Assessing Fitness for Military Enlistment Physical, Medical, and Mental Health Standards (2006) / Chapter Skim
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4 Physical Fitness and Musculoskeletal Injury
4 Physical Fitness and Musculoskeletal Injury
Pages 66-108
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From page 66... ...
Because a key purpose of basic training is to ensure that graduates are able to meet the physical demands of serving as a combat soldier, physical training is a central element of the basic training protocol for all Services. While specific physical training procedures differ across the Services, the demands are substantial in all branches.
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From page 67... ...
Those who enter basic training with a relatively low level of physical fitness would be expected to find the physical training component of basic training to be more demanding and stressful than those who enter with high physical fitness. This chapter summarizes the available evidence regarding the relationship between physical fitness and negative outcomes during the first term of military service.
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From page 68... ...
contractions Reduced risk of low back pain Flexibility Range of motion in a joint Enhanced functional capacity or series of joints (bending, twisting) Reduced risk of low back pain Body composition Fatness; ratio of fat weight Enhanced functional capacity to total body weight Reduced risk of chronic disease aFrom Clarke (1967)
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From page 69... ...
. TABLE 4-2 FITNESSGRAM Test Battery Components of Physical Fitness FITNESSGRAM Test Itemsa Cardiorespiratory endurance The PACER, one-mile run, or walk test Muscular strength and endurance of Curl-up the abdominal musculature Muscular strength and endurance of 90-degree push-up, modified pull-up, upper arm musculature pull-up, or flexed arm hang Flexibility of the low back or Back-saver sit and reach hamstring region Body composition Skinfold measurements or body mass index aFrom Cooper Institute (2004)
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From page 70... ...
: All military personnel, regardless of occupational specialty, unit assign ment, age, or gender should acquire a base level of general physical fitness. This physical fitness promotes a standard of physical readiness TABLE 4-3 Military Service Physical Fitness Test Components Air Marine Army Navy Force Corps Aerobic capacity 2-mile run 1.5-mile run 1.5-mile run 3-mile run Upper body Push-ups Push-ups Push-ups Pull-ups (men)
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From page 71... ...
began in 1970. It was designed to monitor the trends in prevalence, awareness, and treatment of selected risk factors and diseases of Americans.
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From page 72... ...
72 at waist of a points. score 300 sec plus a si Women 31:00 Women 15 Women 50 attain APFT Arm components must the on Men 28:00 Men 3 Men 50 test soldiers Corps attain run fitness All can Marine 3-mile Age 17-26 Pull-ups/Flexed Age 17-26 Crunches Age 17-26 event.
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From page 73... ...
Articles were included if cardiorespiratory fitness expressed as ml/kg/min or two-mile run time was reported. A total of seven articles were included in the final analysis.
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From page 74... ...
Fitness levels of male military personnel were in the upper 70 percent of the distribution, corresponding to a minimum VO2max of 41.2 ml/kg/min or a 2-mile run time of 17 minutes and 28 seconds. For women, the mean VO2max ranged from the 43rd to 77th percentiles, and the standard deviations ranged from the 27th to 99th percentiles.
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From page 75... ...
75 ) min times years, run (ml/kg/ (16-24 2max 2-mile VO 100 population 56.8 90 U.S.
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From page 76... ...
76 ) min (16-24 times (ml/kg/ run 2max 2-mile 50.7 population VO 100 U.S.
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From page 77... ...
PHYSICAL FITNESS, MUSCULOSKELETAL INJURY, AND ATTRITION IN MILITARY BASIC TRAINING This section focuses on the relationship of physical fitness to injury and attrition in basic training. Data are presented demonstrating that low physical fitness is closely associated with diminished performance in basic training (as measured by injury and attrition status)
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From page 78... ...
However, it should be noted that a history of this repair is widely perceived by the military Services to be a waiverable condition, and thus is probably overrepresented in this data source relative to the general applicant population. Ankle and foot conditions accounted for 4 percent of lower extremity failures, joint pain or stiffness for 8 percent, and presence of an orthopedic device or "complications of medical care" for an additional 5 percent.
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From page 79... ...
There is also no routine linkage of the medical failure database to administrative data on basic training attrition. Because of the lack of linkage to outcomes and the great diversity and lack of specificity of the musculoskeletal conditions reported above, the committee did not make any further use of this data source.
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From page 80... ...
A number of previous studies have established a range of risk factors for injury during military training. Recent reviews of risk factors for training-related injuries (Jones and Knapik, 1999; Kaufman, Brodine, and Shaffer, 2000)
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From page 81... ...
Height and weight data were taken at the MEPS and performance on the timed run was measured at entry to basic training. Demographic characteristics of the recruits used in the injury analyses are shown in Table 4-5.
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From page 82... ...
There are striking differences between men and women in the risk of injury during Army basic training (adjusted risk ratio of 2.26, 95 percent confidence interval, CI: 2.08, 2.45)
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From page 83... ...
83 data ed Total 20.7% 20.5% 22.8% 21.1% 50.9% 45.7% 47.6% 47.5% ategories.c 2.6)
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From page 84... ...
84 data d 9.5% 8.6% Total 10.2% 9.2% 14.4% 15.8% 21.8% 16.9% categories.
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From page 85... ...
In a longitudinal study of Army recruits who entered military service in 1999, the physical fitness levels of recruits when arriving at basic training predicted attrition both during training and years later, in operational units.2 Specifically, recruits who passed the Army's physical fitness test both very early in training and later in training had an 18.9 percent attrition rate from their operational unit, whereas those who failed the test both early and later in training had a 26 percent attrition rate from 2Personal communication from Dan Putka, HumRRO, 2005, based on reanalyses of data collected for the Army Research Institute's Project First Term.
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From page 86... ...
A recruit's race was not predictive of pass/fail status on either the early or the later fitness tests during basic training; however, women were much more likely to fail, while those who self-rated their fitness level as high were much more likely to pass. To further analyze the relationship between fitness and attrition, the committee used data provided by USACHPPM (data from two studies conducted at Fort Jackson in 2000 and 2003; see the description in the previous section)
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From page 87... ...
. Correspondingly, there would be reductions in the TABLE 4-9 Multivariate Analysis of Risk Factors for First-Term Attrition During Army Basic Combat Training, Fort Jackson, South Carolina, 2000, 2003 Attrition Risk Ratio (95% CI)
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From page 88... ...
Previously unpublished data from samples of male and female trainees at Fort Jackson, South Carolina. attrition risk for both men and women if the distribution of cardiorespiratory fitness could be shifted towards increasing fitness.
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From page 89... ...
. SCIENCE OF MUSCULOSKELETAL INJURIES Multidimensional Nature of Risk Military and civilian research efforts have identified several risk factors for musculoskeletal injury, categorized as individual characteristics, physical demands, and psychosocial demands.
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From page 90... ...
90 ASSESSING FITNESS FOR MILITARY ENLISTMENT TABLE 4-10 Risk Factors for Developing Overuse and Traumatic Injuries in Military Populations Risk Category Risk Factor Supporting Literature Physical factors Greater physical Berkowitz et al., 1999; DiBenedetto et al., demand levels 2002; Dybel and Seymour, 1997; (including exercise) Feuerstein, Berkowitz, and Peck, 1997; Huang and Feuerstein, 2004; Jones, Cowan, and Knapik, 1994; Lincoln et al., 2002; Potter et al., 2002; Shaffer et al., 1999b; Smith and Cashman, 2002; Tomlinson, Lednar, and Jackson, 1987 Individual factors Low levels of past Almeida et al., 1999; Gardner et al., 1988; physical activity Jones et al., 1993a, 1993b; Kowal, 1980; Shaffer et al., 1999a; Winfield et al., 1997 Low levels of Almeida et al., 1999; Bell et al., 2000; physical fitness Jones et al., 1993a, 1993b; Knapik et al., 1993; Kowal, 1980; Reynolds et al., 1994; Schneider et al., 2000; Shaffer et al., 1999a; Pope, 2002 Smoking Jones et al., 1993a; Lincoln et al., 2002; Reynolds et al., 1994 Age (older)
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From page 91... ...
Brudvig et al., 1983; Feuerstein, Berkowitz, and Peck, 1997; Geary et al., 2002; Gemmell, 2002; Kelly and Bradway, 1997; Kowal, 1980; Pester and Smith, 1992; Smith et al., 2000; Snedecor et al., 2000 Short stature Jones et al., 1993a Race (Caucasian) Bell et al., 2000; Brudvig et al., 1983; Sulsky et al., 2000 Lower extremity Beck et al., 1996; Cowan et al., 1993, morphology 1996; Jones, Cowan, and Knapik, 1994 ; Jones et al., 2000; Kaufman et al., 1999, Winfield et al., 1997 Previous injury Almeida et al., 1999; Jones et al., 1993a; history Lincoln et al., 2002; Smith and Cashman, 2002 Psychosocial/ Occupational stress Feuerstein, Berkowitz, and Peck, 1997; organizational Huang and Feuerstein, 2004; Lincoln et factors al., 2002 Job satisfaction Huang and Feuerstein, 2004; Lincoln et al., 2002 Low pay grade Lincoln et al., 2002 Greater cognitive Huang and Feuerstein, 2004 processing FIGURE 4-5 Traditional load-tolerance relationship between loads imposed upon a tissue and the ability of a tissue to withstand (tolerate)
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From page 92... ...
Acute Injuries Versus Cumulative Trauma Two types of trauma can affect the human body and lead to musculoskeletal disorders in occupational settings. Acute trauma can occur when a single application of force is so large that it exceeds the tolerance of the body structure during an occupational task.
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From page 93... ...
The ultimate consequence of this process is, once again, a functional disability. Although the stimulus associated with the cumulative trauma process is somewhat similar for tendons and muscles, there is a significant
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From page 94... ...
Adaptation also occurs in muscle tissue. Increases in muscle mass can occur if muscle is loaded and then permitted to rest for a sufficient period of time.
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From page 95... ...
Psychosocial Factors and Injuries Psychosocial factors, such as pressure to perform, the organization of tasks, and the social context may also contribute to musculoskeletal injuries and attrition among military recruits. Few studies have attempted to understand the causal relationship between psychosocial factors and biomechanical loading of the musculoskeletal system.
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From page 96... ...
Gender As reported in the analysis above and in the literature (see Table 4-10; Kaufman, Brodine, Shaffer, 2000; Institute of Medicine, 1998) , injury rates for women are generally substantially higher than for men during basic training.
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From page 97... ...
. Similarly, studies of the knee joint muscle mass have also indicated reduced muscle mass and a muscle mechanical advantage in women (Suzuki et al., 1996; Wretenberg et al., 1996; Csintalan et al., 2002; Wojtys et al., 2003)
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From page 98... ...
. Race and Age Increasing age and white race are noted as risk factors for overall injury (Table 4-10)
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From page 99... ...
In addition, smoking may be correlated with behavioral factors that are independent risk factors for injury, such as risk-taking behavior. Previous Injury History A positive injury history is a risk factor for injury during basic training (Table 4-10)
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From page 100... ...
APPROACHES TO REDUCING INJURIES AND ATTRITION Assessment of Physical Fitness Prior to Shipping to Basic Training All branches of the military require active-duty personnel to meet physical fitness standards, and all the branches provide for administration of physical fitness tests during and after basic training. However, currently none of the military branches systematically tests its recruits for low physical fitness prior to their shipping to basic training.
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From page 101... ...
Another alternative, if basic training protocols were modified to allow it, is that low-fit inductees could initiate basic training without delay but complete training procedures that would be scaled to their lower level of fitness. Physical Training Programs for Low-Fit Recruits Prior to Basic Training If testing procedures are adopted that identify some recruits as low fit, they could be referred to physical training programs that would be designed to increase their fitness to acceptable levels prior to initiation of standard basic training.
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From page 102... ...
For example, if fitness was assessed at any point prior to arrival at basic training, those found to be low fit could be provided with guidelines for self-management of a physical training program, or they could be referred to community-based programs that meet specified standards or criteria. Alternatively, low-fit recruits could be referred to physical training programs that would be delivered by the military branch and completed prior to initiation of basic training.
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From page 103... ...
While this method may serve some important purposes, it represents a violation of one of the most widely accepted tenets of exercise training: exercise intensity and dose should be adjusted in accordance with the initial fitness level of the individual. While it would probably not be practical to provide for total individualization of exercise training programs in basic training, it could be possible to consider the initial fitness status of recruits by grouping trainees for physical training on the basis of their current fitness levels.
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From page 104... ...
Fitness test pass rates slightly higher in intervention group Knapik et al., 2004c Risk of injury in basic training reduced by 33 percent in men and 40 percent in women Work-hardening training Reinker and Ozburne, 1979 11 percent reduction stress cycle (gradual increase) fracture rate Preconditioning and Lee et al., 1997 55 percent lower attrition fitness appropriate rates training Multiple intervention Kelly and Bradway, 1997 35 percent reduction in approach lost training days 83 percent reduction in overall attrition rate for musculoskeletal disorders Knapik et al., 2004b 50 percent reduction in (Modified Physical relative risk of a time Training, Injury loss injury Education, Injury Surveillance)
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From page 105... ...
. Accordingly, the current practice of integrating female and male recruits in the same basic training units and exposing the two gender groups to the same physical training program is a prescription for producing high injury rates in female trainees.
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From page 106... ...
However, none of the Services systematically assesses individual physical fitness levels prior to the shipping of recruits to basic training. In an effort to minimize the consequences of injury, previous studies have identified several modifiable risk factors that may synergistically affect injury causality.
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From page 107... ...
Recommendation 4-2: Research should be conducted to examine the relationship between physical training programs prior to basic train ing and the incidence of injury or attrition during basic training, fo cusing on recruits who would fall below a designated physical fitness standard at the start of basic training. Training Although training outcomes are the result of several interrelated factors, preliminary direct evidence suggests that imposing limited physical demands at entry to military training and increasing physical training demands as fitness levels increase could produce comparable levels of physical fitness to current training regimes, with markedly reduced injury rates.
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From page 108... ...
It is therefore unknown whether tailoring the demands of basic training to an individual's fitness level (as per Recommendation 4-3) will fully address the problem of the higher risks of injury and attrition observed in female recruits.
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