I'm going to introduce our next speaker who is my co-director, I'm very thrilled and excited to hear this talk, but Dr. Amandeep Shergal is a professor of clinical medicine at UCSF and serves as the chief of division of GI at the San Fran VA Healthcare System. She did her training at UCLA and completed internal medicine residency and fellowship at UCSF and got a master's in science at, in environmental health sciences with a focus on ergonomics from UC Berkeley. She's a general gastroenterologist with clinical interest in IBD, IBD endoscopy and quality endoscopy, but her big research focus is on ergonomics and mitigating ergonomic endoscopy related injuries. She is a recipient of the 2008 ASGE career development award and endoscopic research award and her work has helped establish the field of endoscopy ergonomics and the mechanisms that cause work-related musculoskeletal disorders in endoscopists. She's a graduate of the ASGE lead program and is completing her term as an associate editor for GIE and is a member of the ASGE women's committee. I think that we all have, I think the thing that makes this course super unique and super exciting and I'm really glad that you're all here is being able to access her brilliance and her experience and her research, so Dr. Shergal. Thank you for that kind introduction. This is definitely a passion of mine and I'm excited to be sharing both this lecture with you as well as the hands-on station that we have planned. So here are my relevant disclosures. I want us to take a moment to reflect that if there was a device on the market today or procedures being performed where 75% of people were experiencing an injury related to that procedure, 20% were needing time off to treat that injury, and ultimately 12% were requiring surgery, that device and those procedures would no longer be being performed if we were talking about patient-related adverse events. But unfortunately, since this is the story of endoscopy-related injury and endoscopist-related adverse events, we're performing more procedures than ever because we can do them safely and efficiently for patients. But it truly is the endoscopist who's paying the price in terms of pain in the distal upper extremities, in the neck, back, and shoulder as well as in the lower legs because of the number and complexity of the procedures that we're now performing. So while there have been many survey-based studies that have now been published, this was one of the largest ones published in 2021 of almost 1,700 ACG endoscopists that really established the 75 prevalence of injury for both men and women. But interestingly, men and women seem to have different mechanisms of injury. Women complained of more distal upper extremity injuries as well as upper back pain, presumably related to non-adjustable workspaces as well as the interaction with the scope versus men who complained more of lower back pain, presumably related to lead apron use as well as the use of the elevator on the duodenoscope. And so what I'd like to do over the course of this lecture and the course of this day is for one thing instill this basic truth that work shouldn't hurt. And if nothing else, go home with this knowledge that work shouldn't hurt and what you're doing at work, we need to figure out ways to do it in a way that allows us to do it pain-free. But because of the fact that over 75% of us are experiencing pain and injury as a result of work, it's important for us to be able to identify risk factors for endoscopy-related injury that are present in our work site, demonstrate knowledge of neutral postures and methods to optimize our posture in the endoscopy suite so we can begin to mitigate some of these risks, understand how to apply the hierarchy of controls to our endoscopy unit to control risks, and things that we'll focus on in the hands-on session is implementing a pre-procedure ergonomic timeout. And we have the pleasure of having Naoko Sasaki here, who will go through a series of post-procedure stretching exercises that I hope will be another tool that you're going to take home with you today. So to start with, what is ergonomics? Ergonomics is the study of how work affects people physically and cognitively. It tries to quantify human capabilities and limitations and then design jobs, apply that to work so that you're really designing it within those capabilities and limitations. So it's evaluating how a job can best be fit to an individual instead of forcing an individual into a job. And what happens when there is a misfit is the external loads of how we're interacting with our work environment or our tools. It results in non-neutral postures, potentially high force and repetition that over time overcome the internal loads and tissue tolerances of our muscles, ligaments, tendons, and nerves leading to pain and injury. In the early stage, this aching and tiredness of the affected limb can occur early in the work shift, disappear at night and during days off work, and there's really no reduction of work performance. But in the intermediate stages, this aching and tiredness is going to occur earlier in the work shift, persist at night, and there may be a reduced capacity for repetitive work associated with that. What we're really trying to avoid is this late stage of pain where the aching, fatigue, and weakness persist even at rest, and there can be an inability to sleep and to perform light duties. And so a key point here is that pain is an important signal, and if you are experiencing pain or discomfort, that's a sign that we need to be doing something differently. And so this is where we want to be able to identify risk factors that are present during endoscopy that may contribute to repetitive strain injury. So there are – it's an established ergonomic risk factors that are already – we know a lot about, but the ones that are present in endoscopy in particular are repetition, high force, awkward joint posture, and sustained static loads. So if we think about repetition, we just have to think about the high volume of procedures that we're performing in this RVU-based reimbursement format, where it's doing more procedures than ever. Our group has been able to demonstrate really high forces in the distal upper extremities in terms of the muscle loads as well as pinch forces that exceed the safe thresholds that have been established in the ergonomics literature that really contribute to an increased risk of both the right and the left distal upper extremity when performing colonoscopy. And the awkward joint posture and the sustained static loading is really how we're holding and manipulating the scope and how we're holding ourselves and our posture in the endoscopy suite. And this was a really interesting study because it really demonstrates how poor a fit the current endoscope design is, how this one-size-fits-all design really does not work. So this study took about 50 medical students, so novices to endoscopy, about half men, half women, and it first had them perform a dexterity task, and it found that the medical students with the smallest hands were the most dexterous. They were able to complete this task, and this is the black line here, in the shortest amount of time. When they had them perform a simulated bronchoscopy with a smaller bronchoscope, there was really no difference in basic scope manipulation, as you can see here by this darker dashed column. But when they gave them the larger endoscope, the smallest hands had the most difficulty completing the endoscopy task. They took the longest time, and this is despite the fact that they were the most dexterous to start with. So this poor fit, the fact that the endoscope is often too big for smaller, especially women or those with smaller glove sizes, hand size, affects our ability to perform procedures adversely. And so if you are experiencing pain, think about how these risk factors may be present in your work site. So non-neutral posture, high force and repetition. If you're having pain in the hand, wrist, and elbows or shoulders, that's going to be related to the biomechanics of your scope handling, and potentially the static load of holding that scope as well. If it's pain in the neck, shoulder, or back, that's going to be non-neutral postures related to where your monitor is, your monitor height, and your bed height, as well as if you're having to wear them, lead aprons, and the static load associated with that. And pain in the lower extremities is going to be related to the static loading of prolonged standing. So what we really want to focus on, then, is how do I optimize endoscopy for myself? How do I optimize the fit? Do you really need an adjustable work environment? How do I minimize my forces? A lot of all of this really relates back to neutral posture. So this is a really key concept that we hope you walk away with from this course today. And so just a show of hands, how many of you feel confident in your knowledge of neutral postures? See, that's so interesting to me, because neutral postures is our natural posture, right? So this should be something that we feel very comfortable with doing. But really, in terms of especially when we're in the work environment, when our work environment is such a poor fit to us, we have become so comfortable, not comfortable, so accustomed to these non-neutral postures in our workplace that I think it really tweaks our idea of what's OK. So ergonomics, then, when we're designing endoscopy and the endoscope to fit the endoscopist, we're thinking about how can this full breadth of users assume neutral posture? So we have to optimize fit, taking into account anthropometrics. This is the study of human dimensions. It's a critical piece of user-centered design, and it's taking into account that smallest fifth percentile female to that largest 95th percentile male, and designing worksites and tools that are comfortable for that full breadth of users, that that full breadth of users can assume neutral postures when interacting with that worksite or tool. Because it's critical that you're in the neutral posture so you can minimize force production. So when we're in our neutral postures, that's our maximum force generation ability. And everything that we're doing in ergonomics is trying to reduce the forces that we're using to the lowest possible and hopefully below safe thresholds to really reduce risk of injury from repetitive forceful movements. So in the hands-on station, you guys are going to spend a lot of time thinking about neutral postures. What are they? Why are they important? How do we achieve them? And a key concept is, as you can see here in this graph, this is the actin-myosin overlap. When you have your normal neutral posture, your actin-myosin overlap is optimized, and this is our maximum ability to generate force. But once you start flexing or decreasing the length of the muscle or extending, increasing the length of that muscle, that actin-myosin overlap is compromised, and so our ability to generate force is also compromised. And unfortunately, women are already at a significant disadvantage when it comes to force generation ability because we have about 20 pounds less muscle mass than men. So posture and age are the most important predictors of strength, and as you can see here, women are strongest in their 20s to 30s, and we're only as strong as approximately 70-year-old men. So you're going to spend some time in the ergonomics station also figuring out what is your percentile grip and what is the comparable-aged man with that grip, and it will be very enlightening, I think, to all of us. I hope I've been able to explain to you why we're at risk. This is of no fault of our own. It has to do with, again, our muscle mass, our ability to attain neutral postures in this misfit of tool and environments. But there are things that we can do by applying the hierarchy of controls to begin to control these risks. So the hierarchy of controls tells us what are the most effective to the least effective mitigation measures that we should start thinking about if we're having issues in the endoscopy unit. And this has to do with both the design of tools, which we don't have a lot of control of currently, but ideally are built with that fifth percentile female to that 95th percentile male in mind, allowing everybody to attain neutral postures and really work at very low forces within safe exposure limits. What we probably have the most control over is the design of our endoscopy suite, so thinking about, again, how can we accommodate that full breadth of users so that they can attain neutral postures? Elimination and substitution are the most effective hierarchy of control methods, but that really is – requires our device companies to consider prevention through design and user-centered design. So what we're really focusing on here is going to be engineering controls, which is like physical changes to the work or workplace, administrative controls, which change the way we work, and then our personal controls. But I would just point out that we're at the bottom of this upside-down pyramid, so anything that we do in isolation may potentially be the least effective, although, again, it's sometimes the only things that we have available to us. So I just offer this up as a reference. This is a top tips that was published in GIE earlier this year, which sort of reviews what I'm about to talk about in greater detail, which is, if you are having pain in the neck, back, and shoulders, for instance, the risk factors for this are going to be non-neutral postures related to the room setup, potentially fixed monitors, non-adjustable beds, and the static loading of performing our procedures. And so when we think about engineering controls, this really requires adjustability – adjustable monitors, adjustable bed. The administrative controls is going to be ergonomic education as well as this idea of an implementation of a pre-procedure ergonomic timeout, because, for one, we do need to ensure that adjustability, but once that adjustability exists, we need to make sure we're using it in the rooms to really optimize the room for ourselves. So this is, again, going to be a focus of the hands-on station. And so this is what you guys are going to be spending time with Dr. Eun-ji Shen as well as Karen Woods with. If you're having pain in the distal upper extremity, this is likely related to the non-neutral postures that we have to assume in order to interact with the scope, the repetitive high-force exertions while holding and manipulating the scope, as well as the static load of just holding that scope, which can, after an hour-long colonoscopy, sometimes feel quite heavy. So again, thinking about engineering controls, while these are the most effective, there really are not a lot available to us. And so the interaction between the tool and the endoscopist continues to be quite poor. So these right-left dial adapters have been used by many endoscopists, especially female endoscopists. Unfortunately, Olympus recently discontinued theirs, so theirs is no longer available on the market. Pentax still has one available, and I believe Fuji has one that's currently in development, but it, in theory, is going to increase that reach for that right-left dial. We did a study looking at a support arm to relieve the static loads of the control section on the left distal extremity, and we were able to show a benefit, and currently we're finishing up a study looking at a scope stand to see if that can as well relieve these loads. Anything that decreases exposure time is going to be helpful in decreasing risk, and so there has now been a robust literature on the use of distal caps, and especially the newest generation, which not only decrease withdrawal time, but they can potentially increase ADR. But there's really not a lot we can do to the scope itself, and so we're left really with administrative controls, and here I would really like to have us focus on schedule endoscope maintenance. So this is a picture that was given to me by a participant in one of our training endoscopy trainer courses at DDW earlier this year, and this is the same scope. It's an upper EGD scope, and you can see here how different that angulation is between the two scopes. And imagine trying to retroflex and look at the GE junction with that first scope. How hard is that going to be? But we're not going to know unless we look at the scope beforehand that we may be in for a really difficult endoscopy, and so you're going to be sitting there doing everything you can to try and see in retroflexion, and you physically may not be able to because of the scope itself. And since we know that exposures to the biomechanical risk factors are high, even when scopes are performing at their best, over time, the angulation control wires can stretch, and you can get that play in your dials. The responsiveness is going to decrease, and so you may need to work even harder to achieve a comparable or even lesser degree of tic deflection, and so we want to try and be proactive and avoid that as much as possible. So take a look at your scope before you start your procedures, and especially if you have a scope like the first one, don't even start the procedure with that scope. Send that back. In terms of endoscopy schedule, we have a lot of data in terms of patient-related outcomes like adenoma detection rate, and really no data on physician-related outcomes in terms of pain and injury. And so the best advice here is try not to stack your endoscopy days, and you should really not be starting a day of endoscopy still recovering from your last day. So if you are experiencing any pain or injury from endoscopy before you start your next session, you should be fully recovered, and you should figure out ways to either have half days of endoscopy or build in time between endoscopy to ensure complete recovery before you start your next shift. There is a lot of talk on different techniques for holding and manipulating the scope, and there's really only out of the U.K. and Canada do we have a formalized technique that's taught. Here in the U.S., we kind of learn from our mentors and figure out what works for us and apply that to our practice that way. So two different schools of thought. One is holding the scope horizontally, as you can see in this first picture. And the idea is that by holding the scope horizontally with the umbilical cord behind you that the weight of the control section is perfectly balanced and actually can be balanced as they're trying to demonstrate here on just one finger. So in theory, this is taking off some of that static load of the control section versus the all-fingers technique where the umbilical cord goes in front of the wrist. This is actually used by a lot of advanced endoscopists, I've noticed. And this allows better, in theory, reach for that right-left dial with all fingers. I've never been able to reach the right-left dial, so this is not a technique that I can use. In terms of holding the insertion tube, we do have a sense that the power grip is going to be a more comfortable grip as well as a more sustainable grip than a pinch grip. So the pinch grip is when the fingers are flexed towards the tip of the thumb, and it's estimated that a pinch grip can be three to five times more stressful on the tendons as compared to a power grip, which is when your fingers are flexed towards the palm. And the power grip is the strongest human grip. It's 75% stronger than a pinch grip. So you want to see how you can convert your grip into a power grip either using gauze. Some people use towels in order to be able to increase their grip size. But that power grip is going to be our more comfortable and powerful grip. So again, I'll just direct you to this website from the Canadian GI Association where they demonstrate this technique called the C-technique, and actually Dr. Woods and Dr. Law are both experts in this, and so people to potentially talk to. But the idea is that you're leveraging your larger muscle groups for tip deflection instead of the smaller muscle groups of the hand. So you can see by moving the biceps and even to some extent the torso that that's what's resulting in tip deflection here. In terms of personal practice, I would really encourage all of you to implement micro breaks. So during procedures, this may be resting your scope during withdrawal or when you get to seek them, or if you're waiting for biceps, really taking a second to just shake out your hands. That's sort of like paying back the lactic acid debt during the procedure and helping you to start the recovery process. And in the survey of ACG endoscopists by Dr. Powa, they were able to show that there was a lower likelihood of endoscopy-related injury in those who took breaks and micro breaks, and the length of break didn't really matter. You just needed to be taking them. In post-procedure, again, consider these stretching exercises, which will be the next session. If you're experiencing pain in the lower extremities, this is likely related to just the static loads of standing during our procedures. In terms of engineering controls, there are anti-fatigue mats. For administrative controls, it's, again, the pre-procedure ergonomic timeout and ergonomic education. I think an important concept here is just what is the difference between static loads and what are we trying to accomplish with the anti-fatigue mats or cushioned insoles. So a static load is when the muscles are contracted, and because they're contracted, blood flow is needed. But because they're contracted, the blood can't get in. So there's a mismatch between the blood needed and the blood flowing through. If you're at rest and your muscles aren't contracting, you don't need significant blood flow. Blood flow isn't coming in. So when you have a dynamic load, the muscles are contracting. There's a good amount of blood that's needed. But because the muscles are contracting and relaxing, the blood flow can match the blood that's needed. So what we're trying to do is convert these static loads, where we're just taking one posture and not moving, and converting them into more dynamic loads so that we can track the muscles and bring blood back into muscle groups that are contracting. So this is where the anti-fatigue mats, as well as the cushioned insoles, they both essentially achieve the same thing. So they're helping to introduce some degree of postural instability so that you're kind of forced to move and forced to have some dynamic movement. Compression stockings are helpful, especially if you're experiencing any lower extremity edema. There are people who actually sit during procedures, although the main issue with sitting is just making sure that your monitor can lower low enough that you're maintaining a neutral neck posture. And again, stretching may play a role here. I'd say a key concept in all of the, whenever you're applying ergonomics to your practice is the idea that you do need management commitment, especially as you're thinking about engineering controls or administrative controls, you kind of need that management buy-in. There are many resources available. So depending upon where you're at, if you're at a big academic institution, there may be an ergonomist on staff, an occupational medicine physician as well. If you don't have access to ergonomists or occupational medicine physicians, then physical therapists can offer some benefit in terms of being able to help you with overall postures. And there was a nice GIE study that showed a benefit of that. And as a last resort, hopefully you never have to go here, but you are, you have the right to a safe workplace, and so OSHA is a resource if you're not able to get the leverage that you need within your own practice. So this next session, I'll be introducing Nao Kusasaki very shortly, but what I wanted to go over, oh, this is going to be the tool that's going to be in your toolkit when you leave here, going over the set of exercises that we'll be reviewing. I wanted to just review briefly what's going to happen at our hands-on station. So there's going to be two parts of it, and you guys will be fluidly moving through the two parts of it. So generally speaking, I think I have groups of six people. So two of you are going to break off and go with Dr. Woods and Dr. Shin in order to do an ergonomic, a procedural assessment with an ergonomic assessment and implementation of a pre-procedure ergonomic timeout. And the rest of us are going to be working on various topics such as what are your anthropometrics, what are your biomechanics, what percentile is your stature, eye height, your grip strength. You'll be working through a series of worksheets. I'm going to be there to help facilitate these. These will all have take-home messages, and we'll be working as a group, sort of like peer-sharing our experiences to be able to establish a strong foundation of ergonomic principles. And then for the ergonomic assessment piece, I'll be speaking to you during the session as well as getting your consent to potentially collect this data to see if it's beneficial. We do have partnered with Velocity EHS, which is an AI-powered app that can give us some feedback on your postures. There is a delay we're finding in being able to get these videos processed, so we're going to be using this kind of a worksheet to do the assessment initially. So you guys will have a pre-assessment, you guys will get feedback, you'll have a post-assessment. Hopefully we've seen an improvement in your overall postures. That'll be done initially with Karen and NG, then you'll come to me and I'll grade those and hopefully I'll have your videos back to be processed, and then we'll speak to you about how we can really make sure you're leaving with a good sense of how to set up the room to really optimize and neutralize your postures. And with that, thank you.

Dr. Amandeep Shergal

prevalence of injuries

endoscopists

ergonomics

risk factors

hierarchy of controls