Today¡¯s topic is ergonomics in interventional procedure: endoscopic intervention.

First of all, I¡¯d like to say that a lot of endoscopists are suffering. 

Endoscopy is physically demanding. Most gastroenterologists report spending more than 40% of their time performing procedures. The prevalence of endoscopy-related musculoskeletal pain and injury ranges from 39 to 89%. It can begin as early as during fellowship training.

Education on ergonomics are strongly required. According to survey results, more than 70% of trainees have received no formal training in endoscopy ergonomics. And it is well-known that injuries are higher among fellows not receiving training. Recent report indicated that education on endoscopy ergonomics can improve ergonomic-related behaviors. 

Dr. Siegel wrote in a classic review that ¡°many gastroenterologists might not have considered becoming endoscopists if they had known beforehand that performing endoscopy might contribute to their becoming physically disabled.¡±

In his article, he mentioned that the more-serious problems are those occurring from repetitive use, such as torqueing and jiggling the endoscope, manipulating the control wheels, and assuming sustained awkward body positions. Serious injuries affect the neck, shoulders, arms, hands, thumbs, wrists, lumbosacral spine, hips, legs and feet. In my own experience, I have suffered many of these injuries.

These images are his neck, lumber spine, and his hand.  

These are another endoscopist¡¯s knuckle and finger in the old endoscopy journal. 

A few years ago, a junior military physician endoscopist send me an e-mail complaining his wrist pain. 

This is his wrist MRI. There was a high signal in the ulno-triquetral ligament area. 

This is not a endoscopy-related injury. Actually he is an anesthesiologist. Because of severe pain in his posterior neck, he took some NSAIDs and developed epigastric pain. In the endoscopy, there were multiple ulcers in the gastric antrum. I guess the pain in the neck may be related with unnatural posture during the long anesthesia procedure. So, this case is another example of ergonomic problem-related NSAID ulcers.  

This is a therapeutic endoscopist¡¯s shoulder. The findings are like this. High-grade articular side partial tear or small-sized full-thickness tear of supraspinatus tendon. Calcific tendinitis of the infraspinatus tendon. Adhesive capsulitis. Subacromial-subdeltoid bursitis. Can you guess whose shoulder is this? It¡¯s my shoulder 3 years ago. 

In my early career, I had some difficulty performing endoscopic submucosal dissection for an early gastric cancer in the difficult area. Fundus is the most difficult area for me. // After the long ESD procedure with this posture, I experienced multiple joint an muscle pain for a couple of days. 

It looks like a regular ESD for EGC. There was a small depressed lesion in the anterior aspect of the gastric angle. ESD was done, and there was no recurrence in the follow-up endoscopy. But, the patient had situs inversus. In a patient with this kind of anatomical variation, any procedure - not only ESD but also simple diagnostic endoscopy - can be very difficult. 

In order to assess the prevalence, severity, risk factors, and clinical impact of work-related musculoskeletal disease among Korean gastrointestinal endoscopists, I performed a self reported questionnaire survey. 55 endoscopists practicing in 4 general hospitals and 2 health promotion centers were included. Workload parameters included total duration of endoscopy practice, weekly working hours and monthly number of endoscopic procedures. The areas of musculoskeletal pain were marked on a figure of the human body, and the severity of pain at each site was expressed using a 100 mm visual analogue scale, The presence of severe pain was defined as a VAS value greater than 55 mm. 

This is the prevalence. Eighty nine percent of the endoscopists reported musculoskeletal pain on at least one anatomic location. The average number of symptomatic areas was 3.9.  

The most painful site during endoscopic procedures was the left finger followed by left shoulder and right wrist, left wrist and right shoulder. 

This is the musculoskeletal pain during the endoscopy procedure and at rest. The most commonly reported painful area during endoscopic procedures was right shoulder, followed by left shoulder and left finger. There was little difference in the overall distribution of the painful areas at rest.

Forty seven percent had severe musculoskeletal pain with a VAS value greater than 55 mm.

Three factors were statistically related to the development of severe musculoskeletal pain: standing position during upper endoscopic procedures, specific posture or habit during endoscopic procedures, and multiple symptomatic areas

Endoscopists were divided into two groups (beginner versus experienced) by the total duration of practicing endoscopy. In the beginner group, the weekly procedure time was longer and the number of endoscopic examinations was greater. However, there was no significant difference in the prevalence of musculoskeletal pain, number of symptomatic areas, and VAS value of the most painful area between the two groups.

By contrast, the location of pain was different between the two groups. During a procedure, the left finger was the most commonly reported painful area in beginners, whereas the left shoulder was the most commonly reported painful area by experienced endoscopists.

Among endoscopists with musculoskeletal pain, 16% reported that they had modified their practice or reduced the number of the endoscopic procedures. A majority of endoscopists with musculoskeletal pain managed their symptoms by themselves using stretching, exercising and rest. 28% reported the use of medications such as nonsteroidal anti-inflammatory drugs or topical analgesic patches.

Only 14% of symptomatic endoscopists had sought advice from specialists on musculoskeletal disorders or had undergone a specific diagnostic work-up. Three endoscopists were diagnosed to have a sprain or a cervical intervertebral disk herniation. In the two endoscopists with herniated disc, one required a 4-wk sick leave until the symptoms improved and the other had modified the practice and reduced the number of endoscopic procedures.

Next topic is the prevention. 

Adequate training environment and early education on ergonomics is so important. I am running a personal webpage, EndoTODAY, which is dedicated to the endoscopy education, especially for the beginners. The first page is the beginner course. 

The beginner course includes the introduction, description exercise, gastroscopy box simulator hands-on training, and educational VODs. / The first topic of the educational VOD section is endoscopy ergonomics for the safer endoscopy procedures. / It is linked to the related educational YouTube lectures. 

In this video clip, I am explaining how to hold the endoscope with your left hand. There are two finger method and three finger method. Ergonomically, three finger method is safer than the two finger method for endoscopists with small hands. 

Endoscopy environment is so important. A neutral body posture is fundamental to minimizing strain during endoscopy and reducing stress on the musculoskeletal system and can be sustained with ease for a prolonged time period. In this regard, the most important factor is the monitor location. 

Let me think about the monitor first. 

The monitor should be adjusted so that it is directly in front of the endoscopist.

When the monitor is located at the patient¡¯s head, the endoscopist should rotate his neck a lot. 

In order to prevent neck strain, the height of the monitor should be adjusted  with the center of the screen 10 to 15 degrees below the horizon. 

So the neck should have no flection, no extension and no rotation. 

In order to change the monitor location and height in an individual patient, endoscopy pendant or arm is very useful. Dual screen is also helpful.  

This is my endoscopy setup. Pendant and dual screen. 

The bed should be adjustable and positioned 10 cm below the elbow height. 

Wrist and fingers are also very important

How do you hold the endoscope control section? The left-hand side is three finger method and the right-hand side is two finger method. I recommend to use mainly three finger method to hold the endoscope tightly. In my experience, three finger method makes less pain in your hand and wrist. 

Some colonoscopists use the left hand shaft grip technique and the pinkie maneuver to prevent rotation of your wrist.

If you have some wrist pain, a wrist wrap can help. 

In the ESD procedure, you need to hold the catheter tightly, so you may experience pain in the thumb and index finger. In this regard, multifunctional ESD knife may help. For example, this is a H knife from FineMedix, a Korean company. Because the H knife has both pin knife and a ball knife, you don¡¯t need to change the catheter frequently during the procedure. 

This is another multifunctional knife. Onestep knife has both pin knife and injector needle in one catheter. 

Shoulder problems are common. 

Some doctors rotate their shoulders too much during the procedure. 

In my gastroscopy box simulator training, BOXIM, I teach young doctors to use the torque rotation to prevent shoulder problems. 

Many doctors twist their shoulder to rotate the endoscope. It makes a lot of strain to your shoulder but the rotation of the endoscope is not enough. I recommend to use the torque rotation technique. There is the boots part between the handle and insertion tube. By moving the boots part, you can rotate the endoscope very effectively without pain in your shoulder. 

In order to prevent ergonomic problems, you need to do regular stretching. Dorsiflection of your hand is the most import stretching in terms of endoscopy. 

This is the neck stretching. 

Also, some strengthen exercise helps. 

Before the COVID 19 pandemic, we had regular stretching classes for endoscopists at Samsung Medical Center. Our fellows really enjoyed the stretching class. Now I am considering restarting the program. 

Ladies and gentlemen. I¡¯d like to conclude my talk by saying that ergonomically safe endoscopy setup is the most important factor followed by the adequate skills such as the torque rotation technique. Because endoscopy is labor intensive, endoscopists should maintain a normal body habitus, exercise regularly, stretch daily, and maintain good cardiopulmonary function.