Surveillance is the first step to preventing injury among fast jet aircrew: results of a 2-year prospective cohort study.

OBJECTIVES: Injury surveillance is imperative for injury prevention but difficult in military populations. Our objective was to accurately describe the pattern of musculoskeletal complaints among Royal Australian Air Force (RAAF) fast jet aircrew (FJA) using the validated University of Canberra Fast Jet Aircrew Musculoskeletal Questionnaire (UC-FJAMQ) over a 2-year period, and determine injury burden on the workforce and operational capability. METHODS: 306 RAAF FJA were monitored over a 2-year period (4×5 month reporting periods). Musculoskeletal complaint episodes (MCEs) were captured weekly using the UC-FJAMQ. Time loss episodes (TLEs) were captured from the UC-FJAMQ and injury registers completed by embedded physiotherapists. Cumulative severity and operational impact scores from the UC-FJAMQ, and time loss duration, were used to describe severity and calculate burden. RESULTS: Mean weekly UC-FJAMQ response rate was 62%. 1012 MCEs were captured, with a mean weekly prevalence of 14.9% (95% CI 14.2-15.6), and incidence of 4.1 episodes per person-year (95% CI 3.9-4.4). A total of 145 TLEs were captured, with a mean 5-month prevalence of 12.4% (range 8.9-15.3%), and incidence of 0.37 episodes per person-year (95% CI 0.31-0.43). Spinal regions accounted for 81% of MCEs and contributed 76% and 85% of burden in relation to cumulative severity and operational impact, respectively. 57% of TLE burden came from spinal regions. CONCLUSIONS: Despite modest weekly UC-FJAMQ response rates, musculoskeletal complaints were shown to be widespread and negatively impact operational capability. Future injury prevention efforts among FJA should focus on spinal regions, particularly the neck.

Musculoskeletal Injury in an Australian Professional Ballet Company, 2018-2021: 953 Medical-Attention and 706 Time-Loss Injuries Over 4 Years.

OBJECTIVES: To describe the incidence rate, frequency, severity, recurrence, and burden of musculoskeletal injury in professional ballet. STUDY DESIGN: Descriptive epidemiological (retrospective). METHODS: Professional dancers (n = 73, 40 females, 33 males) provided consent for retrospective review of musculoskeletal injury data. Medical-attention injuries were reported to and recorded by onsite physiotherapists between January 2018 and December 2021. Time-loss injuries were any injury that prevented a dancer from taking a full part in all dance-related activities for >1 day. Injuries were classified using the OSICS-10.1 system. Injury incidence rates (IIRs; injuries/1000 h), severity, recurrence, and burden were calculated. RESULTS: Nine hundred and fifty-three medical-attention injuries were recorded in 72 (98%) dancers at an IIR of 2.79/1000 h (95% confidence interval [CI], 2.62-2.98). 706 were time-loss injuries, which were reported in 70 dancers at an IIR of 2.07/1000 h (95% CI: 1.92, 2.23). Overuse injuries represented 53% of medical-attention injuries. The most frequently injured body area and tissue/pathology were thoracic facet joint (n = 63/953, 7%) and ankle synovitis/impingement (n = 62/953, 6%). Bone stress injuries (BSIs) were the most severe with the highest median time loss (135 days, interquartile range [IQR] 181) followed by fractures (72.5 days, IQR 132). The injuries with the highest burden were tibial BSIs (13 days lost/1000 h; 95% CI: 13, 14). Jumping and lifting were the most frequently reported injury mechanisms. CONCLUSION: Almost all dancers required medical attention for at least one injury during the surveillance period. Approximately 74% of injuries resulted in time loss. BSIs and ankle synovitis/impingement were of high burden, and a high proportion of BSIs were recurrent. J Orthop Sports Phys Ther 2023;53(11):712-722. Epub 14 September 2023. doi:10.2519/jospt.2023.11858.

Externally validated machine learning algorithm accurately predicts medial tibial stress syndrome in military trainees: a multicohort study.

Objectives: Medial tibial stress syndrome (MTSS) is a common musculoskeletal injury in both sporting and military settings. No reliable treatments exist, and reoccurrence rates are high. Prevention of MTSS is critical to reducing operational burden. Therefore, this study aimed to build a decision-making model to predict the individual risk of MTSS within officer cadets and test the external validity of the model on a separate military population. Design: Prospective cohort study. Methods: This study collected a suite of key variables previously established for predicting MTSS. Data were obtained from 107 cadets (34 women and 73 men). A follow-up survey was conducted at 3 months to determine MTSS diagnoses. Six ensemble learning algorithms were deployed and trained five times on random stratified samples of 75% of the dataset. The resultant algorithms were tested on the remaining 25% of the dataset, with models then compared for accuracy. The most accurate new algorithm was tested on an unrelated data sample of 123 Australian Navy recruits to establish external validity of the model. Results: Calibrated random forest modelling was the most accurate in identifying a diagnosis of MTSS; (area under curve (AUC)=98%, classification accuracy (CA)=96%). External validation on a sample of Navy recruits resulted in comparable accuracy; (AUC=95%, CA=94%). When the model was tested on the combined datasets, similar accuracy was achieved; (AUC=92%, CA=91%). Conclusion: This model is highly accurate in predicting those who will develop MTSS. The model provides important preventive capacity which should be trialled as a risk management intervention.

Statistical shape modelling reveals differences in hamstring morphology between professional rugby players and sprinters.

Hamstring morphology may play an important role in understanding the aetiology of hamstring injury. Currently, the methods available to capture detailed morphological data such as muscle shape have not been utilized for the hamstring muscles. The aim of this study was to examine the utility of statistical shape modelling (SSM) for describing and comparing hamstring muscle shape in rugby and sprinting athletes. Magnetic resonance images of both thighs of nine elite male rugby players and nine track and field sprinters were analysed. Images were converted to three-dimensional models enabling generation of four statistical shape models. Principal components describing the shape variation in the cohort were derived and evaluated. Six principal components were sufficient to discriminate differences in the shape of the hamstring muscles of rugby and sprinting athletes with 89% classification accuracy. Distinct shape features distinguishing rugby players from sprinters included size, curvature and axial torsion. These data demonstrate that SSM is useful for understanding hamstring muscle shape and that meaningful variation can be identified within a small sample. This method can be used in future research to enhance the anatomical specificity of musculoskeletal modelling and to understand the relationship between hamstring shape and injury.

The effect of helmet mass and aircraft acceleration on cervical spine loads during typical fast jet aircraft pilot head motions.

OBJECTIVES: Gravitational Force (Gz), head motion, and helmet mass are associated with neck pain in high performance aircraft pilots. Few studies have quantified neck kinetics (intersegmental neck moments) during aerial combat manoeuvres. DESIGN: Cross-sectional. METHODS: We quantified net joint moments between the skull and C1, and C6-7 during typical flight related headchecks using the Musculoskeletal Model for the Analysis of Spinal Injuries (MASI). We measured the influence of pilot-specific helmets and Gz on joint moments. Nineteen fighter pilots performed four head checks (check6 left, check6 right, extension hold and extension scan) under two helmet conditions. Motion data were transferred to OpenSim where joint moments were calculated at 1G to 9G. Net joint moments were compared across helmet conditions, Gz and headchecks. RESULTS: The Joint Helmet Mounted Cueing System (JHMCS) resulted in higher moments at each segment- by a factor of 1.25 per unit of Gz, at C1, and by a factor of 1.08 per unit of Gz for C7. ExtensionScan and Check6Left were associated with the highest peak (96.13 Nm and 92.56 Nm). ExtensionScan and ExtensionHold accrued the highest mean cumulative loads at C7 at 9Gz (607.35 Nm.sec/motion, 362.99 Nm.sec/motion respectively). Asymmetries were observed between the Left and Right Check6 motions. High variability was evident between and within pilots. CONCLUSIONS: The MASI model has been successfully applied to quantify intersegmental neck joint moments for typical headchecks that are performed during combat flight manoeuvres. In future, data derived from this model may inform conditioning, rehabilitative and preventative interventions to reduce neck pain in fast jet pilots.

A Validated Injury Surveillance and Monitoring Tool for Fast Jet Aircrew: Translating Sports Medicine Paradigms to a Military Population.

BACKGROUND: Military populations, including fast jet aircrew (FJA - aka fighter aircrew/pilots), commonly suffer from musculoskeletal complaints, which reduce performance and operational capability. Valid surveillance tools and agreed recordable injury definitions are lacking. Our objective was to develop and then evaluate the validity of a musculoskeletal complaints surveillance and monitoring tool for FJA. METHODS: A Delphi study with international experts sought consensus on recordable injury definitions and important content for use in a surveillance and monitoring tool for FJA. Using these results and feedback from end-users (FJA), the University of Canberra Fast Jet Aircrew Musculoskeletal Questionnaire (UC-FJAMQ) was developed. Following its use with 306 Royal Australian Air Force (RAAF) FJA over 4 × five-month reporting periods, validity of the UC-FJAMQ was evaluated via multi-level factor analysis (MFA) and compared with routine methods of injury surveillance. RESULTS: Consensus was achieved for: eight words/descriptors for defining a musculoskeletal complaint; six definitions of recordable injury; and 14 domains important for determining overall severity. The UC-FJAMQ was developed and refined. MFA identified three distinct dimensions within the 11 items used to determine severity: operational capability, symptoms, and care-seeking. MFA further highlighted that symptom severity and seeking medical attention were poor indicators of the impact musculoskeletal complaints have upon operational capability. One hundred and fifty-two episodes of time loss were identified, with the UC-FJAMQ identifying 79% of these, while routine methods identified 49%. Despite modest weekly reporting rates (61%), the UC-FJAMQ outperformed routine surveillance methods. CONCLUSIONS: The UC-FJAMQ was developed to specifically address the complexities of injury surveillance with FJA, which are similar to those noted in other military and sporting populations. The results demonstrated the UC-FJAMQ to be sensitive and valid within a large group of FJA over 4 × five-month reporting periods. Adoption of consistent, sensitive, and valid surveillance methods will strengthen the FJA injury prevention literature, ultimately enhancing their health, performance, and operational capability.

Factors associated with neck pain in fighter aircrew: a systematic review and meta-analysis.

Neck pain is a common complaint among fighter aircrew, impacting workforce health and operational capability. This systematic review aimed to identify, evaluate and synthesise the current evidence for factors associated with the occurrence of neck pain among fighter aircrew. Six electronic databases were searched in June 2019 and updated in June 2020 utilising the maximum date ranges. Included studies were appraised for methodological quality, ranked according to level of evidence and relevant data extracted. Where methods were homogeneous and data availability allowed, meta-analyses were performed. A total of 20 studies (16 cross sectional, one case-control, one retrospective cohort and two prospective cohort) were eligible for inclusion. Of the 44 factors investigated, consistent evidence was reported for greater occurrence of neck pain among aircrew operating more advanced aircraft and those exposed to more desk/computer work, while another 12 factors reported consistent evidence for no association. Of the 20 factors where meta-analyses could be performed, greater occurrence of neck pain was indicated for aircrew: flying more advanced aircraft, undertaking warm-up stretching and not placing their head against the seat under greater +Gz. Despite many studies investigating factors associated with neck pain among fighter aircrew, methodological limitations limited the ability to identify those factors that are most important to future preventive programmes. High-quality prospective studies with consistent use of definitions are required before we can implement efficient and effective programmes to reduce the prevalence and impact of neck pain in fighter aircrew. PROSPERO registration number: CRD42019128952.Neck pain is a common complaint among fighter aircrew, impacting workforce health and operational capability. This systematic review aimed to identify, evaluate and synthesise the current evidence for factors associated with the occurrence of neck pain among fighter aircrew.

A Systematic Review and Meta-Analysis About the Prevalence of Neck Pain in Fast Jet Pilots.

BACKGROUND: During flight, fast jet pilots frequently move their heads into extreme positions while withstanding large amounts of stress on their cervical spines. These factors are thought to contribute to episodes of neck pain.METHODS: We conducted a systematic review and meta-analysis of previous neck pain prevalence data in fast jet pilots to determine an overall pooled prevalence. Subgroup analyses were performed according to when pilots complained about their neck pain, whether these same pilots sought treatment, and if they lost time from flying. Four research databases were searched. Studies were eligible for inclusion if they were written in English, involved a group of fast jet pilots who were actively flying high performance aircraft, and reported quantitative prevalence data about neck pain in these pilots. These eligibility criteria were independently applied by two reviewers and risk of bias was evaluated. MetaXL software was used to conduct the meta-analysis.RESULTS: In total, 8003 fast jet pilots across 18 eligible studies were included in the review. The overall pooled prevalence of neck pain in fast jet pilots was 51%. It was found that 39% of subjects lost time from flying, while only 32% sought medical treatment.DISCUSSION: Neck pain in fast jet pilots adversely affects operational capabilities of defense forces. The prevalence of neck pain varies according to the definitions or thresholds of complaints used across the literature. Further research is required to standardize the definition of neck pain.Riches A, Spratford W, Witchalls J, Newman P. A systemic review and meta-analysis about the prevalence of neck pain in fast jet pilots. Aerosp Med Hum Perform. 2019; 90(10):882-890.

Vertebral Artery Dissection in Sport: A Systematic Review.

BACKGROUND: Vertebral artery dissection (VAD) is a potentially catastrophic injury that may occur during sports participation. A comprehensive review is needed to collate documented cases to improve understanding and inform future preventative approaches. OBJECTIVE: This review aimed to understand the extent of VAD in sport and characterise trends suggestive of mechanisms of injury. METHODS: Electronic databases were searched using terms related to VAD and sport. Records were included if they described one or more cases of VAD attributed to sport. RESULTS: A total of 79 records described 128 individual cases of VAD in sport, of which 118 were confirmed by imaging or autopsy and included in analyses. Cases were attributed to 43 contact and non-contact sports. The median age of cases was 33 years (IQR 22-44), and 75% were male. There were 22 cases of fatal injury, of which ten involved an impact to the mastoid region and seven involved an impact to the head or neck. Non-fatal cases of VAD were attributed to impact to the head or neck (not mastoid region), movement or held position without impact, and in some cases no reported incident. CONCLUSIONS: VAD attributed to sports participation is uncommonly reported and the mechanisms are varied. Impact to the mastoid region is consistently implicated in fatal cases and should be the focus of injury prevention strategies in sport. Efforts may also be directed at improving the prognosis of cases with delayed presentation through clinical recognition and imaging. The review was registered on the international prospective register for systematic reviews ( http://www.crd.york.ac.uk/PROSPERO ) (CRD42018090543).

Predicting individual risk for medial tibial stress syndrome in navy recruits.

OBJECTIVES: Quantifying individual risk for medial tibial stress syndrome (MTSS) is valuable due to the high prevalence, substantial financial and service costs, and lengthy recovery time of the condition. Identification of those at risk is a key first step in prevention of the condition. This study aimed to test a suite of best evidence risk factors in a cohort of Navy recruits and to develop a predictive model for individuals at risk of MTSS. DESIGN: Prospective cohort study of Navy recruits undergoing initial training METHODS: A prospective cohort design, this study screened recruits by assessing gender, MTSS history, years of running experience, orthotic use, BMI, navicular drop, ankle plantarflexion and hip external rotation at the beginning of basic training. Follow-up was conducted at completion of training (11 weeks). RESULTS: Volunteers included 123 recruits (28 females and 95 males). Thirty developed MTSS (19 males and 11 females). Stepwise logistic regression of one half of the data produced a significant model (p<0.001), comprising female gender (OR 4.4, 95% CI 1.0, 18.9, p=0.05), MTSS history (OR 18.3, 95% CI 3.6, 91.5, p<0.01) and increased hip ER (OR 1.1 per degree, 95% CI 1.0, 1.202, p=0.05). Findings validated with the other half of the cohort and receiver operating characteristic curve analysis showed the model had 82% sensitivity and 84% specificity. CONCLUSIONS: This predictive model provides military institutions, clinicians and instructors with a strong and accurate calculator for predicting an individual recruit's risk of MTSS.

Shockwave treatment for medial tibial stress syndrome: A randomized double blind sham-controlled pilot trial.

OBJECTIVES: Up to 35% of runners develop medial tibial stress syndrome (MTSS) which often results in lengthy disruption to training and sometimes affects daily activities. There is currently no high quality evidence to support any particular intervention for MTSS. This study aims to investigate the effect of shockwave therapy for MTSS. DESIGN: A randomized, sham-controlled, pilot trial in a university-based health clinic including 28 active adults with MTSS. METHODS: Intervention included standard dose shockwave therapy for the experimental group versus sham dose for the control group, delivered during Week 1-3, 5 and 9. Main outcome measures were pain measured during bone and muscle pressure as well as during running using a numerical rating scale (0-10) and running was measured as pain-limited distance (m), at Week 1 (baseline) and Week 10 (post-intervention). Self-perception of change was measured using the Global Rating of Change Scale (-7 to +7) at Week 10 (post-intervention). RESULTS: Pain (palpation) was reduced in the experimental group by 1.1 out of 10.0 (95% CI -2.3 to 0.0) less than the control group. There were no other statistically significant differences between the groups. CONCLUSIONS: Standard dose shockwave therapy is not more effective than sham dose at improving pain or running distance in MTSS. However, the sham dose may have had a clinical effect. Further investigation including a no intervention control is warranted to evaluate the effect of shockwave therapy in the management of MTSS.

Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis.

BACKGROUND: Medial tibial stress syndrome (MTSS) affects 5%-35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners. METHODS: Medical research databases were searched for relevant literature, using the terms "MTSS AND prevention OR risk OR prediction OR incidence". RESULTS: A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI), ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29-1.04, P<0.001); prior use of orthotics (risk ratio [RR] 2.31, 95% CI 1.56-3.43, P<0.001); fewer years of running experience (SMD -0.74, 95% CI -1.26 to -0.23, P=0.005); female gender (RR 1.71, 95% CI 1.15-2.54, P=0.008); previous history of MTSS (RR 3.74, 95% CI 1.17-11.91, P=0.03); increased body mass index (SMD 0.24, 95% CI 0.08-0.41, P=0.003); navicular drop (SMD 0.26, 95% CI 0.02-0.50, P=0.03); and navicular drop >10 mm (RR 1.99, 95% CI 1.00-3.96, P=0.05). CONCLUSION: Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed. These data can inform both screening and countermeasures for the prevention of MTSS in runners.

Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test.

OBJECTIVE: To examine the relationship between two clinical test results and future diagnosis of (Medial Tibial Stress Syndrome) MTSS in personnel at a military trainee establishment. DESIGN: Data from a preparticipation musculoskeletal screening test performed on 384 Australian Defence Force Academy Officer Cadets were compared against 693 injuries reported by 326 of the Officer Cadets in the following 16 months. Data were held in an Injury Surveillance database and analysed using χ² and Fisher's Exact tests, and Receiver Operating Characteristic Curve analysis. MAIN OUTCOME MEASURE: Diagnosis of MTSS, confirmed by an independent blinded health practitioner. RESULTS: Both the palpation and oedema clinical tests were each found to be significant predictors for later onset of MTSS. Specifically: Shin palpation test OR 4.63, 95% CI 2.5 to 8.5, Positive Likelihood Ratio 3.38, Negative Likelihood Ratio 0.732, Pearson χ² p<0.001; Shin oedema test OR 76.1 95% CI 9.6 to 602.7, Positive Likelihood Ratio 7.26, Negative Likelihood Ratio 0.095, Fisher's Exact p<0.001; Combined Shin Palpation Test and Shin Oedema Test Positive Likelihood Ratio 7.94, Negative Likelihood Ratio <0.001, Fisher's Exact p<0.001. Female gender was found to be an independent risk factor (OR 2.97, 95% CI 1.66 to 5.31, Positive Likelihood Ratio 2.09, Negative Likelihood Ratio 0.703, Pearson χ² p<0.001) for developing MTSS. CONCLUSION: The tests for MTSS employed here are components of a normal clinical examination used to diagnose MTSS. This paper confirms that these tests and female gender can also be confidently applied in predicting those in an asymptomatic population who are at greater risk of developing MTSS symptoms with activity at some point in the future.