Determining what works to prevent the problem: U.S. military evaluations and systematic reviews of injury prevention strategy
Prevention of Physical Training–Related Injuries: Recommendations for the Military and Other Active Populations Based on Expedited Systematic Reviews

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Background

The Military Training Task Force of the Defense Safety Oversight Council chartered a Joint Services Physical Training Injury Prevention Working Group to: (1) establish the evidence base for making recommendations to prevent injuries; (2) prioritize the recommendations for prevention programs and policies; and (3) substantiate the need for further research and evaluation on interventions and programs likely to reduce physical training–related injuries.

Evidence acquisition

A work group was formed to identify, evaluate, and assess the level of scientific evidence for various physical training–related injury prevention strategies through an expedited systematic review process. Of 40 physical training–related injury prevention strategies identified, education, leader support, and surveillance were determined to be essential elements of a successful injury prevention program and not independent interventions. As a result of the expedited systematic reviews, one more essential element (research) was added for a total of four. Six strategies were not reviewed. The remaining 31 interventions were categorized into three levels representing the strength of recommendation: (1) recommended; (2) not recommended; and (3) insufficient evidence to recommend or not recommend.

Evidence synthesis

Education, leadership support, injury surveillance, and research were determined to be critical components of any successful injury prevention program. Six interventions (i.e., prevent overtraining, agility-like training, mouthguards, semirigid ankle braces, nutrient replacement, and synthetic socks) had strong enough evidence to become working group recommendations for implementation in the military services. Two interventions (i.e., back braces and pre-exercise administration of anti-inflammatory medication) were not recommended due to evidence of ineffectiveness or harm, 23 lacked sufficient scientific evidence to support recommendations for all military services at this time, and six were not evaluated.

Conclusions

Six interventions should be implemented in all four military services immediately to reduce physical training–related injuries. Two strategies should be discouraged by all leaders at all levels. Of particular note, 23 popular physical training–related injury prevention strategies need further scientific investigation, review, and group consensus before they can be recommended to the military services or similar civilian populations. The expedited systematic process of evaluating interventions enabled the working group to build consensus around those injury prevention strategies that had enough scientific evidence to support a recommendation.

Introduction

In 2003 the Secretary of Defense (SECDEF) directed that rates of accidents and injuries must be markedly reduced.1 In response to the SECDEF's instruction, the Defense Safety Oversight Council (DSOC) was formed to provide governance on Department of Defense (DoD)-wide efforts to reduce preventable injuries and mishaps. The Under Secretary of Defense for Personnel and Readiness chairs the DSOC, who chartered nine task forces to develop recommendations for policies, programs, and other investments to reduce preventable injuries and accidents. The Military Training Task Force (MTTF) was chartered to support the SECDEF's accident and injury prevention directive with a focus on interventions that relate to all aspects of military training.

Injury is undisputedly the leading health and readiness threat to the armed forces. Injuries are the leading cause of service member hospitalizations and outpatient visits, many resulting in preventable discharges, and account for over 25 million limited duty days DoD-wide annually.2, 3, 4 Training-related injuries have been identified as the leading cause of clinic visits and have a substantial impact on the readiness of the force due to the amount of limited duty time they cause.5, 6 Most of the preventable acute and traumatic injuries sustained by military personnel are due to the cumulative effect of weight bearing physical training activities such as running, particularly for military basic trainees.7, 8, 9, 10, 11, 12, 13, 14, 15, 16 A working group of civilian and military injury experts from the Johns Hopkins Center for Injury Research and Policy and the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM) identified physical training as the largest and most severe health problem for the U.S. Army and the one with the greatest possibility for prevention success.17, 18

The Joint Services Physical Training Injury Prevention Working Group (JSPTIPWG, hereafter referred to as working group, except in the tables) was created under the Military Training Task Force in September 2004 to evaluate military physical training injury prevention programs, policies, and research for recommendations to reduce physical training–related injuries during and after initial military training within the four U.S. military services (army, navy, air force, and Marine Corps). An expedited systematic review process used by the working group served three primary purposes:

  • 1

    Establish the evidence base for making recommendations to prevent physical training–related injuries;

  • 2

    Prioritize the recommendations for prevention programs and policies; and

  • 3

    Substantiate the need for further research and evaluation of interventions and programs likely to reduce physical training–related injuries.

Section snippets

Evidence Acquisition

A working group was formed which included 29 military and civilian researchers, public health practitioners, clinicians, training officers, epidemiologists, and analysts representing the four U.S. military services and injury experts from the CDC as well as professors at academic institutions. The working group initially met twice by teleconference and discussed a strategy for accessing previous subject matter expert panel recommendations, determined how to systematically review the scientific

Evidence Synthesis

There were 40 physical training–related injury prevention strategies identified by the working group. Three were determined to be critical components of a successful injury prevention program and not independent injury prevention strategies: (1) education of military leaders; (2) leadership support; and (3) unit injury surveillance. The working group agreed to categorize them as “essential elements” of an injury prevention program. During the process of the face-to-face meeting, the working

Discussion

As the essential elements of an injury prevention program were not considered independent injury prevention strategies, they were not reviewed with the same scrutiny as the other strategies. The following discusses the rationale for selecting these four components as essential elements of an injury prevention program.

Conclusion

An expedited systematic process of evaluating common strategies enabled the Joint Physical Training Injury Prevention Working Group to build consensus around those injury prevention interventions that had good scientific evidence to recommend to all military services. The systematic, criteria-based process and adaptation of guidelines that required a standardized level of scientific evidence before making any recommendation was central to the formulation of evidence-based recommendations and

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