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Endoscopist injury: shifting our focus to interventions

      Abbreviations:

      ERI (endoscopy-related injury), PT (physical therapist), RAM (risk assessment and management)
      Endoscopists undergo rigorous training to become proficient in diagnostic and therapeutic endoscopy so they may provide high-quality GI care. Unfortunately, performing endoscopy can be hazardous to the endoscopist’s health.
      • Shergill A.K.
      • Harris Adamson C.
      Failure of an engineered system: the gastrointestinal endoscope.
      In some cases, work-related musculoskeletal discomfort and disorders can constrain or end an endoscopist’s practice.
      • Pawa S.
      • Banerjee P.
      • Kothari S.
      • et al.
      Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.
      A high risk of endoscopy-related injury (ERI) is supported by survey-based data and biomechanical risk analysis. In the largest survey-based study to date of >1600 members of the American College of Gastroenterology by Pawa et al,
      • Pawa S.
      • Banerjee P.
      • Kothari S.
      • et al.
      Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.
      75% of respondents reported ERI. Commonly reported sites for pain included the thumb (63.3%), neck (59%), hand/finger (56.5%), low back (52.6%), shoulder (47%), and wrist (45%).
      • Pawa S.
      • Banerjee P.
      • Kothari S.
      • et al.
      Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.
      Neck, back, and shoulder pain may result from the awkward postures adopted in the endoscopy unit, depending on the monitor position, monitor height, and bed height, and the pain can be further exacerbated by the static loads associated with prolonged standing or with wearing a lead apron for radiation protection. Our recently published study of distal upper extremity biomechanical risk factors during colonoscopy provides a rationale for endoscopy-related pain in the thumbs, hands, and elbows and the development of carpal tunnel syndrome with documented high-risk exposures when the endoscopist is holding and manipulating the control section and insertion tube during colonoscopy.
      • Shergill A.K.
      • Rempel D.
      • Barr A.
      • et al.
      Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy.
      Studies such as these provide a better understanding of the scope of the problem and the pathophysiologic mechanisms of injury. As the data on prevalence and mechanisms of injury accumulate, it is clear that we must now shift our focus to interventions to reduce this high risk of injury.
      We have previously written about risk assessment and management (RAM) approaches to mitigate endoscopy-related risk, and workplace-sponsored ergonomic training is an important administrative control to reduce risk of ERI.
      • Shergill A.K.
      • Harris Adamson C.
      Failure of an engineered system: the gastrointestinal endoscope.
      Prior studies have demonstrated a measurable benefit from an ergonomic training program, including benefits to trainees.
      • Khan R.
      • Scaffidi M.A.
      • Satchwell J.
      • et al.
      Impact of a simulation-based ergonomics training curriculum on work-related musculoskeletal injury risk in colonoscopy.
      • Ali M.F.
      • Samarasena J.
      Implementing ergonomics interventions in the endoscopy suite.
      • Sussman M.
      • Sendzischew-Shane M.A.
      • Bolanos J.
      • et al.
      Assurance for endurance? Introducing a novel ergonomics curriculum to reduce pain and enhance physical well-being among GI fellows.
      In this issue of Gastrointestinal Endoscopy, Markwell et al
      • Markwell S.A.
      • Garman K.S.
      • Vance I.L.
      • et al.
      Individualized ergonomic wellness approach for the practicing gastroenterologist (with video).
      report on the results of their pilot study, which used an interactive RAM approach with a physical therapist (PT)-led intervention to reduce endoscopists’ musculoskeletal symptoms. The PT assessment included position and posturing during endoscopy and during rest, with the creation of an individualized wellness plan. The personalized evaluation included recommendations for individualized exercises, static and dynamic posture re-education during and between procedures, optimization of procedure suite setup, pain education, and opportunity for one-on-one sessions with the PT. The evaluations and interventions resulted in improvement of musculoskeletal symptoms among a cohort of endoscopists reporting baseline pain associated with performing endoscopy. We applaud the authors for their work on developing an approach that integrates ergonomics and physical therapy. Interventions that mitigate the risk for work-related musculoskeletal discomfort and disorders are lacking; thus, any approach that reduces some of the common exposures encountered by endoscopists and/or provides them with ways to withstand or recover from these exposures is critical.
      The strengths of this intervention include the individualized participatory approach that provides the endoscopists with actionable feedback. The authors use photography to show the endoscopists what their postural presentations are, including its possible impact on muscle imbalances and pain. Engaging the worker in the intervention to understand the recommendations of the PT is an excellent strategy to gaining adherence.
      • Rivilis I.
      • Van Eerd D.
      • Cullen K.
      • et al.
      Effectiveness of participatory ergonomic interventions on health outcomes: a systematic review.
      The proactive approach to addressing discomfort, muscle imbalances, and poor work posture through a physical therapy screening and intervention is a common-sense approach to supporting the physical wellbeing of the GI physician.
      However, this article is a bit misleading on the application of ergonomics in their intervention, including what an ergonomics program is and what it should include. The “ergonomic” approach included in this intervention focuses on identifying sustained and dynamic awkward postures that likely contribute to the muscle imbalances, postural strategies, and regional discomforts observed in the study participants. The authors conclude that “Ergonomic programs using the new method presented here could potentially contribute to career longevity, decreased burnout, reduce lost days of work, and most importantly reduce pain and fatigue among practitioners.” Endoscopists should be aware that an effective ergonomics program should include a more robust approach to identifying and mitigating all of the various types of physical exposures present during GI procedures, not just postural ones. Therefore, we highlight some of the important considerations of an ergonomic program that could complement the individualized wellness program that the authors present.
      First, the authors misrepresent static and dynamic posture as it relates to ergonomics. The authors define static and dynamic posture as the standing posture and the posture while working. However, in ergonomics, we look for both static and dynamic postures while working. Static postures are those that are held for longer periods of time, thereby preventing full recovery of the muscles. Muscle activation should be quantified by duty cycle (the amount of work time divided by the amount of work plus rest time). This is critical because there are ways to estimate the maximum acceptable exertion given a certain duty cycle, or time that a muscle is activated. The authors describe the implementation of some basic ergonomic principles, like setting up the gurney and monitor to maintain nearly neutral postures, which are good basic suggestions. However, the authors’ intervention lacks any further analysis of the static muscle contractions used to handle the endoscope or insertion tube as they pertain to the magnitude or duration of contraction. A more detailed human factors and ergonomic analysis that incorporates the latest research and risk assessment tools was omitted from this intervention; thus, quantification and mitigation of distal upper extremity risk are not achieved with the current approach. It is important that endoscopists know that this level of analysis and intervention is available through a trained and certified Board of Certification in Professional Ergonomics (BCPE) ergonomist and is especially important for endoscopists with hand or wrist issues.
      What is clear from this study is that educating physicians on basic ergonomics principles such as the importance of neutral postures can have measurable benefits. Pawa et al
      • Pawa S.
      • Banerjee P.
      • Kothari S.
      • et al.
      Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.
      reported that in respondents with ergonomic training, learned strategies that were applied during endoscopy included paying attention to posture and adjusting bed and monitor heights. A key finding in the Pawa et al
      • Pawa S.
      • Banerjee P.
      • Kothari S.
      • et al.
      Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.
      study was that taking microbreaks, another learned strategy through ergonomic education, was associated with a decreased risk of ERI and thus should be included in any wellness intervention. Additional engineering and administrative controls are needed. We have demonstrated that a prototype antigravity support arm that supports the weight of the colonoscope can reduce the loads on the left wrist extensors during simulated colonoscopy.
      • Shergill A.K.
      • Rempel D.
      • Barr A.
      • et al.
      Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy.
      Tools to improve the fit of the endoscope to the breadth of users, such as right/left dial assists and endoscope support stands, may provide benefit and warrant additional study.
      • Shergill A.K.
      • Harris Adamson C.
      Failure of an engineered system: the gastrointestinal endoscope.
      ,
      • Akerkar G.M.
      • McQuaid K.R.
      • Terdiman J.P.
      • et al.
      An angulation dial adapter to facilitate endoscopy [abstract].
      ,
      • Shergill A.K.
      • Barr A.
      • Harris-Adamson C.
      Ergonomic evaluation of an endoscope support stand during simulated colonoscopies [abstract].
      The wellness approach in this article is an excellent first intervention that effectively addresses awkward postures and abnormal posture patterns of endoscopists. A second-stage intervention, should the wellness approach not alleviate discomfort in endoscopists, would be a thorough ergonomic analysis that includes an evaluation of all high-risk activities, including endoscope handling. Given the high prevalence and severity of work-related musculoskeletal discomfort and disorders in endoscopists, the application of basic ergonomic principles and additional interventions to mitigate risk are badly needed.

      Disclosure

      Dr Harris-Adamson and Dr Shergill are the recipients of research gifts from Pentax. Dr Shergill is a consultant for Boston Scientific.

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      Linked Article

      • Individualized ergonomic wellness approach for the practicing gastroenterologist (with video)
        Gastrointestinal EndoscopyVol. 94Issue 2
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          The prevalence and burden of ergonomic-related musculoskeletal injury are well established in the literature, but data are scarce on techniques that can be used to avoid injury. This pilot study aimed to develop a new method of endoscopist wellness assessment. The technique presented here is an intervention by a physical therapist assessing ergonomic position and posturing during endoscopy to create an individualized wellness plan.
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