BRIEF REVIEW PREVENTION AND REHABILITATION OF MUSCULOSKELETAL INJURIES DURING MILITARY OPERATIONS AND TRAINING EDWARD J. ZAMBRASKI AND KATHLEEN E. YANCOSEK Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts ABSTRACT Zambraski, EJ and Yancosek, KE. Prevention and rehabilitation of musculoskeletal injuries during military operations and training. J Strength Cond Res 26(7): S101 S106, 2012 Injuries are a major impacting factor for a military organization. Injuries may be result of direct combat, or noncombat, and may be incurred during deployment, or military operations and training. The impact of injuries is loss of manpower (e.g., lost duty days), medical costs for treatment, and influence that an injury may have on an individual s quality of life. To address this issue, it is essential to understand types of injuries that are occurring, and mechanisms responsible for those injuries, to develop strategies to reduce injury incidence and to allocate resources required for rehabilitation to return individual to duty. This article will review most common medical injury being incurred by our present warfighter; namely, musculoskeletal injuries (MSIs). The number, types, and causal mechanisms of MSIs will be reviewed. Risk factors for MSIs will be identified and various interventions being used to prevent or mitigate severity of MSIs will be discussed. Lastly, programs that have been developed within U.S. Department of Defense and U.S. Army for assessment, care, and rehabilitation of most severe MSIs incurred while deployed will be described. KEY WORDS musculoskeletal, rehabilitation, injury prevention, military INTRODUCTION Scope of Musculoskeletal Injury Problem Musculoskeletal injuries (MSIs) include a broad array of medical conditions involving muscle, tendon, nerve, ligament, and bone tissue. The injuries may occur acutely (trauma), or result Address correspondence to Edward J. Zambraski, edward.zambraski@ us.army.mil. 26(7)/S101 S106 Ó 2012 National Strength and Conditioning Association from repetitive stress (overuse), which tend to be episodic, recurrent, and potentially advance into chronic conditions. Such injuries may include muscle strains, contusions, tendinopathy, fasciitis, bursitis, muscle and tendon tears and ruptures, joint sprains, ligament tears, joint dislocation, bone fractures, cartilaginous damage, and bone stress fractures. The Department of Defense maintains an extensive electronic medical records system. Service members medical data are captured regardless of wher y are treated at a Military Treatment Facility as an inpatient, or in an outpatient setting. Within Department of Defense, re are medical surveillance organizations. Examples are U. S. Army Public Health Command and Armed Forces Health Surveillance Center (AFHSC). The AFHSC maintains Defense Medical Epidemiology Database that captures records of nondeployed service members and or specialized databases that have been established to monitor medical encounters during deployments. Lastly, U.S. Army has established Total Army Health Outcomes Database (TAIHOD). The TAIHOD contains all of medical data on every soldier from approximately 1985 to present (2). These various resources are used to track all medical problems, including MSI. Jones et al. (21) reported that MSI were leading cause for all medical encounters (.1.95 million) in 2006 for all of US military. The MSI medical encounters were 2 3 times greater than next leading category (mental disorders). In 2010, AFHSC reported that MSIs of deployed and nondeployed service members were responsible for greatest number of medical encounters (30%) (3). The next leading cause of medical encounters (15%), were mental disorders. Within U.S. Army, over a 20-year period (1980 2002), medical disability discharge rates increased sevenfold to eightfold, with MSIs being responsible for approximately 70% of se discharges (5). Mental health and neurological types of disability combined were responsible for 11% of se cases. Cohen et al. (8) examined medical evacuations from Iraq and Afghanistan over a 3-year period (2004 2007). There were 34,006 personnel medically evacuated. The most common reason for evacuation (24%) was for noncombat MSI injuries. Noncombat injuries were defined as injuries VOLUME 26 SUPPLEMENT 7 JULY 2012 S101
Prevention and Rehabilitation of Musculoskeletal Injuries not caused by enemy but do include injuries incurred while in operational or battle environment. Combat injuries were responsible for 14% of se evacuations. A U.S. Army Brigade Combat Team (n = 4,122), deployed to Iraq, had 1,324 nonbattle injuries (6). The MSI injuries accounted for 50% of se injuries. The MSIs are also extremely high in Army recruits while y undergo 8 9 weeks of ir initial Basic Combat Training (BCT). A study by Bell et al. (4) reported that 27% of men and 57% of women experienced $1 injuries during BCT. Knapik et al. (24) reported an injury incidence rate of 0.56 and 1.16/100 person days for men and women respectively, completing BCT. These high injury rates during BCT may result in delay of graduation, and in many cases, attrition or withdrawal from military service. A study was done to investigate deployment readiness of 158 soldiers with orthopedic injuries (10). The study tracked injured soldiers 3 months before and throughout deployment to Iraq. Despite compliance with rehabilitation services, 99 soldiers (62.7%) were unable to deploy, or even meet up later, with unit; 35 soldiers were able to deploy on time; and 6 soldiers joined unit within 3 months of initial deployment date. Furr analysis of results revealed that (a) soldiers with spinal injuries were most recalcitrant to rehabilitation and refore more likely to remain non-deployable and (b) behavioral health and or health concerns became secondary problems prohibiting deployment, despite recovery from original orthopedic condition. Studies have also characterized location and types of MSIs. For entire military, across all services, spine or back and injuries of lower extremities each account for 40% of MSIs; 80% of total (13). Upper extremity injuries represent only 14% of total. These results are similar to injury locations associated with BCT. The AFHSC data document that back and abdominal and lower extremity injuries also predominate as major sites of MSIs in deployed troops. A recent study by Roy (30) documented diagnoses and locations of injuries within an Infantry Brigade Combat Team deployed to Afghanistan over a 15-month period. The most common diagnosed MSIs were mechanical low back pain (19.4%), with ankle sprain at 11.6% and knee pain at 4.3%. Information on body regions being injured indicated that greatest number of cases involved spine (30.7%), with 70% of those being in lumbar region. The MSIs at knee and ankle accounted a similar percentage of total injury sites (31.5%) (31). Identified Risk Factors Several major risk factors for MSIs have been identified. These are listed in Table 1. It is clear that some of se factors are amenable to change, such as running mileage, aerobic fitness level, and smoking. Of se factors, most impacting in military setting is gender because, on average, women in BCT have significantly higher MSIs than do men. However, an extremely important finding is that if one compares a group TABLE 1. Risk factors with strong supporting evidence for musculoskeletal injuries within military.* Risk factors Female gender High running mileage Low aerobic fitness and endurance Extremes in flexibility Prior injury Participation in recreational sports activities Cigarette smoking Limited history of prior physical activity Age of running shoes *Information derived from (7,14). of highly fit females, with same maximal oxygen consumption as men, injury levels are similar. Consequently, increased incidence of MSIs in women appears to be because of aerobic fitness and not gender per se. One injury risk factor that has an amplified negative effect on MSIs within military is having a previous injury (20,23). Individuals with a prior ankle sprain have a 30 50% greater probability of having a repeat lower extremity injury (36). Data from TAIHOD have shown that a prior knee injury results in a 7- to 10-fold increase in likelihood of a subsequent knee injury (17). It is important to note that many of se repetitive injuries are location or site specific, suggesting that re may be a direct causal link between 2 injuries. Also, reinjury issue could be that an individual may have a certain general predisposition for MSI (e.g., low aerobic fitness). The implication of this finding is that high level of injury seen in BCT environment are responsible for, or significantly increase, chance of MSIs later in career of a service member. Consequently, one of most important places to try and mitigate MSIs is within BCT. Two studies have examined MSI rates in soldiers in Advanced Individual Training (AIT) (12,15). The more recent study explored injury risk factors of soldiers enrolled in AIT at Aberdeen Proving Ground (12). Results showed time-loss injury incidences of 31% (men) and 54% (women). Race, slower 2-mile run times, and self-reported injury were risk factors for both men and women. Native American race was associated with injuries among men and white race for women. Additionally, results showed that lower sit-up performance on Army Physical Fitness Test and a history of smoking were risk factors for men. To reduce MSI incidence rates at AIT, authors suggested smoking cessation instructions and prearmy conditioning programs. With tens of thousands of service members currently deployed, and millions of soldiers who have been deployed, and high number of noncombat MSIs occurring in ater, attempts have been made to identify risk factors for MSIs S102
www.nsca.com that are associated with battlefield activities or demands of deployment (33). Recently, it was reported that hours per day wearing body armor, weight of equipment carried (i.e., load carriage) and miles walked per day were all significantly correlated to incidence of MSIs during deployment (31). One identified risk factor associated with early discharge from military service is a high body mass index (BMI) (28). A recent study by Packnett et al. (27) demonstrated a U shaped pattern for relationship of BMI to medical discharge from U.S. Army. Those individuals with highest and lowest BMIs were more likely to leave service. One of most severe MSIs is rhabdomyolysis, which is a complete destruction of muscle tissue. Rhabdomyloysis, if severe enough, may lead to kidney failure and death. Rhabdomyolysis is higher in service members as compared with civilian population. Recent epidemiological studies of rhabdomyolysis in military have shown that it is most likely to occur in soldiers with,90 days of service (e.g., in or shortly after BCT) (15). Anor key finding is that a soldier who has had any kind of prior heat injury (heat cramps, heat exhaustion or heat stroke) is 22-fold more likely to experience rhabdomyolysis (18). Prevention of Musculoskeletal Injuries Although prevention of MSIs is important in military setting, historically, re has been a significant interest in MSI prevention strategies in both military and civilian environments. Many injury prevention measures currently used are traditional, anecdotal or teleological (i.e., this makes sense; refore, it must be true). Only in last few years has a concerted effort been made to validate effective MSI prevention measures. These efforts have been supported largely by military organizations. Two recently published reviews have evaluated level and strength of research evidence to support effectiveness of a given intervention to reduce MSIs (7,14). What is surprising is that many traditional measures believed to reduce MSIs are not supported by actual research that has been done. Examples are stretching, warming-up, type and age of running shoes, and targeted muscle strengning (Table 2). Prevention of MSIs is a top priority of Army Medical Department; however, re are several challenges surrounding most prevention strategies. Challenges include reality that military operations are inherently dangerous and demanding. Success on battlefield is predicated on highly trained soldiers who have undergone intense, realistic training to be physically and mentally prepared to execute myriad missions. Additionally, operational tempo of combat requires sustained performance over several months often in austere environments. Sustained military operations create scenarios of altered sleep cycles, restricted caloric intake, and periods of extremely heavy work. These demands have physiological consequences of decremented anabolic hormones, increase in catabolic hormones, loss of skeletal muscle and bone (16,26). Because of limitations in completely diminishing risks of MSI intrinsic to military occupations, prevention strategies to mitigate MSIs are divided into 2 categories: (a) training and (b) operational. Prevention Strategies in Nonoperational Environments Prevention strategies in training environment are less constrained than prevention in operational environment; however, realistic training means soldiers should have exposure (albeit controlled) to risk factors such wearing body armor, carrying heavy loads, sustaining heavy manual labor, and walking and running (foot patrols) on uneven terrain. To examine strategies to prevent avoidable injuries in training, army researchers must work with commanders to compare training scenarios and schedules while controlling for confounding variables. Although resource intensive and logistically difficult to undertake, comparative studies are best way to discover answers to a question such as, What type and amount of training is needed to adequately prepare soldiers for success on battlefield without causing injury from overtraining? TABLE 2. Interventions aimed at reducing musculoskeletal injuries.* Interventions with strong evidence Reduction in running frequency, duration, and distance Training that includes neuromuscular, proprioception, and agility activities Wearing mouth guards Use of ankle braces for high risk activities Improved aerobic fitness Interventions with limited evidence Wearing shock absorbing insoles Replacing running shoes at regular intervals Stretching Targeted muscle strengning Smoking cessation Running on softer surfaces *Information derived from (7,14). VOLUME 26 SUPPLEMENT 7 JULY 2012 S103
Prevention and Rehabilitation of Musculoskeletal Injuries These results have changed doctrine and practices within U.S. military. There is a widespread concerted effort to decrease running mileage to decrease overtraining or overuse MSIs. The U.S. Army has modified its physical fitness training program with Physical Readiness Training (22). This new training program incorporates many of scientific principles for effective training and injury prevention such as progressive overload, variety of exercises, and inclusion of proprioception-balance-agility components. Initial studies suggest that this new physical readiness training (PRT) decreases injuries when compared to traditional Army fitness programs. The U.S. Army Medical Command initiated Musculoskeletal Action Teams (MATs) to reduce burden of MSIs. The MATs consist of physical rapists, athletic trainers, and physical rapy assistants to work with military recruits to tolerate strenuous activity in training environment. The MAT personnel also teach resiliency to stress, nutritional and dietary wellness, and how to recover from arduous training (37). A final, and perceivably unpopular, prevention strategy within training environment is to reduce number of sports injuries, which account for a large number of MSIs in service members. Approximately 20% of noncombat injuries may be because of recreational sports (33,35). Preventing sports injuries is possible with stricter management of recreational activities, such as not permitting inexperienced soldiers to engage in unfamiliar sports, rotating players, and prohibiting unrefereed games. There is an obvious trade-off of losses here: lost benefit of morale building through sport engagement versus reduced risk for duty days lost to recovery time of probable MSIs. Commanders and leaders at all levels need to be properly informed about incidence rates of MSIs caused by sporting activities so y can calculate ir risks and make informed decisions based on needs of ir unit. Figure 1. Rehabilitation team members who address musculoskeletal injuries in deployed environment. Recently, an important intervention was evaluated to decrease bone stress fractures in military recruits. Over 5,000 healthy female Navy recruits were given 200 mg of CA ++ and 800 IU of Vitamin D during 8 weeks of recruit training. Compared with placebo group, group receiving supplementation decreased stress fractures by 20% (25). Prevention Strategies in Operational Environments Given intense nature of combat, prevention strategies in operational environment are often more idealistic than practical. To target improved whole-body health through nutrition, Army developed First Strike Ration, a light portion with essential nutrients to sustain performance and maintain energy for short (3- to 7-day) combat missions (9). Besides keeping soldiers well nourished in operational environment, number one strategy to deal with MSIs is to provide early access to rehabilitation services. Rehabilitation Services in Theater Currently, in ater, re are 33 and 43 physical and occupational rapists, respectively. The medical and operational benefits of having rehabilitation services in ater have long been recognized, because rapists are a vital component to medical and rehabilitation care teams (11,29). Physical and occupational rapists in Army obtain an additional skill identifier as a physician extender, specifically serving as neuromusculoskeletal screeners reby allowing orthopedic doctors to attend, namely, to surgical cases (1,19). Medical benefits of rehabilitation services in ater include providing early MSI diagnosis and treatment; establishing a positive expectancy for recovery; identifying injury trends for higher commands to prevent injury patterns; and managing non-emergent patients close to fight. A perceived downside to positioning rehabilitation assets so close to fight relates to increased pressure (from soldiers and commanders) to quickly return a soldier to duty. A potentially premature return to highly demanding combat operations creates immediate reexposure to risk factors such as extreme load carriage burdens, continual physical stress, and probable disrupted sleep cycles. Furrmore, high operational tempo creates a sustained level of stress throughout deployment that likely affects healing rates and contributes to reinjury risk. The operational benefits of rapy services organic to units in ater include sustaining S104
www.nsca.com unit personnel strength; maintaining unit cohesion during deployment; setting a proactive tone for reporting injuries and seeking immediate diagnosis and rehabilitation; and, boosting soldiers confidence in military leaders and medical system which n improves morale. The operational downside to having rapists in ater is that units are forced to carry out missions with fewer soldiers as y wait for recovering service members. The reduction in strength of fighting force results because a unit commander cannot request a replacement soldier unless injured one is medically evacuated out of ater of operations. Because occupational and physical rapists contribute to making medical decisions about return to duty, risk of reinjury with returning a previously injured (and presumed healed) soldier back to unrestricted duty must be calculated. An injured soldier needs time to heal properly before returning to performance level expected of full duty status. The number one predictor of reinjury is previous injury, and ignoring this critical risk factor invites following potential cascade of events: chronicity, permanent disability, failure to perform one s military duties or responsibilities, and ultimately medical discharge from military. See Figure 1 for diagram of team members who decide about an injured soldier s medical disposition. To assist medical providers in decision making process and to prevent acute MSIs from advancing to chronic conditions through proper management, Army Medical Department created a musculoskeletal screening and referral toolbox, available at https://www.qmo.amedd.army.mil/ srts/srt.h. When a soldier experiences severe MSIs that will require extensive surgery or is sustained from direct combat exposure, he or she is evacuated from ater of operations. The soldier is n assigned to a Warrior Transition Unit and receives rapy (and or) services in a military medical center. Rehabilitation After Aeromedical Evacuation Soldiers evacuated out of ater generally have significant concomitant injuries such as traumatic brain injury, burns, amputation, ocular injury, and behavioral health issues (34). Soldiers with multiple complex injuries (polytrauma) have led to establishment of specialized rehabilitation programs and facilities (38) such as Center for Intrepid in San Antonio, TX; Military Advanced Training Center in Washington, DC, and Comprehensive Combat and Complex Casualty Care (C5) at Naval Medical Center in San Diego, CA. CONCLUSIONS Musculoskeletal injuries are number one medical problem eroding military readiness. The MSIs cost hundreds of million dollars annually and millions of lost and limited duty days among service members (32). 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