OSH Research Report

Survey on the Prevalence of and Risk Factors for

Neck Pain and Upper Limb Pain among
Secondary School Teachers in Hong Kong

January 2006

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Contents

Chapter 1 : Introduction 29
1.1 Prevalence of neck pain 29
1.2 Risk factors of neck pain and upper limb pain 29
1.3 Objectives of the study 32

Chapter 2 : Methods ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
33
2.1 Subjects 33
2.2 Design of questionnaire 33
2.3 Content validity 34
2.4 Data processing and analysis 34

Chapter 3 : Results ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
36
3.1 Return rate 36
3.2 Prevalence of neck pain 36
3.3 Prevalence of upper limb pain 36
3.4 Prevalence of neck pain and upper limb pain 36
3.5 Individual factors 36
3.6 Physical risk factors 38
3.7 Psychosocial risk factors 38
3.8 Multiple logistic regression of risk factors 38

Chapter 4 : Discussion & Conclusion ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

39

Table ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
44

Appendix 1 : Questionnaire ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
53

Appendix 2 : Questionnaire Survey School Participation List 62

References ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
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Table Contents

Table 1 : Prevalence of neck pain in relation to individual factors ○ ○ ○ ○ ○ ○ ○ ○ 44

Table 2 : Prevalence of upper limb pain in relation to individual

factors ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
45

Table 3 : Coping methods for neck pain and upper limb pain ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
46

Table 4 : Percentage of teachers with neck pain (NP) and upper limb
pain (ULP) in relation to writing in overhead posture ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
46

Table 5 : Percentage of teachers with neck pain (NP) and upper limb
pain (ULP) in relation to working in head down posture ○ ○ ○ ○ ○ ○ ○ ○ ○
47

Table 6 : Percentage of teachers with Neck Pain (NP) and upper limb
pain (ULP) in relation to working with computer ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
47

Table 7 : Percentage of teachers with neck pain (NP) in relation to

various psychosocial factors ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
48

Table 8 : Percentage of teachers with upper limb pain (ULP) in

relation to various psychosocial factors ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
49

Table 9 : Frequency of breaks during working hours in a day

(excluding lunch) in relation to neck pain (NP) and upper
limb pain (ULP) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
50

Table 10 : Frequency and duration of exercises in leisure time in

relation neck pain (NP) and upper limb pain (ULP) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
50

Table 11 : Individual and physical factors associated with neck pain

and upper limb pain ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
51

Table 12 : Psychosocial factors associated with neck pain and upper

limb pain ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
52

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Chapter 1: Introduction

1.1 Prevalence of neck pain

Neck pain is common. In European and North American populations, nearly one-third of
adults experienced neck pain in the course of 1 year (1, 2). In Sweden, the prevalence of
neck pain found by Andersson et al (3) was 30% while by Brattberg et al (4) was 22%. A
similar prevalence of 26% was found in Finland (5). In Hong Kong, Chiu et al (6) reported
that 1-year prevalence of neck pain after becoming a university academic staff was 46.7%.
Neck pain is costly in terms of treatment, individual suffering and time lost due to work
absenteeism (7). In 1996, the direct and indirect costs related to chronic non-specific neck
pain in the Netherlands were estimated at US $868 million (8).

Many studies have been conducted to investigate the relationship between neck pain and
occupation. Kamwendo et al (9) reported that 63% of medical secretaries had job-related
factors neck pain. Factory workers as well as office workers have been mentioned as risky
groups (10, 11). Machine operating and carpentry compared to sedentary work were found
to be risk indicators for neck and shoulder symptoms (12). Lau et al (13) found that neck
pain was a prevalent problem among managers and professionals. Chiu et al (6) also
reported that university academic staff had higher prevalence of neck pain and they were
found to be a high-risk group of occupational related neck pain. Since posture and
monotonus work have been pointed out as important factors in the development of
occupational neck and shoulder disorders (14, 15). While secondary school teachers in
Hong Kong always need to do activities such as frequent reading and assignment correction.
Thus, they may be one of the high-risk groups for developing occupational-related neck
pain. However, available studies on them are limited.

1.2 Risk factors of neck pain and upper limb pain

Neck pain has been assumed to be a multifactorial origin. There are a number of risk
factors contributing to its development. These risk factors can be divided into 3 groups:
individual, physical and psychological risk factors (16). Several studies have been conducted
in an attempt to identify risk factors for neck pain. However, many of these studies focused
only on one or a few factors in one dimension, and do not take individual characteristics,
physical factors and psychosocial factors into account.

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1.2.1 Individual Factors

The prevalence of neck pain in women population was found to be increased with age (1,
2, 3). In Hong Kong, Lau et al (13) showed that the 1-year prevalence of neck pain was
15% in men and 17% in women. Krause et al. (17) reported that even after body size and
ergonomic factors were adjusted, women still had a higher risk for back and neck pain.
Chiu et al (6) also found that gender was one of the risk factors for neck pain. The
percentage of female academic staff in university with neck pain was 60.7%, which was
much higher than that in male staff (38%). However, their study could not demonstrate
age was significantly associated with neck pain. Kamwendo et al (9) investigated neck and
shoulder disorders of 420 medical secretaries and showed that age and gender were
significantly related to neck and shoulder pain. Leclerc et al (18) also showed similar results
in their study. Holmstrom et al (19) reported that prevalence rates of neck-shoulder trouble
(NST) increased with age.

Apart from age and gender, length of employment was one of the risk factors to develop
neck pain (9). Moreover, Lau et al (13) reported that subjects with neck pain spent
significantly more time in reading. Since higher educated population generally performs
more reading tasks, higher education level may be one of the risk factors for neck pain.

A longitudinal survey involving 7,669 subjects demonstrated that history of neck injury
appeared to be a separate risk for long-term episodic neck pain (20). Therefore, the present
study investigates whether age, gender, educational level, teaching experience, teaching
subjects and history of trauma are potential risk factors for neck pain in secondary school
teachers in Hong Kong.

1.2.2 Physical Factors:

Holmstrom et al (19) showed that physical factors did contribute significantly to neck-
shoulder pain if confounders such as age, individual and employee-related factors were
excluded. They also found that long duration of work with the hands above shoulder
level showed significant relationship to both NST. Thus, overhead posture may be risk
factors for neck pain in teachers.

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In the study by Harms-Ringdhal and Ekholm (21), neck pain was provoked with maintaining
extreme neck flexion for less than 15 minutes in healthy subjects. Also, Grandjean and
Maeda (22) concluded that the incidence of neck pain increased with the amount of neck
flexion. Lau et al (13) found that reading time significantly associated with neck pain.
Since reading is a head-down posture, it may be another physical risk factors of neck pain.

A number of studies indicated that there was a relationship between time duration spent
working with computers and Visual Display Unit (VDU), and the occurrence of
musculoskeletal symptoms. Purnett (23) found that the risk of having neck symptoms with
VDU work increased after 4 working hours per day. Kamwendo et al. (9) showed that 5
hours or more work with office machines significantly increased the risk for shoulder pain
and headache. Chiu et al (6) also reported that computer processing for 4.45 hours without
rest in between might be a risk factor for neck pain in academic staff.

Since secondary school teachers need frequent use of computers and VDUs in their
preparation of teaching. During the lessons, they are frequently required to do lots of
overhead writing on boards. Moreover, they need to do lots of reading and assignment
correction. Therefore, 3 physical factors (overhead posture, head down posture and working
with computer) will be investigated to examine whether they are risk factors for neck and
upper limb pain.

1.2.3 Psychosocial Factors

A number of studies reported that there was a correlation between psychosocial variables
and musculoskeletal disorders (9,16,18,19,22,26). In a systematic review, Ariens et al. (16)
reported that high job demands, poor coworker support, low job control, low skill
discretion, and low job satisfactions had a positive relationship with neck pain. Holmstrom
et al (19) found that stress, job satisfaction, and social support showed significant association
with NST in 1,773 construction workers. Ariens et al (24) found significant results that high
quantitative job demands and low coworker support were related to neck pain.

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Therefore in this study, we have focused on workload, colleague support, variety of work,
job stress, job satisfaction and job authority on the relationship with neck and upper limb
pain. The present authors also examined whether anxiety, family support and life
satisfaction are the risk factors for neck and upper limb pain in secondary school teachers.

Tayyari et al (25) suggested that taking short breaks and doing relaxation exercises during
work could minimize the chance of getting job-related musculoskeletal disorders. Chiu et
al (6) showed that having rest periods during computer processing helped to decrease the
severity of neck pain.

It seems that breaks and exercises have relationship with neck pain. However, Hong Kong
secondary school teachers’ daily schedule may be closely packed and does not allow them
to take frequent breaks and do exercises. In addition with the risk factors indicated above,
secondary school teachers seem to be a high-risk group for developing occupational-related
neck pain. But this kind of studies are limited.

1.3 Objectives of the study

The aim of this study was to investigate the prevalence and occupational risk factors of
neck and upper limb disorders among secondary school teachers. These risk factors include
individual factors (e.g. age, gender, education level, teaching experience, teaching subjects
and history of trauma), physical factors (e.g. working with computer, posture and duration)
and psychosocial factors (e.g. work demand and colleague support). The strategies used
by the teachers to cope with neck and upper limb pain, the preventive methods or the
methods to decrease neck and upper limb pain were also examined.

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Chapter 2 : Methods

2.1 Subjects
The inclusion criterion was full-time secondary school teachers in Hong Kong. One hundred
secondary schools (about 5,000 teachers) in different regions in Hong Kong were chosen
by convenience. There were no exclusion criteria for this study. Authors first informed the
target schools’ principals by sending fax, phone call or direct visits, asking for their consent
and inviting them to take part in the study. When the school principal consented to join
the study, questionnaires were then sent to the schools by hand and collected from the
schools after 1 to 3 weeks.

2.2 Design of questionnaire

The first part of the questionnaire focused on the subject’s background data including
gender, age, educational level and teaching experience. The second part (Q1-9) investigated
the subjects’ history of neck pain, their coping strategies and the corresponding effect.
The third part of the questionnaire (Q10-18) was adopted from the Northwick Park Neck
Pain Questionnaire (NPQ) (26). It consisted of nine questions for measuring the severity
and functional limitations induced by neck pain. The fourth part (Q19-27) investigated
the subjects’ history of upper limb pain, their coping strategies and the corresponding
effect. The fifth part (Q28-29) investigated the severity of upper limb pain and its association
with neck pain. The sixth part of the questionnaire (Q30-33) was designed to investigate
the physical risk factors. Three working postures frequently assumed by teachers (overhead
work, head-down work, and computer work) were investigated. In the literature, all of
these working postures have been found to be closely related to neck and upper limb
pain. The duration of those working postures including average length of time and maximal
sustained time were investigated. The final part of the questionnaire (Q 34-47) was set to
consider the subjects’ psychosocial risk factors. Psychosocial risk factors, which were
suggested to be closely related with neck and upper limb pain in the systematic review by
Ariens et al. (16), were included in the questionnaire. These factors included workload,
the support of colleagues, job control, job stress, variety of work and job satisfaction.
Questions on anxiety, family support, life satisfaction and opportunities for breaks and
regular exercises were also included in the questionnaire. (Appendix 1)

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2.3 Content Validity

The questionnaire used in this study was subjected to a face-to-face validation by 5
experienced physiotherapists and 5 secondary school teachers with neck pain. They
completed the questionnaire and an evaluation form, which asked them to rate each
individual question on a five point scale, (1 “poor”, 2 “fair”, 3 “good”, 4 “very good” and
5 “excellent”) commenting on how well the question could achieve the aim of this study.
An open-ended question was also given to seek any additional comments. All the subjects
agreed that the questionnaire is able to achieve the aim of the study with minor
modifications.

2.4 Data Processing and Analysis

The severity of neck pain was measured by the adopted NPQ. It is composed of nine
questions, including one optional question (on driving). Each question is rated from 0 to
4, with 0 representing no pain and 4 representing the most disabling pain. The final
percentage score was calculated by dividing the total score with the sum of the highest
scores (a score of 36 for subjects completing Question 18, and 32 for subjects omitting
Question on driving). The higher the percentage score, the greater is the severity of the
neck pain. The severity of upper limb pain was investigated using appropriate questions.

Life-long prevalence and one-year prevalence of both neck and upper limb pain were
compared between gender, age group and years of teaching experience by chi-square
tests.

Information about the subjects’ history of neck pain from the second part of the
questionnaire was used to classify the subjects into two groups: with neck pain (NP+) and
without neck pain (NP-). The NP+ group includes subjects who 1) did not experience neck
pain before becoming teachers but developed neck pain after teaching, and 2) those who
already had neck pain before teaching and experienced a worsening of their conditions
after teaching. The NP- group includes subjects who have: 1) no history of neck pain and
2) had neck pain before becoming teachers but did not experience a worsening of their

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conditions after teaching. Under this classification, all of the subjects in the NP+ group
were regarded as having neck pain related to the teaching occupation. The same procedure
was used for the upper limb pain condition. The associations of the development or
worsening of neck pain after becoming teachers, with several individual risk factors
(including gender, age group, education level and years of teaching experience), history
of trauma, as well as a set of physical and psychosocial risk factors, were examined by chi-
square tests or Fisher’s exact tests, whichever were more appropriate. Factors with p values
less than 0.25 (31, p. 95) in chi-square tests or Fisher’s exact tests were selected to be
candidate variables in multiple logistic regression models. Significant risk factors were
screened in a backward stepwise manner using likelihood ratio tests as a selection criterion.
Hosmer-Lemeshow goodness-of-fit test (31) was also conducted to check the fit of the
model to the data. Similar analyzing strategies were adopted for upper limb pain. Data
were analyzed with SPSS 12.0 (Chicago, IL) and p values of less than 0.05 indicated statistical
significance.

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Chapter 3 : Results

3.1 Return Rate: 5,680 questionnaires were delivered to the teachers in 100 secondary
schools in different regions of Hong Kong, 3,100 were completed and returned. Response
rate of individual school was listed in Appendix 2. A satisfactory return rate of 54.6% was
obtained. There were no significant difference in gender distribution between respondents
and non-respondents (58.0% vs. 56.1% female, p = 0.142).

3.2 Prevalence of Neck Pain: The life-long prevalence of neck pain was found to be
69.3% (2091/3018). 1-year prevalence was 66.7% (2005/3007). Neck pain prevalence after
becoming teachers was 59.7% (1745/2923).

3.3 Prevalence of Upper Limb Pain: The life-long prevalence of upper limb pain
was found to be 35.8% (1088/3042). 1-year prevalence was 33.3% (1011/3032). Upper limb
pain prevalence after becoming teachers was 31.8% (885/2787).

3.4 Prevalence of Neck Pain and Upper Limb Pain: The life-long prevalence of
neck pain and upper limb pain was found to be 31.6% (938/2966). 1-year prevalence was
29.5% (868/2947). For those teachers who have both neck pain and upper limb pain,
71.6% (511/714) reported that the two pains were related.

3.5 Individual Factors:

Gender: The life-long prevalence of neck pain was 59% (726/1231) for males and 76.7%
(1306/1702) for females respectively (Table 1). The prevalence of neck pain after teaching
among males and females were 47.4% (581/1226) and 68.6% (1164/1697) respectively (Table
1). Results demonstrated that females have a significantly higher prevalence of neck pain
( p <0.001).

The life-long prevalence of upper limb pain was 29.4% (364/1239) for males and 40.2%
(691/1718) for females respectively (Table 2). The prevalence of upper limb pain after
teaching among males and females were 24.3% (281/1156) and 37% (604/1631) respectively
(Table 2). Results demonstrated that females have a significantly higher prevalence of
upper limb pain. ( p <0.001).

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Age: The age distribution for neck pain is shown in Table 1. Results showed that the age
group with the highest prevalence of neck pain was 31-35. The results demonstrated that
there was significant difference among different age groups in the prevalence of neck
pain ( p <0.001).

The age distribution for upper limb pain is shown in Table 2. Results showed that the age
groups with the highest prevalence of upper limb pain was 46-50 and >50. The results
demonstrated that there was significant difference among different age groups in the
prevalence of upper limb pain ( p <0.001).

Teaching Experience: Table 1 demonstrated that the groups of teachers with highest
prevalence of neck pain were 0-5 years for both life time (73.2%) and 12-month prevalence
(72.0%). Teachers with 6-10 years of teaching experience have the highest prevalence
(64.7%) of neck pain after becoming teachers. Teachers with 16-20 years of teaching
experience have the highest prevalence of upper limb pain for both life time (41.5%) and
12-month prevalence (38.3%) (Table 2). Teachers with 21-25 years of teaching experience
have the highest prevalence (39.1%) of upper limb pain after becoming teachers (Table 2).

Severity of Neck Pain: Among 1,739 subjects who suffered from neck pain after becoming
a teacher, the mean score of neck pain disability was 18.2% (0-75% SD  12.56).

Severity of Upper Limb Pain: Among 917 subjects with upper limb pain, 45.3% of
them reported that their pain was mild, 19.7% complained of moderate to severe pain,
only 0.2% of them had worst imaginable pain and 34% reported no pain at that moment.

History of trauma and pain: No significant relationship was found between the history
of trauma and neck pain ( p=0.199) and Upper limb pain ( p=0.056).

Coping Methods: Among those methods used by the teachers to manage neck pain,
doing neck exercises (mean rank = 1.99) and taking more breaks (mean rank = 2.17) were
commonly used by the teachers to cope with their neck pain. In order to cope with their
upper limb pain teachers will take more breaks (mean rank = 1.93) and do more exercise
(mean rank = 2.32). Taking sick leave is the last choice to cope with their neck and upper
limb pain (Table 3). For those who seek medical help for their neck and upper limb pain,
doctor (56%) and physiotherapist (41%) were preferred (Table 3).

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3.6 Physical Risk Factors:

For the activities that would induce neck pain, only 46.8% (979/2091) reported that
overhead writing (e.g. writing on board) would induce their pain. However, majority of
them complained that working with head down posture (e.g. correcting assignment)
(85.1%, 1780/2091) and working with computer (84.2%, 1760/2091) would induce their
neck pain.

Percentage of teachers with neck pain and upper limb pain in relation to various working
postures were shown in Tables 4 - 6. Results showed that the longer the time when teachers
were exposed to overhead writing (e.g. writing on board), head down posture (e.g.
correcting assignment) or working with computer, the higher the percentage of teachers
with neck or upper limb pain.

3.7 Psychosocial Risk Factors:

Percentage of teachers with neck pain and upper limb pain in relation to various
psychological factors were shown in Table 7 and Table 8. Results showed that percentage
of teachers with neck pain and upper limb pain increased with high workload, high variety
of work, high job stress and high anxiety. Moreover, percentage of teachers with neck
pain and upper limb pain also increased with low colleague support, low job satisfaction,
low family support, low job authority and low life satisfaction.

Teachers who take no breaks during working hours in a day have the highest percentage
of neck pain and upper limb pain (Table 9). Teachers who never do any exercise in their
leisure time have the highest percentage of neck pain and upper limb pain (Table 10).

3.8 Multiple Logistic Regression of Risk Factors:

Gender, age, and working in head down posture were identified as risk factors for neck
pain and upper limb pain for secondary school teachers (Table 11). High workload, low
colleague support, high anxiety were found to be significant on affecting the neck pain
and upper limb pain developed after becoming teachers (Table 12) Frequency of breaks
during working hours in a day was also found to be related to the presence of neck pain
in secondary school teachers (Table 12).

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Chapter 4 : Discussion & Conclusion

This is the first large-scale study to investigate the prevalence and risk factors of neck pain
and upper limb pain in secondary school teachers in Hong Kong. Teachers from 100
secondary schools took part in the study with a response rate of 54.6%. As shown in
Appendix 2, these schools were located in different regions of Hong Kong and belong to
different categories e.g. private, government, and government subsidized schools. The
sample is a good representation of the general secondary school teachers in Hong Kong.

Prevalence: In the present study, the 1-year prevalence of neck pain (66.7%) was higher
when compared with the results reported by Chiu et al (6) for university academic staff
(58.9%) and was much higher than a local study by Lau et al (13) in 1996.The present
findings were similar to the results suggested by Kamwendo et al (9), who also found a
high 1-year prevalence (63%) of neck pain for medical secretaries. Neck pain prevalence
after becoming teacher was 59.7%. The present authors suggested that secondary school
teachers are high-risk group of occupational related neck pain. The problem of upper
limb pain was not as serious as that of neck pain. Upper limb pain prevalence after becoming
teacher was 31.8%. However, the majority (71.6%) of those teachers who have both neck
pain and upper limb pain reported that the two pains were related. As physical function
of the muscles of the neck and the upper limb are closely related, it is reasonable to
suggest that problems in any one group of muscles may affect the other.

Gender: Results of the present study demonstrated that females were significantly at risk
for both life long prevalence of neck pain and neck pain developed after teaching. This
matched with the study of university academic staff (6), which found a significant association
between gender and neck pain. In contrast, Lau et al(13) reported out that males and
females both had a similar prevalence of neck pain (15% and 17% respectively) in general
Chinese population. The higher risk of developing neck pain after teaching in female may
be due to their lower pain threshold. Torgen et al (27) suggested that pressure pain
thresholds increased with muscle strength and Chiu et al (28) found that the isometric
neck muscle strength in all directions for men was 1.2-1.7 times those in women. Therefore,
females might have a lower pain threshold than males. Chiu et al (6) also suggested that
high decision latitude among women was associated with increasing risk for developing
neck-shoulder symptoms. Similarly results also demonstrated that females have a
significantly higher prevalence of upper limb pain than males ( p<0.001).

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Age: Lau et al (13) reported that the life-long prevalence and 1-year prevalence of neck
pain decreased after the age of 60 for women. This could be due to the reason that the
older population was less likely to report neck pain which had occurred a long time ago
(13). In contrast, Kamwendo et al (9) stated that neck and shoulder pain increased with
age for medical secretaries. In this study, there was significant difference among different
age groups in the prevalence of neck pain ( p <0.001). Results showed that the age group
with the highest prevalence of neck pain was 31-35. In contrast the prevalence of upper
limb pain was highest in older age group (46-50 and >50). The results demonstrated that
there was significant difference among different age groups in the prevalence of upper
limb pain ( p <0.001).

Teaching experience: Teachers with teaching experience of 0-5 years got the highest life-
long prevalence of neck pain. This may be due to the reason that the new teachers are not
adapting well to the new working environment and the physical and psychological stress
may affect the well beings of their musculoskeletal conditions. However, more teachers
suffered from upper limb pain as their teaching experience increased. Further study is
required to explore this.

Coping methods: In this study, doing exercise and taking more breaks were the most
common coping methods used for neck pain and upper limb pain. This is supported by
recent studies which stated that active exercise is effective in the management of neck
pain (29, 30). Taking sick leave is the last choice to cope with their neck and upper limb
pain. This may be due to the reason that teachers were afraid of loosing their job if they
have taken sick leaves too often. From those who sought medical help it was found that
doctors and physiotherapists were the most frequent choices which were similar to previous
study(6). Physiotherapy got 36% and 41%, which showed that physiotherapists play a
major role in the management of neck pain and upper limb pain.

Physical Risk Factors

Overhead Posture: The present study found only 46.8% of the teachers reported that
overhead writing (e.g. writing on board) would induce their pain. Holmstrom et al (19),

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however, had found that working with hands above shoulder level for 1 to 4 hours daily
could induce neck and/or shoulder pain in construction workers. The present study showed
that, for the maximal sustained time, 17.95% of teachers worked with hands overhead for
more than 15 minutes, this was relatively short when compared with the result from
Holmstrom et al. (19). This might be the reason for the insignificant association since most
of the teachers were not exposed to this potential risk factor for a considerable length of
time. The short period of time working in an overhead position could be due to more
teachers teach by using computers or projectors rather than writing on the blackboard.

Head Down Posture: Lau et al. (13)found that reading in a head down posture was
significantly associated with neck pain in the general population. Similarly, the present
study also found that majority of the teachers complained that working with head down
posture would induce their neck pain. More than 72% of those teachers who had a maximal
sustained time of head down posture for more than 2 hours suffered from neck pain.

Computer Work: Results of this study demonstrated that longer maximal sustained time
of computer work was associated with neck pain developed after starting to teach. This
matched with the results of previous studies (6, 9, 23). Chiu et al (6) suggested that working
with a poking chin posture during computer processing would induce a considerable load
on posterior neck muscle, which in turn leaded to muscle fatigue. This would further
increase loading on non-contractile structures and posterior cervical structures causing
neck pain.

Psychosocial Factors: In this study, it was found that percentage of teachers with neck
pain and upper limb pain increased with high workload, high variety of work, high job
stress and high anxiety. Moreover, percentage of teachers with neck pain and upper limb
pain also increased with low colleague support, low job satisfaction, low family support,
low job authority and low life satisfaction. Similarly Holmstrom and his colleagues
demonstrated that job stress, job satisfaction and social support showed significant
association with neck shoulder trouble in 1,773 construction workers (19). Leclerc et al.
also demonstrated that psychosocial factors are important predictors of neck pain (18). It
should be noted that psychological distress may be a risk factor for neck pain and upper

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limb pain, but it is also possible that chronic neck pain or upper limb pain will give rise to
psychological distress (20). Therefore, further studies are required to elucidate the cause
and effect relationship between psychological factors and neck and upper limb pain.

Multiple Logistic Regression of Risk Factors: Our results showed that females were at
higher risk of having neck pain and upper limb pain as compared to men. Similarly a
number of literature also showed that female was a significant risk factor for neck pain (1,
2, 3, 9, 17). Age was another risk factor for neck pain and upper limb pain. It should be
noted that the age group with the highest risk of having neck pain was 31-35 (odds ratio,
(OR) =3.1, 95%C.I. 2.08-4.37). The risk of having upper limb pain tends to increased with
age. The odds ratio (OR) for suffering from upper limb pain after the age of 50 was 3.8
(95% C.I. 2.33-6.21). Working with head down posture was identified as another risk factor
of having neck pain and upper limb pain. In order to reduce the risk of having neck pain
and upper limb pain, teachers are advised not to work in the head down posture for more
than 2.5 hours in a day. Book stands and document stands should be used to avoid the
head down posture. Moreover, working with head down posture should not be sustained
for more than 15 minutes. Teachers should lift up their heads for few seconds every 15
minutes in order to release the stress to the neck muscles.

Result also showed that low colleague support (OR =2.00, 95% C.I. 1.16-3.47), high work
load (OR=2.17, 95% C.I. 1.58-2.97) and high anxiety (OR= 1.49, 95% C.I. 1.07-2.07) were
the significant risk factors for neck pain and upper limb pain. Senior management of the
schools should review the work load distribution so as to reduce the work load
appropriately. Effective supportive system among teachers should be developed to enhance
mutual support among colleagues. Professional advice from the school social worker or
educational psychologists should be available for those teachers with high anxiety.
Workshops or seminars on stress management should be conducted as a preventive measure
for building up anxiety.

In order to reduce the risk of having neck pain, teachers are advised to have “breaks”
after working for every 3 hours.

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Conclusion

Secondary school teachers were found to be a high-risk group in developing neck pain
and upper limb pain. Gender, age and head down posture were found to be significant
risk factors. Psychological factors including high workload, low colleague support and
high anxiety were also significant risk factors which lead to development of neck pain
and upper limb pain after teaching. It is advisable for teachers to recognize and minimize
these occupational risk factors, wherever possible, in order to reduce the chance of
getting neck pain and upper limb pain.

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Table 1. Prevalence of Neck Pain in Relation to Individual Factors

Life Long One-year Neck Pain Developed after

Prevalence (%) Prevalence (%) Becoming Teachers (%)
Gender
Male 59.0 55.4 47.4
Female 76.7 74.9 68.6
p value <0.001 <0.001 <0.001
Age (yrs)
20 - 25 67.5 66.7 45.5
26 - 30 74.9 73.7 61.4
31 - 35 76.1 73.9 67.6
36 - 40 68.2 66.0 61.6
41 - 45 63.2 59.8 55.2
46 - 50 67.5 63.9 63.4
> 50 59.7 54.8 53.7
p value <0.001 <0.001 <0.001
Teaching year (yrs)
0-5 73.2 72.0 53.2
6 - 10 71.7 70.1 64.7
11 - 15 69.5 66.5 61.9
16 - 20 67.7 64.1 61.4
21 - 25 66.3 63.6 60.7
> 25 61.8 56.8 57.2
p value 0.004 <0.001 <0.001

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Table 2. Prevalence of Upper Limb Pain in Relation to Individual Factors

Life Long One-year Upper Limb Pain Developed

prevalence (%) prevalence (%) after Becoming Teachers (%)
Gender
Male 29.4 26.2 24.3
Female 40.2 38.5 37.0
p value <0.001 <0.001 <0.001
Age (yrs)
20 - 25 26.8 25.4 19.0
26 - 30 33.5 32.1 28.5
31 - 35 37.8 36.4 33.3
36 - 40 35.3 32.4 32.1
41 - 45 32.7 30.1 28.2
46 - 50 42.3 39.7 40.4
> 50 41.8 37.3 40.8
p value <0.001 <0.001 <0.001
Teaching year (yrs)
0-5 31.8 30.0 23.8
6 - 10 32.8 31.5 29.6
11 - 15 34.5 32.5 31.3
16 - 20 41.5 38.3 38.0
21 - 25 41.3 37.7 39.1
> 25 39.5 35.1 38.2
p Value 0.002 0.036 <0.001

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Table 3. Coping Methods for Neck Pain and Upper Limb Pain

Coping Methods Neck Pain Upper Limb Pain

1
Take more breaks 2.17 1.93
1
Do more exercises 1.99 2.32
Share workload with colleague1 5.00 4.99
1
Change working posture 2.46 2.46
1
Sick leave 5.31 5.27
Others1 4.05 4.21
1
Seek medical help: 3.42 2.94
Doctor 58% 56%
Physiotherapist 36% 41%
Chiropractor 17% 18%
Bone Setter 12% 13%
Others 10% 10%
1
Values were mean ranks assigned by teachers (with 1 indicated the most important
method).

Table 4. Percentage of Teachers with Neck Pain (NP) and Upper Limb Pain (ULP) in
Relation to Writing in Overhead Posture

Duration of Overhead % with Neck Pain % with Upper Limb

Posture (no. of teachers with Pain (no. of teachers
NP/Total number) with ULP/Total number)
Average length of time
<30 mins 55.6 (484/871) 28.3 (234/827)
30-90 mins 58.9 (502/853) 33.2 (272/820)
>1.5 and 3 hrs 61.3 (416/679) 33.1 (216/653)
>3 and 4 hrs 64.8 (171/264) 38.6 (98/254)
>4 hrs 72.5 (140/193) 31.5 (57/181)
Maximal sustained time
<2 mins 55.6 (267/480) 24.8 (116/468)
2-5 mins 59.8 (457/764) 34.9 (253/725)
>5 and 10 mins 60.3 (360/597) 33.7 (191/567)
>10 and 15 mins 64.9 (176/271) 37.7 (100/265)
>15 mins 66.0 (305/462) 34.6 (152/439)

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Table 5. Percentage of Teachers with Neck Pain (NP) and Upper Limb Pain (ULP) in
Relation to Working in Head Down Posture

Duration of Head % with Neck Pain % with Upper Limb Pain

Down Posture (no. of teachers with (no. of teachers with
NP/Total number) ULP/Total number)
Average length of time
<1 hr 40.5 (120/296) 18.0 (52/289)
>1 and 2.5 hrs 52.8 (435/824) 26.4 (206/781)
>2.5 and 4 hrs 61.5 (576/936) 34.1 (305/895)
>4 and 5.5 hrs 72.6 (257/354) 41.0 (139/339)
>5.5 hrs 72.6 (361/497) 38.7 (184/476)
Maximal sustained time
<15 mins 41.4 (109/263) 17.8 (46/258)
>15 and 30 mins 56.6 (263/465) 29.4 (132/449)
>30 and 60 mins 59.2 (458/774) 30.8 (228/740)
>1 and 2 hrs 64.5 (356/552) 38.1 (197/517)
>2 hrs 72.6 (400/551) 41.2 (218/529)

Table 6. Percentage of Teachers with Neck Pain (NP) and Upper Limb Pain (ULP) in
Relation to Working with Computer

Duration of Working % with Neck Pain % with Upper Limb Pain

with Computer (no. of teachers with (no. of teachers with
NP/Total number) ULP/Total number)
Average length of time
<1 hr 51.4 (221/430) 26.6 (110/413)
>1 and 2 hrs 58.5 (520/889) 31.9 (274/858)
>2 and 3 hrs 63.6 (475/747) 33.4 (239/715)
>3 and 4 hrs 65.4 (253/387) 36.2 (134/370)
>4 hrs 62.6 (289/462) 31.3 (136/435)
Maximal sustained time
<30 mins 54.1 (242/447) 23.5 (100/425)
>30 and 60 mins 56.7 (400/706) 31.2 (214/685)
>1 and 2 hrs 62.3 (424/681) 35.7 (232/649)
>2 and 3 hrs 65.4 (244/373) 37.1 (132/356)
>3 hrs 69.5 (280/403) 37.4 (143/382)

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Table 7. Percentage of Teachers with Neck Pain (NP) in Relation

to Various Psychosocial Factors

Psychosocial % with N/P in Different Perceived Levels

Factors (no. of teachers with NP/Total number)
Very low Low Moderate High Very high
Workload 50.0 71.4 40.0 55.9 70.1
(2/4) (5/7) (136/340) (738/1321) (906/1292)
Colleague support 69.4 70.4 59.2 55.9 30.0
(84/121) (345/490) (950/1604) (386/691) (15/50)
Variety of work 63.2 64.6 55.5 59.6 69.9
(12/19) (122/189) (534/963) (787/1321) (323/462)
Job stress 57.1 40.3 45.3 58.6 72.5
(4/7) (25/62) (236/521) (848/1446) (668/921)
Job satisfaction 68.8 64.9 60.3 56.6 57.4
(95/138) (303/467) (828/1373) (492/869) (62/108)
Anxiety 62.5 56.3 53.8 65.6 72.3
(80/128) (281/499) (579/1077) (596/908) (245/339)
Family support 67.6 66.7 60.3 58.3 59.9
(48/71) (192/288) (699/1160) (662/1135) (178/297)
Job authority 73.7 64.3 58.5 58.2 67.7
(87/118) (303/471) (989/1690) (346/594) (42/62)
Life satisfaction 69.1 69.2 58.9 59.3 57.8
(47/68) (211/305) (827/1405) (614/1036) (78/135)

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Table 8. Percentage of Teachers with Upper Limb Pain (ULP) in Relation

to Various Psychosocial Factors

Psychosocial % with NLP in Different Perceived Levels

Factors (no. of teachers with ULP/Total number)
Very low Low Moderate High Very high
Workload 33.3 25.0 17.4 26.7 40.9
(2/6) (2/8) (55/316) (338/1264) (507/1240)
Colleague support 48.7 38.4 31.6 25.3 21.7
(57/117) (180/469) (487/1541) (165/653) (10/46)
Variety of work 31.6 30.5 27.2 31.5 43.7
(6/19) (57/187) (252/926) (399/1265) (186/426)
Job stress 28.6 15.3 21.9 28.8 43.1
(2/7) (9/59) (106/484) (398/1384) (385/894)
Job satisfaction 46.9 35.0 31.8 27.8 32.3
(60/128) (157/449) (420/1322) (230/827) (32/99)
Anxiety 35.9 25.7 27.0 36.0 44.2
(42/117) (120/467) (283/1049) (310/862) (144/326)
Family support 45.2 41.1 33.0 28.8 29.4
(28/62) (117/285) (370/1122) (308/1071) (83/282)
Job authority 52.7 34.6 29.4 32.7 32.7
(58/110) (160/462) (476/1619) (184/562) (18/55)
Life satisfaction 37.1 38.1 32.4 29.3 32.5
(23/62) (110/289) (439/1357) (291/994) (38/117)

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Table 9. Frequency of Breaks during Working Hours in a Day (Excluding Lunch) in

Relation to Neck Pain (NP) and Upper Limb Pain (ULP)

Frequency % with N/P % with ULP

(no. of teachers with (no. of teachers with
NP/Total number) ULP/Total number)
No breaks 71.2 (405/569) 39.3 (216/549)
Every >3 hrs 62.3 (467/750) 31.1 (223/717)
Every >2 and  3 hrs 57.3 (420/733) 30.7 (217/706)
Every >1 and  2 hrs 49.7 (276/555) 26.7 (137/513)
Every <1 hr 60.2 (210/349) 31.6 (108/342)

Table 10. Frequency and Duration of Exercises in Leisure Time in Relation to Neck Pain
(NP) and Upper Limb Pain (ULP)

Parameters of % with N/P % with ULP

Exercise (no. of teachers with (no. of teachers with
NP/Total number) ULP/Total number)
Frequency
No exercise 63.7 (639/1003) 34.0 (330/972)
Once a week 60.0 (704/1173) 31.5 (351/1113)
Twice a week 59.6 (255/428) 29.7 (120/404)
3 times a week 53.0 (87/164) 33.6 (51/152)
>3 times a week 49.1 (85/173) 28.4 (48/169)
Duration of exercise per week
Never do exercise 62.5 (385/616) 34.0 (199/585)
<30 mins 62.3 (604/970) 31.8 (297/934)
30-60 mins 60.2 (467/776) 33.0 (246/745)
>1 and 2 hrs 58.2 (224/385) 29.3 (105/358)
>2 and 3 hrs 48.8 (63/129) 31.9 (38/119)
>3 hrs 43.2 (57/132) 24.6 (32/130)

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Table 11. Individual and Physical Factors Associated with Neck Pain and Upper Limb Pain*

Neck Pain Upper Limb Pain

Factors OR 95% C.I. p value OR 95% C.I. p value
Gender
Male 1.00 1.00
Female 2.39 1.97 to 2.91 < 0.0005 1.89 1.54 to 2.33 < 0.0005
Age (years)
20-25 1.00 1.00
26-30 2.23 1.55 to 3.21 < 0.0005 1.60 1.03 to 2.47 0.036
31-35 3.01 2.08 to 4.37 < 0.0005 2.00 1.30 to 3.09 0.002
36-40 2.63 1.79 to 3.85 < 0.0005 1.86 1.19 to 2.92 0.007
41-45 2.30 1.54 to 3.42 < 0.0005 1.68 1.05 to 2.69 0.030
46-50 2.71 1.79 to 4.10 < 0.0005 2.85 1.78 to 4.57 < 0.0005
> 50 2.11 1.36 to 3.26 0.001 3.80 2.33 to 6.21 < 0.0005
Working in head down posture — Average length of time
<1 hr 1.00 1.00
>1 and  2.5 hrs 1.19 0.82 to 1.72 0.363 1.45 0.92 to 2.30 0.114
>2.5 and  4 hrs 1.44 0.98 to 2.10 0.061 1.91 1.20 to 3.04 0.006
>4 and  5.5 hrs 2.17 1.38 to 3.40 0.001 1.96 1.17 to 3.28 0.010
>5.5 hrs 1.77 1.14 to 2.74 0.011 1.57 0.95 to 2.62 0.081
Working in head down posture — Maximal sustained time
<15 mins 1.00 1.00
>15 and  30 mins 1.72 1.16 to 2.53 0.006 1.38 0.86 to 2.19 0.181
>30 and  60 mins 1.64 1.13 to 2.40 0.010 1.37 0.87 to 2.16 0.172
>1 and  2 hrs 1.70 1.14 to 2.53 0.010 1.72 1.07 to 2.75 0.025
>2 hrs 2.10 1.38 to 3.19 0.001 1.91 1.18 to 3.10 0.008
* Subjects with no missing data for all risk factors were included in the logistic regression model.
OR - odds ratio, C.I. - confidence interval

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Table 12. Psychosocial Factors Associated with Neck Pain and Upper Limb Pain

Neck pain Upper limb pain

Factors OR 95% C.I. p value OR 95% C.I. p value
Workload
Very low/Low/ Moderate 1.00 1.00
High 1.51 1.12 to 2.05 0.008 1.41 0.97 to 2.07 0.075
Very high 2.17 1.58 to 2.97 < 0.0005 2.07 1.41 to 3.04 < 0.0005
Colleague support
Very low 2.00 1.16 to 3.47 0.013 2.15 1.32 to 3.50 0.002
Low 1.84 1.37 to 2.48 < 0.0005 1.61 1.19 to 2.17 0.002
Moderate 1.14 0.92 to 1.42 0.230 1.31 1.03 to 1.66 0.028
High/Very high 1.00 1.00
Anxiety
Very low/Low/Moderate 1.00 1.00
High 1.40 1.13 to 1.72 0.002 1.37 1.11 to 1.70 0.004
Very high 1.49 1.07 to 2.07 0.019 1.75 1.28 to 2.39 < 0.0005
Frequency of breaks during working hours a day (excluding lunch)
No breaks 1.36 1.02 to 1.82 0.036
Every >3 hrs 1.37 1.07 to 1.75 0.012
Every >2 and 3 hrs 1.14 0.90 to 1.44 0.284
Every 2 hrs 1.00
Hosmer-Lemeshow 2(8) = 2.74, p = 0.95 2(8) = 9.80, p = 0.28
goodness-of-fit test
* Subjects with no missing data for all risk factors were included in the logistic regression model.
OR - odds ratio, C.I. - confidence interval

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Appendix 1:
Neck & Upper Limb Pain Questionnaire for Secondary
School Teachers
Introduction: This questionnaire has been designed to give us information about how
NECK & UPPER LIMB PAIN has affected secondary school teachers. Please answer the
questions according to the instructions no matter you have neck and upper limb pain or
not right now. Thank you.
Date: _________________________

A. Background Information

Gender: ❑ Male ❑ Female

Age: ❑ 20-25 ❑ 26-30 ❑ 31-35 ❑ 36-40 ❑ 41-45 ❑ 46-50 ❑ >50
Education Level: ❑ Secondary ❑ Tertiary ❑ Bachelor ❑ Master ❑ Doctor
Teaching experience:
❑ 0-5 years ❑ 6-10 years ❑ 11-15 years ❑ 16-20 years
❑ 21-25 years ❑ >25 years
Major Teaching Subject: ________________________________

Other Teaching Subjects: ❑ Academic

❑ Physical Education
❑ Music
If you have any neck surgery before, please go to question 19.
Thank you.
Instruction: Please tick ONLY ONE BOX when answering the question.

B. History of Neck Pain

Please refer to the shaded area as shown in the two diagrams at
the right hand side and ignore any trouble you may have in the
adjacent parts of the body.

1. Have you ever had neck pain (any points within the shaded
area)?
❑ Yes (Please go to question 2)
❑ No (Please go to question 19)
adopted from kuorinka J. et al. 1987

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2. Have you ever had neck pain before you have become a teacher?
❑ Yes (Please go to question 3)
❑ No (Please go to question 5)

3. Have you found your neck pain changed after you have become a teacher?
❑ The neck pain has increased
❑ The neck pain has decreased
❑ There has been no change in the neck pain

4. Do you think the change in the neck pain level is related to teaching?
❑ Yes
❑ No

5. Have you ever hurt your neck in an accident?

❑ Yes, I hurt my neck in an accident before I have become a teacher (Please go to
question 6)
❑ Yes, I had hurt my neck in an accident after I have become a teacher (Please go to
question 6)
❑ No (Please go to question 7)

6. Do you think your neck pain is related to the accident?

❑ Yes
❑ No

7. What is the total length of time that you have had neck pain during the last 12 months?
❑ 0 day
❑ 1-7 days
❑ 8-30 days
❑ more than 30 days, but not every day
❑ every day

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8. How do you cope with your neck pain?

(Please prioritize from 1-7 according to the frequency: 1=the most frequent, 7=least
frequent, 0=not applicable)
❑ Take more breaks
❑ Do neck exercises
❑ Share workload with colleague
❑ Change working posture
❑ Seek medical help, please tick the one (you can tick more than one) that you have sought,
❑ Doctor ❑ Physiotherapist ❑ Chiropractor
❑ Bone Setter ❑ Others, Please specify
❑ Sick leave
❑ Others, please specify __________________________________________________________

9. According to question 8, how was the effect of the treatment that you use the most?
❑ The pain became worse
❑ The pain remained unchanged
❑ The pain was slightly improved
❑ The pain was moderately improved
❑ The pain completely subsided

C. Severity of Neck Pain

Please mark only ONE box that most closely describes your problem for each section in the following.
10. Neck pain intensity
❑ I have no pain at the moment
❑ The pain is mild at the moment
❑ The pain is moderate at the moment
❑ The pain is severe at the moment
❑ The pain is worst imaginable at the moment

11. Neck pain and sleeping

❑ My sleep is never disturbed by pain
❑ My sleep is occasionally disturbed by pain
❑ My sleep is regularly disturbed by pain
❑ Because of pain I have less than 5 hours sleep in total
❑ Because of pain I have less than 2 hours sleep in total

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12. Pins and needles or numbness ( ) in the arms

❑ I have no pins and needles or numbness
❑ I have occasional pins and needles or numbness
❑ My sleep is regularly disturbed by pins and needles or numbness
❑ Because of pins and needles or numbness I have less than 5 hours sleep in total
❑ Because of pins and needles or numbness I have less than 2 hours sleep in total

13. Duration of symptoms

❑ My neck and arms feel normal all day
❑ I have symptoms in my neck or arms on waking, which last less than 1 hour per day
❑ Symptoms are present on and off for a total period of 1-4 hours per day
❑ Symptoms are present on and off for a total of more than 4 hours per day
❑ Symptoms are present continuously all day

14. Carrying by hand

❑ I can carry heavy objects without extra pain
❑ I can carry heavy objects, but they give me extra pain
❑ Pain prevents me from carrying heavy objects, but I can manage medium weight
objects
❑ I can only lift light weight objects
❑ I cannot lift anything at all

15. Reading and watching TV

❑ I can do this as long as I wish with no problems
❑ I can do this as long as I wish, if I’m in a suitable position
❑ I can do this as long as I wish, but it causes extra pain
❑ Pain causes me to stop doing this sooner than I would like
❑ Pain prevents me from doing this at all

16. Working/housework etc

❑ I can do my usual work without extra pain
❑ Pain disturbs me to do usual work and shorten <25% of my usual working hours
❑ Pain disturbs me to do my usual work and shorten between 25% and 50% of my
usual working hours
❑ Pain disturbs me to do my usual work and shorten >50% of my usual working hours
❑ Pain prevents me from working at all

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17. Social activities (e.g. shopping, hiking)

❑ My social life is normal and causes me no extra pain
❑ My social life is normal, but increases the degree of pain
❑ Pain has restricted my social life, but I am still able to go out
❑ Pain has restricted my social life to the home
❑ I have no social life because of pain

18. Driving (Omit this question if you never drive a car when in good health)
❑ I can drive whenever necessary without discomfort
❑ I can drive whenever necessary, but with discomfort
❑ Neck pain limits my driving occasionally
❑ Neck pain limits my driving frequently
❑ I cannot drive at all due to neck pain

D. History of Upper Limb Pain

19. Have you ever had upper limb pain?
❑ Yes (Please go to question 20)
❑ No (Please go to question 30)

20. Have you ever had upper limb pain before you have become a teacher?
❑ Yes (Please go to question 21)
❑ No (Please go to question 23)

21. Have you found your upper limb pain changed after you have become a teacher?
❑ The upper limb pain has increased
❑ The upper limb pain has decreased
❑ There has been no change in the upper limb pain

22. Do you think the change in the upper limb pain level is related to teaching?
❑ Yes
❑ No

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23. Have you ever hurt your upper limb in an accident?

❑ Yes, I hurt my upper limb in an accident before I have become a teacher (Please go
to question 24)
❑ Yes, I had hurt my upper limb in an accident after I have become a teacher (Please
go to question 24)
❑ No (Please go to question 25)

24. Do you think your upper limb pain is related to the accident?
❑ Yes
❑ No

25. What is the total length of time that you have had upper limb pain during the last 12
months?
❑ 0 day
❑ 1-7 days
❑ 8-30 days
❑ more than 30 days, but not every day
❑ every day

26. How do you cope with your upper limb pain?

(Please prioritize from 1-7 according to the frequency: 1=the most frequent, 7=least
frequent, 0=not applicable)
❑ Take more breaks
❑ Do more exercises
❑ Share workload with colleague
❑ Change working posture
❑ Seek medical help, please tick the one (you can tick more than one) that you have
sought,
❑ Doctor
❑ Physiotherapist
❑ Chiropractor
❑ Bone Setter
❑ Others, Please specify
❑ Sick leave
❑ Others, please specify __________________________________________________________

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27. According to question 26, how was the effect of the treatment that you use the most?
❑ The pain became worse
❑ The pain remained unchanged
❑ The pain was slightly improved
❑ The pain was moderately improved
❑ The pain completely subsided

E. Severity of Upper Limb Pain and its association with Neck Pain
Please mark only ONE box that most closely describes your problem for the following
questions:
28. Upper limb pain intensity
❑ I have no pain at the moment
❑ The pain is mild at the moment
❑ The pain is moderate at the moment
❑ The pain is severe at the moment
❑ The pain is worst imaginable at the moment

If you have had both neck pain and upper limb pain, please answer the following question:

29. Do you think your upper limb pain is somewhat related to neck pain, or vice versa?
❑ Yes
❑ No

F. Working posture
30. Would the following activities induce your neck pain?
(i) working in overhead writing posture (e.g. writing on board) ❑ Yes
❑ No

(ii) working with head down posture (e.g. correcting assignment) ❑ Yes
❑ No

(iii) computer with computer ❑ Yes

❑ No

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For Questions 31-33, they refer to your condition in a day of your last working month.

Average length of time Maximal sustained time

31. Writing in overhead posture ❑ <30 minutes ❑ <2 minutes
(e.g. writing on board) ❑ 30-90 minutes ❑ 2-5 minutes
❑ >1.5 and  3 hours ❑ >5 and  10 minutes
❑ >3 and  4 hours ❑ >10 and  15 minutes
❑ >4 hours ❑ >15 minutes

Average length of time Maximal sustained time

32. Working in head down posture ❑ <1 hour ❑ <15 minutes
(e.g. correcting assignment) ❑ >1 and  2.5 hours ❑ >15 and  30 minutes
❑ >2.5 and  4 hours ❑ >30 and  60 minutes
❑ >4 and  5.5 hours ❑ >1 and  2 hours
❑ >5.5 hours ❑ >2 hours

Average length of time Maximal sustained time

33. Working with computer? ❑ <1 hour ❑ <30 minutes
❑ >1 and  2 hours ❑ >30 and  60 minutes
❑ >2 and  3 hours ❑ >1 and  2 hours
❑ >3 and  4 hours ❑ >2 and  3 hours
❑ >4 hours ❑ >3 hours

G. Psychosocial factors
Being a teacher, how do you perceive the follow aspects?
Very low Low Moderate High Very high
34. Workload ❑ ❑ ❑ ❑ ❑
35. Colleague support ❑ ❑ ❑ ❑ ❑
36. Variety of work ❑ ❑ ❑ ❑ ❑
37. Job stress ❑ ❑ ❑ ❑ ❑
38. Job satisfaction ❑ ❑ ❑ ❑ ❑
39. Anxiety (e.g. being fired) ❑ ❑ ❑ ❑ ❑
40. Family support ❑ ❑ ❑ ❑ ❑
41. Job authority ❑ ❑ ❑ ❑ ❑
42. Life satisfaction ❑ ❑ ❑ ❑ ❑

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43. How many times do you have breaks during working hours a day (excluding lunch)?
❑ <2 times
❑ 2-3 times
❑ 4-5 times
❑ 6-7 times
❑ >7 times

44. How often do you have breaks during working hours a day (excluding lunch)?
❑ No break
❑ every >3 hours
❑ every >2 and  3 hours
❑ every >1 and  2 hours
❑ every <1 hour

45. How long are the breaks all together during working hours a day (excluding lunch)?
❑ < 30 minutes
❑ 30-60 minutes
❑ >1 and  2 hours
❑ >2 and  3 hours
❑ >3 hours

46. How often do you exercise in your leisure time (including ball games, jogging etc)?
❑ No exercise
❑ Once a week
❑ Twice a week
❑ 3 times a week
❑ > 3 times a week

47. How long do you exercise per week? (Omit this question if you never do exercise in
your leisure time)
❑ < 30 minutes
❑ 30-60 minutes
❑ >1 and  2 hours
❑ >2 and  3 hours
❑ >3 hours
~ The End ~
Thank you for completing the questionnaire

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Appendix 2:
The Prevalence of Risk Factors for Neck Pain and
Upper Limb Pain among Secondary School Teachers
in Hong Kong - School Participation List

Code District School Name School Address Male Female Total Received Response Rate

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Code District School Name School Address Male Female Total Received Response Rate

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Code District School Name School Address Male Female Total Received Response Rate

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Code District School Name School Address Male Female Total Received Response Rate

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Code District School Name School Address Male Female Total Received Response Rate

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