screens is linked to
increased risk of MSDs.7 Because medical dosimetrists fit this description, and according to this
study do experience MSDs, it is critical that their workstations be appropriately designed. For
those medical dosimetrists that had implemented ergonomic equipment into their workspace,
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results of this study showed that 79% (210/265) of the ergonomic equipment implemented
created a perceived improvement in WRMSDs. These results imply that ergonomic adjustments
and equipment may be useful in minimizing WRMSDs in medical dosimetrists. A cost benefit
analysis performed by Sultan-Taieb et al17 concluded that appropriately implemented ergonomic
interventions had a positive economic result in 7/9 studies examined. Ergonomic adjustments
and equipment can be an upfront cost to the employer, however, could be beneficial for long
term health and productivity of the employees.
Conclusion
Medical dosimetrists are at increased risk of developing diagnosed work-related
musculoskeletal disorders (WRMSDs) due to inappropriate posture and poor ergonomics,
repetitive motion, and length of time spent working at a computer. The purpose of this study was
to determine the incidence and variables of workstation ergonomics that contribute to the
increased risk of work-related musculoskeletal disorders seen in medical dosimetrists. To our
knowledge, this was the first study involving increased risk of WRMSDs observed in medical
dosimetrists based on workstation ergonomics.
Researchers in this study revealed that a majority of study participants experienced
WRMSDs that had a slight to moderate impact on work interference and perceived their
workstations as not ergonomically nor individually designed. Researchers also learned from
participants that 79% (210/265) of implemented ergonomic adaptations improved the reported
MSDs of respondents. Because the respondent population was small compared to the true
population of medical dosimetrists, further research is needed to provide conclusive correlations
between WRMSDs and the medical dosimetry population. Regarding the potential impact to
work interference caused by WRMSDs, further research is needed to fully understand the
causative factors for WRMSDs and the financial impact to employers. Furthermore, research to
help define employer awareness and ability to provide ergonomic workspaces for medical
dosimetrists may be of value. It may also be beneficial to recreate this study with a larger volume
of medical dosimetrists to get a more comprehensive representation of the extent of WRMSDs in
medical dosimetrists.
There were several limitations to this study. The study relied on email distribution
without verifying that recipients had active email addresses. Although the sample population was
large (n = 2646), only 37% (988/2646) of emails were opened, and of those opened emails, only
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164 surveys were completed. The most prominent limitation was the time limit for the survey
data collection, potentially impacting participation rates. The survey release was dependent on
distribution through an outside professional organization that was conducting its own research
which concluded in early September 2020; postponing this survey’s release until late September
2020. Due to the timeline of the graduate program and course deadlines, the shortened 8-day data
collection period may have limited this survey’s participation rates.
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Acknowledgements
The authors would like to thank Dr. David Reineke and the University of Wisconsin-La Crosse
Statistical Consulting Center for their guidance with data analysis and display of statistical
results for the study. Any errors in statistics or interpretation of data are the sole responsibility of
the authors.
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Figures

80

70
71 69
60 63
58
Number of Participants experiencing MSDs

50
50
40
36 35
30
31
20
19 17 16
10
7
0
s n isc isc e e .. ue s e
iti
s e
he io ag m t. iti m m
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d
am d r o en atig on d ro e ur d ro
d i e e m /f d
ea in
/f
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at ur /d sy
n
ga in Te
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H pa er upt p ain c k n /li s tra els g ita 'ss
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i
N
ec er n str Ey lt
D
er
N is o n a u
n do rp eQ
Te ten Ca D
o r
s cle
u
MMusculoskeltal Disorder (MSD)
Figure 1. Distribution of musculoskeletal disorders (MSDs) experienced in survey respondents
who answered that they have suffered from work-related musculoskeletal disorders (WRMDs).
 14

Slight Moderate Severe

35

30

25

20

15
Number of Participants

10

0
es on sc sc ag
e e in ue tis e
rit
is e
ach ati di di m r om p ra tig o ni r om u rom
d x d d a d s a d e d
ea /fi ate ur
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n
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n
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N u
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us
M

Musculoskeletal Disorder (MSD)

Figure 2. Reported level of work interference due to specific musculoskeletal disorders (MSDs).

70

60 62
56
Number of implemented adjustments

50
47
40
38
30 32
26
20 22

10

0
Stand/sit desk Ergonomic Ergonomic Specialized Ergonomic Ergonomoic Footrest
chair wrist pad computer keyboard mouse
screen

Ergonomic Adjustment

Figure 3. Distribution of ergonomic adjustments implemented by medical dosimetrists.

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Tables
Table 1. Survey demographic results and office setting question results (n=164).
Characteristic Mode Number
Age Range 51-60 years 47
Gender Female 112
Years of experience >15 years 89
Hours worked per week >40 104
Question Response Percentagea
Home
21%
Free-standing
What is your office setting? 32%
clinic
47%
Hospital
a
Information reflects percentage of 191 responses as 27 individuals worked
at multiple office settings