High Physical Exposure During Female Recruits' Basic Military Training in Sweden-A Descriptive Study

INTRODUCTION

There is a knowledge gap concerning the occurrence of physical complaints/injuries, i.e., musculoskeletal disorders (MSD), among Swedish women who undergo basic military training (BMT). The aims were to describe prevalence and factors related to MSD and explore physical exposure and performance in Swedish female recruits during BMT.

MATERIALS AND METHODS

A total of 144 females (mean age 22 years) who underwent BMT in 2016 participated in this cross-sectional study. Data regarding self-reported MSD, physical performance, physical activity and exercise, motivation and mental and physical preparation, and physical exposure during BMT and perceived health were collected at the end of BMT through the Musculoskeletal Screening Protocol questionnaire. Additional data on muscle strength were retrieved from IsoKai isokinetic lift tests. Descriptive and analytic (paired samples t-test and logistic binary regression) statistics were used.

RESULTS

The prevalence of MSD was high, with 33% (n = 48) reporting MSD before BMT, 78% (n = 113) during, and 50% (n = 72) at the end of BMT. Knee and upper back were the most frequently reported MSD locations. Forty-four (30%) participants felt insufficiently physically prepared for BMT. The physical exposure was high with loaded marches/runs and carrying heavy loads as the most demanding tasks. The longest walking distance was reportedly 55 km, and the reported maximum load was 50 kg. Forty-five participants (31%) had carried a load representing over 50% of their body weight. Most participants reported good to excellent health at the end of BMT. There was a small (8 N) but significant (P = 0.045) increase in mean force over time. Two variables, MSD before BMT (odds ratio 2.24, P = 0.03) and being physically unprepared (odds ratio 3.03, P < 0.01), were associated with MSD at the end of BMT.

CONCLUSION

This study showed that the prevalence of MSD in Swedish female recruits was high before, during, and at the end of BMT, with knee and upper back as the most frequent locations. Although the physical exposure during BMT was occasionally high, self-rated health was mainly perceived as good to excellent at the end of BMT. Previous MSD and being physically unprepared were related to MSD at the end of BMT. These important and relevant findings indicate the necessity for implementing interventions to increase physical fitness and treat MSD at the beginning of BMT.

Twelve weeks of concurrent resistance and interval training improves military occupational task performance in men and women

In the British Army, ground close combat roles have opened to women, however, they must pass the newly developed, gender-neutral Role Fitness Tests for Soldiers (RFT(S)). Due to physiological differences between sexes, training that optimally prepares both sexes for military occupational demands and the RFT(S) is needed. The purpose of this study was to determine the efficacy of a 12-week periodized strength and power programme with concurrent interval training on RFT(S) performance and determine if performance adaptations differed between sexes. 39 recruit-aged (18-35 yrs) participants, including 21 men (29 ± 1 yrs) and 18 women (27 ± 1 yrs), completed the study. Participants performed 3 training sessions per week that included strength and power resistance training followed by interval training. Pre- to post-training, improvements were observed for seated medicine ball throw (4.5%, p < 0.001), casualty drag (29.8%, p < 0.001), single lift (8.9%, p < 0.001), water can carry (13.8%, p = 0.012), repeated lift and carry (6.5%, p < 0.001), 2-km load carriage (7.2%, p < 0.001) and 2-km run (3.2%, p = 0.021). Pre- to post-training improvements were also observed for maximal squat (27.0%, p < 0.001), bench press (8.9%, p < 0.001) and deadlift (24.6%, p < 0.001) maximal strength, but not upper body power or aerobic capacity. No differences in RFT(S) improvements were observed between sexes, however men performed better than women in all RFT(S) and physical performance measures. Concurrent resistance and interval training improves military occupational performance in men and women; however, women may need more training than men to pass the gender-neutral RFT(S).

Risk factors for musculoskeletal-related occupational disability among US Army soldiers

INTRODUCTION

Minimising temporary and permanent disability associated with musculoskeletal conditions (MSK-D) is critical to the mission of the US Army. Prior research has identified potentially actionable risk factors for overall military disability and its MSK-D subset, including elevated body mass index, tobacco use and physical fitness. However, prior work does not appear to have addressed the impact of these factors on MSK-D when controlling for a full range of factors that may affect health behaviours, including aptitude scores that may serve as a proxy for health literacy. Identifying risk factors for MSK-D when providing control for all such factors may inform efforts to improve military readiness.

METHODS

We studied 494 757 enlisted Army soldiers from 2014 to 2017 using a combined medical and administrative database. Leveraging data from the Army's digital 'eProfile' system of duty restriction records, we defined MSK-D as the first restriction associated with musculoskeletal conditions and resulting in the inability to deploy or train. We used multivariable Cox proportional hazards regression to assess the associations between incident MSK-D and selected risk factors including aptitude scores, physical fitness test scores, body mass index and tobacco use.

RESULTS

Among the subjects, 281 278 (45.14%) experienced MSK-D. In the MSK-D hazards model, the highest effect size was for failing the physical fitness test (adjusted HR=1.63, 95% CI 1.58 to 1.67, p<0.001) compared with scoring ≥290 points.

CONCLUSIONS

The analysis revealed the strongest associations between physical fitness and MSK-D. Additional efforts are warranted to determine potential mechanisms for the observed associations between selected factors and MSK-D.

Predictive utility of commercial grade technologies for assessing musculoskeletal injury risk in US Marine Corps Officer candidates

Recently, commercial grade technologies have provided black box algorithms potentially relating to musculoskeletal injury (MSKI) risk and functional movement deficits, in which may add value to a high-performance model. Thus, the purpose of this manuscript was to evaluate composite and component scores from commercial grade technologies associations to MSKI risk in Marine Officer Candidates. 689 candidates (Male candidates = 566, Female candidates = 123) performed counter movement jumps on SPARTA™ force plates and functional movements (squats, jumps, lunges) in DARI™ markerless motion capture at the start of Officer Candidates School (OCS). De-identified MSKI data was acquired from internal OCS reports for those who presented to the Physical Therapy department for MSKI treatment during the 10 weeks of training. Logistic regression analyses were conducted to validate the utility of the composite scores and supervised machine learning algorithms were deployed to create a population specific model on the normalized component variables in SPARTA™ and DARI™. Common MSKI risk factors (cMSKI) such as older age, slower run times, and females were associated with greater MSKI risk. Composite scores were significantly associated with MSKI, although the area under the curve (AUC) demonstrated poor discrimination (AUC = .55-.57). When supervised machine learning algorithms were trained on the normalized component variables and cMSKI variables, the overall training models performed well, but when the training models were tested on the testing data the models classified MSKI "by chance" (testing AUC avg = .55-.57) across all models. Composite scores and component population specific models were poor predictors of MSKI in candidates. While cMSKI, SPARTA™, and DARI™ models performed similarly, this study does not dismiss the use of commercial technologies but questions the utility of a singular screening task to predict MSKI over 10 weeks. Further investigations should evaluate occupation specific screening, serial measurements, and/or load exposure for creating MSKI risk models.

Injuries and Referral Patterns During Basic Combat Training: An Examination of Data From the Certified Athletic Trainer-Forward Program

INTRODUCTION

Injuries sustained during basic combat training (BCT) result in large economic costs to the U.S. Army. The inclusion of athletic trainers (ATs) in other military branches has reduced Troop Medical Clinic (TMC) referrals. However, the inclusion of ATs during BCT has yet to be studied. The purpose of this study was to describe the frequency and nature of sick call visits during BCT and determine how the presence of an AT affects referrals to the TMC.

MATERIALS AND METHODS

A prospective cohort study was conducted at the Fort Jackson Army Training Center for one calendar year. Soldiers in BCT, aged 18-42, who reported to sick call were included. Independent variables collected included: Soldier demographics (sex and age), visit reason, and provider impression. Training battalions were placed in three conditions: control (CON), full-time medic (FTM), and part-time athletic trainer (PAT). The dependent variable was disposition (referred or returned to duty [RTD]). Frequencies and proportions were calculated. Logistic regression compared conditions while considering the other independent variables. Return on investment was calculated.

RESULTS

Fourteen thousand three hundred and four visits were documented. Most soldiers were female (n = 7,650; 53.5%) and under 20 years old (n = 5,328; 37.2%). Visits were most commonly due to physical injury (n = 7,926; 55.4%), injuries affecting the knee (n = 2,264; 15.8%) and chronic/overuse conditions (n = 2,031; 14.2%). By condition, the FTM and PAT conditions resulted in 1.303 (95%CI: 1.187, 1.430; P < .001) and 1.219 (95%CI: 1.103, 1.348; P < .001), or 30.3% and 21.9% higher, odds of being RTD compared to the CON condition, respectively. Return on investment was $23,363,596 overall and $2,423,306 for musculoskeletal-related cases.

CONCLUSIONS

Injuries were common in BCT, particularly in females. Soldiers in both the PAT and FTM conditions were more likely to be RTD compared to those in the CON condition. Athletic trainers (ATs) are effective at reducing potentially unnecessary referrals, demonstrating their value as healthcare providers in the BCT environment. Understanding variables associated with recruit disposition may aid medics and ATs in the development of triage protocols and further reduction of potentially unnecessary soldier referrals. The Certified Athletic Trainer-Forward Program resulted in significant return on investment, further supporting the inclusion of ATs in BCT.

Injury rates in female and male military personnel: a systematic review and meta-analysis

Background

An effective military force is required to be agile, capable, efficient, and potent. Injuries to military personnel interrupt active-duty service and can detract from overall capability. These injuries are associated with a high individual and organizational burden, with lost work time and financial costs—all problematic for the ongoing functioning of a military force. Injury control strategies have therefore been described as force multipliers. Female personnel form an integral part of any modern defence force, but little research has examined their specific experiences of injury, to inform targeted injury control efforts. The aim of this review was to identify and synthesise findings from studies of injury rates and patterns in female military personnel, comparing them to those of male personnel.

Methods

A systematic search was conducted for studies which compared injury rates between the sexes at any stage of military service, from basic training through to deployment. Databases searched included PUBMED, CINAHL and Medline through OVID. Methodological quality of eligible articles was assessed using the Critical Appraisal Skills Program (CASP), and AXIS tools and data were extracted, synthesized, and, where possible, underwent meta-analysis.

Results

Of 2287 identified studies, a total of 25 studies were eligible and included. Methodological quality ranged from 60% up to a perfect score of 100%, with an average of 82% across all studies. Relative risks for injuries (reported as RR [95%CI]) to females when compared to males were 2.10 [1.89–2.33] during basic training, 1.70 [1.33–2.17] during officer training, and 1.23 [1.05–1.43] post initial training. After adjustment for differences between the sexes in average fitness levels (2-mile run time), there was no longer a significant difference in injury rates (adjusted RR: 0.95 [0.86–1.05]). Female personnel tended to make bigger improvements in their fitness during basic training than males and tended to report their injuries more frequently and sooner than males.

Conclusion

While this review found a higher rate of reported injuries in female military personnel when compared to male personnel, differences between the sexes in average fitness levels and injury reporting behaviours may largely explain this rate difference. The difference in rates of reported injuries was greatest during basic training, and reduced thereafter, possibly due in part to a reduced difference in fitness between the sexes or increased opportunity to self-determine workloads relative to fitness levels.

Factors Predicting Training Delays and Attrition of Recruits during Basic Military Training

Ensuring a balance between training demands and recovery during basic military training (BMT) is necessary for avoiding maladaptive training responses (e.g., illness or injury). These can lead to delays in training completion and to training attrition. Previously identified predictors of injury and attrition during BMT include demographic and performance data, which are typically collected at a single time point. The aim of this study was to determine individual risk factors for injury and training delays from a suite of measures collected across BMT. A total of 46 male and female recruits undertaking the 12-week Australian Army BMT course consented to this study. Injury, illness, attrition, and demographic data were collected across BMT. Objective measures included salivary cortisol and testosterone, step counts, cardiorespiratory fitness, and muscular endurance. Perceptions of well-being, recovery, workload, fatigue, and sleep were assessed with questionnaires. Baseline and mean scores across BMT were evaluated as predictors of injury and attrition using generalized linear regressions, while repeated-measures ANOVA was used for the group comparisons. From the 46 recruits, 36 recruits completed BMT on time; 10 were delayed in completion or discharged. Multiple risk factors for injury during BMT included higher subjective ratings of training load, fatigue, and stress, lower sleep quality, and higher cortisol concentrations. Higher ratings of depression, anxiety, and stress, and more injuries were associated with a higher risk of delayed completion. Higher concentrations of testosterone and higher levels of fitness upon entry to BMT were associated with reduced risk of injury and delayed completion of BMT. Ongoing monitoring with a suite of easily administered measures may have utility in forewarning risk of training maladaptation in recruits and may complement strategies to address previously identified demographic and performance-based risk factors to mitigate injury, training delays, and attrition.

Tibial Bone Geometry Is Associated With Bone Stress Injury During Military Training in Men and Women

Bone stress injuries (BSI) are a common musculoskeletal condition among exercising and military populations and present a major burden to military readiness. The purpose of this investigation was to determine whether baseline measures of bone density, geometry, and strength, as assessed via peripheral quantitative computed tomography (pQCT), are predictive of tibial BSI during Marine Officer Candidates School training. Tibial pQCT scans were conducted prior to the start of physical training (n = 504; Male n = 382; Female n = 122) to measure volumetric bone mineral density (vBMD), geometry, robustness, and estimates of bone strength. Bone parameters were assessed at three tibial sites including the distal metaphysis (4% of tibial length measured from the distal endplate), mid-diaphysis (38% of tibial length measured from the distal endplate), and proximal diaphysis (66% of tibial length measured from the distal endplate). Injury surveillance data was collected throughout training. Four percent (n = 21) of the sample were diagnosed with a BSI at any anatomical site during training, 10 injuries were of the tibia. Baseline bone parameters were then tested for associations with the development of a tibial BSI during training and it was determined that cortical bone measures at diaphyseal (38 and 66%) sites were significant predictors of a prospective tibial BSI. At the mid-diaphysis (38% site), in a simple model and after adjusting for sex, age, and body size, total area [Odds Ratio (OR): 0.987, 0.983], endosteal circumference (OR: 0.853, 0.857), periosteal circumference (OR: 0.863, 0.824), and estimated bending strength (SSI; OR: 0.998, 0.997) were significant predictors of a BSI during training, respectively, such that lower values were associated with an increased likelihood of injury. Similarly, at the proximal diaphysis (66% site), total area (OR: 0.989, 0.985), endosteal circumference (OR: 0.855, 0.854), periosteal circumference (OR: 0.867, 0.823), robustness (OR: 0.007, 0.003), and SSI (OR: 0.998, 0.998) were also significant predictors of BSI in the simple and adjusted models, respectively, such that lower values were associated with an increased likelihood of injury. Results from this investigation support that narrower bones, with reduced circumference, lower total area, and lower estimated strength are associated with increased risk for tibial BSI during military training.

Risk factors for musculoskeletal injuries in the military: a qualitative systematic review of the literature from the past two decades and a new prioritizing injury model

BACKGROUND

Musculoskeletal injuries (MSkIs) are a leading cause of health care utilization, as well as limited duty and disability in the US military and other armed forces. MSkIs affect members of the military during initial training, operational training, and deployment and have a direct negative impact on overall troop readiness. Currently, a systematic overview of all risk factors for MSkIs in the military is not available.

METHODS

A systematic literature search was carried out using the PubMed, Ovid/Medline, and Web of Science databases from January 1, 2000 to September 10, 2019. Additionally, a reference list scan was performed (using the "snowball method"). Thereafter, an international, multidisciplinary expert panel scored the level of evidence per risk factor, and a classification of modifiable/non-modifiable was made.

RESULTS

In total, 176 original papers and 3 meta-analyses were included in the review. A list of 57 reported potential risk factors was formed. For 21 risk factors, the level of evidence was considered moderate or strong. Based on this literature review and an in-depth analysis, the expert panel developed a model to display the most relevant risk factors identified, introducing the idea of the "order of importance" and including concepts that are modifiable/non-modifiable, as well as extrinsic/intrinsic risk factors.

CONCLUSIONS

This is the qualitative systematic review of studies on risk factors for MSkIs in the military that has attempted to be all-inclusive. A total of 57 different potential risk factors were identified, and a new, prioritizing injury model was developed. This model may help us to understand risk factors that can be addressed, and in which order they should be prioritized when planning intervention strategies within military groups.

Lower Extremity Musculoskeletal Injury in US Military Academy Cadet Basic Training: A Survival Analysis Evaluating Sex, History of Injury, and Body Mass Index

Background

Injury incidence for physically active populations with a high volume of physical load can exceed 79%. There is little existing research focused on timing of injury and how that timing differs based on certain risk factors.

Purpose/Hypothesis

The purpose of this study was to report both the incidence and timing of lower extremity injuries during cadet basic training. We hypothesized that women, those with a history of injury, and those in underweight and obese body mass index (BMI) categories would sustain lower extremity musculoskeletal injury earlier in the training period than men, those without injury history, and those in the normal-weight BMI category.

Study Design

Cohort study; Level of evidence, 2.

Methods

Cadets from the class of 2022, arriving in 2018, served as the study population. Baseline information on sex and injury history was collected via questionnaire, and BMI was calculated from height and weight taken during week 1 at the United States Military Academy. Categories were underweight (BMI <20), middleweight (20-29.99), and obese (≥30). Injury surveillance was performed over the first 60 days of training via electronic medical record review and monitoring. Kaplan-Meier survival curves were used to estimate group differences in time to the first musculoskeletal injury. Cox proportional hazard regression was used to estimate hazard ratios (HRs).

Results

A total of 595 cadets participated. The cohort was 76.8% male, with 29.9% reporting previous injury history and 93.3% having a BMI between 20 and 30. Overall, 16.3% of cadets (12.3% of male cadets and 29.7% of female cadets) experienced an injury during the follow-up period. Women experienced significantly greater incident injury than did men (P < .001). Separation of survival curves comparing the sexes and injury history occurred at weeks 3 and 4, respectively. Hazards for first musculoskeletal injury were significantly greater for women versus men (HR, 2.63; 95% CI, 1.76-3.94) and for those who reported a history of injury versus no injury history (HR, 1.76; 95% CI, 1.18-2.64). No differences were observed between BMI categories.

Conclusion

Female cadets and those reporting previous musculoskeletal injury demonstrated a greater hazard of musculoskeletal injury during cadet basic training. This study did not observe an association between BMI and injury.

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.

An Attempt to Utilize the Body Composition Analyzer and the Functional Movement Screen (FMS) Test to Determine Injury Risk in Soldiers

INTRODUCTION

Injuries are the most significant health problem of military services. Military medical surveillance data are useful for determining the magnitude and causes of the injury problem, identifying possible prevention targets and monitoring trends among military personnel. Soldiers serving in the Polish Armed Forces took part in the research. The aim of the study was to identify the most common injuries of the musculoskeletal system and to analyze causes of injuries. An additional goal was to examine whether there is a relationship between selected values of body composition indexes, the result of the functional movement screen (FMS) test and occurrence of an injury.

MATERIAL AND METHODS

The Polish Armed Forces soldiers serving in the land forces, military police, air forces took part in the research. The first stage was to complete the questionnaire regarding injuries in the last 5 years, their reasons, and the circumstances of their occurrence. After completing the survey, subjects were measured and weighed on the body composition analyzer. The next step was to perform a FMS to evaluate the locomotor system.

RESULTS

In the groups of examined Polish soldiers, the most frequent injuries concerned lower limbs and, above all, a knee joint. The leading causes of injuries were activities resulting from the service as well as playing football and volleyball.

CONCLUSIONS

Parameters from the body composition analyzer such as body mass index, muscle mass distribution on lower limbs as well as evaluation in the FMS test may be helpful for the initial assessment of predisposition to injury.

Musculoskeletal Injuries and United States Army Readiness Part I: Overview of Injuries and their Strategic Impact

Introduction

Noncombat injuries (“injuries”) greatly impact soldier health and United States (U.S.) Army readiness; they are the leading cause of outpatient medical encounters (more than two million annually) among active component (AC) soldiers. Noncombat musculoskeletal injuries (“MSKIs”) may account for nearly 60% of soldiers’ limited duty days and 65% of soldiers who cannot deploy for medical reasons. Injuries primarily affect readiness through increased limited duty days, decreased deployability rates, and increased medical separation rates. MSKIs are also responsible for exorbitant medical costs to the U.S. government, including service-connected disability compensation. A significant subset of soldiers develops chronic pain or long-term disability after injury; this may increase their risk for chronic disease or secondary health deficits potentially associated with MSKIs. The authors will review trends in U.S. Army MSKI rates, summarize MSKI readiness-related impacts, and highlight the importance of standardizing surveillance approaches, including injury definitions used in injury surveillance.

Materials/Methods

This review summarizes current reports and U.S. Department of Defense internal policy documents. MSKIs are defined as musculoskeletal disorders resulting from mechanical energy transfer, including traumatic and overuse injuries, which may cause pain and/or limit function. This review focuses on various U.S. Army populations, based on setting, sex, and age; the review excludes combat or battle injuries.

Results

More than half of all AC soldiers sustained at least one injury (MSKI or non-MSKI) in 2017. Overuse injuries comprise at least 70% of all injuries among AC soldiers. Female soldiers are at greater risk for MSKI than men. Female soldiers’ aerobic and muscular fitness performances are typically lower than men’s performances, which could account for their higher injury rates. Older soldiers are at greater injury risk than younger soldiers. Soldiers in noncombat arms units tend to have higher incidences of reported MSKIs, more limited duty days, and higher rates of limited duty days for chronic MSKIs than soldiers in combat arms units. MSKIs account for 65% of medically nondeployable AC soldiers. At any time, 4% of AC soldiers cannot deploy because of MSKIs. Once deployed, nonbattle injuries accounted for approximately 30% of all medical evacuations, and were the largest category of soldier evacuations from both recent major combat theaters (Iraq and Afghanistan). More than 85% of service members medically evacuated for MSKIs failed to return to the theater. MSKIs factored into (1) nearly 70% of medical disability discharges across the Army from 2011 through 2016 and (2) more than 90% of disability discharges within enlisted soldiers’ first year of service from 2010 to 2015. MSKI-related, service-connected (SC) disabilities account for 44% of all SC disabilities (more than any other body system) among compensated U.S. Global War on Terrorism veterans.

Conclusions

MSKIs significantly impact soldier health and U.S. Army readiness. MSKIs also figure prominently in medical disability discharges and long-term, service-connected disability costs. MSKI patterns and trends vary between trainees and soldiers in operational units and among military occupations and types of operational units. Coordinated injury surveillance efforts are needed to provide standardized metrics and accurately measure temporal changes in injury rates.

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.