Introduction
Musculoskeletal disorders account for nearly 70 million physician office visits in
the United States annually, and an estimated 130 million total health care encounters,
including outpatient, emergency department, and inpatient visits. The Institute of
Medicine estimates of the economic burden of work-related musculoskeletal disorders
(WMSDs) – as measured by compensation costs, lost wages, and lost productivity – are
between $ 45 billion and $ 54 billion annually [1]. In addition to economic loss, these disorders also lead to decreased quality of
life. Those working in nursing and healthcare facilities are especially prone to WMSDs
[1]. Among physicians, endoscopists are at increased risk for WMSDs compared to internists
and other specialists who are not procedure-oriented with 37 % to 89 % of endoscopists
reporting musculoskeletal injuries [2]
[3].
Several factors influence endoscopy-related musculoskeletal pain. The most commonly
reported factor is high procedure volume and prolonged duration of performing endoscopy,
which leads to overuse injury from repetitive movements [4]
[5]
[6]. Other risk factors that have been reported are improper position during performing
endoscopy and endoscopy-specific maneuvers like torqueing during colonoscopy and use
of control dials [5]
[7]
[8]
[9]. These maneuvers lead to certain endoscopy-specific injuries, such as “Colonoscopist’s
Thumb,” or DeQuervain’s tenosynovitis [10]
[11]. Other common sites of injuries in endoscopists are the neck, back, shoulder and
elbow [6].
While the data alarmingly reveal the problems facing endoscopists in practice, little
is known about musculoskeletal injuries among gastroenterology fellows. Because of
the implications of musculoskeletal injuries and the potential for permanent injury,
we sought to assess the prevalence of injuries among fellows to open future investigations
into ergonomic-specific education that can reduce injuries.
Methods
A 22-question survey about ergonomics and work-related musculoskeletal injuries was
developed (see supplemental appendix). As there were no individual identifiers in
the survey questions, the Institutional Review Board exempted it. An email with an
invitation to participate in the survey was sent to 114 gastroenterology fellows in
different programs across the United States in June 2016 (these were sent by the authors
through their contacts in different programs). The invitation email had a web link
to the survey instrument (Survey Monkey, Palo Alto, California, United States). Fellows
who did not respond within a week were sent a second reminder email. Responses were
collected, and the data were analyzed. An additional 103 paper surveys were distributed
at Digestive Disease Week (DDW) in May of 2017 to fellows who confirmed that they
had not responded to the online survey, and the data were added to the previously
collected online surveys for analysis. No monetary compensation was given for participation
in the survey.
Statistical analysis
We used descriptive statistics to define the prevalence of injuries related to endoscopy.
Responders were classified into two main groups: those reporting no new injury during
fellowship and those reporting a new musculoskeletal injury during fellowship which
was attributable to performing endoscopy. We then applied the Pearson chi-squared
analysis to assess the statistical differences between these groups. Differences across
groups were considered significant if the associated P value was less than 0.05.
Results
Fifty-three out of 114 fellows (46 %) responded to the online survey, and all 103
surveys distributed at DDW were collected. The respondents were equally distributed
across the 3 years of their fellowship training ([Table 1], P = 0.98). Of 156 respondents, 87 (56 %) reported at least one new musculoskeletal
injury sustained since the start of fellowship. Of the 87 gastroenterology fellows
who reported new injuries experienced during fellowship, 74 (47 % overall) reported
that these injuries were related to endoscopy ([Table 1]). When compared to those without endoscopy-related injury, those with endoscopy-related
musculoskeletal injury were similar in age (P = 0.75), gender (56 % of females sustained injury compared to 42 % of males, P = 0.10), and training in endoscopic retrograde cholangiopancreatography (ERCP) (27 %
vs 28 %, P = 0.89) ([Table 1]). There was no significant difference between the groups when we compared the online
respondents to those who took the paper survey.
Table 1
Demographic data from respondents.
|
Endoscopy-related MSK injury
|
|
Yes
(total=74)
|
No
(total=82)
|
Total (%)
|
|
|
Age
|
|
25 to 30
|
9
|
15
|
24
|
χ2 = 1.22
P = 0.75
|
|
31 to 35
|
48
|
51
|
99
|
|
36 to 40
|
16
|
15
|
31
|
|
41 or older
|
1
|
1
|
2
|
|
Gender (P = 0.10)
|
|
Female
|
31
|
24
|
55
|
χ2 = 2.72
P = 0.10
|
|
Male
|
43
|
58
|
101
|
|
Ethnicity (P = 0.79)
|
|
|
|
|
|
|
Asian/Indian
|
39
|
44
|
83
|
χ2 = 1.73
P = 0.79
|
|
White/Caucasian
|
23
|
27
|
50
|
|
Hispanic/Latino
|
6
|
4
|
10
|
|
Black/African American
|
5
|
4
|
9
|
|
Other
|
1
|
3
|
4
|
|
Year in Fellowship at time of response (P = 0.98)
|
|
1st year
|
25
|
26
|
51
|
χ2 = 0.16
P = 0.98
|
|
2nd year
|
24
|
26
|
50
|
|
3 rd year
|
24
|
29
|
53
|
|
Other
|
1
|
1
|
2
|
|
Timing of endoscopy-related injury
|
|
0 – 3 months
|
23
|
|
|
|
|
3 – 6 months
|
28
|
|
|
|
|
6 – 12 months
|
13
|
|
|
|
|
12 – 24 months
|
7
|
|
|
|
|
24 – 36 months
|
3
|
|
|
|
|
|
|
|
|
|
|
ERCP experience (χ2 = 0.020, P = 0.89)
|
|
Yes
|
20
|
23
|
43
|
χ2 = 0.020
P = 0.89
|
|
No
|
54
|
59
|
113
|
|
Ergonomics training received (χ2 = 12, P < 0.001)
|
|
Yes
|
19
|
37
|
|
χ2 = 12
P < 0.001
|
|
No
|
55
|
31
|
|
|
N/A
|
0
|
14
|
|
|
Desire for ergonomics training (χ2 = 8.9, P = 0.0030)
|
|
Yes
|
63
|
41
|
|
χ2 = 8.9
P = 0.0030
|
|
No
|
11
|
24
|
|
|
N/A
|
0
|
17
|
|
MSK, musculoskeletal injury; ERCP, endoscopic retrograde cholangiopancreatography
Sixty-three (85 %) reported that the new injury(ies) occurred during the first year
of fellowship ([Table 1]). The respondents cited multiple injuries sustained, including the right wrist (53 %),
left thumb (48 %), back (31 %), neck (22 %), among others ([Fig. 1]). Of the 74 fellows reporting an endoscopy-related injury, only three (4 %) reported
that time was missed due to that injury, but the time missed did not exceed 3 days
([Table 2]). While 35 fellows (47 %) took pain medications, only one (1 %) saw a specialist
for the injury sustained ([Table 2]).
Fig. 1 Site of endoscopy-related musculoskeletal injury.
Table 2
Consequences of endoscopy-related musculoskeletal injuries.
|
Time missed due to injury
|
|
1 – 3 days
|
3
|
|
None
|
71
|
|
NSAID use for injury
|
|
Yes
|
35
|
|
No
|
36
|
|
No response
|
3
|
|
Other treatments for pain
|
|
Yes
|
3
|
|
|
2
|
|
|
1
|
|
No
|
68
|
|
No response
|
3
|
|
Saw specialist due to injury
|
|
Yes
|
1
|
|
No
|
69
|
|
No response
|
4
|
|
Modified endoscopy technique
|
|
Yes
|
48
|
|
No
|
23
|
|
No response
|
3
|
NSAID, nonsteroidal anti-inflammatory drug
Of the 74 fellows who reported at least one injury related to endoscopy, only 19 (26 %)
had received ergonomics training during fellowship, whereas 37 of the 82 who did not
report endoscopy-related injury (45 %) had received ergonomics training ([Table 1]), which was a statistically significant difference (P < 0.001). 63 (85 %) of those sustaining endoscopy-related injuries and 104 (67 %)
of overall respondents stated that they were interested in receiving ergonomics training
([Table 1]).
Discussion
Endoscopists are at increased risk of musculoskeletal injuries. Published data have
focused on the prevalence of musculoskeletal injuries and assessing the role of ergonomics
among practicing gastroenterologists. As many as 39 % to 89 % overall prevalence of
pain or musculoskeletal injuries is reported among reporting endoscopists [2]
[3]
[11]
[12]. However, prior to our study, prevalence of musculoskeletal injuries among gastroenterology
fellows had not been reported. The results of our study reveal that among the responders,
an alarming 47 % of fellows admitted to at least one new endoscopy-related musculoskeletal
injury sustained during fellowship, most of which (85 %) occurred during the first
12 months of gastroenterology fellowship, arguably the most crucial period for learning
proper techniques.
While factors influencing the development of injuries were not directly assessed in
this study, based on previously published data, several factors influence endoscopy-related
musculoskeletal pain. The most important factors are overuse and repetitive movements
along with prolonged standing, all of which are integral parts of performing endoscopy.
Previous studies have shown that performing endoscopy for more than 16 hours per week
(or 20 cases) increases risk of musculoskeletal injuries [6]
[12]. A considerable proportion of fellows easily exceed this threshold. This is more
relevant for fellowships emphasizing clinical and procedural training with high procedural
volumes rather than fellowships with more of a research focus. While there are regulations
regarding work hours for house staff, including fellows, there are no procedural limitations
placed by the Accreditation Council for Graduate Medical Education for gastroenterology
fellows. We believe this to be an important issue worth addressing by the gastroenterology
societies.
Other factors leading to injuries are improper positioning of the patient and monitor
(height of the bed being too low or too high and monitor not being right in front
of the endoscopist and just below eye level) or improper technique, such as excessive
torqueing and high pinch forces [3]
[11]
[12]. To avoid improper positioning, endoscopy units should consider having an “Ergonomic
Timeout” prior to starting procedures to ensure proper bed height, patient position,
and monitor location. To avoid improper technique, it is crucial that fellows are
monitored closely and informed about these errors early during fellowship before adopting
improper techniques. This is especially important given that most first-time injuries
occur during the first year of fellowship.
Because there are published studies that demonstrated an increase in reported musculoskeletal
injuries among gastroenterologists who practice ERCP [13], we sought to investigate whether there was similarly increased reporting of musculoskeletal
injuries among gastroenterology fellows who performed ERCP during their fellowship;
however, there was no statistically significant reporting of musculoskeletal injuries
in those who were ERCP trained ([Table 2]). This was possibly due to the fact that the majority of gastroenterology fellows
in the United States do not have ERCP experience; that those who have ERCP experience
do not have a significant case volume to experience musculoskeletal injuries; and/or
that advanced or repetitive maneuvers that could lead to injuries were limited in
inexperienced general gastroenterology fellows given the likelihood that attendings
would take over a difficult case that would require such maneuvers.
Not surprisingly, our study demonstrated that those who reported no injuries had a
statistically significantly higher reporting of ergonomics training than those who
reported injuries. The lack of endoscopy-specific ergonomics education is believed
to play a significant role in the overall poor compliance among endoscopists with
regard to ergonomic practices [14], and our study demonstrates a willingness among the majority of fellows (67 % of
all responders) to address this issue by receiving ergonomics training. As such, we
believe there is a need to train the instructors in applying endoscopic-specific ergonomic
principles to their education of fellows and that there is a clear role for widespread
education and implementation of guidelines for best clinical practice of ergonomics
[3]
[14]
[15]
[16]. Based on our study, that training should begin at the start of fellowship.
There are certain drawbacks of our study. First, inherent to any survey is the possibility
of “recall bias” among the respondents. Second, two different methods were used for
data collection (survey by email and paper survey at DDW). However, we found similar
results in respondents of both methods of survey. Third, our study did not assess
the impact of fellows’ procedure volumes and musculoskeletal injuries; given that
the respondents were from many different fellowship programs with varying procedure
scheduled. Finally, our sample size is small, and we were unable to determine whether
specific types of injuries were more common during different years of fellowship and
which specific injuries could be prevented by training in ergonomics.
The findings of our study suggest that musculoskeletal injuries may originate as early
as fellowship (especially during the first year of fellowship) and there is a need
for early ergonomics training. However, further studies are needed to assess the role
of ergonomics training in decreasing work-related injuries; in affecting short-term
and long-term disability; in impacting procedural efficiency and productivity; and
in improving quality of life for endoscopists.
