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Physical Therapy for Robotic Surgeons Using Robotic Surgical Systems

Palmer Concierge Physical Therapy

“Robotic surgeons have a high prevalence of upper limb musculoskeletal pain, often due to poor ergonomic positioning like shoulder abduction and elbows lifted from the armrest. Future research should focus on evaluating these [physical therapy] interventions specifically for robotic surgeons to reduce pain and prevent career-shortening injuries”. – Ergonomic interventions to reduce upper limb musculoskeletal pain during robotic surgery: a narrative review – Journal of Robotic Surgery, May 2024

Robotic Surgeons & Musculoskeletal Pain

While the innovations of robotic surgical systems have been astounding, for robotic surgeons they’ve introduced a new set of ergonomic challenges related to posture, instrument controls, foot pedals, and screen types.  The expectation was that robotic surgery, with its adjustable ergonomic settings, would minimize physical stress for surgeons compared to traditional methods, however a survey revealed that over half of robotic surgeons reported experiencing physical symptoms they attributed to their work.  Study after study has shown surgeons utilizing robotic surgical systems commonly experience musculoskeletal pain in the shoulders, neck, back, hand and more. These physical symptoms, coupled with the heightened mental demands and stress associated with complex tasks, can negatively affect a surgeon’s ability to perform optimally, ultimately risking patient safety.   Recognizing the physical toll of robotic surgery we’ve developed a series of musculoskeletal treatment protocols designed for those seeking to proactively improve surgical environments, enhance patient well-being, and support the sustained physical wellness and careers of surgeons. Our comprehensive training programs in musculoskeletal health equip surgeons with the essential knowledge and skills to operate robotic surgical systems effectively and safely, enabling them to experience less physical fatigue and maintain optimal performance even during long procedures.

Surgeons, Robotic Surgical Systems, Pain & Injury: How It Happens

Research indicates that surgeons operating robotic surgical systems commonly experience increased muscle pain in the middle trapezius, located in the upper back between the shoulder blades. Furthermore, the seated posture adopted at the console can lead to a slight increase in back flexion, and the console itself may limit posture, contributing to a static workload. Even this seemingly minor forward bending necessitates continuous engagement of back and core muscles to counteract gravity. This sustained muscle contraction, lacking movement or relaxation, restricts blood flow and creates a static workload that can eventually trigger musculoskeletal problems over time.

In addition to muscle fatigue, this altered posture contributes to muscle imbalances that destabilize the spine and place increased, uneven pressure on intervertebral discs, potentially leading to bulges. Poor posture can also compress or irritate nerves by narrowing their pathways and cause excessive stress on facet joints, resulting in inflammation and pain. These combined effects illustrate how seemingly minor, sustained postural deviations can lead to both acute and chronic back injuries from a physical therapy standpoint. To mitigate these risks, we offer comprehensive education and training on ergonomic principles, empowering surgeons with the knowledge to maintain optimal posture, minimize physical strain, and ensure the longevity of their careers in robotic surgery.

Robotic Surgeons: Why a Physical Therapy Assessment & What a Protocol Looks Like

Spotlight on the Neck & Shoulders and the Back, Click to Learn More

Surgeon Ergonomic Assessment & Protocol Illustrated

Physical Therapy Assessment for Robtic Surgeons Experiencing Neck & Shoulder Pain

Forward Head Posture: When you extend your neck forward to look at the screen, the weight of your head shifts forward placing inordinate strain on the muscles at the back of your neck (upper trapezius, levator scapulae) stressing them to work harder to hold your head up. Over time, this can lead to chronic neck pain, stiffness, perhaps headaches along with tightness in the upper shoulders.

Rounded Shoulders: Slouching forward in your chair often leads to rounded shoulders causing the chest muscles to tighten and the upper back muscles to weaken. This imbalance pulls the shoulders forward, restricting movement in the shoulder joint and potentially leading to pain, impingement and tension in the upper back and neck.

Elevated Shoulders (Shrugging): Unconsciously holding your shoulders up towards your ears (often due to stress, a poorly positioned keyboard or mouse, or lack of arm support) can cause the upper trapezius muscles to become constantly contracted and fatigued. This can lead to pain and stiffness in the shoulders and neck, possibly tension headaches.

Static Posture and Lack of Movement: Remaining in the same seated position for extended periods restricts blood flow and can cause muscle fatigue and stiffness. The muscles in your neck and shoulders become tense from maintaining a fixed position, regardless of how well your posture is maintained. Failing to take regular breaks to stand up, move around, and stretch allows the muscles in your neck and shoulders to remain in a stressed state for prolonged periods.

Improper Screen Height and Distance: If your screen is too low, too high, or too far away, you'll likely compensate with your neck and shoulders. Looking down at a low monitor can strain the neck muscles, while looking up can cause tension at the base of the skull and upper shoulders.

Poor Chair Support: A chair that doesn't provide adequate lumbar support can lead to slouching and a forward pelvic tilt, which in turn affects the alignment of your entire spine, including your neck and shoulders. Lack of proper armrest support can also lead to elevated shoulders and strain in the upper body.

Awkward Keyboard and Mouse Position: Reaching too far for your mouse, using a keyboard that forces your wrists into awkward angles, or having these peripherals positioned too high or low can lead to strain that radiates up the arm to the shoulder and neck.

The Robotic Surgeon Physical Therapy Protocol for Neck & Shoulder Pain

Based on the assessment, we’ll create a tailored protocol aligned with any identified risk factors for neck & shoulder issues:

  • Surgical System Set Up Evaluation: We meticulously analyze the surgical system setup, including the chair (adjustability, lumbar support, seat height and depth), desk height, screen position (height, distance, angle), keyboard and mouse placement, lighting, and any other relevant factors.  We’re monitoring for mismatches between the robotic surgical system and the surgeon's body dimensions, a situation that is not uncommon: see research.
  • Postural Assessment: We observe the surgeon’s sitting posture during typical tasks, noting any tendencies towards forward head posture, rounded shoulders, slouching, elevated shoulders, or asymmetrical positioning.  
  • Physical Examination: This would involve assessing the surgeon's range of motion in the neck and shoulders, muscle strength and endurance in key postural muscles (e.g., neck flexors, upper back, rotator cuff), identifying any muscle imbalances (e.g., tight chest, weak upper back), and palpating for areas of tenderness or muscle tension.
  • Task Analysis: Understanding the specific tasks performed at the robotic surgical system, the duration of each task, and any repetitive movements involved is important. This helps identify movements or postures that might be contributing to pain.
  • Interview: We discuss the surgeon’s pain history, daily routine, work habits, stress levels, and any other factors that might be contributing to their symptoms.Developing a Personalized Protocol:

Developing a Personalized Protocol:

Based on the assessment findings, we develop a tailored protocol incorporating the following elements:

  • Robot Surgical System Workstation Modifications: Specific recommendations for adjusting the existing workstation or suggesting ergonomic equipment. This might include:
    • Chair Adjustments: Ensuring proper seat height (feet flat on the floor or on a footrest), lumbar support placement, armrest height (allowing shoulders to relax), and seat depth.
    • Screen Positioning: Optimizing monitor height (top of the screen at or slightly below eye level), distance (arm's length away), and angle (perpendicular to the line of sight).
    • Keyboard and Mouse Placement: Positioning the keyboard directly in front of the body at a comfortable height, with the mouse close to the keyboard to minimize reaching. Considering ergonomic keyboards or mice if needed.
    • Document Holder: Suggesting a document holder placed at the same height and distance as the monitor to reduce neck strain from looking down at papers.
  • Movement and Stretching Breaks: Prescribing regular, short breaks (e.g., every 20-30 minutes) to stand up, walk around, and perform specific stretches targeting the neck, shoulders, chest, and upper back. Examples include:
    • Gentle neck stretches (tilts, rotations).
    • Shoulder rolls and squeezes.
    • Chest stretches (clasping hands behind the back and straightening arms).
    • Upper back stretches (hugging arms across the chest).
  • Strengthening Exercises: Recommending exercises to address muscle imbalances and improve postural support. Examples include:
    • Chin tucks (strengthening deep neck flexors).
    • Scapular retractions (strengthening rhomboids and middle trapezius).
    • Rows with resistance bands (strengthening upper back).
    • External rotation exercises (strengthening rotator cuff muscles).
  • Ergonomic Tools and Aids: Recommending specific ergonomic tools if necessary, such as wrist rests, footrests, or standing desk converters.
  • Activity Modification: Advising on how to break up prolonged sitting time by incorporating movement into the workday, such as standing during phone calls or meetings.Training and Education:

Training and Education:

We educate and train surgeon’s to effectively implement the protocol:

  • Education on Ergonomic Principles: Explaining the rationale behind each recommendation, emphasizing how poor posture and prolonged static positions contribute to shoulder and neck pain.
  • Demonstration and Practice: Physically demonstrating proper posture, workstation adjustments, stretches, and exercises. The surgeon would then practice these under our guidance to ensure correct form.
  • Visual Aids and Handouts: Providing written or visual guides with diagrams and instructions for stretches and exercises to reinforce learning.
  • Personalized Feedback: Offering specific feedback on the surgeon’s posture and movement patterns, helping them identify and correct problematic habits.
  • Developing Awareness: Teaching the surgeon to become more aware of their body and recognize early signs of discomfort or tension in their neck and shoulders.
  • Troubleshooting and Problem-Solving: Addressing any challenges the surgeon faces in implementing the protocol and helping them find solutions that fit their specific work environment and routine.
  • Long-Term Strategies: Educating the surgeon on the importance of making these ergonomic practices a long-term habit for preventing future pain and maintaining good musculoskeletal health.

We include follow-up sessions to monitor progress, address any new concerns, and make adjustments to the protocol as needed. The goal is to empower the surgeon with the knowledge and tools to proactively manage their robotic surgical system workstation ergonomics and minimize their risk of developing shoulder and neck pain.

Physical Therapy Assessment for Robotic Surgeons Experiencing Back Pain

Insufficient Lumbar Support and Slouching (Lower Back):  When a chair doesn't provide adequate support for the natural inward curve of your lower spine (the lumbar curve), it can lead to slouching. Slouching flattens this curve, putting excessive pressure on the intervertebral discs and stretching the ligaments that support the spine. Over time, this can cause muscle strain, pain, and even contribute to disc problems. A forward pelvic tilt, often associated with poor lumbar support, can also strain the lower back muscles.  

Rounded Shoulders and Forward Head Posture (Upper and Middle Back): While primarily associated with neck and shoulder pain, rounded shoulders and forward head posture also significantly impact the upper and middle back. Rounded shoulders cause the muscles in the upper back to become stretched and weak, leading to pain and a feeling of tightness. The forward head posture can also pull the upper back into a more rounded position, further straining the muscles in this area.  

Static Posture and Lack of Movement (Overall Back): Remaining in a seated position for extended periods without movement restricts blood flow to the muscles and discs in your back. This can lead to muscle fatigue, stiffness, and pain throughout the back.  

Improper Seat Height and Depth (Lower Back):  

  • Seat too high: If your feet aren't flat on the floor, it can put pressure behind your knees, potentially leading to a posterior pelvic tilt and flattening of the lumbar curve, straining the lower back.  
  • Seat too low: This can cause excessive flexion at the hips, which can also strain the lower back muscles.  
  • Seat too deep: If you can't comfortably rest your back against the chair's backrest and utilize the lumbar support, you're more likely to slouch, leading to lower back pain.  

Lack of Armrest Support (Upper and Middle Back): Without proper armrest support, your upper back and shoulder muscles have to work harder to support the weight of your arms. This can lead to fatigue and pain in the upper and middle back, as well as the shoulders.

Awkward Keyboard and Mouse Position (Middle and Lower Back): Reaching too far to the side or forward for your keyboard or mouse can cause twisting or asymmetrical strain on the muscles in your middle and lower back. 

Lack of Breaks and Stretching (Overall Back): Failing to take regular breaks to stand up, walk around, and stretch the muscles in your back allows tension to build up. Stretching helps to maintain flexibility and reduce stiffness, preventing pain from developing over time.  

Leg Positioning (Lower Back): Not having your feet flat on the floor or using a footrest when needed can lead to uneven weight distribution and strain on your lower back. Crossing your legs for extended periods can also contribute to pelvic imbalances and back pain.  

By understanding these common origins, surgeons can take proactive steps to improve their workstation setup and sitting habits to minimize the risk of developing chronic back pain

The Robotic Surgeon Physical Therapy Protocol for Back Pain

Based on the assessment, we’ll create a tailored protocol aligned with any identified risk factors for back pain:

  • Robotic Surgical System Workstation Modifications:
    • Chair Optimization: Ensuring the chair provides proper and adjustable lumbar support that fits the surgeon's spinal curve. Adjusting seat height so feet are flat on the floor or a footrest, and setting the seat depth to allow a few fingers' width between the back of the knees and the seat edge.
    • Screen Positioning: Placing the screen at a height and distance that encourages a neutral spine and avoids the need to lean forward or crane the neck, which can indirectly affect the back.
    • Keyboard and Mouse Placement: Positioning these close to the body to minimize reaching and twisting, which can strain back muscles.
  • Posture Correction Strategies:
    • Maintaining the Lumbar Curve: Educating the surgeon on how to actively engage their core and maintain the natural "S" curve of their spine while sitting. This might involve using the chair's lumbar support or a separate lumbar roll.
    • Pelvic Positioning: Teaching the surgeon to sit with a neutral pelvic tilt, avoiding excessive anterior or posterior tilt.
    • Avoiding Slouching: Providing cues like "sit tall through your spine" and encouraging regular self-correction.
  • Movement and Stretching Breaks: Prescribing specific, short breaks for movements that counteract the effects of extended sitting on the back. Examples include:
    • Gentle Back Extensions: Standing up and gently leaning back, supporting the lower back with hands.
    • Seated Torso Twists: Gently twisting the upper body while keeping the hips facing forward.
    • Standing and Walking: Encouraging regular movement to improve circulation and reduce pressure on the spine.
  • Strengthening Exercises (Core and Back Support): Recommending exercises to strengthen the core muscles (abdominals, obliques, and deep back muscles) which act as a natural corset for the spine. Examples include:
    • Pelvic Tilts: Engaging core muscles to rock the pelvis forward and backward.
    • Bridges: Strengthening glutes and hamstrings, which support the lower back.
    • Planks: Engaging core muscles for overall trunk stability.
    • Bird-Dogs: Improving balance and strengthening back extensors.
  • Activity Modification: Advising on strategies to break up long periods of sitting, such as standing during phone calls, walking during meetings, or using a timer to prompt movement.

Training and Education:

We’ll provide comprehensive training and education to empower the surgeon to minimize their risk of developing back pain:

  • Education on Back Ergonomics: Explaining the anatomy of the spine, how prolonged sitting and poor posture affect it, and the importance of maintaining the natural spinal curves.
  • Demonstration and Practice: Showing the surgeon how to properly adjust their workstation, perform the prescribed stretches and exercises with correct form, and maintain good sitting posture. Hands-on guidance and feedback are crucial.
  • Visual Aids and Handouts: Providing diagrams and written instructions for workstation setup, posture correction techniques, stretches, and exercises for easy reference.
  • Body Awareness Training: Teaching the surgeon to recognize when they are starting to slouch or adopt poor postures and how to self-correct. They would learn to identify early signs of back discomfort and take proactive steps. 
  • Problem-Solving and Troubleshooting: Addressing any specific challenges the surgeon encounters in implementing the protocol and providing tailored solutions.
  • Long-Term Strategies: Emphasizing the importance of making these ergonomic principles and movement habits a lifelong practice for preventing chronic back pain and promoting overall back health.

We’ll also schedule follow-up sessions to assess the surgeon’s progress, responding to any new issues, and adjust the protocol as needed. The goal is to provide the surgeon with the knowledge, skills, and tools to actively manage their robotic surgical system workstation ergonomics and minimize their risk of developing debilitating back pain

Are you a surgeon experiencing work-related aches and pains? Our specialized physical therapy service provides convenient postural assessments and tailored treatment protocols, available either on-site at your OR or virtually. We’ll begin with a discussion of your pain points, followed by guided movements to assess your physical condition. This comprehensive evaluation allows us to create a personalized therapeutic plan focused on pain relief and restoring your optimal function.

Research on Robotic Surgeons & Musculoskeletal Pain

Given the well-documented research highlighting the prevalence of neck, shoulder, back pain, and other musculoskeletal issues experienced by robotic surgeons, we invite you to explore the comprehensive body of evidence supporting the need for physical therapy assessment and targeted training protocols. Our website features this research, underscoring the critical role of ergonomic education and preventative strategies in mitigating these risks. By understanding the science behind maintaining optimal musculoskeletal health while operating robotic surgical systems, surgeons can enhance their comfort, performance, and career longevity.

“The study noted ergonomic challenges related to surgeon body size and anecdotal observations suggesting that shorter female surgeons may struggle with the pedal platform height, leading to awkward postures and strain. Similarly, taller surgeons might face limitations with the console’s height adjustments, potentially causing discomfort, suggesting current console design might not optimally accommodate surgeons of all sizes, particularly in a field like gynecology with a significant number of female surgeons”. – Does a robotic surgery approach offer optimal ergonomics to gynecologic surgeons?: a comprehensive ergonomics survey study in gynecologic robotic surgery

“Studies indicate that robotic-assisted laparoscopy is also associated with poor ergonomics and musculoskeletal pain. The ergonomic condition in the robotic console is partially dependent upon the chair provided, which often is a regular office chair. Our study quantified and compared the muscular load during robotic-assisted laparoscopy using one of two custom built ergonomic chairs and a regular office chair. The results demonstrated no differences that could be considered clinically relevant.” – Surgeons’ muscle load during robotic-assisted laparoscopy performed with a regular office chair and the preferred of two ergonomic chairs: A pilot study

“A significant portion of [robotic-assisted] surgeons still experience physical symptoms, primarily neck stiffness and finger/eye fatigue. While physical demands might be lower, the mental workload can be higher, with stress levels closely linked to the complexity of the task and mental demand. The study also found increased muscle activation in specific areas like the middle trapezius (upper back between the shoulder blades). Furthermore, while the surgeon remains seated, there can be a slight increase in back flexion, and the console itself can sometimes limit posture, leading to static workload. Forearm muscles also show signs of high strain, potentially related to the use of the hand controls.” – Comparative Study of Ergonomics in Conventional and Robotic-Assisted Laparoscopic Surgery

“While the study has limitations, including a small sample size and potential translation issues, it underscores the importance of addressing ergonomic concerns [muscular pain] and providing proper training to robotic surgeons to ensure their well-being and longevity in the field”. – Assessing Muscular Pain and Ergonomics Among Robotic Surgeons in China: A Validation

“Robotic surgery is ergonomically superior to open and laparoscopic surgery. However, rates of physical strain remain significant and should be addressed by formal ergonomic training and adequate console familiarization.” – A systematic review of the true benefit of robotic surgery: Ergonomics

“Studies indicate that robotic-assisted laparoscopy is also associated with poor ergonomics and musculoskeletal pain. The ergonomic condition in the robotic console is partially dependent upon the chair provided, which often is a regular office chair. Our study quantified and compared the muscular load during robotic-assisted laparoscopy using one of two custom built ergonomic chairs and a regular office chair. The results demonstrated no differences that could be considered clinically relevant.” – Surgeons’ muscle load during robotic-assisted laparoscopy performed with a regular office chair and the preferred of two ergonomic chairs: A pilot study

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We can help you get back to your active and pain-free lifestyle with our personalized, one-on-one sessions, all in the comfort and convenience of your home or office.

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K.A., New York

I can’t say enough about Palmer Concierge Physical Therapy. Six weeks ago, I was in severe pain stemming from a tight right hip issue and severe tension in my upper back and neck. A friend recommended I get in touch with Jim ASAP. From our very first session, Jim was professional and extremely easy going. He really meets you where you are. He was able to immediately assess my issues and to prescribe exercises that built upon once another with each session that we worked together.

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P.F., New York

My 2 boys ages (10 and 12) were dealing with some minor injuries from playing high level competitive soccer. After testing and diagnosing them individually, Jim was able to put together a stretching program for both boys before soccer training. The results have been fantastic. Both boys haven’t complained of pain or discomfort since instituting Jim’s regime. I would highly recommend Jim for Sports PT for both adolescents and adults.

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L.L., New York

How wonderful to find concierge physical therapy, and how even more wonderful to find such a competent, skilled therapist as Dr. Palmer! I had injured my upper arm, resulting in extreme pain and limited range of motion (inability to raise my arm above shoulder level). After assessing my condition, Dr. Palmer explained and prescribed a few simple exercises that I could do at home without any extra equipment. I was thrilled when within 2-3 weeks, I was totally pain free and had full range of motion!

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Patients often have to wait weeks or months to gain access to providers—long enough for conditions to move from acute to chronic.  The Palmer Concierge PT Team brings physical therapy to you, to meet your wellness goals with the convenience of a mobile service that comes to your home, office or hotel.  Our goal in providing personalized one-on-one care is to help you achieve a pain-free and healthy lifestyle.  We offer a mobile physical therapy experience in New York City, Brooklyn and the Hamptons that empowers, educates, and restores balanced healthy movement without the drive to appointments, having to re-schedule your day, or cope with crowds and traffic.

–The Palmer Concierge PT Team

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