Pinch force and forearm-muscle load during routine colonoscopy: a pilot study

Advances in objective assessment of ergonomics in endoscopic surgery: a review

Background

Minimally invasive surgery, in particular endoscopic surgery, has revolutionized the benefits for patients, but poses greater challenges for surgeons in terms of ergonomics. Integrating ergonomic assessments and interventions into the multi-stage endoscopic procedure contributes to the surgeon's musculoskeletal health and the patient's intraoperative safety and postoperative recovery.

Objective

The purpose of this study was to overview the objective assessment techniques, tools and assessment settings involved in endoscopic procedures over the past decade and to identify the potential factors that induce differences in high workloads in endoscopic procedures and ultimately to design a framework for ergonomic assessment in endoscopic surgery.

Methods

Literature searches were systematically conducted in the OVID, pubmed and web of science database before October 2022, and studies evaluating ergonomics during the process of endoscopic procedures or simulated procedures were both recognized.

Results

Our systematic review of 56 studies underscores ergonomic variations in endoscopic surgery. While endoscopic procedures, predominantly laparoscopy, typically incur less physical load than open surgery, extended surgical durations notably elevate ergonomic risks. Surgeon characteristics, such as experience level and gender, significantly influence these risks, with less experienced and female surgeons facing greater challenges. Key assessment tools employed include electromyography for muscle fatigue and motion analysis for postural evaluation.

Conclusion

This review aims to provide a comprehensive analysis and framework of objective ergonomic assessments in endoscopic surgery, and suggesting avenues for future research and intervention strategies. By improving the ergonomic conditions for surgeons, we can enhance their overall health, mitigate the risk of WMSDs, and ultimately improve patient outcomes.

Enhancing Ergonomics in Pediatric Endoscopy Training and Practice

Pediatric endoscopists are at risk of work-related injuries from overuse and repetitive motions during endoscopy. Recently, there has been increasing appreciation for the importance of ergonomics education and training to help build long-term habits that prevent injury. This article reviews the epidemiology of endoscopy-related injuries in pediatric practice, describes methods for controlling exposures in the workplace, discusses key ergonomic principles that can be used to mitigate injury risk, and outlines tips for integrating education on endoscopy ergonomics during training.

Musculoskeletal injury and ergonomics in pediatric gastrointestinal endoscopic practice

BACKGROUND AND AIMS

Endoscopy-related musculoskeletal injuries (ERI) are increasingly prevalent in adult endoscopists; however, there are no studies that have evaluated ERI and ergonomic practices among pediatric gastroenterologists and trainees. We aimed to examine the prevalence, nature, and impact of musculoskeletal injuries in pediatric endoscopic practice and assess attitudes towards ergonomic training needs.

METHODS

Pediatric gastroenterologists and trainees were surveyed to collect information on endoscopist and practice characteristics, the prevalence, nature, and impacts of ERI, ergonomics strategies employed in practice, previous ergonomics training, and perceptions of ergonomics training (elicited using a 1 (strongly disagree) to 5 (strongly agree) Likert scale). Responses were analyzed using descriptive statistics, and bivariate analyses were conducted to explore correlates of ERI.

RESULTS

Among 146 survey respondents, 50 (34.2%) were trainees and 96 (65.8%) were practicing endoscopists with a mean duration of endoscopic practice of 9.7 ± 9.4 years. Overall, 55.6% (n = 80/144) reported experiencing a musculoskeletal injury, with 34.7% (n = 50/144) reporting an injury attributable to endoscopy. Among those with ERI, the most common sites were the neck/upper back (44.0%), thumb (42.0%), hand/finger (38.0%), and lower back (36.0%). Women were more likely to experience ERI compared to men (43.4% vs. 23.4%; p = 0.013). Only 20.9% of participants had formal training in ergonomics. Respondents reported being motivated to implement practice changes to prevent ERI (4.41 ± 0.95) and perceived ergonomics training as important (4.37 ± 0.96).

CONCLUSIONS

Pediatric endoscopists, and particularly women, experience significant ERI; however, formal endoscopy ergonomics training is rare. Improved ergonomics training is needed for both practicing pediatric gastroenterologists and trainees.

Methods for Gastrointestinal Endoscopy Quantification: A Focus on Hands and Fingers Kinematics

Gastrointestinal endoscopy is a complex procedure requiring the mastery of several competencies and skills. This procedure is in increasing demand, but there exist important management and ethical issues regarding the training of new endoscopists. Nowadays, this requires the direct involvement of real patients and a high chance of the endoscopists themselves suffering from musculoskeletal conditions. Colonoscopy quantification can be useful for improving these two issues. This paper reviews the literature regarding efforts to quantify gastrointestinal procedures and focuses on the capture of hand and finger kinematics. Current technologies to support the capture of data from hand and finger movements are analyzed and tested, considering smart gloves and vision-based solutions. Manus VR Prime II and Stretch Sense MoCap reveal the main problems with smart gloves related to the adaptation of the gloves to different hand sizes and comfortability. Regarding vision-based solutions, Vero Vicon cameras show the main problem in gastrointestinal procedure scenarios: occlusion. In both cases, calibration and data interoperability are also key issues that limit possible applications. In conclusion, new advances are needed to quantify hand and finger kinematics in an appropriate way to support further developments.

Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists

BACKGROUND AND AIMS

Musculoskeletal (MSK) injuries among gastroenterologists are common. Our study describes risk factors and consequences of injury by comparing provider-specific anthropometric and objective procedural data to self-reported injury patterns.

METHODS

A validated MSK symptom survey was sent to gastroenterologists to gauge prevalence, distribution, and severity of active injury. Respondents' procedural activities over 7 years were collected via an endoscopic database.

RESULTS

64 surveys were completed. 54 respondents had active pain; 53.1% reported activity-limiting injury. Activity-limiting injuries lead to longer colonoscopy times (25.3 vs. 22.1 min, P = 0.03) and lower procedural volumes (532 vs. 807, P = 0.01). Hand/wrist injuries yielded longer colonoscopy insertion times (9.35 vs. 8.21 min, P = 0.03) and less hands-on scope hours (81.2 vs. 111.7 h, P = 0.04). Higher esophagogastroduodenoscopy volume corelated with shoulder injury (336.5 vs. 243.1 EGDs/year, P = 0.04). Females had more foot injuries (P = 0.04).

CONCLUSION

Activity-limiting MSK symptoms/injuries affect over 50% of endoscopists with negative impact on procedural volume and efficiency.

Pinch Grip per SE Is Not an Occupational Risk Factor for the Musculoskeletal System: An Experimental Study on Field

Introduction: Some ergonomic evaluation methods define pinch grip as a risk factor independent of the exerted force. The present experimental study was performed with the main aim of objectively measuring the muscle engagement during the execution of pinch grip. Methods: the participants of the study were healthy workers occupationally involved in a high-intensity repetitive job related to the sorting of letters and small packages. Surface electromyography (sEMG) was used to study the activity of the abductor pollicis brevis and first dorsal interosseous fibers related to the execution of the required working tasks, while the force exerted during voluntary muscle contraction for pinch grip was measured by a portable acquisition system. The subjects were specifically asked to exert the maximum voluntary isometric contraction (MVIC) and further voluntary isometric contractions with a spontaneous force (SF) equal to 10%,20% and 50% of the MVIC; finally, the workers were asked to hold in pinch grip two types of envelopes, weighing 100 g and 500 g, respectively. Results: The force required to pinch 100 and 500 g envelopes by the fifteen subjects of the study corresponded to 4 and 5% MVIC, respectively. The corresponding sEMG average rectified values (ARV) were approximately 6% of that at MVIC for first dorsal interosseus (FDI) fibers and approximately 20–25% of MVIC for abductor pollicis brevis (ABP) fibers. Bivariate correlation analysis showed significant relationships between force at MVIC and FDI ARV at MCV. Conclusions: The obtained results demonstrate that muscle recruitment during pinch grip varies as a function of the SF: not only the position but also the exerted force should be considered when assessing the pinch grip as risk factor for biomechanical overload of the upper limb.

The impact of endoscopic activity on musculoskeletal disorders of high-volume endoscopists in Germany

Physical stress is common in GI endoscopists, leading to musculoskeletal disorders. Considering the increasing complexity of interventional GI endoscopy with prolonged examination time, work-related musculoskeletal disorders have come into focus. However, data on work-related health stress in German endoscopists are elusive. The aim of this study was therefore to investigate the prevalence and consequences of work-related musculoskeletal disorders in German endoscopists. A 24-item questionnaire on endoscopy-associated musculoskeletal disorders and standardized pain assessment was developed by an interdisciplinary team of endoscopists and sports medics. The survey was distributed online by the leading German societies for gastroenterology and endoscopy. Overall, 151 German practicing endoscopists took part in the study. Regarding the average number of endoscopic procedures per week, the study collective consisted mainly of high-volume endoscopists. The survey showed that most participants suffered from general musculoskeletal disorders (82.8%) and from work-related musculoskeletal disorders (76.8%). The most affected body parts were the neck, low back, thumb, and shoulder. Temporary absence from work due to symptoms was reported by 9.9% of the respondents. Over 30% of participating endoscopists stated the need for analgesics or physiotherapy due to musculoskeletal disorders. Age, professional experience and work time were identified as relevant risk factors for musculoskeletal health issues. A high number of German endoscopists are affected by musculoskeletal disorders due to specific working postures and repetitive movements with a large impact on personal health. Further interventional studies are mandatory to improve the risk prevention of endoscopic activity.

Gastrointestinal endoscopy and work-related injuries: an international survey

Background and study aims  Recently, the awareness of work-related musculoskeletal injuries (MSIs) among gastrointestinal endoscopists has increased because of their effect on the private and work life of clinicians as well as on the health care system. The high injury incidence (reported to range from 37 % to 89 %) has been correlated with the intensive muscular demand required during a procedure. Patients and methods  An online survey with 32 questions was conducted globally. Clinically active endoscopists (doctors and nurses) participated anonymously and voluntarily. The questionnaire included questions about endoscopist anthropometrics, experience of MSI, treatment, and preventive measures such as ergonomic training. Descriptive statistics were used to analyse the data. Results  Of 204 clinicians (78 % males; 81 % > 35 years of age), 107 (53 %) stated to have experienced a work-related MSI. The most frequent locations were in the neck (n = 49), shoulder and thumb (n = 39, both). Female clinicians resulted to be significantly more prone to develop MSI. In addition, endoscopists who performed more than 15 hours of endoscopy or more than 15 procedures per week reported a significantly higher rate of MSI. Conclusions  The high frequency of MSIs among gastrointestinal endoscopists highlights the importance of implementing ergonomic training. Including simple precautions before and during endoscopy may reduce the risk of developing an injury.

Effects of endoscopy-related procedure time on musculoskeletal disorders in Japanese endoscopists: a cross-sectional study

Background and study aims  There has been little evidence assessing the prevalence of musculoskeletal disorders (MSDs) among endoscopists performing recent diagnostic and therapeutic endoscopic procedures requiring prolonged procedural times. We evaluated the prevalence and identified the risk factors for developing MSDs, focusing on procedural time. Methods  An electronic survey of endoscopists (n = 213) employed at the Nagoya University Hospital and its affiliated hospitals was developed by a multidisciplinary group.  Results  Of the 110 endoscopists (51.6 %) who responded to the survey, eighty-seven endoscopists (79.1 %) had experienced endoscopy-related MSDs during the previous 1 year, and 49 endoscopists (44.5 %) had experienced these MSDs during the previous week. Nineteen endoscopists (17.3 %) reported absence from work due to severe MSDs. The most frequent sites of MSDs were neck, low back, and shoulders. Logistic regression analyses showed that longer upper endoscopic submucosal dissection ESD, (odds ratio: 5.7; 95 %CI: 1.3-25.0), lower ESD (odds ratio 4.9; 95 %CI: 1.1-22.0), and lower gastrointestinal treatment (odds ratio: 5.6; 95 %CI: 2.3-13.3) were significantly associated with the development of MSDs in the low back area. Moreover, longer lower ESD (odds ratio: 5.0; 95 % CI: 1.2-20.2) was a risk factor for symptoms in the left shoulder. Conclusion  This study suggests a correlation between the volume of therapeutic endoscopic procedures including ESD and the risk of MSDs mainly low back area and left shoulder. Managing monthly total endoscopic time, in light of organizational ergonomics, could contribute to minimizing such risks of endoscopy-related MSDs.

Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy

BACKGROUND AND AIMS

Endoscopists experience upper extremity musculoskeletal injuries. The primary aim of this study was to compare distal upper extremity biomechanical risk factors during colonoscopy with established risk thresholds. Secondary aims were to determine which subtasks during colonoscopy are associated with the greatest risk and to evaluate an intervention to reduce risks.

METHODS

Twelve endoscopists performed 2 to 4 colonoscopies while thumb pinch force and forearm muscle loads of extensor carpi radialis (ECR) and flexor digitorum superficialis (FDS) muscles were collected. Peak exertion values were analyzed using amplitude probability distribution functions. An endoscope support device was evaluated during simulated colonoscopy (n = 8).

RESULTS

Mean endoscopist age was 42.3 years; 67% were men. Peak thumb pinch force exceeded risk thresholds for pinch force (10 N) and percent of time spent in forceful pinch for all colonoscopy subtasks. Peak ECR and FDS muscle activity exceeded the action limit (10% maximum voluntary contraction [MVC]) in both forearms. Peak left FDS, left ECR, and right ECR activity exceeded the threshold limit value (>30% MVC). Peak left FDS and ECR activity were significantly greater during insertion than during withdrawal (P < .05). Peak right FDS and ECR activity were significantly greater during right colon insertion compared with withdrawal (P < .05). The endoscope support device reduced left ECR muscle activity (P = .02).

CONCLUSIONS

Thumb pinch forces and time spent in forceful pinch indicate high-risk exposures during colonoscopy. Left wrist extensor muscle activity exceeded established thresholds with the greatest risk occurring during insertion. An endoscope support device reduced loads to the left wrist extensors.

Are All Endoscopy-Related Musculoskeletal Injuries Created Equal? Results of a National Gender-Based Survey

INTRODUCTION

Endoscopy-related injury (ERI) is common in gastroenterologists (GI). The study aim was to assess the prevalence of self-reported ERI, patterns of injury, and endoscopist knowledge of preventative strategies in a nationally representative sample.

METHODS

A 38-item electronic survey was sent to 15,868 American College of Gastroenterology physician members. The survey was completed by 1,698 members and was included in analyses. Descriptive, univariate, and multivariate analyses were conducted to evaluate the likelihood of ERI based on workload parameters and gender.

RESULTS

ERI was reported by 75% of respondents. ERI was most common in the thumb (63.3%), neck (59%), hand/finger (56.5%), lower back (52.6%), shoulder (47%), and wrist (45%). There was no significant difference in the prevalence of ERI between men and women GI. However, women GI were significantly more likely to report upper extremity ERI while men were more likely to report lower-back pain-related ERI. Significant gender differences were noted in the reported mechanisms attributed to ERI. Most respondents did not discuss ergonomic strategies in their current practice (63%). ERI was less likely to be reported in GI who took breaks during endoscopy (P = 0.002).

DISCUSSION

ERI is highly prevalent in GI physicians. Significant gender differences regarding specific sites affected by ERI and the contributing mechanisms were observed. Results strongly support institution of training in ergonomics for all GI as a strategy to prevent its impact on providers of endoscopy.

Colonoscopy-related injury among colonoscopists: an international survey

Background and study aims  Colonoscopy is physically demanding for endoscopists and patients. Repetitive movements during colonoscopy can lead to overuse injuries. We aimed to explore the prevalence and range of colonoscopy-related musculoskeletal injuries (CRIs) in endoscopists. Methods  A cross-sectional electronic survey of 1825 endoscopists was performed. The sample was composed of members of the British Society of Gastroenterology, European Society of Gastrointestinal Endoscopy, and National Nurse Endoscopy Group (UK). The survey comprised 20 questions. These included: endoscopists' workload, level of experience, and their perceived CRIs. All endoscopists who perform colonoscopy independently were included in the analysis. Results  A total of 368 questionnaires were completed of 1825 surveyed (20.16 %). Of those, 319 participants (17.48 %) were fully independent in colonoscopy. Of 319 endoscopists, 254 (79.6 %) have experienced musculoskeletal injuries. These were reported as either possibly (n = 143, 56.3 %) or definitely (n = 90, 35.4 %) related to colonoscopy. Commonly injured areas were the lower back (n = 85, 36.5 %), neck (n = 82, 35.2 %) and left thumb (n = 79, 33.9 %). Of the injured endoscopists, 98 (30.7 %) made some modification to their practice, such as stretching exercises and ergonomic changes. Of the endoscopists, 134 (42.0 %) thought that repetitive limb strain was a likely causative mechanism. Around 40 % believed that torquing the scope and challenging body position were precipitating CRIs. Several treatment modalities were used to treat CRIs. These included; physiotherapy (n = 109), medications (n = 70), rest (n = 43), splinting (n = 31), steroid injections (n = 26) and surgery (n = 11). Conclusions  A significant proportion of colonoscopists experience CRIs. The majority of the suggested modifications to practice can be adopted by any endoscopist. These results highlight the need to recognise CRI as an important occupational health hazard and to adopt preventative strategies routinely in the future.

Musculoskeletal Pain Symptoms and Injuries Among Endoscopists Who Perform ERCP

BACKGROUND AND AIMS

The leaded protective gear worn, patient and endoscopist positioning, and longer average procedural time place endoscopists who perform endoscopic retrograde cholangiopancreatography (ERCP) at an increased risk of injuries as compared to other endoscopists. While multiple studies have investigated the prevalence of various pain symptoms and injuries among endoscopists, only one has been carried out in endoscopists who perform ERCP, and none have investigated potential predisposing risk factors. Our aim was thus to assess the prevalence of these pain symptoms, injuries, and potential risk factors.

METHODS

An anonymous electronic survey containing 23 questions was sent to 3276 gastroenterologists. Only providers that performed ERCPs were asked to respond.

RESULTS

A total of 203 surveys were completed. Of the 203 respondents, 91% reported a musculoskeletal pain symptom. The most prevalent pain symptoms were neck pain (24%) and lower back pain (17%). In total, 48% of respondents reported a musculoskeletal injury. In total, 32% attributed these injuries to performing ERCPs. The most prevalent musculoskeletal injuries were De Quervain's tenosynovitis (16%) and cervical radiculopathy (12%). Only 25% of participants had received any education/training on ergonomics in endoscopy.

CONCLUSIONS

The majority of endoscopists who perform ERCPs suffer from a musculoskeletal pain symptom, and almost half report a musculoskeletal injury. Further investigation regarding risk factors and preventative strategies is warranted. This information can then be incorporated into ergonomics education which only a small proportion of advanced endoscopists report having received any training in.

High prevalence of musculoskeletal symptoms and injuries in third space endoscopists: an international multicenter survey

Background and study aims  Third space endoscopy (TSE), including per-oral endoscopic myotomy and endoscopic submucosal dissection, is technically challenging and physically demanding. The aim of this study was to assess the prevalence and types of musculoskeletal symptoms and injuries (MSI) in third space endoscopists and its impact on clinical practice. Materials, Patients and methods  A 22-item survey measuring endoscopist characteristics, procedure volumes, MSI, and its effect on clinical practice was distributed to endoscopists practicing TSE. Descriptive statistics were used to depict MSI. Logistic regression was used to identify predictors for MSI related to TSE. Results  The survey was completed by 45 of 110 endoscopists (40.9 %) who received the survey, representing 10 countries across four continents. Thirty-one (69 %) endoscopists reported current MSI with 71 % (n = 22/31) believing these began after starting TSE, and 48.9 % (22/45) reporting more symptoms after TSE compared to endoscopic ultrasound/endoscopic retrograde cholangiopancreatography. Common MSI included the shoulders (42.2 %), back (37.8 %), neck (33.3 %), and wrist (24.4 %). Lower extremity MSI were also reported with foot symptoms (11.1 %) being most common. A minority required disability (2.2 %), change in endoscopy scheduling (6.7 %) or surgery (2.2 %). Only 15.6 % of endoscopists had received prior ergonomics training. Logistic regression revealed no significant predictors for MSI. Conclusions  Over two-thirds of endoscopists performing TSE suffer from MSI, with many reporting onset of their symptoms after starting TSE in their practice. Further studies are needed to understand and reduce the risk of MSI in TSE given the growing demand for these procedures and the potential long-term impact of this occupational hazard.

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study

Background and study aims  Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods  A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results  The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions  Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.

Ergonomic endoscopy: An oxymoron or realistic goal?

The current endoscope design is not ergonomic. There is a high prevalence of endoscopy-related injury reported in the literature, and studies have demonstrated high-risk biomechanical exposures during the performance of routine colonoscopy. Endoscopy ergonomics focuses on understanding the endoscopist's interaction with the endoscope and the endoscopy unit and re-designing these tasks to minimize the risk of endoscopy-related injury. The discussion to date has focused on what the endoscopist can do to minimize his or her risk of injury. It is imperative that we re-frame that discussion because the implication that physicians are responsible for implementing personal or workplace interventions places an undue burden on physicians and will be the least effective exposure control method. Endoscope companies need to consider the endoscopist in their design process. As a profession, we need to collectively advocate for endoscopist safety. We offer a perspective on how ergonomic endoscopy can become a realistic and achievable goal.

ASGE EndoVators Summit: simulators and the future of endoscopic training

Interest in the use of simulation for acquiring, maintaining, and assessing skills in GI endoscopy has grown over the past decade, as evidenced by recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines encouraging the use of endoscopy simulation training and its incorporation into training standards by a key accreditation organization. An EndoVators Summit, partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, (NIH) was held at the ASGE Institute for Training and Technology from November 19 to 20, 2017. The summit brought together over 70 thought leaders in simulation research and simulator development and key decision makers from industry. Proceedings opened with a historical review of the role of simulation in medicine and an outline of priority areas related to the emerging role of simulation training within medicine broadly. Subsequent sessions addressed the summit's purposes: to review the current state of endoscopy simulation and the role it could play in endoscopic training, to define the role and value of simulators in the future of endoscopic training and to reach consensus regarding priority areas for simulation-related education and research and simulator development. This white paper provides an overview of the central points raised by presenters, synthesizes the discussions on the key issues under consideration, and outlines actionable items and/or areas of consensus reached by summit participants and society leadership pertinent to each session. The goal was to provide a working roadmap for the developers of simulators, the investigators who strive to define the optimal use of endoscopy-related simulation and assess its impact on educational outcomes and health care quality, and the educators who seek to enhance integration of simulation into training and practice.

Endoscopy-related musculoskeletal injuries in gastroenterology fellows

Background and study aims  Gastroenterologists are at high risk for work-related musculoskeletal injuries. Studies have shown that 37 % to 89 % of endoscopists have work-related musculoskeletal injuries. While all surveys until now have focused on practicing endoscopists, there have been no publications assessing the prevalence of musculoskeletal injuries among gastrointerology fellows, which we sought to investigate. Methods  A 22-question survey about ergonomics and work-related musculoskeletal injuries was sent to 114 gastroenterology fellows in different programs across the United States in June 2016, and an additional 103 surveys were distributed at Digestive Disease Week in May 2017. Responses were collected, and data were analyzed. Results  A total of 156 surveys were collected. Of these, 74 fellows (47 %) reported a new musculoskeletal injury related to endoscopy. Injuries occurred mostly in the first year of fellowship (85 %, P  < 0.001). The most common sites of injury were the right wrist (53 %), left thumb (42 %), back (27 %), and neck (22 %). Only 26 % those who had endoscopy-related musculoskeletal injuries had received training in ergonomics compared to 45 % of those who did not have injury ( P  = 0.012), and ergonomics training was highly desirable among respondents, particularly among those with previous injuries ( P  = 0.0030) Conclusion  Musculoskeletal injuries related to endoscopy are very common among gastroenterology fellows, particularly during the first year of fellowship. While the overall percentage of fellows who received training in ergonomics was low, those who did receive training were less like to report a musculoskeletal injury. There is an urgent need for ergonomics training among Gastroenterology fellows.

Musculoskeletal injuries in gastrointestinal endoscopists: a systematic review

Gastrointestinal(GI) endoscopy forms a significant proportion of clinicians' workloads. However, little attention is given to the ergonomic aspects of endoscopy. This systematic review of musculoskeletal pain and/or injuries in GI endoscopists aims to better understand the types of occupational injuries resulting from endoscopic procedures and associated risk factors. Areas covered: Systematic literature search conducted for articles evaluating prevalence, risk factors and mechanism of musculoskeletal pain and/or injuries related to GI endoscopy. In 13 included studies, 39-89% of surveyed endoscopists reported pain and/or injuries related to endoscopy. Common areas of pain were the back(15-57%), neck(9-46%), shoulders(9-19%), elbows(8-15%) and hands/fingers(14-82%). Risk factors included procedure volume, time spent doing endoscopy, cumulative time in practice and endoscopist age. Experimental studies showed that forces and loads placed on endoscopists' bodies during procedures place them at risk of occupational injury. Areas of pain differed between novice and experienced endoscopists implying separate mechanisms of injury. Expert commentary: Comprehensive investigation into the prevalence, types, pathophysiology and methods to minimise endoscopy-related musculoskeletal injuries is vital to ensure the continued efficient provision of endoscopy services in the face of rising demands worldwide. A paradigm shift is required in endoscopic devices and techniques to improve safety and comfort.

Evidence-based Approach to Training Pediatric Gastrointestinal Endoscopy Trainers

Endoscopy training has evolved in recent years from the traditional model of "learning by doing" to the current skillful application of evidence-based educational principles. Endoscopy training should ideally be provided by individuals with the requisite skills and behaviors to teach endoscopy effectively and efficiently, including an awareness of principles of adult education, best practices in procedural skills education, and appropriate use of beneficial educational strategies such as feedback. The aim of this article is to outline principles that underlie successful endoscopy training and describe the "Preparation-Training-Wrap-up" framework that can be used by pediatric endoscopy trainers to help guide an effective endoscopy training session. Looking to the future, application of content from well-developed "train the trainer" courses to pediatric endoscopy practice would help to improve the quality of endoscopy training and facilitate the development of conscious competences among pediatric endoscopy trainers.

In-training gastrointestinal endoscopy competency assessment tools: Types of tools, validation and impact

The ability to perform endoscopy procedures safely, effectively and efficiently is a core element of gastroenterology practice. Training programs strive to ensure learners demonstrate sufficient competence to deliver high quality endoscopic care independently at completion of training. In-training assessments are an essential component of gastrointestinal endoscopy education, required to support training and optimize learner's capabilities. There are several approaches to in-training endoscopy assessment from direct observation of procedural skills to monitoring of surrogate measures of endoscopy skills such as procedural volume and quality metrics. This review outlines the current state of evidence as it pertains to in-training assessment of competency in performing gastrointestinal endoscopy as part of an overall endoscopy quality and skills training program.

Training and Assessment in Pediatric Endoscopy

A key aspect of pediatric gastroenterology practice is the ability to perform endoscopy procedures safely, effectively, and efficiently. Similar to adult endoscopy, performance of pediatric endoscopy requires the acquisition of related technical, cognitive, and integrative competencies to effectively diagnose and manage gastrointestinal disorders in children. However, the distinctive requirements of pediatric patients and their families and the differential spectrum of disease highlight the need for a pediatric-specific training curriculum and assessment framework to ensure endoscopic procedures are performed safely and successfully in children. This review outlines the current state of evidence as it pertains to pediatric endoscopy training and assessment.

Kinematic analysis of wrist motion during simulated colonoscopy in first-year gastroenterology fellows

BACKGROUND AND STUDY AIMS

Gastroenterology trainees acquire skill and proficiency in performing colonoscopies at different rates. The cause for heterogeneous competency among the trainees is unclear. Kinematic analysis of the wrist joint while performing colonoscopy can objectively assess the variation in wrist motion. Our objective was to test the hypothesis that the time spent by the trainees in extreme ranges of wrist motion will decrease as the trainees advance through the fellowship year.

SUBJECTS AND METHODS

Five first-year gastroenterology fellows were prospectively studied at four intervals while performing simulated colonoscopies. The setting was an endoscopy simulation laboratory at a tertiary care center. Kinematic assessment of wrist motion was done using a magnetic position/orientation tracker held in place by a custom-made arm sleeve and hand glove. The main outcome measure was time spent performing each of four ranges of wrist motion (mid, center, extreme, and out) for each wrist degree of freedom (pronation/supination, flexion/extension, and adduction/abduction).

RESULTS

There were no statistically significant differences in the time spent for wrist movements across the three degrees of freedom throughout the study period. However, fellows spent significantly less time in extreme range (1.47 ± 0.34 min vs. 2.44 ± 0.34 min, P = 0.004) and center range (1.02 ± 0.34 min vs 1.9 ± 0.34 min, P = 0.01) at the end of the study compared to the baseline evaluation. The study was limited by the small number of subjects and performance of colonoscopies on a simulator rather than live patients.

CONCLUSIONS

Gastroenterology trainees alter the time spent at the extreme range of wrist motion as they advance through training. Endoscopy training during the first 10 months of fellowship may have beneficial effects on learning ergonomically correct motion patterns.

Prevalence and risk factors for musculoskeletal injuries related to endoscopy

BACKGROUND

There are limited data regarding work-related injury among endoscopists.

OBJECTIVE

To define the prevalence of endoscopy-related musculoskeletal injuries and their impact on clinical practice and to identify physician and practice characteristics associated with their development.

DESIGN

Survey.

SETTING

Electronic survey of active members of the American Society for Gastrointestinal Endoscopy with registered e-mail addresses.

PARTICIPANTS

Physicians who currently or ever performed endoscopy and responded to the survey between February 2013 and November 2013.

INTERVENTION

A 25-question, self-administered, electronic survey.

MAIN OUTCOME MEASUREMENTS

Prevalence, location, and ramifications of work-related injuries and endoscopist characteristics and workload parameters associated with endoscopy-related injury.

RESULTS

The survey was completed by 684 endoscopists. Of those, 362 (53%) experienced a musculoskeletal injury perceived definitely (n = 204) or possibly (n = 158) related to endoscopy. Factors associated with a higher rate of endoscopy-related injury included higher procedure volume (>20 cases/week; P < .001), greater number of hours per week spent performing endoscopy (>16 hours/week; P < .001), and total number of years performing endoscopy (P = .004). The most common sites of injury were neck and/or upper back (29%) and thumb (28%). Only 55% of injured endoscopists used practice modifications in response to injuries. Specific treatments included medications (57%), steroid injection (27%), physiotherapy (45%), rest (34%), splinting (23%), and surgery (13%).

LIMITATIONS

Self-reported data of endoscopy-related injury.

CONCLUSION

Among endoscopists there is a high prevalence of injuries definitely or potentially related to endoscopy. Higher procedure volume, more time doing endoscopy per week, and cumulative years performing endoscopy are associated with more work-related injuries.

Flexible and capsule endoscopy for screening, diagnosis and treatment

Endoscopy dates back to the 1860s, but many of the most significant advancements have been made within the past decade. With the integration of robotics, the ability to precisely steer and advance traditional flexible endoscopes has been realized, reducing patient pain and improving clinician ergonomics. Additionally, wireless capsule endoscopy, a revolutionary alternative to traditional scopes, enables inspection of the digestive system with minimal discomfort for the patient or the need for sedation, mitigating some of the risks of flexible endoscopy. This review presents a research update on robotic endoscopic systems, including both flexible scope and capsule technologies, detailing actuation methods and therapeutic capabilities. A future perspective on endoscopic potential for screening, diagnostic and therapeutic gastrointestinal procedures is also presented.

Assessment of competence in pediatric gastrointestinal endoscopy

Gastrointestinal endoscopy is an invaluable tool for the diagnosis and treatment of upper and lower gastrointestinal diseases in children. Pediatric and adult endoscopy differ in several respects including differences in procedural indications, sedation practices, pre-procedure preparation, equipment, and the importance of routine tissue sampling and terminal ileum intubation. In the same way that performance of endoscopy in children requires pediatric-specific training, assessment of pediatric endoscopists requires an approach that is tailored to pediatric practice and the use of assessment methods and measures that have been developed and validated specifically within the pediatric context.

Review of musculoskeletal injuries and prevention in the endoscopy practitioner

Practitioners of endoscopy often experience musculoskeletal pain and injury (most often in the back, neck, shoulders, hands, wrists, and thumbs) that are associated with the minute and repetitive strain that is placed on these areas during endoscopic procedures. This review of the current documentation of endoscopy-related pain and injuries among practitioners finds that such problems are widespread and specific in kind as well as strongly correlated with high procedure volume and procedure duration. Research on the nature and impact of cumulative trauma and overuse syndromes in other professions such as dentistry, pianists, production labor, and athletics is brought to bear on the work of the endoscopist. A more thorough understanding of the nature and prevalence of work-related pain and injury sustained by endoscopists should inform further development of ergonomic practices and equipment design. This article reviews current recommendations for ergonomic design in the endoscopy procedure space and finds that reported compliance with those recommendations is quite low. Strategies for the management of the risk of musculoskeletal injuries related to the practice of endoscopy include compliance with currently recommended ergonomic practices, education of trainees in ergonomic technique when practicing endoscopy, and research toward the modification and development of more ergonomic endoscopes and procedure spaces.

Characterization of right wrist posture during simulated colonoscopy: an application of kinematic analysis to the study of endoscopic maneuvers

BACKGROUND

Endoscopic maneuvers are associated with a high incidence of musculoskeletal injuries.

OBJECTIVE

To quantify wrist motion patterns during simulated endoscopic procedures to identify potential causes of endoscopy-related overuse injury.

DESIGN

Twelve endoscopists with different levels of experience were tested on 2 simulated endoscopic procedures that differed in their level of difficulty.

SETTING

Right wrist movement patterns were recorded during simulated colonoscopies by using a magnetic motion-tracking device. Analysis focused on 3 wrist degrees of freedom: abduction/adduction, flexion/extension, and pronation/supination.

INTERVENTIONS

Subjects were tested on 2 GI lower endoscopies (colonoscopies) on a simulator.

MAIN OUTCOME MEASUREMENTS

Time spent within ranges of the entire wrist range of motion for 3 wrist degrees of freedom.

RESULTS

Endoscopists spent up to 30% of the duration of the procedures at the extremes of the wrist joint range of motion. Endoscopic experience did not affect the time spent at the extremes of the wrist joint of motion. The time spent within each range of motion differed depending on the wrist degrees of freedom and difficulty of procedure.

LIMITATIONS

This study examined only 1 upper limb joint in a limited number of subjects and did not measure interaction forces with endoscopic tools.

CONCLUSIONS

We identified wrist movement patterns that can potentially contribute to the occurrence of musculoskeletal injury in endoscopists. This study lays the foundation for future work on establishing links between upper limb movement patterns and the occurrence of overuse injury caused by repetitive performance of endoscopic procedures.

Ergonomic considerations in endoscopic sinus surgery: lessons learned from laparoscopic surgeons

BACKGROUND

Endoscopic sinus procedures are increasingly common, and more technically difficult procedures are being undertaken to provide patients with minimally invasive alternatives to traditional open surgical techniques. However, such endoscopic approaches have increasing physical demands on the surgeon. The aim of this review is to summarize current literature on surgical ergonomic principles as they relate to endoscopic sinus and skull base surgery and focus on future needs for our specialty.

METHODS

Literature review was performed of surgical ergonomics and, particularly, laparoscopic ergonomic principles.

RESULTS

Existing ergonomic principles for laparoscopic surgery can be applied to endoscopic sinus and skull base surgery and can be expected to offer benefits in terms of surgeon fatigue, physical discomfort, and task efficiency.

CONCLUSION

Increasing surgeon awareness will allow for many basic ergonomic principles to be applied to endoscopic sinus and skull base surgery. Although many simple changes can be immediately made, there is a clear need for further study and abundant room for innovation.

Holding a tablet computer with one hand: effect of tablet design features on biomechanics and subjective usability among users with small hands

The purpose of this study was to evaluate tablet size (weight), orientation, grip shape, texture and stylus shape on productivity, biomechanics and subjective usability and fatigue when the tablet was held with just the left hand. A total of 15 male and 15 female subjects, ages 16-64 years, tested eight tablets and three styluses. Overall, the usability, fatigue and biomechanical evaluation of tablet design features supported the use of smaller to medium-sized tablets, with a ledge or handle shape on the back and surfaced with a rubberised texture. Larger, heavier tablets had significantly worse usability and biomechanics and their use with one hand should be limited. The stylus with a tapered grip (7.5-9.5 mm) or larger grip (7.6 mm) had better usability and biomechanics than one with a smaller grip (5 mm). There were no significant differences in productivity between design features. These design parameters may be important when designing tablets.

PRACTITIONER SUMMARY

Different tablet and stylus design features were evaluated for usability and biomechanical properties. On the basis of short-term tasks, emulating functional tablets, usability was improved with the smaller and medium-sized tablets, portrait (vs. landscape) orientation, a back ledge grip and rubberised texture. There were no differences in productivity between design features.

The effect of keyboard key spacing on typing speed, error, usability, and biomechanics: Part 1

OBJECTIVE

In this study, we evaluated the effects of key spacing on a conventional computer keyboard on typing speed, percentage error, usability, and forearm muscle activity and wrist posture.

BACKGROUND

International standards that specify the spacing between keys on a keyboard have been guided primarily by design convention because few studies have evaluated the effects of key spacing on productivity, usability, and biomechanical factors.

METHOD

Experienced male typists (N = 37) with large fingers (middle finger length > or = 8.7 cm or finger breadth of > or = 2.3 cm) typed on five keyboards that differed only in horizontal and vertical key spacing (19 x 19 mm, 18 x 19 mm, 17 x 19 mm, 16 x 19 mm, and 17 x 17 mm) while typing speed, percentage error, fatigue, preference, extensor carpi ulnaris and flexor carpi ulnaris muscle activity, and wrist extension and ulnar deviation were recorded.

RESULTS

Productivity and usability ratings were significantly worse for the keyboard with spacing of 16 x 19 mm compared with the other keyboards. Differences on these measures between the other keyboards were not significant. Muscle activity tended to increase in the left forearm and decrease in the right with decreasing horizontal key spacing. There was also a trend for left wrist extension to increase and left ulnar deviation to decrease with decreasing horizontal key spacing. Reducing vertical key spacing from 19 to 17 mm had no significant effect on productivity or usability ratings.

CONCLUSIONS

The study findings support key spacing on a computer keyboard between 17 and 19 mm in both vertical and horizontal directions.

APPLICATIONS

These findings may influence keyboard standards and the design of keyboards.

Design and development of an automated, portable and handheld tablet personal computer-based data acquisition system for monitoring electromyography signals during rehabilitation

This article describes the design of a robust, inexpensive, easy-to-use, small, and portable online electromyography acquisition system for monitoring electromyography signals during rehabilitation. This single-channel (one-muscle) system was connected via the universal serial bus port to a programmable Windows operating system handheld tablet personal computer for storage and analysis of the data by the end user. The raw electromyography signals were amplified in order to convert them to an observable scale. The inherent noise of 50 Hz (Malaysia) from power lines electromagnetic interference was then eliminated using a single-hybrid IC notch filter. These signals were sampled by a signal processing module and converted into 24-bit digital data. An algorithm was developed and programmed to transmit the digital data to the computer, where it was reassembled and displayed in the computer using software. Finally, the following device was furnished with the graphical user interface to display the online muscle strength streaming signal in a handheld tablet personal computer. This battery-operated system was tested on the biceps brachii muscles of 20 healthy subjects, and the results were compared to those obtained with a commercial single-channel (one-muscle) electromyography acquisition system. The results obtained using the developed device when compared to those obtained from a commercially available physiological signal monitoring system for activities involving muscle contractions were found to be comparable (the comparison of various statistical parameters) between male and female subjects. In addition, the key advantage of this developed system over the conventional desktop personal computer-based acquisition systems is its portability due to the use of a tablet personal computer in which the results are accessible graphically as well as stored in text (comma-separated value) form.

A medical hand tool physical interaction evaluation approach for prototype testing using patient care simulators

The purpose of this study was to develop and test a physical ergonomics assessment approach for medical device handles. The method assesses wrist posture and force of exertion simultaneously by task element. Electrogoniometers and EMG sensors were connected through a data acquisition module for synchronization with video recordings of trials. Task analysis of video recordings were performed offline with Observer XT software. Average posture and force data across several repetitions of individual task elements were calculated and presented in a format suitable for informing product designers of specific issues during a test trial. A handle comfort questionnaire is proposed to survey subjective responses. The evaluation approach was applied to an endoscope needle in sampling a biopsy from the stomach wall using a gastrointestinal track simulator with ten physician surrogates. The results showed that for all task elements the wrist was in extension (33(°)-45(°)). Peak muscle forces ranged from 28% to 68% MVC across the three muscles studied. Muscle peak forces were above ACGIH HAL maximum threshold limits for four of the seven task elements, and above the action limit for all seven task elements for two muscles. The handle comfort questionnaire data also supported the high muscle force findings, and also on force distribution on the handle due to contact stresses. This combined approach could be used to collect and report detailed early stage ergonomics data from user trials on patient care simulators. The approach is proposed for use by medical device designers at the design stage of new products using prototypes, but it could also be used on existing products with real patients.

Stenosing tenosynovitis

Tenosynovitis refers to an inflammatory condition involving the synovial sheath of a tendon. Stenosing tenosynovitis is a peculiar entity caused by multiple factors, including local anatomy, mechanical factors, and hormonal factors. The main forms include de Quervain tendinopathy; trigger finger (stenosing tenosynovitis involving the flexor digitorum tendons); stenosing tenosynovitis of the extensor carpi ulnaris, extensor carpi radialis, or extensor comunis tendons; stenosing tenosynovitis of the flexor hallucis tendon; and stenosing tenosynovitis of the peroneal tendons. The cardinal finding on ultrasonography is the presence of a thickened retinaculum or pulley that constricts the osseofibrous tunnel through which the tendon runs.

Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, by using a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to personal protection equipment by using the key words "personal protection equipment" (exp Protective Clothing/ or exp Protective Devices/ or exp Masks/ or exp Occupational Exposure/'') "infection control" paired with "Endoscopy." For the radiation section, the following key words were used: "radiation and endoscopy," "radiation and ERCP," and "radiation safety." For the ergonomics section, the following key words were used: "ergonomics of endoscopy," "endoscopist injury," "medical ergonomics," "endoscopy and musculoskeletal strain," "musculoskeletal injury and endoscopists," "occupational diseases and endoscopy," "cumulative trauma disorder and endoscopy," "repetitive strain injury and endoscopy." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Injury to endoscopic personnel from tripping over exposed cords, wires, and tubing in the endoscopy suite: a preventable cause of potentially severe workplace injury

BACKGROUND The endoscopy unit before remediation may be a high-risk area for slip and fall injuries due to a large number of exposed above-the-floor wires in the endoscopy rooms, dimmed lighting during endoscopic procedures, and staff inattention to obstacles due to preoccupation with the endoscopic patient. AIM To describe a novel, previously unappreciated workplace hazard to endoscopic personnel: Exposed wires in the endoscopy unit.METHODS This study is a retrospective review of 110,000 endoscopic procedures performed during the last 5 years at an academic, teaching hospital with a high-volume endoscopy unit. All significant orthopedic injuries to endoscopic personnel from slips, twists, and falls from tripping over exposed cords in the endoscopy unit were reviewed. The severity of injury was documented based on roentgenographic findings, number of days of missed work, number of days with a modified work schedule, and requirement for orthopedic surgery. The number of potentially exposed cords per endoscopy room was determined. RESULTS During the 5-year study period, three endoscopic personnel suffered significant orthopedic injuries from slips, twists, and falls from tripping over cords, wires, or tubing lying exposed over the floor in the endoscopy suite: The resulting injuries consisted of fourth and fifth metacarpal hand fractures due to a fall after tripping on oxygen tubing; a rib fracture due to tripping on electrical wires trailing from an endoscopy cart; and a grade II ankle sprain due to the foot becoming entangled in oxygen tubing. All injuries resulted in lost days of work [mean 9.3 +/- 11.0 (SD) days] and in additional days of restricted work (mean 41.7 +/- 31.8 days). One injury required orthopedic surgery. Hospital review revealed a mean of 35.3 +/- 7.5 cords, wires, or tubing per endoscopy procedure room, the majority of which were exposed above the floor before remediation (n = 10 rooms). Remediation of exposed wires included: bundling related wires together in a cable to reduce the number of independent wires, covering exposed wires on the floor with a nonslip heavy mat, and running wires from ceiling outlets to equipment high above ground (e.g. mounted endoscopy video monitors). CONCLUSIONS Tripping, slipping, and falling over exposed wires can cause significant injury to endoscopic personnel. This previously undescribed hazard should be preventable by simple remediation, and all endoscopic personnel, hospital architects, hospital administrators, and governmental regulators should be alerted to this potential hazard

Characterization of forces applied by endoscopists during colonoscopy by using a wireless colonoscopy force monitor

BACKGROUND

To perform a colonoscopy, the endoscopist maneuvers the colonoscope through a series of loops by applying force to the insertion tube. Colonoscopy insertion techniques are operator dependent but have never been comprehensively quantified.

OBJECTIVE

To determine whether the Colonoscopy Force Monitor (CFM), a device that continually measures force applied to the insertion tube, can identify different force application patterns among experienced endoscopists.

DESIGN

Observational study of 6 experienced endoscopists performing routine diagnostic and therapeutic colonoscopy in 30 patients.

SETTING

Outpatient ambulatory endoscopy center.

PATIENTS

Adult male and female patients between 30 and 75 years of age undergoing routine colonoscopy.

INTERVENTIONS

CFM monitoring of force applied to the colonoscope insertion tube during colonoscopy.

MAIN OUTCOME MEASUREMENTS

Maximum and mean linear and torque force, time derivative of force, combined linear and torque vector force, and total manipulation time.

RESULTS

The CFM demonstrates differences among endoscopists for maximum and average push/pull and mean torque forces, time derivatives of force, combined push/torque force vector, and total manipulation time. Endoscopists could be grouped by force application patterns.

LIMITATIONS

Only experienced endoscopists using conscious sedation in the patients were studied. Sample size was 30 patients.

CONCLUSIONS

This study demonstrates that CFM allows continuous force monitoring, characterization, and display of similarities and differences in endoscopic technique. CFM has the potential to facilitate training by enabling trainees to assess, compare, and quantify their techniques and progress.