The assessment and prevention of work-related injury to physicians who perform endoscopy is a remarkably understudied area, but an extremely important one. Endoscopists are at risk of musculoskeletal strain and repetitive motion injury due to procedures requiring repetitive push-and-pull movements of the arms, torquing of the endoscope with force, and a prolonged grip of the control dials. Endoscope design contributes to strain on the gastroenterologist. In addition, endoscopists often work in awkward postures while manipulating the scope, and factors such as suboptimal monitor position and bed height can aggravate neck and back strain.
An ASGE technology report estimates the prevalence of musculoskeletal symptoms in gastroenterologists to be from 37 percent up to 89 percent.1
Skeletal muscle complaints are more common in gastroenterologists than in other internal medicine specialists. A number of surveys have linked musculoskeletal injuries to a high-volume endoscopy practice. According to a recent study, gastroenterologists performing more than 20 endoscopies per week are at risk of endoscopy-related injury.3
The Occupational Repetitive Actions (OCRA) index is an ergonomic risk assessment tool; itestimates that about 10 percent of endoscopists will develop upper extremity musculoskeletal injury after 10 years of performing endoscopic procedures. Overuse injuries occur due to repeated microtrauma to a tendon or ligament, or from ischemia to peripheral nerves.2
The most common injuries reported by endoscopists are carpel tunnel syndrome, pain in the left thumb, the right wrist, the cervical spine and the lower back. A “colonoscopist’s thumb” is De Quervain’s tenosynovitis of the left thumb due to repetitive strain from controlling the endoscope dials. A “biliary endoscopist’s knuckle” is injury to the metacarpophalangeal joint and results from making a forceful pinch grip and advancing catheters, endoscopic instruments and devices, through biliary strictures.1
In my practice at a tertiary care cancer hospital, about 1,100 to 1,200 endoscopies are performed monthly. A number of endoscopic procedures are complex and time consuming, reflective of our patient population. Patients may require treatment of malignant biliary obstruction, control of bleeding in thrombocytopenic patients, tumor staging and ablation; high-volume screening and surveillance endoscopy is also performed. There are 14 full-time gastroenterologists, 11 of whom spend 22 hours or more per week in the endoscopy unit. In the past two years, three of the 11 endoscopists who spend half their time or more performing endoscopies have required prolonged leave of absence due to musculoskeletal injuries of the spine and upper extremities. These injuries are most likely related to chronic overuse strain. Many endoscopists alter their endoscopy practice due to pain or injury, including three of my colleagues who now perform endoscopies while sitting down. Several other colleagues, including technicians in our unit, complain of recurring neck, arm and back pain.
Several factors could improve the ergonomic environment in the endoscopy suite. There is clearly a need for comprehensive guidelines presenting best clinical practice for ergonomics. Training should include information for the endoscopist and the technician on the optimal ergonomics in order to help minimize physical discomfort and maximize productivity. Optimizing the ergonomic environment includes attention to posture and position, procedure room equipment, daily case volumes and endoscope design factors.
We know that performing an endoscopy while maintaining a neutral position of the spine and upper extremities may reduce injury. Neck rotation should be minimized by placing the monitor directly in front of the endoscopist. The monitor height should be just below eye level so that the cervical spine is not in extension. Additionally, the bed level should be adjusted to avoid undue flexion of the lower back. Equipment such as cushioned floor mats can also decrease foot discomfort from prolonged standing. A two-piece lead apron during fluoroscopic procedures will lessen weight placed on the intervertebral disk spaces, as compared to a single full-body shield.
There should also be recognition of muscle fatigue and adequate rest time allowed for recovery between procedures.
In general, the design of the endoscope needs to be retooled to better fit ergonomic principles. The basic shape of the endoscope has not changed over time. For example, the endoscopy control dials come in only one size so regardless of hand span, all endoscopists uses the same size dial. Endoscope design should become a major focus of interventions to reduce muscle strain and fatigue for endoscopists.
Other areas that require further study include defining the optimal workload and rest period, the impact of sedation (monitored anesthesia vs. conscious sedation) in limiting injury, and if patient gender is an independent risk factor for injury (as colonoscopies in women can require more time and manipulation).
Risk of injury to the endoscopist should be minimized by adjusting reimbursement and allowing additional time for anticipated difficult procedures. We must involve ergonomic engineers, equipment manufacturers and occupational therapists in the design of a safe, highly functional endoscopy unit.
Work related injury can be devastating to the career of an endoscopist. While the safety of the patient is the highest priority in the endoscopy unit, we must equally ensure that the endoscopy unit is not a hazardous place for the endoscopist.
Dr. Shafi serves on the AGA Women’s Committee.
1.Shergill AK, McQuaid, KR, Rempel D. Ergonomics and GI Endoscopy. Gastrointest Endosc 2009, 70:145-53.
2. Pedrosa MC, Farraye FA, Shergill AK et al. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010, 72:227-35
3. Ridtitid W, Cote, GA, Leung W et al. Prevalence and risk factors for musculoskeletal injuries related to endoscopy. Gastrointest Endosc 2015,81:294- 302