THESIS PROGRESS REPORT Prevention and Control of Musculoskeletal Injuries associated with physical related activities and training among soldiers of Maldives National Defense Force THESIS PROGRESS REPORT 05-09-2017 IKRAM HAMEED G5638081

PREVIEW I – Objectives II – Overview of Study 1 III – Study 2 Introduction Objective

General objective to describe and analyses the influence of preventive intervention on, musculoskeletal injuries associated with physical activities from military service compared to earlier years and to conduct and propose a comprehensive intervention exercises and programme for Maldives National Defense Force.

Specific objectives To evaluate and determine the incidence of musculoskeletal injury associated with basic fitness test in the military services in Maldives National Defense Force

Specific objectives To analyze the literature on the incidence of musculoskeletal injury in military and to review the current knowledge on the possibilities for preventing knee injuries and the effectiveness of prevention programmes

Specific objectives To conduct an experimental study in order to analyze the influence on musculoskeletal injuries associated with the proposed comprehensive intervention exercises and programme for Maldives National Defense Force.

CLARIFICATION of under- recognized musculoskeletal injuries WITH BASIC fitness test in Maldives national defense force - STUDY 1

Purpose To evaluate and determine the occurrence of musculoskeletal injury with basic fitness test in Maldives National Defense Force.

Incidence of knee injuries in the military and the effectiveness of prevention programmes: A systemic review STUDY 2

introduction Knee injuries are the predominant cause of Musculoskeletal injuries of lower extremities and the leading cause of loss of manpower in defense force

Military soldiers from different armed forces around the world participate in physical activities other than military physical trainings such as sports for personal interests, relaxation, health and fitness training

Classification of injury prevention research 1. Establishing the extent of the military injury problem - Incidence - Severity 2. Establishing the aetiology and mechanism of military injury 3. Introducing a preventive measure 4. Evaluating the effectiveness of a preventive measures The Classification of injury prevention research has been described by Van Mechelen et al. as model of four different steps

the extent of the military injury problem - Incidence - Severity Step 1 1. Establishing the extent of the military injury problem - Incidence - Severity Before initiating any prevention program for military injuries, especially knee injuries, the magnitude of the problem must be identified and the extent of the injury defined in terms of the incidence and severity

2. Establishing the aetiology and mechanism of military injury STEP 2 2. Establishing the aetiology and mechanism of military injury The second step of the sequence of injury prevention research is to establish the risk factors and mechanisms that play a role in the incidence of knee injuries in military activities.

3. Introducing a preventive measure STEP 3 3. Introducing a preventive measure Thirdly, measures that has the prospective to reduce the future risk or severity of knee injuries should be introduced. These measures should be based on information (aetiology and injury mechanisms) gathered in the second phase.

4. Evaluating the effectiveness of a preventive measures STEP 4 4. Evaluating the effectiveness of a preventive measures Finally, to assess the effectiveness of these preventive measures.

Purpose to analyze the literature on the incidence of musculoskeletal injury in military and to review the current knowledge on the possibilities for preventing knee injuries and the effectiveness of prevention programmes

Relevant studies were searched using the Data sources Relevant studies were searched using the PubMed database (1965 to June 2017) MEDLINE database (1966 to June 2017). Google scholar www.li.mahidol.ac.th

Additionally, relevant reviews were searched and assessed from reference lists and retrieved articles for possible information on trials of interest. Keywords in this search were “military injuries”, “musculoskeletal injuries”, “knee injuries”, “incidence”, “risk factors”, “prevention”, “preventive”, and “physical training”. All these terms were combined with each other in different ways.

Incidence and characteristics Several investigation has studied the incidence causes and risk factors of knee injuries in male soldiers; However, epidemiological data on knee injuries in female soldiers were still limited

Articles not written in English were excluded Articles not available in the library in Mahidol University were requested from other sources.

What did the Literature tell us about injuries in 2013-2015

Breakdown of knee injuries

Ways of preventing injuries in military Most of the programme includes Warmup and cooldown with special emphasis on stretching Adequate rehabilitation and time for recovery from an injury

Improvement in fitness with special emphasis on proprioceptive training Protective equipment Excellent training ground / area

Other programmes add further items on this list Screening prior to the training Nutrition and hydration Improved technique and better injury recording

Studies on Preventing Military injuries Author / year /country Type of unit n Intervention Result Pope, Rodney P./ 1999/ Australia (50) Army 143 female recruits Reduced foot marching speed from 7.5 to 5km/h Allowed women to march on their own steps length rather than marching in step Encouraged marching and running in more widely spaced formation to aid in obstacle awareness Conducted running on grass in preference to roads wherever possible Substitute interval running for longer distance runs where possible Incidence of pelvic stress fractures reduced from 11.2% pre-intervention to 0.6% post- intervention.  

Stopped running in formation Rudzki, Stephan J / 1999/ Australia (51) Army 318 females 1634 Males Stopped running in formation Introduce interval training of 400 and 800 meter on grassy surface Reduced distance on the running test from 5 to 2.4km Standardized foot marched to include control of march speed, progressive load increments and a prohibition on running Ran in water as a cross training technique Compared to the pre-intervention cohort, injury rates post- intervention decreased 46% for men and 35% for women Medical discharges decreased 41% among men but unexpectedly rose 58% for women

Run less mileage than control group Knapik et al, 2004, USA (52) Army 518 men 416 women Wide variety of exercises such as calisthenics, movement and climbing drills, interval training and distance running compared to usual basic combat training physical training program consisting of long distance running, stretching, calisthenics, sit-ups and pushups practice Run less mileage than control group Highly prescriptive program with enforced progressive overload Experimental group men and women were respectively lower risk of overuse injuries than experimental group Overall Advanced physical fitness test pass rate higher for experimental group

What we learned from the review Multi model intervention programme may result in injuries in general However, more well designed studies were required to evaluate the effect of specific preventive intervention

Proprioceptive and / or coordination trainings seems to prevent severe knee injuries in military service

Prevention programmes probably have different effects in male and female soldiers

Further studies should monitor compliance of soldiers with the programme because this was found to be an essential factor for its effectiveness

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