Original researchMitigating the risk of musculoskeletal injury: A systematic review of the most effective injury prevention strategies for military personnel
Introduction
Musculoskeletal injuries (MSkI) are the primary cause of medical discharge and medical downgrade in the United Kingdom Armed Forces.1 Given the impact of MSkI on deployability and combat effectiveness, understanding how to most effectively mitigate against this risk is crucial for achieving, maintaining and retaining a healthy, effective and operationally deployable workforce. Physical training (PT) is a primary cause of, and risk factor for, MSkI,2 yet developing and maintaining physical capability is a critical aspect of military training and employment. Acquiring and maintaining a high level of physical fitness (aerobic endurance, anaerobic endurance, muscle strength and muscle endurance) is necessary for successful performance of military-specific tasks during training and operations. Optimising this cost-benefit trade-off between PT-mediated combat effectiveness and injury risk is critical for achieving and maintaining the required performance standards, and reducing injury rates, of Service personnel. Mitigation strategies for MSkI therefore include, but are not limited to, optimising PT and injury prevention.
Women are at higher risk of MSkI than men throughout military training and employment.1 Accordingly, female sex is often considered a major risk factor for injury.3 However, this risk may be reflective of lower aerobic fitness in women than men, rather than a fundamental sex difference in injury risk.3 Currently, it is not known whether different injury prevention strategies should be adopted for men and women to promote recovery from injury and protect against future injury. During initial military training, rates of MSkI, and particularly rates of debilitating injuries including hip and pelvic stress fractures, are higher in women and Infantry males than men undergoing Standard Entrant military training.1 If women are to be successfully incorporated into the Combat arms, the projected increased risk of MSkI in this demographic group will require attention. Understanding the most effective strategies for injury prevention will facilitate this mitigation of risk and promote a healthier Force that is effective in combat.
We undertook a systematic review of the literature relating to prevention strategies for PT-related injuries. This review was undertaken to update the existing evidence base reported by Bullock and colleagues in 2010.4 Evaluation of 31 PT-related injury prevention strategies by Bullock et al.4 resulted in identification of 6 strategies that were graded as having a strong evidence base for the working group to make implementation recommendations for the military. These 6 strategies included; (1) prevent overtraining, (2) perform multiaxial, neuromuscular, proprioceptive and agility training, (3) wear mouthguards during high-risk activities, (4) wear semi-rigid ankle braces for high-risk activities, (5) consume nutrients to restore energy balance within 1 h following high-intensity activity, and (6) wear synthetic-blend socks to prevent blisters. Within all successful injury prevention strategies, 4 components were deemed critical to their success. These critical components (‘essential elements’) included; (1) education of military leaders, (2) leadership support, (3) unit injury surveillance, and (4) adequate resources for injury research and programme evaluation.
Our aims were to: (1) update the current injury prevention strategy evidence base for making recommendations to prevent PT-related MSkI covering the period 2008–2015; (2) prioritise the recommendations for MSkI prevention programmes, strategies and policies, with consideration for the influence of sex, and (3) highlight areas for further research to evaluate interventions likely to reduce PT-related MSkI. The years 2008–2015 were chosen as the date parameters for our literature search to directly follow on from the papers reviewed by Bullock et al.4
Section snippets
Methods
Our methodological approach closely followed that outlined in the paper by Bullock et al.4 Literature was searched and extracted from five databases (PUBMED, COCHRANE, ATHENA, Defense Technical Information Centre Scientific and Technical Information Network, Google Scholar), with papers also identified from the reference lists of appropriate articles. Searches included the terms “injury prevention”, AND “physical training” OR “physical fitness”. A total of 764 articles were identified from the
Results
The eligible full-text reviewed intervention studies were broadly categorised into 6 types of injury prevention intervention. These intervention categories included; (1) conditioning (n = 266, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31), (2) footwear modification (n = 632, 33, 34, 35, 36, 37), (3) bracing (n = 218, 38), (4) physical activity volume (n = 539, 40, 41, 42, 43), (5) physical fitness (n = 344, 45, 46) and, (6)
Discussion
We provide an updated position to the injury prevention evidence base detailed by Bullock et al.4 Combined findings support a reduction in physical activity volume, and bracing for high-risk activities, to reduce injury rates, particularly in military cohorts. However, using multiaxial, neuromuscular, proprioceptive and agility training to reduce injury rates was not supported by the additional studies in our review. Although no negative effects of these types of conditioning programmes were
Limitations of the review
The systematic literature search was limited to a few, specific search terms. Although we feel that these search terms enabled us to retrieve the most appropriate articles, we can not be sure that equally relevant articles were not missed. The searches were performed by only one author (SW). However, the strategy for searching, identifying and screening articles was agreed by both authors and discussed with our wider research group to ensure consistency of approach. Some of the evaluated
Conclusion
Prevention strategies can be implemented effectively to reduce MSkI rates in both sexes, even in military training environments where competing demands and the requirement to achieve desired output standards are high. Appropriate leadership, improving physical fitness in the absence of high physical activity volumes, and bracing for high-risk activities/rehabilitation appear beneficial for reducing PT-related MSkI, whereas modification of footwear and conditioning exercises would not be
Practical implications
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Appropriate leadership, and awareness of injury prevention strategies by individuals in leadership positions, are important contributors to the effectiveness of injury prevention strategies.
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Improving physical fitness, in the absence of excessive time on foot, is an effective strategy to reduce musculoskeletal rates and may reduce female injury rates.
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There is no existing evidence to suggest that different injury prevention strategies should be adopted by men and women separately, although
Conflict of interest statement
No conflict of interest declared.
Acknowledgements
We wish to acknowledge the Women in Ground Close Combat research team for their input into the study design and data interpretation. No financial support was received directly for this piece of work.
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