Perceived barriers and facilitators to implementation of injury prevention programs in the military: Feedback from inside the trenches

BACKGROUND

Musculoskeletal injuries enact a substantial burden in military settings, incurring high costs, long-term disability, and impacting military readiness. This has led to a prioritization of injury prevention programs. Understanding the challenges faced by those trying to implement these programs could help standardize and better inform future efforts. The purpose was to capture perceptions of barriers and facilitators to implementation of injury prevention programs in the US Armed Forces.

METHODS

A cross-sectional survey with open-ended questions was circulated to relevant stakeholders; key themes were derived using conceptual content analysis. Four questions were asked concerning injury prevention programs: 1) barriers, 2) facilitators, 3) how can leadership best support, and 4) how can subject matter experts best collaborate to make these programs successful?

RESULTS

The survey reached at least 300 individuals working with the armed services worldwide; 91 completed the survey. The mean (SD) time working with military service members was 11.5 (8.2) years; 93 % worked with active-duty service members, 71.4 % were licensed healthcare providers, and 55 % worked in settings with established injury prevention programs. Only 45.2 % of participants believed an appropriate, clear way to measure program success currently exists. Nearly 85 % believed that lacking standardization of definitions and metrics hinders program assessment. Wide variability existed in opinions regarding who should be primarily responsible for promoting/supporting injury prevention efforts. Key themes included resources as both a facilitator (when present) and barrier (when absent), organizational culture, and leadership support. Leadership can best help by prioritizing the programs and valuing the programming through modeling the desired behavior. Program staff can collaborate by focusing on enabling change, integrating into organizational/unit culture and collaborating with leaders to change policy.

CONCLUSIONS

Factors leading to incidence and recovery of musculoskeletal injuries are multifactorial, requiring collaborative multidisciplinary approaches for optimal injury prevention program development and implementation. Leadership support/prioritization, unit-level cultural acceptance and sufficient resources are essential facilitators to implementing prevention programs. Developing standardized, relevant metrics for assessing program effectiveness and establishing organizational best practices are necessary for long term program viability and lasting change.

Home Use Therapies for Pain, Disability, and Quality of Life in Military Service Members with a Musculoskeletal Injury: An Updated Systematic Review Meta-Analysis

INTRODUCTION

Musculoskeletal (MSK) injury can negatively affect service members by compromising job performance and readiness. These injuries can impact the service member's physical health, functional abilities, and quality of life (QoL). Rehabilitation therapies for MSK injuries can reduce these impacts. One approach is home use rehabilitative therapy, usable during deployment and at home stations. The purpose of this updated systematic review with meta-analysis was to broaden our scope of pain/symptoms, disability, and QoL as outcome measures for nonpharmaceutical MSK therapies in a military population versus controls.

MATERIALS AND METHODS

An updated systematic literature search was conducted from inception to September 2022 using electronic databases. From 2790 retrievals, 22 reports were identified from 21 randomized or nonrandomized control trials. Interventions included exercise, electrotherapy, bracing, and other devices compared to a standard control treatment. Outcomes for MSK pain/symptoms, disability, and QoL were summarized as (1) standardized change from baseline for both intervention and control by time and (2) standardized mean differences (SMDs) in the time change between the intervention and control.

RESULTS

Relative to baseline, pain improved during treatment and follow-up (P < .0001) with differences between intervention and control groups (P < .0001) but no significant interactions between group and time (P = .11). Overall, interventions showed modest (0.33 SMD, 95% CI, 0.11 to 0.54) improvement relative to controls across body regions and time. On average, disability exhibited an SMD of 0.12 (95% CI, -0.20 to 0.44) across all measures with substantial heterogeneity (I2 = 0.93). Time (P = .02) but not intervention (P = .87) was a significant moderator with no clear pattern of change over time and no time by group interaction (P = .84). Quality of life had an overall modest effect with an SMD of 0.10 (95% CI, -0.04 to 0.24) with no evidence supporting a difference between the intervention and control groups (P = .10) and no significant interaction between time and group (P = .41). The QoL measures were primarily derived using the Short Form Health Survey (SF12/36), which provide a mental and physical component summary score. For the mental component, there was either no change or a small decline during the study (P(time) = .80), with a difference between the intervention and control (P = .04) but no interaction between groups over time (P = .40). For the physical component scale, there was improvement during the study (P = .01), with the intervention showing better improvement than the control (P = .005), with no interaction between the time and treatment/control group (P = .80). The report considers responses by region and individual treatments.

CONCLUSIONS

This analysis demonstrated modest improvement in pain and physical well-being with therapy, with low certainty across diverse military cohorts. The impact on overall health-related disability and QoL was limited, with little change in mental well-being. The substantial heterogeneity and low certainty across diverse military cohorts limit generalizability, suggesting that further research in homogeneous environments is important for guiding clinical decisions. The study's findings suggest that nonpharmacological home use interventions may offer modest improvements in pain relief, particularly early in treatment, and in strength and function, according to our previous report. These interventions could complement standard care, providing options that may benefit service members during deployment and at home.

Musculoskeletal system injuries in the Polish Territorial Defence Forces

BACKGROUND

Musculoskeletal system injuries (MSIs) are the major health problem of soldiers. The aim of this study was to assess the types of MSIs that occurred most frequently among soldiers and which parts of the body they generally affected.

METHODS

The study included 140 Territorial Army soldiers, both men and women, serving in the Polish Territorial Defence Forces (TDF). Times and frequency of MSIs were assessed using an original questionnaire available via a web-based platform, the TDF Information Portal and the Yammer network.

RESULTS

Among the participants, 42% reported MSIs, most often a single one (19%), incurred while doing military service. Damaged muscles and ligaments were the most common injuries in both groups (p>0.05). The knee joint was the main location of injuries for both sexes (24% in men vs 50% in women, p>0.05). Other parts of the body often affected by injuries were the shoulder joint (24%, p>0.05), head, spine, wrist, fingers, ankle and feet (19% each) in the male soldiers and the ankle (24%), spine (14%), head, chest, shoulder joint and foot (10% each) in the female soldiers. Injuries reoccurred with similar frequency in the female and male soldiers (43% vs 40%, p>0.05) and had the same location in both groups (43% vs 40%, respectively, p>0.05). Difficult terrain, too intensive military training and heavy loads were the main risk factors for MSIs in both groups (p>0.05).

CONCLUSIONS

More than half of all the participants (19% of the men and 33% of the women) reported at least one injury incurred during military service. Over 40% of all the study subjects had reinjuries. The males and females were similar in terms of the most common type and location of MSI. Occurrence of MSIs rarely required interruption in the military training/service.

Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review

INTRODUCTION

Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities.

METHODS

A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified.

RESULTS

From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions.

CONCLUSION

Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Comparison of Health Outcomes Over Time Among Women 1990-1991 Gulf War Veterans, Women 1990-1991 Gulf Era Veterans, and Women in the U.S. General Population

INTRODUCTION

The aim of this study is to examine health over almost 20 years of follow-up among women Gulf War veterans and women Gulf Era veterans and compare their health to that of women in the U.S. general population.

METHODS

We used data from a health survey of 1,274 women Gulf War veteran and Gulf Era veteran participants of the Gulf War Longitudinal Study who responded to all three waves. Data on the U.S. population of women came from the 1999-2000, 2005-2006, and 2011-2014 National Health and Nutrition Examination Survey (NHANES). Generalized estimating equations (GEEs) were used to compare the report of disease over time in women Gulf War and Gulf Era veterans. Differences in prevalence at the three survey timepoints were calculated between women Gulf War veterans and the NHANES women population, and women Gulf War Era veterans and the NHANES women population.

RESULTS

Women veterans who deployed to the 1990-1991 Gulf War report poorer health than women veterans who served during the same time but did not deploy. Women veterans reported a lower prevalence of hypertension, stroke, and diabetes than women in the NHANES sample. Women veterans also reported a higher prevalence of arthritis, chronic obstructive pulmonary disease, and skin cancer than women in the NHANES sample.

CONCLUSIONS

This study is the first to characterize the health of a population-based cohort of women Gulf War and women Gulf Era veterans over time and compare it with women's health in a civilian NHANES population. This demonstrates the value of epidemiological research on women veterans and the importance of developing longitudinal cohorts across genders.

The Impact of Footwear on Occupational Task Performance and Musculoskeletal Injury Risk: A Scoping Review to Inform Tactical Footwear

The aim of this scoping review was to investigate the impact of footwear on worker physical task performance and injury risk. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews protocol and registered in the Open Science Framework. Key search terms were entered into five academic databases. Following a dedicated screening process and critical appraisal, data from the final articles informing this review were extracted, tabulated, and synthesised. Of 19,614 identified articles, 50 articles informed this review. Representing 16 countries, the most common populations investigated were military and firefighter populations, but a wide range of general occupations (e.g., shipping, mining, hairdressing, and healthcare workers) were represented. Footwear types included work safety boots/shoes (e.g., industrial, gumboots, steel capped, etc.), military and firefighter boots, sports shoes (trainers, tennis, basketball, etc.) and various other types (e.g., sandals, etc.). Occupational footwear was found to impact gait and angular velocities, joint ranges of motion, posture and balance, physiological measures (like aerobic capacity, heart rates, temperatures, etc.), muscle activity, and selected occupational tasks. Occupational footwear associated with injuries included boots, conventional running shoes, shoes with inserts, harder/stiffer outsoles or thin soles, and shoes with low comfort scores-although the findings were mixed. Occupational footwear was also linked to potentially causing injuries directly (e.g., musculoskeletal injuries) as well as leading to mechanisms associated with causing injuries (like tripping and slipping).

Myostatin/Activin Receptor Ligands in Muscle and the Development Status of Attenuating Drugs

Muscle wasting disease indications are among the most debilitating and often deadly noncommunicable disease states. As a comorbidity, muscle wasting is associated with different neuromuscular diseases and myopathies, cancer, heart failure, chronic pulmonary and renal diseases, peripheral neuropathies, inflammatory disorders, and, of course, musculoskeletal injuries. Current treatment strategies are relatively ineffective and can at best only limit the rate of muscle degeneration. This includes nutritional supplementation and appetite stimulants as well as immunosuppressants capable of exacerbating muscle loss. Arguably, the most promising treatments in development attempt to disrupt myostatin and activin receptor signaling because these circulating factors are potent inhibitors of muscle growth and regulators of muscle progenitor cell differentiation. Indeed, several studies demonstrated the clinical potential of "inhibiting the inhibitors," increasing muscle cell protein synthesis, decreasing degradation, enhancing mitochondrial biogenesis, and preserving muscle function. Such changes can prevent muscle wasting in various disease animal models yet many drugs targeting this pathway failed during clinical trials, some from serious treatment-related adverse events and off-target interactions. More often, however, failures resulted from the inability to improve muscle function despite preserving muscle mass. Drugs still in development include antibodies and gene therapeutics, all with different targets and thus, safety, efficacy, and proposed use profiles. Each is unique in design and, if successful, could revolutionize the treatment of both acute and chronic muscle wasting. They could also be used in combination with other developing therapeutics for related muscle pathologies or even metabolic diseases.

Musculoskeletal disorders and the physical activity of territorial army soldiers during the COVID-19 pandemic

BACKGROUND

The aim of this study was to assess the occurrence of self-reported musculoskeletal disorders (MSD) among Polish territorial army soldiers during the COVID-19 pandemic and to investigate whether there was a relationship between occupational physical activity (OPA), leisure time physical activity (LTPA), and MSD.

METHODS

The study used a cross-sectional design with a sample of 373 territorial army soldiers ages 18-55 who had not previously suffered from COVID-19 and were not convalescents. The symptoms prevalence data was collected using the standardized Nordic Musculoskeletal Questionnaire. OPA and LTPA data was collected using the Seven-Day Physical Activity Recall (SDPAR).

RESULTS

The OPA, LTPA, and total physical activity (PA) among the studied soldiers was very diverse and the mean level of PA was relatively high. A total of 56 and 40% of territorial army soldiers had experienced pain or other discomfort in one or more of nine body regions during the past 12 months and during the past 7 days, respectively. The most common MSD among Polish territorial army soldiers were low back pain, followed by pain in the neck and knees.

CONCLUSIONS

The study revealed that the OPA of the studied soldiers, especially vigorous-intensity and high vigorous-intensity OPA, was associated with a higher prevalence of MSD in several regions of the body, i.e. the lower back, elbows, wrists or hands, hips or thighs, and ankles or feet. Along with the increase in energy expenditure on total PA, a greater percentage of respondents experienced low back pain. Vigorous and high vigorous-intensity PA may contribute to the occurrence of MSD.

Prevalence of Musculoskeletal Injuries in a Security Force Assistance Brigade Before, During, and After Deployment

INTRODUCTION

The Security Force Assistance Brigades (SFABs) are specialized units designed to strengthen allied and partnered nations through advising, supporting, liaising, and assessing in support of U.S. national security interests and combatant commanders' war fighting objectives. As the 1st SFAB was the pioneer unit, descriptive analysis of the musculoskeletal injures and body regions occurring before, during, and after deployment was previously unavailable, limiting the ability of embedded holistic health and fitness teams to proactively address the unit's musculoskeletal needs and medical readiness.

MATERIALS AND METHODS

Physical therapists collected and retrospectively analyzed data from 4597 encounters over 19 months: 4 months before, 9 months during, and 4 months after deployment using descriptive statistics.

RESULTS

Physical therapy encounters averaged 124 per month during pre-deployment preparation, 363 per month during deployment, and 206 per month post-deployment. The most common musculoskeletal injuries identified during pre-deployment were to the lumbar spine (31.8%), knee (18.1%), and shoulder (9.1%). The most common areas of injury during deployment were to the lumbar spine (28.4%), thoracic spine (18.3%), and shoulder (14.0%). The most common post-deployment injuries consulted were to the lumbar spine (21.3), shoulder (19.6%), and knee (17.8%).

CONCLUSION

Musculoskeletal injuries are a concern that may limit medical readiness in the SFABs in the time of before, during, and after deployment. Low back pain is the primary musculoskeletal injury of the 1st SFAB throughout the entire deployment cycle. Based on these findings, recommendations include embedding injury prevention programs to address low back pain to improve medical readiness. More research is required to assess the effectiveness of these programs in reducing incidents of musculoskeletal injuries before, during, and after deployment cycles.

Sex and Stride Impact Joint Stiffness During Loaded Running

This study determined changes in lower limb joint stiffness when running with body-borne load, and whether they differ with stride or sex. Twenty males and 16 females had joint stiffness quantified when running (4.0 m/s) with body-borne load (20, 25, 30, and 35 kg) and 3 stride lengths (preferred or 15% longer and shorter). Lower limb joint stiffness, flexion range of motion (RoM), and peak flexion moment were submitted to a mixed-model analysis of variance. Knee and ankle stiffness increased 19% and 6% with load (P < .001, P = .049), but decreased 8% and 6% as stride lengthened (P = .004, P < .001). Decreased knee RoM (P < .001, 0.9°-2.7°) and increased knee (P = .007, up to 0.12 N.m/kg.m) and ankle (P = .013, up to 0.03 N.m/kg.m) flexion moment may stiffen joints with load. Greater knee (P < .001, 4.7°-5.4°) and ankle (P < .001, 2.6°-7.2°) flexion RoM may increase joint compliance with longer strides. Females exhibited 15% stiffer knee (P = .025) from larger reductions in knee RoM (4.3°-5.4°) with load than males (P < .004). Stiffer lower limb joints may elevate injury risk while running with load, especially for females.

Association Between Musculoskeletal Injuries and the Canadian Armed Forces Physical Employment Standard Proxy in Canadian Military Recruits

INTRODUCTION

Musculoskeletal injuries (MSKIs) and recruitment are major challenges faced by modern military forces. The Canadian Armed Forces uses a physical employment standard (PES) proxy to determine occupational fitness and job suitability. It is unknown whether the performance on the PES proxy can be also used as predictor of MSKIs. The purpose of this study was to investigate for relationships between age, sex, body composition, aerobic fitness, performance on the Canadian Armed Forces PES proxy (FORCE evaluation), and risk of sustaining a MSKI requiring intervention in the Training Rehabilitation Program (MSKI-TRP1) during Canadian Basic Military Qualification.

MATERIALS AND METHODS

This was a retrospective analysis of MSKIs in recruits introduced in the Training Rehabilitation Program (TRP1) in 2016 and 2017. A two-tailed t-test and a multivariate stepwise logistic regression were completed to investigate the interrelationships of sex, age, FORCE performance (20 m rushes, sandbag lift, intermittent loaded shuttles, sandbag drag) and health-related characteristics (waist circumference, predicted peak oxygen consumption [$\dot{V}$O2peak]), and odds for sustaining a MSKI-TRP.

RESULTS

The MSKI-TRP1 intervention rate observed was 4.3%. Rehabilitation duration was an average (SD) of 87 (76) days; nearly 80% of MSKI-TRP were lower body injuries. MSKI-TRP recruits were older, had a lower score on FORCE, and had a larger mean waist circumference and lower $\dot{V}$O2peak than non-TRP1 recruits (all P < 0.01). Recruits with performance lower than 1 SD below mean on the 20 m rushes, intermittent loaded shuttle, or sandbag drag were 2.69 (1.89-3.83), 2.74 (1.91-3.95), and 2.26 (1.52-3.37) times more likely to sustain a MSKI-TRP1, respectively (all P < 0.01). Recruits with $\dot{V}$O2peak lower than 1 SD below mean were also 2.19 (1.30-3.70) times more likely to sustain a MSKI-TRP. Neither sex, age, nor waist circumference impacted the risk of MSKI-TRP1 when controlling for FORCE performance.

CONCLUSIONS

The Canadian Armed Forces PES proxy performance can be used to assess the odds of sustaining a MSKI-TRP1 in Canadian military recruit training.

Musculoskeletal injury outcomes: 2-year retrospective service evaluation of a UK defence primary care rehabilitation facility (PCRF)

INTRODUCTION

Musculoskeletal injury represents the leading cause of medical discharge from the UK Armed Forces. This study evaluates effectiveness of care provision within a large primary care rehabilitation facility (PCRF) against directed defence best practice guidelines (BPGs) METHODS: All new patient electronic records from January to July 16 were interrogated to identify demographics, causation, injury pathology, timelines and outcomes.

RESULTS

393 eligible records (81.9% male) were identified. 17.6% were officers, 32.8% were seniors and 49.6% were juniors. The average age was 35.1 years (mode 30). The average wait to treatment was 8.3 days with 75.6% key performance indicator compliance. 47.3% were repeat injuries. The average care timeline was 117.1 days with 8.7 average treatment sessions needed. 30 remained under care at 2 years. 17.8% accessed hydrotherapy and 44% underwent exercise remedial instructors care. 14.2% of individuals required concurrent DCMH care (15.9% male and 26.8% female). 28.5% required multidisciplinary injury assessment clinic intervention with 74.1% compliance against BPGs. 2.9% used the Defence Medical Rehabilitation Centre. Common pathologies were low back pain (LBP) (n=67), upper limb (UL) soft tissue (n=40) and knee trauma (n=38). LBP had the highest recurrence rates (71.6%). Anterior knee pain took the longest (173.1 days) but had the best outcome on discharge. Ankles and lower limb muscle injuries had the best outcomes. Patella tendinopathy and knee trauma had the poorest outcome on discharge. LBP and patellar tendinopathy had the lowest fully fit rates at 2 years (56.7% and 53.8%, respectively). At 2 years, 58.2% of individuals achieved full fitness (60.7% men and 46.4% women), rising to 64% and 55%, respectively, when including those retained with limitations.

CONCLUSIONS

The PCRF was generally compliant with BPGs, achieving good functional outcomes on discharge. Women were disproportionally represented, had higher concurrent DCMH attendance and poorer overall long-term outcomes. Repeat injury rates were significantly high.

Musculoskeletal Injuries and United States Army Readiness. Part II: Management Challenges and Risk Mitigation Initiatives

Introduction

Noncombat injuries (“injuries”) threaten soldier health and United States (U.S.) Army medical readiness, accounting for more than twice as many outpatient medical encounters among active component (AC) soldiers as behavioral health conditions (the second leading cause of outpatient visits). Noncombat musculoskeletal injuries (MSKIs) account for more than 80% of soldiers’ injuries and 65% of medically nondeployable AC soldiers. This review focuses on MSKI risk reduction initiatives, management, and reporting challenges within the Army. The authors will summarize MSKI risk reduction efforts and challenges affecting MSKI management and reporting within the U.S. Army.

Materials/Methods

This review focuses on (1) initiatives to reduce the impact of MSKIs and risk for chronic injury/pain or long-term disability and (2) MSKI reporting challenges. This review excludes combat or battle injuries.

Results

Primary risk reduction Adherence to standardized exercise programming has reduced injury risk among trainees. Preaccession physical fitness screening may identify individuals at risk for injury or attrition during initial entry training. Forward-based strength and conditioning coaching (provided in the unit footprint) and nutritional supplementation initiatives are promising, but results are currently inconclusive concerning injury risk reduction.

Secondary risk reduction

Forward-based access to MSKI care provided by embedded athletic trainers and physical therapists within military units or primary care clinics holds promise for reducing MSKI-related limited duty days and nondeployability among AC soldiers. Early point-of-care screening for psychosocial risk factors affecting responsiveness to MSKI intervention may reduce risk for progression to chronic pain or long-term disability.

Tertiary risk reduction

Operational MSKI metrics enable commanders and clinicians to readily identify soldiers with nonresolving MSKIs. Monthly injury reports to Army leadership increase command focus on soldiers with nonresolving MSKIs.

Conclusions

Standardized exercise programming has reduced trainee MSKI rates. Secondary risk reduction initiatives show promise for reducing MSKI-related duty limitations and nondeployability among AC soldiers; timely identification/evaluation and appropriate, early management of MSKIs are essential. Tertiary risk reduction initiatives show promise for identifying soldiers whose chronic musculoskeletal conditions may render them unfit for continued military service.

Clinicians must document MSKI care with sufficient specificity (including diagnosis and external cause coding) to enable large-scale systematic MSKI surveillance and analysis informing focused MSKI risk reduction efforts. Historical changes in surveillance methods and injury definitions make it difficult to compare injury rates and trends over time. However, the U.S. Army’s standardized injury taxonomy will enable consistent classification of current and future injuries by mechanism of energy transfer and diagnosis. The Army’s electronic physical profiling system further enables

standardized documentation of MSKI-related duty/work restrictions and mechanisms of injury. These evolving surveillance tools ideally ensure continual advancement of military injury surveillance and serve as models for other military and civilian health care organizations.

Surveyed Reasons for Not Seeking Medical Care Regarding Musculoskeletal Injury Symptoms in US Army Trainees

INTRODUCTION

Musculoskeletal injuries (MSKIs) pose a significant threat to military readiness and are difficult to monitor due to Soldiers' reluctance to seek medical treatment. There is high risk of developing MSKIs while going through initial entry training (IET), many of which go unreported. The purposes of this study were to identify the contributing factors that influence US Army trainees to not seek medical care for self-reported symptoms of musculoskeletal injury (SMSKI) and establish how those factors may differ by sex, training school, and installation site.

MATERIALS AND METHODS

Data were collected from 739 trainees (607 males, 132 females) completing IET at either Fort Benning, GA, Fort Sill, OK or Fort Leonard-Wood, MO, USA. Male trainees were in combat arms jobs while female trainees were from both combat arms and other physically demanding jobs. All surveys were completed within 5 weeks of graduation from Advanced Individual Training and One Station Unit Training. Trainees answered a series of questions about SMSKIs sustained during IET that lasted seven or more days. Using a Likert-type scale (1-strongly disagree through 5-strongly agree), trainees rated the influence that each of the following seven statements contributed to their decision not to seek medical care: "graduating on time," "avoiding negative perceptions associated with injuries," "avoiding profile," "inconvenience in seeing a provider," "self-managing the injury based on past experience," "severity of the injury," and "prior negative experiences seeking medical care in the military." Pearson's Chi-square test was used to assess significant relationships among SMSKI reporting across sex, training school and training installation.

RESULTS

Overall, SMSKI incidence was 36.1% and 58.3% among IET male and female trainees, respectively (40% overall). Nearly two-thirds (64%) of all trainees injured during IET had a SMSKI that they did not report to leadership or a medical provider. Across sex, female trainees were more likely to report SMSKIs than male trainees (p < 0.01), but there was no difference in SMSKI reporting rates by sex (p = 0.48). There was a difference in SMSKI rates by training school (p < 0.01), where infantry had higher SMSKI rates than field artillery (p < 0.01). There were no differences across training schools in how often trainees sought medical care (p = 0.58). The most common reasons selected for not reporting SMSKIs (i.e., not seeking medical care) included "I wanted to graduate on time" and "I wanted to avoid a profile." "I had prior negative experiences seeking medical care in the military" was consistently rated as the least important reason. Female trainees were more likely to not report SMSKIs in order "to avoid a profile" than male trainees (p < 0.05).

CONCLUSION

Over 64% of trainees' did not seek medical care for their SMSKI during IET. As early detection, better reporting and timely treatment may result in reductions in SMSKI severity, reduced IET attrition, and lower medical expenses, trainees should be encouraged to report SMSKIs for proper early stage treatment. These study findings could be used to assist military leadership to create a positive environment for reporting and seeking care for SMSKIs.

Remarkable increase of musculoskeletal disorders among soldiers preparing for international missions - comparison between 2002 and 2012

Background

Musculoskeletal disorders (MSD) are common among soldiers and constitute the most common reason for discontinuing military service within different military populations worldwide. The aims of this study were to investigate the prevalence of musculoskeletal disorders in two cohorts, 10 years apart, in the Swedish Armed Forces, to explore differences between these cohorts and to determine associated factors with MSD.

Method

Comparative cross-sectional study. Participants were recruited from the Swedish Armed Forces, i.e. soldiers preparing for international missions in 2002 and 2012. A total of 961 soldiers, 7% women, participated in the study.

Data were collected using the Musculoskeletal Screening Protocol (MSP), which includes questions regarding prevalence of MSD in ten anatomical locations (neck, upper back, low back, shoulders, elbow, hand, hip, knee, lower limb and foot). An additional five questions concern perceived self-rated health, i.e. how the respondent perceives their own physical body, mental health, social environment, physical environment and work ability.

Results

Over a ten-year period, both point prevalence and one-year prevalence of MSD in any body part increased significantly, with point prevalence increasing from 7.1 to 35.2% (p < 0.001) and one-year prevalence from 27.9 to 67.9% (p < 0.001). The knee was the most common anatomic location for MSD in both cohorts. Across each anatomical location (neck, upper back, low back, shoulders, elbow, hand, hip, knee, lower leg and foot), both point prevalence (p < 0.039) and one-year prevalence (p < 0.005) increased significantly from 2002 to 2012.

Most soldiers reported good to excellent perceived health, i.e. self-perception of their physical body, mental health, physical and social environments, and work ability.

The odds of reporting one-year prevalence of MSD in any body part was 5.28 times higher for soldiers in Cohort 2012, 1.91 times higher in age group 31–40 and 2.84 times higher in age group 41 and above.

Conclusions

The prevalence of MSD increased remarkably over a ten-year period among Swedish soldiers preparing for international missions. With increasing age as one risk factor, systematic monitoring of MSD throughout the soldiers’ careers and implementation of targeted primary-to-tertiary preventive programs are thus important.

Physical Therapists Forward Deployed on Aircraft Carriers: A Retrospective Look at a Decade of Service

Introduction

Navy physical therapists (PTs) have been a part of ship's company aboard Aircraft Carriers since 2002 due to musculoskeletal injuries being the number one cause of lost duty time and disability. This article describes a decade of physical therapy services provided aboard aircraft carriers.

Materials and Methods

A retrospective survey was conducted to evaluate the types of services provided, volume of workload, value of services provided, and impact of PTs on operational readiness for personnel aboard Naval aircraft carriers. Thirty-four reports documenting workload from PTs stationed onboard aircraft carriers were collected during the first decade of permanent PT assignment to aircraft carriers.

Results

This report quantifies a 10-yr period of physical therapy services (PT and PT Technician) in providing musculoskeletal care within the carrier strike group and adds to existing literature demonstrating a high demand for musculoskeletal care in operational platforms. A collective total of 144,211 encounters were reported during the 10-yr period. The number of initial evaluations performed by the PT averaged 1,448 per assigned tour. The average number of follow-up appointments performed by the PT per tour was 1,440. The average number of treatment appointments per tour provided by the PT and PT technician combined was 1,888. The average number of visits per patient, including the initial evaluation, was 3.3. Sixty-five percent (65%) of the workload occurred while deployed or out to sea during training periods. It was estimated that 213 medical evacuations were averted over the 10-yr period. There were no reports of adverse events or quality of care reviews related to the care provided by the PT and/or PT technician. Access to early PT intervention aboard aircraft carriers was associated with a better utilization ratio (lower average number of visits per condition) than has been reported in prior studies and suggests an effective utilization of medical personnel resources.

Conclusions

The impact of Navy PTs serving afloat highlights the importance of sustaining these billets and indicates the potential benefit of additional billet establishment to support operational platforms with high volumes of musculoskeletal injury. Access to early PT intervention can prevent and rehabilitate injuries among operational forces, promote human performance optimization, increase readiness during war and peace time efforts, and accelerate rehabilitation from neuromusculoskeletal injuries. With the establishment of Electronic Health Records within all carrier medical groups a repeat study may provide additional detail related to musculoskeletal injuries to guide medical planners to staff sea-based operational platforms most effectively to care for the greatest source of battle and disease non-battle injuries and related disability in the military.

Self-reported musculoskeletal complaints and injuries and exposure of physical workload in Swedish soldiers serving in Afghanistan

Background

Musculoskeletal complaints and injuries (MSCI) are common in military populations. However, only a limited number of studies have followed soldiers during international deployments and investigated the prevalence of MSCI during and at the end of their deployment. The aim was to describe the prevalence of MSCI in different military occupational specialties and categorise their most common tasks in terms of exposures to physical workloads during a six-month long international deployment in Afghanistan.

Methods

Cross-sectional survey, including 325 soldiers (300 men), aged 20–62 participating in an international deployment in Afghanistan during the spring of 2012. Soldiers were clustered into different military occupational specialties: Infantry, Administration, Logistics, Logistics/Camp, Medical and Other. Data were collected through the use of the Musculoskeletal Screening Protocol at the end of the international mission.

Results

Forty-seven percent reported MSCI during deployment, with 28% at the end.

The most common locations of MSCI during the mission were lower back, knee, shoulders, upper back, neck and foot, while the knee and lower back prevailed at the end of the mission. Almost half of the soldiers who had MSCI reported affected work ability. The most common duties during the mission were vehicle patrolling, staff duties, guard/security duties, foot patrols and transportation. Soldiers reported that vehicle patrolling, staff duties and transportation were demanding with respect to endurance strength, guard/security duties challenged both maximum and endurance strength while foot patrolling challenged maximum and endurance strength, aerobic and anaerobic endurance and speed.

Conclusions

MSCI during international deployment are common among Swedish soldiers. The results indicate the need to further develop strategies focusing on matching the soldiers’ capacity to the job requirements, with relevant and fair physical selection-tests during the recruitment process and proactive interventions targeting MSCI before and during deployment, in order to enhance soldiers’ readiness and promote operational readiness.

Mitigating the risk of musculoskeletal injury: A systematic review of the most effective injury prevention strategies for military personnel

OBJECTIVES

To update the current injury prevention strategy evidence base for making recommendations to prevent physical training-related musculoskeletal injury.

DESIGN

We conducted a systematic review to update the evidence base on injury prevention strategies for military personnel.

METHODS

Literature was systematically searched and extracted from five databases, and reported according to PRISMA guidelines. Sixty one articles meeting the inclusion criteria and published during the period 2008-2015 were selected for systematic review.

RESULTS

The retrieved articles were broadly categorised into six injury prevention strategies; (1) conditioning, (2) footwear modifications, (3) bracing, (4) physical activity volume, (5) physical fitness, and (6) leadership/supervision/awareness. The majority of retrieved articles (n=37 (of 61) evaluated or systematically reviewed a conditioning intervention of some nature. However, the most well-supported strategies were related to reducing physical activity volume and improving leadership/supervision/awareness of injuries and injury prevention efforts.

CONCLUSIONS

Several injury prevention strategies effectively reduce musculoskeletal injury rates in both sexes, and many show promise for utility with military personnel. However, further evaluation, ideally with prospective randomised trials, is required to establish the most effective injury prevention strategies, and to understand any sex-specific differences in the response to these strategies.

BMI and Lower Extremity Injury in U.S. Army Soldiers, 2001-2011

INTRODUCTION

Little data exist regarding the long-term impact of excess weight on lower extremity musculoskeletal injury/disorder (MID) in U.S. Army Soldiers. This prospective analysis examines the association between BMI of Soldiers at accession and risk of MID.

METHODS

A total of 736,608 Soldiers were followed from accession into the Army, 2001-2011. Data were analyzed January through March 2015. MID was categorized as any first incident lower extremity musculoskeletal injury/disorder, and secondarily, as first incident injury/disorder at a specific site (i.e., hips, upper legs/thighs, knees, lower legs/ankles, feet/toes). Multivariable-adjusted proportional hazards models estimated associations between BMI category at accession and MID risk.

RESULTS

During 15,678,743 person-months of follow-up, 411,413 cases of any first MID were documented (70,578 hip, 77,050 upper leg, 162,041 knee, 338,080 lower leg, and 100,935 foot injuries in secondary analyses). The overall MID rate was 2.62 per 100 person-months. Relative to Soldiers with normal BMI (18.5 to <25 kg/m(2)) at accession, those who were underweight (<18.5); overweight (25 to <30); or obese (≥30) had 7%, 11%, and 33% higher risk of MID, respectively, after adjustment. Risks were highest in Soldiers who were obese at accession, and lowest in those with a BMI of 21-23 kg/m(2).

CONCLUSIONS

Soldier BMI at accession has important implications for MID. A BMI of 21-23 kg/m(2) in newly accessing Soldiers was associated with the lowest risk of incident MID, suggesting that accession be limited to people within this range to reduce overall incidence of MID among service personnel.

Low fitness, low body mass and prior injury predict injury risk during military recruit training: a prospective cohort study in the British Army

Background

Injuries sustained by military recruits during initial training impede training progression and military readiness while increasing financial costs. This study investigated training-related injuries and injury risk factors among British Army infantry recruits.

Methods

Recruits starting infantry training at the British Army Infantry Training Centre between September 2008 and March 2010 were eligible to take part. Information regarding lifestyle behaviours and injury history was collected using the Military Pre-training Questionnaire. Sociodemographic, anthropometric, physical fitness and injury (lower limb and lower back) data were obtained from Army databases. Univariable and multivariable Cox regression models were used to explore the association between time to first training injury and potential risk factors.

Results

58% (95% CI 55% to 60%) of 1810 recruits sustained at least 1 injury during training. Overuse injuries were more common than traumatic injuries (65% and 35%, respectively). The lower leg accounted for 81% of all injuries, and non-specific soft tissue damage was the leading diagnosis (55% of all injuries). Injuries resulted in 122 (118 to 126) training days lost per 1000 person-days. Slower 2.4 km run time, low body mass, past injury and shin pain were independently associated with higher risk of any injury.

Conclusions

There was a high incidence of overuse injuries in British Army recruits undertaking infantry training. Recruits with lower pretraining fitness levels, low body mass and past injuries were at higher risk. Faster 2.4 km run time performance and minimal body mass standards should be considered for physical entry criteria.

Injury during U.S. Army basic combat training: a systematic review of risk factor studies

CONTEXT

Approximately one quarter of men and half of women in U.S. Army basic combat training experience an injury. Preventing basic combat training-related injuries would reduce associated human and economic costs and discharges from the Army. Identification of risk factors for such injuries is a crucial step toward their prevention. Although some research has begun to address this need, prior studies of risk factors for training-related injury have not been reviewed systematically. This study systematically reviews the literature on risk factors for injury during U.S. Army basic combat training.

EVIDENCE ACQUISITION

Original studies of risk factors for injury during U.S. Army basic combat training published since 1990 in peer-reviewed journals were identified using PubMed and manual searches of reference lists. This search was last performed in May 2013. Nineteen studies met the inclusion criteria.

EVIDENCE SYNTHESIS

Methodologic quality and potential for bias were assessed. The findings of 11 studies deemed to be of high or medium quality were synthesized to determine the level of evidence supporting the association between each risk factor studied and risk of injury during basic combat training. Quality assessment and evidence synthesis were performed from June to September 2013.

CONCLUSIONS

There is strong or moderate evidence supporting association of older age, history of smoking, and self-rated low physical activity level prior to basic combat training with increased risk of training-related injury among male trainees. There is limited, mixed, or insufficient evidence to identify risk factors for injury among female trainees.