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

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          Abstract

          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.

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          Most cited references14

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          Military training-related injuries: surveillance, research, and prevention.

          K. Kaufman (2000)
          Musculoskeletal physical training-related injuries are a major problem in military populations. Injuries are important in terms of loss of time from work and training and decreased military readiness. The implications of these injuries in terms of patient morbidity, attrition rates, and training costs for military personnel are staggering. This article reviews: (1) pertinent epidemiologic literature on musculoskeletal injury rates; (2) injury type and location; and (3) risk factors for military populations. Suggestions for injury surveillance and prevention are also offered. Existing military and civilian epidemiologic studies were used to estimate and compare the size of the injury problem, identify risk factors, and test preventive measures. Most of the military research data obtained was from Marine and Army recruits, Army Infantry soldiers, and Naval Special Warfare candidates. Additional studies conducted in operational forces provided documentation of the injury problem in these populations as well. Injury rates during military training are high, ranging from 6 to 12 per 100 male recruits per month during basic training to as high as 30 per 100 per month for Naval Special Warfare training. Data collected show a wide variation in injury rates that are dependent largely on the following risk factors: low levels of current physical fitness, low levels of previous occupational and leisure time physical activity, previous injury history, high running mileage, high amount of weekly exercise, smoking, age, and biomechanical factors. (Data are contradictory with respect to age.) Considering the magnitude of training injuries in military populations, there is a substantial amount of work that remains to be performed, especially in the areas of surveillance, prevention, and treatment. Modifiable risk factors have been identified suggesting that overuse and other training injuries could be decreased with proper interventions. Outpatient surveillance systems are available to capture musculoskeletal injury data but need to be refined. Given the size of the problem, a systematic process of prevention should be initiated starting with routine surveillance to identify high-risk populations for the purpose of prioritizing research and prevention. Properly planned interventions should then be implemented with the expectation of dramatically reduced lost work/training time, attrition, and medical costs, while increasing military readiness.
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            Soldier load carriage: historical, physiological, biomechanical, and medical aspects.

            This study reviews historical and biomedical aspects of soldier load carriage. Before the 18th century, foot soldiers seldom carried more than 15 kg while on the march, but loads have progressively risen since then. This load increase is presumably due to the weight of weapons and equipment that incorporate new technologies to increase protection, firepower, communications, and mobility. Research shows that locating the load center of mass as close as possible to the body center of mass results in the lowest energy cost and tends to keep the body in an upright position similar to unloaded walking. Loads carried on other parts of the body result in higher energy expenditures: each kilogram added to the foot increases energy expenditure 7% to 10%; each kilogram added to the thigh increases energy expenditure 4%. Hip belts on rucksacks should be used whenever possible as they reduce pressure on the shoulders and increase comfort. Low or mid-back load placement might be preferable on uneven terrain but high load placement may be best for even terrain. In some tactical situations, combat load carts can be used, and these can considerably reduce energy expenditure and improve performance. Physical training that includes aerobic exercise, resistance training targeted at specific muscle groups, and regular road marching can considerably improve road marching speed and efficiency. The energy cost of walking with backpack loads increases progressively with increases in weight carried, body mass, walking speed, or grade; type of terrain also influences energy cost. Predictive equations have been developed, but these may not be accurate for prolonged load carriage. Common injuries associated with prolonged load carriage include foot blisters, stress fractures, back strains, metatarsalgia, rucksack palsy, and knee pain. Load carriage can be facilitated by lightening loads, improving load distribution, optimizing load-carriage equipment, and taking preventive action to reduce the incidence of injury.
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              Incidence of injury and physical performance adaptations during military training.

              Strenuous physical activity, such as military training, is known to demand a high degree of physical performance and to cause overuse injuries. However, the exact relation between injury incidence and physical fitness level and the influence of military training on measures of functional performance, such as intermittent endurance capacity and maximal jump performance, are not fully described. A total of 330 military conscripts were prospectively followed during military basic training. They were divided into 4 self-assessed physical fitness level groups (well trained, trained, less trained, and untrained) and underwent physical performance tests together with registration of injury incidence. Twelve weeks of military basic training was found to result in an overall injury rate of 28%, with an inverse relation between physical fitness level and incidence of overuse injury (P < 0.0001). Furthermore a fourfold higher injury rate was observed in the previously untrained soldiers compared with the well-trained soldiers. An increase in intermittent endurance capacity (20-m intermittent shuttle run test) was seen in all groups, (13 to 62%, P < 0.05), whereas only the previously untrained group of soldiers improved in aerobic capacity (8 and 16%, P < 0.05; maximal oxygen uptake and Coopers 12-minute running test). Maximal jump performance, both with and without backpack loading (15 kg), decreased (5 to 13%, P < 0.05) in 93% of the soldiers despite weight loss. Military basic training has a positive effect on intermittent endurance capacity but a detrimental effect on jump performance. Furthermore, low levels of physical fitness are strongly associated with proneness toward overuse injury development in soldiers going through intense training.
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                Author and article information

                Contributors
                Role: Formal analysisRole: SoftwareRole: VisualizationRole: Writing – original draft
                Role: Data curationRole: InvestigationRole: Project administration
                Role: MethodologyRole: ValidationRole: Writing – review & editing
                Role: Data curationRole: SoftwareRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                5 April 2018
                2018
                : 13
                : 4
                : e0195548
                Affiliations
                [1 ] Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, SE, Huddinge, Sweden
                [2 ] Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden
                [3 ] Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University,Umeå, Sweden
                [4 ] Swedish Armed Forces, Headquarters, Medical Services, Stockholm, Sweden
                University of Illinois at Urbana-Champaign, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-0893-7653
                Article
                PONE-D-17-41211
                10.1371/journal.pone.0195548
                5886608
                29621324
                2706368b-dc8e-48c9-8995-24138641775f
                © 2018 Halvarsson et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 November 2017
                : 23 March 2018
                Page count
                Figures: 5, Tables: 4, Pages: 15
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Trauma Medicine
                Traumatic Injury
                Musculoskeletal Injury
                Engineering and Technology
                Equipment
                Medicine and Health Sciences
                Pediatrics
                Biology and Life Sciences
                Biotechnology
                Medical Devices and Equipment
                Medicine and Health Sciences
                Medical Devices and Equipment
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                Anatomy
                Musculoskeletal System
                Limbs (Anatomy)
                Legs
                Knees
                Medicine and Health Sciences
                Anatomy
                Musculoskeletal System
                Limbs (Anatomy)
                Legs
                Knees
                Engineering and Technology
                Transportation
                Medicine and Health Sciences
                Sports and Exercise Medicine
                Biology and Life Sciences
                Sports Science
                Sports and Exercise Medicine
                Social Sciences
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                Custom metadata
                There are ethical restrictions regarding data availability for public release in this study since identification of participants from the data cannot be ruled out and data contained in this paper are considered as sensitive. According to the Ethical committee in Sweden, and within the Swedish Armed Forces, we are not allowed to have data available for public release. Data is available upon reasonable request, which will also involve discussions with the Swedish Armed Forces. Data access requests can be sent to: Swedish Armed Forces Research coordinator Anders Claréus ( anders.clareus@ 123456mil.se ); Ethical Committee ( kansli@ 123456stockholm.epn.se ; https://www.epn.se/en/start/).

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