directors for inviting me, so thank you very much, and it's an honor to speak in front of you. So I think I've been tasked for the next 25 minutes to talk about endoergonomics, work smart, stay safe. And these are my relevant disclosures. And I'm going to try to impress upon you, my talk will be divided in three different categories, and I'll try to impress upon you the scope of the problem, where you'll understand the prevalence of endoscopic-related injury, also listed as ERI, in practice and in fellowship, recognize the ergonomic risk factors during endoscopy and the importance of a neutral posture, then the problem of the endoscope, and recognize the biomechanical risk factors for repetitive strain injury during endoscopy, and also understand the hierarchy of controls and how you can utilize it in your practice, and then apply ergonomics knowledge to the endoscopy suite. So let's get started. So what is the scope of the problem? There is increasing demand for GI endoscopy, right? The United States Task Force, Preventative Task Force, has now lowered the age of colonoscopy to 45 years. What does that mean? That means more screening colonoscopies, more post-polypectomy surveillance. You have AI now, which is increasing your adenoma detection rate and different technologies, and you'll have more scopes. There is increased utilization of advanced GI procedures in disease states that were predominantly managed by surgery. So we're doing more and more advanced procedures now. And most importantly, the GI user mix is changing, meaning there are more female GIs now. So half or one-third of the workforce now is GI, and most of the GIs, active GIs, or half of them, are greater than 55 years of age. So we've got GIs that are now actively doing endoscopy but more age, and we have females in the mix as well. This is a paper that came out this year which talked about work-related musculoskeletal injury rates, risk factors in ergonomics, and different endoscopic specialties. And they looked at GI, ENT, urology, and pulmonary, and noticed that there's been an uptick in the activity of GI endoscopy, and more research has gone into ERI in the last six years. So since 2018, you're suddenly seeing a whole burst of GI papers on ERI. But that's not true, right? We can go back to 1994, when Bush Barker, out of Indiana, did the first survey of ASGE attendings, or ASGE members, not attendings, but ASGE members, and there were 265 members that took the survey, and they found that half of them were complaining of endoscopic-related injury, and he came to the conclusion that they were suffering from overuse syndromes of the hand, the finger, the wrist, the thumbs, and most likely due to an endoscopic technique. Since then, there have been studies that have kind of made their way, and you notice in the last eight years, a huge bump in the studies, and injuries have been reported anywhere between 39 to 89 percent. There have also been four or five major studies amongst GI trainees, and sadly enough, their injury rate is high as well. There are 20 to 55 percent of trainees complaining of pain and injury almost in their first year, which could be related to technique, but nevertheless deserves a pause to figure out what's going on. So what are some of the key papers out of this whole body of robust body of survey literature, which is what it is, and so I'm going to kind of point out what we've learned along the way as these papers came out, and this was the first one that I want to highlight, which came out of ASGE. There were 684 practicing endoscopists, half of which experienced endoscopic-related injury, and said the common sites of injury were neck, upper back, and thumb. The risk factors in this particular paper were more than 20 cases per week, something that Dr. Adler does in a day, less than six, greater than 16 hours of procedures, and total number of years performing endoscopy. We're almost there or we're getting there, so all of us are in this zone right now, and 55 percent required interventions in the form of either physical therapy or NSAIDs or surgery. I think 13 percent of those required surgery. The second paper came out of AGA. This actually never saw a publication but remains an abstract form. This came out in 2017. 826 practicing endoscopists, pre-endoscopy injury rates were high at 45, which doubled post-endoscopy. Women and men were nicely represented in this paper and have suffered equal injury. Women, however, had more injury in the wrist, elbow, shoulder, upper back, right thumb. Training in ergonomics was rare, only 4 percent. And risk factors, we were kind of forming a theme here, were procedure volume, older age, weight, prior injury. And then came the ACG paper. This was the largest study to date. This came out in 2021. Again, 1,600 some practicing endoscopists. We also had fellows in the mix. Again, no difference in injury between males and females, but three-fourths of them experienced ERI. And more importantly, 90 percent said we had more than one ERI. And again, better than the AGA, but 61.5 reported no training in ergonomics. And risk factors independently associated with injury, again, were years performing endoscopy. So the more you do, the more chances are that you're going to get to this zone where things are going to hurt, hurt enough to cause an injury. And then hours per week performing endoscopy. In this particular study, 20 percent took time off from injury and 12 percent required surgery. This is a graphical abstract of the same study, but notice here that I want to highlight the mechanisms of injury and the areas of injury. And you start to see a pattern emerge between our male colleagues and female colleagues. So gender differences started to occur. Women complained more of wrist injury, hand, finger, and thumb pain, and also upper back pain. Men had more lower back pain and elbow pain. Reported mechanism of ERI in women, non-adjustable bed monitor, talking with the right hand. In men, and this could be skewed a little bit, but more lead apron use of elevator on the duodenoscope. And for the first time, we did a poll on pregnancy-related ERI, which was at an all-time high of 79 percent. So this study is then apt because we want to know, is gastroenterology the cause for injury? Because there's endoscopy in gastro as opposed to the other internal medicine specialties. And this came out of Mayo, a case-controlled study where they had GI physicians versus non-procedural specialties. And once again, they showed that the rate of injury was higher in the GI group, confirming that endoscopy might be contributing to injury. And so the ESG took note, and that's what I think Doug was referring to, was the Standards of Practice Committee, where Doug and I were co-authors on this, or lead authors on this paper, led by our Bashar Kamsaya, who is the chair of our SAP committee. And we did a systematic review and meta-analysis to find out the rates and sites of ERI. 17 survey studies, about 5,000 respondents, overall rate, half of them complaining of injury. Again, most common sites, hand, fingers, back, and neck. We also tried to find out, does gender play a role in endoscopic-related injury? The way survey studies, which actually compared male and female, there were about 3,355 respondents, ERI in female endoscopists, when compared to male, showed that female endoscopists were at higher odds of developing ERI. So being a female was an independent risk factor for ERI, or endoscopic-related injury. So the take-home was endoscopists are reporting higher rate of ERI, female endoscopists are at higher rate of risk, as opposed to male endoscopists. And again, the more you expose yourselves, meaning time spent in endoscopy volume, the more the chances are that you are going to get caught in this. So I think it's apt to talk about ergonomics a little bit. And what is ergonomics? Ergonomics comes from the Greek word ergon, meaning work, and nomos meaning laws. And it's a multidisciplinary activity striving to assemble information on people's capacities and capabilities. And to use that information in designing jobs, products, workplaces, and equipment, or simply put, it seeks to understand the workspaces that humans occupy, and the work they do, and understand the risks that are involved, and then try to medicate that risk. So it's based on two factors. One is anthropometry. So anthropometry is the study of human dimensions. So for example, if you look at the picture that's on the screen, it's a hand, and we're measuring the hand length, the hand breadth, and the hand circumference. So you take the smallest hand, which would be the fifth percentile of a Japanese hand, Japanese female hand, and you take the largest hand, which they talk about as the 95th percentile of a Caucasian male hand, and everything in between, and design an instrument which will take the whole broad swath of users. That's what you're looking for when you talk about fit instruments, not an instrument that will only cater to one need. So you want that kind of a design that will satisfy all and reduce the risk of injury. And another important thing that I want to impress upon you is the neutral body position. That's very important because this is the posture where all your joints and all your muscles are aligned. And the more you work in neutral positions, the maximum force that you can use, the more you deviate from neutral postures, the more force you're trying to apply to achieve the same effect. And if you are starting to cross those safe zones, that will lead to pain, which is an indicator that something is wrong, and eventually injury as well. So what is neutral body position? Neutral body position is if I'm standing in a comfortable stance, hip width apart, and then standing on both my feet, my equal weight distribution, and natural curves in my back and the neck. And that's the position you should have when you're trying to scope. And so when you look at some examples of neutral postures, look at the wrist or the elbow or the shoulders, how many times are we actually scoping in out of non-neutral postures as we're trying to get to the cecum or we're trying to get something done. So every time you deviate from that neutral position where you have maximum overlap of your actin and myosin filaments, and so maximum muscle activity, you're actually requiring more activity to do the same work, causing fatigue. So good ergonomics is good economics. I mean, there's no doubt about that. And one example is a boning knife that you can see in the first picture, where a lot of workers were complaining of carpal tunnel syndrome. Look at the way the wrist is deviated while they're trying to do the work. And so now you've got a pistol-shaped knife where they're holding the wrist in a very neutral position, and as a result of which, no carpal tunnel syndrome, no injury. And there are many on the market now which strive to be more ergonomically sound. So what is work-related musculoskeletal disorders? It arises from a complex interaction of events that may accumulate over time. So injury results from accumulated effects of transient external loads. So in isolation, they may be insufficient to exceed your internal tolerance, but when the loading accumulates by repeated exposures or long-duration exposures, the internal tolerance of the tissue is eventually exceeded, and you get pain and disability. So initially, it just might be pain during the course of the day, but you go home, there's no pain, everything's fine. The pain that now lingers on to the end of the day, and then a pain that now is accompanied by fatigue, and you can't sleep at night. So you know that you're progressing into that zone. So what are GI-specific risk factors? And this is my fellow who boldly shares a picture every time, but was actually struggling that day in the endoscopy suite. But you can notice the repetitive motions, the awkward positions, the long hours of standing, the lack of breaks, the adjustment of the tip angulation controls, and the talking with the right hand. All of them repeatedly can lead to working in non-neutral postures, increasing forces, which then can go out of the safe range and cause pain and injury. So we talk about now the problem of the endoscope and who actually, what is this all about? So the endoscope, the prototype endoscope was built by Basil Hershovitz at the University of Michigan. And it had an eyepiece, it had a camera at the end, and it had an inflation bulb. And the second picture of what it was sits in the Smithsonian. But since then, the video endoscopes were introduced in the 1980s, and you've seen a significant growth in the imaging technology. I mean, you've got superb optics when you look at the way the scopes have developed over time. But what hasn't changed? There has been no significant advances in the endoscope human interface design. That has remained the same. So it's a one-size-fits-all device for a non-one-size workforce, which could be causing a problem. And so does hand size matter, actually? There's been a lot of debate on small hands versus large hands. And this was a survey study by Cohen back in 2008, which assessed the perception of effects of hand size on learning and performing endoscopy in GI fellows. And three-fourths of the GI fellows felt that the hand size affected endoscopic learning. Forty-one percent felt the hand was too small. But, you know, we couldn't really prove that they had more injury than the other. In our own study, which was the ACG survey in 2021, almost all women reported extra-small to medium glove size. Seventy-three percent of the male reported large to extra-large glove size. Rate of ERI was not significant. And then there was a paper by Miller, which came out of Mayo in 2022, which measured the procedural and anthropometric factors associated with ERI and found that small-handed endoscopists, which wear small and medium-sized gloves, had longer colonoscope insertion times as opposed to large-handed endoscopists. So then came this study. This came in 2022. This said, does controller size matter? So what they did was they took 50 naive endoscopists, so medical students, and equally divided male and female, and gave them, checked them for small glove size and large glove size, and noted that the smaller glove sizes were actually the most dexterous. They performed the best. And they gave them the smaller scopes, which I think in this case was the bronchoscope, and they could do as well as the larger glove sizes, in fact better, because they were more dexterous. Then they handed them the endoscope, which was a large-handed endoscope, and they noticed that they were slower, they were developing more fatigue, as opposed to the large glove size. So the size does matter, and you generate more force to accomplish the same task, which makes it difficult to work in neutral postures. And that's something the endoscope does do. This is a study which talks about kinematic analysis of two simulated colonoscopies with two levels of difficulty, and they were measuring right wrist patterns, which were recorded by a magnetic motion tracking device. I think they had one on the shoulder, one on the wrist, and they had gyrometers, which were looking at velocity and space and various kinds of movement. And they noticed that they analyzed three wrist degrees of freedom, and noticed that the endoscopist spent up to 30% of procedure duration at extreme range of motion in the right wrist. So we are now working repetitively. We are working in non-neutral postures. We are working longer than ever and repeating that same motion, and we are exerting greater forces. So all of that is leading to the increased rate of injury that we're seeing now in our colleagues. And so this is to sum up what I just said about procedure volume, more work, bad posture, and bad instrument. So we want to talk a little bit about the hierarchy of controls and what this means. And a hierarchy of controls and how you can utilize this in your practice. And the hierarchy of controls basically can be industry-led, can be employer-led, and can be led by you. And basically, it talks about the most effective method at the top to the least effective method to control exposures to mitigate the risk of injury. So at the top, the very top, is elimination and substitution. Change the design of the scope. Make it user-friendly so that it actually helps that fifth percentile female hand to the 95th percentile male hand and in between. But this is very difficult to do. This is a different market. And even though the scope companies are listening and they're coming up with certain prototypes which were introduced at least in the last DDW, it's still a long way to go. So there's not much we can do about it. So then let's go to the second one, which is employer control, where we talk about a culture of safety, a more accommodative culture. In that case, can you at least give them adjustable monitors, adjustable beds? How about ergonomic timeouts? Can we scatter the schedules a little bit? And all that needs admin buy-in. That's something you're dependent on. That's your second one. And then the least effective is what's in your hand, what you can do. Can you keep yourself fit? Can you exercise regularly? Can you take micro breaks? Can you develop your techniques or perfect your techniques so that you don't injure yourself as much? So that's how this upside down pyramid looks. And what we can focus on is just the bottom, which is the least effective, but probably what we can really do right now and we should do. So that's where the ASGE guidelines came last year, which was the first guideline on ergonomics and their recommendations. And there were strong recommendations for ergonomic education, for a neutral monitor position, and for neutral bed height, and conditional recommendations for anti-fatigue mats and micro breaks and breaks. So let's talk about ergonomic education real quickly. And so the idea here is continued reinforcement of behavior modification for performance of endoscopy in a neutral position to prevent endoscopic-related injury. And you can do it. Studies have shown that education sessions can help teaching conferences, online courses, short written guides, posters that are hanging in your endoscopy unit. And two studies that actually did show that this made a difference was this one came out of Canada, where they actually had a group, simulation studies, which they had a group which actually underwent ergonomic education and a second group which didn't undergo ergonomic education. And then they measured Rebus scores, which is a surrogate for ERI as it looks at your joints and the various movements of the joints. They noticed that the ones that had education actually had better Rebus scores than the ones who did not get ergonomic education. So education does matter. At least it's been shown in this randomized study. There's ergonomic consult. This came out of Duke. Markwell is a physical therapist in Chapel Hill. She actually gives personalized assessments, quality ergonomic consult. She actually spent time with all of them, gave them personalized assessments, and they noticed that six to eight months later, their pain sites were reduced or resolved. So there was some improvement there as well. So that's another way to look at it. And then, obviously, the training committee of the ASGE came out with a core curriculum for ergonomics and endoscopy led by Catherine Walsh. And they talked about cognitive aspects, technical and non-technical aspects, of teaching endoscopy and starting very early. So their main thing was start with a fellowship early. Start talking about correct posture. Start talking about the ergonomics that they need to utilize rather than wait till they actually get more settled in their habits and their difficulty change. For that, you're going to need dedicated trainers who can actually pick one or two things that they're going to discuss with a fellow today. Say, OK, today we're just going to talk about your neutral posture, and we'll see how you do or look at your monitor position. So that the fellows are not overwhelmed, and you actually develop a working relation, and you kind of get feedback. The feedback has to be during endoscopy, pre-endoscopy, and then reflective, post-endoscopy, that the fellow can reflect on, OK, this is what I did right. This is probably what I did not do right. So that culture of safety to allow them to be able to do this in their own time and to give them the adjustable monitors and the adjustable beds and all of that. So that's very important that this starts to develop. In the cognitive piece, obviously, to highlight a few, you need to know why you're getting injuries, what are the risk factors. And the technical aspect, probably know what your room setup should look like, what is the ideal room setup for you. And then the non-technical, what does an endoscopic timeout mean, support the team members to adopt ergonomic principles, and avoid injury, to name a few. So what is a neutral monitor position? The monitor is placed directly in front of you. You're standing in a fairly neutral position. Your hands, your legs, hip-width apart, and your natural contours of your body, and your monitor is right over here. So your eye is resting right in the center of the screen, 15 to 25 degrees below the horizon. If the monitor is too high, it leads to excessive cervical extension and neck strain. Same thing with the bed. It should be elbow height or 5 or 10 centimeters below the elbow height. If it's really low, you're flexing forward, increasing discomfort. If it's a higher bed, you're hurting your deltoid and trapezius muscle. And then anti-fatigue mats. Again, our surgical counterparts have actually done a whole lot more than what we've done, and most of our guidelines, when we were writing these guidelines, was extrapolating from surgical literature, because they're ahead of us in this field. And so the studies actually do come from them, but prolonged standing has been directly implicated with lower extremity tiredness and discomfort, low back pain, whole body tiredness, and the use of floor mats was associated with less pain and less overall discomfort. And it actually makes you move a little bit. The whole idea is to move yourself. You know, you get stuck in these positions, and this goes on and on and on, and suddenly you're in an hour, and when you kind of finish, you're hurting pretty much everywhere. So it's just regrouping every few, and saying, okay, let me just get back, let all that lactic acid that accumulated, let it leave my body, and let me come back. And the mats do that, too. They create that uneven surface that you're actually moving a little bit on them. And so, as we're ending, we're talking a little bit about microbreaks. What are microbreaks? And they're defined differently. In our paper, we defined it as short biologically meaningful breaks, lasting 30 seconds to two minutes. You could be doing nothing in them. You could just be changing your posture, just stopping the procedure for 30 seconds, while you kind of just straighten yourself out. And these are maybe longer procedures, maybe a third space procedure, advanced GI procedure, which is lasting more, or a colonoscopy that's particularly tough that's going on for a while. But either which way, you're just taking a little break in the middle. In the surgical literature, they talked about targeted stretching microbreaks. And what they did was, in their long surgeries, they took these one-and-a-half-minute breaks every 40-minute intervals, and you can see them standing. They stepped to the side of the OR, and they actually had dedicated exercises that they would target either the neck, the back, the wrist, the hand, the knees, and the ankles. And then we talk about macrobreaks, which is where you need that employer buy-in of taking a break in the middle of the day, if possible. And so what we learned was that in our study, which came out in 2021, there was lower likelihood of ERI in those who took breaks and microbreaks, both macro and micro. It didn't matter which one you took. And in the surgical study, we showed that there was improved physical post-procedure pain scores in all evaluated anatomic regions. There was improved physical performance, mental focus. Most surgeons wanted to incorporate this in their practice, and it did not really dent their operative duration times. And again, this is a slide of Dr. Raju's. Again, you want to scatter your day a little bit. Maybe you do one half of the day. Don't do the full day. If you do the full day, take a break in the middle. Take microbreaks throughout the day. Or don't scope continuous days. If you're in pain, don't come the next day and start scoping again. Take that day off and maybe scatter your scope days a little differently as well. These were right and left dial adapters, which made the controls more accessible to smaller hands. These were pulled from the market, both by Pentax and Olympus. Olympus really didn't inform anybody. We really had to go after them to figure out what happened, but they said they've now introduced better scopes. That is debatable, but I think Pentax is reintroducing them in the market, though you can find them on eBay, from what I'm told. Endoscopic technique. This is more in Canada and Europe. They talk about a C-shaped loop that's formed. You kind of lay the scope on the table and you actually torque with your left hand, not so much with the right hand. It's well known that the women use more torque. They drive the scope forward by using right-hand torque quite a bit, and they can only use their thumb on the dials, or they have to use their right hand to actually move the thumb on the dials. Men drive the scope with just the fingers and thumb on the dial, and that has a lot to do with a larger hand versus a smaller hand. So that whole torque that you're doing in those non-neutral positions, instead of that, if you can kind of keep the C like that and try to torque, so it's a bigger joint, now that's involved, you could torque with the left hand. But there are many others, and so it depends on which one you like better. There's also the power grip, and there's also the pinch grip. The power grip is where the palms, the fingers are coming towards the palm, the pinch is more towards the thumb, more stressful on the pinch, more power in the power grip. So trying to do that as well. This was another paper which talked about gender differences, and again, nobody knows why, but the females will have the umbilical cord outside of the forearm, males have it inside of the forearm. Again, we don't know why, and what's really the significance of this, but again, the movements are more right torque with the women, and more thumb and fingers with the men when they're driving the scope forward. Females prefer pediatric colonoscopes, male prefer adult colonoscopes. So I'm gonna end with encouraging you to implement in your practice, even as fellows, ergonomic checklist, which actually will go a long way in at least trying to tune you as you get into your day of scopes. And we talk about monitor bed, the endoscopy tower, which should be behind you, the foot pedal, which should be in front of you, the cords and wires, which are contained on the floor, a mat if possible. If you are doing advanced procedures, you wanna do a two-piece sled instead of a one-piece sled to break the force that it generates, and then your neutral posture is key, even in the middle of the scope when you are heavily straining it to do something, and you're in these awkward postures to actually come back to the neutral and then go at it again. And communication is key. Encourage team members to raise any ergonomic related concerns. There are many ASG resources. You know about the guidelines that came out. You know about the core curriculum. There is a ASG video, Ergonomic Essentials for Your Practice, by Amandeep Shergill, who's done some seminal work in ergonomics over the last several years. I would encourage you to watch her video. Dr. Raju has YouTube videos on how to set up an endoscopy suite, as well as endoscopy ergonomics. And then there's a video GI series by Drs. Chang and Young. I cannot be remiss if I ended this talk without talking about disability insurance, which actually I encourage our fellows to take, and most of them have it. You all need to explore this in your practice right now as fellows, because this is the time to do it. Once you're injured, your premiums go high, and it's difficult to get these kind of insurances. But understanding the terminology used in disability insurance will aid in choosing the appropriate policy. Disability insurance pricing is, again, based on age, health, age, gender, medical specialty, and state of residence. They might replace a portion of your income when you're unable to work, due to injury or illness. It can be short-term, starting 14 days to six months. It can be long-term, until your retirement. Just key things. Owner occupation is important. So you should stress the fact that you should be unable to practice as a gastroenterologist, and that it shouldn't be, oh, you can still do internal medicine. So you want to make sure that when you are looking at these disability insurances, that it's actually your own occupation that's listed there. And at least for you all who are young in your careers, you should have future purchase option, which allows you to increase the future coverage as your income grows, without requiring additional medical screening. So something to consider, something I'd encourage you all to look into. In summary, ERIs can be debilitating. Modifiable and non-modifiable factors can contribute to these overuse injuries. Most effective measures to prevent ERI are industry and organization-led. Prioritizing ergonomics and incorporating the guidelines may help prevent ERI and disability. We lag behind other disciplines. A great need for research focus and funding, and obviously prevention is better than cure. Thank you for your attention.

endoscopic-related injuries

gastrointestinal practitioners

ergonomic practices

endoscopic equipment design

injury prevention

ergonomic education