American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled “Methodology and Review of Evidence,” which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI. This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled “Methodology and Review of Evidence,” which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI. This guideline document was prepared by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy using the best available scientific evidence and considering a multitude of variables including but not limited to adverse events, patient values, and cost implications. The purpose of these guidelines is to provide the best practice recommendations, which may help standardize patient care, improve patient outcomes, and reduce variability in practice. We recognize that clinical decision-making is complex. Guidelines, therefore, are not a substitute for a clinician’s judgment. Such judgements may, at times, seem contradictory to our guidance because of many factors that are impossible to fully consider by guideline developers. Any clinical decisions should be based on the clinician’s experience, local expertise, resource availability, and patient values and preferences. This document is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating for, mandating, or discouraging any particular treatment. Our guidelines should not be used in support of medical complaints, legal proceedings, and/or litigation, as they were not designed for this purpose. Sixty-one percent of gastroenterologists report spending greater than 40% of their time performing endoscopic procedures.1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Survey-based studies reported a 39% to 89% prevalence of endoscopy-related injuries (ERIs)2Buschbacher R. Overuse syndromes among endoscopists.Endoscopy. 1994; 26: 539-544Crossref PubMed Scopus (62) Google Scholar, 3O'Sullivan S. Bridge G. Ponich T. Musculoskeletal injuries among ERCP endoscopists in Canada.Can J Gastroenterol. 2002; 16: 369-374Crossref PubMed Scopus (50) Google Scholar, 4Liberman A.S. Shrier I. Gordon P.H. Injuries sustained by colorectal surgeons performing colonoscopy.Surg Endosc. 2005; 19: 1606-1609Crossref PubMed Scopus (60) Google Scholar, 5Hansel S.L. Crowell M.D. Pardi D.S. et al.Prevalence and impact of musculoskeletal injury among endoscopists: a controlled pilot study.J Clin Gastroenterol. 2009; 43: 399-404Crossref PubMed Scopus (43) Google Scholar, 6Byun Y.H. Lee J.H. Park M.K. et al.Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea.World J Gastroenterol. 2008; 14: 4359-4364Crossref PubMed Scopus (40) Google Scholar, 7Kuwabara T. Urabe Y. Hiyama T. et al.Prevalence and impact of musculoskeletal pain in Japanese gastrointestinal endoscopists: a controlled study.World J Gastroenterol. 2011; 17: 1488-1493Crossref PubMed Scopus (30) Google Scholar, 8Battevi N. Menoni O. Cosentino F. et al.Digestive endoscopy and risk of upper limb biomechanical overload.Med Lav. 2009; 100: 171-177PubMed Google Scholar, 9Geraghty J. George R. Babbs C. A questionnaire study assessing overuse injuries in United Kingdom endoscopists and any effect from the introduction of the National Bowel Cancer Screening Program on these injuries.Gastrointest Endosc. 2011; 73: 1069-1070Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 10Morais R. Vilas-Boas F. Pereira P. et al.Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.Endosc Int Open. 2020; 8: E470-E480Crossref PubMed Google Scholar, 11Han S. Hammad H.T. Wagh M.S. High prevalence of musculoskeletal symptoms and injuries in third space endoscopists: an international multicenter survey.Endosc Int Open. 2020; 8: E1481-E1486Crossref PubMed Scopus (5) Google Scholar, 12Campbell 3rd, E.V. Muniraj T. Aslanian H.R. et al.Musculoskeletal pain symptoms and injuries among endoscopists who perform ERCP.Dig Dis Sci. 2021; 66: 56-62Crossref PubMed Scopus (5) Google Scholar, 13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar, 14Al-Rifaie A. Gariballa M. Ghodeif A. et al.Colonoscopy-related injury among colonoscopists: an international survey.Endosc Int Open. 2021; 9: E102-E109Crossref PubMed Scopus (4) Google Scholar, 15Yung D.E. Banfi T. Ciuti G. et al.Musculoskeletal injuries in gastrointestinal endoscopists: a systematic review.Expert Rev Gastroenterol Hepatol. 2017; 11: 939-947Crossref PubMed Scopus (34) Google Scholar, 16Matsuzaki I. Ebara T. Tsunemi M. et al.Effects of endoscopy-related procedure time on musculoskeletal disorders in Japanese endoscopists: a cross-sectional study.Endosc Int Open. 2021; 9: E674-E683Crossref PubMed Scopus (5) Google Scholar in practicing gastroenterologists and a 20% to 47% prevalence in gastroenterology trainees.17Austin K. Schoenberger H. Sesto M. et al.Musculoskeletal injuries are commonly reported among gastroenterology trainees: results of a national survey.Dig Dis Sci. 2019; 64: 1439-1447Crossref PubMed Scopus (22) Google Scholar,18Villa E. Attar B. Trick W. et al.Endoscopy-related musculoskeletal injuries in gastroenterology fellows.Endosc Int Open. 2019; 7: E808-E812Crossref PubMed Google Scholar ERIs are musculoskeletal injuries caused by repetitive microtrauma to the connective tissues of the body. Risk factors for ERI include higher procedure volume,1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,9Geraghty J. George R. Babbs C. A questionnaire study assessing overuse injuries in United Kingdom endoscopists and any effect from the introduction of the National Bowel Cancer Screening Program on these injuries.Gastrointest Endosc. 2011; 73: 1069-1070Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,12Campbell 3rd, E.V. Muniraj T. Aslanian H.R. et al.Musculoskeletal pain symptoms and injuries among endoscopists who perform ERCP.Dig Dis Sci. 2021; 66: 56-62Crossref PubMed Scopus (5) Google Scholar,13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar,16Matsuzaki I. Ebara T. Tsunemi M. et al.Effects of endoscopy-related procedure time on musculoskeletal disorders in Japanese endoscopists: a cross-sectional study.Endosc Int Open. 2021; 9: E674-E683Crossref PubMed Scopus (5) Google Scholar time spent performing endoscopy,1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,2Buschbacher R. Overuse syndromes among endoscopists.Endoscopy. 1994; 26: 539-544Crossref PubMed Scopus (62) Google Scholar,13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar cumulative time in practice,1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,3O'Sullivan S. Bridge G. Ponich T. Musculoskeletal injuries among ERCP endoscopists in Canada.Can J Gastroenterol. 2002; 16: 369-374Crossref PubMed Scopus (50) Google Scholar,10Morais R. Vilas-Boas F. Pereira P. et al.Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.Endosc Int Open. 2020; 8: E470-E480Crossref PubMed Google Scholar,13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar small hand size,19Miller A.T. Herberts M.B. Hansel S.L. et al.Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists.Appl Ergon. 2022; 104103805Crossref PubMed Scopus (3) Google Scholar age,7Kuwabara T. Urabe Y. Hiyama T. et al.Prevalence and impact of musculoskeletal pain in Japanese gastrointestinal endoscopists: a controlled study.World J Gastroenterol. 2011; 17: 1488-1493Crossref PubMed Scopus (30) Google Scholar,19Miller A.T. Herberts M.B. Hansel S.L. et al.Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists.Appl Ergon. 2022; 104103805Crossref PubMed Scopus (3) Google Scholar,20Sturm N. Leukert J. Perkhofer L. et al.The impact of endoscopic activity on musculoskeletal disorders of high-volume endoscopists in Germany.Sci Rep. 2022; 12: 8538Crossref PubMed Scopus (4) Google Scholar and female gender.10Morais R. Vilas-Boas F. Pereira P. et al.Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.Endosc Int Open. 2020; 8: E470-E480Crossref PubMed Google Scholar,17Austin K. Schoenberger H. Sesto M. et al.Musculoskeletal injuries are commonly reported among gastroenterology trainees: results of a national survey.Dig Dis Sci. 2019; 64: 1439-1447Crossref PubMed Scopus (22) Google Scholar Biomechanical forces that contribute to ERI include repetitive, high-force loads in non-neutral postures, such as while using torque steering (right wrist extensors), grasping and stabilizing the endoscope controller (left forearm extensors), manipulating the endoscope dial (left thumb abductors), and high-risk pinching.21Lipowska A.M. Shergill A.K. Ergonomics of endoscopy.Gastrointest Endosc Clin North Am. 2021; 31: 655-669Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 22Cappell M.S. Colonoscopist's thumb: DeQuervains's syndrome (tenosynovitis of the left thumb) associated with overuse during endoscopy.Gastrointest Endosc. 2006; 64: 841-843Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 23Siegel J.H. Kasmin E.E. Cohen S.A. Health hazards and endoscopy: the known and newly experienced—a personal report.Endoscopy. 1994; 26: 545-548Crossref PubMed Scopus (13) Google Scholar, 24National Research Council (US) and Institute of Medicine (US) panel on musculoskeletal disorders and the workplace. Musculoskeletal disorders and the workplace: Low back and upper extremities. Washington, DC: National Academies Press (US); 2001.Google Scholar, 25Shergill A.K. Rempel D. Barr A. et al.Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy.Gastrointest Endosc. 2021; 93: 704-711Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 26Rempel D.M. Harrison R.J. Barnhart S. Work-related cumulative trauma disorders of the upper extremity.JAMA. 1992; 267: 838-842Crossref PubMed Scopus (300) Google Scholar, 27Harris-Adamson C. Eisen E.A. Kapellusch J. et al.Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers.Occup Environ Med. 2015; 72: 33-41Crossref PubMed Scopus (123) Google Scholar, 28Mohankumar D. Garner H. Ruff K. et al.Characterization of right wrist posture during simulated colonoscopy: an application of kinematic analysis to the study of endoscopic maneuvers.Gastrointest Endosc. 2014; 79: 480-489Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 29Rempel D. Lee D. Shergill A. Distal upper extremity musculoskeletal risk factors associated with colonoscopy.Work. 2012; 41: 4680-4682Crossref PubMed Scopus (3) Google Scholar Long-term consequences of ERIs can be disruptive or even devastating to an endoscopist’s livelihood and range from pain and physical restrictions while performing procedures to disability, all potentially leading to provider dissatisfaction and loss of a highly skilled workforce.30Safety CC for OH and work-related musculoskeletal disorders (WMSDs): OSH answers. Available at: https://www.ccohs.ca/oshanswers/diseases/rmirsi.html. Accessed December 11, 2022.Google Scholar The aim of this American Society for Gastrointestinal Endoscopy (ASGE) guideline is to provide contemporary evidence-based recommendations regarding ergonomics in preventing ERI in gastroenterologists, surgeons, and others performing endoscopy. Our committee acknowledges that the study of ergonomics in the endoscopy suite is relatively new, with scant studies. As a result, we recognized from the onset that producing evidence-based guidelines on this topic would be challenging. However, we also recognized that ERIs are common in gastroenterologists and, as a society, it is our duty to provide meaningful and actionable guidance to our members on this very important topic. This document was prepared by the Standards of Practice Committee of the ASGE and was conceptualized and conducted according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The GRADE panel developed recommendations based on certainty in the evidence and on the overall balance of benefits and harms, patient values and preferences, cost-effectiveness, and resource utilization.31Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar,32Wani S. Sultan S. Qumseya B. et al.The ASGE's vision for developing clinical practice guidelines: the path forward.Gastrointest Endosc. 2018; 87: 932-933Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Consensus among the panel members was used to determine recommendations. The GRADE approach was used to categorize recommendations as strong or conditional: “Recommend” was used for strong recommendations and “suggest” for conditional recommendations. Further details of the methodology used for this guideline are presented separately including systematic reviews, evidence profile, and results from all meta-analyses. The guideline focused on 3 broad categories:1.Estimation of the rates and most common sites of ERIs.2.Estimation of the predictors of ERI.3.Interventions that can reduce the risk of ERI:a.Dedicated ergonomics educationb.Targeted stretching microbreaksc.Adjustable monitors to allow work in a neutral postured.Adjustable patient beds and stretchers to allow work in a neutral posturee.Antifatigue mats Neutral posture is defined in the ergonomics literature as the position of the body when the muscles are in resting length and the joints are naturally aligned. This is achieved when endoscopists work with their joints at about the middle point of their range of motion, thus allowing for maximum control and strength and minimizing stress on joints and spine.33Centers for Disease Control and PreventionWork-related musculoskeletal disorders & ergonomics.http://www.cdc.gov/workplacehealthpromotion/health-strategies/musculoskeletal-disordersDate: 2016Google Scholar Our panel included 2 content experts (A.S. and S.C.G.), a GRADE methodologist (N.C.T.), Standards of Practice Committee members, and Standards of Practice Chair (B.J.Q.). For this document, there were no patient representatives because the study focused on ERI. Therefore, all panel members, who are practicing endoscopists, served as “patient representatives” on this panel. Details of our literature searches, data analyses, pooled-effect estimates, evidence profiles, forest plots, and panel deliberation for each outcome can be found in the accompanying article subtitled “Methodology and Review of Evidence.” A summary of our final recommendations for the role of ergonomics for prevention of ERI are listed in Table 1.Table 1Summary of recommendations and findingsRecommendations1The ASGE recommends ergonomics education to reduce the risk of ERI. (Strong recommendation, very low quality of evidence)2The ASGE suggests that GI endoscopists take microbreaks and scheduled macrobreaks to reduce the risk of ERI. (Conditional recommendation, very low quality of evidence)3The ASGE recommends a neutral monitor position during endoscopies to reduce the risk of ERI. (Strong recommendation, very low quality of evidence)4The ASGE recommends the use of a neutral bed height to reduce the risk of ERI. (Strong recommendation, very low quality of evidence)5The ASGE suggests the use of antifatigue mats to reduce the risk of ERI. (Conditional recommendation, very low quality of evidence)Findings1Endoscopists report high rates of ERI.2Female endoscopists are at higher risk of ERI compared with male endoscopists.3Greater exposure to endoscopy procedures (time spent performing endoscopy and procedure volume) is associated with higher rates of ERIs.ASGE, American Society for Gastrointestinal Endoscopy; ERI, endoscopy-related injury. Open table in a new tab ASGE, American Society for Gastrointestinal Endoscopy; ERI, endoscopy-related injury. Finding 1: Endoscopists report high rates of ERI. Finding 1: Endoscopists report high rates of ERI. For this question, we performed a systematic review and meta-analysis. Our search identified 17 survey studies assessing the prevalence of ERI in 5227 respondents. Fourteen of 17 studies evaluated practicing gastroenterologists,1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 2Buschbacher R. Overuse syndromes among endoscopists.Endoscopy. 1994; 26: 539-544Crossref PubMed Scopus (62) Google Scholar, 3O'Sullivan S. Bridge G. Ponich T. Musculoskeletal injuries among ERCP endoscopists in Canada.Can J Gastroenterol. 2002; 16: 369-374Crossref PubMed Scopus (50) Google Scholar,5Hansel S.L. Crowell M.D. Pardi D.S. et al.Prevalence and impact of musculoskeletal injury among endoscopists: a controlled pilot study.J Clin Gastroenterol. 2009; 43: 399-404Crossref PubMed Scopus (43) Google Scholar, 6Byun Y.H. Lee J.H. Park M.K. et al.Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea.World J Gastroenterol. 2008; 14: 4359-4364Crossref PubMed Scopus (40) Google Scholar, 7Kuwabara T. Urabe Y. Hiyama T. et al.Prevalence and impact of musculoskeletal pain in Japanese gastrointestinal endoscopists: a controlled study.World J Gastroenterol. 2011; 17: 1488-1493Crossref PubMed Scopus (30) Google Scholar, 8Battevi N. Menoni O. Cosentino F. et al.Digestive endoscopy and risk of upper limb biomechanical overload.Med Lav. 2009; 100: 171-177PubMed Google Scholar, 9Geraghty J. George R. Babbs C. A questionnaire study assessing overuse injuries in United Kingdom endoscopists and any effect from the introduction of the National Bowel Cancer Screening Program on these injuries.Gastrointest Endosc. 2011; 73: 1069-1070Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 10Morais R. Vilas-Boas F. Pereira P. et al.Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.Endosc Int Open. 2020; 8: E470-E480Crossref PubMed Google Scholar, 11Han S. Hammad H.T. Wagh M.S. High prevalence of musculoskeletal symptoms and injuries in third space endoscopists: an international multicenter survey.Endosc Int Open. 2020; 8: E1481-E1486Crossref PubMed Scopus (5) Google Scholar, 12Campbell 3rd, E.V. Muniraj T. Aslanian H.R. et al.Musculoskeletal pain symptoms and injuries among endoscopists who perform ERCP.Dig Dis Sci. 2021; 66: 56-62Crossref PubMed Scopus (5) Google Scholar, 13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar, 14Al-Rifaie A. Gariballa M. Ghodeif A. et al.Colonoscopy-related injury among colonoscopists: an international survey.Endosc Int Open. 2021; 9: E102-E109Crossref PubMed Scopus (4) Google Scholar,34Bhatt A. Thosani N. Patil P. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract].Gastrointest Endosc. 2021; 93: AB42-AB43Abstract Full Text Full Text PDF Google Scholar 1 study evaluated colorectal surgeons,4Liberman A.S. Shrier I. Gordon P.H. Injuries sustained by colorectal surgeons performing colonoscopy.Surg Endosc. 2005; 19: 1606-1609Crossref PubMed Scopus (60) Google Scholar and 2 studies evaluated GI trainees.17Austin K. Schoenberger H. Sesto M. et al.Musculoskeletal injuries are commonly reported among gastroenterology trainees: results of a national survey.Dig Dis Sci. 2019; 64: 1439-1447Crossref PubMed Scopus (22) Google Scholar,18Villa E. Attar B. Trick W. et al.Endoscopy-related musculoskeletal injuries in gastroenterology fellows.Endosc Int Open. 2019; 7: E808-E812Crossref PubMed Google Scholar Outcomes of interest were overall rate of ERI and most common sites for ERI. Our meta-analysis identified the overall rate of ERI to be 57.7% (95% confidence interval [CI], 48.8-66.1; I2 = 93%). The most common sites of ERI were hands and fingers, back, and neck. Pooled rates of ERIs based on our meta-analysis were 35.8% (95% CI, 18.1-58.6; I2 = 97%) for hands and fingers, 35.3% (95% CI, 24.3-48; I2 = 92%) for the back, 32.6% (95% CI, 21.3-46.3; I2 = 93%) for the upper back and neck, 29.2% (95% CI, 16.3-46.7; I2 = 98%) the thumb alone, and 26.1% (95% CI, 16.9-37.9; I2 = 97%) for the neck alone. Several predictors of ERI were elucidated and included gender of the endoscopist, procedure volume, and hand size. Finding 2: Female endoscopists are at higher risk of ERI compared with male endoscopists. Finding 2: Female endoscopists are at higher risk of ERI compared with male endoscopists. To address the relationship of gender and ERI, we performed a systematic review and identified 8 eligible studies that included 3355 gastroenterology respondents.1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,6Byun Y.H. Lee J.H. Park M.K. et al.Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea.World J Gastroenterol. 2008; 14: 4359-4364Crossref PubMed Scopus (40) Google Scholar,10Morais R. Vilas-Boas F. Pereira P. et al.Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.Endosc Int Open. 2020; 8: E470-E480Crossref PubMed Google Scholar,13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar,14Al-Rifaie A. Gariballa M. Ghodeif A. et al.Colonoscopy-related injury among colonoscopists: an international survey.Endosc Int Open. 2021; 9: E102-E109Crossref PubMed Scopus (4) Google Scholar,34Bhatt A. Thosani N. Patil P. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract].Gastrointest Endosc. 2021; 93: AB42-AB43Abstract Full Text Full Text PDF Google Scholar Two studies were specific to gastroenterology trainees,17Austin K. Schoenberger H. Sesto M. et al.Musculoskeletal injuries are commonly reported among gastroenterology trainees: results of a national survey.Dig Dis Sci. 2019; 64: 1439-1447Crossref PubMed Scopus (22) Google Scholar,18Villa E. Attar B. Trick W. et al.Endoscopy-related musculoskeletal injuries in gastroenterology fellows.Endosc Int Open. 2019; 7: E808-E812Crossref PubMed Google Scholar and the overall rate of ERI in female endoscopists was 62.4% (96% CI, 46.7-75.9) compared with 45.5% (95% CI, 28.1-64.0) in male endoscopists. On meta-analysis, female endoscopists had higher odds of developing ERIs (odds ratio, 1.79; 95% CI, 1.35-2.38; P < .01; I2 = 64%). Finding 3: Greater exposure to endoscopy procedures (time spent performing endoscopy and procedure volume) is associated with higher rates of ERIs. Finding 3: Greater exposure to endoscopy procedures (time spent performing endoscopy and procedure volume) is associated with higher rates of ERIs. Our systematic review identified 24 survey studies that assessed these exposure variables. Pawa et al13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar conducted a survey study of members of the American College of Gastroenterology with 1698 respondents. On multivariable analysis, the number of hours performing endoscopy per week (P = .009) and the number of years in practice (P = .022) were found to be independent predictors of ERI.13Pawa S. Banerjee P. Kothari S. et al.Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey.Am J Gastroenterol. 2021; 116: 530-538Crossref PubMed Scopus (20) Google Scholar Morais et al10Morais R. Vilas-Boas F. Pereira P. et al.Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.Endosc Int Open. 2020; 8: E470-E480Crossref PubMed Google Scholar surveyed 171 endoscopists in Europe and reported >15 years in practice (P = .03) as an independent risk factor of ERI. Ridtitid et al1Ridtitid W. Cote G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar surveyed 684 ASGE members and found that higher procedure volume (>20 endoscopies per week, P < .001), more endoscopy hours per week (>16 hours per week, P < .001), and higher total number of years performing endoscopy (P = .004), were associated with higher rates of ERI. Question 1: In those performing GI endoscopies, should ergonomics education be implemented to reduce the risk of ERI?Recommendation 1. The ASGE recommends ergonomics education to reduce the risk of ERI.(Strong recommendation, very low quality of evidence) Question 1: In those performing GI endoscopies, should ergonomics education be implemented to reduce the risk of ERI? Recommendation 1. The ASGE recommends ergonomics education to reduce the risk of ERI. (Strong recommendation, very low quality of evidence) For this question, we performed a systematic review and identified 6 studies for inclusion.35Khan R. Scaffidi M.A. Satchwell J. et al.Impact of a simulation-based ergonomics training curriculum on work-related musculoskeletal injury risk in colonoscopy.Gastrointest Endosc. 2020; 92: 1070-1080Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 36Markwell S.A. Garman K.S. Vance I.L. et al.Individualized ergonomic wellness approach for the practicing gastroenterologist (with video).Gastrointest Endosc. 2021; 94: 248-259Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 37Ali M.F. Samarasena J. Implementing ergonomics interventions in the endoscopy suite.Techn Gastrointest Endosc. 2019; 21: 159-161Abstract Full Text Full Text PDF Scopus (11) Google Scholar, 38Sussman M. Sendzischew-S