today s competitive labour market requires high levels of competitive and physical performance from professionals that can result in stress and fatigue and may promote the occurrence of errors and work - related musculoskeletal disorders ( wrmsds ) [ 1 , 2 ] . the development and adoption of human factors and ergonomic strategies are essential to guarantee safe working conditions during the performance of work tasks , services or when using equipment . these can contribute to a decrease or increase in the quality of a radiographers '   work and their productivity [ 2 , 3 ] . in mammography departments , radiographers need to adapt their behaviour and performance to the patient s characteristics when performing mammography procedures [ 1 , 2 , 4 ] . for this reason , it is essential to implement actions focussed on the system ( namely the equipment ) and in the examination room ( layout ) so that working conditions can be improved and radiographers ' health risks reduced [ 1 , 4 , 5 ] . nothing has been done in this area , and we expect to find conflicting mammographic design variables that are difficult for radiographers . recently , the society of radiographers published a document describing the wrmsds that can affect radiographers working in mammography rooms . this , accompanied by time constraints and high workloads , can lead to a range of symptoms ( pain , tenderness , swelling and muscle weakness ) that often result in wrmsds ( rotator cuff syndrome , tendinitis , trigger finger ) [ 6 , 7 ] . pniou and kapitaniak presented methods that allow the analysis of a subject undertaking tasks that can be considered high risk through a drawing of the activity or a picture where the mechanical axis , mass centre and rotation centre are the focus . the vector calculations are performed for each joint , and the results are analysed comparing them with references and standards . the lack of national and international studies on digital mammography ( dm ) hinders the optimisation of radiographers working conditions and performance . it seems assumed that system design is fundamentally guided by mammography equipment specifications in the form of a set of criteria that the final system has to meet , forgetting radiographers characteristics . from a patient - safety perspective , it is also possible to consider a range of work system factors contributing to radiographer errors , such as time pressure , verbal or written communication problems , and bad equipment design . therefore , it is important to explore the gap in the concepts of mammography equipment design . the objective of this study was to investigate how the design of mammography equipment affects radiographers postures during mammography procedures . the study was performed in a private hospital in lisbon using digital mammography equipment ( general electric healthcare model senographe ds ) . in a first phase , observation was used to collect data related to the stature of patients who had scheduled a mammography on 3 different days ( monday , wednesday , friday ) ( n  =  93 ) and radiographers ( i  =  7 ) to identify the extremes ( taller and shorter ) . observation was also used to characterise the equipment and the practice , defining the main tasks related to the positioning performed by radiographers during mammography examination on a time scale . the data were collected during three different 6-h shifts on different week days ( monday , wednesday , friday ) . in a second phase , a simulation of patient positioning for the most frequent mammographic projections [ craniocaudal ( cc ) and mediolateral oblique ( mlo ) ] using volunteers was performed . three combinations of radiographer - patient statures were analysed using the data related to the stature extremes : the radiographer was taller than the patient ( anthropometric stature radiographer / patient combination : 171  cm/153  cm);the radiographer was shorter than the patient ( anthropometric stature radiographer / patient combination : 148  cm/174  cm);the radiographer and patient had approximately the same stature ( anthropometric stature radiographer / patient combination : 171  cm/174  cm ) . the radiographer was taller than the patient ( anthropometric stature radiographer / patient combination : 171  cm/153  cm ) ; the radiographer was shorter than the patient ( anthropometric stature radiographer / patient combination : 148  cm/174  cm ) ; the radiographer and patient had approximately the same stature ( anthropometric stature radiographer / patient combination : 171  cm/174  cm ) . periods of awkward and prolonged postures during each mammography procedure were analysed from photos obtained during procedure simulations and selected by four raters via consensus ( 1.245 , 1.187 and 1.092 photographs for the three simulations , respectively ) . for this , a canon eos 70d with four frames per second was used . the main body angles ( head / neck , trunk and arms ) were assessed according to the methodology proposed by kapitaniac   by the same four raters in loco consensus observing the frames . angle measurements were performed using the meazure 2.0.158 programme and the postures evaluated and classified according to european standard bs en 10054 : 2005 + a1:2008 ( table  1 ) on three different levels : acceptable , conditionally acceptable and not acceptable . it was also taken into account whether the radiographer was in a static ( no movement ) or dynamic posture ( performing tasks associated with positioning requiring movement of the joints , namely the shoulder , elbow , knees and neck ) . 10054:2005  +  a1:2008 ) : acceptable , conditionally acceptable and not acceptableposturesreference valuesacceptableconditionally acceptablenot acceptabletrunkforward/ backward bending0to 2020 to 60 or  < 0 
 < 60sideways bending/ twisting0 to |10|>|10|upper armflexionabduction0 to 2020 to 60 
 > 60 or  < 0head / neckupward/ downward bending()40 to 0<40 or  > 0sideways bending0 to |10||10| 
 acceptability depends upon the duration of the posture and period of recovery ; acceptable if there is full trunk support ; acceptable if there is full arm support ; if there is no full arm support , acceptability depends upon the duration of the posture and period of recovery reference values for postural assessment ( norma bs en 10054:2005  +  a1:2008 ) : acceptable , conditionally acceptable and not acceptable 
 acceptability depends upon the duration of the posture and period of recovery ; acceptable if there is full trunk support ; acceptable if there is full arm support ; if there is no full arm support , acceptability depends upon the duration of the posture and period of recovery individual interviews were conducted with seven radiographers with experience in dm focussed on physical discomfort , repetition of movements , work sequence and postures . the content analysis technique was used to organise the information analysing the frequency of occurrence of the terms associated with mammography activities and the equipment by three researchers . during the interview , all radiographers also classified the level of the task demand ( effort ) according to the borg cr10 scale at each posture . this scale is used for estimating effort and exertion , breathlessness and fatigue during physical work . the borg cr10 scale is a category ratio ( cr ) scale based on the number 10 , which represents extreme intensities . also , it was asked about the equipment characteristics , namely : control station height , accessibility of the monitor , accessibility of compression devices , accessibility of the compression paddles and intensity of the positioning light . patient preparation was identified as the most time - consuming task ( informed consent ) , as was sending the images to the pac systems at the end of the mammography examination . the time required for c - arm adjustment was variable for the first projection , while the others did not cause a time loss as they were performed automatically by the equipment after the activation of the control button . in mlo views , the average time spent for right breast positioning was slightly higher ( 13  s ) than for the left breast . in addition , it was noticed that the average duration of this task increased gradually when compared to the beginning of the work shift . the duration of breast compression on average reached its highest value in the right breast cc view ( 14  s ) at the end of the shift . the average duration of the breast compression application for mlo views reached its higher value in the middle of the work shift at 12  s. for the time interval prior to effective exposure , a variation in the three periods considered for the study was found , the lowest values always being registered in the middle of the work shift . the positioning of the breast for cc image acquisition when the radiographer and patient have the same height ( fig .  1 and table  2 ) requires the radiographer to assume an orthostatic posture . the right arm assumes a slight flexion , and the forearm performs a rotation in the inner direction so that the palm of the hand supports the patient 's back . the left hand ( although not visible in the image ) smoothes the breast down and forward with the fingers . the right leg supports part of the radiographer s body weight , while the left leg performs a slight flexion to reach the compressor foot pedal .fig . 1postures assumed by the radiographer with similar height compared to the patienttable 2positioning angles : radiographer smaller than the patientposturepositioningmeasured angleobs.trunkforward/ backward bendingcc0acceptableoml8.1acceptablesideways bending/ twistingcc12.3not acceptableoml5.8acceptablearmsflexioncc135.5not acceptableoml76.1not acceptableabductioncc91.6not acceptableoml57.5conditionally acceptablehead / neckupward / downward bendingcc()10.2acceptableoml20.4not acceptablesideways bendingcc()13.2not acceptableoml25not acceptable postures assumed by the radiographer with similar height compared to the patient positioning angles : radiographer smaller than the patient according to european norm 10054 , the trunk posture is classified as  acceptable  in both static and dynamic body postures once the trunk maintains a vertical posture without inclinations or rotations . the right arm also assumes an  acceptable  posture during the flexion and abduction in dynamic and static contexts . the head / neck did not tilt or rotate during the procedure ; therefore , it is always in an the radiographer 's trunk was flexed and the head / neck extended to observe all breast tissue . the right arm remained flexed , and the hand kept supporting the patient s back . the radiographer s body weight was supported by the right leg , which kept a slight flexion , while the left leg was in position to easily reach the compression foot pedal . the arm position was rated as  not acceptable  in the static situation , whether in flexion or abduction , and was rated as  acceptable  while in motion once this posture was kept for a short duration . the head / neck posture was classified as  not acceptable  in static conditions and  acceptable  in motion . if the radiographer is smaller than the patient ( fig . 2 and table  3 ) , the positioning of the breast for cc patient positioning was done maintaining an orthostatic posture with the vertebral spine aligned to the mid - sagittal plane of the body . the right forearm revealed internal rotation , and the palm of the hand stayed on the patient back , ensuring that the patient remained still and in the correct position . the left hand was positioning the patient s breast , exerting a slight pressure on it and smoothing it in the anterior direction to ensure the nipple was appropriately positioned before starting the compression . in this specific context , due to the height difference between the radiographer and the patient , the breast area that the radiographer visualised was reduced , showing a tendency for the radiographers to compensate for the height difference by standing on their tiptoes . 2postures assumed by a radiographer smaller than the patienttable 3positioning angles : radiographer taller than the patientposturepositioningmeasured angleobs.trunkforward/ backward bendingcc6.7acceptableoml63.6not acceptablesideways bending / twistingcc0acceptableomlarmsflexioncc18.2acceptableoml108.5not acceptableabductioncc41.4conditionally acceptableoml118.6not acceptablehead / neckupward/ downward bendingcc()20acceptableoml87.2not acceptablesideways bendingccnot measurableoml postures assumed by a radiographer smaller than the patient positioning angles : radiographer taller than the patient the postural assessment of the trunk was classified as  acceptable  either for static posture or in movement . the right arm posture , when in static position , was considered as  not acceptable  in flexion and abduction positions . in movement , its positioning was  acceptable  for both flexion and abduction , following the condition of being maintained for a short period of time . the head / neck postures were  acceptable  for both considered situations . in mlo patient breast positioning , the radiographer maintained a slight flexion and left lateral inclination of the trunk . the posture of the arms and legs was similar to what was previously described for the cc positioning in this same context . the head / neck stood in extension with a slight left inclination , so the radiographer was able to obtain a good view of all areas under study . according to the european norm en-1005 - 4 , the trunk posture was  acceptable  for both static and movement situations . in the static situation , this fact compromises the postural acceptability of the body region considered . in a radiographer s dynamic body situation , the arm flexion posture was  acceptable  once it had been kept for a short period . the arm abduction posture , in the threshold of acceptability , was determined to be  acceptable  according to the same parameters described for the static situation . acceptable  if maintained for a short period of time . when the radiographer is taller than the patient ( fig .  3 and table  4 ) , the positioning of the breast for the acquisition of cc patient positioning requires that the radiographer maintain an orthostatic posture , performing a slight flexion of the trunk and head / neck as a guarantee for the correct visualisation of the breast . the right forearm performed an internal rotation when the radiographer placed an arm around the patient 's shoulder . the left hand applied the necessary pressure to hold the breast and to prevent the formation of skin wrinkles . both legs were aligned with the trunk , with the left in slight flexion to reach the foot pedal and to activate the compression mechanism .fig . 3postures assumed by a radiographer taller than the patienttable 4positioning angles : the radiographer and patient with similar heightsposturepositioningmeasured angleobs.trunkforward/ backward bendingcc0acceptableoml46.4conditionally acceptablesideways bending/ twistingcc0acceptableoml0acceptablearmsflexioncc7.3acceptableoml123.5not acceptableabductioncc31.9conditionally acceptableoml103,5not acceptablehead / neckupward/ downward bendingcc()14.8acceptableoml51.9not acceptablesideways bendingcc0acceptableomlnot measurable postures assumed by a radiographer taller than the patient positioning angles : the radiographer and patient with similar heights according to the european norm , in cc breast positioning , the trunk assumed an  acceptable  posture for both static and movement situations . concerning the arm posture , flexion and abduction , the  acceptable  classification was attributed to the small duration of its recovery period . when the radiographer was moving , the arm posture was considered the head / neck posture was  acceptable  for a static posture and also during the radiographer 's movement . side bending or rotations were not identified . for the mlo patient breast positioning , the radiographer performed severe trunk flexion . the head / neck was in hyperextension to allow the radiographerto have correct visualisation of the breast that was being positioned . both arms were outstretched above the shoulders and flexed at the elbow level , and while the right hand was resting on the patient s back , the left hand was positioning the breast on the equipment . the leg , extremely flexed , and the right foot were supporting the majority of the radiographer s body weight . the left leg was slightly flexed in a way to keep the body balanced and be able to reach the foot pedal . the height difference of both the radiographer and the patient requires greater physical effort from the radiographer to maintain a body position that allows him / her to work ( tables  5 and 6 ) . table 5interview analysis : work space and postures adopted by the radiographercategorysub - categoryfrequencypercentwork pace and movementsrepetition of the same movements729.17accelerated pace416.66normal pace729.17depends on the physician 's work pace312.5depends on the type of examination312.5total24100adopted posturesnot adequate834.78uncomfortable521.73required postures to perform the examination28.7longstanding417.39corporal adjustment28.7information about this subject does not exist28.7total23100table 6interview analysis : situations that trigger physical effort and affected anatomical regionscategorysub - categoryfrequencypercentsituations that trigger physical effortmlo positioning1045.45shorter patients522.72taller patients313.64bigger breasts29.09smaller breasts14.55patient s 1 mammography14.55total22100affected anatomical regionscervical spine214.29shoulder428.57hands17.14lumbar spine535.71legs214.29total14100 interview analysis : work space and postures adopted by the radiographer interview analysis : situations that trigger physical effort and affected anatomical regions the evaluation of the radiographer s posture in mlo patient positioning demonstrated that the trunk posture was  not acceptable  in the static position . in motion , the position of the arms ( flexion and abduction ) was classified as " not acceptable " in the static situation and " acceptable " in motion for the same reason mentioned in the trunk assessment . the head / neck posture was  acceptable  in both considered situations . during the interviews , all radiographers referred physical discomfort during the patient positioning to the muscular effort . the positioning of the mlo projection was considered the most demanding by 45.5  % of the radiographers , followed by the positioning of patients who have a shorter stature ( 22.7  % ) . the body areas identified as being subjected to greater effort were the shoulder , which is used for positioning the breast ( 28.6  % ) and also the neck ( table  2 ) . of those , 71  % reported physical fatigue at the end of the work shift ( table  3 ) . regarding the body postures , radiographers indicated that breast positioning can cause discomfort . as a consequence , radiographers suggested that the implementation of specialised training to correct and adopt the appropriate body postures might reduce the negative impacts on health . regarding the equipment the monitor was referred to four times ( 30.8  % ) as being at the level of the radiographers eyes . in the equipment category , 100  % of the radiographers considered the buttons used to adjust the equipment to have an adequate size and location in the gantry . they stated that the mobility of the pedals allowed an easier positioning of the patient and the breast since their hands were free to work . their opinion was also unanimous regarding the ease with which the button symbols could be interpreted . considering the light field used to position the breast , 71.4  % of the radiographers classified it as sufficient to identify the breast boundaries . the positioning of the breast for cc image acquisition when the radiographer and patient have the same height ( fig .  1 and table  2 ) requires the radiographer to assume an orthostatic posture . the right arm assumes a slight flexion , and the forearm performs a rotation in the inner direction so that the palm of the hand supports the patient 's back . the left hand ( although not visible in the image ) smoothes the breast down and forward with the fingers . the right leg supports part of the radiographer s body weight , while the left leg performs a slight flexion to reach the compressor foot pedal .fig . 1postures assumed by the radiographer with similar height compared to the patienttable 2positioning angles : radiographer smaller than the patientposturepositioningmeasured angleobs.trunkforward/ backward bendingcc0acceptableoml8.1acceptablesideways bending/ twistingcc12.3not acceptableoml5.8acceptablearmsflexioncc135.5not acceptableoml76.1not acceptableabductioncc91.6not acceptableoml57.5conditionally acceptablehead / neckupward / downward bendingcc()10.2acceptableoml20.4not acceptablesideways bendingcc()13.2not acceptableoml25not acceptable postures assumed by the radiographer with similar height compared to the patient positioning angles : radiographer smaller than the patient according to european norm 10054 , the trunk posture is classified as  acceptable  in both static and dynamic body postures once the trunk maintains a vertical posture without inclinations or rotations . the right arm also assumes an  acceptable  posture during the flexion and abduction in dynamic and static contexts . the head / neck did not tilt or rotate during the procedure ; therefore , it is always in an the radiographer 's trunk was flexed and the head / neck extended to observe all breast tissue . the right arm remained flexed , and the hand kept supporting the patient s back . the radiographer s body weight was supported by the right leg , which kept a slight flexion , while the left leg was in position to easily reach the compression foot pedal . the arm position was rated as  not acceptable  in the static situation , whether in flexion or abduction , and was rated as  acceptable  while in motion once this posture was kept for a short duration . the head / neck posture was classified as  not acceptable  in static conditions and  acceptable  in motion . the positioning of the breast for cc image acquisition when the radiographer and patient have the same height ( fig .  1 and table  2 ) requires the radiographer to assume an orthostatic posture . the right arm assumes a slight flexion , and the forearm performs a rotation in the inner direction so that the palm of the hand supports the patient 's back . the left hand ( although not visible in the image ) smoothes the breast down and forward with the fingers . the right leg supports part of the radiographer s body weight , while the left leg performs a slight flexion to reach the compressor foot pedal .fig . 1postures assumed by the radiographer with similar height compared to the patienttable 2positioning angles : radiographer smaller than the patientposturepositioningmeasured angleobs.trunkforward/ backward bendingcc0acceptableoml8.1acceptablesideways bending/ twistingcc12.3not acceptableoml5.8acceptablearmsflexioncc135.5not acceptableoml76.1not acceptableabductioncc91.6not acceptableoml57.5conditionally acceptablehead / neckupward / downward bendingcc()10.2acceptableoml20.4not acceptablesideways bendingcc()13.2not acceptableoml25not acceptable postures assumed by the radiographer with similar height compared to the patient positioning angles : radiographer smaller than the patient according to european norm 10054 , the trunk posture is classified as  acceptable  in both static and dynamic body postures once the trunk maintains a vertical posture without inclinations or rotations . the right arm also assumes an  acceptable  posture during the flexion and abduction in dynamic and static contexts . the head / neck did not tilt or rotate during the procedure ; therefore , it is always in an the radiographer 's trunk was flexed and the head / neck extended to observe all breast tissue . the right arm remained flexed , and the hand kept supporting the patient s back . the radiographer s body weight was supported by the right leg , which kept a slight flexion , while the left leg was in position to easily reach the compression foot pedal . the arm position was rated as  not acceptable  in the static situation , whether in flexion or abduction , and was rated as  acceptable  while in motion once this posture was kept for a short duration . the head / neck posture was classified as  not acceptable  in static conditions and  acceptable  in motion . if the radiographer is smaller than the patient ( fig .  2 and table  3 ) , the positioning of the breast for cc patient positioning was done maintaining an orthostatic posture with the vertebral spine aligned to the mid - sagittal plane of the body . both arms were flexed and abducted . the right forearm revealed internal rotation , and the palm of the hand stayed on the patient back , ensuring that the patient remained still and in the correct position . the left hand was positioning the patient s breast , exerting a slight pressure on it and smoothing it in the anterior direction to ensure the nipple was appropriately positioned before starting the compression . in this specific context , due to the height difference between the radiographer and the patient , the breast area that the radiographer visualised was reduced , showing a tendency for the radiographers to compensate for the height difference by standing on their tiptoes . 2postures assumed by a radiographer smaller than the patienttable 3positioning angles : radiographer taller than the patientposturepositioningmeasured angleobs.trunkforward/ backward bendingcc6.7acceptableoml63.6not acceptablesideways bending / twistingcc0acceptableomlarmsflexioncc18.2acceptableoml108.5not acceptableabductioncc41.4conditionally acceptableoml118.6not acceptablehead / neckupward/ downward bendingcc()20acceptableoml87.2not acceptablesideways bendingccnot measurableoml postures assumed by a radiographer smaller than the patient positioning angles : radiographer taller than the patient the postural assessment of the trunk was classified as  acceptable  either for static posture or in movement . the right arm posture , when in static position , was considered as  not acceptable  in flexion and abduction positions . in movement , its positioning was  acceptable  for both flexion and abduction , following the condition of being maintained for a short period of time . the head / neck postures were  acceptable  for both considered situations . in mlo patient breast positioning , the radiographer maintained a slight flexion and left lateral inclination of the trunk . the posture of the arms and legs was similar to what was previously described for the cc positioning in this same context . the head / neck stood in extension with a slight left inclination , so the radiographer was able to obtain a good view of all areas under study . according to the european norm en-1005 - 4 , the trunk posture was  acceptable  for both static and movement situations . in the static situation , this fact compromises the postural acceptability of the body region considered . in a radiographer s dynamic body situation , the arm flexion posture was  acceptable  once it had been kept for a short period . the arm abduction posture , in the threshold of acceptability , was determined to be  acceptable  according to the same parameters described for the static situation . when the radiographer is taller than the patient ( fig .  3 and table  4 ) , the positioning of the breast for the acquisition of cc patient positioning requires that the radiographer maintain an orthostatic posture , performing a slight flexion of the trunk and head / neck as a guarantee for the correct visualisation of the breast . the right forearm performed an internal rotation when the radiographer placed an arm around the patient 's shoulder . the left hand applied the necessary pressure to hold the breast and to prevent the formation of skin wrinkles . both legs were aligned with the trunk , with the left in slight flexion to reach the foot pedal and to activate the compression mechanism .fig . 3postures assumed by a radiographer taller than the patienttable 4positioning angles : the radiographer and patient with similar heightsposturepositioningmeasured angleobs.trunkforward/ backward bendingcc0acceptableoml46.4conditionally acceptablesideways bending/ twistingcc0acceptableoml0acceptablearmsflexioncc7.3acceptableoml123.5not acceptableabductioncc31.9conditionally acceptableoml103,5not acceptablehead / neckupward/ downward bendingcc()14.8acceptableoml51.9not acceptablesideways bendingcc0acceptableomlnot measurable postures assumed by a radiographer taller than the patient positioning angles : the radiographer and patient with similar heights according to the european norm , in cc breast positioning , the trunk assumed an  acceptable  posture for both static and movement situations . concerning the arm posture , flexion and abduction , the  acceptable  classification was attributed to the small duration of its recovery period . the head / neck posture was  acceptable  for a static posture and also during the radiographer 's movement . side bending or rotations were not identified . for the mlo patient breast positioning , the radiographer performed severe trunk flexion . the head / neck was in hyperextension to allow the radiographerto have correct visualisation of the breast that was being positioned . both arms were outstretched above the shoulders and flexed at the elbow level , and while the right hand was resting on the patient s back , the left hand was positioning the breast on the equipment . the leg , extremely flexed , and the right foot were supporting the majority of the radiographer s body weight . the left leg was slightly flexed in a way to keep the body balanced and be able to reach the foot pedal . the height difference of both the radiographer and the patient requires greater physical effort from the radiographer to maintain a body position that allows him / her to work ( tables  5 and 6 ) . table 5interview analysis : work space and postures adopted by the radiographercategorysub - categoryfrequencypercentwork pace and movementsrepetition of the same movements729.17accelerated pace416.66normal pace729.17depends on the physician 's work pace312.5depends on the type of examination312.5total24100adopted posturesnot adequate834.78uncomfortable521.73required postures to perform the examination28.7longstanding417.39corporal adjustment28.7information about this subject does not exist28.7total23100table 6interview analysis : situations that trigger physical effort and affected anatomical regionscategorysub - categoryfrequencypercentsituations that trigger physical effortmlo positioning1045.45shorter patients522.72taller patients313.64bigger breasts29.09smaller breasts14.55patient s 1 mammography14.55total22100affected anatomical regionscervical spine214.29shoulder428.57hands17.14lumbar spine535.71legs214.29total14100 interview analysis : work space and postures adopted by the radiographer interview analysis : situations that trigger physical effort and affected anatomical regions the evaluation of the radiographer s posture in mlo patient positioning demonstrated that the trunk posture was  not acceptable  in the static position . in motion , the position of the arms ( flexion and abduction ) was classified as " not acceptable " in the static situation and " acceptable " in motion for the same reason mentioned in the trunk assessment . the head / neck posture was  acceptable  in both considered situations . during the interviews , all radiographers referred physical discomfort during the patient positioning to the muscular effort . the positioning of the mlo projection was considered the most demanding by 45.5  % of the radiographers , followed by the positioning of patients who have a shorter stature ( 22.7  % ) . the body areas identified as being subjected to greater effort were the shoulder , which is used for positioning the breast ( 28.6  % ) and also the neck ( table  2 ) . of those , 71  % reported physical fatigue at the end of the work shift ( table  3 ) . regarding the body postures as a consequence , radiographers suggested that the implementation of specialised training to correct and adopt the appropriate body postures might reduce the negative impacts on health . regarding the equipment the monitor was referred to four times ( 30.8  % ) as being at the level of the radiographers eyes . in the equipment category , 100  % of the radiographers considered the buttons used to adjust the equipment to have an adequate size and location in the gantry . they stated that the mobility of the pedals allowed an easier positioning of the patient and the breast since their hands were free to work . their opinion was also unanimous regarding the ease with which the button symbols could be interpreted . considering the light field used to position the breast , 71.4  % of the radiographers classified it as sufficient to identify the breast boundaries . through this simulation and body posture evaluation according to the european norms ( bs en 10054:2005 ) , it was possible to verify that some of the postures were classified as  not acceptable  mostly for mlo breast positioning considering the static posture of the radiographer . this was also noted by the radiographers who reported physical discomfort required for the positioning of the mlo projections considering the smaller patients . according to the european norms , it was possible to verify the postures that had not been classified as  acceptable  in a static position . however , it became  acceptable  when performed during the dynamic context when the lower limbs were fully supported . the body position may be maintained for a short period of time ( < 2  min ) after a recovery period while changing the body posture . mammography positioning requires a continuous repetition of the same movements during the entire work shift ( more than 20 patients per shift ) . body postures may contribute to an increasing risk to develop wrmsds [ 2 , 4 ] . the major risks in breast positioning are caused by the need for continuous observation of the breast while standing too close to the patient and during the breast positioning on the breast support to guarantee that all tissue is included on the image . the first situation requires an exaggerated extension and rotation of the radiographer 's neck due to the equipment design and will also have an influence on the adoption of awkward postures at the level of the trunk and legs . in the second situation these movements increase the risk when associated with a constant application of force in the breast to support its weight and to keep it in the proper position performing the compression . although interventions were not mentioned in this study , they have already been described in other studies , including the existence of different mammography positioning strategies mainly for the mlo projection [ 1 , 4 ] . the radiographers adoption of a lower position relative to the patient , by sitting or kneeling , might result in a lower neck extension and trunk twisting , as well as lesser effort for the lower limbs [ 1 , 4 ] . . however , this focused intervention ( worker centred ) does not substitute a broader one that minimises constraints such as equipment redesign . therefore , the mammograph used in this study could not be adjusted by the radiographers , particularly in the mlo position of the breast and when a great discrepancy between the heights of the radiographers and patients existed . it is possible that motion features developed considering only the adjustability for the patient , without considering the radiographers ' well - being at work [ 13 , 14 ] . mammograph design according to this study does not allow for the comfort and safety of radiographers and patients . according to the en 1005 recommendations , the mammography equipment in use during this simulation was not adjustable for radiographers . cc and mlo mammography proceedings were highly demanding for radiographers , and there are postures classified as  not acceptable  during working procedures in mammography . mlo patient positioning required the radiographers to assume frequent awkward postures , which can increase symptoms , pain and perhaps wrmsds . the ergonomic design of the mammography equipment may make a substantive contribution to wrmsd prevention considering radiographers anthropometric characteristics . interventions should have two main approaches : ( 1 ) equipment redesign preventing radiographers ' awkward postures during mammography positioning ; ( 2 ) education and training of radiographers in ergonomics and work - related musculoskeletal disorders that include different types of patient and radiographer positioning , for instance , asking the patient to sit when the patient is taller than the radiographer ( for cc projection positioning ) , or the radiographer can sit when the patient is shorter ( for mlo projection positioning ) . improving workplace health and safety in radiology and empowering
objectivesidentify radiographers postures during frequent mammography procedures related to the mammography equipment and patient characteristics.methodsa postural task analysis was performed using images acquired during the simulation of mammography positioning procedures . 
 simulations included craniocaudal/(cc ) and mediolateral - oblique/(mlo ) positioning in three different settings : radiographers and patients with similar statures , radiographers smaller than the patients and radiographers taller than the patients . 
 measurements of postural angles were performed by two raters using adequate software and classified according to the european standard en1005 - 4:2005 + a1:2008.resultsthe simulations revealed that the most awkward posture in mammography is during the positioning of mlo projection in short - stature patients . 
 postures identified as causing work - related musculoskeletal disorder ( wrmsd ) risk were neck extension , arms elevated and the back stooped , presenting angles of 87.2 , 118.6 and 63.6 , respectively . if radiographers were taller than patients , then the trunk and arm postures were not acceptable.conclusionsworking in a mammography room leads to awkward postures that can have an impact on radiographers health , namely wrmsds . 
 the results in this study showed that there are non - acceptable postures associated with frequent working procedures in mammography . 
 mlo is the most demanding procedure for radiographer postures and may be related to wrmsds . 
 mammography devices should be redesigned considering adjustability for radiographers.main messages mammography constraints for radiographers in mammography procedures have not been well studied. performing mammography leads to awkward postures that can impact radiographers health. mlo , the most demanding procedure for radiographers , is possibly related to wrmsds .