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Abstract Background A one-year prospective examination of injury rates and injury risk factors was conducted in Federal Bureau of Investigation (FBI) new agent training. Methods Injury incidents were obtained from medical records and injury compensation forms. Potential injury risk factors were acquired from a lifestyle questionnaire and existing data at the FBI Academy. Results A total of 426 men and 105 women participated in the project. Thirty-five percent of men and 42% of women experienced one or more injuries during training. The injury incidence rate was 2.5 and 3.2 injuries/1,000 person-days for men and women, respectively (risk ratio (women/men) = 1.3, 95% confidence interval = 0.9-1.7). The activities most commonly associated with injuries (% of total) were defensive tactics training (58%), physical fitness training (20%), physical fitness testing (5%), and firearms training (3%). Among the men, higher injury risk was associated with older age, slower 300-meter sprint time, slower 1.5-mile run time, lower total points on the physical fitness test (PFT), lower self-rated physical activity, lower frequency of aerobic exercise, a prior upper or lower limb injury, and prior foot or knee pain that limited activity. Among the women higher injury risk was associated with slower 300-meter sprint time, slower 1.5-mile run time, lower total points on the PFT, and prior back pain that limited activity. Conclusion The results of this investigation supported those of a previous retrospective investigation emphasizing that lower fitness and self-reported pain limiting activity were associated with higher injury risk among FBI new agents.

Abstract Background A retrospective examination was conducted of injuries, physical fitness, and their association among Federal Bureau of Investigation (FBI) new agent trainees. Methods Injuries and activities associated with injuries were obtained from a review of medical records in the medical clinic that served the new agents. A physical fitness test (PFT) was administered at Weeks 1, 7 and 14 of the 17-week new agent training course. The PFT consisted of push-ups, sit-ups, pull-ups, a 300-meter sprint, and a 1.5-mile run. Injury data were available from 2000 to 2008 and fitness data were available from 2004 to early 2009. Results During the survey period, 37% of men and 44% of women experienced one or more injuries during the new agent training course (risk ratio (women/men) = 1.18, 95% confidence interval = 1.07-1.31). The most common injury diagnoses were musculoskeletal pain (not otherwise specified) (27%), strains (11%), sprains (10%), contusions (9%), and abrasions/lacerations (9%). Activities associated with injury included defensive tactics training (48%), physical fitness training (26%), physical fitness testing (6%), and firearms training (6%). Over a 6-year period, there was little difference in performance of push-ups, sit-ups, pull-ups, or the 300-meter sprint; 1.5-mile run performance was higher in recent years. Among both men and women, higher injury incidence was associated with lower performance on any of the physical fitness measures. Conclusion This investigation documented injury diagnoses, activities associated with injury, and changes in physical fitness, and demonstrated that higher levels of physical fitness were associated with lower injury risk.

IntroductionUS Army Initial Entry Training (IET) aims to develop general fitness and conditioning among large groups of trainees. Despite group mean improvement in physical fitness during IET, some trainees experience substantial gains and others experience no improvement or even declines in fitness. The purpose of this study was to examine the associations between trainee baseline fitness (Army Physical Fitness Test (APFT), the primary fitness assessment at the time of data collection) or estimated baseline body fat (%BF) and the change in fitness by the end of IET., Methods: Trainee (n=774 men, 195 women) APFT performance data were obtained, and baseline anthropometrics were used to estimate %BF. APFT performance change (final-baseline) was analysed directly (t-tests) or by quartiles of baseline APFT performance or %BF (analysis of variance). Cochran-Armitage χ 2 for linear trend test and risk ratios allowed for comparison against the lowest initial performance referent quartile (Q1), providing the likelihood of fitness improvements. Significance was set at p≤0.05., Results: Performance improved (p<0.01) on all final APFT events for men and women, respectively (push-ups: +38.4% and +91.8% repetitions; sit-ups: +26.8% and +33.5% repetitions; 2-mile run: -9.6% and -10.4% time). Significant trends in both sexes indicated that moving from low-to-high initial APFT fitness quartiles, trainees were increasingly less likely to improve their fitness. Specifically, men and women in the highest initial fitness quartiles (Q4) were 22%-32% and 25%-34% less likely (p<0.01) to improve, respectively, versus the within-sex lowest initial fitness quartiles (Q1). Only the male trainee's 2-mile run time change was related to the initial %BF., Conclusions: Although most trainees' fitness improved by the end of IET, the likelihood and magnitude of improvement were clearly associated with initial fitness levels. Attention to individualised conditioning and training intensity in the physical readiness training programme of instruction may optimise training strategies across all trainee conditioning levels., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Low physical activity (PA) and physical fitness (PF) are well-known factors for chronic diseases generally and cardiovascular diseases specifically. The economic burden from these chronic diseases is also well documented, as is their disproportionate prevalence among states in the Southern region of the U.S. Low PA and PF have also become recognized factors impacting military readiness and national security. Specifically, low PA and PF are highly correlated with musculoskeletal injures (MSKIs), now considered the greatest medical impediment to military readiness. Prior research shows low PF and MSKI incidence are greater among Army recruits from Southern states, however no previous research has investigated the economic impact of MSKIs at the state- and regional-level. The aim of this study was to determine the economic impact of MSKIs among U.S. Army initial military trainees on a state- and regional-basis., Methods: Rosters for recruits entering U.S. Army Initial Military Training (IMT) for fiscal year 2017 were obtained (n = 103,487). Roster data included the unique personal identifier, demographics with postal zip code, training start/end dates, and height and weight and were subsequently linked to medical encounters and cost data from the Military Health System Data Repository. Trainees with one or more MSKIs were considered injury cases (n = 33,509) and were stratified by gender. The percent of trainee MSKI cases was calculated as number of injury cases divided by total number of trainees. For each injury case, the direct medical cost for MSKIs was calculated. The percent of trainees and direct medical costs for MSKIs were aggregated to home-state and regional-levels for the four U.S. Census tract regions. A test for equality of proportions was performed at state- and regional-levels to investigate differences in percent of trainees with MSKIs by state/region. A one-way ANOVA was used to investigate possible differences in medical cost/trainee by region., Results: 34% (n = 33,509) of all trainees sustained at least one MSKI. State-specific MSKI percentages showed ten states having the greatest percentage of trainees with at least one MSKI, eight of which were from the South region (AL, FL, GA, LA, MS, NC, SC, TN). The South was the only region to have a statistically significantly higher percentage of trainees with MSKIs at 34% (p < 0.001), as compared to all other regions. The total direct medical cost of treating MSKIs among all trainees was $14,891,563. The South was the costliest region ($7,168,997), accounted for nearly 50 % of the total national cost, and had the highest mean MSKI cost/trainee., Discussion: This study was the first in demonstrating the disproportionate economic burden Southern states pose to the U.S. Department of Defense resulting from its significantly higher MSKI cost. PA and PF are known to ameliorate chronic disease and MSKI burden among general and military populations. Therefore, increasing PA and PF among all young Americans, and specifically those living in Southern states, is imperative for improving public health and reducing the economic and practical burden of MSKIs on military readiness and national security., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The World Health Organization considers the optimal rate of delivery by Cesarean among healthy nulliparous women to be <15%. In 2020, the rate of primary Cesarean delivery (CD) in the US among nulliparous women with singleton, vertex pregnancies was 26%. An enhanced understanding of factors associated with women undergoing CD may assist in reducing this rate. One potential factor is the level of physical fitness in women before pregnancy. Active duty (AD) soldiers provide a cohort of women who begin pregnancy while actively pursuing physical fitness. The research team sought to assess the effects of pre-pregnancy physical fitness of AD soldiers as measured by the Army Physical Fitness Test (APFT) on the incidence of CD in AD women, in addition to examining known demographic and pregnancy risk factors in this cohort., Materials and Methods: We conducted a retrospective study of healthy AD nulliparous women who delivered their singleton pregnancy of >32 weeks at a tertiary medical center between 2011 and 2016. Soldiers undergoing non-labored CD were excluded. Demographics, pre-pregnancy APFT results, antepartum and labor and delivery data were collected from the Digital Training Management System, the outpatient, and inpatient medical records respectively. Weight gain in pregnancy was assessed using the Institute of Medicine Guidelines for pregnancy. Fisher's exact tests and chi-squared tests assessed associations between categorical outcomes, and unpaired t-tests assessed differences in APFT scores between women who underwent CD vs. vaginal delivery. Multivariable logistic regression analysis was used to assess for independent risk factors among all collected variables. The protocol was approved by the Regional Health Command-Pacific Institutional Review Board., Results: Five-hundred-and-twenty-three women delivering singleton pregnancies between 2011 and 2016 were reviewed for this study. Three-hundred ninety women met inclusion criteria: 316 in the vaginal delivery cohort, and 74 in the CD cohort, with a CD rate of 19%. Twenty non-labored CDs were excluded. Neither total APFT performance nor performance on the individual push-up, sit-up or run events in the 15 months prior to pregnancy was associated with mode of delivery. Excessive gestational weight gain (EWG) and neonatal birth weight were the only two factors independently associated with an increased rate of cesarean delivery. Women who had excessive gestational weight gain, were twice as likely to undergo CD as those who had adequate or insufficient weight gain (24% vs. 12%, p = 0.004). Soldiers delivering a neonate ≥4,000 g were 2.8 times as likely to undergo CD as those delivering a neonate <4,000 g (47% vs. 17%, p < 0.001). Age, race, and rank, a surrogate marker for socioeconomic status, were not associated with mode of delivery., Conclusion: Pre-pregnancy fitness levels as measured by the APFT among healthy physically active nulliparous AD women showed no association with the incidence of labored CD. EWG is one modifiable factor which potentially increases the risk for CD in this cohort and has been documented as a risk factor in a recent metanalysis (RR-1.3). Counseling on appropriate weight gain in pregnancy may be the most effective way to reduce the rate of CD among this population of healthy and physically active women., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: To provide an overall perspective on musculoskeletal injury (MSI) epidemiology, risk factors, and preventive strategies in military personnel., Design: Narrative review., Methods: The thematic session on MSIs in military personnel at the 5th International Congress on Soldiers' Physical Performance (ICSPP) included eight presentations on the descriptive epidemiology, risk factor identification, and prevention of MSIs in military personnel. Additional topics presented were bone anabolism, machine learning analysis, and the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on MSIs. This narrative review focuses on the thematic session topics and includes identification of gaps in existing literature, as well as areas for future study., Results: MSIs cause significant morbidity among military personnel. Physical training and occupational tasks are leading causes of MSI limited duty days (LDDs) for the U.S. Army. Recent studies have shown that MSIs are associated with the use of NSAIDs. Bone MSIs are very common in training; new imaging technology such as high resolution peripheral quantitative computed tomography allows visualization of bone microarchitecture and has been used to assess new bone formation during military training. Physical activity monitoring and machine learning have important applications in monitoring and informing evidence-based solutions to prevent MSIs., Conclusions: Despite many years of research, MSIs continue to have a high incidence among military personnel. Areas for future research include quantifying exposure when determining MSI risk; understanding associations between health-related components of physical fitness and MSI occurrence; and application of innovative imaging, physical activity monitoring and data analysis techniques for MSI prevention and return to duty., (Copyright © 2021 Sports Medicine Australia. All rights reserved.)

Objectives: To describe the etiologic distribution of all injuries among U.S. Army Active Duty soldiers by causal energy categories., Design: Retrospective cohort, descriptive analysis., Methods: Injury was defined as the interruption of tissue function caused by an external energy transfer (mechanical, thermal, radiant, nuclear, chemical, or electrical energy). A comprehensive injury matrix standardized categories by causal energies, body locations, and injury types. Categories differentiated acute (ACT) from cumulative micro-traumatic (CMT) overuse injuries, and musculoskeletal injuries (MSKI) from those affecting other or multiple body systems (non-MSKI). International Classification of Diseases (ICD) diagnoses codes were organized into established categories. The matrix was applied to electronic health records for U.S. Army soldiers in 2017., Results: Mechanical energy transfers caused most injuries (97%, n = 809,914): 76% were CMT overuse and the remaining were ACT (<21%). The majority (83%) were MSKI (71% CMT, 12% ACT). While almost one-half (47%) were to lower extremities (38% CMT, 9% ACT) the most frequently injured anatomical sites were the knee and lower back (16% each, primarily CMT)., Conclusions: For the first time all soldiers' injuries have been presented in the same context for consistent comparisons. Findings confirm the vast majority of injuries in this physically-active population are MSKI, and most are CMT MSKI. A very small portion are non-MSKI or injuries caused by non-mechanical energy (e.g., heat- or cold-weather). Most Army injuries are to the lower extremities as a grouped body region, but additional matrix specificity indicates the most injured anatomical locations are the knee, lower back, and shoulder., (Copyright © 2019. Published by Elsevier Ltd.)

Background: US Army initial entry training (IET) trainees engage in intense physical activities for 10 or more weeks prior to their assignment to operational units. Many trainees succumb to injury during IET. Injuries to the lower extremities and back have historically been the most common, and thus have been the focus of routine health surveillance., Objectives: The primary goal of this analysis was to verify the training-related injuries of greatest concern and to update the clinical diagnostic codes (ICD-10-CM) used in surveillance. The investigation also aimed to develop a sense of the financial magnitude of these injuries., Methods: The distribution of all IET injuries was determined using a comprehensive injury taxonomy. Injuries were categorized based on causal energy source (mechanical, thermal, radiant, nuclear, chemical, or electrical). Mechanical energy transfers included acute trauma and cumulative microtrauma ("overuse"). Injury ICD-10-CM codes were identified in calendar year 2016 IET trainees' electronic healthcare records. Injury frequencies were reported for gender, body region, and injury type. Costs were calculated from medical encounters and estimated lost training time using the most frequently injured anatomical site as a baseline., Results: Among 106,367 trainees, 65,026 separate injuries were identified. Mechanical energy transfers to lower extremities caused 75% of all injuries; most (65%) were cumulative microtraumatic. The most frequently injured anatomical site (the knee, 20% of injuries), is estimated to have cost over $39 million., Conclusions: Lower extremity injuries, followed by those of the low back continue to be leading "training-related injuries". This suggests the need to ensure distances and/or frequencies of weight-bearing activities (running, foot-marching) are not increased too rapidly or too excessively, and that trainees' fitness prior to IET is adequate. Medical costs and lost training time should be included in future monitoring.

Accidents are a leading cause of deaths in U.S. active duty personnel. Understanding accident deaths during wartime could facilitate future operational planning and inform risk prevention efforts. This study expands prior research, identifying health risk factors associated with U.S. Army accident deaths during the Afghanistan and Iraq war. Military records for 2004-2009 enlisted, active duty, Regular Army soldiers were analyzed using logistic regression modeling to identify mental health, injury, and polypharmacy (multiple narcotic and/or psychotropic medications) predictors of accident deaths for current, previously, and never deployed groups. Deployed soldiers with anxiety diagnoses showed higher risk for accident deaths. Over half had anxiety diagnoses prior to being deployed, suggesting anticipatory anxiety or symptom recurrence may contribute to high risk. For previously deployed soldiers, traumatic brain injury (TBI) indicated higher risk. Two-thirds of these soldiers had first TBI medical-encounter while non-deployed, but mild, combat-related TBIs may have been undetected during deployments. Post-Traumatic Stress Disorder (PTSD) predicted higher risk for never deployed soldiers, as did polypharmacy which may relate to reasons for deployment ineligibility. Health risk predictors for Army accident deaths are identified and potential practice and policy implications discussed. Further research could test for replicability and expand models to include unobserved factors or modifiable mechanisms related to high risk. PTSD predicted high risk among those never deployed, suggesting importance of identification, treatment, and prevention of non-combat traumatic events. Finally, risk predictors overlapped with those identified for suicides, suggesting effective intervention might reduce both types of deaths., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Accidents are one of the leading causes of death among U.S. active-duty Army soldiers. Evidence-based approaches to injury prevention could be strengthened by adding person-level characteristics (e.g., demographics) to risk models tested on diverse soldier samples studied over time., Purpose: To identify person-level risk indicators of accident deaths in Regular Army soldiers during a time frame of intense military operations, and to discriminate risk of not-line-of-duty from line-of-duty accident deaths., Methods: Administrative data acquired from multiple Army/Department of Defense sources for active duty Army soldiers during 2004-2009 were analyzed in 2013. Logistic regression modeling was used to identify person-level sociodemographic, service-related, occupational, and mental health predictors of accident deaths., Results: Delayed rank progression or demotion and being male, unmarried, in a combat arms specialty, and of low rank/service length increased odds of accident death for enlisted soldiers. Unique to officers was high risk associated with aviation specialties. Accident death risk decreased over time for currently deployed, enlisted soldiers and increased for those never deployed. Mental health diagnosis was associated with risk only for previous and never-deployed, enlisted soldiers. Models did not discriminate not-line-of-duty from line-of-duty accident deaths., Conclusions: Adding more refined person-level and situational risk indicators to current models could enhance understanding of accident death risk specific to soldier rank and deployment status. Stable predictors could help identify high risk of accident deaths in future cohorts of Regular Army soldiers., (Copyright © 2014 American Journal of Preventive Medicine. All rights reserved.)

The aim of this study was to document risk factors for any injury and sports- and exercise-related injuries, including personal and occupational stress among active duty service members (SMs) in the Air Force, Army, Marine Corps, and Navy. A total of 10,692 SMs completed the April 2008 Status of Forces Survey of Active Duty Members. The survey asked about demographics, personal stress and occupational stress, injuries from any cause, and participation in sports- and exercise- related activities in the past year. The survey used a complex sampling procedure to create a representative sample of SMs. Logistic regression was used to examine the associations of injury outcomes with potential risk factors. 49% of SMs sought medical care for an injury in the past year and 25% sustained a sports- and exercise-related activities injury. Odds of injury were higher for the Army and Marine Corps than for the Air Force or Navy. This survey showed that higher personal and occupational stress was associated with higher risks of injury. SMs who experienced higher levels of personal or occupational stress reported higher risks of injuries. The effects of stress reduction programs on injury risks should be evaluated in military and other young physically active populations., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Objectives: Previous literature suggests that injury rates during physical activity may be higher in the summer than in the fall or winter, possibly due to the greater amount or intensity of physical activity in the summer. This study examined seasonal differences in injury incidence during US Army Basic Combat Training, where physical activity was similar at all times of the year., Methods: Four independent groups of subjects (total n = 1543 men and 1025 women) were investigated, two training in the summer and two training in the fall. Injury data were obtained from a retrospective review of the subjects' medical records at the conclusion of the 8 week training program., Results: For men, the corrected relative risk of suffering an injury or a time loss injury in the summer was, respectively, 2.0 [95% confidence interval (CI) = 1.7-2.4] and 2.5 (95% CI = 1.9-3.0) times higher than in the fall. For women, the corrected relative risk of suffering an injury or time-loss injury in the summer was, respectively, 1.4 (95% CI = 1.3-1.6) and 1.7 (95% CI = 1.5-2.0) times higher than in the fall. These risks were essentially unchanged after adjustment for subject physical characteristics (age, stature, body mass, body mass index) and physical fitness (push-ups, sit-ups and 2 mile run), indicating that the summer season was an injury risk factor independent of these variables. Linear correlations (r-values) between maximal daily temperature and injury incidence ranged from 0.92 to 0.97, indicating a strong relationship between these two variables., Conclusions: These data suggest that injury incidence among physically active individuals is higher in the summer than in the fall and that environmental temperature may provide a partial explanation for this finding.