10.1055/a-0811-5985
Endoscopy is a complex skill that requires training and practice to ensure that the
procedure is performed competently. Frequently, the focus of initial training is to
ensure that a trainee has the skills to technically complete the procedure before
assimilating some of the more cognitive elements of endoscopic practice. Eagerness
to complete the procedure by trainees is often facilitated by trainers, who can be
guilty of training technical completion with little if any attention given to the
ergonomics involved in endoscopy. The consequences of poor ergonomics may result in
acute or persistent musculoskeletal problems for the endoscopist, which can result
in periods of inability to work or train.
Many athletes also require training in complex skills acquisition. In contrast to
endoscopy, athletic training invests heavily in the all aspects of the motor challenges
early during training. This helps to inform a tailored training program designed to
ensure optimal physical performance. Training involves focus on relevant muscle groups
and their coordination, to develop strength, stamina and flexibility. Once the basic
skill is mastered, other elements including strategy and tactics are added to try
to achieve a competitive advantage. Throughout training, individuals are managed to
minimize fatigue, strain or injury. One could argue that endoscopists should be trained
more like athletes in relation to ergonomics.
Ergonomics (Greek: ergos: work; nomos: custom) relates to the study of interactions
between humans and the work environment to optimize well-being and performance. In
endoscopy, the “custom of work” is relevant as practitioners are at high risk of musculoskeletal
injuries (MSI), with an estimated prevalence of 39 % to 89 % [1]. Although global efforts have strived to improve patient safety, attention to the
safety of endoscopists in relation to MSIs has been underwhelming. This poses a significant
challenge as MSIs can be detrimental to the individual (chronic pain, disability,
confidence, premature retirement), endoscopy service (missed days at work) and the
patient (impaired performance) [2]
[3]. Moreover, the burden of MSIs in trainees is relatively unknown. In this issue,
Villa and colleagues present their US survey of MSIs in 156 gastrointestinal endoscopy
fellows [4]. The authors reported that 47 % had succumbed to an endoscopy-related MSI, 69 %
of which occurred within the first 6 months of training, with the wrist, thumb, back,
and neck being predominantly affected [4]. Such data point to an impending “ergonomics crisis” in a relatively evidence-free
zone within endoscopy.
Can endoscopy learn from sports? Certain sports that involve use of equipment may
be comparable to endoscopy, e. g. archery, javelin, rifling, snooker etc. In archery,
one arm is dedicated to stabilizing an accessory against gravity, whereas the other
arm draws the arrow under tension and subjects the fingers to high pinch forces. Like
endoscopists, archers require a stable core stance with consideration given to placement
of the feet, hip, spine, and neck to provide proper posture and balance. Other similarities
and differences may be appraised using the mnemonic ERGONOMICS ([Table 1]), which covers ergonomically-relevant considerations.
Table 1
Ergonomics-related considerations shared between endoscopy and sports (in this case – an
archer), presented using the ERGONOMICS evaluation framework: E – Equipment, R – Rotation,
G – Grip, O – Orientation, N – Neck, O – Others, M – Muscles, I – Infrastructure,
C – Complications, S – Support.
|
Archer
|
Endoscopist
|
Shared Learning
|
|
Equipment
|
Arms wield bow and arrow which are tailored to the archer.
Bow arm subjected to gravitational load and arrow arm to high tension.
|
Handles endoscope + /- accessories (e. g. lead apron); not generally tailored to the
endoscopist.
Room layout (e. g. position of monitor, patient bed, umbilicus) important.
|
Improper design and handling of equipment can lead to MSI.
Equipment should be more customisable.
|
|
Rotation
|
Poor core alignment affects precision.
|
Improper rotation of pelvic girdle can strain hips and spine. Right wrist prone to
high torque forces (De Quervain’s tenosynovitis).
|
Rotation should be optimiszd to reduce forces on core muscles and reduce risk of repetitive/traumatic
injury.
|
|
Grip
|
Firm grip on bow by non-dominant arm while held in extension.
Fingers gripping onto arrow subject to high pinch forces.
|
Left thumb prone to MSI due to over-angulation when manoeuvring control wheels if
position not optimal – usually seen in conjunction with left hand position on head
of instrument.
|
Grip should be ergonomic.
Stretching of finger joints to promote flexibility.
Grip can be optimised to allow maximal functionality of instrument with minimal adverse
forces on joints and muscles.
|
|
Orientation
|
Body position lining: Eye, bow, target.
|
Considerations with patient bed, monitor, shoulders and spine. Bed height should be
at 10 cm below resting angle of endoscopist’s right elbow.
|
Consider cushioned footwear (to avoid plantar fasciitis) + /- adopt endo-athlete stance.
“Ergonomics timeout”
Video-recordings can provide trainees with insight.
|
|
Neck
|
Stable neck position critical for aiming.
Avoids excessive cervical flexion/extension.
|
Monitor placement critical to posture and forces on neck.
|
Warm up exercises.
Inappropriate/prolonged position or load can lead to neck and shoulder strains.
|
|
Others
(personnel)
|
Appreciates distance from others within archery range.
|
Works with patient and assisting nurses, who need access to equipment and the endoscope.
|
Room layout and staff positioning considerations.
|
|
Muscles
|
Stretching routinely performed before, and after each training session, and in between
sessions.
|
Warm-up not widely practised.
|
Stretch and warm-up routines.
Intervals of rest to prevent fatigue and allow recovery.
|
|
Infrastructure (ergonomics training)
|
Training: Athlete-centred; ergonomics prioritized; good access to resources/funding.
Research: Rich literature arising from sports.
|
Training: Endoscopy-specific induction rare; ergonomics not prioritized; resources
limited.
Research: Very limited.
|
Positioning, body movement and scope handling could be reviewed by an ergonomics expert.
|
|
Complications (of MSI)
|
RICE principles (Rest, Ice, Compression and Elevate).
Comprehensive rehabilitation program with ergonomics evaluation following injury.
|
MSIs likely to be under-reported; endoscopists may continue despite suffering from
MSIs.
Limited access to ergonomics assessment post injury.
|
Earlier incorporation of ergonomics during training, supplemented with high performance
feedback to prompt reflection.
Multidisciplinary team involvement to prevent and manage MSIs with root cause analyses
and workplace reviews.
Allow rest/reduced endoscopy activity to promote recovery.
|
|
Support
|
Multidisciplinary team in addition to dedicate coach which addresses ergonomics and
human factors: physiotherapist, psychotherapist, nutritionist, etc.
|
Lack of access to dedicated ergonomics training and support team, even after MSI.
Physical demands may increase with service demands.
|
Ergonomics training in sports training involves analysis of how athletes apply their
core and task-dependent muscles and joints to deliver optimal performance. Athletes
also benefit by directly observing how trainers and other professionals perform the
skill. Ergonomics training may not only prevent MSIs, but improving efficiency of
movement and load handling may also improve performance and stamina. The ergonomic
challenges associated with endoscopy are complex but can be broadly divided into room
set-up, scope handing, and tip control. These three elements are interrelated and
directly affect posture and mechanical strain on certain muscle groups and joints.
Lack of formal training is another factor. In a survey of 826 American Gastroenterology
Association (AGA) endoscopists [3], only 4.5 % claimed to have received ergonomics training during their fellowship. Since
the AGA guidelines on ergonomics, the situation may have improved. In the Villa survey
[4], 36 % of fellows had undergone ergonomics training; MSIs appeared to be less prevalent
in those who had attended ergonomics training (26 %) than in those who had not (45 %,
P = 0.012), suggesting a beneficial effect on an important endoscopist-centered outcome.
Commercial sponsorship and investment may entitle world-class athletes to unsurpassed
levels of training infrastructure and technology to support development and optimize
performance. In addition to their dedicated trainer(s), they may also have access
to a multidiscliplinary team of support staff, centered on the athlete. Athletes may
even work with suppliers to customize equipment, clothing, and footwear. This luxury
does not exist in endoscopy, where equipment remains universal regardless of hand
dominance or physical stature. Endoscopy units may be designed with more consideration
for plant layout rather than endoscopist ergonomics. The authors recommend an “ergonomic
time out” [4], where trainees consider room positioning including bed height, patient position,
and monitor location, and close monitoring of the trainee to avoid improper technique.
This could be incorporated into endoscopy training and competency-assessment tools.
Athletes routinely engage in stretching exercises before and after a task. These may
complement warm-up exercises in priming relevant joints and muscle groups to deliver
peak performance, and after an activity help to reduce muscle fatigue. Although this
hypothesis is unsupported by evidence, stretching is considered good practice.
Novice athletes are particularly prone to MSIs [5]. Athletes may have access to rehabilitation programs that manage the physical and
psychological aspects of the injury, and help prevent recurrence. Movements may be
video-recorded and analyzed by an ergonomics specialist, e. g. trainer, dedicated
sports physiotherapist or orthotist, to carefully evaluate the nature of the MSI and
optimize biomechanics. Injured endoscopists rarely have access to such facilities
nor can they easily abstain from endoscopy commitments. Following an MSI, 85 % of
endoscopy trainees expressed the desire for ergonomics training [4]. Given the burden of MSIs in longstanding endoscopists, a considerable proportion
may be trainers affected by MSIs themselves, who may not be aware of the principles
of ergonomics. Inviting an occupational therapist to appraise the technique of endoscopists
has reportedly led to improvements in posture and discomfort from MSI [6].
While further studies are desperately warranted, the survey suggests that MSIs are
frequently incurred by endoscopists as early as the training stage [4]. Endoscopy is highly repetitive and from an early stage in training, muscle memory
can develop in relation to endoscopy-related ergonomics, which can be difficult to
correct. This suggests a need for trainers, workplaces and training programs to review
their approach to ergonomics. Ergonomics could be taught prior to patient-based endoscopy
in standardized courses or incorporated into simulation training. Workplaces could
do more with optimizing human factors within a confined environment, both in terms
of room design and equipment provision, and to accommodate ergonomics review from
multidisciplinary support staff. The AGA provides recommendations on ergonomics [7] but these remain unavailable elsewhere. A concerted effort from endoscopy societies
is needed to standardize ergonomics training and to ensure that working environments
are ergonomically sound. In light of these results, we should reevaluate how we appraise
the “custom of work” in our trainee endoscopists, both with regard to MSI prevention
and rehabilitation. The ERGONOMICS framework ([Table 1]) is a starting point.
Finally, the goal of training in endoscopy is to ensure that trainees have developed
the necessary technical and cognitive competencies to perform “safely” and effectively
in different situations. Perhaps It is time for the concept of safety to extend beyond
the patient and to include the endoscopist. Adopting this perspective could change
how ergonomics is taught and assessed in endoscopy, with potential health and performance
benefits for trainees.
