Microscopy’s dangers: From wear and tear to disabling injury

Anne Paxton

April 2019—When pathologist Sandra Ewaskow, MD, was asked at a recent medical conference what topic she would choose if she were to write a book in her field, she thought of her own experience with musculoskeletal pain and of her mother, who had recently been hospitalized for occupational therapy after a hip fracture. “It was very much on my mind, the kinds of things she had to do to get comfortable and retrain her body to move,” says Dr. Ewaskow, of Pacific Pathology Partners in Seattle. “I said I would write a book on pathology and ergonomics.”

The idea touched a nerve. “The rest of the meeting, for days, different specialists in pathology, primary care, orthopedics, and surgery kept coming up and saying, ‘You’ve got to write that book. We sit at a computer all day and we have those issues in our practice.’”

In fact, she notes, people in any immobile, static position all day are likely to encounter problems. From the standpoint of ergonomics, it’s not only the microscope but also other elements of pathology work that are hard on the body. “Practitioners are spending so much time at the computer now—much more than a few years ago. We can now access surgical reports and imaging at our desk where in the old days, we would have to get up and could stretch. Now there is less need for us to move from our workstations.”

Prolonged microscope use has been known for almost four decades to be associated with developing chronic pain syndromes, says Evan George, MD, clinical associate professor in the Department of Anatomic Pathology, University of Washington. He published an article in 2010 that addressed microscopy as an occupational hazard of pathology practice (Am J Clin Pathol. 2010;133[4]:543–548), but he believes the knowledge gap remains sizable. “It’s a subject that pathologists don’t talk about a lot,” Dr. George says.

Ergonomics caught his attention because of pain he experienced during his anatomic pathology work. When he began to have problems while practicing in a community hospital setting, he noticed that symptoms were most intense when he was working at the microscope—to the extent that it was difficult to concentrate and complete his daily work. “There wasn’t a specific event, and because I used to lift weights for exercise, I first consulted an orthopedist. Symptoms did not improve with anti-inflammatory medications, and there were no radiographic abnormalities. The orthopedic physician was puzzled, and I hadn’t made the connection that the pain might be from the microscope work.”

After confiding his symptoms to other pathologists in his group, several of them told him they too had experienced musculoskeletal symptoms at some point in their careers, which improved with physical therapy or workstation modifications, or both. One colleague had herniated discs in the cervical spine that required surgery and a month or two away from work.

Luckily, Dr. George happened to mention his symptoms to a physical medicine doctor at his hospital who offered to visit his office. “He made an almost instantaneous diagnosis of repetitive stress syndrome.” After Dr. George obtained an ergonomically designed microscope, allowing him to gaze straight ahead, as one would do with a periscope, “My symptoms diminished a lot.”

The neck and upper back are the areas most intensely affected by microscope use, Dr. George has found. Surface electromyography has confirmed that “the neck and back muscles truly are working when we are sitting down viewing slides at the microscope or staring at a computer,” he writes in his 2010 article. But since microscope work includes repetitive movement of the arms and hands and because the body’s joints and muscles are connected in such complex ways, pain in the shoulders, arms, wrists, hands, and lower back can also result. For example, “I notice that if you’re a short stature pathologist and your feet don’t reach the floor when you are sitting, it brings a lot of excess stress to the shoulders.”

Repetitive stress syndrome, also known as cumulative trauma disorder, refers to wear and tear on tendons, muscles, and sensitive nerve tissue caused by continuous use over an extended period. The exact pathophysiology of cumulative trauma disorder and its associated musculoskeletal disorders is not established, but possible mechanisms include repetitive mechanical irritation, microischemia, and accumulation of metabolic products that promote inflammation and fibrosis or interfere with neuromuscular function, according to Dr. George. With time, he says, muscle fiber shortening and fibrosis may lead to postural imbalances, which, if uncorrected, cause additional strain on affected tissue or injury at previously uninvolved anatomic sites.

The risk factors for symptoms in pathology and cytotechnology practice are better known: hours of microscope work, duration of work without breaks, fast work pace, and poor workstation ergonomic conditions. Over the years, these can steadily add up, leading to disabling injury. “There are a variety of types of medical problems or injuries, probably resulting from recurrent microtrauma to myofascial tissue that occurs so gradually most people don’t realize it until a critical threshold is reached and symptoms become severe,” he explains.

Marilyn Bui, MD, PhD, was one such person. On her first job in pathology, she routinely put in 10- to 12-hour days and exercised regularly after work. “You feel young and invincible. You just keep working until you are exhausted,” says Dr. Bui, who is now senior member of pathology and president of the medical staff, Moffitt Cancer Center, Tampa, Fla.

But one day, after three years on the job, she discovered she couldn’t get out of bed. “My back muscle was frozen. I couldn’t walk.” As radiology testing confirmed, “It was a very bad back muscle spasm.” She saw a chiropractor who surmised that her work on the microscope was creating a posture problem and advised her to stop wearing high heels, to correct the bad postures, and to start walking every hour. She complied with most of that advice and started getting back adjustments and deep muscle massages. “It went well for one or two years with treatment, then it happened again. My back was completely frozen one day when I was trying to pick up something very light.”

One provider explained to her that the repetitive stress of her working environment was like a million small paper cuts on the body, and the body was defending itself, in her case with back pain. The advice she received this time was sobering: “As long as you are doing your job,” the provider told her, “if you don’t change your behavior, this pain will not go away. And when you get older, it will get worse.”

In anatomic pathology, there can be considerable repetitive motion beyond the microscopy arena, Dr. Ewaskow points out. “The typical workflow will consistently go from one side to another. Pathologists will have a specific place to set up slides, they’ll pick them up the same way, put them on the scope in the same way, and move the slides with the same hand.”

The effects of repetitive motion may not become apparent for years, but then they can make themselves known in subtle or unexpected ways. “I remember a conversation with another pathologist who found after seven years of this kind of practice full time that he noticed a change when looking at a rear-view mirror while driving. He perceived just looking over his shoulder as being difficult,” Dr. Ewaskow says.

Kay Ballen, OTR/L, is an occupational therapist and ergonomic specialist for employees at EvergreenHealth, Kirkland, Wash. Her job is not to diagnose musculoskeletal disorders but to evaluate office setups and provide recommendations to improve postures, positioning, and comfort, and to overall reduce the risk for musculoskeletal disorders. “Generally, when we have a request for an evaluation, it is because someone is reporting discomfort or pain or a new employee is making sure their workstation is set up properly,” Ballen says. “There are several laboratories within our hospital, and most often those employees using a microscope during the majority of their shift request an ergonomic evaluation due to having neck, back, and shoulder discomfort or pain.”

When a chair is not properly adjusted or a desk, table, monitor, or microscope is not at the proper height, Ballen finds that the faulty positioning may induce leaning or flexing of the neck. But a behavior pattern with possibly even greater impact is the increased amount of sitting that people are doing during the day. “Sitting has increased tenfold in the last four years because people are going paperless, and people are working more 10-hour or 12-hour shifts at a computer instead of five eight-hour shifts. As their day progresses, their body becomes more fatigued the longer they are sitting. We start to see a lot of postural issues and upper body or neck pain.”

Ballen’s professional focus when conducting ergonomic in-service training for clinics and departments at EvergreenHealth is on prevention. New employees receive information regarding proper sitting postures and positioning and ergonomic contact information as part of their one-week orientation.

When employees request an ergonomic evaluation, “we evaluate their desk height and the need for chair adjustments, including seat depth and armrests. We evaluate the computer screen viewing distance, screen height, keyboard and mouse types and their placement, microscope height, positioning of the scope, and how a person’s arms are placed on the table or desk.” In addition, they evaluate tasks that are done repetitively during the work shift that could contribute to discomfort or pain, including the length of time a person is sitting. “Would they benefit from a certain kind of workstation or elevated desk? Do they need improved lighting?”

These considerations reflect a central idea: Work has to move with the human body, not vice versa. “Instead of us adjusting to a camera or an angle of a desk or a chair, somehow the design has to be more fluid. It has to coordinate more with the natural inclination or movement of our body,” Dr. Ewaskow says.

For Donna Hansel, MD, PhD, interest in ergonomics also stemmed from an injury: a massive lumbar disc herniation she experienced after surgery when she worked as an assistant professor of anatomic pathology at Cleveland Clinic, leading to two years of rehabilitation. “It became difficult just to walk, I lost a lot of range of motion with my leg, and it was almost impossible to sit.”