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Endoscopy
DOI: 10.1055/a-2307-6443
Editorial

Endoscopy-related musculoskeletal injuries to endoscopists: time for an “ergonomic time-out”

Referring to Singh AD et al. doi: 10.1055/a-2270-4174
Mihir S. Wagh
1   Division of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, United States (Ringgold ID: RIN156400)
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“Safety doesn’t happen by accident” –– Anonymous

Endoscopic procedures are becoming a major part of the practice of gastroenterology, with many gastroenterologists spending a bulk of their clinical time performing endoscopy. As a result, the prevalence of endoscopy-related musculoskeletal pain and injuries among endoscopists is rising, with reports suggesting 29%–89% of endoscopists suffer from such problems [1] [2] [3] [4]. Endoscopy-related injuries (ERIs) result from performing multiple endoscopic procedures daily and the prolonged endoscopy time for complex cases, often involving repetitive movements, awkward posture, and the handling of tedious and cumbersome endoscopic tools. Musculoskeletal pain, carpal tunnel syndrome, and de Quervain’s tenosynovitis are a few of the reported injuries related to performing numerous hours of endoscopy over an endoscopist’s career. However, most of the available data are from survey studies, where these injuries are likely to be grossly under-reported.

Using adjustable-height endoscopy monitors and patient beds, and cushioned floormats are easily implementable “low hanging fruit”.

In this issue of Endoscopy, Singh and colleagues present the results of their systematic review and meta-analysis of ERIs and their impact on clinical practice [5]. Data were extracted from 12 survey-type studies, including 4563 respondents (73% male). The investigators reported that the pooled career prevalence of carpal tunnel syndrome was 5.3%, while the prevalence of de Quervain’s tenosynovitis was 8.5%; however, their data included some even more alarming findings. First, almost one in four endoscopists had reported thumb (24.4%) or neck (24.2%) pain, and around one in five endoscopists had back pain (20.8%). Second, ERI even included serious injuries, requiring surgery in 3.4% and leading to long-term disability in 1.3%. Third, almost 10% of the respondents had missed work because of an ERI, and the pooled prevalence of endoscopists who had reduced the number of procedures they performed per day was 12.7%. These numbers are likely an underestimation owing to the use of survey data in these studies, where response rates are typically low; the results are therefore highly concerning.

The American Society for Gastrointestinal Endoscopy (ASGE) Guidelines for ergonomics in endoscopy recommend the use of a neutral endoscopy monitor position, neutral patient-bed height, anti-fatigue floormats, and that endoscopists take microbreaks (and stretching breaks) during procedures, and macrobreaks during the day to reduce the risk of ERI [6]. Interestingly, in the current study, less than half of the respondents used adjustable-height patient beds (42.0%) and adjustable monitors (40.2%), and only a minority (11.6%) took breaks.

There are multiple questions that arise after reviewing this study and considering its limitations. Survey studies are only as good as the responses, and potentially fraught with bias. More details regarding pain management, the use of narcotic medications and/or mechanical support braces, the need for physical therapy, and the types of surgery would be helpful. Also, the data do not provide information on the time-period over which these injuries occurred, the types of procedures performed, or whether certain procedures were more likely to be associated with specific types of injuries. In addition, there was no mention of lower-extremity symptoms and injuries due to unbalanced stance, and pivoting between multiple foot pedals for irrigation, electrosurgery, and jet injection through endoscopic knives, etc. The investigators also did not assess the risk of ERIs based on the age of the endoscopist, cumulative number of years performing endoscopy, gender, or hand-size, all relevant factors that are worth evaluating if we are to overcome these inherent evils of endoscopy.

Nevertheless, it is clear that ERIs pose a serious problem and it is now time to make some significant changes to protect ourselves and future generations of endoscopists. Change begins with awareness, and awareness results from education. Sadly, only a small percentage of endoscopists receive ergonomics education. Through the ASGE Training Committee, we have suggested an ergonomics curriculum [7] applicable to endoscopy training programs and clinical practice, and its importance cannot be overemphasized. As shown in a recent systematic review [8], interventions such as didactic teaching and/or videos were effective in reducing musculoskeletal injuries and improving knowledge. But education about ergonomics alone is unlikely to be enough to mitigate the ever-increasing problem of ERIs among endoscopists.

A simple start is an “ergonomic timeout” before an endoscopic procedure – a reminder to check for proper ergonomics upfront before every case. Using adjustable-height endoscopy monitors and patient beds, and cushioned floormats are easily implementable “low hanging fruit.” Merely improving posture during endoscopy will however not be enough – two major areas still need change: (i) deconstructing the endoscope that was built decades ago purely for diagnostic purposes and transforming it into a lightweight multifaceted tool that is designed for therapeutic interventions and available for various hand-sizes, to promote ergonomic comfort and reduce physical stress; and (ii) a shift in the culture and mindset of clinical practice and hospital administration that allows breaks between endoscopic procedures and adjustment of the daily caseload to avoid muscle injury and promote tissue recovery.

But are micro and macro breaks truly feasible in the typical high volume endoscopy units of today? Will there be time assigned for stretching exercises and breaks during and between endoscopic procedures? We have duty-hour limits in many professions, including those for residents and fellows in training, so should we have similar procedure-hour limits as well? There is increasing awareness of the need to address physician burnout and promote well-being; however, just these philosophical concepts will not be able to reverse physical injury sustained during decades of performing endoscopic procedures or prevent future injuries. There has to be a move to emphasize the risk of ERIs and the reality of the occupational hazards of endoscopy. We need to partner with industry to develop an improved ergonomic endoscope. The authors of this study have again highlighted the gravity of ERIs and their implications. To make a long story short, if we do not take care of ourselves, how will we take care of our patients?



Publication History

Article published online:
15 May 2024

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