Page 101 - JSOM Winter 2017

provided positive effects on injury reduction 25,26 (in particular or cost-effective; therefore, the focus needs to shift to global
on lower extremity stress fractures), but MSK-I problems were prevention. To facilitate this culture shift across SOF and
not effectively solved. In 2017, injury rates in basic training throughout the services, global prevention efforts to reduce
remain high. the negative stigma surrounding MSK-I and pain, and encour-
age early care to combat the cumulative chronic effects of
Importantly, MSK-I prevention efforts in basic training have MSK-I and pain (Figure 3) can go a long way. Also, embracing
not served as a springboard to expand and integrate efforts the paradigm shift toward MSK-I prevention and HPO as part
into secondary training or during regular active duty. Few ini- of everyday life can assist in keeping all Servicemembers in the
tiatives have documented ways to address MSK-I prevention green and purple zones of the HPO spectrum (Figure 3).
in secondary or advanced training, and studies conducted on
deploying Servicemembers have identified largely nonmodifi- Figure 3 The Human Performance Optimization Spectrum.
able risk factors as the greatest contributor to MSK-I. Our
27
team recently conducted a large-scale study of US Military ap-
plicants entering basic training. We found that 21% of male
and 15% of female applicants entered service with a self-
reported injury history. Our work with deploying Marines
28
showed that 60% of deploying Marines self-reported a history
of MSK-I. There remains a need to identify an optimal inter-
29
vention point for primary and secondary MSK-I prevention.
This has shifted our team’s focus to secondary training, with
a 5-year follow-up to track traditional MSK-I risk factors and
both self-reported and medically documented MSK-Is. The re-
sult will be establishing a longitudinal path for the burden of
MSK-I through the early stages of the life cycle. Collecting
data on self-reported injury in populations that do not seek
medical attention (to prevent being removed from duty) can
provide further context to fully decipher other factors that
contribute to the MSK-I problem and help design programs To do so, personnel at all levels need to be engaged in the
to prevent them. process of MSK-I prevention and HPO program implemen-
tation, with continual evaluations on their Reach, Effective-
Although we lack a full understanding of pre-existing MSK- ness, Adoption, Implementation, and Maintenance (RE-AIM;
Is for entry-level training through to SOF, SOF communities Figure 4); adjustments can and should be made where neces-
have many resources to address their needs. SOCOM’s Pres- sary. The RE-AIM framework provides a platform for levels
ervation of the Force and Family has various service-specific of engagement, with each having its own drivers and barriers
programs addressing the issues of MSK-I and HPO. These in- for MSK-I prevention and HPO. Successful MSK-I prevention
clude the Army’s Ranger Athlete Warrior, the Tactical Human programs implemented en masse 30–32 are principally driven
Optimization, Rapid Rehabilitation and Reconditioning, and by compliance and adherence, 33–36 for which the drivers and
other such programs, which provide sizeable resources and barriers are numerous. 13,36 Through RE-AIM, engaging with
education to SOF. They show promise for reducing the MSK-I leadership, instructors, sports medicine staff, providers, and
burden, but the state in which a SOF arrives may compromise the users (i.e., SOF, athlete, Servicemember) to identify barri-
these efforts far down the injury prevention stream and the ers and drivers to MSK-I prevention and HPO efforts up front
injuries will persist until objective performance metrics are es- should help ensure an effective program design, thereby im-
tablished that show where on the continuum the optimal SOF proving adherence and compliance, as well as global diffusion
is from a human performance perspective. Also, objective re- and uptake.
turn to duty and full-fitness metrics after injury are needed to
ensure recovery before deploying with an underlying MSK-I. Figure 4 The Reach, Effectiveness, Adoption, Implementation, and
Without operationally based metrics, disparate decisions are Maintenance (RE-AIM) framework.
made and individual medical providers are required to deter-
mine whether a SOF is fit for duty. A systematic and systemic
approach, with continuity and integration of MSK-I preven-
tion could do wonders for human performance and reduction
of MSK-I. Focusing efforts “left of the bang” and creating a
consistent implementation structure for HPO would address
the more short-term issues of secondary and tertiary MSK-
I prevention. Concurrently, key stakeholders would benefit
from collaborating on developing the metrics needed to estab-
lish a threshold for the optimal SOF and fit-for-duty standards
after MSK-I.

Global Prevention: Creating a Culture Shift and
Improving MSK-I Prevention and HPO
HP, human performance; MSK-IP, musculoskeletal injury preven-
Efforts to individualize preventive care have not yet produced tion; RE-AIM, Reach, Effectiveness, Adoption, Implementation, and
the desired effects, nor have they necessarily been time and/ Maintenance.

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