Introduction
Self-reported musculoskeletal pain has been shown to affect up to 20 % of adults in
the general population and is a significant cause of disability that affects social
functioning, mental health and quality of life (QoL) [1].
Occupational musculoskeletal injuries (MI) are an increasing problem among healthcare
professionals [2]
[3]
[4]. Approximately 10 % of workers in the European Union are healthcare employees, with
this sector having the second-highest incidence rate of work-related MI, after construction
[5]. A recent retrospective observational study based on the analysis of 1621 cases
of work-related accidents of employees of Centro Hospitalar Universitário de São João
(Porto, Portugal) from January 2011 to December 2014 identified a total of 824 cases
of MI, which corresponded to a total of 22159 lost workdays [6].
Gastrointestinal endoscopy has assumed an exponential role in the diagnostic and therapeutic
approach of conditions, with an increasing number of procedures performed worldwide
[7]
[8]
[9]. The ever-growing performance of longer, more complex and technically challenging
procedures such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic
ultrasonography (EUS), endoscopic submucosal dissection (ESD) or natural orifice transluminal
endoscopic surgery (NOTES) may predispose endoscopists to higher rates of overuse
injuries than previously reported [10]
[11].
Furthermore, the increasing scope of cancer screening programs will inevitably lead
to an increase in demand for endoscopic procedures [12]
[13].
Gastrointestinal endoscopy requires the physician to perform repetitive motions in
challenging positions. Several studies and guidelines have been carried out on patient
safety and quality of gastrointestinal endoscopy [8]
[14]. However, less data are available on the safety and welfare of the endoscopists
themselves, with little reported information about short-term and long-term disability
from endoscopy-related MI [15]. Some studies have suggested a high prevalence of MI in endoscopists, including
among fellows in training [16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]. A systematic review estimated that 39 % to89 % of endoscopists developed work-related
MI [24]. A recent study among active members of the American Society for Gastrointestinal
Endoscopy (ASGE) reported that 53 % of endoscopists had a MI related to endoscopy
and identified higher procedure volume, number of weekly hours performing endoscopy,
and number of years performing endoscopy as factors associated with a higher rate
of MI [10]. Nevertheless, ergonomic factors like bad posture during the procedure [18] or poor ergonomic design of facilities [16] have also been related to development of MI.
Despite previous American [10]
[17]
[19]
[22]
[23], Korean [18], and Japanese [20] reports on this topic, little evidence has come from European countries. Therefore,
our main aim was to evaluate prevalence, type, and impact of MI in regular and labor
activity among Portuguese endoscopists. We also sought to identify risk factors for
development, severity, and number of endoscopy-related MI.
Material and methods
We conducted an electronic survey directed to all endoscopists who are members of
the Portuguese Society of Gastroenterology (SPG). Members who have ever performed
endoscopy were eligible to participate. At least 6 months of endoscopy practice was
required for participation. Informed consent was implied by the response to the survey.
No financial compensation was given for participation. Ethical approval was obtained
from the Ethics Committee for Health of the Centro Hospitalar Universitário de São
João (Porto, Portugal).
Survey instrument
A 39-question, self-administered, electronic survey was developed by a group of gastroenterologists
from 21 Portuguese centers and a physiatrist (Supplementary Table 1). Survey items were generated based on a review of the literature and multidisciplinary
discussion. The survey was initially distributed, tested, and optimized among endoscopists
of the Gastroenterology Department of Centro Hospitalar Universitário de São João
to evaluate the content, clarity of the questions, and time necessary to complete
the survey. The final survey evaluated endoscopist characteristics, workload parameters,
type, treatment, and impact of MI (including the severity of worst pain ever felt
assessed by the Numerical Rating Scale [NRS]). Severe pain was defined as NRS ≥ 8
[25]. The survey required approximately 5 minutes to be filled out.
Survey administration
The electronic survey was sent to all members of SPG who met inclusion criteria (n = 705),
during May 2019. Subjects were contacted via email to participate. The initial email
included a cover letter explaining the study and a link to the survey. A reminder
email was sent 2 weeks after the initial invitation. One month after the first email,
the survey was terminated. All the answers remained anonymous. Study data were collected
and managed using REDCap electronic data capture tools hosted at SPG – CEREGA.
Statistical analysis
All data were arranged, processed, and analyzed with SPSS v.24.0 data. For analysis
of the characteristics of the endoscopists and endoscopy-related data, responders
were classified into two main groups (those with or without MI). For analysis of prevalence,
type, treatment and impact of MI, consultants and fellows were analyzed separately.
Categorical variables were described through absolute and relative frequencies and
continuous variables were described through mean, standard deviation, median, minimum
and maximum. Hypotheses were tested using Fisher’s exact test and Pearson chi-square
test for categorical variables, independent sample t-test and one-way ANOVA for continuous variables with normal distribution and Mann-Whitney
test and Kruskal-Wallis test for continuous variables with non-normal distribution.
Binary logistic regression was used to identify factors associated with MI and factors
associated with severe pain. Variables having P < 0.150 on univariate analysis were incorporated into a stepwise multivariate regression
model to confirm its independent association with the expected outcome. A stepwise
multiple linear regression was performed to identify the variables associated with
the number of MI. All significance levels were set at P < 0.05.
Results
A total of 705 endoscopists (624 consultants and 81 fellows) were invited to participate.
The survey was completed by 171 individuals (24.3 %). The response rate was higher
among fellows compared to consultants (46.9 % vs. 21.3 %).
Endoscopist characteristic
Characteristics of endoscopists are summarized in [Table 1]. Fifty-five percent were female, with a median age of 36 years (range 26–78). Most
of the respondents were currently performing endoscopy (97.7 %). Fifty-two percent
worked in academic centers (AC), 41.5 % in community centers (CC) and 63.7 % in private
practice (PP), with 56.1 % having more than one work-setting simultaneously.
Table 1
Characteristics of endoscopists.
|
Total [n (%)]
n = 171
|
No endoscopy-related MI [n (%)]
n = 52
|
Endoscopy-related MI [n (%)]
n = 119
|
P value
|
|
Gender
|
|
|
|
0.068
|
|
|
94 (55.0 %)
|
23 (44.2 %)
|
71 (59.7 %)
|
|
|
|
77 (45.0 %)
|
29 (55.8 %)
|
48 (40.3 %)
|
|
|
Age, median (range), years
|
36 (26–78)
|
34 (26–76)
|
37 (27–78)
|
0.076
|
|
Dominant hand
|
|
|
|
0.251
|
|
|
157 (91.8 %)
|
45 (86.5 %)
|
112 (94.1 %)
|
|
|
|
10 (5.9 %)
|
5 (9.6 %)
|
5 (4.2 %)
|
|
|
|
4 (2.3 %)
|
2 (3.9 %)
|
2 (1.7 %)
|
|
|
Glove size
|
|
|
|
0.734
|
|
|
54 (31.6 %)
|
15 (28.9 %)
|
39 (32.8 %)
|
|
|
|
79 (46.2 %)
|
23 (44.2 %)
|
56 (47.1 %)
|
|
|
|
34 (19.9 %)
|
13 (25.0 %)
|
21 (17.6 %)
|
|
|
|
4 (2.3 %)
|
1 (1.9 %)
|
3 (2.5 %)
|
|
|
Physical activity level[1]
|
|
|
|
0.725
|
|
|
5 (2.9 %)
|
1 (1.9 %)
|
4 (3.4 %)
|
|
|
|
37 (21.6 %)
|
12 (23.1 %)
|
25 (21.0 %)
|
|
|
|
81 (47.4 %)
|
27 (51.9 %)
|
54 (45.4 %)
|
|
|
|
48 (28.1 %)
|
12 (23.1 %)
|
36 (30.2 %)
|
|
|
Height, median (range), cm
|
170 (150–190)
|
172 (156–190)
|
169 (150–186)
|
0.020
|
|
Weight, median (range), kg
|
65 (47–92)
|
68.5 (50–92)
|
64 (47–89)
|
0.138
|
|
BMI, median (range), kg/m2
|
22.6 (17.6–31.6)
|
22.3 (18.1–31.5)
|
22.7 (17.6–31.6)
|
0.817
|
|
Endoscopist’s experience
|
|
|
|
0.564
|
|
|
38 (22.2 %)
|
13 (25.0 %)
|
25 (21.0 %)
|
|
|
|
133 (77.8 %)
|
39 (75.0 %)
|
94 (79.0 %)
|
|
|
Practice setting[2]
|
|
|
|
0.491
|
|
|
29 (17.0 %)
|
10 (19.2 %)
|
19 (16.0 %)
|
|
|
|
32 (18.7 %)
|
9 (17.3 %)
|
23 (19.3 %)
|
|
|
|
14 (8.2 %)
|
5 (9.6 %)
|
9 (7.6 %)
|
|
|
|
57 (33.3 %)
|
19 (36.6 %)
|
38 (31.9 %)
|
|
|
|
36 (21.0 %)
|
7 (13.5 %)
|
29 (24.4 %)
|
|
|
|
1 (0.6 %)
|
1 (1.9 %)
|
0 (0.0 %)
|
|
|
|
2 (1.2 %)
|
1 (1.9 %)
|
1 (0.8 %)
|
|
MI, musculoskeletal injuries; BMI, body mass index; AC, academic center; CC, community
center; PP, private practice
1 Vigorous: 6–7 days/week; moderate: 3–5 days/week; light: 1–2 days/week; sedentary:
little to no exercise
2 Includes both small and large practice settings.
Endoscopy-related data
A detailed description of endoscopic procedure-related data and endoscopy workload
parameters can be seen in [Table 2] and [Table 3], respectively. Median time of endoscopic practice was 9 years (range 0.5–45.0).
The majority performed esophagogastroduodenoscopy (EGD) and colonoscopy, 21.6 % ERCP
and 21.6 % EUS. Over 90 % performed therapeutic endoscopic procedures.
Table 2
Endoscopic procedure-related data.
|
Total [n (%)]
n = 171
|
No endoscopy-related MI [n (%)]
n = 52
|
Endoscopy-related MI [n (%)]
n = 119
|
P value
|
|
Years in practice, median (range)
|
9 (0.5–45)
|
6 (0.5–44)
|
9 (0.5–45)
|
0.027
|
|
Type of endoscopic procedures performed
|
|
EGD
|
|
|
|
–
|
|
|
0 (0.0 %)
|
0 (0.0 %)
|
0 (0.0 %)
|
|
|
|
171 (100 %)
|
52 (100.0 %)
|
119 (100 %)
|
|
|
Colonoscopy
|
|
|
|
0.347
|
|
|
2 (1.2 %)
|
0 (0.0 %)
|
2 (1.7 %)
|
|
|
|
169 (98.8 %)
|
52 (30.8 %)
|
117 (98.3 %)
|
|
|
ERCP
|
|
|
|
0.840
|
|
|
134 (78.4 %)
|
40 (76.9 %)
|
94 (79.0 %)
|
|
|
|
37 (21.6 %)
|
12 (23.1 %)
|
25 (21.0 %)
|
|
|
Diagnostic EUS
|
|
|
|
0.690
|
|
|
134 (78.4 %)
|
42 (80.8 %)
|
92 (77.3 %)
|
|
|
|
37 (21.6 %)
|
10 (19.2 %)
|
27 (22.7 %)
|
|
|
Therapeutic EUS
|
|
|
|
0.876
|
|
|
157 (91.8 %)
|
48 (92.3 %)
|
109 (91.6 %)
|
|
|
|
14 (8.2 %)
|
4 (7.7 %)
|
10 (8.4 %)
|
|
|
BAE
|
|
|
|
0.278
|
|
|
154 (90.1 %)
|
49 (94.2 %)
|
105 (88.2 %)
|
|
|
|
17 (9.9 %)
|
3 (5.8 %)
|
14 (11.8 %)
|
|
|
Therapeutic endoscopy
|
|
Therapeutic endoscopy
|
|
|
|
0.517
|
|
|
16 (9.4 %)
|
6 (11.5 %)
|
10 (8.4 %)
|
|
|
|
155 (90.6 %)
|
46 (88.5 %)
|
109 (91.6 %)
|
|
|
EMR
|
|
|
|
0.254
|
|
|
27 (15.8 %)
|
11 (21.2 %)
|
16 (13.4 %)
|
|
|
|
144 (84.2 %)
|
41 (78.8 %)
|
103 (86.6 %)
|
|
|
ESD
|
|
|
|
0.652
|
|
|
157 (91.8 %)
|
47 (90.4 %)
|
110 (92.4 %)
|
|
|
|
14 (8.2 %)
|
5 (9.6 %)
|
9 (7.6 %)
|
|
|
Endoscopic stenting
|
|
|
|
|
|
|
100 (58.5 %)
|
31 (59.6 %)
|
69 (58.0 %)
|
0.842
|
|
|
71 (41.5 %)
|
21 (40.4 %)
|
50 (42.0 %)
|
|
|
Endoscopic dilation
|
|
|
|
0.405
|
|
|
79 (46.2 %)
|
27 (51.9 %)
|
52 (43.7 %)
|
|
|
|
92 (53.8 %)
|
25 (48.1 %)
|
67 (56.3 %)
|
|
|
PEG
|
|
|
|
0.299
|
|
|
59 (34.5 %)
|
21 (40.4 %)
|
38 (31.9 %)
|
|
|
|
112 (65.5 %)
|
31 (59.6 %)
|
81 (68.1 %)
|
|
MI, musculoskeletal injuries; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde
cholangiopancreatography; EUS, endoscopic ultrasonography; BAE, Balloon-assisted enteroscopy;
EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; PEG, percutaneous
endoscopic gastrostomy
Table 3
Endoscopy workload parameters.
|
Total
n = 171
|
No endoscopy-related MI [n (%)]
n = 52
|
Endoscopy-related MI [n (%)]
n = 119
|
P value
|
|
Weekly-working time, median (range), hours
|
50 (5–75)
|
52.5 (15–75)
|
50 (5–70)
|
0.171
|
|
Weekly-time performing endoscopy, median (range), hours
|
25 (3–52)
|
25 (10–50)
|
25 (3–52)
|
0.361
|
|
Weekly proportion of time Performing endoscopy, median (range), %
|
50 (15–100 %)
|
50 (23–100 %)
|
50 (15–95 %)
|
0.690
|
|
Proportion of time performing procedures, median (range), %
|
|
|
30 (5–100 %)
|
40 (10–90 %)
|
30 (5–100 %)
|
0.020
|
|
|
60 (0–90 %)
|
50 (10–90 %)
|
60 (0–90 %)
|
0.030
|
|
|
0 (0–40 %)
|
0 (0–40 %)
|
0 (0–40 %)
|
0.644
|
|
|
0 (0–40 %)
|
0 (0–40 %)
|
0 (0–32 %)
|
0.743
|
|
|
0 (0–20 %)
|
0 (0–8 %)
|
0 (0–20 %)
|
0.952
|
|
|
0 (0–20 %)
|
0 (0–5 %)
|
0 (0–20 %)
|
0.127
|
|
Proportion of procedures under general anesthesia median (range), %
|
60 (0–100 %)
|
60 (0–100 %)
|
63 (0–100 %)
|
0.807
|
|
Breaks during endoscopy[1]
|
|
|
|
0.256
|
|
|
29 (17.0 %)
|
12 (23.1 %)
|
17 (14.3 %)
|
|
|
|
126 (73.7 %)
|
34 (65.4 %)
|
92 (77.3 %)
|
|
|
|
16 (9.4 %)
|
6 (11.5 %)
|
10 (8.4 %)
|
|
|
Environmental modifications during endoscopy[2]
|
|
|
158 (92.4 %)
|
48 (92.3 %)
|
110 (92.4 %)
|
0.977
|
|
|
122 (71.3 %)
|
40 (76.9 %)
|
82 (68.9 %)
|
0.359
|
|
|
51 (29.8 %)
|
15 (28.8 %)
|
36 (30.3 %)
|
0.853
|
|
|
12 (7.0 %)
|
3 (5.8 %)
|
9 (7.6 %)
|
0.673
|
|
|
6 (3.5 %)
|
1 (1.9 %)
|
5 (4.2 %)
|
0.456
|
MI, musculoskeletal injuries; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde
cholangiopancreatography, EUS: endoscopic ultrasonography; BAE, Balloon-assisted enteroscopy
1 Occasionally: 1–2 times per shift; Frequently: 3–4 times per shift
2 More than one may be present per endoscopist
Median weekly-working time was 50 hours (range 5–75). Median weekly-time performing
endoscopy was 25 hours (range 3–52), with a higher proportion of time spent performing
EGD and colonoscopy (median 30 % and 60 %, respectively).
Most endoscopists took breaks (83 %) during endoscopic practice. The main usual environmental
modification made during endoscopy was the use of a height-adjustable table (92.4 %).
Prevalence and type of musculoskeletal injuries
One hundred and twenty-nine respondents (75.4 %) reported having experienced MI since
the start of endoscopic practice. Prevalence of at least one MI related to endoscopy
was 69.6 % (n = 119) ([Table 4]). Median time for MI development was 6 years (range 2 months-30 years). Median NRS
value of the most painful area was 5 (range 1–10). Severe pain was reported by 19.3 %.
Although there was no significant difference between prevalence of MI in consultants
and fellows (70.7 % vs. 65.8 %, P = 0.555), consultants had a significantly higher number of MI (median 3 vs. 2, P = 0.007). Except for the first year in practice, fellows were similarly distributed
across the 4 years of their fellowship (first year: n = 4 [10.5 %]; second year: n = 12
[31.6 %]; third year: n = 9 [23.7 %]; fourth year: n = 13 [34.2 %]). Despite no available
data on three fellows, in 50 % (11/22) MI occurred during the first year of fellowship,
27.3 % in the second year, 18.2 % in the thirrd year and 4.5 % in the last year. The
prevalence of MI did not differ significantly between each year of fellow in training
[first year: n = 3/4 (75 %); second year: n = 6/12 (50 %); third year: n = 6/9 (66.7 %);
fourth year: n = 10/13 (76.9 %); P = 0.532].
Table 4
Prevalence, characteristics, and types of endoscopy-related MI.
|
Total [n (%)]
n = 171
|
Consultants
n (%)] n = 133
|
Fellows [n (%)]
n = 38
|
P value
|
|
Endoscopy-associated MI
|
119 (69.6 %)
|
94 (70.7 %)
|
25 (65.8 %)
|
0.555
|
|
Number of MI, median (range)
|
2 (1–8)
|
3 (1–8)
|
2 (1–4)
|
0.007
|
|
Time to MI after starting endoscopy practice, median (range), years
|
6 [0 (2 months)-30]
|
9 [0 (2 months)-30]
|
1 [0 (4 months)-3]
|
< 0.001
|
|
Maximum pain severity, median (range), NRS
|
5 (1–10)
|
5 (1–10)
|
5 (2–9)
|
0.120
|
|
Types of endoscopy-associated MI[1]
|
|
Thumb pain
|
50 (29.2 %)
|
41 (30.8 %)
|
9 (23.7 %)
|
0.427
|
|
Wrist pain
|
46 (26.9 %)
|
41 (30.8 %)
|
5 (13.2 %)
|
0.037
|
|
Hand pain
|
25 (14.6 %)
|
18 (13.5 %)
|
7 (18.4 %)
|
0.443
|
|
Shoulder pain
|
47 (27.5 %)
|
41 (30.8 %)
|
6 (15.8 %)
|
0.098
|
|
Elbow pain
|
16 (9.4 %)
|
15 (11.3 %)
|
1 (2.6 %)
|
0.107
|
|
Neck pain
|
52 (30.4 %)
|
39 (29.3 %)
|
13 (34.2 %)
|
0.555
|
|
Thoracic back pain
|
26 (15.2 %)
|
23 (17.3 %)
|
3 (7.9 %)
|
0.204
|
|
Lower back pain
|
30 (17.5 %)
|
27 (20.3 %)
|
3 (7.9 %)
|
0.092
|
|
Hand numbness
|
21 (12.3 %)
|
20 (15.0 %)
|
1 (2.6 %)
|
0.048
|
MI, musculoskeletal injuries; NRS, Numerical Rating Scale
1 More than one lesion may be present per endoscopist
The most frequently reported types of MI were neck pain (30.4 %) and thumb pain (29.2 %).
Wrist pain and hand numbness were significantly more prevalent among consultants than
fellows, with no significant differences regarding the remaining MI.
Impact of MI, practice modifications, and treatment
A complete overview of the impact of MI, practice modifications and treatment is described
in [Table 5]. Almost half the respondents with MI (45.4 %) reported symptoms during both work
and daily activities, while 20.2 % were only symptomatic during endoscopy. In 22.7 %,
symptoms were present all the time. Change of endoscopic technique was undertaken
by 61.3 %, with 7.0 % reported sitting while performing endoscopy. The most commonly
undertaken practice modification was using of adjustable bed (49.6 %), although 26.9 %
reported not undertaking any modification. Reduction of endoscopic caseload was performed
in 22.7 % of the respondents, with a significantly higher proportion in consultants
than in fellows (27.7 % vs. 4.0 %, P = 0.014). Missing work was reported by 10.1 %, with the median time off from work
being 30 days (range 1–90). In 33.6 %, MI led to a reduction in physical activity
(PA) outside of work.
Table 5
MI characterization, impact, and treatment.
|
Total [n (%)]
n = 119
|
Consultants [n (%)]
n = 94
|
Fellows [n (%)]
n = 25
|
P value
|
|
MI associated-pain timing
|
|
|
|
0.286
|
|
|
24 (20.2 %)
|
16 (17.0 %)
|
8 (32.0 %)
|
|
|
|
8 (6.7 %)
|
5 (5.3 %)
|
3 (12.0 %)
|
|
|
|
54 (45.4 %)
|
46 (49.0 %)
|
8 (32.0 %)
|
|
|
|
3 (2.5 %)
|
2 (2.1 %)
|
1 (4.0 %)
|
|
|
|
27 (22.7 %)
|
22 (23.4 %)
|
5 (20.0 %)
|
|
|
|
3 (2.5 %)
|
3 (3.2 %)
|
–
|
|
|
Changes in endoscopic technique
|
|
|
|
0.646
|
|
|
73 (61.3 %)
|
59 (62.8 %)
|
14 (56.0 %)
|
|
|
|
17 (14.3 %)
|
12 (12.8 %)
|
5 (20.0 %)
|
|
|
|
27 (22.7 %)
|
21 (22.3 %)
|
6 (24.0 %)
|
|
|
|
2 (1.7 %)
|
2 (2.1 %)
|
–
|
|
|
Practice modification[1]
|
|
|
27 (22.7 %)
|
26 (27.7 %)
|
1 (4.0 %)
|
0.014
|
|
|
20 (16.8 %)
|
16 (17.0 %)
|
4 (16.0 %)
|
0.903
|
|
|
26 (21.8 %)
|
23 (24.5 %)
|
3 (12.0 %)
|
0.276
|
|
|
59 (49.6 %)
|
45 (47.9 %)
|
14 (56.0 %)
|
0.470
|
|
|
18 (15.1 %)
|
15 (16.0 %)
|
3 (12.0 %)
|
0.624
|
|
|
32 (26.9 %)
|
25 (26.6 %)
|
7 (28.0 %)
|
0.888
|
|
Treatment
[1]
|
|
|
68 (57.1 %)
|
61 (64.9 %)
|
7 (28.0 %)
|
0.001
|
|
|
21 (17.6 %)
|
17 (18.1 %)
|
4 (16.0 %)
|
0.808
|
|
|
15 (12.6 %)
|
14 (14.9 %)
|
1 (4.0 %)
|
0.145
|
|
|
2 (1.7 %)
|
2 (2.1 %)
|
0 (0.0 %)
|
0.462
|
|
|
12 (10.1 %)
|
10 (10.6 %)
|
2 (8.0 %)
|
0.697
|
|
|
36 (30.3 %)
|
33 (35.1 %)
|
3 (12.0 %)
|
0.028
|
|
|
12 (10.1 %)
|
12 (12.8 %)
|
0 (0.0 %)
|
0.060
|
|
|
2 (1.7 %)
|
2 (2.1 %)
|
0 (0.0 %)
|
0.462
|
|
|
35 (29.4 %)
|
30 (31.9 %)
|
5 (20.0 %)
|
0.326
|
|
|
30 (25.2 %)
|
16 (17.0 %)
|
14 (56.0 %)
|
< 0.001
|
|
Missing work
|
12 (10.1 %)
|
11 (11.7 %)
|
1 (4.0 %)
|
0.234
|
|
Missing work (maximum consecutive days), median (range)
|
30 (1–90)
|
30 (1–90)
|
–
|
–
|
|
Missing work (total number of days), median (range)
|
30 (1–90)
|
35 (1–90)
|
–
|
–
|
|
Reduction in physical activity outside of work[3]
|
40 (33.6 %)
|
35 (37.2 %)
|
5 (20.0 %
|
0.152
|
MI, musculoskeletal injuries; NRS, Numerical Rating Scale; NSAIDs, Nonsteroidal anti-inflammatory
drugs
1 More than one may be present per endoscopist
2 Tramadol n = 2; tramadol + paracetamol n = 1; paracetamol + thiocolchicoside n = 1;
paracetamol + codeine n = 1; diazepam n = 3; topical NSAIDs n = 2; cyclobenzaprine
chloridrate n = 1; oral corticosteroids n = 1
3 Work at home, hobbies
In 25.2 %, no targeted treatment was performed, especially in fellows (56.0 % vs.
17.0 % in consultants, P < 0.001). The most common specific treatments performed included NSAIDs (57.1 %)
and physiotherapy (30.3 %). Surgery was performed on two endoscopists ([Fig. 1]).
Fig. 1 A female endoscopist with 20 years in practice reported progressive limitation of
left hand metacarpophalangeal joint motion associated with pain, especially during
colonoscopy performance. X-ray revealed subluxation of the metacarpophalangeal joint,
with associated arthrosis. Multiple treatments were tried, including corticosteroid
injections, topical and oral NSAIDs and use of splinting during procedures, without
symptomatic improvement. The endoscopist underwent metacarpophalangeal joint arthrodesis,
with excellent clinical and functional outcome.
One hundred and forty-five respondents (84.8 %) would be interested in having their
work setting assessed ergonomically, while 128 (74.9 %) would like to receive preventive
information regarding MI.
Predictive factors for MI
A multivariable regression model was developed to predict factors associated with
endoscopy-related MI (Supplementary Table 2). Female gender (odds ratio [OR] 2.443, 95 % confidence interval [CI] 1.166–5.121;
P = 0.018), ≥ 15 years in practice (OR 3.514; 95 % CI 1.490–8.284; P = 0.004) and the proportion of time performing EGD (OR 0.974, 95 % CI 0.951–0.997;
P = 0.026) were independently associated with MI.
Predictive factors of severe pain
Sub-analysis of respondents with MI was performed to identify predictive factors of
severe pain, independently of lesion location (Supplementary Table 3). Female gender (OR 3.598, 95 % CI 1.162–11.137; P = 0.026), moderate/vigorous PA level (OR 3.318, 95 % CI 1.056–10.424; P = 0.040) and ≥ 15 years in practice (OR 4.284, 95 % CI 1.440–12.745; P = 0.009) were independently associated with severe pain.
Predictive factors of the number of MI
Simple and multiple linear regression was performed to identify the variables associated
with the number of MI (Supplementary Table 4).
Backward linear regression was performed, with the age, gender, endoscopist’s experience,
years in practice, weekly-time performing endoscopy and practice settings forced in
the model. A significant regression equation was found (F(3,111) = 7.221, P < 0.001), with an R2 of 0.163. Respondent’s predicted number of MI was equal to 0.195 + 0.522
(gender) + 0.042 (years in practice) + 0.041 (weekly-time performing endoscopy), where
gender was coded as 1 = Male, 2 = Female, years in practice was measured in years
and weekly-time performing endoscopy was measured in hours. The number of MI increased
0.042 for each year of practice, 0.041 for each weekly-hour performing endoscopy and
females had 0.522 more MI than males. Years in practice (P < 0.001), weekly-time performing endoscopy (p = 0.005) and gender (P = 0.049) were significant predictors of the number of MI.
Discussion
Endoscopists are at risk for MI, which can lead to loss of productivity and possibly
career shortening [15]. Surprisingly, considering the negative impact of its occurrence, there is practically
no data from European centers, with only one previous letter to the editor published
by Geraghty et al reporting pain more than once a week during endoscopy in 57 % of
a group of 58 gastroenterologists surveyed in the northwest of England [26].
Cultural differences in the way work-related pain and injury are perceived were previously
described, even within the same occupation [27]. On the other hand, differences in endoscopy practice are known, even among different
European countries [7]. Except for the study by Ridtitid et al [10] that evaluated all active members of ASGE, quality issues in previous studies arose
mainly from the fact that the survey responders were self-selected, being unclear
if that led to response modulation [24]. Taking these into account, we performed a nationwide study on this topic. Prevalence
of endoscopy-related MI was 69.6 %, significantly higher compared to most of the previous
studies, including the survey among all ASGE members (prevalence of 53 %) [10] and the study among Japanese endoscopists (prevalence of 43 %) [20], but inferior to the study in Korean endoscopists (89.1 %) [18]. It is important to note that the workload among respondents in our study was significant,
with a median of 25 hours per week spent performing endoscopy. More than half had
more than one work-setting, often reconciling the work in an AC or CC with PP. Although
no direct comparison can be made, this may be one of the possible explanations for
the high prevalence of MI in our survey.
Despite the fact that most of the published data focused on longtime endoscopy practitioners,
recent studies analyzed risk of MI among fellows. Prevalence of MI varied between
20 % [23] to 47 % [22]. In our study, the prevalence of MI among fellows was 65.8 % with 77.3 % of the
cases occurring during the first two years of fellowship. One could argue that the
endoscopic workload in Portuguese fellows is higher than in these studies, however
considering the low number of procedures performed until MI development, specific
unique factors unrelated to endoscopy workload and time in practice are likely associated
with MI [23]. Ende et al analyzed force application during colonoscopy using a novel device and
concluded that experts used higher average forward forces during insertion compared
to all trainees and significantly less clockwise torque maneuver compared to novice
trainees [28]. Differences in endoscopic technique can lead to development of specific MI. Some
studies previously reported differences in location of MI between beginners and experienced
endoscopists [18]. In our study, prevalence of hand numbness and wrist pain were significantly higher
in consultants, while neck and hand pain were more frequent in fellows (although not
reaching statistical significance). Interestingly, in response to MI, reduction in
endoscopic caseload and treatment were rarely undertaken by fellows compared to consultants.
To some extent, this may reflect reluctance to acknowledge the occurrence of the lesion
or seek help, with associated fear of seeing evolution as an endoscopist hindered
or delayed.
Nevertheless, the repetitive and cumulative nature of the physical maneuvers involved
in endoscopy can have long-term consequences, suggesting the importance of proper
training in endoscopic technique as well as in ergonomics since fellowship [15]. In Portugal, there is no specific training in ergonomics. In the study by Villa
E et al, prevalence of MI was significantly lower among fellows who received ergonomics
training [22] suggesting that lack of integration of ergonomics in training can be one of the
possible contributors to a higher prevalence of MI among fellows in our study.
In previous studies, the most consistent risk factors associated with MI were endoscopic
workload (measured by procedure volume or proportion of time spent performing endoscopy)
and cumulative time spent performing endoscopy [24]. In our study, although we did not evaluate the total number of endoscopic procedures
performed, we used the total weekly time performing endoscopy and the percentage of
time performing endoscopy and specific endoscopic procedures as surrogate markers
for the endoscopy workload. We identified female gender and ≥ 15 years in practice
as independent risk factors for MI, severe pain and a higher number of MI. Even though
a recent study performed among ASGE fellows reported female gender as the only significant
risk factor for MI [23], most of the prior studies have shown no gender differences in MI risk, which could
be limited by the low number of women included. In our study, more than half of the
respondents were women, a number far higher than, for example, in the study by Ridtitid
et al, which had 11.9 % women respondents [10]. Higher risk of MI in women may be related to differences in hand size and grip
strength. In a study performed among 227 fellows, 41.0 % considered their hand too
small for a standard endoscope, 78.2 % considered that hand size affected endoscopy
learning, and 34.2 % would use smaller endoscopes if possible. Ninety-seven percent
of the respondents with smaller hands were women [29]. A previous study reported women’s grip strength to be 59 % of men’s and fingertip-pinch
strength to be 71 % to 73 % of men’s [30]. In our study, we identified female gender as a significant predictor not only for
prevalence but also for severity and number of MI. In Portugal the female:male ratio
in gastroenterologists increased from 0.5 among doctors aged 51 to 65 to 1.6 among
those with aged 31 to 50 [31]. It is crucial to identify potentially modifiable factors (such as the ergonomics
of the endoscopy suites or even the design of the endoscope) [15] that would allow for risk reduction of MI in female endoscopists.
Regarding the remaining predictors of MI, a higher proportion of time performing EGD
was identified as a protective factor. One can assume that endoscopists performing
more EGD performed significantly fewer more technically demanding procedures, including
colonoscopy, that have previously been associated with an increased risk of MI [32]. Moderate/vigorous PA was also a risk factor for severe pain. Nevertheless, a response
bias cannot be excluded because respondents may have increased PA in response to MI
development or, on the other hand, a higher level of PA could have led to exacerbation
of MI symptoms.
Although most studies focused on prevalence of endoscopic-related MI, few have evaluated
its impact not only in work but also on regular activities. In our study, missing
work was reported by 10.1 % of respondents, with a median of 30 days off work. These
results contrast with previous studies, in which few endoscopists reported missing
work and when necessary, it usually lasted a few days [17]
[19]
[26]. On the other hand, 33.6 % of respondents had to reduce PA outside work. These data
highlight the possible negative impact of MI on regular daily-life activities. Additionally,
MI can have a “domino effect” [19] and may affect not only the individual but also colleagues or even family relationships.
Further studies are necessary to evaluate psychological morbidity and real impact
on the QoL of these injuries.
In our study, 84.8 % of respondents would have liked to have their work setting assessed
ergonomically and 74.9 % would have liked to receive preventive information regarding
MI. The term “ergonomics” originally comes from the Greek words ergon (work) and nomos
(natural laws) and relates to the study and optimization of the interactions between
the worker, the equipment and the work environment. The importance of the design of
the endoscopy suite for MI has previously been emphasized, with the ASGE guidelines
on ergonomics recommending that the workplace should accommodate the fifth percentile
female to the 95th percentile male [33]. On the other hand, some authors argue that endoscopists should be trained like
athletes concerning ergonomics (the “endo-athlete”) to further prevent endoscopy-related
MI [34]
[35]. Our results highlight the fact that despite lack of a formal training program in
ergonomics, it is a matter of interest for endoscopists in our country. In a survey
of 826 American Gastroenterology Association endoscopists, only 4.5 % received ergonomics
training during the fellowship [36]. ASGE guidelines may have been the starting point for a paradigm shift [32], with apparent beneficial effect already evident in the survey by Villa et al [22].
In our study, the number of participants was significant. Limitations of our study
included a survey response rate of 24.3 % which may subject the study to bias, making
interpretation of results more challenging. Nevertheless, despite being modest, the
response rate was superior compared to the other nationwide studies previously performed
[10]
[23]. Other limitations need to be addressed, namely response and recall bias inherent
in this type of study. Endoscopists with MI may have been more prone to participate
in the study and overestimate the role of endoscopy in MI development. On the other
hand, endoscopists working at an AC may have had a different attitude toward research,
and may have been less likely than those in community settings or private practice
to be non-respondents (whether having experienced MI or not). Regarding predictive
factors for severe pain, the specific type of lesion associated with symptoms was
not evaluated, thus limiting our conclusions. Finally, it was not possible to evaluate
the role of more complex procedures such as ERCP, EUS or ESD in MI development due
to the low number of endoscopists performing them procedures. One area of interest
would be to study development of specific lesions after the beginning of the practice
of particular techniques, as well as the timing of their occurrence.
