ORIGINAL ARTICLE

Coaching Reduced the Radiation Dose of Pain

Physicians by Half during Interventional
Procedures

ultuna, MD†; J. A. Aukes, MD†;

A. S. Slegers, MSc* ; I. G€
E. J. J. A. A. van Gorp, MD†; F. M. N. Blommers, BHS‡; S. P. Niehof, PhD§;
J. Bosman, MSc, PhD*
*Department of Medical Physics, Albert Schweitzer Hospital, Dordrecht; †Department of
Anesthesiology, Albert Schweitzer Hospital, Dordrecht; ‡Department of Radiology, Albert
Schweitzer Hospital, Dordrecht; §Department of Medical Physics, Maasstad Hospital,
Rotterdam, the Netherlands

& Abstract: The increased use of C-arm fluoroscopy in
interventional pain management has led to higher radiation
exposure for pain physicians. This study investigated whether
or not real-time radiation dose feedback with coaching can
reduce the scatter dose received by pain physicians. Firstly,
phantom measurements were made to create a scatter dose
profile, which visualizes the average scatter radiation for
different C-arm positions at 3 levels of height. Secondly, in
the clinical part, the radiation dose received by pain physi-
cians during pain treatment procedures was measured real-
time to evaluate (1) the effect of real-time dose feedback on
the received scatter dose, and (2) the effect of knowledge of
the scatter dose profile and active coaching, on the scatter
dose received by the pain physician. The clinical study
included 330 interventional pain procedures. The results
showed that real-time feedback of the received dose did not
lead to a reduction in scatter radiation. However, visualiza-
tion of the scatter dose in a scatter dose profile and active
coaching on optimal positions did reduce the scatter radia-
Address correspondence and reprint requests to: A. S. Slegers, MSc,
Albert Schweitzerplaats 25, Postbus 444, 3300 AK Dordrecht, the Nether-
lands. E-mail: s.slegers@asz.nl.
Submitted: May 28, 2014; Revised: August 9, 2014;
Revision accepted: September 1, 2014
DOI. 10.1111/papr.12251
© 2014 World Institute of Pain, 1530-7085/14/$15.00
Pain Practice, Volume 15, Issue 5, 2015 400–406
tion received by pain physicians during interventional pain
procedures by 46.4% (P = 0.05). Knowledge of and real-time
coaching with the scatter dose profile reduced the dose of
pain physicians by half, caused by their increased awareness
for scatter radiation and their insight into strategic position-
ing. &
Key Words: scatter dose, pain interventions, coaching,
education, scatter dose profile, fluoroscopy, radiology, C-arm
INTRODUCTION
Scatter radiation, as a side effect of fluoroscopy,
increasingly constitutes an occupational hazard for pain
physicians. Fluoroscopic guidance is used for accurate
needle placement to ensure target specificity and accu-
rate delivery of the injected drug, often combined with
pulsed radiofrequency/radiofrequency (PRF/RF) treat-
ments of the nerves and intradiscal procedures. Fluo-
roscopy involves risks of radiation exposure, not only
for the patient, but also for the pain physician and the
personnel in the room.1–4
Studies evaluating dose levels received by pain
physicians performing fluoroscopically guided interven-
tional procedures show that radiation dose levels to
physicians are within regulated acceptable dose limits if
 Reduction of Radiation Dose Received By Pain Physicians  401
adequate radiation protection measures have been
implemented.1,5–10 Still, the as low as reasonably
achievable (ALARA) principle has to be taken into
account in view of the uncertainties in the cumulative
effects of low levels of radiation.5,11,12
A method to optimize radiation protection during
fluoroscopy is knowledge of radiation dose levels and of
basic strategies to minimize these levels.13 Awareness of
dose levels can be provided to specialists using a system
that gives real-time information about the received
dose.14,15 The Dose Aware system (Philips Healthcare,
Best, the Netherlands) contains personal dosimeters for
real-time visualization of the received dose on a mon-
itor. A prototype of the Dose Aware system was used in
an angiography room in a study of Sanchez et al.14 They
concluded that the system can help to optimize staff
members’ radiation protection during fluoroscopy.
Recently, the Dose Aware system was used by Sandblom
et al.15 to evaluate its impact on the dose rate of
cardiologists during fluoroscopically guided procedures.
They found that real-time visualization of radiation dose
rate may have a positive impact on optimization of
occupational radiological protection for cardiac inter-
ventions.15
The primary source of radiation to pain physicians
during interventional procedures is from scatter radia-
tion that is reflected by the patient. Pain physicians
performing fluoroscopically guided procedures gener-
ally stand close to the patient and the radiation source,
which makes it difficult to avoid exposure to radiation
scatter.16–19 Furthermore, new possibilities and
increased complex pain treatments demand a higher
number of fluoroscopic guided procedures.20 As an
indication, the pain physicians in our hospital treat
about 1,080 patients a year, and receive a dose of
7.1 mSv a year on top of their lead apron. So far, little is
known about scatter radiation dose in pain intervention
management. Therefore, this study investigated if it was
possible to further reduce the scatter radiation dose
received by pain physicians.
The aim of this research was firstly to evaluate the
effect of real-time dose feedback on the dose received by
pain treatment physicians. Dose registration and real-
time visualization of the radiation dose was achieved
using the Philips Dose Aware system. Additionally, we
evaluated the effect of actively coaching the pain
physicians to optimize their dose using scatter dose
profiles, a visualization of scatter radiation from the
X-ray tube in different directions, in combination with
real-time feedback of the received dose.
METHODS
This study was performed at the Albert Schweitzer
hospital, location Sliedrecht, the Netherlands in 2012 to
2013. It consists of both phantom and clinical measure-
ments. The study was granted exempt status by the
Institutional Review Board.
Scatter radiation was measured using a Dose Aware
system, which used personal dosimeters (PDMs). These
PDMs have a solid-state detector with an X-ray dose
rate range of 3 nSv/second to 15 lSv/second. This
system was used to measure scatter radiation dose in
both phantom and clinical stage. The PDM has a solid-
state detector equipped with a wireless connection that
sends the scatter dose rate and cumulative scatter dose
readings to a base station each second when it detects a
certain level of radiation.14 If the dosimeter does not
detect any significant radiation levels, information is
transmitted to the base station each hour.
Phantom Measurements
Phantom measurements were made to create a scatter
dose profile of the situation on site. This profile
visualizes the average scatter radiation for different
C-arm (Ziehm, Vision Ortho Plus) positions at 3 levels
of height.
The PDMs were used in phantom measurements to
visualize the scatter radiation in transverse and longitu-
dinal directions. The obtained phantom measurements
were visualized in a scatter dose profile. For the
phantom measurements, a PMMA block, size
8 9 30 9 30 cm, was placed at the center of the table
to symbolize a scattering surface of a human body. We
measured at 3 levels of height, representing three parts
of the physicians body: 45 cm from the floor for the
knees, 110 cm for the abdomen, and 165 cm for eye
level. The scatter radiation was measured in 16 angles
from the target for each height, at a radius of 60 cm,
100 cm, 150 cm, and 200 cm from the center of the
table, (Figure 1). A profile was estimated for the
posterior–anterior (PA) position as well as for the lateral
(LAT) position of the C-arm. The settings used for the
PA position were an automatic fluoroscopy of 67 kV,
7.8 mAs, 25 pulses/second, and a table position of
83 cm from floor level. The settings for the LAT position
were an automatic fluoroscopy of 110 kV, 7.2 mAs, 25
pulses/second, and a table position of 100 cm from floor
level. These settings were adjusted to the C-arm at the
operation room, as well as to the C-arm at the pain
402  SLEGERS ET AL.
A
B was similar.
Figure 1. (A and B) The pain treatment center for pain interven-
tions. The images show the set up which is used to measure the
dose profile of the C-arm using the Dose aware badges (see
marks). In figure (A), the posterior-anterior position of the C-arm
is shown, in figure (B), the lateral position. The PMMA block is
placed at the center of the table.
treatment unit. The measured radiation doses were
processed in Matlab (version 2013b; The Mathworks
Inc., Natick, MA, USA).
Clinical Measurements
The clinical study included 596 interventional pain
procedures. Dose measurements were performed during
nerve blocks (head/neck, thorax, lumbar, pelvis, and
sacrum) and other complex treatments (neuromodula-
tion, epiduroscopy, and nucleoplasty). Nerve blocks
were performed with fluoroscopy in the operating room
as well as in our pain treatment unit.
The received doses of the pain physicians were
measured in mSv during a variety of pain procedures.
Only adults were considered for pain procedures in our
hospital. There was no patient selection; all pain
procedures between October 15, 2012 and January 4,
2013 with fluoroscopic guidance were included in this
study. Nerve blocks were performed with fluoroscopy in
the operation room as well as in a pain treatment unit.
Both locations were equipped with the same model
mobile C-arm and had the same measurements.
Three clinical measurement stages were distin-
guished in this study. The time period for each stage
was 3 weeks. During these measurement stages, one
PDM was placed on top of the pain physicians lead
apron at chest level. A second PDM was positioned on
the mobile C-arm, 33 cm from the X-ray tube, to
obtain a reference scatter dose for each interventional
procedure. The patients’ weight was measured to assess
whether the patient population between the 3 stages
The first stage was the ‘blind phase’, the baseline
measurement. The pain physician wore the Philips Dose
Aware personal dose meter (PDM) during this stage,
but the dose was not displayed, nor was the scatter dose
profile of the C-arm explained. In the second phase, the
‘open phase’, the pain physician could see his received
scattering dose on a display but was not trained on the
dose profile of the C-arm. During the last stage, the
‘open coaching phase’, the pain physician was sup-
ported by a coach. The coach could observe the dose
the physician received and had knowledge from the
scatter dose profile and gave the pain physicians
instructions to reduce their received scatter dose. The
coaching was done real-time in the clinical setting in
which the coach focused on optimal position of
physicians in relation to the dose profile of the C-arm.
When an increased scatter dose was measured and
observed, the coach advised the physicians in using a
position in which they received less scatter radiation.
For lateral fluoroscopy, the physicians were instructed
to stand at the caudal or detector side instead of the X-
ray tube side, because there is a high risk of scatter
radiation close to the X-ray tube side. For posterior–
anterior fluoroscopy, the physicians were advised to
increase the distance to the table when an increased
scatter dose was measured. Coaching did not influence
the progress of the pain procedures.
Additional coaching in between procedures explained
the basic strategies of radiation dose minimization, such
as the effect of positioning, shielding, and minimizing
 Reduction of Radiation Dose Received By Pain Physicians  403
the exposure time.1 The scatter dose profiles were used
to explain the differences in dose profile in posterior and
anterior positions of the C-arm and helped the physi-
cians in finding strategic positions to stand. A variety of
precautions were already taken in our pain treatment
center, eg. the obligation to wear a lead apron, and
adjustment of protocols to lower the dose.
Statistical Analysis
Data were analyzed using SPSS software (released 2009,
PASW Statistics for Windows, Version 18.0, Chicago,
IL, USA). The following information was collected for
each intervention in the SPSS database: patients’ weight
(kg), fluoroscopy time (seconds), type of procedure,
attending physician, dose received by the pain physician
(mSv), dose of reference badge on C-arm (mSv), location
Figure 2. The profiles are measured at three heights in the room: eye, abdomen, and knee level.
of procedure (operation room or pain treatment unit),
and date of the procedure. Logistic and linear regression
were used for multivariate analysis to relate the outcome
variable (scatter dose received by pain physicians) to
causal variables (the reference dose and the measure-
ment stage). We used a multiple linear regression
analysis in SPSS (Anova, 95% confidence interval) to
analyze if the dose reduction was significant. A P-value
lower than 0.05 was considered significant.
RESULTS
Phantom Measurements
Figure 2 shows the scatter dose profiles for the different
C-arm positions. For the PA position, the scattering was
the highest at knee level, which was caused by the patient
404  SLEGERS ET AL.
and operating table that reflected the X-rays coming from
the tube below. For the LAT position, scatter doses were
the highest at abdomen level. The table leg stopped some
of the radiation as can be observed in south direction in
the PA knee figure. Dose received by radiation scatter is
higher in the LAT position than for the PA position. For
the LAT position, when standing at the detector side of
the table less scatter radiation is received than at the
X-ray tube side of the table.
Clinical Measurements
In total, 596 interventional pain procedures were
included in this study (228, 163, and 205 for the three
phases, respectively). Three highly experienced pain
physicians, accompanied by an experienced diagnostic
radiographer performed all procedures.
One PDM used by a pain physician had technical
failures, as was confirmed by the manufacturer. Conse-
quently, the data obtained with this PDM were excluded
from the data analysis. Also, all 48 complex treatments
(neuromodulation, epiduroscopy, and nucleoplasty)
were excluded in the analysis, because of the big
variations in fluoroscopy time compared to other
procedures and because of the small number of proce-
dures. As a result, all 330 nerve block treatments
performed by 2 pain physicians were included in our
analysis. The included nerve blocks were divided into 5
anatomical regions, head/neck, thorax, lumbar, pelvis,
and sacrum. Table 1 presents an overview of the
included number of procedures and of the mean weight
of the patients.
Figure 3 presents box plots of the dose received by
the pain physician per procedure for the 3 different
phases. No significant (P = 0.05) dose reduction was
found between the blind (baseline phase) and open
phase. The median dose was similar in the first stages,
2.65 lSv/procedure in the blind phase and 2.64 lSv/
Table 1. Overview of Number of Procedures and Mean
Weight for the Different Phases
Phases
Blind Phase Open Phase
Number of 117 100
Procedures*
Mean Weight (kg)† 80.5 83.0
(r = 15.6) (r = 19.4)
*Complex procedures and data from one pain physician is excluded in the data analysis.
†
t-test, one-sample.
procedure in the open phase. The open coaching phase
showed a dose reduction compared to the blind phase,
from a median dose of 2.65 to 1.20 lSv/procedure. In
addition, the degree of dispersion was much smaller in
the last phase than in the blind phase, and the dose was
more consistent after coaching.
A log transformation was applied to the reference
dose and the dose of the specialist to enroll a more
normal distribution. The dose of the specialist was taken
as a dependent variable, and the reference dose and
phase (blind, open, or open coaching) as explanatory
variables. The reference dose corrected for variations in
fluoroscopic time.
The weight of the patient had no significant influence
on the dose of the specialist. The open coaching phase
showed a significant dose reduction of 46.4%
(P = 0.05). The open phase revealed not a significant
reduction.
DISCUSSION
The aim of this study was to evaluate the effects of using
real-time dose feedback on the scatter dose received by
pain physicians. Our findings reflect that real-time dose
feedback from the Dose Aware system without coaching
had no effect on the scatter dose received by the pain
physicians. However, the dose was reduced by half due
to active coaching. Active coaching made use of scatter
Open Coaching
Phase
113 Figure 3. Box plot showing the dose of the specialist per
procedure for the different phases. The lower and upper limits
83.4
of the box are the first and third quartile, respectively, and the
(r = 15.8)
line inside the box represents the median value. The tails
represent the 1.5 interquartile range of the lower quartile, and
the 1.5 interquartile of the upper quartile.
 Reduction of Radiation Dose Received By Pain Physicians  405
dose profiles and translated them in optimal positions
during pain interventions.
Probably because of the active coaching approach,
the findings of our clinical study are not in line with
the study of Sandblom et al.15, who only used real-
time visualization of radiation dose rate and stated that
this may have a positive impact on optimization of
occupational radiological protection. They found a
significant dose reduction in 1 of 3 cardiologists when
the radiation dose rates were displayed, while we did
not find a dose reduction using only real-time dose
visualization. Sanchez et al. used in his study a
prototype of the Dose Aware system in an angio-
graphic room to optimize the radiation protection of
staff members’ during fluoroscopy.14 However, they
did not verify if there was a significant reduction of
dose rate when the Dose Aware system was used. Real-
time visualization of dose rate may be less effectiv in
pain management because of the short fluoroscopy
times. As a consequence, pain physicians have not
enough time to look at the display and correct their
position, if necessary.
However, in the last stage the coach helped the pain
physicians to instruct and alert them in using a position
in which they received less scatter radiation. Dose
profiles based on the phantom measurements gave the
physicians useful information on strategic positions in
which they could receive less radiation. It is more
strategic to stand at the caudal or detector side instead of
the X-ray tube side where there is a high risk of scatter
radiation, especially for a lateral position of the C-arm.
Demonstrating dose profiles increased the awareness of
the pain physicians as to scatter radiation and provided
strategic positions in which to stand. A major advantage
of using dose profiles is that the physicians could plan in
advance the best location to stand during a procedure.
A limitation of the study was technical failure of one
of the Dose Aware badges, however, there was enough
data collected from the other badges for the statistical
analysis. Another limitation is that this research is
performed in 1 hospital, although an interhospital
comparison could be valuable.
Our findings reflect that using the Dose Aware system
by itself has no effect on the scatter dose in experienced
hands. On the other hand, we would have expected a
more significant effect in less experienced pain physi-
cians and trainees taking more time to look at the Dose
Aware monitor and respond to it. The less experienced
physicians and trainees are likely to use higher fluoros-
copy times than experienced pain physicians. Therefore,
a PDM with real-time dose feedback could alert them
and increased their awareness of the scatter dose they
received.
CONCLUSIONS
Knowledge of and real-time coaching on scatter dose
profiles reduced the dose received by pain physicians by
almost 50% for interventional pain procedures. Dose
profiles increased the physicians’ awareness for scatter
radiation in advance and gave them insight into strategic
positioning. Real-time display of the radiation dose
did not reduce the dose received by the pain physi-
cian, but was helpful during on site coaching to
visualize the effects of positioning during interventional
procedures.
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