Interventions to Reduce Musculoskeletal Pain in Ophthalmologists: A Systematic Review

Abstract

Background: Musculoskeletal (MSK) discomfort is a significant occupational hazard for eye care professionals, including ophthalmologists, who report high rates of MSK discomfort. This systematic review investigated the impact of various interventions, such as regular exercise, posture-correcting aids, and surgical heads-up displays, on reducing MSK pain in the operating room. Methods: This review was reported following PRISMA guidelines and was prospectively registered in the PROSPERO database (CRD42024559189). A systematic literature search was conducted of Embase, MEDLINE, and Web of Science from inception to 2024. Included studies were categorized as exercise modifications, equipment modifications, or training aids. All MSK pain-related outcomes from any time point were extracted. Risk of bias was assessed using the Murad tool, the Cochrane risk-of-bias tool for randomized trials (RoB 2), and the Risk Of Bias In Non-Randomized Studies-of Interventions (ROBINS-I) tool. Results: The systematic search strategy identified 2276 studies, of which 53 qualified for full-text screening with 13 resultant studies including 712 eyecare specialists. Physical activity was found unanimously to reduce MSK pain, with favourable evidence for the utilization of posture-correcting aids. There was mixed—but mostly favourable—evidence for the use of surgical heads-up displays. Conclusions: Exercise modifications, such as yoga and regular exercise; equipment modification with heads-up displays during surgery; and training aids for posture correction were shown to be beneficial for MSK-related pain among ophthalmologists. Future studies should strive to improve the certainty of evidence on ergonomics-related interventions for ophthalmologists, which will better support practice and guideline development.

1. Introduction

Musculoskeletal (MSK) concerns pose a serious threat to the performance and career longevity of physicians [1]. While this issue is pertinent across all medical specialties, it is particularly relevant in ophthalmology, where practitioners report higher rates of MSK pain compared to non-surgical specialities [2]. Practicing ophthalmology poses significant risk factors for musculoskeletal (MSK) disorders. The repetitive movements and prolonged maintenance of awkward postures commonly observed during ophthalmic surgery and clinical procedures which rely on microscopes, surgical loupes, and laser-based devices are well-documented contributors to work-related MSK pain [3]. In Canada, 50% of ophthalmologists report experiencing occupational MSK pain, with most citing operating as a key etiology of their pain [4]. Similarly, surveys conducted in the United States have found that a majority of ophthalmologists experience occupational MSK pain, with one study notably observing that 14% of respondents planned to retire early due to MSK symptoms [5,6].

Ergonomic interventions have recently gained increased attention as a potential solution to minimize work-related MSK pain and preserve surgeons’ career longevity while also improving job satisfaction [7]. Although previous reviews have explored the impact of surgical ergonomic interventions, no ophthalmology-specific reviews have been conducted to date. Existing investigations have identified exercise-based interventions and posture-correcting measures as effective strategies to reduce MSK pain in surgeons [8,9]. We hypothesize that exercise- and posture-related interventions have the potential to significantly alleviate MSK pain in ophthalmologists, enhancing their overall well-being and professional sustainability.

Given the high rates of MSK pain and lack of summative research on ophthalmology-specific interventions, this systematic review seeks to investigate the impact of any strategy or intervention aimed at reducing MSK pain in the operating room compared to usual practice patterns for ophthalmologists and trainees. Furthermore, this review aims to centralize all ergonomic interventions studied in ophthalmology, providing a practical resource for ophthalmologists interested in implementing strategies to improve their workplace ergonomics.

2. Materials and Methods

This review was reported following PRISMA guidelines (Figure 1) and was prospectively registered in the PROSPERO database (CRD42024559189). A systematic literature search was conducted of Embase, MEDLINE, and Web of Science from inception to 15 April 2024. Supplemental Table S1. Randomized trials, or observational studies assessing the impact of any strategy or intervention to reduce MSK pain compared to usual practice patterns were eligible for inclusion. Opinion or anecdotal articles, studies without staff ophthalmologists or trainees, and non-English articles were excluded. Title/abstract screening and full text screening were completed in duplicate by two independent reviewers (K.N., T.J.) using the online Covidence software (Melbourne, Australia). All duplicates were automatically removed by the screening software. Any disagreements between reviewers were resolved through discussion.

After satisfying the inclusion criteria, included studies were categorized into themes by the reviewers (J.G., B.S., T.J.) to reduce heterogeneity and facilitate meaningful comparisons between interventions. These themes were developed post-screening based on the nature and objectives of the interventions described in the studies. The categorization process aimed to group interventions with similar mechanisms of action, ensuring that comparable strategies could be assessed collectively. This thematic approach enabled a more structured synthesis of results and improved comparability across the diverse range of studies. With consensus, studies were assigned to one of following categories: exercise modifications, equipment modifications, and training aids. Data collection was conducted by three reviewers (J.G., K.N., T.J.) and inputted into Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). All MSK pain-related outcomes from any time point were extracted. Following guidance from the Cochrane Handbook for synthesizing evidence when there are inconsistencies in effect measures and data reporting, the synthesis of results was conducted through vote counting based on the direction of effect (i.e., favourable versus unfavourable). Each study was classified by two independent reviewers (J.G., K.N., T.J.) as either showing benefit or harm based on the observed direction of effect alone to create a standardized binary metric. Any conflicts were resolved through discussion. Following guidance from the Cochrane Handbook, the statistical significance and magnitude of effect were not incorporated into the direction of effect ascertainment.

Risk of bias was assessed using the Murad tool for case series and case reports, which features an eight-item questionnaire categorized into four domains to evaluate the methodical rigour of non-comparative studies [10]. Randomized trials and observational studies were assessed for risk of bias using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and the Risk Of Bias In Non-Randomized Studies-of Interventions (ROBINS-I) tools, respectively. Two independent reviewers (J.G., K.N., T.J.) conducted certainty of evidence evaluations using the GRADE approach, a systematic framework designed to transparently assess the quality of evidence for outcomes. Outcomes were categorized as ‘high’, ‘moderate’, ‘low’, or ‘very low’ certainty based on considerations of risk of bias, inconsistency, indirectness, publication bias, and imprecision [11].

3. Results

The systematic search strategy identified 2276 studies, of which 53 advanced to full-text screening, resulting in 13 studies [12,13,14,15,16,17,18,19,20,21,22,23,24] that included 712 eyecare specialists (Figure 1).

Table 1. Characteristics of the included studies.

Study ID	Country	Study Type	Sample Size	Intervention	Intervention Duration	Intervention Parameters
				Exercise Modifications
Akler 2024 [12]	United States	Case Series	50	Ivengar Yoga	4 weeks	15 min sessions thrice weekly
Al-Marwani 2015 [13]	Saudi Arabia	Cross Sectional	165	Regular exercise	Not reported	45–60 min sessions twice weekly
Markatia 2023 [14] *	United States	Case Series	8	Regular exercise	Not reported	Sessions twice weekly (session duration unreported)
Equipment Modifications
Barak 2019 [15]	Israel	Case Series	5	Heads-up display (Beyeonics)	34 surgeries	Used in cataracts and vitrectomy
Gomel 2023 [16]	Israel	Case Series	3	Heads-up display (Beyeonics)	3 surgeries	Used in Descemet-stripping automated endothelial keratoplasy
Huang 2023 [17]	Canada	Case Series	21	Heads-up display (Artevo 800)	21 surgeries	Used in minimally invasive glaucoma surgery
Palacios 2019 [18]	Brazil	Case Series	14	Heads-up display (Ngenuity)	20 surgeries	Used in vitrectomy
Weinstock 2021 [19]	United States	Cross Sectional	64	Heads-up displays (Ngenuity, TrueVision, Artevo 800)	2.3 years	Used in minimally invasive glaucoma surgery, cataracts, and corneal surgery
Tan 2022 [20]	United States	Cross Sectional	144	Heads-up displays (Ngenuity, ARTEVO 800)	3.5 years	Used in all ophthalmological surgeries
Rani 2021 [21]	India	Case Series	11	Heads-up display	34 surgeries	Used in vitrectomy
Eckardt 2016 [22]	Germany	Case Series	20	Heads-up display (TrueVision)	900 surgeries	Used in cataracts and vitrectomy
Bin Helayel 2021 [23]	Saudi Arabia	Cross Sectional	140	Heads-up display	Not reported	Used in all ophthalmological surgeries
Bhadri 2007 [24]	United States	Case Series	10	Heads-up display (Digital Microsurgical Workstation)	10 surgeries	Used in simulated setting
				Training Aids
Markatia 2023 [14] *	United States	Case Series	8	Posture-correcting aid (Upright Go)	2 weeks	Posture device was worn at all times and vibrated anytime a wearer slouched past 90 degrees

* Study listed twice as it investigated multiple relevant themes.

displays the included study characteristics.

Table 2. Results of the included studies.

Study ID	Follow Up Post Intervention	Outcome Measure	Risk of Bias	Direction of Effect on MSK Pain	Certainty of Evidence Evaluation
Exercise Modifications
Akler 2024 [12]	None	Self-Created Survey	High	Favours intervention	Very low
Al-Marwani 2015 [13]	None	Self-Created Survey	High	Favours intervention
Markatia 2023 [14] *	2 days	Nordic Musculoskeletal Questionnaire (Validated)	Some Concerns	Favours intervention
Equipment Modifications
Barak 2019 [15]	None	Self-Created Survey	High	Favours control	Very Low
Gomel 2023 [16]	None	Self-Created Survey	High	Favours intervention
Huang 2023 [17]	None	Self-Created Survey	High	Favours intervention
Palacios 2019 [18]	1 year	Self-Created Survey	High	Favours intervention
Weinstock 2021 [19]	None	Nordic Musculoskeletal Questionnaire (Validated)	Some Concerns	Favours intervention
Tan 2022 [20]	None	Self-Created Survey	High	Favours intervention
Rani 2021 [21]	None	Self-Created Survey	High	Favours control
Eckardt 2016 [22]	None	Self-Created Survey	High	Favours intervention
Bin Helayel 2021 [23]	None	Self-Created Survey	High	Favours intervention
Bhadri 2007 [24]	None	Self-Created Survey	High	Favours intervention
Training Aids
Markatia 2023 [14] *	2 days	Nordic Musculoskeletal Questionnaire (Validated)	High	Favours intervention	Very Low

* Study listed twice as it investigated multiple relevant themes.

demonstrates the summary of findings, risk of bias evaluations, and certainty of evidence assessments.

Three included studies investigated the impact of exercise modifications. One study assessed the utility of 15 min yoga sessions three times per week, while the two other studies investigated the relationship between exercising a minimum of three times per week and MSK pain. All three studies (100%) found that physical activity resulted in a reduction in reported MSK pain. Ten studies investigated equipment modification using heads-up displays during surgery. Eight studies (80%) found these interventions had a positive effect on MSK pain, while two studies (20%) observed a negative effect. One study investigated the use of a wearable posture training aid that vibrated any time the wearer slouched past 90 degrees. This study reported a positive effect for both neck and back pain.

4. Discussion

We found that the vast majority of included studies favoured such interventions, which included exercise modifications, such as yoga and regular exercise; equipment modification with heads-up displays during surgery; and training aids for posture correction. Both posture-correcting devices and heads-up displays aim to improve the surgeon’s posture while operating. The posture-correcting device provided haptic feedback to alert an individual if they slouched below 90 degrees, while the heads-up displays allowed surgeons to sit further back in the chair and avoid the forward neck flexion position associated with using microscope oculars. Increased forward head posture has been well documented to cause increased pain through an additional strain on the neck and upper back [25]. As such, both interventions exert their effect by reducing the amount of time spent in forward flexion head posture, thereby lessening the cumulative strain on the upper neck and back throughout the operating day. Exercise in a variety of forms has been shown to be beneficial for a musculoskeletal symptoms and pain [26,27]. Yoga, in particular, has robust evidence supporting its effectiveness in managing pain chronic pain related to occupational hazards, which aligns with the results of our review [28,29]. It has been postulated that yoga acts on a combination of both physical factors, such as improved flexibility and enhanced blood supply to affected muscles, as well as psychological and neurophysical mechanisms that reduce the subjective experience of pain [30,31].

4.1. Strengths and Limitations

While this is the first systematic review to assess the role of interventions to improve ergonomics in ophthalmology, there are important limitations. Firstly, despite following the recommendations of the Cochrane Handbook’s for data synthesis in scenarios where a meta-analysis is not feasible, the vote counting method is known to have significant limitations including a lack of account for effect sizes, oversimplification of heterogeneity, and lack of quantitative analysis. As such, the strength of the conclusions are inherently limited by the analysis employed and should only be utilized when necessary. However, given the nature of included studies, this approach was indicated in our systematic review and helps to provide a preliminary assessment of intervention efficacy, guiding future research, and identifying patterns in the existing literature. Future directions include the development of studies to assess MSK-related pain and ergonomics in ophthalmology with standardized outcome measures; one such example includes the use of validated pain scales. Indeed, the lack of psychometric properties of the outcome measures assessed is another limitation, particularly given the subjective nature of MSK pain. Furthermore, there was very minimal follow-up across studies, with only two studies following participants for 3 months or longer, and only one study recording outcomes after the cessation of the study intervention. Thus, there remains substantial uncertainty regarding any prolonged benefits to the interventions discussed. Lastly, many studies employed a volunteer sampling approach, which may have resulted in a selection bias. Given that the ophthalmologists who volunteered for studies also assessed their own self-perceived pain scores, this sampling method may have resulted in perception or confirmation biases across studies. These limitations resulted in ‘High’ risk of bias ratings for 11 of the 13 included studies and contributed to the ‘Very Low’ certainty of evidence ratings across outcomes. Accordingly, conclusions of this review should be interpreted with significant caution.

4.2. Implications for Practice

Despite the limitations of the current literature, the different interventional domains represent intriguing methods for ophthalmologists and trainees to reduce the occupational hazards associated with operating. Physical exercise, equipment modifications and training aids represent possible strategies to address this critical issue. While the ergonomics literature within ophthalmology is not yet well developed, it may be worthwhile for ophthalmologists to incorporate these interventions into their practice, given the supporting evidence from outside the speciality and the practical rationale behind their effects. Integrating heads-up displays may not currently be feasible for all practitioners due to cost and operational challenges; however, starting an exercise programme, such as yoga, could serve as a low-barrier intervention with multiple benefits. Notably, exercise has been found to be effective in managing chronic back and shoulder pain—two areas frequently cited as concerns by ophthalmologists in previous investigations [2,5]. Routine exercise is also strongly associated with improved mood and cardiovascular health, in addition to its beneficial effects on MSK pain [32,33]. Therefore, the reviewers recommend the adoption of routine exercise programmes, such as yoga, for all ophthalmologists as a low-barrier intervention with multifaceted benefits. Additionally, posture training devices represent an intriguing intervention as they have supporting evidence for their effectiveness in other specialties as well. It is plausible that surgeons may find these devices distracting as they buzz frequently while operating, which could make them slightly more challenging to incorporate into practice. On the other hand, the integration of posture-correcting devices in clinic, while ophthalmologists are often using the slit lamp biomicroscope and/or laser-based devices—which also contribute to MSK-related pain—may represent another potential for implementation.

To date, there are no other systematic reviews on interventions aimed to reduce MSK pain in ophthalmology. However, published commentaries align with the recommendations provided in this review. For instance, an article by the American Academy of Ophthalmology emphasized the importance of maintaining proper posture in the operating room and recommended incorporating daily exercise into surgeons’ routines to mitigate occupational health hazards [34]. Additionally, a review by Betsch et al. focused on optimizing ergonomics in the operating room highlighted the impact of eliminating poor postures, with specific recommendations for surgeons to focus on eliminating the forward head posture with increased neck extension when viewing through oculars as discussed above [35].

4.3. Future Directions

Future studies with longer follow ups are required to improve the certainty of evidence associated with these interventions in their ability to improve MSK pain in ophthalmologists specifically. Importantly, considering that many of the included studies relied on volunteer sampling, future studies would benefit from using random sampling techniques to reduce the risk of bias. Researchers should strive to perform comparative analyses that control for placebo effects, incorporating either randomized or cohort designs, and prioritize validated tools such as the Nordic Musculoskeletal Questionnaire over self-developed surveys for outcome assessment [36]. There remains significant potential for research into novel ophthalmology ergonomic interventions. Equipment modification of surgical loupes, chairs, and operating room set ups have shown promise outside the field of ophthalmology and represent an area for future research [37,38]. It would also be valuable for future studies to examine how demographic factors interact with ergonomic interventions, providing more personalized guidance in specific contexts; for example, ergonomic modifications depending on subspecialty, body morphology, and type of MSK-related pain experienced by the clinician. When future reviews are warranted, they should aim to limit or control the inclusion of high of risk of bias studies as the data allows, given the substantial impact these studies have on certainty of evidence evaluations.