Preventing musculoskeletal injury in GI endoscopy is a critical unmet need. The work by Kahn et al
1
provides a necessary element in the development of a comprehensive set of tools for training in general and ergonomics in endoscopy in particular. The U.S. Department of Labor states that work-related musculoskeletal disorders are “among the most frequently reported causes of lost or restricted work time.”2
Furthermore, the Department of Labor identifies training and reporting as important components for musculoskeletal disorder risk reduction.United States Department of Labor. Occupational Safety and health Administration. Ergonomics. Available at: https://www.osha.gov/SLTC/ergonomics/. Accessed September 14, 2020.
Endoscopists performing colonoscopy are workers on an assembly line designed to reduce colon cancer mortality. Notwithstanding the nobility of purpose, endoscopists are at significant risk of injury. Prevention of injury requires expanding well-defined standards of training based on current knowledge, expert consensus, and collaborative research. Prevention requires interdisciplinary understanding of the basis of human performance as it applies to endoscopy. Congresses, conferences, and online presentations are now part of the educational activities provided by several of our specialty societies. Yet, implementation of best ergonomic practices does not appear to be an obligatory component of training or endoscopy unit performance improvement programs.
The first survey of injury associated with endoscopy was published 26 years ago, and a general guidance approximately 10 years ago.
3
,4
The very limited research in endoscopic technique and ergonomics clearly demonstrates a significant variance in colonoscopy force application among endoscopists.5
Muscle loads also demonstrate wide variability and with peak right thumb pinch as high as 10 N (1 kg).6
Finally, the frequency of neck and back injuries suggests significant alterations in postural muscle tension.7
In spite of our general understanding of ergonomics and injury and our specific knowledge of musculoskeletal injury in endoscopy, only general recommendations on prevention and training are available. The approach to solving the problem of injury and training involves identifying the components of a comprehensive approach.The current work
1
and those of others provide a sound basis for expanding the development, testing, and implementation of methods to reduce the risk of injury. The authors clearly recognize that it is in the training phase that muscle memory is established. They have proposed a comprehensive approach to include ergonomic training as part of an established endoscopy curriculum. The authors have worked diligently to develop and implement improved training in endoscopy, particularly as it pertains to the use of simulation with benchtop and virtual reality simulators.8
The components they describe are simple and traditional in concept but difficult in execution: didactic teaching, video instruction on ideal ergonomic behavior, ergonomic-specific feedback from expert endoscopists, and an ergonomic checklist.The limitations of small sample size study in a single center and absence of long-term durability data should not dissuade the community from adopting as an initial strategy the development and testing of specific standards of training and practice to reduce ergonomic injury. Furthermore, the component approach defined by these authors forms the basis for the systematic construction of a reasonable set of tools that could be adapted by training and care delivery centers.
Many models of skill development based on the education and training of athletes may prove to be the basis for ergonomic training.
9
Understanding how to manage the risk of injury through training and assessment should be required not only for novices new to the craft but for experts as well. An extensive literature on training and testing of endoscopic skill is available.10
The current work now adds the tools of video assessment with quantification by rapid entire body assessment and rapid upper limb assessment. The resources are available and should be implemented.To some extent we are trapped in the well-established conundrum first identified by the 18th-century proverb “Il meglio è l'inimico del bene,” translated as “the best is the enemy of the good.” It is time to establish very specific guidance for training based on the “good” consensus and to iterate toward the “best.” Furthermore, ensuring the durability of effect implementation of ergonomic test and training systems should be part of every endoscopy center’s quality assurance and improvement program.
Disclosure
Dr Korman is a co-patent holder with Artann Laboratories.
References
- Impact of a simulation-based ergonomic training curriculum on work-related musculoskeletal injury risk in colonoscopy.Gastrointest Endosc. 2020; 92: 1070-1080
United States Department of Labor. Occupational Safety and health Administration. Ergonomics. Available at: https://www.osha.gov/SLTC/ergonomics/. Accessed September 14, 2020.
- Overuse syndromes among endoscopists.Endoscopy. 1994; 26: 539-544
- Ergonomics and GI endoscopy.Gastrointest Endosc. 2009; 70: 145-153
- Characterization of forces applied by endoscopists during colonoscopy by using a wireless colonoscopy force monitor.Gastrointest Endosc. 2010; 71: 327-334
- Pinch force and forearm-muscle load during routine colonoscopy: a pilot study.Gastrointest Endosc. 2009; 69: 142-146
- Prevalence and impact of musculoskeletal injury among endoscopists: a controlled pilot study.J Clin Gastroenterol. 2009; 43: 399-404
- Simulation in endoscopy: practical educational strategies to improve learning.World J Gastrointest Endosc. 2019; 11: 209-218
- Training the endo-athlete: an update in ergonomics in endoscopy.Clin Gastroenterol Hepatol. 2018; 16: 1003-1006
- Ergonomic endoscopy: an oxymoron or realistic goal?.Gastrointest Endosc. 2019; 90: 966-970
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