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Surgery Is Physically Demanding and Associated With Multisite Musculoskeletal Pain: A Cross-Sectional Study

Open AccessPublished:March 22, 2019DOI:https://doi.org/10.1016/j.jss.2019.02.048

      Abstract

      Background

      Performing surgery involves well-known risk factors for developing musculoskeletal pain. Multisite musculoskeletal pain has shown to have an even higher adverse impact on the individual. We examined prevalence and intensity of multisite musculoskeletal pain in surgeons and identified characteristics associated with two or more painful body sites.

      Materials and methods

      Information on sociodemographic, work experience, work demands, health status, physical capacity, and prevalence and intensity of musculoskeletal pain were collected from an internet-based questionnaire in 284 surgeons. Descriptive statistics were used to report prevalence and intensity of musculoskeletal pain. A logistic regression model was conducted to assess the characteristics associated with multisite musculoskeletal pain.

      Results

      Musculoskeletal pain was reported by 93% of the surgeons and 77% experienced multisite pain. The reported median pain intensities ranged from 2 to 4. Multisite musculoskeletal pain was significantly associated with being a female surgeon (OR: 3.4; 95% CI: 1.5-7.4), physical work demands (OR: 1.5 95% CI: 1.2-1.7), work ability (OR: 3.4; 95% CI: 1.6-7.0), and feeling a sense of heaviness in the head/headache (OR:4.8; 95% CI: 2.0-11.5). In addition, 21%-40% of the surgeons who experienced multisite pain reported that pain influenced their work, leisure time, and sleep negatively.

      Conclusions

      The observed high prevalence of multisite musculoskeletal pain and high pain intensities adds new knowledge to the emerging literature on surgeons' health. In addition, several characteristics, for example, work ability, were significantly associated with multiple pain sites. This is concerning as pain could ultimately shorten a surgeon's career. Therefore, it is pertinent to develop preventive and rehabilitating strategies.

      Keywords

      Introduction

      Surgeons have long workdays and have a physically demanding job. They are exposed to cumulative awkward postures, repetitive motions, and forceful exertions during the performance of surgery.
      • McDonald M.E.
      • Ramirez P.T.
      • Munsell M.F.
      • et al.
      Physician pain and discomfort during minimally invasive gynecologic cancer surgery.
      • Franasiak J.
      • Ko E.M.
      • Kidd J.
      • et al.
      Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
      • Arora S.
      • Sevdalis N.
      • Nestel D.
      • et al.
      The impact of stress on surgical performance: a systematic review of the literature.
      These exposures lead to muscular strain and the development of musculoskeletal pain.
      • Ribeiro D.C.
      • Aldabe D.
      • Abbott J.H.
      • Sole G.
      • Milosavljevic S.
      Dose-response relationship between work-related cumulative postural exposure and low back pain: a systematic review.
      • Mayer J.
      • Kraus T.
      • Ochsmann E.
      Longitudinal evidence for the association between work-related physical exposures and neck and/or shoulder complaints: a systematic review.
      • Matern U.
      Ergonomic deficiencies in the operating room: examples from minimally invasive surgery.
      Moreover, the operating room is a complex environment where the patient's safety is first priority. Surgeons adopt operative positions based on the patient-specific situation, assisting personnel, and/or personal preferences as opposed to ergonomically guided principles and their own comfort.
      • Cavanagh J.
      • Brake M.
      • Kearns D.
      • Hong P.
      Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members.
      • Bartnicka J.
      Knowledge-based ergonomic assessment of working conditions in surgical ward - a case study.
      Musculoskeletal pain accounts for approximately 40% of all occupational diseases in Europe.
      • Schneider E.
      • Irastorza X.
      OSH in Figures: Work-Related Musculoskeletal Disorders in The EU: Facts and Figures Luxembourg.
      It is considered to be a growing problem and is associated with decreased work ability and increased sickness absence as well as economic societal consequences.
      • Schneider E.
      • Irastorza X.
      OSH in Figures: Work-Related Musculoskeletal Disorders in The EU: Facts and Figures Luxembourg.
      • McDonald M.
      • DiBonaventura M.
      • Ullman S.
      Musculoskeletal pain in the workforce: the effects of back, arthritis, and fibromyalgia pain on quality of life and work productivity.
      • Cancelliere C.
      • Cassidy J.D.
      • Ammendolia C.
      • Cote P.
      Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature.
      A recent study demonstrated that health care professionals who reported multisite musculoskeletal pain were 2.4 times more likely to report a low work ability compared with those health care professionals who did not report multisite musculoskeletal pain.
      • Phongamwong C.
      • Deema H.
      The impact of multi-site musculoskeletal pain on work ability among health care providers.
      Prior studies have found a comparatively high prevalence of musculoskeletal pain reported by surgeons (73% to 88%).
      • Franasiak J.
      • Ko E.M.
      • Kidd J.
      • et al.
      Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
      • Sari V.
      • Nieboer T.E.
      • Vierhout M.E.
      • Stegeman D.F.
      • Kluivers K.B.
      The operation room as a hostile environment for surgeons: physical complaints during and after laparoscopy. Minimally invasive therapy & allied technologies.
      • GPY S.
      • Ho P.
      • Ting A.C.W.
      • et al.
      Work-related musculoskeletal symptoms in surgeons.
      • Park A.
      • Lee G.
      • Seagull F.J.
      • Meenaghan N.
      • Dexter D.
      Patients benefit while surgeons suffer: an impending epidemic.
      However, no study has investigated the presence of multisite pain and whether specific characteristics are significantly associated with reporting multisite musculoskeletal pain. This is important given that musculoskeletal pain has been shown to influence a surgeon's dexterity and quality of life.
      • Park A.
      • Lee G.
      • Seagull F.J.
      • Meenaghan N.
      • Dexter D.
      Patients benefit while surgeons suffer: an impending epidemic.
      • Huysmans M.A.
      • Hoozemans M.J.
      • van der Beek A.J.
      • de Looze M.P.
      • van Dieen J.H.
      Position sense acuity of the upper extremity and tracking performance in subjects with non-specific neck and upper extremity pain and healthy controls.
      • Soueid A.
      • Oudit D.
      • Thiagarajah S.
      • Laitung G.
      The pain of surgery: pain experienced by surgeons while operating.
      • Ruitenburg M.M.
      • Frings-Dresen M.H.
      • Sluiter J.K.
      Physical job demands and related health complaints among surgeons.
      Multisite pain, with all things being equal, may have a greater adverse effect on surgeon health.
      The present study investigated musculoskeletal pain among surgeons working in the fields of pelvic surgery (urology, colorectal surgery, and gynecology). The objectives were to quantify the prevalence and the intensity of musculoskeletal pain reported by surgeons within these specialties and further, to identify surgeon characteristics associated with reporting two or more painful body sites.

      Materials and methods

      This was a cross-sectional internet-based survey of surgeons who were practicing in Denmark and registered with the Danish Medical Association. We selected surgeons within the specialties of urology, abdominal surgery, and gynecology as these three specializations entail similar physical work characteristics and work demands.

      Survey

      A link to the survey was sent by email to all potential participants. It consisted of validated questionnaires as well as ad hoc questions specifically developed for this study. The survey package was pilot tested by three surgeons and adapted accordingly. The survey collected information about the surgeon's sociodemographic, work experience, work demands, current health status, levels of physical capacity, and presence and intensity of musculoskeletal pain.

      Musculoskeletal pain

      Musculoskeletal pain in the neck, shoulders, elbows, hands, upper back, and lower back was measured using the validated Nordic Musculoskeletal Questionnaire.
      • Kuorinka I.
      • Jonsson B.
      • Kilbom A.
      • et al.
      Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms.
      For each site, the surgeon was asked how many days during the past 3 mo they experienced pain using the response categories of: 1) 0 d, 2) 1-7 d, 3) 8-30 d, 4) more than 30 d, and 5) every day. In addition, if pain was present for one or more days, the surgeon rated his or her pain intensity for each site on an 11-point numerical rating scale, ranging from 0 (no pain) to 10 (worst possible pain) during the past 3 mo and during the past 7 d. Surgeons were also asked if their musculoskeletal pain impacted negatively on their work, leisure time activities, or sleep.

      Health status

      Current health status was measured by a question from the validated 36-Item Short Form Health Survey, as well as questions on health complaints within the past month, and the use of medication within the previous 3 mo. The surgeon's general health was assessed by the question, “How do you perceive your overall health?” with the response categories of: 1) poor, 2) less well, 3) well, 4) very well, and 5) excellent.
      • Ware Jr., J.E.
      • Gandek B.
      Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project.
      Because of small cell sizes, we collapsed the five categorizes to 1) poor/less well/well, 2) very well, and 3) excellent. Items on health complaints dealt with feelings of heaviness in the head/headaches, concentration problems, and sleep problems and were phrased: “During the past month, have you been bothered by [complaint]?” Each complaint was rated on a 5-point ordinal scale of: 1) never, 2) rarely, 3) sometimes, 4) often, and 5) very often. Because of small cell sizes, categories were dichotomized to 1) never or rarely, and 2) sometimes, often or very often. For medication usage (i.e., painkillers, sedatives, and sleeping pills), the surgeon was asked, “During the past 3 mo, have you used [medication]?” with the response categories of: 1) rarely or never, 2) one to several times a month, 3) one to several times a week, and 4) daily. For ease of interpretation and small cell sizes, the response categorizes were dichotomized to 1) never or rarely and 2) one to several times a mo/wk/daily.

      Work experience

      Information about the surgeon's length of time in performing surgery, average total working hours per week (clinical and surgical performance), and the number of surgical procedures performed during the past year using open surgery, conventional laparoscopy, and robotic-assisted laparoscopic surgery was collected. For each surgical modality, the number of performed surgical procedures was collapsed into tertiles. The number of surgeons who had not performed the relevant modality was also assessed.

      Work demands

      Work demands experienced by the surgeon were assessed by validated questions about their physical work demands, work ability, and work performance. Physical work demands were measured using the question: “How physically demanding do you perceive your current work?” and rated on a 10-point numerical rating scale, ranging from “1” (not demanding) to “10” (maximal demanding).
      • Borg E.
      • Kaijser L.
      A comparison between three rating scales for perceived exertion and two different work tests.
      Work ability was measured using one item from the work ability index questionnaire
      • Ahlstrom L.
      • Grimby-Ekman A.
      • Hagberg M.
      • Dellve L.
      The work ability index and single-item question: associations with sick leave, symptoms, and health--a prospective study of women on long-term sick leave.
      : “Imagine that your work ability is worth 10 points when it is the best. How many points would you give your current work ability?” The rating went from “0” (unable to work) to “10” (best work ability). Work performance was assessed by the item: “How do you perceive your overall productivity during the past 4 wk?” This item was rated on an 11-point numerical rating scale with “0” representing “the worst anyone could do” and “10” representing “the very best that top workers in a job like mine could do”.
      • Pronk N.P.
      • Martinson B.
      • Kessler R.C.
      • et al.
      The association between work performance and physical activity, cardiorespiratory fitness, and obesity.
      Because of a right-skewed distribution, work ability and work performance were dichotomized by the medians: Very best
      • McDonald M.
      • DiBonaventura M.
      • Ullman S.
      Musculoskeletal pain in the workforce: the effects of back, arthritis, and fibromyalgia pain on quality of life and work productivity.
      versus everything else (0-9).

      Physical capacity and levels of physical activity

      The surgeon was asked to compare his or her level of cardiorespiratory fitness, muscle strength, and balance with people of the same age and gender using a 1 to 10 numerical rating scale. The value of “5” on the scale indicated that the surgeon felt their level of physical capacity was equal to their peer age and gender group. A score below or above five, implied a lower or a higher physical capacity, respectively, than their peers.
      • Stroyer J.
      • Essendrop M.
      • Jensen L.D.
      • et al.
      Validity and reliability of self-assessed physical fitness using visual analogue scales.
      Physical capacity was dichotomized into same or below average
      • McDonald M.E.
      • Ramirez P.T.
      • Munsell M.F.
      • et al.
      Physician pain and discomfort during minimally invasive gynecologic cancer surgery.
      • Franasiak J.
      • Ko E.M.
      • Kidd J.
      • et al.
      Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
      • Arora S.
      • Sevdalis N.
      • Nestel D.
      • et al.
      The impact of stress on surgical performance: a systematic review of the literature.
      • Ribeiro D.C.
      • Aldabe D.
      • Abbott J.H.
      • Sole G.
      • Milosavljevic S.
      Dose-response relationship between work-related cumulative postural exposure and low back pain: a systematic review.
      • Mayer J.
      • Kraus T.
      • Ochsmann E.
      Longitudinal evidence for the association between work-related physical exposures and neck and/or shoulder complaints: a systematic review.
      and above average.
      • Matern U.
      Ergonomic deficiencies in the operating room: examples from minimally invasive surgery.
      • Cavanagh J.
      • Brake M.
      • Kearns D.
      • Hong P.
      Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members.
      • Bartnicka J.
      Knowledge-based ergonomic assessment of working conditions in surgical ward - a case study.
      • Schneider E.
      • Irastorza X.
      OSH in Figures: Work-Related Musculoskeletal Disorders in The EU: Facts and Figures Luxembourg.
      • McDonald M.
      • DiBonaventura M.
      • Ullman S.
      Musculoskeletal pain in the workforce: the effects of back, arthritis, and fibromyalgia pain on quality of life and work productivity.
      As well, the surgeon was asked to rate their level of light, moderate, and vigorous physical activity during leisure time. It was measured using the question “How much time have you spent, on average, on the following activities the past year? Also include transportation to and from work and other activities”. Possible answers were within three activity categories of light intensity, moderate intensity, and vigorous intensity: less than 2 h per wk, 2-4 h per wk, more than 4 h per wk, or no such activity. The latter and less than 2 h per week were collapsed in the analysis.

      Sociodemographics

      The sociodemographic information collected was gender, age, height, weight, and dominant hand. Body mass index (BMI) was calculated using the self-reported measures of height and weight and was dichotomized into normal weight (BMI ≤ 25 kg/m2) and overweight (> 25 kg/m2).

      Survey administration

      The Danish Medical Association e-mailed an invitation to participate in the study and a link to the survey to 822 surgeons in February 2015. A reminder was e-mailed after 3 wk requesting those who did not reply to complete the survey. Data collection ended the 10th of March 2015. The survey could be completed at any time, and questions that were not completed were treated as missing data. SurveyXact was used as the platform for survey construction and on-line administration.
      After receiving the completed survey, we excluded: 1) surgeons who had not performed surgeries within the past 12 mo, 2) surgeons who worked less than 25 h per wk, and 3) surgeons who had not completed the questions about musculoskeletal pain. These exclusion criteria were chosen to ensure inclusion of surgeons with a current high surgical volume.

      Statistical analysis

      Data were analyzed using Stata 15.1. Descriptive statistics were used to report prevalence and intensity of musculoskeletal pain for each body site for the whole group. Univariate analyses were applied to compare surgeons’ characteristics in strata of painful body sites (0-1 painful body sites versus two or more painful body sites). A backward stepwise logistic regression model was conducted to assess the characteristics associated with two or more painful body sites. We set a P-value to remove of 0.10. Variance inflation factors were calculated to examine the multicollinearity of the final model. The overall fit of the model was tested by calculating the hat and hat squared and the Hosmer Lemeshow test. Finally, the standardized residuals were plotted against the predicted values and visually examined to see if they were similar to each other. A P-value ≤ 0.05 was regarded as statistically significant.

      Results

      In total, 373 surgeons (60% males, 40% females) completed the survey, corresponding to a response rate of 46%. Subsequently, 89 surgeons were excluded from the analysis because they either did not respond to the questions regarding musculoskeletal pain, reported they had not performed any surgeries the past year, and/or worked less than 25 h per wk. Thus, a total of 284 were included in the final analysis. Surgeons who did not meet the inclusion criteria did not differ with regard to sex distribution, age, or BMI compared with surgeons who were included in the analysis.
      The surgeons were on average 57 y old, 38% were females, and the majority (90%) were right-handed (Table 1). For type of specialty, 43% of the surgeons worked within gynecological surgery, 46% within colorectal surgery, whereas 12% was specialized within urological surgery (Table 2). Almost 70% of the surgeons were engaged in physical activity of light intensity for two or more hours per week. For moderate intensity, the proportion of surgeons who were engaged in physical activity decreased to 54% and for vigorous intensity only 13% of the surgeons were engaged in physical activity for two or more hours per week. More than 60% of the surgeons reported their current health to be very well/excellent, and the majority of the surgeons rated their physical capacity higher than their peers (Table 3). More than one fifth of the surgeons reported using painkillers several times a week, and 40% of the surgeons reported sleeping problems sometimes or often.
      Table 1Sociodemographic characteristics of all surgeons and for groups stratified by number of painful body sites.
      ParametersAll (n = 284)0-1 painful body sites≥2 painful body sites
      n% or mean (95% CI
      The 95% confidence interval around either the proportion or the mean.
      )
      n% or mean (95% CI
      The 95% confidence interval around either the proportion or the mean.
      )
      n% or mean (95% CI
      The 95% confidence interval around either the proportion or the mean.
      )
      Female (%)10938.4 (32.9-44.2)1218.2 (10.6-29.5)9744.5 (38.0-51.2)
      Age (y) (Mean)28457.1 (56.2-57.9)6659.6 (57.6-61.6)21856.3 (55.3-57.3)
      Height (cm) (mean)284176.7 (175.8-177.7)66178.5 (176.6-180.4)218176.2 (175.1-177.4)
      BMI >25 kg/m2 (%)11239.4 (33.9-45.3)2943.9 (32.4-56.2)8338.1 (31.8-44.7)
      The 95% confidence interval around either the proportion or the mean.
      Table 2Work characteristics of all surgeons and for groups stratified by number of painful body sites.
      ParametersAll (n = 284)0-1 painful body sites≥2 painful body sites
      n% (95% CI
      The 95% confidence interval around the proportion.
      ) or median (IQ
      The 25th and the 75th percentiles.
      )
      n% (95% CI
      The 95% confidence interval around the proportion.
      ) or median (IQ
      The 25th and the 75th percentiles.
      )
      n% (95% CI
      The 95% confidence interval around the proportion.
      ) or median (IQ
      The 25th and the 75th percentiles.
      )
      Weekly work hours >45 h (%)9834.5 (29.2-40.3)2639.4 (28.3-51.7)7233.0 (27.1-39.6)
      Type of specialty (%)
       Gynecology12142.6 (36.4-48.5)2131.8 (21.6-44.1)10045.9 (39.3-52.7)
       Gastrointestinal surgery13045.8 (40.0-51.6)3857.6 (45.3-69.0)9242.2 (35.8-48.9)
       Urological surgery3311.6 (8.4-15.9)710.6 (5.1-20.8)2611.9 (8.2-17.0)
      Years practicing MIS (%)
       0-5 y5118.0 (13.9-22.9)812.1 (6.1-22.6)4319.7 (14.9-25.6)
       6-10 y6322.2 (17.7-27.4)1725.8 (16.6-37.7)4621.1 (16.2-27.1)
       11-15 y6623.2 (18.7-28.5)1319.7 (11.7-31.2)5324.3 (19.0-30.5)
       16-20 y4816.9 (13.0-21.7)1218.2 (10.6-29.5)3616.5 (12.1-22.1)
       >20 y5619.7 (15.5-24.8)1624.2 (15.3-36.1)4018.3 (13.7-24.1)
      Surgeries yearly—open surgery (median)27560 (25-120)6570 (24-150)21050 (25-120)
      Surgeries yearly—LAP (median)21658 (25-120)5060 (20-144)16650 (25-120)
      Surgeries yearly—RALS (median)5047 (24-70)1245 (25-70)3847 (24-70)
      Surgeries yearly—total (median)284140 (72-212)66150 (70-220)218134 (72-212)
      Surgeries yearly—open surgery (%)
       0 surgeries93.2 (1.7-6.0)11.5 (0.2-10.1)83.7 (1.8-7.2)
       1-40 surgeries9633.8 (28.5-39.5)1725.8 (16.6-37.7)7936.2 (30.1-42.9)
       41-100 surgeries9934.9 (29.5-40.6)2740.9 (29.6-53.2)7233.0 (27.1-39.6)
       100-2500 surgeries8028.2 (23.2-33.7)2131.8 (21.5-44.1)5927.1 (21.5-33.4)
      Surgeries yearly—LAP (%)
       0 surgeries6823.9 (19.3-29.3)1624.2 (15.3-36.1)5223.9 (18.6-30.0)
       1-36 surgeries8529.9 (24.9-35.5)1928.8 (19.1-40.9)6630.3 (24.5-36.7)
       37-100 surgeries6823.9 (19.3-29.3)1522.7 (14.1-34.5)5324.3 (19.0-30.5)
       101-720 surgeries6322.1 (17.7-27.4)1624.2 (15.3-36.1)4721.6 (16.5-27.6)
      Surgeries yearly—RALS (%)
       0 surgeries23482.4 (77.5-86.4)5481.8 (70.5-89.4)18082.5 (76.9-87.1)
       1-25 surgeries207.0 (4.6-10.7)57.5 (3.2-17.1)156.9 (4.2-11.1)
       30-50 surgeries144.9 (2.9-8.2)34.5 (1.5-13.3)115.0 (2.8-8.9)
       60-200 surgeries165.6 (3.5-9.0)46.1 (2.3-15.2)125.5 (3.1-9.5)
      LAP = conventional laparoscopy; MIS = minimally invasive surgery; RALS = robotic-assisted laparoscopic surgery.
      The 95% confidence interval around the proportion.
      The 25th and the 75th percentiles.
      Table 3Work demands and health characteristics of all surgeons and for groups stratified by number of painful body sites.
      ParametersAll (n = 284)0-1 painful body sites≥2 painful body sites
      n% or mean (95% CI
      The 95% confidence interval around either the proportion or the mean.
      )
      n% or mean (95% CI
      The 95% confidence interval around either the proportion or the mean.
      )
      n% or mean (95% CI)
      Physical work demands (1-10) (mean)2844.9 (4.6-5.1)663.7 (3.2-4.2)2185.2 (5.0-5.4)
      Work ability—score 10 (%)
      n = 278.
      13548.6 (42.7-54.5)4671.9 (59.5-81.6)8941.6 (35.1-48.4)
      Work performance—score 10 (%)
      n = 278.
      11340.6 (35.0-46.6)3656.3 (43.8-67.9)7736.0 (29.8-42.7)
      Current health (%)
       Less well/well10536.8 (31.5-42.8)1827.3 (17.8-39.3)8739.9 (33.6-46.6)
       Very well13346.8 (41.1-52.7)3146.9 (35.2-59.1)10246.8 (40.2-53.5)
       Excellent4616.2 (12.3-21.0)1725.8 (16.6-37.7)2913.3 (9.4-18.5)
      Heaviness/headache —Never/rarely (%)16758.8 (52.9-64.4)5786.4 (75.7-92.8)11050.5 (43.8-57.1)
      Concentration problems—never/rarely (%)22278.2 (73.0-82.6)5887.9 (77.4-93.9)16475.2 (69.0-80.5)
      Sleep problems (%)
       Rarely or never16859.2 (53.3-64.8)4669.7 (57.5-79.6)12256.0 (49.3-62.5)
       Sometimes7927.8 (22.9-33.3)1725.6 (16.6-37.7)6228.4 (22.8-34.8)
       Often3713.0 (9.6-17.5)34.5 (1.5-13.3)3415.6 (11.3-21.1)
      Use of painkillers (%)
       Rarely or never10737.7 (32.2-43.5)4060.6 (48.3-71.7)6730.7 (24.9-37.2)
       One to several times a month11440.1 (34.6-46.0)1624.2 (15.3-36.1)9845.0 (38.4-51.7)
       One to several times a week/daily6322.2 (17.7-27.4)1015.2 (8.3-26.1)5324.3 (19.0-30.5)
      Use of sedatives—Never/rarely (%)26794.0 (90.6-96.3)6395.5 (86.7-98.5)20493.6 (89.4-96.2)
      Use of sleeping pills—never/rarely (%)25790.5 (86.5-93.4)6293.9 (84.8-97.7)19589.4 (84.6-92.9)
      Physical activity—light intensity
       <2 h (%)8330.1 (24.9-35.8)2234.4 (23.7-46.9)6128.8 (23.0-35.3)
       2-4 h (%)10136.6 (31.1-42.5)2335.9 (25.1-48.5)7836.8 (30.5-43.5)
       >4 h (%)9233.3 (28.0-39.1)1929.7 (19.7-42.1)7334.4 (28.3-41.1)
      Physical activity—moderate intensity
       <2 h (%)12645.7 (39.8-52.0)3250.0 (37.8-62.2)9444.3 (37.7-51.1)
       2-4 h (%)11441.3 (35.6-47.2)2437.5 (26.4-50.0)9042.5 (35.9-49.2)
       >4 h (%)3613.0 (9.5-17.6)812.5 (6.3-23.2)2813.2 (9.3-18.5)
      Physical activity—vigorous intensity
       <2 h (%)24087.0 (82.4-90.5)6093.8 (84.3-97.7)18084.9 (79.4-89.1)
       2-4 h (%)259.0 (6.2-13.1)34.7 (1.5-13.7)2210.4 (6.9-15.3)
       >4 h (%)114.0 (2.2-7.1)11.6 (0.2-10.5)104.7 (2.5-8.6)
      Cardiorespiratory fitness—Above (%)
      n = 278.
      18767.5 (61.7-72.8)4062.5 (50.0-73.6)14769.0 (62.4-74.9)
      Strength—above (%)
      n = 278.
      19971.8 (66.2-76.6)4570.3 (57.9-80.3)15472.3 (65.9-77.9)
      Balance—above (%)
      n = 278.
      20975.5 (70.0-80.2)5179.7 (67.9-87.9)15874.2 (67.8-79.6)
      The 95% confidence interval around either the proportion or the mean.
      n = 278.
      Multisite musculoskeletal pain was reported by 218 surgeons (77%). Thirty-seven surgeons (13%) reported musculoskeletal pain in one body site, and 10% of the surgeons reported no pain. The neck (63%) and lower back (60%) were the most prevalent painful body sites (Fig. 1). A fourth of the surgeons who experienced pain in the neck and lower back reported feeling pain for more than 30 d within the past 3 mo. Pain when performing surgery was reported in 56%, 65%, and 28% of the surgeons performing open surgery, conventional laparoscopy, and robotic-assisted laparoscopic surgery, respectively. Lower back was reported to be the most prevalent painful body site (34%) in open surgery, the shoulders were the most prevalent painful body sites (30%) in conventional laparoscopy, and in robotic-assisted laparoscopic surgery the neck was reported to be the most prevalent painful body site (23%). Conventional laparoscopy was reported by 40% of the surgeons to be the surgical modality most painful to perform, followed by open surgery (33%). Almost all surgeons (91%) reported that pain did not influence the choice of surgical modality. More than half of the surgeons (55%) reported having taken action to reduce their pain. Initiatives related to ergonomics (57%), for example, changing table height, placement of screens etc. physical exercise training (30%), for example, strength training or running, performing microbreaks during surgery (6%), or others (7%), for example, reduced number of performed operations or taking analgesic before surgery.
      Figure thumbnail gr1
      Fig. 1Prevalence and intensity of musculoskeletal pain. Prevalence of pain: Proportion of 284 surgeons. 3 mt: 3 mo intensity; 7d: 7 d intensity. Data shown as median (25th and 75th percentiles). (Color version of figure is available online.)
      Almost half (47%) of the surgeons experiencing multisite musculoskeletal pain reported four or more painful body sites. When collapsing right and left side for hands, elbows, and shoulders, a total of 42 multisite pain combinations were evident. The six most common pain combinations are shown in Fig. 2. The most prevalent combination of pain was pain in the neck, shoulders, upper back, and lower back (Fig. 2A). In surgeons reporting two or more painful body sites, pain influenced negatively on work, leisure time activities, and sleep by 21%, 40%, and 27%, respectively. For surgeons reporting one painful body site, these percentages were 8%, 11%, and 3%, respectively.
      Figure thumbnail gr2
      Fig. 2Six most common combinations of multisite musculoskeletal pain. (Color version of figure is available online.)
      In the final logistic regression model, reporting two or more painful body sites was significantly associated with being female, physical work demands, work ability, and feeling a sense of heaviness in the head/headache (Table 4). Female surgeons were 3.4 (95% CI: 1.5-7.4) times as likely to report two or more painful body sites compared to male surgeons. A one-unit increase on the scale of physical work demands was associated with odds of 1.5 (95% CI: 1.2-1.7) of reporting two or more painful body sites. Surgeons who reported 0-9 in work ability were 3.4 (95% CI: 1.6-7.0) times more likely to report two or more painful body sites compared to those surgeons who reported 10 (very best) in work ability. Surgeons who reported that they sometimes or often felt a sense of heaviness in the head/headache during the past month were 4.8 (95% CI: 2.0-11.5) times more likely to report two or more painful body sites compared to those surgeons who never or rarely reported feeling a sense of heaviness in the head/headache.
      Table 4Final regression model of surgeons’ characteristics associated with multisite pain.
      ParametersOR95% CIP-value
      Female3.41.5 - 7.40.002
      P ≤ 0.05.
      Physical work demands1.51.2 - 1.7<0.001
      P ≤ 0.05.
      Work ability (score 0-9)3.41.6 - 7.00.001
      P ≤ 0.05.
      Heaviness/headache (sometimes or often)4.82.0 - 11.50.001
      P ≤ 0.05.
      Painkillers (several times a mo/wk/daily)2.61.2 - 5.90.063
      Cardiorespiratory fitness (same/below)0.50.3 - 1.10.087
      OR = odds ratio; 95% CI = 95% confidence interval around the odds ratio.
      P ≤ 0.05.

      Discussion

      The major findings of this cross-sectional study were the high proportion of Danish surgeons (77%) who reported multisite musculoskeletal pain and a high pain intensity. Further, 21%-40% of the surgeons who experienced pain in more than one body site reported that pain influenced their work, leisure time activities, and sleep negatively. Our study also identified several characteristics (gender, physical work demands, work ability, and sense of heaviness in the head/headache) that were significantly associated with reporting multisite musculoskeletal pain.
      The neck and the lower back were identified as the most prevalent painful body sites, both individually and in combination with other body sites. This is consistent with previous findings among surgeons.
      • Franasiak J.
      • Ko E.M.
      • Kidd J.
      • et al.
      Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
      • Gutierrez-Diez M.C.
      • Benito-Gonzalez M.A.
      • Sancibrian R.
      • et al.
      A study of the prevalence of musculoskeletal disorders in surgeons performing minimally invasive surgery.
      • Alleblas C.C.
      • Formanoy M.A.
      • Konemann R.
      • et al.
      Ergonomics in gynecologists' daily practice: a nationwide survey in The Netherlands.
      • Vijendren A.
      • Yung M.
      • Sanchez J.
      • Duffield K.
      Occupational musculoskeletal pain amongst ENT surgeons - are we looking at the tip of an iceberg?.
      • Adams S.R.
      • Hacker M.R.
      • McKinney J.L.
      • Elkadry E.A.
      • Rosenblatt P.L.
      Musculoskeletal pain in gynecologic surgeons.
      Prolonged repetitive movements, limited workspace, uncomfortable and exhausting postures, and high patient BMI have been identified as the most prominent factors related to bodily discomfort.
      • GPY S.
      • Ho P.
      • Ting A.C.W.
      • et al.
      Work-related musculoskeletal symptoms in surgeons.
      • Ruitenburg M.M.
      • Frings-Dresen M.H.
      • Sluiter J.K.
      Physical job demands and related health complaints among surgeons.
      • Alleblas C.C.
      • Formanoy M.A.
      • Konemann R.
      • et al.
      Ergonomics in gynecologists' daily practice: a nationwide survey in The Netherlands.
      This is supported by our result showing that a one-unit increase in physical work demands, on a scale from one to ten, was associated with a 50% increased risk of reporting pain in multiple body sites. The fact that 77% of the surgeons reported two or more painful body sites is alarming. Multisite musculoskeletal pain has been shown to reduce work ability and may potentially shorten the career as an active surgeon and increase the risk for long-term sickness absence.
      • Phongamwong C.
      • Deema H.
      The impact of multi-site musculoskeletal pain on work ability among health care providers.
      • Sell L.
      • Bultmann U.
      • Rugulies R.
      • et al.
      Predicting long-term sickness absence and early retirement pension from self-reported work ability.
      • Miranda H.
      • Kaila-Kangas L.
      • Heliovaara M.
      • et al.
      Musculoskeletal pain at multiple sites and its effects on work ability in a general working population.
      • Roelen C.A.
      • Koopmans P.C.
      • de Graaf J.H.
      • van Zandbergen J.W.
      • Groothoff J.W.
      Job demands, health perception and sickness absence.
      • Davis W.T.
      • Fletcher S.A.
      • Guillamondegui O.D.
      Musculoskeletal occupational injury among surgeons: effects for patients, providers, and institutions.
      Recently, a study revealed that 23% of surgeons with musculoskeletal pain had taken time off work due to pain and that 44% had undergone physiotherapy, osteopathy, or chiropractic treatment.
      • Vijendren A.
      • Yung M.
      • Sanchez J.
      • Duffield K.
      Occupational musculoskeletal pain amongst ENT surgeons - are we looking at the tip of an iceberg?.
      Another study found that 38% of the respondents used medication and/or therapy to reduce their musculoskeletal pain and that 27% required work leave due to musculoskeletal pain.
      • Janki S.
      • Mulder E.
      • JNM I.J.
      Tran TCK Ergonomics in the operating room.
      In our study, 40% of the surgeons reported using painkillers several times a month and 22% reported a weekly/daily use. Although it is unknown to which extent the analgesic use was related to surgically induced pain, the high proportion of surgeons using weekly to daily painkillers and undergoing pain-relieving therapy is alarming from a societal perspective.
      The operating room is a complex work environment with intensive psychological and physiological challenges combined with a constant awareness of patient safety. Further, most surgeons are unaware of ergonomic principles in surgery
      • Cavanagh J.
      • Brake M.
      • Kearns D.
      • Hong P.
      Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members.
      • Wauben L.S.
      • Van Veelen M.A.
      • Gossot D.
      • Goossens R.H.
      Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of 284 surgeons.
      and do not pay attention to their own health during surgery.
      • Bartnicka J.
      Knowledge-based ergonomic assessment of working conditions in surgical ward - a case study.
      • Reyes D.A.G.
      • Tang B.
      • Cuschieri A.
      Minimal access surgery (MAS)-related surgeon morbidity syndromes.
      In a study by Park et al.,
      • Park A.
      • Lee G.
      • Seagull F.J.
      • Meenaghan N.
      • Dexter D.
      Patients benefit while surgeons suffer: an impending epidemic.
      40% of the surgeons reported that they disregard their physical complaints, and another study showed that 36% of the surgeons reported to work through pain, as they consider pain to be part of the job.
      • GPY S.
      • Ho P.
      • Ting A.C.W.
      • et al.
      Work-related musculoskeletal symptoms in surgeons.
      In addition, several studies have reported that performing surgery caused or worsened the surgeons' musculoskeletal pain.
      • Franasiak J.
      • Ko E.M.
      • Kidd J.
      • et al.
      Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
      • Cavanagh J.
      • Brake M.
      • Kearns D.
      • Hong P.
      Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members.
      • GPY S.
      • Ho P.
      • Ting A.C.W.
      • et al.
      Work-related musculoskeletal symptoms in surgeons.
      • Adams S.R.
      • Hacker M.R.
      • McKinney J.L.
      • Elkadry E.A.
      • Rosenblatt P.L.
      Musculoskeletal pain in gynecologic surgeons.
      and that it even affected their surgical performance.
      • Ruitenburg M.M.
      • Frings-Dresen M.H.
      • Sluiter J.K.
      Physical job demands and related health complaints among surgeons.
      • Adams S.R.
      • Hacker M.R.
      • McKinney J.L.
      • Elkadry E.A.
      • Rosenblatt P.L.
      Musculoskeletal pain in gynecologic surgeons.
      • Davis W.T.
      • Fletcher S.A.
      • Guillamondegui O.D.
      Musculoskeletal occupational injury among surgeons: effects for patients, providers, and institutions.
      The pain intensities reported by the surgeons in this study were high, even compared with other professions known to have a high prevalence of musculoskeletal pain.
      • Lange B.
      • Toft P.
      • Myburgh C.
      • Sjogaard G.
      Effect of targeted strength, endurance, and coordination exercise on neck and shoulder pain among fighter pilots: a randomized-controlled trial.
      • Zebis M.K.
      • Andersen L.L.
      • Pedersen M.T.
      • et al.
      Implementation of neck/shoulder exercises for pain relief among industrial workers: a randomized controlled trial.
      • Blangsted A.K.
      • Sogaard K.
      • Hansen E.A.
      • Hannerz H.
      • Sjogaard G.
      One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers.
      • Christensen J.R.
      • Faber A.
      • Ekner D.
      • et al.
      Diet, physical exercise and cognitive behavioral training as a combined workplace based intervention to reduce body weight and increase physical capacity in health care workers - a randomized controlled trial.
      • Gram B.
      • Holtermann A.
      • Bultmann U.
      • Sjogaard G.
      • Sogaard K.
      Does an exercise intervention improving aerobic capacity among construction workers also improve musculoskeletal pain, work ability, productivity, perceived physical exertion, and sick leave?: a randomized controlled trial.
      For most body sites, surgeons reported a pain intensity of three or more which has been used as a clinically relevant cutpoint defining a pain case in an occupationally active population.
      • Kaergaard A.
      • Andersen J.H.
      • Rasmussen K.
      • Mikkelsen S.
      Identification of neck-shoulder disorders in a 1 year follow-up study. Validation of a questionnaire-based method.
      The lack of surgeons’ ergonomic awareness in the operating room is likely to contribute to the observed high rate of bodily pain. Greater ergonomic awareness is essential for being able to alleviate musculoskeletal pain in surgeons.
      Gender has previously been recognized as an important factor for developing musculoskeletal pain with a more than two-fold increased risk for female surgeons compared with male surgeons.
      • McDonald M.E.
      • Ramirez P.T.
      • Munsell M.F.
      • et al.
      Physician pain and discomfort during minimally invasive gynecologic cancer surgery.
      • Adams S.R.
      • Hacker M.R.
      • McKinney J.L.
      • Elkadry E.A.
      • Rosenblatt P.L.
      Musculoskeletal pain in gynecologic surgeons.
      • Sutton E.
      • Irvin M.
      • Zeigler C.
      • Lee G.
      • Park A.
      The ergonomics of women in surgery.
      This increased risk could be due to a gender difference in perception of complaints or coping strategies in dealing with occupational stressors.
      • Cavanagh J.
      • Brake M.
      • Kearns D.
      • Hong P.
      Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members.
      Alternatively, female surgeons could have a higher relative exposure because of their ergonomic disadvantage in the operating room as they are generally shorter, have less upper body strength, and have to adjust to surgical instruments usually designed for the larger male hand.
      • McDonald M.E.
      • Ramirez P.T.
      • Munsell M.F.
      • et al.
      Physician pain and discomfort during minimally invasive gynecologic cancer surgery.
      • Sutton E.
      • Irvin M.
      • Zeigler C.
      • Lee G.
      • Park A.
      The ergonomics of women in surgery.
      • Berguer R.
      Surgical technology and the ergonomics of laparoscopic instruments.
      • Lux M.M.
      • Marshall M.
      • Erturk E.
      • Joseph J.V.
      Ergonomic evaluation and guidelines for use of the daVinci Robot system.
      With a likely increase in female surgeons in the future, these differences should be investigated more quantitatively. Robotic-assisted laparoscopic surgery may offer ergonomic advantages, but we were unable to explore this hypothesis in the present study, given too few surgeons who used this surgical modality.
      Studies have described a high level of ergonomic and mental stress among surgeons performing minimally invasive surgery compared to open procedures.
      • Berguer R.
      • Smith W.D.
      • Chung Y.H.
      Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery.
      • Plerhoples T.A.
      • Hernandez-Boussard T.
      • Wren S.M.
      The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery.
      • Cass G.K.S.
      • Vyas S.
      • Akande V.
      Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse.
      • GPY S.
      • Cheng S.W.K.
      • Poon J.T.C.
      • et al.
      Surgeons' static posture and movement repetitions in open and laparoscopic surgery.
      The surgeons in the present study reported open surgery as the most common procedure, but this is likely to change due to the rapid increase in minimally invasive surgery. Those surgeons who performed both techniques reported the laparoscopic approach to be the most painful procedure. Thus, the high prevalence and intensity of pain may become even higher with the increased use of minimally invasive surgery. A recent study using surface electromyography found robotic-assisted laparoscopic surgery to be less demanding compared with conventional laparoscopy.
      • Dalsgaard T.
      • Jensen M.D.
      • Hartwell D.
      • et al.
      Robotic surgery is less physically demanding than laparoscopic surgery.
      As the number of surgeons performing all three surgical procedures is too low in the present study, we were not able to evaluate the impact of robotic-assisted laparoscopic surgery on musculoskeletal pain.
      Initiatives to alleviate surgeons’ discomfort have been suggested, such as change of posture and microbreaks during surgery, reduction of time in the operating room, and a reduction in the overall caseload.
      • Franasiak J.
      • Ko E.M.
      • Kidd J.
      • et al.
      Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
      • GPY S.
      • Ho P.
      • Ting A.C.W.
      • et al.
      Work-related musculoskeletal symptoms in surgeons.
      • Adams S.R.
      • Hacker M.R.
      • McKinney J.L.
      • Elkadry E.A.
      • Rosenblatt P.L.
      Musculoskeletal pain in gynecologic surgeons.
      • Hallbeck M.S.
      • Lowndes B.R.
      • Bingener J.
      • et al.
      The impact of intraoperative microbreaks with exercises on surgeons: a multi-center cohort study.
      However, the latter two solutions may result in reduced productivity which could be critical with the increased demand for surgical services.
      • Williams Jr., T.E.
      • Ellison E.C.
      Population analysis predicts a future critical shortage of general surgeons.
      An initiative that has been successful in other professions is the implementation of physical exercise training.
      • Sjøgaard G.
      • Christensen J.R.
      • Justesen J.B.
      • et al.
      Exercise is more than medicine: the working age population’s well-being and productivity.
      Our results showed that the surgeons rated themselves above their peers in relation to their physical capacity. Likewise, the surgeons reported engaging in mainly light and moderate intensity physical activity. Surprisingly, no significant association was evident between level of physical capacity or physical activity and the presence of multisite pain. However, our data do not distinguish between the kinds of physical activity that were being performed. Strengthening the most exposed muscles during surgery may reduce the relative workload and thereby, has the potential to relieve musculoskeletal pain. A recent study demonstrated muscle strength, measured by a hand dynamometer, as a protective factor against musculoskeletal pain among surgeons.
      • Gutierrez-Diez M.C.
      • Benito-Gonzalez M.A.
      • Sancibrian R.
      • et al.
      A study of the prevalence of musculoskeletal disorders in surgeons performing minimally invasive surgery.
      Prior studies among other job sectors have successfully implemented physical exercise training during working hours.
      • Sjøgaard G.
      • Christensen J.R.
      • Justesen J.B.
      • et al.
      Exercise is more than medicine: the working age population’s well-being and productivity.
      Evidence demonstrates a large flexibility regarding training frequency and duration as long as the total training volume is accomplished. Even as little as 2 min of daily exercises for the neck and shoulders demonstrated reduced pain and increased muscle strength.
      • Andersen L.L.
      • Saervoll C.A.
      • Mortensen O.S.
      • et al.
      Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial.
      Factors shown to be important for the implementation of such initiatives are that they are initiated by the management and have a participatory approach.
      • Rivilis I.
      • Van Eerd D.
      • Cullen K.
      • et al.
      Effectiveness of participatory ergonomic interventions on health outcomes: a systematic review.
      Thus, the authors advocate that similar approaches are investigated among surgeons.
      This study presents several strengths. We have used validated questionnaires in combination with designated questions on work ability and productivity, which are areas of significant importance for the medical profession. In addition, we present data on both the prevalence and the intensity of pain which enables us to compare with other professions. The low response rate is the main limitation. This may have induced a selection bias with surgeons experiencing musculoskeletal pain being more likely to respond. However, the response rate was higher than average for this profession,
      • Alleblas C.C.
      • de Man A.M.
      • van den Haak L.
      • et al.
      Prevalence of musculoskeletal disorders among surgeons performing minimally invasive surgery: a systematic review.
      and if we recalculate the pain prevalence by imputing no pain for all of the surgeons who did not respond, the prevalence of pain (33%) would still be high. This is higher than European workers, who report a 24.7% prevalence of backache and a 23% prevalence of neck and shoulder pain.
      • Schneider E.
      • Irastorza X.
      OSH in Figures: Work-Related Musculoskeletal Disorders in The EU: Facts and Figures Luxembourg.
      In the present study, the mean age is comparatively high, 57 y. Unfortunately, we do not have any information about the age of nonresponders. Correspondingly, we do not know if and why our survey was more appealing to surgeons of higher age. The higher age of the participating surgeons in the present study may be due to specifically Danish societal factors such as high age at education start, long maternity leave for both females and males, etc. These factors that hinder a direct comparison to other nationalities. Another Danish study including gynecological surgeons reported a mean age of 52 y,
      • Dalsgaard T.
      • Jensen M.D.
      • Hartwell D.
      • et al.
      Robotic surgery is less physically demanding than laparoscopic surgery.
      whereas international studies reported a mean age of 44-47 y.
      • Alleblas C.C.
      • Formanoy M.A.
      • Konemann R.
      • et al.
      Ergonomics in gynecologists' daily practice: a nationwide survey in The Netherlands.
      • Adams S.R.
      • Hacker M.R.
      • McKinney J.L.
      • Elkadry E.A.
      • Rosenblatt P.L.
      Musculoskeletal pain in gynecologic surgeons.
      • Hallbeck M.S.
      • Lowndes B.R.
      • Bingener J.
      • et al.
      The impact of intraoperative microbreaks with exercises on surgeons: a multi-center cohort study.
      • Epstein S.
      • Sparer E.H.
      • Tran B.N.
      • et al.
      Prevalence of work-related musculoskeletal disorders among surgeons and interventionalists: a systematic review and meta-analysis.
      However, in our sample, we did not find any association between age and pain. We cannot preclude this is due to our sample size and the variation within our sample, and the literature shows conflicting results in this regard.
      • Alleblas C.C.
      • de Man A.M.
      • van den Haak L.
      • et al.
      Prevalence of musculoskeletal disorders among surgeons performing minimally invasive surgery: a systematic review.
      This may present an important question for future research.
      In conclusion, our findings of a high prevalence of multisite musculoskeletal pain and a high pain intensity add new knowledge to the emerging literature on musculoskeletal pain in surgeons. We identified several characteristics that were associated with multiple pain sites and, in particular, work ability may be of concern with regard to surgeons’ future surgical career. It seems pertinent to develop preventive and rehabilitating strategies.

      Acknowledgment

      Authors' contributions: T.D., K.S., P.T.J., and O.M. designed the study concept. T.D. and E.B. did the statistical analyses. All authors have made substantial contributions to the interpretation of data. All authors were involved in drafting the article, revising it critically for important intellectual content, and have given final approval of the version to be published.
      Funding was received from Odense University Hospital Frontline Research, Denmark Grant for T.D. and P.T.J.

      Disclosure

      The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

      Supplementary data

      References

        • McDonald M.E.
        • Ramirez P.T.
        • Munsell M.F.
        • et al.
        Physician pain and discomfort during minimally invasive gynecologic cancer surgery.
        Gynecol Oncol. 2014; 134: 243-247
        • Franasiak J.
        • Ko E.M.
        • Kidd J.
        • et al.
        Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery.
        Gynecol Oncol. 2012; 126: 437-442
        • Arora S.
        • Sevdalis N.
        • Nestel D.
        • et al.
        The impact of stress on surgical performance: a systematic review of the literature.
        Surgery. 2010; 147 (330.e1-330.e6): 318-330
        • Ribeiro D.C.
        • Aldabe D.
        • Abbott J.H.
        • Sole G.
        • Milosavljevic S.
        Dose-response relationship between work-related cumulative postural exposure and low back pain: a systematic review.
        Ann Occup Hyg. 2012; 56: 684-696
        • Mayer J.
        • Kraus T.
        • Ochsmann E.
        Longitudinal evidence for the association between work-related physical exposures and neck and/or shoulder complaints: a systematic review.
        Int Arch Occup Environ Health. 2012; 85: 587-603
        • Matern U.
        Ergonomic deficiencies in the operating room: examples from minimally invasive surgery.
        Work. 2009; 33: 165-168
        • Cavanagh J.
        • Brake M.
        • Kearns D.
        • Hong P.
        Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members.
        Am J Otolaryngol. 2012; 33: 441-446
        • Bartnicka J.
        Knowledge-based ergonomic assessment of working conditions in surgical ward - a case study.
        Saf Sci. 2015; 71: 178-188
        • Schneider E.
        • Irastorza X.
        OSH in Figures: Work-Related Musculoskeletal Disorders in The EU: Facts and Figures Luxembourg.
        European Agency for Safety and Health at Work, Luxembourg2010: 1-184
        • McDonald M.
        • DiBonaventura M.
        • Ullman S.
        Musculoskeletal pain in the workforce: the effects of back, arthritis, and fibromyalgia pain on quality of life and work productivity.
        J Occup Environ Med. 2011; 53: 765-770
        • Cancelliere C.
        • Cassidy J.D.
        • Ammendolia C.
        • Cote P.
        Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature.
        BMC Public Health. 2011; 11: 395
        • Phongamwong C.
        • Deema H.
        The impact of multi-site musculoskeletal pain on work ability among health care providers.
        J Occup Med Toxicol. 2015; 10: 21
        • Sari V.
        • Nieboer T.E.
        • Vierhout M.E.
        • Stegeman D.F.
        • Kluivers K.B.
        The operation room as a hostile environment for surgeons: physical complaints during and after laparoscopy. Minimally invasive therapy & allied technologies.
        MITAT. 2010; 19: 105-109
        • GPY S.
        • Ho P.
        • Ting A.C.W.
        • et al.
        Work-related musculoskeletal symptoms in surgeons.
        J Occup Rehabil. 2009; 19: 175-184
        • Park A.
        • Lee G.
        • Seagull F.J.
        • Meenaghan N.
        • Dexter D.
        Patients benefit while surgeons suffer: an impending epidemic.
        J Am Coll Surg. 2010; 210: 306-313
        • Huysmans M.A.
        • Hoozemans M.J.
        • van der Beek A.J.
        • de Looze M.P.
        • van Dieen J.H.
        Position sense acuity of the upper extremity and tracking performance in subjects with non-specific neck and upper extremity pain and healthy controls.
        J Rehabil Med. 2010; 42: 876-883
        • Soueid A.
        • Oudit D.
        • Thiagarajah S.
        • Laitung G.
        The pain of surgery: pain experienced by surgeons while operating.
        Int J Surg. 2010; 8: 118-120
        • Ruitenburg M.M.
        • Frings-Dresen M.H.
        • Sluiter J.K.
        Physical job demands and related health complaints among surgeons.
        Int Arch Occup Environ Health. 2013; 86: 271-279
        • Kuorinka I.
        • Jonsson B.
        • Kilbom A.
        • et al.
        Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms.
        Appl Ergon. 1987; 18: 233-237
        • Ware Jr., J.E.
        • Gandek B.
        Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project.
        J Clin Epidemiol. 1998; 51: 903-912
        • Borg E.
        • Kaijser L.
        A comparison between three rating scales for perceived exertion and two different work tests.
        Scand J Med Sci Sports. 2006; 16: 57-69
        • Ahlstrom L.
        • Grimby-Ekman A.
        • Hagberg M.
        • Dellve L.
        The work ability index and single-item question: associations with sick leave, symptoms, and health--a prospective study of women on long-term sick leave.
        Scand J Work Environ Health. 2010; 36: 404-412
        • Pronk N.P.
        • Martinson B.
        • Kessler R.C.
        • et al.
        The association between work performance and physical activity, cardiorespiratory fitness, and obesity.
        J Occup Environ Med. 2004; 46: 19-25
        • Stroyer J.
        • Essendrop M.
        • Jensen L.D.
        • et al.
        Validity and reliability of self-assessed physical fitness using visual analogue scales.
        Percept Mot Skills. 2007; 104: 519-533
        • Gutierrez-Diez M.C.
        • Benito-Gonzalez M.A.
        • Sancibrian R.
        • et al.
        A study of the prevalence of musculoskeletal disorders in surgeons performing minimally invasive surgery.
        Int J Occup Saf Ergon. 2017; 24: 1-7
        • Alleblas C.C.
        • Formanoy M.A.
        • Konemann R.
        • et al.
        Ergonomics in gynecologists' daily practice: a nationwide survey in The Netherlands.
        Work. 2016; 55: 841-848
        • Vijendren A.
        • Yung M.
        • Sanchez J.
        • Duffield K.
        Occupational musculoskeletal pain amongst ENT surgeons - are we looking at the tip of an iceberg?.
        J Laryngol Otol. 2016; 130: 490-496
        • Adams S.R.
        • Hacker M.R.
        • McKinney J.L.
        • Elkadry E.A.
        • Rosenblatt P.L.
        Musculoskeletal pain in gynecologic surgeons.
        J Minim Invasive Gynecol. 2013; 20: 656-660
        • Sell L.
        • Bultmann U.
        • Rugulies R.
        • et al.
        Predicting long-term sickness absence and early retirement pension from self-reported work ability.
        Int Arch Occup Environ Health. 2009; 82: 1133-1138
        • Miranda H.
        • Kaila-Kangas L.
        • Heliovaara M.
        • et al.
        Musculoskeletal pain at multiple sites and its effects on work ability in a general working population.
        Occup Environ Med. 2010; 67: 449-455
        • Roelen C.A.
        • Koopmans P.C.
        • de Graaf J.H.
        • van Zandbergen J.W.
        • Groothoff J.W.
        Job demands, health perception and sickness absence.
        Occup Med (Lond.). 2007; 57: 499-504
        • Davis W.T.
        • Fletcher S.A.
        • Guillamondegui O.D.
        Musculoskeletal occupational injury among surgeons: effects for patients, providers, and institutions.
        J Surg Res. 2014; 189: 207-212.e206
        • Janki S.
        • Mulder E.
        • JNM I.J.
        Tran TCK Ergonomics in the operating room.
        Surg Endosc. 2017; 31: 2457-2466
        • Wauben L.S.
        • Van Veelen M.A.
        • Gossot D.
        • Goossens R.H.
        Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of 284 surgeons.
        Surg Endosc. 2006; 20: 1268-1274
        • Reyes D.A.G.
        • Tang B.
        • Cuschieri A.
        Minimal access surgery (MAS)-related surgeon morbidity syndromes.
        Surg Endosc. 2006; 20: 1-13
        • Lange B.
        • Toft P.
        • Myburgh C.
        • Sjogaard G.
        Effect of targeted strength, endurance, and coordination exercise on neck and shoulder pain among fighter pilots: a randomized-controlled trial.
        Clin J Pain. 2013; 29: 50-59
        • Zebis M.K.
        • Andersen L.L.
        • Pedersen M.T.
        • et al.
        Implementation of neck/shoulder exercises for pain relief among industrial workers: a randomized controlled trial.
        BMC Musculoskelet Disord. 2011; 12: 205
        • Blangsted A.K.
        • Sogaard K.
        • Hansen E.A.
        • Hannerz H.
        • Sjogaard G.
        One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers.
        Scand J Work Environ Health. 2008; 34: 55-65
        • Christensen J.R.
        • Faber A.
        • Ekner D.
        • et al.
        Diet, physical exercise and cognitive behavioral training as a combined workplace based intervention to reduce body weight and increase physical capacity in health care workers - a randomized controlled trial.
        BMC Public Health. 2011; 11: 671
        • Gram B.
        • Holtermann A.
        • Bultmann U.
        • Sjogaard G.
        • Sogaard K.
        Does an exercise intervention improving aerobic capacity among construction workers also improve musculoskeletal pain, work ability, productivity, perceived physical exertion, and sick leave?: a randomized controlled trial.
        J Occup Environ Med. 2012; 54: 1520-1526
        • Kaergaard A.
        • Andersen J.H.
        • Rasmussen K.
        • Mikkelsen S.
        Identification of neck-shoulder disorders in a 1 year follow-up study. Validation of a questionnaire-based method.
        Pain. 2000; 86: 305-310
        • Sutton E.
        • Irvin M.
        • Zeigler C.
        • Lee G.
        • Park A.
        The ergonomics of women in surgery.
        Surg Endosc. 2014; 28: 1051-1055
        • Berguer R.
        Surgical technology and the ergonomics of laparoscopic instruments.
        Surg Endosc. 1998; 12: 458-462
        • Lux M.M.
        • Marshall M.
        • Erturk E.
        • Joseph J.V.
        Ergonomic evaluation and guidelines for use of the daVinci Robot system.
        J Endourol. 2010; 24: 371-375
        • Berguer R.
        • Smith W.D.
        • Chung Y.H.
        Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery.
        Surg Endosc. 2001; 15: 1204-1207
        • Plerhoples T.A.
        • Hernandez-Boussard T.
        • Wren S.M.
        The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery.
        J Robot Surg. 2012; 6: 65-72
        • Cass G.K.S.
        • Vyas S.
        • Akande V.
        Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse.
        J Obstet Gynaecol. 2014; 34: 74-78
        • GPY S.
        • Cheng S.W.K.
        • Poon J.T.C.
        • et al.
        Surgeons' static posture and movement repetitions in open and laparoscopic surgery.
        J Surg Res. 2012; 172: e19-e31
        • Dalsgaard T.
        • Jensen M.D.
        • Hartwell D.
        • et al.
        Robotic surgery is less physically demanding than laparoscopic surgery.
        Ann Surg. 2018; ([Epub ahead of print]. https://doi.org/10.1097/SLA.0000000000002845)
        • Hallbeck M.S.
        • Lowndes B.R.
        • Bingener J.
        • et al.
        The impact of intraoperative microbreaks with exercises on surgeons: a multi-center cohort study.
        Appl Ergon. 2017; 60: 334-341
        • Williams Jr., T.E.
        • Ellison E.C.
        Population analysis predicts a future critical shortage of general surgeons.
        Surgery. 2008; 144 (discussion 554-546): 548-554
        • Sjøgaard G.
        • Christensen J.R.
        • Justesen J.B.
        • et al.
        Exercise is more than medicine: the working age population’s well-being and productivity.
        J Sport Health Sci. 2016; 5: 159-165
        • Andersen L.L.
        • Saervoll C.A.
        • Mortensen O.S.
        • et al.
        Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial.
        Pain. 2011; 152: 440-446
        • Rivilis I.
        • Van Eerd D.
        • Cullen K.
        • et al.
        Effectiveness of participatory ergonomic interventions on health outcomes: a systematic review.
        Appl Ergon. 2008; 39: 342-358
        • Alleblas C.C.
        • de Man A.M.
        • van den Haak L.
        • et al.
        Prevalence of musculoskeletal disorders among surgeons performing minimally invasive surgery: a systematic review.
        Ann Surg. 2017; 266: 905-920
        • Epstein S.
        • Sparer E.H.
        • Tran B.N.
        • et al.
        Prevalence of work-related musculoskeletal disorders among surgeons and interventionalists: a systematic review and meta-analysis.
        JAMA Surg. 2018; 153: e174947