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The injured endoscopist: A roadmap for recovery
Techniques in Gastrointestinal Endoscopy 21 (2019) 155158
Contents lists available at ScienceDirect
Techniques in Gastrointestinal Endoscopy journal homepage: www.techgiendoscopy.com/locate/tgie
The injured endoscopist: A roadmap for recovery Nimisha K. Parekh, MD, MPH, FACG, AGAF*, Kenneth McQuaid Division of Gastroenterology, University of California Irvine, 101 The City Drive, Zot 4092, Orange, California 92868
A R T I C L E
I N F O
Article history: Received 30 March 2019 Revised 25 June 2019 Accepted 2 July 2019 Keywords: Ergonomics Injury Endoscopy athlete Disability insurance
A B S T R A C T
Gastroenterologists are at increased risk for musculoskeletal injuries from overuse and repetitive motions during endoscopy. Recently there has been more awareness of ergonomics in endoscopy and strategies for improvement since an injury can be shocking to a physician's career. This article reviews common injuries seen in those who practice endoscopy, steps in managing an injury, guidelines for ergonomic design of a procedure suite, and a basic primer on disability insurance. Incorporation of ergonomic principles in the endoscopy suite and during use of electronic health record can minimize risk of work-related injuries. © 2019 Elsevier Inc. All rights reserved.
1. Our stories 1.1. Author 1 In 2015, I developed a left hand DeQuervain’s tenosynovitis, also known as colonoscopist’s thumb, which is a tendonitis of the wrist first extensor compartment caused by thumb strain from repeated turning of the endoscope dials [1,2]. At first, I was incredulous. How could this happen so early in my career after only 9 years of practice? I was in further shock and disbelief when the hand specialist I consulted affirmed that the injury was likely from repetitive use and recommended surgery for probable scarring. As an alternative, he offered a steroid injection and conservative measures, while warning that there was a less than 50% likelihood of long-term relief. I chose initial conservative management and initiated hand therapy 2 times per week. After months of frustration, I reluctantly underwent the recommended surgery and am gratified to report that it went well. During this time, I began a journey to understand more about ergonomics in gastroenterology. What I learned was quite surprising. 1.2. Author 2 Mine is the story of one who has practiced endoscopy for almost 35 years. For the first 15 years, there was little awareness of ergonomic injury among endoscopists, including me. Endoscopes (heavily used and variably maintained) were less sophisticated than today with low-definition images, stiff insertion tubes, and turning dials that could be stiff due to stretched or tight cables. Small monitors and gurneys were placed at awkward or fixed heights. Suboptimal * Corresponding author. E-mail address: [email protected] (N.K. Parekh). https://doi.org/10.1016/j.tgie.2019.07.008 1096-2883/© 2019 Elsevier Inc. All rights reserved.
equipment and suboptimal technique led to prolonged colonoscopies that resulted in physician and nursing fatigue. During these early years, I denied to myself the possibility of occupational injury. "Minor" aches and pains were dismissed and "worked through." Unit efficiency and throughput were a source of personal pride. When fellows reported fatigue, I assured them that they would get stronger. . .just as I had been assured. With colonoscopy, I prided myself on my ability to control both steering dials with my left thumb, which allowed me to keep my right hand on the insertion tube throughout the procedure and optimize my efficiency. As my years of experience increased and the volume of cases exploded, I became aware of a growing number of musculoskeletal "issues" with my colleagues and, most disturbingly, former fellows with far fewer "endoscopic miles" on their bodies than mine. Cervical spine disease, shoulder impingements, frozen shoulder, tennis elbow, DeQuervain’s tenosynovitis, wrist tendinosis, carpal tunnel syndrome, acute injury to the thenar muscles, and finger tendinopathies were all too common. Some disclosed with personal embarrassment, sadness, and anxiety that the injury had forced them to reduce their endoscopic volume or eliminate specific procedures (especially, endoscopic retrograde cholangiopancreatography [ERCP] and endoscopic ultrasound [EUS]). In my own case, I remained relatively unscathed until recently, when I developed a pain at the base of the metacarpophylangeal joint of my left thumb, which was diagnosed as osteoarthritis. Is it related to age, divine error in joint design, or years of endoscopy using a one handed technique? The absence of problems in my right thumb leads me to suspect the latter. 2. Recognizing the risks for injury Many endoscopists are not aware of the increased risk of musculoskeletal strain and repetitive use injury from performing
156
N.K. Parekh and K. McQuaid / Techniques in Gastrointestinal Endoscopy 21 (2019) 155158
endoscopic procedures. The prevalence of injury ranges from 29% to 89% [1,2]. Risk factors associated with injury in gastroenterologists include working duration, repetitive movements of the dials on the endoscope, static muscle loading in the upper extremities, trapezius, and back from prolonged standing, and awkward body posture and technique [3]. A recent study found that gastroenterologists performing higher procedure volume (>20 per week) and higher number of procedure hours (>16 hours per week) are at increased risk for endoscopy related injury [4], while another estimated that 10% of endoscopists will develop musculoskeletal upper extremity injuries after only 10 years of procedures [5]. Endoscopy entails a variety of repetitive movements, including pushing, pulling, torqueing and gripping of the insertion tube, turning of the dials for tip deflection, and thumb/forefinger pincer squeezing in order to insert and manipulate instruments. These may culminate in acute or chronic injury of the neck, hand, wrist, or shoulder. Performing endoscopy also requires prolonged standing with a relatively fixed posture relative to the gurney and monitors that can result in neck, back, and lower extremity fatigue and injury [6]. In addition, interventional endoscopists should be aware of a correlation of low back pain with wearing of lead aprons or shields [7]. The one piece lead shield increases the static load on the spine and low back whereas a 2-piece shield more evenly distributes the load across the spine and pelvis [2]. It is not entirely clear which gastroenterologists are at risk for development of upper extremity musculoskeletal injuries from repetitive stress, but possible predictive factors include those with small hand and wrist size [8]. Small hand size can affect ability to use laparoscopic instruments [9] and possibly increase risk of injury amongst gastroenterologists, although this is not clear. Those with smaller wrists could be at higher risk due to the small carpal tunnel space. Tool manufacturers are beginning to realize the importance of a manufacturing tool grips that are the correct size for the operator. An in vitro study by Cobb et al simulating active grip, showed that tool grip size can have a significant effect on carpal tunnel pressure [10]. Furthermore, grip size can affect grip strength and hand forces, dependent on the size of the operator’s hands [11,12]. The risk of upper extremity injury is compounded by poor endoscope design, most particularly a "one size fits all" design of the turning dials that is ill fitted to smaller hands. Although the optics of endoscopes has improved in the last 20 years, instrument design has not changed, hence tip deflection still requires mechanical application of force to the control dials [2]. Computer work can further exacerbate the same muscles fatigued during endoscopy procedures. Electronic health records have increased time gastroenterologists spend on computers (desktop or laptop), increasing risks of repetitive stress. Using the mouse and keyboard require some of the same muscles required to hold/manipulate the scope [13].
Table 1 Types of injury seen in gastroenterologists.
3. Types of injury and management
After sustaining a repetitive use injury and undergoing treatment including rest, rehabilitation and/or surgery, it is vital that changes be made to the work environment to avoid a reinjury or new injury. Recent literature has clarified the optimal location of equipment within the endoscopy suite. Monitors should be placed directly in front of the endoscopist at a height 20 cm lower than the height of the endoscopist so that monitor height is at eye-level or lower to prevent neck strain [2,18]. Studies from the laparoscopy literature estimate that the optimal distance between the endoscopist and a 1400 monitor is between 52 and 182 cm, which allows for the least amount of image degradation and less "leaning" of the endoscopist to view images [2,19]. Bed height affects both spine and arm position; surgical data again suggest that optimal bed height is between elbow height and 10 cm below elbow height, which lowers the shoulders (reducing
Repetitive use injuries among gastroenterologists result from repetitive application of force to the same group of muscles, joints, or tendons that leads over time to microtrauma with inflammation or local tissue damage [14]. One example is endoscopist’s thumb or DeQuervain’s tenosynovitis that results from repetitive use of the left thumb to turn the dials that control the angulation of the endoscope [6]. Musculoskeletal injuries commonly seen in gastroenterologist are listed in Table 1 [6,15,16]. Cumulative damage may result in joint synovitis, tendonitis, ligament strains, stress fractures, or degenerative arthritis. Symptoms of repetitive stress are highly variable. Early on they can be mild, easily dismissed, and characterized as stiffness, mild aching, or fatigue. With repeated or more severe injury, they may
Colonoscopist’s thumb/ DeQuervain’s tenosynovitis
Endoscopist’s neck
Shoulder injuries Upper extremity Thumb osteoarthritis
Biliary endoscopist knuckle
Lumbosacral strain Lower extremity
A wrist tendonitis at the first extensor compartment attributed to left thumb strain because of repeated turning of dials of the control section of the endoscope Cervical neck issues (disk, arthritis, stenosis) with pain and nerve impingement caused by neck extension, flexion and/or turning relative to the monitor Bursitis, impingement, frozen shoulder and rotator cuff issues caused Tendonitis, "tennis elbow," ulnar and radial nerve entrapment, carpal tunnel syndrome A relatively common condition (women more than men) that may be exacerbated by thumb abduction for turning of outer dial and pincer movements Injury to metacarpophalangeal joint from forceful pinch grip and advancement of stents and catheters. Caused by standing for long periods of time or lifting and moving of patients Hip, knee and ankle arthritis and plantar fasciitis; these are all common conditions in the adult population that may be exacerbated by prolonged standing on hard floors without movement or stretching
manifest more severe pain; joint tenderness, effusions, or limited range of motion; neurologic symptoms such as tingling, paresthesias, or weakness; and muscle swelling or atrophy. It is important to seek medical care early when discomfort or pain occurs as it may prevent progression to a more disabling injury. For many of these injuries, initial conservative therapy of ice, splint or wraps, elevation, and rest may be helpful. Of all of these, rest may be the most important, however, many endoscopists may be unwilling or unable to rest due to concerns about loss of income, negative impact upon patient care or their colleagues, or fear of their reputation being negatively affected. Anti-inflammatories are often prescribed and localized steroid injection into the affected joint can also help [14]. Working with an occupational or physical therapist for short-term rehabilitation may include strengthening of the injured muscle groups, or scar tissue mobilization with ultrasound and iontophoresis. Surgery may be indicated for progressive symptoms of continued pain, diminishing muscle strength, herniated discs, and nerve entrapment. Long-term preventive strategies to prevent recurrent injury are vital and may include strengthening and stabilization of muscle groups, stretching, and massage [13]. Floor mats, shoe inserts, and compression stockings have been shown to reduce symptoms of discomfort and fatigue from prolonged standing [17]. 4. Optimization of the work environment
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Table 2 Ergonomic timeout. Bed height Monitor height Monitor distance Endoscopist stance
Between elbow height to 10 cm below elbow height Eye level or lower 52 to 182 cm from endoscopist to monitor Athlete stance
impingement) and reduces arm fatigue [9]. In addition, trauma to the legs may be reduced through use of rubber cushioning mats and lumbar strain minimized through use of a short stool on which the endoscopist’s feet can be placed and alternated as needed during procedures [6]. Just as preprocedure time-out process is done for patient safety, it is important to institute a preprocedure ergonomic timeout (see Table 2). The ergonomic timeout ensures proper positioning of the equipment in the procedure room, including monitor and bed height, and the endoscopist’s stance relative to the patient and monitors. The gastrointestinal nurses and technicians should be trained in ergonomics to prevent injuries to themselves and to monitor the endoscopist during procedures, giving immediate feedback on awkward position or poor posture. Along with ergonomic positioning, adjustment in endoscopy technique may help reduce injuries [1]. Though possibly less efficient than one-handed manipulation of the endoscope dials, a two-handed technique [6] and pinkie maneuver can free the right hand to assist with turning of the dials while stabilizing the shaft of the endoscope [1,20] and thereby decrease hand forces on the thumb and wrist. Commercial accessories are available including a vest to help support the endoscope (reducing tension on the arms and wrists) and an extender knob on the endoscope dial to increase accessibility of the right/left dial (see Figure 1). In addition, in between procedures, especially longer more complex procedures, it important to take breaks to rest the fatigued muscles and to engage in stretches, most especially of the arms and hands. The endoscopy suite is not the only site for repetitive trauma. Many organizations will provide an ergonomic evaluation of your office workspace, including your desk and computer. The chair height, monitor height, position of the mouse, and hand and feet position should be adjusted to prevent muscle strain. Ergonomically designed chairs with back, neck and forearm support are helpful. In addition, ergonomically designed computer accessories (keyboard and mouse) are available. Utilization of a dictation system attached to the electronic health record helps to decrease fatigue and pain from typing along with the proper setup of chair, mouse, and keyboard. This sounds basic, but small changes can be life altering. 5. Primer on disability insurance Gastroenterologists should recognize that temporary or permanent ergonomic injuries can have a devastating impact upon one’s income and financial stability. To protect ourselves and our families, everyone should investigate options for disability insurance, something that can be quite daunting. Understanding the terminology used in disability insurance will aid in choosing the appropriate policy. Issues to consider are the benefit amount, waiting period, cost of living increases, benefits for partial versus complete disability, and the financial stability of the insurance company [21,22]. Working with a team of financial advisors who understand what a physician needs for disability protection as part of their financial planning is important. Disability insurance pricing is based on age, gender, health status, medical specialty, and state of residence [21,22]. The definition of disability is quite important. Buying a policy that has a wide definition of disability including the activities of one’s “own occupation” is crucial. “Own occupation” refers to the inability to practice as a
Fig. 1. Extender knob.
gastroenterologist, even if one can do work despite the disability in another occupation [21,22]. As a gastroenterologist, it is critical to have "own occupation" coverage as we have a higher risk for musculoskeletal injuries [1]. Women should try to get a unisex or gender neutral policy rates because they are considered to have a higher risk for health-related issues [21]. For gastroenterologists in training or early in their careers, it is important to have a future purchase option that allows one to increase future coverage as income grows without requiring additional medical screening [21]. This is a crucial feature to protect the higher income that can be achieved mid-career and beyond. Although your current employer may provide disability insurance as a benefit, most financial planners recommend the purchase of a private policy because employer-based policies do not always provide adequate coverage [22]. Furthermore, should you change employers, your policy stays with you even if you have developed a disability or chronic medical issues that might otherwise limit future insurability. 6. Endoscopy athlete The amount of evidence is limited, but applying ergonomic interventions and muscles strengthening may be considered promising treatment strategies [23]. As gastroenterologists, we invest years to master our craft, but as we go into practices, the demands of our jobs and hectic lives may distract us from the need to care for ourselves. Surely, we can invest a small amount of time into understanding how best to prevent injuries that can threaten our livelihood. In addition to educating ourselves, it is vital to also take a systems approach at your institution to create a culture of injury prevention.
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Table 3 Roadmap for recovery. Prevention
Recognition of symptoms
Treatment and recovery
Return to work
Ergonomics education Optimization of endoscopy unit and computer work stations Have a good disability insurance policy
Pain or discomfort Paresthesia
NSAIDs Rest PT/OT Localized injections Surgery
Ergonomic evaluation of work areas Adjustment in schedule to allow for breaks Stretching between cases Continued awareness
Abbreviations: Physical therapy (PT)/ Occupational Therapy (OT).
As the demands of endoscopy and computer work continue to increase, none of us can predict how our body will handle the cumulative, repetitive physical stress sustained over a 30-year career. Thankfully, over the last few years, there is more awareness about ergonomic injuries among gastroenterologists which may lead to loss of productivity, diminished physician wellbeing, and shortened careers. If you have never had an injury, you may be inclined to dismiss the techniques described above which may otherwise slow slightly your unit flow and patient throughput. We need to think of ourselves as elite athletes. We too have spent years in training and depend upon our bodies to perform complex, repetitive, and physically demanding tasks with great skill and precision. Taking a few moments to reduce your chances of a career-slowing (or career-ending) injury can pay long-term dividends [18]. Just as we maintain our medical knowledge with continuing medical education, we need a program of “body maintenance” in order to build and maintain our strength and flexibility and reduce injury. This can be done with a regular exercise regimen that focuses on strength and interval training, stretching, pilates, or yoga. Incorporating foam rolling and massage helps release of the myofascial tension build-up that can develop after doing hundreds of procedures [24]. This is the same advice we give our patients and our families, and we need to heed it ourselves. While there is no guarantee or evidence to prove that it will prevent ergonomic injury, it is proven to improve overall health and wellbeing and reduce stress. 7. Lessons learned (see Table 3)
1. Do not ignore musculoskeletal symptoms even if they seem mild. These may be the harbinger of more serious injury from repetitive stress that could lead to temporary or permanent disability. It is vital to your long-term career as a gastroenterologist to get evaluated early in hopes of preventing long-term injury. There is no reason to "tough it out." Nobody will thank you for your stoicism, least of all your family. 2. Start to use good ergonomic principles NOW in your clinic/office and endoscopy unit. Do not wait to get injured. Although many endoscopists do not develop injuries, you cannot predict how your body will respond. 3. Body maintenance is key! Think of yourself has an elite, highlypaid athlete. Your body is your livelihood. Be consistent in your exercise, strength training, and stretching. It is every bit as important as your blood pressure, cholesterol, cancer screening, and seat belt. 4. Insist on a well-designed, ergonomic endoscopy unit. Pay attention to the monitor location, gurney height, floor pads, and aprons. Make sure you and your co-workers have optimal equipment for safe-patient handling and position changes to avoid injury. Be the squeaky wheel! In the long run, your co-workers will thank you. 5. Optimize your schedule to allow for adequate rest and recovery. Work proactively with your chief, partners and administrators, partners, and chief in trying different procedure and clinic schedules.
6. Have a good disability policy and review on a yearly basis to make any needed updates depending on your financial situation. 7. Continue to be aware of the issue of injury, well-being and ergonomics in gastroenterology. Keep learning and incorporate it into continuing medical educational plans. Attend talks on ergonomics at national meetings and read the new literature.
Endoscopists need to recognize that the risks of ergonomic injury are real and potentially devastating. It is vital that they learn how to optimize their work environment and biomechanics in hopes of reducing injury. Acute injuries should be evaluated and not ignored. Like professional athletes or craftsmen, your livelihood depends upon it. References [1] Harvin G. Review of musculoskeletal injuries and prevention in the endoscopy practitioner. J Clin Gastroenterol 2014;48(7):590–4. [2] Shergill AK, McQuaid KR, Rempel D. Ergonomics and GI endoscopy. Gastrointest Endosc 2009;70(1):145–53. [3] Mittal A. Recognizing musculoskeletal injury hazards in the upper extremities and lower back. Occup Health Saf 1997;66(8):91–9. [4] Ridtitid W, et al. Prevalence and risk factors for musculoskeletal injuries related to endoscopy. Gastrointest Endosc 2015;81(2):294–302. e4. [5] Pedrosa MC, Farraye FA, Shergill AK, et al. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010;72(2):227–35. [6] Siegel J. Risk of repetitive-use of syndromes and musculoskeletal injuries. Tech Gastrointest Endosc 2007;9:200–4. [7] Moore B, et al. The relationship between back pain and lead apron use in radiologists. AJR Am J Roentgenol 1992;158(1):191–3. [8] da Costa BR, Vieira ER. Risk factors for work-related musculoskeletal disorders: a systematic review of recent longitudinal studies. Am J Ind Med 2010;53(3): 285–323. [9] Berguer R, Hreljac A. The relationship between hand size and difficulty using surgical instruments: a survey of 726 laparoscopic surgeons. Surg Endosc 2004;18 (3):508–12. [10] Cobb TK, Cooney WP, An KN. Aetiology of work-related carpal tunnel syndrome: the role of lumbrical muscles and tool size on carpal tunnel pressures. Ergonomics 1996;39(1):103–7. [11] Fransson C, Winkel J. Hand strength: the influence of grip span and grip type. Ergonomics 1991;34(7):881–92. [12] Oh S, Radwin RG. Pistol grip power tool handle and trigger size effects on grip exertions and operator preference. Hum Factors 1993;35(3):551–69. [13] Rempel DM, Harrison RJ, Barnhart S. Work-related cumulative trauma disorders of the upper extremity. JAMA 1992;267(6):838–42. [14] O'Connor FG, Sobel JR, Nirschl RP. Five-step treatment for overuse injuries. Phys Sportsmed 1992;20(10):128–42. [15] Hirschowitz BI. The cost of doing business: occupational hazards for endoscopists. Endoscopy 1994;26(6):559–61. [16] Buschbauer R. Overuse syndromes among endoscopist. Endoscopy 1994;26:539–44. [17] Waters TR, Dick RB. Evidence of health risks associated with prolonged standing at work and intervention effectiveness. Rehabil Nurs 2015;40(3):148–65. [18] Singla M, et al. Training the endo-athlete: an update in ergonomics in endoscopy. Clin Gastroenterol Hepatol 2018;16(7):1003–6. [19] Cuschieri A. Epistemology of visual imaging in endoscopic surgery. Surg Endosc 2006;20(Suppl 2):S419–24. [20] Guelrud M. Improving control of the colonoscope: the "pinkie maneuver". Gastrointest Endosc 2008;67(2):388–9. author reply 389. [21] www.whitecoatinvestor.com [22] Jarvis CR, Mandell DB, O’Dell JM et al. For California Doctors: a guide to asset protection, tax and estate planning. 2009. [23] Staal JB, de Bie RA, Hendriks EJ. Aetiology and management of work-related upper extremity disorders. Best Pract Res Clin Rheumatol 2007;21(1):123–33. [24] Cheatham SW, Kolber MJ, Cain J, et al. The effects of self myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery and performance: a systematic review. Int J Sports Phys Ther 2015;10(6):827–38.
Contents lists available at ScienceDirect
Techniques in Gastrointestinal Endoscopy journal homepage: www.techgiendoscopy.com/locate/tgie
The injured endoscopist: A roadmap for recovery Nimisha K. Parekh, MD, MPH, FACG, AGAF*, Kenneth McQuaid Division of Gastroenterology, University of California Irvine, 101 The City Drive, Zot 4092, Orange, California 92868
A R T I C L E
I N F O
Article history: Received 30 March 2019 Revised 25 June 2019 Accepted 2 July 2019 Keywords: Ergonomics Injury Endoscopy athlete Disability insurance
A B S T R A C T
Gastroenterologists are at increased risk for musculoskeletal injuries from overuse and repetitive motions during endoscopy. Recently there has been more awareness of ergonomics in endoscopy and strategies for improvement since an injury can be shocking to a physician's career. This article reviews common injuries seen in those who practice endoscopy, steps in managing an injury, guidelines for ergonomic design of a procedure suite, and a basic primer on disability insurance. Incorporation of ergonomic principles in the endoscopy suite and during use of electronic health record can minimize risk of work-related injuries. © 2019 Elsevier Inc. All rights reserved.
1. Our stories 1.1. Author 1 In 2015, I developed a left hand DeQuervain’s tenosynovitis, also known as colonoscopist’s thumb, which is a tendonitis of the wrist first extensor compartment caused by thumb strain from repeated turning of the endoscope dials [1,2]. At first, I was incredulous. How could this happen so early in my career after only 9 years of practice? I was in further shock and disbelief when the hand specialist I consulted affirmed that the injury was likely from repetitive use and recommended surgery for probable scarring. As an alternative, he offered a steroid injection and conservative measures, while warning that there was a less than 50% likelihood of long-term relief. I chose initial conservative management and initiated hand therapy 2 times per week. After months of frustration, I reluctantly underwent the recommended surgery and am gratified to report that it went well. During this time, I began a journey to understand more about ergonomics in gastroenterology. What I learned was quite surprising. 1.2. Author 2 Mine is the story of one who has practiced endoscopy for almost 35 years. For the first 15 years, there was little awareness of ergonomic injury among endoscopists, including me. Endoscopes (heavily used and variably maintained) were less sophisticated than today with low-definition images, stiff insertion tubes, and turning dials that could be stiff due to stretched or tight cables. Small monitors and gurneys were placed at awkward or fixed heights. Suboptimal * Corresponding author. E-mail address: [email protected] (N.K. Parekh). https://doi.org/10.1016/j.tgie.2019.07.008 1096-2883/© 2019 Elsevier Inc. All rights reserved.
equipment and suboptimal technique led to prolonged colonoscopies that resulted in physician and nursing fatigue. During these early years, I denied to myself the possibility of occupational injury. "Minor" aches and pains were dismissed and "worked through." Unit efficiency and throughput were a source of personal pride. When fellows reported fatigue, I assured them that they would get stronger. . .just as I had been assured. With colonoscopy, I prided myself on my ability to control both steering dials with my left thumb, which allowed me to keep my right hand on the insertion tube throughout the procedure and optimize my efficiency. As my years of experience increased and the volume of cases exploded, I became aware of a growing number of musculoskeletal "issues" with my colleagues and, most disturbingly, former fellows with far fewer "endoscopic miles" on their bodies than mine. Cervical spine disease, shoulder impingements, frozen shoulder, tennis elbow, DeQuervain’s tenosynovitis, wrist tendinosis, carpal tunnel syndrome, acute injury to the thenar muscles, and finger tendinopathies were all too common. Some disclosed with personal embarrassment, sadness, and anxiety that the injury had forced them to reduce their endoscopic volume or eliminate specific procedures (especially, endoscopic retrograde cholangiopancreatography [ERCP] and endoscopic ultrasound [EUS]). In my own case, I remained relatively unscathed until recently, when I developed a pain at the base of the metacarpophylangeal joint of my left thumb, which was diagnosed as osteoarthritis. Is it related to age, divine error in joint design, or years of endoscopy using a one handed technique? The absence of problems in my right thumb leads me to suspect the latter. 2. Recognizing the risks for injury Many endoscopists are not aware of the increased risk of musculoskeletal strain and repetitive use injury from performing
156
N.K. Parekh and K. McQuaid / Techniques in Gastrointestinal Endoscopy 21 (2019) 155158
endoscopic procedures. The prevalence of injury ranges from 29% to 89% [1,2]. Risk factors associated with injury in gastroenterologists include working duration, repetitive movements of the dials on the endoscope, static muscle loading in the upper extremities, trapezius, and back from prolonged standing, and awkward body posture and technique [3]. A recent study found that gastroenterologists performing higher procedure volume (>20 per week) and higher number of procedure hours (>16 hours per week) are at increased risk for endoscopy related injury [4], while another estimated that 10% of endoscopists will develop musculoskeletal upper extremity injuries after only 10 years of procedures [5]. Endoscopy entails a variety of repetitive movements, including pushing, pulling, torqueing and gripping of the insertion tube, turning of the dials for tip deflection, and thumb/forefinger pincer squeezing in order to insert and manipulate instruments. These may culminate in acute or chronic injury of the neck, hand, wrist, or shoulder. Performing endoscopy also requires prolonged standing with a relatively fixed posture relative to the gurney and monitors that can result in neck, back, and lower extremity fatigue and injury [6]. In addition, interventional endoscopists should be aware of a correlation of low back pain with wearing of lead aprons or shields [7]. The one piece lead shield increases the static load on the spine and low back whereas a 2-piece shield more evenly distributes the load across the spine and pelvis [2]. It is not entirely clear which gastroenterologists are at risk for development of upper extremity musculoskeletal injuries from repetitive stress, but possible predictive factors include those with small hand and wrist size [8]. Small hand size can affect ability to use laparoscopic instruments [9] and possibly increase risk of injury amongst gastroenterologists, although this is not clear. Those with smaller wrists could be at higher risk due to the small carpal tunnel space. Tool manufacturers are beginning to realize the importance of a manufacturing tool grips that are the correct size for the operator. An in vitro study by Cobb et al simulating active grip, showed that tool grip size can have a significant effect on carpal tunnel pressure [10]. Furthermore, grip size can affect grip strength and hand forces, dependent on the size of the operator’s hands [11,12]. The risk of upper extremity injury is compounded by poor endoscope design, most particularly a "one size fits all" design of the turning dials that is ill fitted to smaller hands. Although the optics of endoscopes has improved in the last 20 years, instrument design has not changed, hence tip deflection still requires mechanical application of force to the control dials [2]. Computer work can further exacerbate the same muscles fatigued during endoscopy procedures. Electronic health records have increased time gastroenterologists spend on computers (desktop or laptop), increasing risks of repetitive stress. Using the mouse and keyboard require some of the same muscles required to hold/manipulate the scope [13].
Table 1 Types of injury seen in gastroenterologists.
3. Types of injury and management
After sustaining a repetitive use injury and undergoing treatment including rest, rehabilitation and/or surgery, it is vital that changes be made to the work environment to avoid a reinjury or new injury. Recent literature has clarified the optimal location of equipment within the endoscopy suite. Monitors should be placed directly in front of the endoscopist at a height 20 cm lower than the height of the endoscopist so that monitor height is at eye-level or lower to prevent neck strain [2,18]. Studies from the laparoscopy literature estimate that the optimal distance between the endoscopist and a 1400 monitor is between 52 and 182 cm, which allows for the least amount of image degradation and less "leaning" of the endoscopist to view images [2,19]. Bed height affects both spine and arm position; surgical data again suggest that optimal bed height is between elbow height and 10 cm below elbow height, which lowers the shoulders (reducing
Repetitive use injuries among gastroenterologists result from repetitive application of force to the same group of muscles, joints, or tendons that leads over time to microtrauma with inflammation or local tissue damage [14]. One example is endoscopist’s thumb or DeQuervain’s tenosynovitis that results from repetitive use of the left thumb to turn the dials that control the angulation of the endoscope [6]. Musculoskeletal injuries commonly seen in gastroenterologist are listed in Table 1 [6,15,16]. Cumulative damage may result in joint synovitis, tendonitis, ligament strains, stress fractures, or degenerative arthritis. Symptoms of repetitive stress are highly variable. Early on they can be mild, easily dismissed, and characterized as stiffness, mild aching, or fatigue. With repeated or more severe injury, they may
Colonoscopist’s thumb/ DeQuervain’s tenosynovitis
Endoscopist’s neck
Shoulder injuries Upper extremity Thumb osteoarthritis
Biliary endoscopist knuckle
Lumbosacral strain Lower extremity
A wrist tendonitis at the first extensor compartment attributed to left thumb strain because of repeated turning of dials of the control section of the endoscope Cervical neck issues (disk, arthritis, stenosis) with pain and nerve impingement caused by neck extension, flexion and/or turning relative to the monitor Bursitis, impingement, frozen shoulder and rotator cuff issues caused Tendonitis, "tennis elbow," ulnar and radial nerve entrapment, carpal tunnel syndrome A relatively common condition (women more than men) that may be exacerbated by thumb abduction for turning of outer dial and pincer movements Injury to metacarpophalangeal joint from forceful pinch grip and advancement of stents and catheters. Caused by standing for long periods of time or lifting and moving of patients Hip, knee and ankle arthritis and plantar fasciitis; these are all common conditions in the adult population that may be exacerbated by prolonged standing on hard floors without movement or stretching
manifest more severe pain; joint tenderness, effusions, or limited range of motion; neurologic symptoms such as tingling, paresthesias, or weakness; and muscle swelling or atrophy. It is important to seek medical care early when discomfort or pain occurs as it may prevent progression to a more disabling injury. For many of these injuries, initial conservative therapy of ice, splint or wraps, elevation, and rest may be helpful. Of all of these, rest may be the most important, however, many endoscopists may be unwilling or unable to rest due to concerns about loss of income, negative impact upon patient care or their colleagues, or fear of their reputation being negatively affected. Anti-inflammatories are often prescribed and localized steroid injection into the affected joint can also help [14]. Working with an occupational or physical therapist for short-term rehabilitation may include strengthening of the injured muscle groups, or scar tissue mobilization with ultrasound and iontophoresis. Surgery may be indicated for progressive symptoms of continued pain, diminishing muscle strength, herniated discs, and nerve entrapment. Long-term preventive strategies to prevent recurrent injury are vital and may include strengthening and stabilization of muscle groups, stretching, and massage [13]. Floor mats, shoe inserts, and compression stockings have been shown to reduce symptoms of discomfort and fatigue from prolonged standing [17]. 4. Optimization of the work environment
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Table 2 Ergonomic timeout. Bed height Monitor height Monitor distance Endoscopist stance
Between elbow height to 10 cm below elbow height Eye level or lower 52 to 182 cm from endoscopist to monitor Athlete stance
impingement) and reduces arm fatigue [9]. In addition, trauma to the legs may be reduced through use of rubber cushioning mats and lumbar strain minimized through use of a short stool on which the endoscopist’s feet can be placed and alternated as needed during procedures [6]. Just as preprocedure time-out process is done for patient safety, it is important to institute a preprocedure ergonomic timeout (see Table 2). The ergonomic timeout ensures proper positioning of the equipment in the procedure room, including monitor and bed height, and the endoscopist’s stance relative to the patient and monitors. The gastrointestinal nurses and technicians should be trained in ergonomics to prevent injuries to themselves and to monitor the endoscopist during procedures, giving immediate feedback on awkward position or poor posture. Along with ergonomic positioning, adjustment in endoscopy technique may help reduce injuries [1]. Though possibly less efficient than one-handed manipulation of the endoscope dials, a two-handed technique [6] and pinkie maneuver can free the right hand to assist with turning of the dials while stabilizing the shaft of the endoscope [1,20] and thereby decrease hand forces on the thumb and wrist. Commercial accessories are available including a vest to help support the endoscope (reducing tension on the arms and wrists) and an extender knob on the endoscope dial to increase accessibility of the right/left dial (see Figure 1). In addition, in between procedures, especially longer more complex procedures, it important to take breaks to rest the fatigued muscles and to engage in stretches, most especially of the arms and hands. The endoscopy suite is not the only site for repetitive trauma. Many organizations will provide an ergonomic evaluation of your office workspace, including your desk and computer. The chair height, monitor height, position of the mouse, and hand and feet position should be adjusted to prevent muscle strain. Ergonomically designed chairs with back, neck and forearm support are helpful. In addition, ergonomically designed computer accessories (keyboard and mouse) are available. Utilization of a dictation system attached to the electronic health record helps to decrease fatigue and pain from typing along with the proper setup of chair, mouse, and keyboard. This sounds basic, but small changes can be life altering. 5. Primer on disability insurance Gastroenterologists should recognize that temporary or permanent ergonomic injuries can have a devastating impact upon one’s income and financial stability. To protect ourselves and our families, everyone should investigate options for disability insurance, something that can be quite daunting. Understanding the terminology used in disability insurance will aid in choosing the appropriate policy. Issues to consider are the benefit amount, waiting period, cost of living increases, benefits for partial versus complete disability, and the financial stability of the insurance company [21,22]. Working with a team of financial advisors who understand what a physician needs for disability protection as part of their financial planning is important. Disability insurance pricing is based on age, gender, health status, medical specialty, and state of residence [21,22]. The definition of disability is quite important. Buying a policy that has a wide definition of disability including the activities of one’s “own occupation” is crucial. “Own occupation” refers to the inability to practice as a
Fig. 1. Extender knob.
gastroenterologist, even if one can do work despite the disability in another occupation [21,22]. As a gastroenterologist, it is critical to have "own occupation" coverage as we have a higher risk for musculoskeletal injuries [1]. Women should try to get a unisex or gender neutral policy rates because they are considered to have a higher risk for health-related issues [21]. For gastroenterologists in training or early in their careers, it is important to have a future purchase option that allows one to increase future coverage as income grows without requiring additional medical screening [21]. This is a crucial feature to protect the higher income that can be achieved mid-career and beyond. Although your current employer may provide disability insurance as a benefit, most financial planners recommend the purchase of a private policy because employer-based policies do not always provide adequate coverage [22]. Furthermore, should you change employers, your policy stays with you even if you have developed a disability or chronic medical issues that might otherwise limit future insurability. 6. Endoscopy athlete The amount of evidence is limited, but applying ergonomic interventions and muscles strengthening may be considered promising treatment strategies [23]. As gastroenterologists, we invest years to master our craft, but as we go into practices, the demands of our jobs and hectic lives may distract us from the need to care for ourselves. Surely, we can invest a small amount of time into understanding how best to prevent injuries that can threaten our livelihood. In addition to educating ourselves, it is vital to also take a systems approach at your institution to create a culture of injury prevention.
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Table 3 Roadmap for recovery. Prevention
Recognition of symptoms
Treatment and recovery
Return to work
Ergonomics education Optimization of endoscopy unit and computer work stations Have a good disability insurance policy
Pain or discomfort Paresthesia
NSAIDs Rest PT/OT Localized injections Surgery
Ergonomic evaluation of work areas Adjustment in schedule to allow for breaks Stretching between cases Continued awareness
Abbreviations: Physical therapy (PT)/ Occupational Therapy (OT).
As the demands of endoscopy and computer work continue to increase, none of us can predict how our body will handle the cumulative, repetitive physical stress sustained over a 30-year career. Thankfully, over the last few years, there is more awareness about ergonomic injuries among gastroenterologists which may lead to loss of productivity, diminished physician wellbeing, and shortened careers. If you have never had an injury, you may be inclined to dismiss the techniques described above which may otherwise slow slightly your unit flow and patient throughput. We need to think of ourselves as elite athletes. We too have spent years in training and depend upon our bodies to perform complex, repetitive, and physically demanding tasks with great skill and precision. Taking a few moments to reduce your chances of a career-slowing (or career-ending) injury can pay long-term dividends [18]. Just as we maintain our medical knowledge with continuing medical education, we need a program of “body maintenance” in order to build and maintain our strength and flexibility and reduce injury. This can be done with a regular exercise regimen that focuses on strength and interval training, stretching, pilates, or yoga. Incorporating foam rolling and massage helps release of the myofascial tension build-up that can develop after doing hundreds of procedures [24]. This is the same advice we give our patients and our families, and we need to heed it ourselves. While there is no guarantee or evidence to prove that it will prevent ergonomic injury, it is proven to improve overall health and wellbeing and reduce stress. 7. Lessons learned (see Table 3)
1. Do not ignore musculoskeletal symptoms even if they seem mild. These may be the harbinger of more serious injury from repetitive stress that could lead to temporary or permanent disability. It is vital to your long-term career as a gastroenterologist to get evaluated early in hopes of preventing long-term injury. There is no reason to "tough it out." Nobody will thank you for your stoicism, least of all your family. 2. Start to use good ergonomic principles NOW in your clinic/office and endoscopy unit. Do not wait to get injured. Although many endoscopists do not develop injuries, you cannot predict how your body will respond. 3. Body maintenance is key! Think of yourself has an elite, highlypaid athlete. Your body is your livelihood. Be consistent in your exercise, strength training, and stretching. It is every bit as important as your blood pressure, cholesterol, cancer screening, and seat belt. 4. Insist on a well-designed, ergonomic endoscopy unit. Pay attention to the monitor location, gurney height, floor pads, and aprons. Make sure you and your co-workers have optimal equipment for safe-patient handling and position changes to avoid injury. Be the squeaky wheel! In the long run, your co-workers will thank you. 5. Optimize your schedule to allow for adequate rest and recovery. Work proactively with your chief, partners and administrators, partners, and chief in trying different procedure and clinic schedules.
6. Have a good disability policy and review on a yearly basis to make any needed updates depending on your financial situation. 7. Continue to be aware of the issue of injury, well-being and ergonomics in gastroenterology. Keep learning and incorporate it into continuing medical educational plans. Attend talks on ergonomics at national meetings and read the new literature.
Endoscopists need to recognize that the risks of ergonomic injury are real and potentially devastating. It is vital that they learn how to optimize their work environment and biomechanics in hopes of reducing injury. Acute injuries should be evaluated and not ignored. Like professional athletes or craftsmen, your livelihood depends upon it. References [1] Harvin G. Review of musculoskeletal injuries and prevention in the endoscopy practitioner. J Clin Gastroenterol 2014;48(7):590–4. [2] Shergill AK, McQuaid KR, Rempel D. Ergonomics and GI endoscopy. Gastrointest Endosc 2009;70(1):145–53. [3] Mittal A. Recognizing musculoskeletal injury hazards in the upper extremities and lower back. Occup Health Saf 1997;66(8):91–9. [4] Ridtitid W, et al. Prevalence and risk factors for musculoskeletal injuries related to endoscopy. Gastrointest Endosc 2015;81(2):294–302. e4. [5] Pedrosa MC, Farraye FA, Shergill AK, et al. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010;72(2):227–35. [6] Siegel J. Risk of repetitive-use of syndromes and musculoskeletal injuries. Tech Gastrointest Endosc 2007;9:200–4. [7] Moore B, et al. The relationship between back pain and lead apron use in radiologists. AJR Am J Roentgenol 1992;158(1):191–3. [8] da Costa BR, Vieira ER. Risk factors for work-related musculoskeletal disorders: a systematic review of recent longitudinal studies. Am J Ind Med 2010;53(3): 285–323. [9] Berguer R, Hreljac A. The relationship between hand size and difficulty using surgical instruments: a survey of 726 laparoscopic surgeons. Surg Endosc 2004;18 (3):508–12. [10] Cobb TK, Cooney WP, An KN. Aetiology of work-related carpal tunnel syndrome: the role of lumbrical muscles and tool size on carpal tunnel pressures. Ergonomics 1996;39(1):103–7. [11] Fransson C, Winkel J. Hand strength: the influence of grip span and grip type. Ergonomics 1991;34(7):881–92. [12] Oh S, Radwin RG. Pistol grip power tool handle and trigger size effects on grip exertions and operator preference. Hum Factors 1993;35(3):551–69. [13] Rempel DM, Harrison RJ, Barnhart S. Work-related cumulative trauma disorders of the upper extremity. JAMA 1992;267(6):838–42. [14] O'Connor FG, Sobel JR, Nirschl RP. Five-step treatment for overuse injuries. Phys Sportsmed 1992;20(10):128–42. [15] Hirschowitz BI. The cost of doing business: occupational hazards for endoscopists. Endoscopy 1994;26(6):559–61. [16] Buschbauer R. Overuse syndromes among endoscopist. Endoscopy 1994;26:539–44. [17] Waters TR, Dick RB. Evidence of health risks associated with prolonged standing at work and intervention effectiveness. Rehabil Nurs 2015;40(3):148–65. [18] Singla M, et al. Training the endo-athlete: an update in ergonomics in endoscopy. Clin Gastroenterol Hepatol 2018;16(7):1003–6. [19] Cuschieri A. Epistemology of visual imaging in endoscopic surgery. Surg Endosc 2006;20(Suppl 2):S419–24. [20] Guelrud M. Improving control of the colonoscope: the "pinkie maneuver". Gastrointest Endosc 2008;67(2):388–9. author reply 389. [21] www.whitecoatinvestor.com [22] Jarvis CR, Mandell DB, O’Dell JM et al. For California Doctors: a guide to asset protection, tax and estate planning. 2009. [23] Staal JB, de Bie RA, Hendriks EJ. Aetiology and management of work-related upper extremity disorders. Best Pract Res Clin Rheumatol 2007;21(1):123–33. [24] Cheatham SW, Kolber MJ, Cain J, et al. The effects of self myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery and performance: a systematic review. Int J Sports Phys Ther 2015;10(6):827–38.