Page 107 - Journal of Special Operations Medicine - Summer 2016

training base between training sessions, 9,20 and this po- course of training and to achieving a conditioning benefit
tentially involved a notable increase to lower limb skel- from the physical loads imposed by the broader training
etal loading. Over the Australian Army Recruit Training program without reaching the point of overload. For this
course, an 11.5-week course, walking around 7.5km process to be effective, however, the staff responsible for
per day would equate to 600km of walking embedded developing the physical training program must clearly
into the trainee program—a cumulative musculoskeletal be aware of what training is taking place over a given
load that excludes any formal physical training. On the day and across the training period. Even once the pro-
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US Army Basic Combat Training course, over the then gram is established this consultation is important since
9-week training period, the total distance moved on foot the operational training for the day may change (e.g.,
was 699 to 806km, and the longer distances were as- due to weather, unavailability of a training site, etc.). As
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sociated with higher injury rates. Trainers should only such, the physical training staff will need to be advised or
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gradually increase the amount of traversing on foot, consulted to avoid cumulative overload for the day and
while considering carefully the physical capabilities, adjust future physical training sessions. If the physical
previous exercise experience and previous foot march- training staff members are the same as the staff members
ing loading of their trainees (i.e., where they are in their providing operational training (as in some basic training
training continuum). contexts), the cadre needs to be aware of the day’s re-
quirement and make appropriate adjustments themselves.
Mitigating PICO
Musculoskeletal Injury Prevention Strategies
Two strategic approaches to mitigate PICO are (1) fo- Excessive musculoskeletal load has been identified as
cusing on administration and logistic practices and (2) a leading cause of increased risk of injury in military
optimizing and employing musculoskeletal injury pre- training populations. 16,18,19,22,23 Research investigating
vention strategies. risk factors for injury in military training programs has
identified several notable individual traits, including low
Administration and Logistic Practices aerobic fitness, low muscular endurance, low levels of
As noted, one potential cause of PICO is the segregation prior physical activity, cigarette smoking, and high and
of physical training from the remainder of the overall low extremes of flexibility. 24–26 While these findings are
training program, during both initial course planning vital to inform trainee physical training and health edu-
and ongoing daily adjustments. When course training cation programs, it should be noted that these explain
programs are developed, physical training may typically only a relatively small proportion of individual differ-
be a time period noted as “Physical Training” on the ences in injury occurrences and there are additional stra-
training schedule every day or on many days, without tegic findings that should be considered as part of the
any understanding of what this physical training will overarching training program’s risk management. The
entail. Staff responsible for generating the physical most prevalent of these other factors are increased levels
training program would then do so using the given time of physical activity and increased running mileage,
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periods allocated within the broader training program while other known factors like lack of sleep and mus-
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and considering the desired outcomes of the physical cle fatigue also bear consideration. When developing
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training program—typically better physical condition- or reviewing the overarching training program, trainers
ing and the passing of a physical fitness assessment. As could consider the amount of movement on foot that
such, the physical training program, which may be well occurs when performing scheduled physical training
periodized in itself or follow a mandated preconceived and operational training and when moving around the
format, would not take into account other operational area (e.g., from the barracks to the mess hall). The in-
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training events that might stress specific anatomical lo- clusion of load carriage when moving around the area
cations and muscle groups on the same or surrounding could form the basis of a physical training session, while
days. As operational training activities would typically patrolling when moving around the area (e.g., from bar-
take priority, efforts are needed to develop the physi- racks to a lecture theater for a theory session) would
cal training program cognizant of these broader train- provide an opportunity to enhance operational skills.
ing stresses. Initially, the staff involved in planning and With this movement now being used more effectively,
conducting physical training should be fully integrated the additional time can be used for other activities, such
with the staff involved in planning and conducting op- as strength or recovery work during physical training.
erational training, or alternatively the same staff could However, the use of such approaches must be super-
develop both, so that the overarching training schedule vised by qualified trainers who ensure associated injury
minimizes cumulative or acute overload. risks are well managed. Conversely, logistic practices
could be considered to decrease musculoskeletal load-
Consideration should be given to minimizing musculo- ing, whereby vehicle transport is provided to traverse
skeletal stress on any particular day and over the entire the distance between operational training activities that

PICO (Program-Induced Cumulative Overload) 93