Compliance compromises an interventional study on iron supplementation in female combatants.

INTRODUCTION: Low iron levels are related to overuse injuries, poor physical performance and cognitive impairments in female recruits. The aim of this study was to evaluate iron supplement compliance in female combatants during basic training, and its effect on haemoglobin (Hgb), ferritin and injuries. METHODS: 329 female recruits to light infantry units filled induction questionnaires regarding smoking status, previous overuse injuries and iron deficiency. Blood was drawn for Hgb and ferritin. Subjects with ferritin levels below 20 ng/mL were considered iron depleted and were prescribed a ferrous fumarate supplement. After 4 months of basic training, the subjects completed a follow-up questionnaire regarding overuse injuries, reasons for failure to complete basic training and compliance with iron supplementation. Blood tests were repeated. RESULTS: Mean ferritin levels declined during training (from 18.1±18.2 to 15.3±9.6, p=0.01). Compliance with iron supplementation was observed in 26 (26.3%) of the subjects. In compliant subjects, Hgb levels remained constant and ferritin levels increased by 2.9±5.4 (p=0.07). The main reasons for reported non-compliance were forgetfulness, 26 (35.6%), and gastrointestinal side effects, 17 (23.3%). Injuries during training were not found to be associated with iron status. Smokers had a significantly higher rate of reported injuries prior to training (p<0.01). CONCLUSIONS: Ferritin levels decline during training. Compliance with iron supplementation is low. Iron supplementation has a significant effect on ferritin levels, even in the non-compliance group. Injuries were not related to iron status in this group. Further research is needed in order to clarify the most appropriate iron supplementation method.

Utility of preinduction tests as predictors of attrition in infantry recruits: a prospective study.

INTRODUCTION: Infantry recruit attrition wastes resources and can affect combat readiness. The purpose of this study was to examine the utility of preinduction tests as a predictor of attrition among conscripts in the first year of infantry training. METHODS: 303 infantry conscripted recruits participated in a prospective study. Before their service, recruits received health profile and Quality Group Scores (QGSs). Recruits were screened at induction using questionnaires, by functional movement screening (FMS) and by upper and lower quarter Y-balance, dynamic and anthropometric tests. They were followed for musculoskeletal injuries and attrition during the first year of training. RESULTS: 165/303 (54.5%) recruits were diagnosed with musculoskeletal injury or pain during the first year of their training. 15.2% did not complete their first year of service as combatants and 5.9% were discharged. On multivariable binary stepwise logistic regression analysis for attrition, protective factors were higher QGSs (OR 0.78, 95% CI 0.69 to 0.89) and recruits diagnosed with musculoskeletal injuries or pain (OR 0.20, 95% CI 0.09 to 0.48). Pain in the balance test performed at the beginning of training was a risk factor (OR 3.31, 95% CI 1.44 to 7.61). These factors explained only 15.4% of the variance in attrition. CONCLUSIONS: FMS was not a significant predictor of infantry attrition. Measuring the three variables found to be associated with infantry attrition would seem to be valuable when the number of infantry candidates greatly exceeds the number of infantry positions. Transferring infantry attriters to non-combatant roles and not discharging them is a way to manage the problem of attrition.

Significance of tibial MRI findings of special forces recruits at the onset of their training.

INTRODUCTION: MRI is commonly used to evaluate medial tibial stress syndrome (MTSS), based on grading assessments developed in civilian populations. When MTSS represents stress fracture, rest is required to allow for bone remodelling to occur. False positive evaluations can lead to unnecessary recruit attrition. METHODS: Thirty randomly selected new recruits to a special forces training unit underwent MRI of their tibias using the T2-Dixon sequence at the onset of training. Evaluation was according to the Fredericson MTSS grading system. Prior to undergoing MRI, anthropomorphic measurements, a survey of sports history and an orthopaedic examination of subject tibias were performed. Orthopaedic follow-up was through 11 weeks of training. RESULTS: Medial periosteal oedema without the presence of bone marrow oedema, corresponding to a grade 1 stress reaction, was present on MRI in 10 recruits (17 tibias). In only one case did the periosteal oedema include the posterior aspect of the medial cortex where medial tibial stress fractures usually occur. Tibial tenderness was present in seven tibias on examination done just prior to the MRI studies, but none were symptomatic and only one had periosteal oedema present on MRI, but without anatomical correlation between the site of the tenderness and the periosteal oedema. During subsequent training, five tibias in four recruits developed pain and tenderness. Two had periosteal oedema in their prior MRIs, but the location did not coincide anatomically with that of the tibial tenderness. The time from stopping sports before induction and the presence of periosteal oedema was not significant. CONCLUSION: Periosteal oedema, one of the hallmarks used in MRI grading systems to evaluate MTSS, was found to have a 37.7% false positive rate for anatomically corresponding tibial tenderness at the time of the examination and during subsequent training, indicating the grading systems' low utility for the military.

Test-retest reliability of myofascial trigger point detection in hip and thigh areas.

BACKGROUND: Myofascial trigger points (MTrP's) are a primary source of pain in patients with musculoskeletal disorders. Nevertheless, they are frequently underdiagnosed. Reliable MTrP palpation is the necessary for their diagnosis and treatment. The few studies that have looked for intra-tester reliability of MTrPs detection in upper body, provide preliminary evidence that MTrP palpation is reliable. Reliability tests for MTrP palpation on the lower limb have not yet been performed. OBJECTIVE: To evaluate inter- and intra-tester reliability of MTrP recognition in hip and thigh muscles. DESIGN: Reliability study. SUBJECTS: 21 patients (15 males and 6 females, mean age 21.1 years) referred to the physical therapy clinic, 10 with knee or hip pain and 11 with pain in an upper limb, low back, shin or ankle. METHODS: Two experienced physical therapists performed the examinations, blinded to the subjects' identity, medical condition and results of the previous MTrP evaluation. Each subject was evaluated four times, twice by each examiner in a random order. Dichotomous findings included a palpable taut band, tenderness, referred pain, and relevance of referred pain to patient's complaint. Based on these, diagnosis of latent MTrP's or active MTrP's was established. The evaluation was performed on both legs and included a total of 16 locations in the following muscles: rectus femoris (proximal), vastus medialis (middle and distal), vastus lateralis (middle and distal) and gluteus medius (anterior, posterior and distal). RESULTS: Inter- and intra-tester reliability (Cohen's kappa (κ)) values for single sites ranged from -0.25 to 0.77. Median intra-tester reliability was 0.45 and 0.46 for latent and active MTrP's, and median inter-tester reliability was 0.51 and 0.64 for latent and active MTrPs, respectively. The examination of the distal vastus medialis was most reliable for latent and active MTrP's (intra-tester k = 0.27-0.77, inter-tester k = 0.77 and intra-tester k = 0.53-0.72, inter-tester k = 0.72, correspondingly). CONCLUSIONS: Inter- and intra-tester reliability of active and latent MTrP evaluation was moderate to substantial. Palpation evaluation can be used for clinical diagnosis of MTrP's in the hip and thigh muscles. SIGNIFICANCE: This study provides evidence that MTrP palpation is a moderately reliable diagnostic tool in the hip and thigh muscles and can be used in clinical practice and research.

Predictors of return to work with upper limb disorders.

BACKGROUND: Return to work (RTW) is a key goal in the proper management of upper limb disorders (ULDs). ULDs stem from diverse medical aetiologies and numerous variables can affect RTW. The abundance of factors, their complex interactions and the diversity of human behaviour make it difficult to pinpoint those at risk of not returning to work (NRTW) and to intervene effectively. AIMS: To weigh various clinical, functional and occupational parameters that influence RTW in ULD sufferers and to identify significant predictors. METHODS: A retrospective analysis of workers with ULD referred to an occupational health clinic and further examined by an occupational therapist. Functional assessment included objective and subject ive [Disability of the Arm, Shoulder and Hand (DASH) score] parameters. Quantification of work requirements was based on definitions from the Dictionary of Occupational Titles web site. RTW status was confirmed by a follow-up telephone questionnaire. RESULTS: Among the 52 subjects, the RTW rate was 42%. The DASH score for the RTW group was 27 compared with 56 in the NRTW group (P < 0.001). In multivariate analyses, only the DASH score was found to be a significant independent predictor of RTW (P < 0.05). CONCLUSIONS: Physicians and rehabilitation staff should regard a high DASH score as a warning sign when assessing RTW prospects in ULD cases. It may be advisable to focus on workers with a large discrepancy between high DASH scores and low objective disability and to concentrate efforts appropriately.

Physical and psychological stressors linked with stress fractures in recruit training.

This study aimed to measure ambulation in infantry army basic training, and to evaluate if covering more distance can explain stress fractures in a stressor-stress model. Forty-four male combat recruits (18.7 ± 0.7 years) participated in a 6-month rigorous high intensity combat training program. Baseline data included anthropometric measurements, VO(2)max, and psychological questionnaires. Actual distance covered was measured using a pedometer over an 11-week training period. Psychological questionnaires were repeated after 2 months. Sixteen recruits were diagnosed with stress fractures by imaging (SFi = 36.4%). Statistical analysis included comparing measured variables between SFi and those without stress fractures (NSF). The recruits covered 796 ± 157 km, twofold the distance planned of 378 km (P < 0.001). The SFi group covered a distance 16.4% greater than that of the NSF group (866 ± 136 and 744 ± 161 km, respectively, P < 0.01), and also demonstrated greater psychological stress. These data reveal the importance of adherence to or enforcement of military training programs. In the light of these data, the Israeli Defense Forces program needs reappraisal. A stressor-stress response might explain the susceptibility of certain recruits for injury. Using advanced technology, monitoring ambulation may prevent stress fracture development by limiting subjects exceeding a certain level. Psychological profile may also play a role in predicting stress fracture development.

Diagnostic medical auxiliary equipment in a field hospital: experience from the Israeli delegation to the site of the Turkish earthquake at Adapazari.

An earthquake striking a highly populated area is likely to cause a mass casualty situation for even the most advanced trauma center. If the local medical teams are injured and the hospitals are damaged beyond immediate repair, external intervention is needed. In the Turkish earthquake crisis, Israel was one of many states to deploy a field hospital to the crisis site. This was set up in Adapazari, the second most severely hit city in terms of the amount of damage. The hospital provided advanced surgical and medical facilities, including laparotomy, cesarean section, and intensive care surveillance. These facilities require sophisticated laboratory and radiology services, including hematology, chemistry, microbiology, and blood bank. The speed with which the hospital must be assembled and transported to be efficient and the basic conditions of a field hospital dictate specific considerations regarding diagnostic auxiliary equipment. Considerations in choosing this equipment, problems encountered during installation, and recommendations for the future are presented.

[Pre-induction sport activity in prevention of stress fractures in elite infantry recruits].

Pre-induction sports participation of 392 elite infantry recruits was evaluated for correlation with incidence of stress fractures (SF) during 14 weeks of basic training. 23.7% developed lower extremity stress fractures. 72% of the recruits had participated in sports on a regular basis during the 2 years prior to induction. Their fitness as examined by the Bar-Or induction fitness test, was significantly better than that of those who had not trained. 14.9% of the soldiers who had previously participated in ball games (primarily basketball) as an only sport suffered stress fractures, compared to 31.0% of those whose only sport was running (p < 0.005). Training for only 6 months prior to induction had no effect on the incidence of SF. The reason for the difference between ball games and running is probably related to the higher strains and strain rates developed during ball games and to their multidirectional nature, as compared to running. These findings suggest that participation in a pre-induction program that includes activities that create strains, such as basketball, can reduce incidence of SF in infantry recruits. The training period has to last at least 2 years.