TY - JOUR
AU - Vedran,, Hadžiž
AB - Abstract Introduction Injury registration is an important first step of the musculoskeletal injury (MSI) prevention process that helps establish the magnitude of the problem and focus prevention on the body parts that are most frequently injured. However, an injury definition used in that process may influence the reported prevalence of MSI, causing some injuries to be under-reported which in turn alters the prevention efforts. The primary goal of our study was to identify the 10-year prevalence of MSI in members of the Slovenian Armed Forces (SAF), to help plan and implement preventive measures for the reduction of MSI. Our secondary goal was to compare MSI data collected using two different approaches. The first one was prospective approach where only time-loss injuries were collected during a 10-year period, and the second one was a cross-sectional approach where at one point in time soldiers were asked about any musculoskeletal complaint. Materials and Methods The study was an introductory part of trial that was registered in the U.S. Clinical Trials Registry (clinical.trials.gov) under the identifier number NCT03415464. For the retrospective analysis, injury data from the Department of Safety and Occupational Safety of the SAF were used for a 10-year period (2006–2015) where only injuries that cause a soldier to be absent from duty for three or more working days are registered. For cross-sectional analysis, 129 members (N = 129) of an infantry SAF regiment (118 males, 11 females) volunteered to participate in the study. A modified Oslo Sports Trauma Research Centre (OSTRC) injury report form was used to collect injury data about current musculoskeletal complaints. Results The 10-year prevalence of MSI in SAF was 4.9%, with significantly (p = 0.0004) lower prevalence in females (3.1%) than males (5.4%). The most frequently injured body parts were ankles (23%) and knees (21%). The cross-sectional analysis has shown a much higher MSI prevalence of 48.8% (50.8% in males and 27.7% in females), demonstrating that some MSIs are probably under-reported. For all reported injuries in a cross-sectional analysis, a previous injury was a strong and significant injury risk factor (p < 0.001 for all instances). Conclusions To the best of our knowledge, this is the first comprehensive analysis of MSI among SAF members showing that the currently used injury surveillance system in SAF, that reports only the prevalence of time-loss injuries (4.9%), is probably underestimating the true and overall MSI prevalence (48.8%) in SAF members, suggesting a need for a better injury registration process. Based on the most frequent injury locations, preventive measures in SAF should focus on knee and ankle injuries in males with previous lower limb injuries. A best preventive approach would probably be to train smarter and harder to develop the physical capability to better protect against those injuries. INTRODUCTION Musculoskeletal injuries (MSIs) in the armed forces are endemic1 and occur on a daily basis during a variety of activities. Tasks performed by Slovenian Armed Forces (SAF) members include, but are not limited to shooting a firearm, wearing a backpack, throwing a grenade, walking, running, digging, transferring ammunition and other heavy loads, hanging from hand holds, crawling, climbing, and rope descents. These and many other tasks are carried out in an urban environment, the desert, forests, and in and under water. In performing these tasks, soldiers encounter many obstacles such as felled trees, large and small holes, barricades, wire obstacles, rocks, footbridges, vertical or horizontal ropes, and others. To carry out these tasks, members of SAF need excellent physical and functional abilities. Therefore, within an 8-hour soldier workday, 1 hour is dedicated to physical training (PT).2 Improvement in physical abilities through regular PT is associated with a higher level of combat readiness3 and has numerous positive health effects, although sometimes paradoxically, the very PT activities required to improve soldier performance may also result in injury.4 MSIs in the military are associated with approximately 25 million lost duty days each year5 and they are also leading cause of disability discharge6 affecting both financial (such as the economic burden from medical, healthcare, and disability costs) and human manpower resources (soldiers medically unable to optimally perform their duties and to deploy).7 Therefore, the examination of injuries in the military is an important first step for injury prevention in this population.4 Available data from the U.S. Armed Forces Health Surveillance Center for the 2000–2006 period8 show that around 13% of all MSIs are sports-related. Furthermore, a prospective study of MSI in 6,608 British Army recruits during a 26-week initial military training program over a 2-year period has shown the prevalence of MSI to be 48.6%.9 A Finnish study reports an occurrence rate of 33%,10 and adds that overuse (66%) MSIs are more frequent than traumatic (34%). A study performed on U.S. Special Operations Forces has shown a somewhat lower injury prevalence of 24.5%, but the authors stressed that the injuries were significantly related to PT.11 The most commonly reported types of MSI in members of the armed forces were knee injuries (16–22%), low back pain (20%), and ankle sprains (13%).10,12 A 6-year study looking at hospitalizations due to sports injuries in the U.S. Army showed that they accounted for 29,435 lost work days each year, and knees were by far the most frequently injured body part.13 To conclude, the reported prevalence of MSI in the military is between 13% and 50%, MSI are strongly associated with PT, and affect mainly lower limbs. MSIs are second only to motor vehicle-related injuries6 and that because of such a high prevalence, the U.S. Department of Defense has begun to implement the sports medicine model of care to improve the access, efficiency, and effectiveness of care for soldiers who experience MSI related to sports and training.6 Fortunately, MSI injuries (especially those that occur due to military PT) are preventable to some extent, and a recent systematic review has shown that injury prevention strategies can be broadly categorized into six injury prevention strategies: (1) conditioning, (2) footwear modifications, (3) bracing, (4) physical activity volume, (5) physical fitness, and (6) leadership/supervision/awareness. However, the most well-supported strategies were related to reducing physical activity volume and improving leadership/supervision/awareness of injuries and injury prevention efforts.14 Injury registration is an important first step of the injury prevention process, and without it, successful injury prevention cannot be sustained. The main aim of that step is to establish the magnitude of the problem15 and focus prevention on the body parts that are most frequently injured. Considering that MSIs are important causes of morbidity and work absenteeism, the primary endpoint of our study was to identify the 10-year prevalence of MSI in members of the SAF, as this information will allow us to better plan and implement preventive measures for the reduction of MSI. However, the ability to record and report the magnitude of injuries reliably is a critical factor across all stages of injury prevention research, and it has been shown in sports medicine that incidence as a traditional measure of injury risk is not so appropriate to highlight the true magnitude of some overuse injuries and pain problems (e.g., lower back pain and medial tibial stress syndrome), and that prevalence (a proportion of athletes affected by problems at any given time) should be used instead. If only a time-loss injury definition is used, than we may face the situation where our epidemiological data will not be sensitive to the overuse MSIs – a situation explained in the literature as no injuries, but plenty of pain.16 In a military setting, this may mean that physical and combat readiness may be influenced by some musculoskeletal complaint that does not qualify as an injury, but is quite prevalent. Our secondary goal was therefore to compare MSI data in SAF members collected using a prospective (a time-loss injury definition) and a cross-sectional (musculoskeletal complaint) approach. METHODS The study was performed on members of the SAF as an introductory part of the research project, “Prevention of Musculoskeletal Injuries in Slovenian Armed Forces.” This project is registered at ClinicalTrials.gov under the identifier NCT03415464. The study was also approved by the Ethics Board of the Faculty of Sport in Ljubljana (No. 454/2017) and the Headquarters of the SAF (No. 630–1/2016-3). This was a two-step study. Step 1 was a retrospective analysis of MSI, while Step 2 was a cross-sectional analysis of injuries in a chosen SAF sample. For the retrospective analysis, we analyzed data from the Department of Safety and Occupational Safety of the SAF. The Department has been prospectively collecting data since 2006 using a unique ER-8 injury report form for the registration of work-related injuries. This injury report form is being used for the whole public sector in the Republic of Slovenia, and has 45 fields collecting basic information about the employers, the employee that was injured, and the injury (date of injury, the injured body part, and the nature of injury). All medical data are later confirmed by the employee’s physician, and completed form is the basis for medical insurance reimbursement. When using this form, only injuries that cause an employee (in this case a member of the SAF; soldier) to be absent from duty for three or more working days, are recorded (time-loss injury definition). For the purposes of our research, we have collected and analyzed data for members of the SAF over a 10-year period (2006–2015). For the cross-sectional analysis, 129 (N = 129) members of the SAF (118 males, 11 females; age range 20–47 years) volunteered to participate in the study. The minimal representative sample size was calculated a priori from the known SAF population size (N = 7,000) with a hypothesized frequency of MSI of 25%, and an 80% confidence level was N = 122. Participants were recruited from an infantry regiment. Prior to enrollment, the soldiers provided informed consent. No compensation was given or promised for participation in the study. We used a modified Oslo Sports Trauma Research Centre (OSTRC) injury report form17 to collect data about current musculoskeletal complaints (defined as MSI in 2016). We also collected additional data, such as the smoking status, sleep quantity, previous injury, and self-reported physical activity levels (MVPA – moderate and vigorous physical activity) and PT habits. For the retrospective analysis, we calculated the MSI prevalence for males and females separately for each body region. Data are presented as the yearly prevalence in percentage for a given time frame. For the cross-sectional analysis, we have first reported descriptive statistics (means, standard deviations, and frequencies). We then performed the chi-square test to analyze possible relationships between previous injury, smoking status, sleep, and PT habits, and MSI. The chi-square with the Fisher exact test was used to compare injury proportions (e.g., males vs. females). Sex-related differences were evaluated using one-way analysis of variance. All statistical analyses were performed using IBM SPSS Statistics for Windows, (Version 21.0; Armonk, NY, USA). The significance threshold was set at 0.05. RESULTS Retrospective Data In a 10-year period from 2006 to 2015, there were 3,443 MSIs among members of the SAF. The overall prevalence of injuries was 4.9%, with significantly (X2 (2, N = 7,000) = 12.62, p = 0.0004) lower prevalence in females (3.1%) than males (5.4%) – with a negative trend line for each over a 10-year period (Fig. 1). FIGURE 1. View largeDownload slide A 10-year prevalence of MSIs in SAF. FIGURE 1. View largeDownload slide A 10-year prevalence of MSIs in SAF. Overall, the most frequently injured body parts were the ankle (23%) and the knee (21%), with some small, but non-significant differences between males and females (Fig. 2). However, it should be mentioned that the trend line for knee injuries was positive for females over a 10-year period (Fig. 2, right, broken line), probably due to an almost constant increase since 2011. FIGURE 2. View largeDownload slide A 10-year prevalence of ankle (left) and knee (right) injuries in SAF. FIGURE 2. View largeDownload slide A 10-year prevalence of ankle (left) and knee (right) injuries in SAF. Cross-sectional Data The baseline characteristics of the studied sample are presented in Table I. Gender-related differences were observed for body mass and body mass index. It should be noted that both genders within our sample had an average of over 8 years of military service. The majority of soldiers within our sample regularly warm-up before and stretch after an exercise session. However, the proportion of those who regularly perform strength training is low (males 37%, females only 9%; p = 0.06). The most frequent form of physical activity for each gender is running. This is followed by weight training and football/soccer in males. The overall prevalence of MSI in 2016 was 48.8% (50.8% in males and 27.7% in females), and the most common MSIs were knee injuries, accounting for 26% of all MSI reported in 2016 (Fig. 3). TABLE I. Baseline Characteristics of Participants Male (N = 118) Female (N = 11) Mean Std. Dev. Mean Std. Dev. Age (years) 30 6 30 6 Body height (cm) 182 7 168 6 Body mass (kg) 87.8* 10.7 66.4 8 Body mass index (kg/m2) 26.43* 2.81 23.63 2.83 Military service (years) 8.9 5.0 8.1 6.0 Sleep quantity (hours/night) 6.7 1.1 6.4 1.1 MVPA (minutes/week) 232 147 219 117 Smoking status  Smokers 35.6% 45.5%  Former smokers 6.8% 9.1% Regular warm-up 90.7% 90.9% Regular strength training 37.3% 9.1% Regular flexibility training 86.4% 90.9% Self-reported sports activity Running (43%) Running (70%) Fitness (15%) Other (30%) Football (14%) Other (28%) Male (N = 118) Female (N = 11) Mean Std. Dev. Mean Std. Dev. Age (years) 30 6 30 6 Body height (cm) 182 7 168 6 Body mass (kg) 87.8* 10.7 66.4 8 Body mass index (kg/m2) 26.43* 2.81 23.63 2.83 Military service (years) 8.9 5.0 8.1 6.0 Sleep quantity (hours/night) 6.7 1.1 6.4 1.1 MVPA (minutes/week) 232 147 219 117 Smoking status  Smokers 35.6% 45.5%  Former smokers 6.8% 9.1% Regular warm-up 90.7% 90.9% Regular strength training 37.3% 9.1% Regular flexibility training 86.4% 90.9% Self-reported sports activity Running (43%) Running (70%) Fitness (15%) Other (30%) Football (14%) Other (28%) *Significant sex-related differences (p < 0.001 for all instances). TABLE I. Baseline Characteristics of Participants Male (N = 118) Female (N = 11) Mean Std. Dev. Mean Std. Dev. Age (years) 30 6 30 6 Body height (cm) 182 7 168 6 Body mass (kg) 87.8* 10.7 66.4 8 Body mass index (kg/m2) 26.43* 2.81 23.63 2.83 Military service (years) 8.9 5.0 8.1 6.0 Sleep quantity (hours/night) 6.7 1.1 6.4 1.1 MVPA (minutes/week) 232 147 219 117 Smoking status  Smokers 35.6% 45.5%  Former smokers 6.8% 9.1% Regular warm-up 90.7% 90.9% Regular strength training 37.3% 9.1% Regular flexibility training 86.4% 90.9% Self-reported sports activity Running (43%) Running (70%) Fitness (15%) Other (30%) Football (14%) Other (28%) Male (N = 118) Female (N = 11) Mean Std. Dev. Mean Std. Dev. Age (years) 30 6 30 6 Body height (cm) 182 7 168 6 Body mass (kg) 87.8* 10.7 66.4 8 Body mass index (kg/m2) 26.43* 2.81 23.63 2.83 Military service (years) 8.9 5.0 8.1 6.0 Sleep quantity (hours/night) 6.7 1.1 6.4 1.1 MVPA (minutes/week) 232 147 219 117 Smoking status  Smokers 35.6% 45.5%  Former smokers 6.8% 9.1% Regular warm-up 90.7% 90.9% Regular strength training 37.3% 9.1% Regular flexibility training 86.4% 90.9% Self-reported sports activity Running (43%) Running (70%) Fitness (15%) Other (30%) Football (14%) Other (28%) *Significant sex-related differences (p < 0.001 for all instances). FIGURE 3. View largeDownload slide The prevalence of previous injuries and injuries in 2016. FIGURE 3. View largeDownload slide The prevalence of previous injuries and injuries in 2016. A chi-square test of independence was performed to examine the relation between previous injury, gender, smoking, strength training, flexibility training, warm-up, and BMI. For all reported injuries, a previous injury was a strong and significant injury risk factor (p < 0.001 for all instances). The relation between smoking and low back pain was significant (X2(2, N = 128) = 9.14, p = 0.003). Smokers were 3.57 times (95% confidence interval 1.53–8.35) more likely to report low back pain than were non-smokers and former smokers. All other parameters were not significantly related with any of the reported MSI. DISCUSSION The primary finding of our study is that about 5% of SAF members sustain an injury each year and that the prevalence of injuries is significantly higher in males than in females. The most frequently injured body parts are ankles (23%) and knees (21%). A cross-sectional analysis in which soldiers were asked to report musculoskeletal complaints that did not necessarily cause them to report any lost duty days, has revealed that the prevalence of MSI is much higher (48.8%), and that injuries are significantly associated with previous injuries. This coincides with the data of one of the latest systematic reviews about the influence of previous injury of re-injury rates.18 The retrospective prevalence of MSI injuries (4.9%) is much lower than is usually reported. When compared with data from the U.S. Armed Forces Health Surveillance Center for the 2000–2006 period,8 where the reported MSI prevalence was 13%, it seems that prevalence in SAF is lower by more than 50%. However, we must stress that their report was for the period 2000–2006, while our data are reported for the period 2006–2015. During the intervening period, a general awareness of MSI has increased, and numerous systematic preventive measures have been taken to decrease the rate of MSI in the military.6 The findings from other studies also reported much a higher prevalence of MSI,9–11 but are not comparable to our retrospective data, as they reported all and not only time-loss injuries, but they are in line with our cross-sectional data (48.8% prevalence). The injury surveillance system in Slovenia using the registers only time-loss injuries demanding 3 or more days of work absenteeism, while musculoskeletal complaints where soldiers are present at work, but are not performing at their best due to MSI complaints are under-reported. It has been shown previously (but not military-related literature) that different injury definitions can result in incidences that vary between 7.5% and 58.0%.19 Furthermore, unreported, under-reported, and untreated injuries can lead to re-injury, chronic pain, performance decrements, and increased costs associated with disability benefits. Additionally, unreported injuries can undermine injury surveillance efforts aimed at reducing the MSI problem in the military.20 While in the previously cited study, the most common reasons for not reporting injuries were fear that an injury might affect future career opportunities and avoidance of military “profiles” (mandated physical restrictions) in our case the reason for un(der)reporting was probably related to injury surveillance system. However, the pattern of injuries was in concordance with previously reported data with the most prevalent MSI being knee injuries (international data 16–22%; 21% in our retrospective analysis; and 26% in the cross-sectional analysis) followed by low back pain and ankle injuries.10,12,13 The authors would also like to acknowledge some limitations of the current study. The main limitation is related to the sample size calculation in cross-sectional part of the study, where an 80% confidence interval (CI) was used that was fairly low, meaning that 20% of the time the real value, although the sample falls into the CI, the true population value would fall outside of the CI. We must stress that the cross-sectional part of this study was a pilot project and that future research should cover much larger proportion of SAF members than the current one, therefore the analysis of some mentioned risk factors was not further elaborated or discussed. CONCLUSIONS To the best of our knowledge, this is the first comprehensive analysis of MSIs among SAF members. We have shown that the currently used injury surveillance system in SAF (that reports the MSI prevalence of 4.9%) is probably underestimating the true and overall MSI prevalence (48.8%) in SAF members that is shown by cross-sectional approach. Based on the most frequent injury locations, preventive measures in SAF should focus on knee and ankle injuries in males with previous lower limb injuries. A best preventive approach would probably be to train smarter and harder to develop the physical capability to better protect against those injuries.21 Our results show that only 35% of males and 9% of females regularly perform strength training, which may further support this assertion. In addition, core stability exercises should be incorporated to help prevent lower back pain, which is the second-ranked MSI among SAF members in 2016. Finally, we propose a more appropriate methodology to quantify MSI injuries in studies on military populations across all phases of injury prevention research. Also, the OSTRC questionnaire, that has been validated for that purposes, enables a prospective research approach with continuous (e.g., once per week or once per month) measurements of symptoms, pain, and functional disability, and provides real-time injury data for accurate and quick prevention actions. Funding Supported by Slovenian Research Agency through a project P5-014. References 1 Owens BD , Cameron KL : Musculoskeletal injuries in the military [Internet]. In: Musculoskeletal Injuries in the Military , pp 1 – 317 . Edited by Cameron KL , Owens BD New York, NY , Springer New York , 2016 . Available at http://link.springer.com/10.1007/978-1-4939-2984-9 2 The Official Gazette of the Republic of Slovenia : Rules of service in the Slovenian Armed Forces . 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Google Scholar Crossref Search ADS PubMed Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the Slovenian Armed Forces, the Department of Defense of the Republic of Slovenia or Slovenian Government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Retrospective and Cross-sectional Analysis of Physical Training-Related Musculoskeletal Injuries in Slovenian Armed Forces
JO - Military Medicine
DO - 10.1093/milmed/usy156
DA - 2019-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/retrospective-and-cross-sectional-analysis-of-physical-training-KCUH3Gi1Tf
SP - e195
VL - 184
IS - 1-2
DP - DeepDyve
ER -