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Background: Most of the school meal service workers in Korea are middle-aged individuals. They have high workload, which increases their incidence of musculoskeletal disorders. This study aimed to evaluate the prevalence and risk factors of subjective musculoskeletal symptoms, presumptive diagnosis, medical care use, and sick leave among female school meal workers. Methods: We analyzed the results of musculoskeletal disease screening of 1581 female school meal workers. The screening consisted of self-administered questionnaire, history taking by occupational physicians, and physical examination. The prevalence of subjective musculoskeletal symptoms, presumptive diagnosis after initial examination by occupational physicians, use of medical care for more than 7 days, and sick leave due to musculoskeletal diseases during the past year were evaluated in this study. The relative risk of four outcome indicators of musculoskeletal disorders was compared with respect to potential factors, such as age, subjective physical loading, present illness, injury experience, and type of school, using log-binomial regression. Results: The prevalence of subjective musculoskeletal symptom was 79.6%; presumptive diagnosis, 47.6%; hospital visits over 7 days, 36.4%; and sick leave, 7.3%. The relative risk of musculoskeletal symptoms by age (≥50 years vs < 50 years) was 1.04 (95% confidence interval (CI): 1.00–1.09); presumptive diagnosis of musculoskeletal disease, 1.17 (95% CI: 1.06–1.30); hospital visits over 7 days, 1.26 (95% CI: 0.85–1.85); and sick leave, 1.17 (95% CI: 1.02–1.34). The relative risk of musculoskeletal symptoms due to subjective physical loading (very hard vs low) was 1.45 (95% CI: 1. 33–1.58); presumptive diagnosis, 2.92 (95% CI: 2.25); hospital visits over 7 days, 1.91 (95% CI: 1.02–3.59); and sick leave, 2.11 (95% CI: 1.63–2.74). Conclusions: Subjective physical loading was a more important factor in musculoskeletal disorders than the age of female school meal workers. Keywords: School meal, Female, Musculoskeletal diseases * Correspondence: email@example.com Department of Occupational and Environmental Medicine, Chosun University Hospital, College of Medicine, Chosun University, Gwangju, Republic of Korea Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Moon et al. Annals of Occupational and Environmental Medicine (2019) 31:1 Page 2 of 7 Background loskeletal diseases among 1930 school meal employees Musculoskeletal disorders are the most common occupa- from February to December 2016. The health examination tional diseases. In Korea, musculoskeletal disorders a of musculoskeletal disease was requested to three hospi- ccounted for about 10% of all occupational diseases in the tals with occupational and environmental medicine de- 1990s. In 2003, however, it accounted for 49.6% of all oc- partments. A total of 1581 (82%) individuals participated cupational diseases. Since 2006, it has consistently acco in this screening program. We obtained a written consent unted for 60–70% of all occupational diseases. Of the from all participants, which permits the use of collected 4947 workers, 76.64% of men and 20.36% of women were data for preventive action. We retrospectively analyzed compensated for musculoskeletal diseases, according to the data of the GMOE’s musculoskeletal disease screening workers’ compensation statistics from Korea Workers’ program. This study was approved by the Institutional Re- Compensation & Welfare Service in 2016 . view Board (Chosun 2018–05-015). However, the burden of musculoskeletal disease in the general population is higher in women than in men. Ac- Research tools cording to a study conducted in South Korea, back pain General characteristics and occupational characteristics ranked first among the 30 major diseases in women and Variables were collected using the musculoskeletal symp- second in men based on the estimated disability-adjusted tom questionnaire developed by the Korea Occupational life years . Another study conducted on a 20-to-64- Safety and Health Agency (KOSHA) . The variables con- year-old working population using the database of the Na- sisted of job control, household work time, current illness, tional Health Insurance Service in South Korea reported injury experience, current illness, injury experience, work- that the total loss due to musculoskeletal diseases in men ing hour, the number of meals per day, career of school in 2008 was $16.74 billion and that of women was $32.09 meal service worker, type of school, and subjective physical billion. The productivity loss was $750 million for men loading. Job control is categorized based on whether it can and $1.53 billion for women . control work speed and break time. Household work time South Korea’s public schools have been providing school refers to the average time spent performing certain tasks meals for students since 2003. As a result, the number of such as cooking, washing, cleaning, and taking care of chil- school meal service workers had increased dramatically; dren under 2 years old at home and is categorized by a 2-h most of them were middle-aged women. This job was eas- cut-off. Current illnesses mean diagnosis of diseases such as ily accessible to individuals without a career because of rheumatoid arthritis, diabetes, lupus disease, gout, and alco- similarities with housework. Hence, school meal workers holism by physicians. Moreover, they developed hand, fin- have been exposed to musculoskeletal risk factors such as ger, wrist, arm, elbow, shoulder, neck, waist, leg, and feet manual handling, repetitive motion, and awkward posture. injuries due to exercise-related accidents, traffic accidents, Because older female workers performed high burden falls, and crash. Subjective physical loading was assessed on work, they had higher incidence of musculoskeletal di a five-point scale (very low, low, slightly hard, hard, and seases. very hard) based on the physical burden felt for current In this study, the musculoskeletal diseases of female work and was categorized into three levels by combining school meal workers experiencing the highest level of “very low,”“low,” and “slightly hard” into “low.” physical burden were evaluated. Furthermore, details regarding the burden of musculoskeletal disease among Four outcome indicators of musculoskeletal diseases female workers are limited. Some studies showed the To investigate the characteristics of musculoskeletal dis- prevalence and major site of musculoskeletal disorders eases in female school meal workers, the four outcome in- among school meal service workers [4–8]. However, dicators were categorized as follows: subjective muscu these studies did not provide sufficient information since loskeletal symptoms, presumptive diagnosis, the rate of they only used the musculoskeletal symptom question- hospital visits over 7 days during the past 12 months, and naire. Hence, this study aimed to investigate the pre therateofsickleaveduring thepast12months. Thesub- sumptive diagnosis, medical care use, and sick leave rate jective musculoskeletal symptoms were defined as pain that of musculoskeletal diseases based on the physical exami- developed more than once per month or pain that lasted nations and history taking of occupational physicians. It more than 1 week, which was assessed using the musculo- also aimed to identify the risk factors for musculoskel- skeletal symptoms questionnaire from KOSHA . The etal disorders. presumptive diagnosis was defined as being diagnosed and treated as a musculoskeletal disease by a doctor or having Methods severe pain and objective signs upon physical examination. Participants and data collection Severe pain was characterized by difficulty sleeping and re- The Gwangju Metropolitan Office of Education (GMOE) stricted work performance or limited performance of daily conducted a screening program for prevention of muscu activities. Pain severity was assessed by the doctor through Moon et al. Annals of Occupational and Environmental Medicine (2019) 31:1 Page 3 of 7 history taking. Objective signs on physical examination indicators and potential risk factors such as job control, were defined as positive response in provocation test, te household work time, current illness, injury experience, nderness, and limited range of joint motion. working hour, number of meals per day, type of school, The detailed diagnosis of musculoskeletal disorders was and subjective physical loading. We compared the rela- made based on the following criteria. Myofascial syn- tive risk of each outcome indicators by log-binomial re- drome has pain on the affected muscle or referred pain, gression analysis using SAS 9.3 (SAS Institute Inc.). tenderness, taut band, and pain during contraction. Finger joint osteoarthritis has joint stiffness or pain during joint Results motion and limited range of joint motion, Heberden’s General characteristics and work-related factors node, Bouchard’s node, and joint swelling. Elbow epicon- Table 1 shows the general characteristics and dylitis has pain and tenderness in the medial or lateral epi- work-related factors of the study population. The mean condylar area without neurological symptoms and symp age was 51.1 years (standard deviation: 5.4). The rate of tom induced by resistance against bending and extension subjective physical loading was only 16.0%. The rates of of the wrist. Rotator cuff syndrome has no abnormal sen- present illness and injury experience were 10.4 and sation in the corresponding shoulder area, but the pain is 25.0%, respectively. present with a positive sign in empty or full can test, im- pinge (Neer sign and Hawkins-Kennedy test) test, resisted Prevalence of the four outcome indicators according to internal rotation test, external rotation test, or lift-off test. major variables Carpal tunnel syndrome is marked by intermittent sensory Table 2 shows that the prevalence of subjective musculo- disorders or pain in the first, second, third, and fourth fin- skeletal symptoms was 79.6%, presumptive diagnosis was gers and pain in the wrist and palms or radiating pains in the proximal part of the wrist. Phalen’s test, Tinel’stest Table 1 Characteristics of the study participants (percussion), and wrist compression test revealed positive Variables Frequency % results. Finger tenosynovitis is marked by pain when mov- Age (years) < 50 591 37.4 ing the tendon and tenderness when palpating the tendon. ≥50 990 62.6 Lumbar radiculopathy is characterized by leg pain, numb- Subjective physical loading Low or slightly hard 252 16.0 ness, difficulty in walking, positive straight leg raising test, Hard 650 41.2 positive Lasegue sign, sensory changes in the specific site, or decline in motor function. Cervical radiculopathy is Very hard 676 42.8 marked by intermittent pain and neck stiffness. With re- Present illness No 1417 89.6 gard to head movement, an abnormal sensation or pain is Yes 164 10.4 felt that stretches from the neck to the upper limb. A pain Injury experience No 1186 75.0 is felt in the upper extremity during active or passive neck Yes 395 25.0 rotation and the result of Spurling test is positive. Knee Frequency of meal service 1 1179 74.6 osteoarthritis is characterized by knee pain in individuals older than 40 years of age, morning stiffness in the knees 2–3 402 25.4 with bone spurs quadriceps muscle atrophy, or presence Career (years) ~ 9 635 40.3 of varus deformity. These diagnostic criteria were shared 10~19 864 54.9 by occupational and environmental physicians who partic- ≥20 75 4.8 ipated in the screening. Type of job Chefs (manager) 263 16.6 To investigate the rate of medical care use and sick Cooks or assistants 1318 83.4 leave among workers with musculoskeletal diseases, the following question was asked: “Have you ever been ab- Job control Yes 591 37.6 sent or treated for musculoskeletal (joints, muscles, liga- No 982 62.4 ments, tendons, and nerves) pain during the past 12 Household work (hours) < 2 1052 66.7 months (excluding accidental injuries, visits to the hos- ≥2 526 33.3 pital for health checkups, and absence due to personal Working hour < 48 1285 81.3 issues)?” Hence, we categorized medical care use and ≥48 296 18.7 sick leave as follows: more than 7 days of medical care use and more than 1 day of sick leave. Type of school High 467 29.5 Middle 358 22.6 Statistical analysis Elementary 756 47.8 The univariate and multivariate analysis was conducted Total 1581 100.0 to examine the relationship between the four outcome Moon et al. Annals of Occupational and Environmental Medicine (2019) 31:1 Page 4 of 7 Table 2 Prevalence of musculoskeletal disorder related outcomes according to major variables Variables Subjective symptoms, % Presumptive diagnosis, % Medical care use, % Sick leave, % Age (years) < 50 75.5 * 42.5* 32.5* 5.9* ≥50 82.0 50.7 38.8 8.1 Physical loading Low 46.8 * 19.4* 20.2* 4.4* Hard 79.8 47.0 33.5 6.2 Very hard 91.7 58.7 45.3 9.5 Present illness No 78.5* 44.6* 34.9* 6.9 Yes 89.0 73.8 49.4 10.4 Injury experience No 77.2* 45.8* 34.1* 6.2* Yes 86.6 53.0 43.3 10.6 Frequency of meal service 1 81.5* 48.8 38.6* 8.1* 2-3 73.9 44.0 30.1 4.7 Career (years) ~ 9 73.9* 42.4* 30.9* 6.3 10~19 83.2 51.2 40.0 7.6 ≥20 89.3 54.7 45.3 12.0 Type of job Chefs (manager) 79.8 47.9 36.9 8.4 Cooks or assistants 79.5 47.5 36.3 7.1 Job control Yes 78.2 44.2* 37.1 6.4 No 80.4 49.5 36.0 7.8 Household work (hours) < 2 78.6 48.0 35.5 6.7 ≥2 81.7 47.0 38.4 8.6 Working hour < 48 80.2 48.8 37.5 7.5 ≥48 77.0 42.6 31.8 6.4 Type of school High 74.9* 43.5 31.0* 5.6 Middle 81.3 49.0 38.5 6.1 Elementary 81.6 49.5 38.8 8.9 Total 79.6 47.6 36.4 7.3 *p < 0.05 by chi-squared test 47.6%, medical care use over 7 days was 36.4%, and sick tunnel syndrome, finger tenosynovitis, and lumbar radi leave by musculoskeletal disease was 7.3%. The four out- culopathy. come indicators showed differences according to age, subjective physical loading, presence of present illness, Relationship between major variables and outcome injury experience, number of meals per day, the career indicators of school meals service, and the type of school. Table 4 shows the relative risk of four outcome indica- tors by age, subjective physical loading, present illness, Prevalence of presumptive diagnosis of doctors and injury experience. In particular, the relative risks for Table 3 shows the details of presumptive diagnosis of subjective musculoskeletal symptoms, presumptive diag- doctors. The most frequent diagnosis was myofascial nosis, and medical care use among workers who had syndrome (241 patients, 15.2%), followed by finger joint very hard physical loading were 1.45 (95% confidence osteoarthritis (233 patients, 14.7%), elbow epicondylitis interval (CI): 1.33–1.58), 2.92 (95% CI: 2.25–3.78), 1.91 (171 patients, 10.8%), rotator cuff syndrome (141 pa- (95% CI: 1.02–3.59), and 2.11 (95% CI: 1.63–2.74) com- tients, 8.9%), carpal tunnel syndrome (100 patients, pared with those who had low physical loading. 6.3%), and finger tenosynovitis (62 patients, 3.9%). There were significant differences in the prevalence of finger Discussion joint osteoarthritis and rotator cuff syndrome by age. According to the results of this study, the rate of muscu- Subjective physical loading showed a significant relation- loskeletal symptoms among school meal workers was ship with myofascial syndrome, finger joint osteoarth- very high (79.5%) but relatively low compared with those ritis, elbow epicondylitis, rotator cuff syndrome, carpal reported in previous studies. Compared with the results Moon et al. Annals of Occupational and Environmental Medicine (2019) 31:1 Page 5 of 7 Table 3 Prevalence of musculoskeletal disorders by presumptive diagnosis of doctors Presumptive diagnosis Total Age, n (%) Subjective physical loading, n (%) (of 1581) < 50 years ≥50 years Low Hard Very hard Myofascial syndrome 241 (15.2) 91 (15.4) 150 (15.2) 11 (4.4) 99 (15.2) 131 (19.4)* Finger joint osteoarthritis 233 (14.7) 62 (10.5) 171 (17.3) 17 (6.7) 80 (12.3) 136 (20.1)* Elbow epicondylitis 171 (10.8) 58 (9.8) 113 (11.4) 3 (1.2) 71 (10.9) 97 (14.3)* Rotator cuff syndrome 141 (8.9) 39 (6.6) 102 (10.3) 67 (9.9) 62 (9.5) 11 (4.4)* Carpal tunnel syndrome 100 (6.3) 39 (6.6) 61 (6.2) 3 (1.2) 38 (5.8) 59 (8.7)* Finger tenosynovitis 62 (3.9) 28 (4.7) 34 (3.4) 2 (0.8) 34 (5.2) 26 (3.8) Lumbar radiculopathy 34 (2.2) 10 (1.7) 24 (2.4) 1 (0.4) 11 (1.7) 22 (3.3) Cervical radiculopathy 29 (1.8) 8 (1.4) 21 (2.1) 3 (1.2) 10 (1.5) 16 (2.4) Knee osteoarthritis 24 (1.5) 5 (0.8) 19 (1.9) 1 (0.4) 11 (1.7) 12 (1.8) *p < 0.01 by chi-squared test of other studies that applied the same KOSHA criteria compared with other occupations, the rate of musculo- for musculoskeletal symptoms, the rate of subjective skeletal symptom among school meal workers is very musculoskeletal symptom was 91.4% in a study of 326 high. For example, the rate of musculoskeletal symptoms female food service workers in Nowon-gu, Seoul . In among melon-cultivating farmers was 75.2% , and the the study of 1513 female food service workers in rate of musculoskeletal symptoms among automobile Gangwon-do in 2012, the rate of subjective musculoskel- engine assemblers was 42.2% . etal symptoms was 93.4% . In a study of 891 female According to presumptive diagnosis by physicians, school meal workers in Seoul in 2012, the rate of sub- myofascial pain syndrome was most common musculo- jective musculoskeletal symptoms was 89.0% . The skeletal disorder among school meal workers. This dis- proportion of musculoskeletal symptoms reported in an order can affect any of the skeletal muscles in the body unpublished study of school meal service workers in and the prevalence varies by physician [11, 12]. The Gwangju metropolitan city was 89.8% in 2013 . It is prevalence of musculoskeletal diseases affecting the unclear whether the relatively low rate of musculoskel- upper limb was relatively higher than that in other body etal symptoms rate in this study represents a reduction parts. In particular, finger- and wrist-related diseases in actual musculoskeletal disease. However, since the were common. This result is similar with those reported GMOE has promoted preventive education and im- in other studies [4, 5]. School meal service consisted of provement of food service facilities, the effectiveness of several tasks such as preprocessing, cooking, feeding, these efforts may have been reflected. Nevertheless, washing dishes, and cleaning the kitchen accompanied Table 4 Relative risk of four outcome indicators of musculoskeletal disorders according to major variables Variables Subjective Presumptive diagnosis by Medical care use (≥7 days/ Sick leave by musculoskeletal symptoms, % physician, % year), % diseases% RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) Age (years) < 50 1.00 1.00 1.00 1.00 ≥50 1.04 (1.00–1.09) 1.17 (1.06–1.30) 1.26 (0.85–1.85) 1.17 (1.02–1.34) Subjective Physical Low 1.00 1.00 1.00 1.00 loading Hard 1.32 (1.21–1.44) 2.39 (1.84–3.11) 1.32 (0.68–2.53) 1.59 (1.21–2.08) Very hard 1.45 (1.33–1.58) 2.92 (2.25–3.78) 1.91 (1.02–3.59) 2.11 (1.63–2.74) Present illness No 1.00 1.00 1.00 1.00 Yes 1.03 (0.98–1.08) 1.51 (1.37–1.66) 1.28 (0.78–2.08) 1.26 (1.06–1.48) Injury experience No 1.00 1.00 1.00 1.00 Yes 1.04 (0.99–1.08) 1.05 (0.95–1.15) 1.60 (1.11–2.30) 1.16 (1.02–1.33) Type of school High 1.00 1.00 1.00 1.00 Middle 1.04 (0.98–1.10) 1.09 (0.96–1.24) 1.08 (0.62–1.88) 1.23 (1.02–1.47) Elementary 1.00 (0.96–1.05) 0.99 (0.89–1.11) 1.46 (0.94–2.26) 1.16 (0.99–1.36) By log-binomial regression. Adjusted by age, subjective physical loading, present illness, injury experience, and type of school Moon et al. Annals of Occupational and Environmental Medicine (2019) 31:1 Page 6 of 7 by repetitive movements, uncomfortable postures, and alternative labor. They complained that their co-workers excessive use of force of the upper limbs. The use of should have an excessive workload if they have sick relatively heavy metal plates and cooking utensils, or leave. high intensity of kitchen cleaning for hygiene control is This study had some limitations. First, physical loading considered to be an additional risk factor. was evaluated using a self-reported questionnaire. The In this study, the risk of musculoskeletal symptoms, number of meals per worker was widely used to identify presumptive diagnosis, and sick leave was significantly physical loading. However, this indicator does not reflect higher in patients older than 50 years of age, but the the physical loading accurately, because food service en- relative risks of musculoskeletal symptoms and pre- vironment varied depending on the modernization or sumptive diagnosis were 1.04 and 1.17, respectively. layout of school’s kitchen, the age of the students served There were significant differences in the prevalence of with meals, and additional tasks such as food prepar- finger joint osteoarthritis and rotator cuff syndrome by ation and cleaning. Rather, subjective physical loading age. This result is similar with previous studies [13–15]. can reflect this situation comprehensively. Second, there There are few cases of knee osteoarthritis in this study is likely to be a bias in the presumptive diagnosis of to determine whether a result is statistically significant. musculoskeletal disorders in this study. The six occupa- By contrast, the relative risks of musculoskeletal symp- tional physicians participating in musculoskeletal screen- toms and presumptive diagnosis by subjective physical ing may have had a different experience regarding the loading were 1.45 and 2.92, respectively. According to a diagnosis of musculoskeletal disorders and may have a previous study conducted on 7100 food service workers different understanding of the diagnostic criteria. How- in Japan, a large number of meals per person, insuffi- ever, since most of the diagnostic criteria for musculo- cient rest in the morning, poor kitchen environment, skeletal diseases are not clear, epidemiologic studies of and inadequate height of the countertop were significant musculoskeletal disorders can only be made by oper- risk factors of musculoskeletal disorders . A 2-year ational definition. In this study, the presumptive diagno- prospective study of 385 employees in a community res- sis of the physician was based on the necessity of taurant in Finland showed that high physical workloads disturbance of daily life due to pain and discomfort and play a major role in predicting the occurrence of multi- the existence of objective signs. This type of diagnosis site musculoskeletal pain. This study has shown that complements the limitations of subjective symptom higher physical workloads have a greater impact on mus- reporting. Third, the relationship shown in this study culoskeletal pain incidence than individual factors such seemed to be underestimated or overestimated due to as obesity and smoking . In a survey of 114 elemen- selection bias. Therefore, other evidence is needed to de- tary school meal workers showed that age, job stress, termine the causality between related factors and mus- and presence of lunchroom were not significant risk fac- culoskeletal disorders. However, musculoskeletal disea tors for musculoskeletal symptoms. However, when the ses have a long prevalence duration, and there is short number of meals per worker was over 150, the odds ra- latency period between the exposure to the harmful fac- tio adjusted by age, job stress, and presence of lunch- tors and the onset of the disease; hence, even a cross room was 4.67 (95% CI: 1.04–21.0) . In a study of -sectional study can be one of evidence for judging the school meal workers in Seoul, it was concluded that job causal relationship. demands and stress due to physical environment were The strength of this study was the large number of associated with musculoskeletal symptoms, with odds participants. In addition to the subjective symptoms ratios of 3.3 and 2.5, respectively . Therefore, in the assessed using a questionnaire, the results were obtained case of school meal workers, the physical labor intensity through doctors’ surveys and physical examinations, as is generally the most important risk factor for musculo- well as assessing the burden of diseases such as hospital skeletal disorders than age. The groups that responded use and sick leave. “very high” to the physical loading showed a lower prevalence rate of rotator cuff syndrome than the group Conclusion that responded “low or high”. We supposed that this In this study, the musculoskeletal symptoms were inves- phenomenon is a survivor effect, because patients suffer- tigated using questionnaires and by conducting physical ing from this disease are no longer able to perform examinations of school meal workers. The rate of mus- high-level burden work. culoskeletal symptoms was 79.6%; musculoskeletal pa- According to the results of this study, the prevalence tients, 47.6%; medical care use for 7 days or more, 36.4%; of medical care use and sick leave are low considering and sick leave, 7.3%. It is confirmed that the level of sub- high prevalence of musculoskeletal disorder. We sup- jective physical loading is an important factor in devel- posed through interviews with school meal service oping musculoskeletal diseases rather than the age of worker that this phenomenon is due to a lack of school meal workers. Moon et al. Annals of Occupational and Environmental Medicine (2019) 31:1 Page 7 of 7 These results suggest that it is important to reduce 6. Lee SR, Kim KS, Kim EA, Kim JH, Kim DH. Job stress and musculoskeletal disorder in Seoul city's school foodservice employees. Korean J Occup physical burden, especially the upper limb physical bur- Health Nurs. 2014;23(4):245–53. den for prevention of musculoskeletal diseases among 7. Gwangju Metropolitan Office of Education. Study on improvement of food service workers. working environment for school meals employees. 2013. 8. Jung-Choi KH, Lee SY, Ki M, Cho KH, Kang HT, Kwon YJ, et al. Multilevel analysis of risk factors related to musculoskeletal symptoms among caterers Abbreviations for elementary school lunch services. Korean J Occup Environ Med. 2004; CI: Confidence interval; COMWEL: Korea Workers’ Compensation & Welfare 16(4):436–49 Gwangju Metropolitan Office of Education. Study on Service; GMOE: Gwangju Metropolitan Office of Education; KOSHA: Korea improvement of working 328 environment for school meals employees. occupational safety and Health agency 2013.329 http://www.gen.go.kr/community/department2/board.php?mode= downpost&number=5005&t330 bnum=48&sCat=0&page=3&keyset= Acknowledgements &searchword=(2013). Accessed 8 August 2018. was deleted. Please check if Authors thank the Gwangju metropolitan office of education. the action taken was correct. 9. Korea Occupational Safety & Health Agency. Guidelines for the investigation Funding of musculoskeletal burdens work hazards (H-9-2016). http://www.kosha.or. This study was supported by research fund from Chosun University (2017). kr/www/cmsTiles.do?url=/cms/board/board/Board.jsp?communityKey= B0678&menuId=5285(2016). Accessed 8 August 2018. Bae KJ, Lee KS, Kong Availability of data and materials YK, Oh GJ, Lee SJ. The prevalence of musculoskeletal symptoms and the Not applicable. ergonomic risk factors among oriental melon-growing farmers. Korean J Occup Environ Med. 2011;23(1):1–8. Authors’ contributions 10. Kim YK, Kang DM, Koh SB, Son BC, Kim JW, Kim DW, et al. Risk factors of Moon YH was involved in writing the manuscript. Song HS participated in work-related musculoskeletal symptoms among motor engine assembly the study design and is the corresponding author of this study. Chae HJ, Kim plant workers. Korean J Occup Environ Med. 2004;16(4):488–98. SH participated in the study design. Yang YJ, Do SY, and Kim JY participated 11. Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain in the data collection. Lee CG reviewed the article. All authors read and syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011;25(2): approved the final manuscript. 185–98. 12. Gerwin RD. Diagnosis of myofascial pain syndrome. Phys Med Rehabil Clin Ethics approval and consent to participate N Am. 2014;25(2):341–55. This study was approved by the Institutional Review Board of Chosun 13. Jonsson H. Age related prevalence of hand osteoarthritis diagnosed by University Hospital (Chosun 2018–05-015). An informed consent was photography (HOASCORE). Jonsson BMC Musculoskelet Disord. 2017;18:508. obtained from all participants. 14. Bodin J, Ha C, Manac’h APL, Sérazin C, Descatha A, Leclerc A. At al. Risk factors for incidence of rotator cuff syndrome in a large working Consent for publication population. Scand J Work Environ Health. 2012;38(5):436–46. Written informed consent was obtained from all participants for the 15. Anderson AS, Loeser RF. Why is osteoarthritis an age-related disease? Best publication of this report. Pract Res Clin Rheumatol. 2010;24(1):15. 16. Nagasu M, Sakai K, Ito A, Tomita S, Temmyo Y, Ueno M, et al. Prevalence Competing interests and risk factors for low back pain among professional cooks working in The authors declare that they have no competing interests. school lunch services. BMC Public Health. 2007;7:171. 17. Haukka E, Ojajärvi A, Takala EP, Viikari-Juntura E, Leino-Arjas P. Physical workload, leisure-time physical activity, obesity and smoking as predictors of Publisher’sNote multisite musculoskeletal pain. A 2-year prospective study of kitchen Springer Nature remains neutral with regard to jurisdictional claims in workers. Occup Environ Med. 2012;69:485–92. published maps and institutional affiliations. Author details Department of Occupational and Environmental Medicine, Chosun University Hospital, College of Medicine, Chosun University, Gwangju, Republic of Korea. Department of Occupational and Environmental Medicine, Donggunsan Hospital, Gunsan, South Korea. Department of Occupational and Environmental Medicine, KS hospital, Gwangju, South Korea. Received: 17 October 2018 Accepted: 4 January 2019 References 1. Korea Occupational Safety & Health Agency. Analysis of industrial accidents. http://www.kosha.or.kr/board.do?menuId=554(2016). Accessed 8 August 2. Yoon JH, Oh IH, Seo HY, Kim EJ, Gong YH, Ock MS, et al. Disability-adjusted life years for 313 diseases and injuries: the 2012 Korean burden of disease study. J Korean Med Sci. 2016;31:S146–57. 3. Oh IH, Yoon SJ, Seo HY, Kim EJ, Kim YA. The economic burden of musculoskeletal disease in Korea: a cross sectional study. BMC Musculoskelet Disord. 2011;12:157. 4. Labor and Environmental Health Research Institute. Survey on working environment and health status of school meals employees in Nowong-gu. 5. Gangwon Provincial Office of Education. Working condition improvement research for school meals employees. https://www.slideshare.net/runkilsh/ 2012-27442704). Accessed 10 Jan 2019.
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