（83）

WORK＿R玉LATEDMUSCULOSKELETALDISORDERSAND

ASSOCIATED

FACTORSIN TEACHERS OF PHYSICAI．LY ANDINTELLECTUAI．LY
DISABI．EDPUPILS：ASELF−ADMINISTEREDQU】三STIONNAIRESTUDYNoBUHIROYAMAMOTO，KEIGOSAEKIand
NoRIOKURUMATANI

功抑吻酬函〃勉励吼飽和朋適地Ⅶ壷肌砂
ReceivedFebruary12，2003

Abstract：TeachersinschooIsforphysicallyandintellectuallydisabledpupilsare
assumed to have a risk of developing musculoskeletal disordersincluding thecervicobrachial andlower back reglOnS．To date，however，Studies concerning theseissuesareextremelylimited．Thepresentstudyaimedatclarifyingthemagnitudeofthe
musculoskeletal disorders among the teachers，its work−relatedness and associatedfactors．First，We COnducted self−administered questionnaires and medical checkups
simultaneouslyfor126femalenurseryschoolnursestoascertainthevalidityofquestions
andansweroptionswhichwedevelopedforepidemiologicresearch・Questions

hadanypalnOrStiffnessinyourneck，ShouldersorarmSinthepastmonth？

youhadanypalnOrStiffnessinyourlowerbackP

everyday

were

found

to

correlatewellwith，andanansweroption

theresultsofclinicalhaveyouandhave

almostallday，

examinations

anddifficultiesin daily activities．Secondly，Weanalyzed self−administered questionnaires of
975teachers working for physically andintellectually disabled pupils at munlClpal
schooIsinacity．Thequestionsandansweroptionswhichhadbeenvalidatedinthefirststudywereused．Inthemales16％and20％Complained

almostallday，eVeryday

ofthe

cervicobrachialandlowerbacksymptoms，reSpeCtively，andinthefemales20％and16％
in，that order．Adjusted odds ratios of both symptomsincreased with anincreasein
objectivescoreswhichwereobtainedby thehomogeneityanalysis andwereconsidered
to reflect the quantity of nursing care burden on the teachers．In case of thecervicobrachial symptom females against males had a significantly higher odds ratio
thanunity．TheseresultsdemonstratedthatthemusculoskeletalsymptOmSCOmplainedof
highlybytheteacherswerework−related，andthatthe questionandansweroptionswe
developed could be usefulparameterSin epidemiologic research for the symptoms now
widelyprevailinglnVariousworkplaces．

Key words：disabled children，queStionnaire study，risk factors，teaChers，WOrk−related
musculoskeletaldisorders

NTRODUCTION
SchooIsforpupilswithdisabilitiesweremadepartofthecompulsoryeducationsystem
inJapanin Apri11974．From that time，allpupils who had formerly not been required toattendschoolbecauseofseverephysicalorintellectualdisabilitywereobligedtoattend・The

（84）Work−relatedmusculoskeletaldisordersamongteachersfordisabledpupils

numberofschooIsforsuchpupils hasgraduallyincreasedwithteachernumbersincreaslng
accordingly．As of May2001，there were818such schooIs nationwide，With over50，000
teachersl）．In addition，the number of teachersin charge of disabled childrenin regularelementary and junior highschooIsisincreasing recently，because disabled children whowant to attend regular schooIs areincreaslngln number and these schooIs must arrange
SpeCialeducationclassesforthem．
Bendingtheneck，forwardrepetitivewristmotions，forcefulgrlpplng，frequenthandlingof heavyloads and prolonged awkward postures are widely recognized risk factors formusculoskeletal disordersincluding the cervicobrachial andlower back regions．These
results

have

been

accumulated

throughstudieschieflyofindustrial

workers2￣16）．The

disorders arealsoobserved，however，inhospitalnurses17・18），nurSerySChoolteachersl9・20）and

careglVerSinelderlynursinghomes21・22）．AmOngthesetheriskfactorsaboveareobservedbut
COntinuallywitharathershorterdurationwhencomparedwiththoseinindustrialworkers．

WorkpracticesamOngteaChersinschooIsfordisabledpupilsaresimilartothoseofnurses，nurseryschoolteachersandcaregivers．Therefore，theteachersinsuchschooIsareassumed
tohavethesamehealthproblems．Todate，however，repOrtSOnthisissuearelimitedtotheStudiesbyTokunaga23），Maedaetal．24），andTaodaetal25）．Topromotehealthcareandfurther
workplaceimprovementsin schooIs，We need more knowledge about the prevalence ofmusculoskeletaldisordersamongtheteachers，theirworkrelatedness，andthecontributionof
individualfactorssuchasageandphysicalattributes．

Themagnitudeofriskfactorsisaslowastwotothreetimes6・11・18）withafewexceptions
formusculoskeletaldisordersso thatacomparativelylargenumberofsubjects arerequired
to detect the factors．Subjective symptoms such as stiffness，pain，and numbness are
COnSidered abetter parameter to obtain early slgnS Ofthe disorders because the symptoms
usually precede clinical findings．To ascertain subjective symptoms，interviews and self−
administeredquestionnairesarecommonlyconducted．Astudyofalargenumberofsubjects
prefersthelatterforeaseofadministrationandcostefficiency．Thismethod，however，hasa
shortcoming．The validity of self−administered answersis relativelylow26）when comparedwithinterviews which can confirm recorded answers，Or COmparedwith amedicalcheckup，Which can obtain objective findings．Therefore，tO uSe the results of self−administeredanswers as an epidemiologic parameter，the validity of the questions and answer options
shouldbeevaluated

beforehand．However，there

have

been

few

reports27￣29）On

this

point

of

musculoskeletaldisorders．
In the present study，We first conducted self−administered questionnaires and medical
Checkups simultaneously for overlOO subjects to ascertain the validity of questions andanswer options，Which the authors developed as an epidemiologic parameter formusculoskeletaldisorders．Secondly，aSelf−administered questionnairestudywascarriedout
forallteachersworkingforphysicallyandintellectuallydisabledpupilsatmunlClpalschooIs
inOsakaCity．Themainobjectiveofthepresentstudywastoelucidatethecurrentstatusof
musculoskeletaldisorders among the teachers and to clarify theirwork relatedness．Results
OntheseissueswouldprovidecluestodevelopanymeasurestopreventdisordersamOngthe
more than50，000teachers nationwide．The next objective was to evaluate the validity ofquestions and answer options developed by the authors concernlng muSCuloskeletal

N．Yamamoto，etal．

（85）

SymptOmS．WeconsideredthattheresultsonthispointcouldprovideausefulepidemiologlC
parameterin aninvestigation of the symptOmS amOng WOrkers with risk factors ofCOntraCtingmusculoskeletaldisorders．

Partl．ValidityofmusculoskeletalsymptOmSObtainedbyself・administeredquestionnaires
l．Subjects

We performed medicalexaminations for work−related musculoskeletaldisorders on435
female nursery schoolnurses workingatmunicipalday nurseriesin Osaka Cityin August

2000．Fromthoseexamined，126individualswhowereexaminedbythesamedoctor伽．K．）
Were selected as study subjects to exclude any bias of different examination techniquesamongmedicaldoctors．
2．Methodsl）QuestionnairesformusCuloskeletalsymptoms
Priortotheclinicalexamination，Subjectswererequestedtofillinthequestionnaires．To
Check on subjective symptoms ofthe cervicobrachialandlowerback regions，the questions
haveyouhadanypainorstiffnessinyourneck，ShouldersorarmSinthepastmonth？

haveyouhadanypalnOrStiffnessinyourlowerbackinthepastmonth？
answerconsistedoffouroptions：

everyday，but

severaltimesaalmostallday，eVeryday

week

and

almostnone，

nOtallday，buteveryday．Questions

on

and

wereasked．Eachthe，treatment

nOt

statusincludedany treatmentin thepasthalfyearfor symptomsin theneck，Shoulders or amS，
andinthelowerback．Thesubjectswereallowedtochoosemultipleansweroptionscoverlng
theirattendanceatahospital，aCupunCture，Chiropractororosteopath，OrnOne．Wealsoasked
Subjects about the effects ofsymptOmS On daily activities．In respect ofthe cervicobrachialregion，Sixitems

telephonereceiverbee

Tablel）including

for

along

time

difficulty

Werepreparedcombing

accordingtotheForthelowerback，fourquestions6eeTablel）includingStandingup？

inthelowerandanddifficultyquestionnaire

holdingabyItani30）．

doyouhavelowerbackpainon

doyouhaveanydifficultyinwalkingduetopaln，numbnessorstiffness

extremities？

were

askedinthequestionnairedevisedbytheCommitteeofOccupationalLower Back Pain，Japan Society for OccupationalHealth31）．The subjects wererequestedtochooseananswerfromthreeoptionssuchas

always，SOmetimes

and

none

，

Which were seml・quantitative responses to the times of the symptOmSintrudinginto daily
activitiesinthepastmonth．

2）Clinicalexamination3732−34）
Allsubjectsreceived thesameclinicalexamination．Inthesittingposition，mOtionpaln
andlimitation of movement of the neck were observed by anteflexing，retrOflexing，
lateroflexingandrotatingtheneck．AIso，thoSe SlgnSintheshoulderandelbowjointswere
Observedbyabductionandadductionoftheshoulderandextensionandflexionoftheelbow，
respectively．The doctors asked the subjects to expand and contract knuckle joints ofbothhands to detect the presence of snapping fingers．The tendon reflexes of the biceps andtriceps brachiimuscleswere checked．Tactile sensein theproperregionsinnervatedby the
medialand ulnar nerves balms of the second and fifth finger tips，reSpeCtively）was（86）Work−relatedmusCuloskeletaldisordersamongteachersfordisabledpupils

Tablel．Clinicalfindings，aCtivities of dailyliving and treatment status byfrequency of subjective
symptomsincervicobrachialandlowerbackreg10nSamOng126femalenurseryschoolnurses
Almostnone

Numberofsubrcgionswithtendemessl）≧4

Dailyactivities（lAlwayslinthepast

always

32
9．3
6．2

…浄

；持・
37．5

0．0
0．0

7．3

9．1

2．4

9．1

25．0

0．0

2．4
0．0

0．0
0．0

18．8
12．5

4．9

0．0

9．4

0．0

0．0
84．8

6．3
40．6

month）

Dimcultyholdingatelcphonereceiverforalongtime
DifncultysqueezingwateroutofduStClothm爪cultycombing
Easilylctsomething魚11丘omhands
AwakeduringnightdlletOnumbnessofhaJldsor訂mS
Difncultydressingorundressing
Thetotalnumberof

33
39．4
6．1

2

1
2−3

41
U

None

4349
3744

2095．〜00

Painorsti蝕essinthcneck，Shouldcrsorarmsinthepastmonth

Notevcryday，but Notallday， Almostallday，
SeVCraltimcSaWeek butcvcryday cveryday

intheabove6items

O

0．0
0．0
0．0
lOO．0

1

3：3】0・0≧2
TreatmcntstatusinthepaSthalfyear Hospital，Clinicor；：；】11・2

1紺15・1 号紺59・4…

17．1

39．4

34．4

a￠upun￠仙帽

PainorstimIeSSinthelowerback
None

Numberofsubregionswithtendemess

Locdtendem￠SS2）

30

54

17

25

96．7

57．4

29．4

8．0

苦言：写

壬；：主

語3…

3．7
5．6
5．6
0．0

0．0
17．6
5．9
0．0

44．0
36．0
28．0
12．0

3．3

Sp帽撼喝t孤dem￠SS3）0．0
Dailyactivities（．

AIwaysinthefiastmonth）

Havelowcrbackpainonst弧dingup O．0
HaYelowerba￠kpainonmmlngOV併inbed
Havelowerbackpainonwashingfhce
Difncultywalkingduetopain，nunbnessorstimIeSS
Thetotalnumberof

always．intheabove4items

O

lOO・0

1
≧2

TreatmcntstAtuSinthepasthlfyear Hospital，Clinicor

1抽11．11紬17・6 4㍑】56・0…
20，4

58．8＋

16．0

aGupul（；tⅧ陀1）totalnumberofthepartswithtendernessamonglOsubregionsinthecervicobrachialregion・2）and3）tendernesswasobservedineitherorboth，reSpeCtively，theparavertebralmusCleand／ortheiliolumbar
ligament．＊and＊＊showslgnificantdifferencesinpercentagesinthegroupconcernedcomparedwiththoseofthegroupscomplainingofthesymptomlessfrequentlyatthelevelofO・05・＋showsastatisticallyhighervaluethanthoseintheotherthreegroups．

examined uslng a brush，and atrophy of the thenar，hypothenar andinterosseous musCles
wasalsoexamined．TestsforcarpaltunnelsyndromesuchasthePhalentestandPerfectO
slgn Were added when necessary．While asking the subjects whether they felt tenderness，doctors sequentially palpated the muscles of the finger and forearmS，lateraland medial
eplCOndyles of the humerus，brachial muscles，ligaments attached to the shoulder joints，
musCles of the pectoralis maJOr，anterior scalene，neCk，Shoulder reglOn Of the trapezius，
scapulalevator and rhomboideus・In a suplne pOSition，the Laseue，Achilles tendon reflex，and patellar tendon reflex tests were checked and tenderness of thelumbar paravertebral

musCle andiliolumbarligament WaS eXamined．In the standing position，mOtion paln andlimitationofmovementinthelumbarregiOnwereobservedbybendingtheupperpartofthebody back and forth．The series of examinations was performed on averagein about15
minutes with the completed questionnaire masked．Diagnosticimaglngincluding
COnVentionalradiographywasnotcarriedout．

The extent of tendernessin the cervicobrachial region foundin the examination was
evaluatedbythetotalnumberofthepartswithtenderneSSamOnglOsubregions：（1）fromthe

N．Yamamoto，etal．

（87）

fingerstotheproximalupperarmkightandleft，Ventralanddorsal）；C2）theshoulderjoint
anditssurroundingskightandleft）；Q）thecervicalregionkentralanddorsal）；and也）theupper back kight andleft of the backbone）．The extent oftendemeSSin thelower backregionwasclassifiedintothree：nOtenderness

paravertebralmuscleoriliolumbarligament）

；

；and

localtendernessbbservedineitherlumbar

spreadingtendernessbbservedinboth）

・

3）Statisticalanalysis
Differencesin the rates between two groups were evaluated by x2test，and a null
hypothesiswasrejectedwhenPvaluewasbelow5％．
3．Results
All self・administered questionnaires returned by the126

subjects were filledin

adequately，andtherewasnomissingdata．
As showninTable1，20subjects answered thattheyhadhadpaln OrStiffnessin theneck，Shoulders

or

armS

kervicobrachial

symPtOm，hereafter）

almost

none

in

the

past

month．Among these，95．0％showedno tendernessin the cervicobrachialregionby clinicalexamination．Thegreaterthefrequencyofthesymptomcomplainedofinthepastmonth，thelesserthepercentage

of

those

showingnotenderneSS．In

thealmostallday，eVeryday

group，Only9．3％of32subjects had no tendernessin the region・Contrarily，this group

showed the highest valuein the proportion of those having tendernessin four or more
subreglOnS．Thevalueof53．1％wasstatisticallyhigherthanthoseoftheotherthreegroups，
and

the

corresponding

valuein

the

not

all

day，but

everyday

group

was

slgnificantly

higherthanthoseoftheremainingtwogroups．Morethanhalf69．4％）ofthesubjectsinthe
almostallday，eVeryday

group

alwayshadhaddifficultyinoneormoredai1yactivities

inthepastmonth，beingstatisticallyhigherthanthecorrespondingvaluesintheotherthreegroups．Thepercentageofsubjectswhohadahistoryoftreatmentinthepasthalfyearinthealmostallday，eVeryday

and

not

alldaybut

everydaygroupswere

similar，but

higherthanthoseoftheothergroups．
Inthepastmonth，25subjectshadhadpainorstiffnessinthelowerbackqowerback
symptom，hereafter）

almost allday，eVeryday．Among these，60％showed tendernessin

boththelumbarparavertebralmuscleandiliolumbarligament・Thisfigurewassignificantly
higherthanthoseoftheotherthreegroups．Morethanhalf（56．0％）ofthe
everydaygroup

always

had

one

or

more

difficultiesin

daily

almostallday，

activities，incontrastless

than20％didintheotherthreegroups．Regardingthehistoryoftreatmentinthepasthalf
year，thenotallday，but

everydaygroup

showedthehighestpercentage，Whichwas

Slgnificantlyhigherthanthoseoftheothergroups．
Part2．MusculoskeletalsymptOmS and associated factorsamOng teaChers at schooIs for
pupilswithdisabilities

We conducted a questionnaire study for all teachers working with physically andintellectuallydisabledpupilsatpublicschooIsinOsaka，Japan．
1．Subjects
Subjects were1663

staff working at special education classes for physically or（88）Work−relatedmusculoskeletaldisordersamongteachersfordisabledpupils

intellectually disabled pupils at regular elementary and junior high schooIs，andlO schooIs

for pupils with disabilitieS極schooIs for physically disabled pupils，3forintellectuallydisabledpupils，1forinvalidpupils，lfortheblindandlforthedeaf）．
2．Methodsl）Questionnaires
The questionnaire consisted of three parts．The first part was to collect demographic

dataincluding the name of school，gender，age，height and body weight of subjects．The
SeCOndpartaskedaboutcervicobrachialandlowerbacksymptomswiththesameWOrdingof
questionsandansweroptionsusedinthestudyinPartl，daystakenawayfromworkdueto
the symptOmSin the past year，the severity，duration and appearance status

Of theSymptOmS．The third partinquired about nurslng−Care needed by pupils of whom the
Subjects werein charge．The questions consisted of nineitems，Which were developed by
WOrkplaceinspections andinterviews with teachers at severalrepresentative schooIs by theauthors，andfromthereportofTaodaetal．25）Thesubjectswererequestedtorespond
or

No

to

each

Yes

oftheitems．

Answers to each questionwerechosen fromalreadyprepared options，eXCeptage，body

Weight，heightandnumberofyearsworking．Questionnaireswereunregisteredtohelpelicita favorable response rateand distributed by the Secretariat of the Board of Education of

OsakaCitytoallschooIstaffthroughprincipals．Thequestionnairewaskeptfortwoweeks
bythesubjectsandreturnedthroughprlnClpalsandtheSecretariatoftheBoardofEducation．
2）Statisticalanalysis
Differencesintheaveragesbetweentwogroupswereevaluatedbyttest，andthex2test
WaS uSed to evaluate differencesin the rates．Nullhypothesis was rejected when a P value
WaS below5％，butin the case of multiple comparisons，judgment was made from theadjustedPvaluemultipliedby thenumberofcombinations oftestschallengedaccordingto
the method of Bonferroni35）．The factors associated with cervicobrachial andlower back

SymptOmS Were eValuated by multiplelogistic regression analysis．Independent variables
includedindividualfactors such as gender，age and BMI Q30dy massindex：Obtained byweightinKgdividedbythesquareofheightinm）aswellasoccupationalfactorssuchas
thekindsofschooIsandthequalityandquantityofworkload．AgeswereclassifiedintolO−
yearintervals，and BMIwas categorizedinto＜18．5hnderweight），18．5−25hormal）andbbese）．Thehomogeneityanalysis36）wasappliedtothe

Yes／No25

answeringpatternsforthenine questions about nurslng Care needed with regard to the conditions ofpupils ofwhom

thesubjectswereincharge，andcalculatedindividualobjectscores，Whichweresummarized
On a tWO−dimensionalplane，Were prOVided as a parameter for the quantity and quality of
WOrkload ofeach subject．Goodness offit for the regressionmodels and trend on the odds
ratio were tested by the Hosmer and Lemeshow test37）and the Cochran−Mantel Haenszel
test38），reSpeCtively．SPSS11．0．1J for Windows was usedfor homogeneity analysis，and the
OtherstatisticalanalyseswereperformedonSASrelease6．12forWindows．
3．Results

N．Yamamoto，etal．

（89）

Table2．Demographicdataofsubjectswhorespondedtothequestionnairebyschoolandgender

N。．嘉

M 453
F 661

YWSOrWOrk

Meam SD

M飽n SD43．2 9．8
42．7 9．7

15．110．3

Sclasses

M
F

172
316

44．さ
46．0

9．4
8．5

IschoolS

M
F

128
156

43．5
40．2

10．7
9．4

14．7
14．8

10．5
8．9

PSChooIs

M
93
F l10

39．8
37．5

9．5
9．9

12．1
11．7

‡．9
8．5

…欝…蕊監監扇th

M
13
F lO

39．4
41，2

8．6
12．1

14．6
13．7

8．＄
12．8

M

25

F

27

45．6
43．4

8．2
9，1

17．2 10．3
18．1 9．4

M
F

22
42

43．3
41．4

SchooIsfbrthoblind

Schoo18fbrthodear

8．7
10．6

16．7 10．8
19．4 10．8

14，8
16．5

9．7
10．4

Sclasses：SpeCialeducationclassesforphysicallyorintellectuallydisabledpupilsin

regularelementaryorJuniorhighschooIs，IschooIs：SChooIsforintellectuallydisabledpupils，PschooIs：SChooIsforphysicallydisabledpupils，M：male，F：female．

1）Subjectsforanalysis
Questionnaireswerereturnedfrom1，411毎4．8％）ofthe1663subjects．Excludedsubjects
were19who did not answer the questions on gender or age and278subjects who were
engagedin management or office work and notin teaching classes．Table2shows thedemographic dataofthe remalnlngl，114teachersby schoolandgender．In total，themean
agewasabout43inbothmalesandfemalesandtheyhadbeenworkingforabout15years・Over40％

極88／1114）worked at specialeducation classes for physically orintellectuallydisabledpupilsatregularelementaryorjuniorhighschooIs6classes，hereafter）．TherewerelO pupils at mostin a slngle S class，With one to three teachers．A totalof284teachers
worked at schooIsforintellectually disabled pupils任schooIs，hereafter）．The pupils had
hardly any physicalproblems．Two to five teachersin a team took charge of around20
pupilsinaclass．Atotalof203teachersworkedatschooIsforphysicallydisabledpupils住｝
schooIs，hereafter）．Themeanages ofthese teacherswereyounger than thoseofthe otherschooIsinbothgenders．Pupilshadphysicalproblemsandneededintensiveandvarioushelpin dailylife．Two or three teachersin a team had a class of severalpupils．The ages ofpupilsrangedfromsixto18inPandIschooIs．Twenty−threeteachersworkedataschool
forpupilswithapoorconstitution，52fortheblindand64forthedeaf．Thesethreenumbers
weretoosmalltoanalyze，particularlywhenthesubjectswereclassifiedbygender．Forthe
followingstudy，therefore，atOtalof975teachersworkingatPorIschooIsorSclasseswere
includedonly．

2）Nursingcarerequiredbythepupilsandworkloadamongtheteachers
FigurelshowsthepercentageofteachersinchargeofpupilswhoneedednurslngCareby gender and schooIs．AlmostlOO％of both male andfemale teachersin P schooIs had
pupilswhoneededholdingformovingorgettinglnandoutofawheelchair，

Whoneeded（90）Work−relatedmusculoskeletaldisordersamongteachersfordisabledpupils

Res廿扇nSllppOrt

Reshain

Supporl

d血gsi血g un鍔peCted

d血ngs血ng qneX阿ted

behadorbehdor

Fig．1．Radarchartsshowingthepercentagesofteacherswhotookchargeofpupilsbygender，SChooland
ninekindsofnursingcarepointsrequired．酬蝉鞘：PschooIs，酬：IschooIsand

聯開間：Sclasses』eethefootnoteofTable2）

help changlngClothes
wereinchargeSputumneeded

，

the

Of

Who

and

pupilsneededsupportwhowore diapers
whotoofhands

needed

be

or

help

supportedamS

duringwhoneededwashingafterevacuation．Inaddition，mOrethan75％ofthe teachers

drinking

byarms

sittingthefewestduringmoving

pupilswhoneededswallowing

by．Thesehands

nurslng

food

on

or

discharglng

movlngCare

andpOints

and

who

those

showedthehighestvaluesinPschooIs．Ontheother

hand，thepercentagesofteachersinchargeofpupils

Oftensatdown

or

orled

whobehavedunexpectedly

werethehighestinIschooIs．The

varioustypes

movlngOrgettinglnandoutofawheelchairof

nursing

care

and

who

teachersinSclasseshad

exceptneededholdingfor．

IndividualpatternsofanswerstotheninenurslngCarepOintswereintegratedintotwo−
dimensionalinformation based on the homogeneity analysis 町ig．2）．The cumulative
contribution ratio ofthe firstand the second factors was60．7％，Which was satisfactory．In
thepositivedirectionofthexaxis，WithYes

answersindicatingthepresenceofpupilswho

neededrespectivenursingcarewereplaced，andinthenegativedirection，theNoanswers

indicatingtheabsenceofsuchpupilswerearranged．Inthepositivedirectionoftheyaxis，
With

the

SWallowing

Yes

food

answersindicatingordischarging

thesputumpresence，Who

movingorgettinginandoutofawheelchairduringsitting

indicatingtheunexpectedly

Wereplaced，andin

presence

were

of

the

pupilsarranged．These

often

pupilswore

andnegative

whoofdiapers

arrangements

needed

，

Who

help

neededdrinkingorholdingforwhoneededthesupportofhandsorarmS

direction

sat

who

down

of

the

while

showedyaxis，themoving

that

the

y

and

axis

Yes

answerswhobehavedreflected

thephysicalandintellectualconditionsofpupils．

3）Complaintratesofcervicobrachialsymptomsandassociatedfactors

Table3showsthecomplaintratesofcervicobrachialsymptOmSandtheircharacteristics

N．Yamamoto，etal．

（91）

Fig．2．Configurationofnursing−Careitemsbasedonhomogeneityanalysis・A〜Ishowthechildrenwho

neededvarioustypeofnursingcare・A：Holdingformovingorgettinginandoutofawheelchair，B：
Supportbyarmsorledbyhandsonmoving，C‥Sittingdownduringmoving，D：Washingafter
evacuation，E：Restrainingunexpectedbehavior，F：Supportofhandsorarmsduringsitting，G‥Help

drinkingorswallowingfoodordischargingsputum，H：Wearingdiapers，Ⅰ‥Helpchangingclothes・

Squaresandtrianglesindicatethepresenceandabsence，reSpeCtively，Ofchildrenwhoneededthe
respectivenursingcare．

intermSOfgenderandschooIs・Amongthe393maleteachersintotal，16・3％complainedof
cervicobrachialsymptoms

answering
everydayclinicalmostall

not all day，but everyday

day，eVeryday

in

the

past

month・When・Morethanhalfofthemaleteachershadanexperienceofattendinga

inthepastyear．Thosewhotook

thosewere added，29・3％complained of the symptOm

paidholidays

andsickleave

hospitalor

duetothesymptom

reached15．5％andl．0％of the subjects，reSpeCtively．Among the243mole teachers whocomplainedofcervicobrachialsymptOmSmOrethanseveraltimesaweekinthepastmonth，
7．8％feltitwasdifficulttocontinuetheirworkwithouttakingpaidholidays．Thesymptom
appearedgraduallywithoutawarenessin63．8％ofthe subjects，but

suddenly

9．5％．MorethanOne−thirdofsubjectscomplainedofthesymptomlastingfor
ayearandanotherthirdsaiditwas

recurrence．Compared

with

these

in alowmorethanhalf

difficulttoanswerbecauseofrepetitiveremissionand

resultsin

themales，thefemale

cervicobrachialsymptomsmorefrequently，didnotneedrestbutfelt

teachers

complainedof

thesymptomstrongly

moretimesduringwork，butattendedahospitalorcliniclessfrequently・Thepercentagesof
femalestaking

paidholidays

andsickleave

wereslightlylowerthanthoseofthemales・IntermsofschooIs，theratesofmaleswhocomplainedofcervicobrachialsymptoms

everyday，butseveraltimesaweek

andtookpaidholidays

notbecauseofthesymptOmSWere

slgnificantlyhigherinthosewhoworkedatPschooIsthaninSclasses・Inaddition，therate
offemaleswhotook

paidholidays

wasslgnificantlyhigherinIschooIsthaninSclasses・

（92）work−relatedmusculoskeletaldisordersamongteachersfordisabledpupils

Table3・Cervicobrachialsymptoms，treatment eXperience，and current status of the symptOmS amOng
teachers by genderand school．Allfigures with a decimalpoint show the percentages ofthe
COrreSpOndingnumberofthesubjectsineachcolumn
Totd

393

582

156

ズlkSt

316

0 0 7

2

4

●

5

2L
2
5

1

0
J 9
9 9
7

つ 一

5

4

4

80
2

2

4

5

2

7

t 一

4
0

60
1

9

m m nS nS n閏 m ＞ mS

O

2

8163
1 2 3

2

′ 0
5 5

8

＄
n

2
4
2

2

■−一

t
一

nnnnn爪nnnnn

5

n

れ
m
n
n

J

4

一

0

7

n

m

9

○○

J

m

3

■■一−．一

5

4

n

3

0

ウーOP一b

ノ

nH

1

′0

一

0

n

1

■j

5

n

O′

4

′00

n

O

0

2

00
■J
︷J

t 一 6

00−ヽ′一ヽ一〇〇■

1

′○

l

n

一b

1

6

127142414

7

59897
1．
4906．1 029 0 10 4
4■
9J
31
ヽ7
J3452254
44
4

2

＞

00

1

3

2．
08
0朝
03
02
︵．
U2
4．
04
0．
0臥
0
0
4
0
0
0
1・1
4．
1 0
00
00．
4 72．4．
7
4
1

5

3

710
84
91
13
203
J4
57
2−
11
95
ヽ
J
L1
69
13
84−4
9
6
4

0 ′
tJ 0

1

9

5

6312734＜200′ 0 9 一 〇1

0 0

Abouthlr▲y蝕・Moreth即日HuIry塊r
鮎叩血h加減on肌dr的mnC●
N01個Wer8一5′○Abutlmonth2−3mon血I

ノ 0

3
1

No且n＄Wer

Abutlwt杷k

DumtionorthHymptOm＞

7

App血恥ddenly血血喝WOrkin8
App別け由鮎ddenlyduri喝nOn・WOr臨場time
App町dnot餌ddenlybutinHhontim￠
伽du811y叩p町dwithout8W椚爪田島

一 ︶ 4

9

App肌雄鳥t血lさOrthHym〆Om

へ J ヽ J 5

MiId8ymptOmS 32．5
32・6
刃mo銘ignor鵬le 6．6 ＞ 3，3
No山鳩Wer
8．2
4．3

0

Nod0∝里iomlrostdud喝WOrklime l1．9
9．8
tnedre虞butf如1血Hy叫伽m如Ⅶ喝ly 32．9くく43．7

0775 L 8
2 23 1
4 1

Don

nmmnnnnnnnn

460
6．3

9 97 9 9 0 70070〇二978005
17 一 32つ−9 4 7■J ○○
′3
01
9′
3〇
6400 V5′020t0
3

DiEncu）ttocoJltinueworkwithouttAkingpaidh01id＆y8

90
15
9．
3鉦
36
′．
0L
14
3糾
1し
11
′
1 0
0 0 0 23 1
1
．
1
4
．
3
甘
6
．
1
44

243
7．8

Currcnt如hJSOftheSymPtOm▲

Numkror乳l切餌tSり0．】p

Sickle■Ve l．0

110r

pddhol血yl15．5 12．5

P血∞lsIaGOO18S618舶頓＄172n38．2＞＞21．0

Ho叩i血，Clinic 56．0 ＞ 49．1
Acupumdure 23．7
21．1
Holi血y8t止enduotothe00Mcobr血i■18ymptOm

128

m m＄＞椚 田 m ＞ m

Almo鯉nolle

Tr塊Im印tp甲demceinthep鮎ty塊r

93

ズlt頭

0002﹂ 6 432
1914祁40 6124 91．

C併Yi∝血制止■1町mptOmin血￠pa虞mon仙山mo虞dld■y eV打y血y16，3
20．4
Not811血y，buteY倒y血y13．0くく23．7
Not即叩血y，but挿Yt血time＄■W00k 32．6
34．9

Femde

P血0018Ⅰ血001島SCh＄椚
0 3 3 3 5 5 2
2 L7
5
・2
56
0
・3
・・
9
日 88・川 7 6 一h▼23 V22252
00
つ
J
0 5
5 5
5 3
一3
h2
V1
一1
一′
00
79390▲
955
5
1

Fom■1015．・
朋943︒︒
L・7
8
・2
2
462
■
︒
︒・
朗
・

NumberMd￠

M山1）thenumberofthesubjectswhocomplainedofthesymptOmmOrethanSeVeraltimesaweek．PschooIs，IschooIsand
Sclasses：SeethefootnotetoTable2．＞，＞＞or＜，くくindicatethatthevalueoftheleftsideissignificantlyhigheror

lowerthanthatoftherightsideatthelevelsofO．05andO．01，reSpeCtively，bythe x2test．nsmeansthatnoslgnificant
differencewasfoundbetweenanycombinationamongthethreegroupsbyschool，Noslgnificantdifferenceswerefoundintheotherinventoriesinbothgenders．
Table4showsthe results of thelogistic regression analysis under three different
models，inwhichtheconditionofthecervicobrachialsymptOminthepastmonthwassettobeadependent

variable．Only

theansweralmostallday，eVeryday

wasregardedaspresenceofthesymptom，andtheotheranswerswereregardedasnone．Ineachmodel，thefitnessfortheregressionmodelwasaccepted住〉＞0．1）．InModelI，inwhichonlyindividual

factors wereincluded，female against male as well as the thirties age group and older
generationsagainst the twentiesagegroupwere shown tobe thefactors thatsignificantly
increasedthecomplaintrateofcervicobrachialsymptoms．InModelII，addedschoolfactors
WerenOtSignificant，butobesity亀MI≧25）wasfoundtobeasignificantriskinadditionto
age・ModelIIIadded theworkload factors representedby thelst and2nd objective scores
Obtained by the homogeneity analysIS．In this model，Obesity was not a slgnificant factor．
Age remained a slgnificant factor as shownin the other models，With the odds ratio
increasingwithage．Regardingthelstscore，beingtheQlgroup6corevalue：＜25％ile）used
asareferent，theoddsratiosofQ3（≧50％ileand＜75％ile）andQ4（≧75％ile）groupsboth

Showed2．6，Significantlyhigherthan1，andtheoddsratioincreasedwiththeobjectscores．
Contrarily，thesecondfactordidnotshowanyslgnificantassociationwiththesymptOm・

N．YamamOtO，etal．

（93）

Table4．Individual and occupational factors related to the cervicobrachial
symptOm bylogistic regressionanalysis under three differentmodels・
Figuresshowoddratioswith95％Confidenceintervalsafteradjusting
forallotherfactorsineachmodel
FICtW
Gond釘

MOd81I

Mod01Ⅱ：FomddMd0

1．4

ModelIⅢ

1．0−1．1

BMl ：UTlderweightnVormd O．5 0．1−1．2
0b ssルbnnd l．5 0．9−2．3
Ago：30扉20s l．8

0．9−3．7

40扉20＄

Sd001

1．0−2．1

1．5

1．0−2．l

0．5 0．1−1・20・5 0・1−1・3
1，6 1．0−2．4 1．6 0．9−2．4

1．8

2．31．2−4．5

50扉20S

1．5

0．9−3．9

1・7

2．41．3−4．9

2：P引血0015誼sd10015

0．9

0・9−3・6「

2．01．1−4．2Pl三ミ・01

81．4−5．8

2．71．4−5．5」

0．6−1．5

0．7

SdaS＄鰯爪駆h00ls

1．2 0．7−2．2「lSt血血r：q2／ql
q3／ql
Q4／q1

2．61．5−4．7P戸．01

2md鮎br：Q2／ql

1．2 0．7−1．9

2．6 1．4−4．‡」

Q3／ql

1．0 0．6−1．8

Q4／ql

0．8 0．4−1．5

Underweight：BMI＜18．5，Obese：BMI之25，Ql：Scorevalue＜25％ile，Q2：Scorevalue＿≧
25％ileand＜50％ile，Q3：Scorevalue＿≧50％ileand75％ile，Q4：Scorevalue＿≧75％ile．Pland
P2Showtheresultsoftrendtestforageandlstfactor，reSpeCtively．PschooIs，IschooIsand
Sclasses：SeethefootnotetoTable2．

4）ComplaintratesoflowerbacksymptOmSandtheirassociatedfactors
Table5showsthecomplaintratesoflowerbacksymptOmSandtheircharacteristicsin
temS Of gender and schooIs・Among the393male teachers，19・6％
symptom

almostexperience

leave

of

all

day，eVeryday

attendingahospitalor

in

the

clinic

past

in

the

month，and

past

complained of thenearly

year・

Paid

ohe−third

holidays

had

and

an

sick

becauseofthesymptomweretakenby30．8％and1．5％ofthemales，reSpeCtively・In

the290maleswhocomplainedofthesymptommorethanseveraltimesaweekinthepast
month，thelower

higher

than

that

back

symptOm

appearlng

remission and recurrenceinappearing

Suddenly

44．5％

gradually

duringworking

andlasted forwithout．The

awareness

symptomwasshowedmore than half a year

a

in

four

times

repetitive

38．3％．

Compared with these resultsin the males，female teachers showed significantlylower
percentagesthanthosewhoattendedahospitalorclinic，tOOk

difficulttocontinueworkwithouttakingpaidholidays

paidholidays

andfeltitwas

duetothelowerbacksymptOm・No

Slgnificantdifferencewasfoundinotherinventories．
IntemSOfschooIs，therateofteacherswhodescribedtheirsymptomsas

almostnone

was slgnificantlyloweratPschooIs thanSclassesinthemales，and thanSclassesandI
schooIsinthefemales．

Paidholidays

takenbecauseofthesymptOmOCCurredmoreoftenat

PschooIsthanSclassesinbothgenders．Thesymptomappeared

suddenlyduringworking

with a significantly higherfrequency at P schooIs compared with S classes onlyin themales．ThemaleteachersofSclasses experiencedrepeatedremissionandrecurrenceofthe
symptomlessfrequentlythanthoseatIschooIs．
Table6shows theresultsofthelogisticregressionanalysIS，inwhichtheconditionof
lowerbacksymptOmSinthepastmonthwassettobeadependentvariable，andthesame
factorsasinthecaseofthecervicobrachialsymptomwereconsideredindependentvariables・
Onlythealmostallday，eVeryday

answerwasregardedaspresenceofthesymptom，and（94）work−relatedmusculoskeletaldisordersamongteachersfordisabledpupils

Table5．Lowerbacksymptoms，treatmenteXperience，andcurrentstatusOfthesymptomsamOngteaChers
bygenderandschool．Allfigureswithadecimalpointshowthepercentagestothecorresponding
numberofthesubjectsineachcolumn
Tot81
M山

S
＞

p▲

＞

S

︑r

叫nSnS︽ nSm

nr

S

︾m

2

5
3
5

′ 0

■ て ﹂ −

′ ○

0 0

4

9

2

0

3日

7
1
4

5

400
J

3

1

5

5

2

ヽ J

9

−て一7

8

霊山・

＄

06
′
0
1
什
3．
糾1
し8 5

0

8

4 1

55
54
11
7 13．3．4．2．38叫3．
5
1
1′
○3

0

1

nSmmnSnSmnSnSm＞mmmSmmSmnSmn＄
nr

1

1

J

O4
O5
O1
2．
33
一9
〇3
▲5
葛1
06
81
7．
32
34
〜8
62
33
13
34
76
52
2
6
3
0
5
1
1′
05

9

4

784
15
2
5
3
3
0
・
6
2〜
3
・6
・
2
・
6
・日
2
・1
3・
5
06
2
・8
・胃
3
・3・
＄6
2・ 8
3・
22534

8

′ 0

＞

t J

′

Morethnhlrly払rRope血dmmis扇ondndrecummG￠
No且nSWerq

2・3monthS
About■hl丹紺

1

Aboutlweek
Aboutl month4

mr如ionortl旭丘ymptOm

1

App醜・edsuddenlydudngworkingApp鴎redsuddenlyduringnOn−WOrkinBtime
Appednot凱IddenlybutinaShorttime
Gradudlyapp町dwithoutaWmneSS
No…Wer

1 61 4 3 2

No8rはWer

App朗∫■nG＝山山遁Orthosymptom458

9：2二91475て一
42
13
92
42
41
71
61
1

O

Numkror8両∝t81） 290
Current如mSOfthesymPtOm
Di爪culttocontinueworkwithoutt止ing画dholi血yS
N餌do皿ionalr朗tdudngworbimo
Don t冊dro虞but蝕lthHymptOmStIOndy
MildlymptOmS〟mostigmor血10316

日6．1634382．0．14．9．9．糾2．1．−．3．0．36．52．L

l2

pddh01i血ys 30．＄＞＞19．4
SiCkl也Ve l．5
1．2

156

93
71
73
751
87
91
3
0
1
つ一
40−
22
1一

一

Holi血yit止enduetothesymPtOm

ズ2test

110

1ト7
2
1
4
・
4
1
3
3
00
0
・川
・
・‖畏ト60
1㍊
・ ト03
35
4
−0
0
8
・・
・
2522413
川
2
22300 12U

9

Hospital，Clinic 30．3 ＞ 23・2
Acupuncturc15．5 19．8

172

Sn
SSnS＜mSm︾nS SSSSM
nSn＄mmnS＞nS＞mnmmmmS＜mSmnS＞m
pp
lnr︼1

4

Almo且tnOne

Tredmentexpcricnceinthep鮎tyeu

128

7′
へ0
J0
80
20
く0
一4
−5
ヽ1
一07 2
00
▲．
︾4
20
89
20
84
29
26
71
24
86
25
24
74
76
363
J＄
76
24
2
2
13
32
12

一

Noteveryday，butsevcTdtiJTleS＆Week

93

17
20
′0
00
17
つ5
J0
′′
0L
7′0 92㍍︒〝・
8
4告
・墨㌫‖㍑M
4
l
14
22
12

t

9

Notlll血y，but即亡けdly

8 2 73520L
l1 2 4269

l l1 3 2LowerbACksynptominthepAStmOnth
刃most山ldly，eV即yday

582

J0
O4
4一
1b7
9201
12
0
2
31
31
47 一L

393

NumberM81e Femde

Fomle P虻0018Ⅰ血0015Scl蛸闇。がteSt P血001sI甚hooIs Sd8S50S

1）thenumberofthesubjectswhocomplainedofthesymptOmmOrethanSeVeraltimesaweek．PschooIs，IschooIsand
Sclasses：SeethefootnotetoTable2．＞，＞＞or＜，くくindicatethatthevalueoftheleftsideisslgnificantlyhigheror

lowerthanthatoftherightsideatthelevelsofO．05andO．01，reSpeCtively，bythe x2test．nsmeansthatn（）Slgnificant
differencewasfoundbetweenanycombinationamongthethreegroupsbyschool．

the others were regarded as none．In each model，fitness for the regression model was
accepted住）＞0．1）．NeithergendernorBMIwasasignificantfactorinanyofthemodels，While

age was always aslgnificant factor．The odds ratio forsubjectsin theirfiftieswas highest
bround3），and there was a tendency toincrease with age．The object scores of the two

factorswere dividedasinthe cases ofthe cervicobrachialsymptOmandincorporatedas anindexforworkloadinModelIII．Inthismodel，theoddsratiowashigherinthegroupswith
largerscoresofthefirstscore住）＝0．058fortrendtest）．Onthecontrary，thesecondfactordid
notshowanyslgnificantassociation．Afterconsideringthese twofactors，the oddsratios ofthe symptomin P schooIs and S classes were slgnificantly higher thanl，WhenI schooIs
were referent．
DISCUSSION

IthasbeenwidelyacceptedthatcontinuedandrepeatedloadsonaspecificregiOninthe
upperextremitiesdevelopwork−relateddiseaseswheredamagedareasareratherlimitedsuch
aslateralandmedialepicondylitis5・39），Cubitalandcarpaltunnelsyndromes6・40￣42），peritendinitis

Or

tenOSynOVitis

or

De

Quervainsdisease2・43），and

rotatorcuffsyndrome44）．Aside

from

these

diseases，the existenceofconditionspresentingchronicpainorstiffness overawiderrange

N．Yamamoto，etal．

（95）

Table6．1ndividualandoccupationalfactorsrelatedtothelowerbacksymptomby
logisticregressionanalysis under three differentmodels．Figures show
odd ratios with95％Confidenceintervals after adjusting for all otherfactorsineachmodelF蜘r Mod011

Mod81Ⅲ

ModdIⅡ

Gmd訂 ：Femd仙e O．8 0．6−1．1 0．8 0．6−1．1 0．‡ 0．6−1．1
BMl ：Underwei由t朋omd l．7 0．8−16 1．7 0・8−3・6 1・9 0・8−4・00b頗dNonnd l．3
Ago

Sd1001：30S佗恥0．8−2．0

1．2

2．41．2−5．340‡佗0＄

2．31．2−4．‡508佗0＄

2

0．‡−1．9

1．2

2．61．3−5．8
2．61．3−5．5

4−6．0：PschooIs〟sd001s32．40．8−2．O

2・51・2−5・2「2．21．1−4，82

1．5−3．9

Pl＝．05

3．11．5−7．0」

2．0

1．0−3．9

SCl鮎S郎几肛h0015

lst血ct併：Q2／ql
q3／Ql

1．6 0．9−3・0「

q4／q1
2nd鮎br：Q2／ql
q3／Ql
q4／ql

2．4

1．2−4．8」

0．9

0．5−1．5

1．0

0．5−1．7

2・51・3−4・6

Pユ＝・0580．‡ 0．4−1．4

Underweight：BMI＜18．5，Obese：BMI之25，Ql：Score value＜25％ile，Q2：Score value＿≧
25％ileand50％ile，Q3：Scorevalue＿≧50％ileand＜75％ile，Q4：Scorevalue＿≧75％ile・Pland
P2Showtheresultsoftrendtestforageandlstfactor，reSpeCtively．PschooIs，IschooIsand
Sclasses：SeethefootnotetoTable2．

fromthefingerstotheshoulderandneckhasrecentlybeenrecognized，andattractedmuch
attention．This featureis referred to as nonspecific upper−eXtremity musculoskeletal
disorder32・45・46），andisconsideredthedominantportionofdisorderspreviouslyreferredtoas
repetitive straininjuries47・48），Cumulative trauma disorders3），andoccupationalcervicobrachialdisorders49・50）．Wheredamagedareastendtoberestrictedasaresultofworkingpractices，it
isappropriatetodesignquestionsthataskaboutsymptomsseparatelyintheneck，Shoulder，

arms，elbows，andwristjointsandintherightandleftregions．However，SChoolteachersof
disabledpupilsperformaVarietyofshortdurationactions23，24・51）suchasholdingapupilinclass，SuppOrtingsittingorstandingpositions，SuppOrtingwalkingorrestrainingunexpectedbehaviorsofapupil．Theseactionswerealsoapplicabletonurseryschoolnurses52），Whowere
the subjects of the present study，tO eXamine the validity of the self−administeredquestionnaire・Theeffectsofsuchworkpracticesexertedonalltheupperextremitiesarenot
limited to a specific region．So，nOnSpeCificupper−eXtremitymusculoskeletaldisorders mustaccount for the maJOrity of diseased conditions

amOng the nursery school nurses・

Accordingly，aentirequeStion

which

we

developed

for

the

upperextremities；

haveexperiencedanypalnOrStiffnessinyourneck，ShouldersorarmSinthepastmonth？

you

would

beappropriate．Thealternativewouldhavebeentopreparequestionsforeachsubregionof
the upper extremitiesand then to evaluate the combinations that were generated・This
alternative，however，WOuld have resultedin more questions，Which naturallylnCreaSe thenumbersofquestionsnotanswered，reducingthenumberofvalidresponses．

There was only one question relating tolower back symptOmSin the present study：
have

you

experiencedany

paln

Or

Stiffnessin

yourlowerbackinthepastmonth？

・No

questionwasincludedtoscreenthepresenceoflumbardischerniationorfacetsyndromeas
represented by a radiating pain to thelower extremities．This was prlmarily because themaJOrityoflowerbacksymptOmSdetectedinworkersofvariousjobswasofthemuscularor
hscial nature53），and partly because the question providedin this study couldidentify

（96）Work−relatedmusCuloskeletaldisordersamongteachersfordisabledpupils

persons with disorders such aslumbar disc hemiation aslong asit was accompanied bylowerbacksymptOmS．
Fouransweroptionsexclusiveofoneanotherwerepreparedtoascertaincervicobrachial
andlower back symptoms．MusCle tenderness evident by our clinical examination wasrecognizedamongonly5％ofthesubjectswhochosetheansweroptionof

almostnone

inbothofthesymptoms．Themorefrequentlysubjectscomplainedofsymptoms，thewiderthe
reg10nSWheretendernesswasobserved．Further，theratesofthosefeelingdifficultyindaily

activities were significantly higherin the group most frequently complaining of symptoms
thanintheotherthreegroups．
Thus，the question and answer options adoptedin the present study reflected well
Clinicalconditionsofnonspecificupper−eXtremitymusculoskeletaldisordersandtheextentto
Which musculoskeletalsymptomsintervenedin daily activities．The descriptions used wereplain and the number of questions waslimited．We considered that these questions andanswer options could be applicablein a self−administered questionnaire study on

musculoskeletaldisordersincludingthecervicobrachialandlowerbackregions．
Our present self−administered questionnaire survey of about a thousand teachers
WOrking for disabled pupils clarified that19．6％ofmale teachers complained oflower back
SymptOmS

almostallday，eVeryday

in

the

previous

month．AIso

the

study

30．3％ofthemalesattendedahospitalorclinicinthepastyear，30．8％took
and1．5％

sickleave

revealedthat

paidholidays

inthepastyearbecauseofthesymptoms．Thecorrespondingratesfor

femaleswere15．8％，23．2％，19．4％，and1．2％，reSpeCtively．Thesefigureswereconsistentwith
those reported by Taoda et al．25），Who surveyed teachers of physically andintellectuallydisabled pupils．Furthermore，these were comparable with results obtained fromJapanese
WOrkersin occupations prone tolower back problems：male sanitation workers53），
COnStruCtion workers54），and forest workers55）；for women：nurSeS17），nurSery SChoolnurses23），

and schoollunch cooks56・57）．Thelower back symptOm amOng the present subjects appeared
graduallywithoutawarenessThe

numbers

recurrence

of

those

whose

orpersisted

fourtofive

symptOmStOOktimesgreaterachronic

formorethanahalfyear

thancoursesuddenlyofduringworktime

repetitive

remission．

andwerehigh，nearly80％ofthesubjectsin

total．SuchcoursesofthesymptOmWereOneOfthefeatures58）observedinstaticmusclework
OCCupations where awkwardposture，SuCh as bendingforwardand twisting，WaS undergone

frequentlyratherthanadynamicmusCleworkoccupationwhereprlmarilyheavyloadswere
handled．
MorefemalescomplainedofcervicobrachialsymptOmS

almostallday，eVeryday

pastmonth（20．4％）thanmales（16．3％）．Theratesofthosewhotook
leavebecauseOf

cervicobrachial

symptOmS

Were

ratherlowin

paidholidays
both

males

and

inthe

or

sick

females

COmparedwiththosetakenduetolowerbacksymptOmS．Contrarily，eXperiencesoftreatment
in

the

past

awareness

year

and

recurrence

werepersistedhigh．Thefor

cervicobrachial

more

than

a

half

symptOmyearorappearedwasgradually

repetitive

without

remissionandinthemajorityofthesubjects，aSWaSthecasewithlowerbacksymptOmS．

Inthepresentstudy，WeuSedthetwofactorsintegratedbythehomogeneityanalysISaS
anindexoftheworkloadonteachersworkingwithdisabledpupils．Thepositivedirectionof
the first factor axis was plotted with answers showing the presence ofpupils who needed

N．Yamamoto，etal．

（97）

nurslng Care，While the negative direction of the same axis showed the absence of such

pupils．We considered thatthe firstfactorindicated the quantity ofnursingcareburdenon
the teachers，and that the higher the points scored，the greater the burden．On the second
factoraxis，thedischarglng

pupilspresence

Sputum

and

of

who

pupilswore

whoneededdiapers

whooftensatdownwhilemovlng

and

Were

help

drinkingplottedinaorswallowing

positive

whobehavedunexpectedly

food

or

direction，While

Wereplottedin

anegativedirection．Fromthis，WeCOnSideredthatthesecondfactorsuggestedthequalityof
anurslngCareburden，andthatthehigherthepoints scored，themorephysicalnurslngCarethat was needed．

Aninvestigationuslnglogistic regression analysis showed that of the two factors wehave used asindices of the burden of nursing care，the first factorincreased the risk

Significantly for developlng the cervicobrachialsymptOm，eVen after consideringindividual
factors，i．e．gender，age，and BMI，and the different types of schooIs that teachers areattending．Further，the higher the points of the first factor，namely the more nurslng Carerequired，the significantly higher the odds ratio became．Maeda et al．24）asslgned school
teachersintogroupsofslight，mOderate，andheavynursingcareburdengroups，basedonthe
physicalconditions of the pupilsin the classes．They observed that the complaint rates ofpalnSin the neck，Shoulders，and armSincreased gradually according to this order ofgrouplngS．Althoughthecriteriaforthisclassificationwerenotclearlystated，theirfindings
agreedwithourresult．NurslngCarerepreSentedbythefirstfactorincludesmaintainingthe
Sitting and standingposture ofpupils，holding them formovlng24・51），and holding the upper
extremities to restrain against unexpected behaviors．These correspond to static muscle
loads，forceful wrist extension／flexion or grasping with an armeXtended，and sustained
flexion／extension ofthe neck．

As forlower back symptOmS，the first factor was confirmed as anindependent risk
factorshowingadose−reSpOnSerelationship．Theteachersofdisabledpupilswererequiredto
use repetitive anteflexing posture for many aspects of their working practices23，24・51・59）・Our
previousstudy51）showedthatthetrunkinclinationangleofteachersinclasswasanaverage

24．1degrees＄D4．3），Whichwaswellovertheconsidered20degreespointwheretheriskof
lower back symptom beginsincreasing60・61）．This was because their point of working wasalwaysatalowheightsincetheirpupilswereusuallyinadorsalpositiononafloormat，Or
On an anCillary skid due to theirillness．Additionally，Weightloads were exerted on the
lumbar area while holding pupils to move or whenlifting pupils．These working practices

mightcausethesignificantaSSOCiationbetweenthefirstfactorandthecomplaintrateofthe
lowerbacksymptOm．
Thesecondfactor，WhichweconsideredtheindexforthequalityofnurslngCareburden
On the teachers，Showed no slgnificant relationship with either the cervicobrachialorlower

backsymptOmS．Inourstudy，thesubjectswereonlyrequestedtorespondtowhetherornot
they tookcharge ofpupilswhoneeded the nine differentnursingcarepoints．The resultof

thelower back symptOm Study showed that the type of schoolremained a slgnificant risk
factor even after the first and second factors were takeninto account．This suggested that
WOrkloads other than those represented by the two factors could associate with themusculoskeletalsymptoms．Furtherinvestigation should be conducted considering the body（98）Work−relatedmusCuloskeletaldisordersamongteachersfordisabledpupils

weight，physicalconstitution and the nature of paralysIS Of the pupilconcerned，With orwithoutapplicationofancillarytooIs，andthenumbersofteachingstaffandsoon・As forindividualfactors，age WaS a risk factor for both the cervicobrachialandlower
back symptOmS・In addition，eVery regreSSion modelin this study confirmed that being
femalewasaslgnificantriskfactorforcervicobrachialsymptoms・Similarresultswerefoundin other jobs5・62）．Gender difference63・64）in musCle fiber compositionin the trapezius muscle

couldbeoneofthereasons．Thepresentstudy，however，Showedahigherriskofthelower
back symptomin males，thoughnot significantly．Further，in anotherjob56）cervicobrachial
symptoms were also foundmorefrequentlyin females，While the complaint rates oflower

backsymptOmSWerehigherinmales．Fromthese，thereisapossibilitythatthedifferencein
theprevalenceofthemusculoskeletalsymptombetweenmalesandfemalesisattributableto
workloads reflected by differencesin the roles ofworking naturally borne between males

andfemalesinthesameworkplace．BMIwasnotasignificantriskfactorin theregression
modelincorporating allfactors．However，ifa standardbodyweight（18．5≦BMI＜25）wasreferencedforthecervicobrachialsymptom，alowerriskwasnoticedwithlowerweight（BMI＜18．5）andahigherriskwithobesity炬MI≧25lwhile ariskofthelowerback symptOm
tended to be highin bothlower weight and obese subjects・These results are ofinterest
becausethereisapossibilityofloweringtheriskofdeveloplngmuSCuloskeletalsymptOmS
byinterveningin the body weight of subjects．Further studyis necessary on this point，
however．
CONCLUSIONSThe present self−administered questionnaire study clarified that complaint rates ofthe

cervicobrachialandlower back symptoms were clearly highin teachersin charge ofphysicallyandintellectually disabledpupils・Thesesymptomswereconsidered tobework−
relatedcausingtheteachers

to

take

paid

holidays

andsickleavefrequently・AIso

thepresent study showed that the question and answer options we developed are usefulparametersin epidemiologlC reSearCh formusculoskeletalsymptOmS nOW Widely prevailinginvariousworkplaces．
REFERENCESl）Ministry ofEducation，Culture Sports，Scienceand Technology：Report on Fisical2001SchooIBasic
Survey．Zaimu−insatukyoku，Tokyo，pp．15，45，2001．

2）Amstrong，T．J．，Fine，L．J．，Goldstein，A．A．，Lifshitz，Y．R．and Silverstein，B・：Ergonomics
considerationsinhandandwristtendonitis．J．HandSurg．12A：830−837，1987．

3）vemputz−Anderson：Cumulativetraumadisorders：AmanualformusCuloskeletaldiseasesoftheupper
limbs．NationalInstituteforOccupationalSafetyandHealth．Cincinnati，Ohio，USA，NewYork，1988・
4）Ohlsson．K．，Attewell，R．and Skerfving，S．：SelfてepOrted symptomsin the neck and upperlimbs offemaleassemblyworkers：impactoflengthofemployment，andselection．Scand．J．WorkEnviron・Health
15：75−80，1989．
5）viikari−Juntura，E．，Ktuppa，K．，Kuosma，E．，Huuskonen，M．，Kuorinkn，Ⅰ．，Ketola，R・，etal・‥Prevalence

ofepicondylitisandelbowpaininthemeatl）rOCeSSing．Scand．J．WorkEnviron・Health17：38−45，1991・
6）Hagherg，M．，Morgenstem，H．andKelsh，M．：Impactofoccupationsandjobtasksontheprevalenceof

N．YamamOtO，etal．

（99）

Carpaltunnelsyndrome．Scand．J．WorkEnviron．Health18：337−345，1992．
7）Moore，J．S．andGarg，A．：Upperextremitydisordersinaporkprocessingplant：relationshipsbetween

jobribfactorsandmorbidity．Am．Ind．Hyg．Assoc．J．55：703−715，1994．
8）ohlsson，K．，Attewell，R．G．，Palsson，B．，Karlsson，B．，Bal0gh，Ⅰ．，Jolmsson，B．，Ahlm，A．andSkerfving，

S．：Repetitiveindustrialworkandneckandupperlimbdisordersinfemales．Am．J．Ind．Med．27：731−747，
1995．

9）Bergqvist，U．，Wolgast，E．，Nilsson，B．and Voss，M．：Musculoskeletaldisorders among visualdisplay
terminalworkers：individual，ergOnOmic，andworkorganizationalfactors．Ergonomics38：763−776，1995．

10）Ranney，D．，Wells，R．and Moore，A．：Upperlimb musculoskeletal disordersin highly repetitive
industries．Preciseanatomicalphysicalfindings．Ergonomics38：1408−1423，1995．
11）Ktmatani，N．，Dejima，M．，Ohkndo，K．，Yoshiokn，N．，Sak肌OtO，R．，Zheng，Y．and Yonemasu，K．：
Occupational and personal factors associated withlow−back painin female workers carryingloads
frequently．AdvanCeSinOccupationalErgonomicsandSafetyl：321−326，1996．

12）H咽heS，R・E・，Silverstein，B．A．and Evanoff，B．A・：Risk factors for workTelated musculoskeletal
disordersinanaluminumSmelter．Am．J．Ind．Med．32：66−75，1997．
13）sobti，A．，Cooper，C．，Inskip，H．，Searle，S．andCoggon，D．：Occupationalphysicalactivityandlong−termriskofmusCuloskeletalSymptOmS：anationalsurveyOfpostofficepensioners．Am．J．Ind．Med．32：76−83，
1997．

14）Btlrdorf，A．，VanRiel，M．and Brand，T．：Physicalload as risk factor for musculoskeletalcomplaints
amongtankterminalworkers．Am．Ind．Hyg．Assoc．J．58：489−497，1997．
15）Fredriksson，K．，Alfredsson，L．，Koster，M，．ThodomSSOn，C．B．，Toomiingas，A．，Torgen，M．and Asa
Kilbom：Riskfactorsforneckandupperlimbdisorders：reSultsfrom24yearsoffollowup．Occup．Envi−ron．Med．56：59−66，1999．
16）AriesG．A．M．，Mechelen，W．，Bongers，P．M．，Bouter，LM．andWal，G．：Physicalriskfactorsforneck
pain．Scand．J．WorkEnviron．Health26：7−19，2000．
17）Koda，S．，Hisashige，A．，Ogawa，T．，Kurumatani，N．Dejima，M．，Miyakita，T．，Kodera，R．，Hamada，H．，
Nakagiri，S．and Aoyama，H．：An epidemiologic study onlow back palnand occupationalrisk factors
amOngClinicalnurses．Jpn．J．Ind．Health33：410L422，1991．
18）Lagerrstram，M．，Wenemark，M．，Hagherg，R．，qjelm，E．W．andMosesStudyGroup：Occupationaland
individual factors related to musculoskeletal symptomsin five body reglOnS amOng・Swedish nurslng
personnel．Int．Arch．Occup．Environ．Health68：27−35，1995．
19）Ktlrumatani，N．，Iki，M．and Katayama，K．：A studyonoccupationalcervicobrachialdisorderのCD）ofnurseryschoolteachersbasedonsubjectivesymptomsrelatedtoOCD．Jpn．J．Ind．Health26：389−396，1984．

20）ono，Y．，lmaeda，T．，Shimaokn，M．，Hiruta，S．，Hattori，Y．，Ando，S．，Hori，F．，and Tatsllmi，A．：
Associations oflength ofemployment andworkingconditionswithneck，Shoulderand armpainamOng
nurseryschoolteachers．Ind．Health40：149−158，2001．

21）Amari，N．：SubjectivepainandtenderneSSinlowbackamOngCareWOrkersinrelationtoworkloadand
dallylife．J．Occup．Health41：166−173，1999．
22）Fujimura，T．，Yasuda，N．andOhara，H．：Work−relatedfactorsoflowbackpainamongnursingaides
innursinghomesfortheelderly．J．Occup．Health3789−981995．
23）Tokunaga，R．：Current status ofhealthproblemsandpreventivemeasuresamongworkersfor disabledChildren．DigestofScienceofLabour32（7）：39−44，1977．
24）Maeda，K．，Taknhasi，A．and Tanakn，S．：Health problems among workers engagedin education ofhandicappedchildren
1986．

−Staffdailycareandtrendofphysicalcomplaints−．Jpn．J．Ind．Health28：17−27，

（100）

Work−relatedmusculoskeletaldisordersamongteachersfordisabledpupils

25）Taoda，K．，Wayanabe，S．，Yamasita，H．，Kitahara，T．andNisiyama，K・‥Healthandlowbackpainin

JapaneSeSChoolteachersforthedisabledchildren・J・ScienceofLabour73：1−22，1997・
26）Kelsey，J．L．，Thompson，W．D．and EvaLnS，A．S．：Methodsin ObservationalEpidemiology・0Ⅹford

UniversityPress，NewYork，pp．309−336，1986・
27）Toomingas，A．，Nemeth，G．，Afredsson，L．andtheStockholmMUSICIStudyGroup：Selfradministeredexamination versus conventional medical

examination of the musculoskeletal systemin the neck，

shoulders，andupperlimb．J．Clin．Epidemiol．48：1473−1483，1995・
28）Baron，S．，Hales，T．andHtlrrell，Ⅰ．：Evaluation ofsymptOm SurveySforoccupationalmusculoskeletal

disorders．Am．J．Ind．Med．29：609−617，1996．
29）Fran2blau，A．，Salemo，D．F．，Armstrong，T．J．and Wemer，R・A・：TestTeteSt reliability of an
upper−eXtremitydiscomfortquestionnaireinanindustrialpopulation・Scand・J・WorkEnviron・Health23：299−307，1997．

30）Itani，T．：Keikenwansyougainokenkoukanri炬ealthcaremanagementofoccupationalcervicobrachialdisorders）．DigestofScienceofLabour 31（7）：45−56，1977・
31）Roudousyou Roudoueiseikn：Youtsuu yobou taisaku manyuaru・Tyuouroudou saigaibousi kyoukai，Tokyo，P242−243，1998．

32）Sluiter，J．K．，ReSt，K．M．and Frings−Dresen．M．H．W・：Criteria documentfor evaluating the
workTelatednessofupperleXtremitymusculoskeletaldisorders．Scand・J・WorkEnviron・Health27：1，102，
2001．

33）PlanCher，K．D．，Peterson，R．K．andSteichen，J．B．：Compressiveneuropathiesandtendinopathiesinthe
athleticelbowandwrist．ClinicsinSportsMedicine15（2）：33卜371，1996．
34）Nakan0，N．：Youtuunorinsyou．Nankoudou，Tokyo，pp．4−18，1985・
35）Dawson−Saunders，B．and TrappR．G．：Basicand Clinical：Biostatistics．AppletonandLange，London，pp．133−134，1994．
36）SPSS：SPSSCategories11．0．SPSSInc．，Chicago，pp．59−64，2001・
37）Hosmer，D．W．andLemeshowS．：Appliedlogisticregression．JohnWiley＆Sons，NewYork，pp・140￣145，
1989．

38）Amitage A．and Berry G．：StatisticalMethodsin MedicalResearch・BlackwellScientific Publication，London，pp．420−422，1994．
39）ono，Y．，Nakamura，R．，Shimaoka，M．，Hiruta，S．，Hattori，Y．，Ichihara，G・，etal・：EpicondylitisamongcooksinnurseryschooIs．Occup．Environ・Med55：172−179，1998・
40）Kurumatani，N．，Ddima，M．，Enomoto，Y．and Moriyama，T．：Carpaltunnelsyndrome symptoms andoccupationalfactor．JJTOM40：28−38，1992・
41）Dawson，D．M．：Entrapmentneuropathiesoftheupperextremities・NewEngl・J・Med・329：2013￣8，1993・

42）viikari−Juntura，E．andSilverstein，B．：Roleofphysicalloadfactorsincarpaltunnelsyndrome・Scand・J・
WorkEnviron．Health25：168−185，1999．
43）cotton，F．J．，Morrison，G．M．andBradford，C．H．：DeQuervain

sdisease：radialstyloidtendovaginitis・N・Engl．J．Med，219：120−123，1938・
44）Herberts，P．，Kadefors，R．，Hogfors，C．andSigh01m，G．：Shoulderpainandheavymanuallabor・ClinicalOrthopaedics191：166−178，1984・
45）Methom，M．J．：Cumulative trauma disorders and repetitive straininjuries・ClinicalOrthopaedicsand
RelatedResearCh361：107−126，1998．
46）Harrington，J．M．，Carter，J．T．，BirrellK．and

Gompert2＝，D．：Surveillancecasedefinitions

forwork

relatedupperlimbpainsyndromes．Occup．Environ．Med・55‥264−271，1998・

47）Miller，M．H．and Topliss，D．J．：Chronic upperlimb pain syndrome kepetitive staininjury）in the

N．Yamamoto，etal．

（101）

AustralianWOrkforce：a SyStematic cross sectionalrheumatOlogicalstudy of229patients．J．RlleumatOl．
15：1705−1712，1988．
48）Yassi，A．：Repetitivestraininjuries．Lancet，349：943−947，1997．
49）Nakaseko，M．，Tokunaga，R．and Hosokawa，M．：History of occupationalcervicobrachialdisordersin
Japan．J．HumanEngol，ll：7−16，1982．
50）Ono，Y．：0ccupationalcervicobrachialdisorderのCD），Jpn．J．Ind．HealthRaview13：ト16，2000．
51）Ktlrumatani，N．，Yamamoto，N．，Ogata，N．，Morita，N．and Matsuda R．：Analysis ofworking postures
uslnga neWly developedinclinometer：aStudy on trunkinclinationangleamong teachers forphysicallyhandicappedstudents．J．ErgonomicsOccupationalSafetyandHealth3：42L47，2001．

52）Kumagai，S．，Tabuchi，T．，Taninaka，H．，Miyajlma，K．，Matsunaga，I．，Kosakn，H．，Andoh，H．andSeo，A．：LoadonthelowbackofteachersinnurseryschooIs．Int．Arch．Occup．Ennviron．Health68：52−57，1995．
53）Yosi2；aWa，S．：LowbackpainandcountermeaSureSamOngSanitationworkers．DigestofScienceofLabour
30（4）：25−29，1975．

54）Yoshida，T．，Goto，M．，Nagira，T．，Ono，A．，Fijita，I．，Goda，S．andBando，M．：Studiesonlowbackpain
amOng WOrkersin small scale construction companies−Reportl Analysis of clinical and radiologicalfindingsT．Jap．J．Ind．Health13：37−45，1981．
55）Moriyama，T．，Kurumatani，N．，Sugimoto，K．，etal．：EffectsofvibratingtooIsonforestryworkersand
Validity of medical examination to detect vibration disease．−A comprehensive review of medical
examinationprogramsforvibrationdisease overlOyearsand somefutureissuesin Naraprefecture−．J．
NaraMed．Assoc．42：261−292，1991．
56）Kurumatani，N．，Iki，M．，Arai，T．，Moriyama，T．，et al．：Questionnaire survey of occupational
cervicobrachialdisorderandlowbackpainamongthe cooksprovidingmeals forschooIchildren．JJTOM
35：366−373，1987．
57）Ono，Y．，Shimaoka，M．，Hiruta，S．andTakeuchi，Y．：LowbackpainamongcooksinnurseryschooIs．Ind．
Health35（2）：194−201，1997．
58）Nagira，T．：StudiesonthelowbackpainamOng electricconstructionworkers．Jap．J．Ind．Health16：
201−211，1974．

59）Okun0，M．，tJketa，S．，Naknseko，M．andTokunaga，R．：Workandworkloadofnursingpersonnelina
nurseryschoolandtwoinstitutionsforhandicappedchildren．Ind．Health35（2）：202−211，1997．
60）Keyserling，W．M．：Posturalanalysisofthetrunkandshouldersinsimulatedrealtime．Ergonomics29：
569−583，1986．

61）ptmettL．，etal．：Backdisordersandnonneutraltrunkposturesofautomobileassemblyworkers．Scand．
J．WorkEnviron．Health17：337−346，1991．
62）Hagherg，M．andWegman，D．H．：Prevalenceratsandoddsratiosofshoulder−neCkdiseasesindifferent
OCCuOationalgrouos．Br．J．Ind．Med．44：602−610，1987．
63）Lindman，R．，Erikson，Q．and Thomell，L．E．：Fiber type composition ofthe human female trapezius
muscle．Am．J．Anat．190：385−392，1991．
64）Lindman，R．，Hagberg，M．，AJlgqvist，K．A．，Soderlund，K．，Hultman，E．andThornell，L．E．：Chengesin
musclemorphologyinchronictrapeziusmyalgia．Scand．J．WorkEnviron．Health17：347r355，1991．