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without adequate recovery, performance will decline, and the review and recommended revisions for each section of this re-
body will show signs of increased wear and tear, known as NFO. view. RS provided extensive re-organization of the Introduc-
NFO can result in harmful psychological and hormonal disrup- tion section of this review.
tions and decreased performance, leading to OTS. NFO com-
monly occurs in SOs when mission demands exceed recovery, References
during both training and deployments, and can persist even after 1. O’Hara R, Henry A, Serres J, Russell D, Locke R. Operational
returning to the home station. If NFO continues over more ex- stressors on physical performance in Special Operators and counter-
measures to improve performance: a review of the literature. J Spec
tended periods, OTS will develop. OTS can lead to a chronic con- Oper Med. 2014;14(1):67–78.
dition in which performance and health decline further in SOs. 2. Linderman JK, O’Hara R, Ordway J. Effect of special operations
training on testosterone, lean body mass, and strength and the po-
We propose a theoretical continuum model, which describes in- tential for therapeutic testosterone replacement therapy: a review of
the literature. J Spec Oper Med. 2020;20(1):94–100.
cremental stages leading to increased risk of acute and chronic 3. Henning PC, Park B-S, Su Kim J-S. Physiological decrements during
decrements in physical, mental, neuroendocrine, and immu- sustained military operational stress. Mil Med. 2011;176(9):991–997.
nological systems. Further, we postulate that the biochemical 4. Nindl BC, Barnes BR, Alemany JA, Frykman PN, Shippee RL,
conditions for NFO/OTS arise from SO exposure to repeated Friedl KE. Physiological consequences of US Army Ranger training.
Med Sci Sports Exerc. 2007;39(8):1380–1387.
acute stressors, lack of adequate recovery time between stress 5. Maupin G. Epidemiologic Studies in Elite Warfighters: US Air
exposures, and SO perceptive/cognitive/emotional reaction to Force Battlefield Airmen, Army Rangers, and Navy SEALs.
these stressors. Finally, we found that continual overactivation Wright-Patterson AFB, OH: Air Force Research Laboratory, US Air
of the homeostatic adaptive pathways will likely limit the abil- Force School of Aerospace Medicine. Technical Report AFRL-SA-
WP-TP-2012-0001. December 2010. https://apps.dtic.mil/sti/pdfs/
ity of SOs to extend their homeostatic range, ultimately lead- ADA562061.pdf. Accessed 20 December 2021.
ing to compressed adaptive spectra, manifesting into chronic 6. Vrijkotte S, Roelands B, Pattyn N, et al. The overtraining syndrome
low-grade stress. in soldiers: insights from the sports domain. Mil Med. 2019;184
(5–6):e192–e200.
7. Conkright WR, Barringer ND, Lescure PB, Feeney KA, Smith MA,
Our findings illustrate the importance for health practitioners Nindl BC. Differential recovery rates of fitness following US Army
to consider the biological uniqueness of individuals. Thus, a Ranger training. J Sci Med Sport. 2020;23(5): 529–534.
recommended first step for investigating NFO/OTS in elite 8. Farina EK, Taylor JC, Means GE, et al. Effects of combat deployment
populations would be to avoid the usual population-based ap- on anthropometrics and physiological status of US Army Special
Operations Forces soldiers. Mil Med. 2017;182(3):e1659–e1668.
proach. Recovery monitoring should begin in the early phases 9. Freuh C, Madan A, Fowler JC, et al. “Operator syndrome”: a
of the initial training of a SO. The baseline measures obtained unique constellation of medical and behavioral healthcare needs of
during the initial training phase should be used as a compar- military special operations forces. Int J Psychiatry Med. 2020;55(4):
281–295.
ator throughout an Operator’s career to detect early signs of 10. McEwen BS. Allostasis and allostatic load: implications for neu-
NFO/OTS. Establishing standardized testing combined with ropsychopharmacology. Neuropsychopharmacology. 2000;22(2):
structured data aggregation in the SO community is also es- 108–124.
sential. Finally, our findings illustrate the importance of im- 11. Guidi J, Lucente M, Sonino N, Fava GA. Allostatic load and its im-
plementing MDRT as well as effective recovery strategies and pact on health: a systematic review. Psychother Psychosom. 2021;
90(1):11–27.
technologies for SOs to reduce their attrition rates, enhance 12. White RL, Cohen SP. Return-to-duty rates among coalition forces
their readiness, and prevent the chronic overuse injuries so of- treated in a forward- deployed pain treatment center: a prospective
ten reported in this community. observational study. Anesthesiology. 2007;107(6):1003–1008.
13. McEwen BS, Stellar E. Stress and the individual: mechanisms lead-
ing to disease. Arch Intern Med. 1993;153(18):2093–2101.
Disclaimer 14. Chapelle W, Thompson W, Ouenpraseuth S, et al. Pre-Training
The view(s) expressed herein are those of the author(s) and Cognitive and Non- Cognitive Psychological Predictors of US Air
do not reflect the official policy or position of the Henry M. Force Pararescue Training Outcomes. Wright-Patterson AFB, OH:
Air Force Research Laboratory, US Air Force School of Aerospace
Jackson Foundation for the Advancement of Military Medi- Medicine. Technical Report AFRL-SA-WP-TR-2018-0016. July
cine Inc., Brooke Army Medical Center, the US Army Medical 2018. https://apps.dtic.mil/sti/pdfs/AD1061533.pdf.
Department, the US Army Office of the Surgeon General, the 15. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scop-
Department of the Army, the Department of the Air Force, the ing reviews (PRISMA-ScR): checklist and explanation. Ann Intern
Med. 2018,169(7):467–473.
Department of Defense or the US Government. 16. Peters MD, Godfrey C, Mclnerney P, Munn Z, Tricco AC, Khalil
H. Scoping reviews. In: Aromataris E, Munn Z, eds. JBI Manual for
Financial Disclosure Evidence Synthesis. JBI, 2020. https://jbi-global-wiki.refined.site
/space/MANUAL. Accessed 15 October 2021.
The authors have no financial relationships relevant to this 17. Joanna Briggs Institute: Critical Appraisal Tools. https://jbi.global/
article to disclose. critical-appraisal-tools Accessed 15 October 2021.
18. Davies KJA. Adaptive homeostasis. Mol Aspects Med. 2016;49
(Suppl 1):1–7.
Acknowledgments
The authors would like to thank Mr. Michael Vernon (Center 19. Peters A, McEwen BS. Stress habituation, body shape and cardio-
vascular mortality. Neurosci Biobehav Rev. 2015;56:139–150.
for the Intrepid, Brooke Army Medical Center) for assisting 20. Smith SM, Vale WW. The role of the hypothalamic-pituitary-adre-
with the drawing and graphics of Figure 2 (Theoretical Model nal axis in neuroendocrine response to stress. Dialogues Clin Neu-
for Allostatic Imbalance Continuum). rosci. 2006;8(4):383–395.
21. Szabo S, Yoshida M, Filakovsky J, Juhasz G. “Stress” is 80 years
old: from Hans Selye original paper in 1936 to recent advances in
Author Contributions GI ulceration. Curr Pharma Des.2017;23(27):4029–4041.
RBO performed the first literature review search and tran- 22. Warha D, Webb T, Wells T. Illness and injury risk and healthcare
scribed the initial review draft. RBO and LS performed the utilization, United States Air Force battlefield airmen and security
forces, 2000–2005. Mil Med. 2009;174(9):892–898.
three-step search strategy and independently reviewed and ap- 23. Jensen AE, Arrington LJ, Turcotte LP, Kelly KR. Hormonal balance
praised articles. BK assisted in revising the introduction and and nutritional intake in elite tactical athletes. Steroids. 2019;152:
the psychological section of this review. JT provided critical 10854.

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