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The occurrance of pain in the knee as well as in the foot in the Swedish marine training

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    The occurrence of musculoskeletal pain in the knee as well as in the foot and how its affecting work ability. A prospective observational study in the Swedish marine training course.

     

     

    Background

     

    The definition of pain: "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"


    • International Association for the study of Pain, IASP.



    Pain and musculoskeletal disorders

    Musculoskeletal disorders means as the name insinuates disorders that are affecting the muscles or the bones. Musculoskeletal disorders are common reasons for pain and reduced work ability. AFA försäkring is a Swedish insurance company with 2,7 million Swedes connected to their health insurance. According to a survey made by AFA försäkring looking at their health insurance, musculoskeletal disorders are the most common reason for reduced work ability and reporting sick, both short-term and long-term. Most cases of musculoskeletal disorders involve disorders in the back followed by disorders affecting joints and soft tissues (AFA försäkring). In the whole Swedish population, mental illness is the most common reason for reporting sick for both men and women followed by musculoskeletal disorders (Försäkringskassan 2016).


    The military is no exception when it comes to facing musculoskeletal disorders (Jones et al. 1993; Kaufman, Brodine & Shaffer, 2000; Taanila et al. 2009; Hauret, Jones, Bullock, Canham-Chervak, Canada, 2010). A previous study of american marines found that 39,6% of the marines were injured during training and that foot/ankle and knee were the most common location. Most of these injuries were diagnosed as overuse injuries (Almeida, Williams, Shaffer, Brodine, 1999). Since the physical demands are high and musculoskeletal injuries are common and affect the operational readiness, focus needs to be put on these issues in the military (Kaufman, Brodine & Shaffer, 2000).
     

    Knee pain

    Attending the military and undergoing military training is both physically and mentally exhausting. It is very common to experience pain such as knee like ankle in connection with training in military education. The perceived pain in the lower limbs may come from the acute injuries, related to musculoskeletal lesions including inflammations, stress fractures and fractures. It is common to suffer from pain related to any form of overload associated with the training regardless of the training background, sex and age. It is understandable that participation in the military represents a significant load on the lower limbs and is classified as the most common injuries in military training. The rapid increase in exercise volume and intensity is included, among other things. marching, running and jumping in combination with shorter recovery time. The fact that the soldiers seek care for pain and injuries, that are not classified as life threatening, also makes this an economic issue in the military and thus an area of ​​interest (Kucera et al., 2017).                

    Risk factors have previously been considered and highlighted in studies aimed at preventing injuries and reducing the incidence of various lower limb damage. Some of the risk factors that are important are the person's training background, high BMI (but also a low BMI) and the person in question has a shorter body length. This study highlights common knee injuries and pain in young men during physically demanding military training. (Pihlajamäki, Parviainen, Kautiainen & Kiviranta, 2017).  

               

    Ankle pain

    It has also been proven to be common with ankle injuries and pain in connection with military education and training. Common injuries are in addition to stress fractures also achilles tendinopathy and plantar fasciit. The economic part mentioned earlier, that studies have previously highlighted the economic side of the pain experience of the soldiers. It appears that it is important to highlight this area as rehabilitation or recovery is experienced both physically and mentally stressful by the person in question (Franklyn-Miller, Wilson, Bilzon, PhD & McCrory, 2011).


    How the foot and arch of the foot looks like is another risk factor that is highlighted in studies. A high footvalue (pes cavus) or a low pelvic plane (pes planus) seems to be important for possible knee pain as well as foot pain (Psaila & Ranson, 2016). 
     

    Swedish marines

    The Swedish Armed Forces’ Amphibious Battalion is, together with the Naval Flotillas, the Submarine Flotilla and the Marine base, a part of the Swedish marine (Försvarsmakten, verksamhetsområde, marinen).

    329 professional officers, 513 group commanders/soldiers/sailors and 37 civilians are on permanent employment at the Amphibious Regiment, Amf 1, located in Berga. The main task for the marines is to protect and work along the coastlines, where water meets land, both in Sweden and abroad. This requires skills operating in and above water, on land and in the air which puts high demands on the soldiers’ flexibility (Försvarsmakten, organisation amfibieregementet). The marines are able to move fast and of high endurance. Fast-moving battle boats and modern weapons are often used (Försvarsmakten. Organisation, andra amfibiebataljonen).

    To become a marine you first need to meet the marine requirements at the military recruitment. If you are accepted as a marine recruit, you start with 3 month of basic military training (grundläggande militär utbildning, GMU) and then you proceed with the basic marine course (grundkurs amfibie, GK Amf) for about 20 weeks (Försvarsmakten 2016. Aktuellt, grundkurs amfibie).

    The GMU consists of seven parts where the recruits for example are learning about the military environment, the equipment, how to shoot and handle vapons, combat training, to work in a group, to protect and defend objects etc. Most of the training are carried out in field and some tasks are high demanding physically and mentally. In the end of the course the recruit should have learned the things listed above and have insights on own limits and been working out a personal plan together with a careers officer (Försvarsmakten, utbildning, grundutbildning).

    The GK Amf is mostly focused on physical training and combat training and the demands are high both physically and mentally. (Note that the training course to become a marine has changed since the autumn 2016, and it is now called grundutbildning ny) (Försvarsmakten 2016. Aktuellt grundkurs amfibie).


    Musculoskeletal pain in Swedish marines

    In previous work by Monnier et al. 2015, 49,6 % of the marines working in the Swedish Armed Forces reported having musculoskeletal pain limiting work ability during the last 6 months. 17,9 % of the marines reported having knee pain limiting work ability making the knee the second most common location (after back pain) for pain in Swedish marines. 13,3 % of the marines reported having pain in the foot limiting work ability. These study results are based on a retrospective questionnaire about pain during the last 6 months recalled by the marines (Monnier, Larsson, Djupsjöbacka, Brodin, Äng, 2015). The ability to recall has been studied when it comes to elite military personnel and musculoskeletal disorders, and recall are generally low and seem to go down with time for less severe injuries (Lovalekar et al., 2017).


    The previous Swedish studies of marines have mainly focused on employed marines. But data have also been collected during the marine training course (grundkurs amfibie, GK Amf) with analysis’ describing the occurrence of musculoskeletal pain in the back and neck/shoulder (Monnier, Larsson, Nero, Djupsjöbacka, Äng, manuscript; Gottvall & von Stedingk, 2017)



    Aim

    To survey the occurrence of musculoskeletal pain in the knee and foot areas affecting work ability in the Swedish marine training course.   


    Research questions


    • What is the prevalence of knee and foot pain respectively, limiting work ability during the marine training course?


    • What is the incidence ratio measured in person-weeks of knee and foot pain respectively in the marine training course?

     

    • How long is the duration of the pain episodes in the knee respectively the foot in the marine training course?


    • What is the prevalence of both knee and foot pain limiting work ability during the marine training course?
       

    Design

    Quantitative study. Prospective observational study.


    Outcome measure

    Knee and foot pain affecting work ability. (Since pain is a complex matter influenced strongly by individual factors, we have chosen to concentrate on pain affecting work ability in our study).


    Data collection

    Data for this study was previously collected for another study between january and may 2015 during the 4-month marine training course. Data was collected by weekly self-assessment questionnaires. The participants also filled out a questionnaire with background information at baseline.


    Population

    The marine recruits in the marine training course vinter/spring 2015 at the Amphibious battalion in Berga, Sweden. 
     

    References


    Almeida SA, Williams KM, Shaffer RA, Brodine SK. 1999. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999 Aug;31(8):1176-82.


    AFA försäkring. Besvär i rörelseapparaten. Cited 2018-10-15. Available from: https://www.afaforsakring.se/globalassets/forebyggande/analys-och-statistik/arbetsskaderapporten/ovriga-rapporter-om-arbetsskador-och-sjukfranvaro/f6345-rorelseapparaten.pdf


    Franklin-Miller A, Wilson C, Bilzon J, McCrory P. 2011. Foot Orthoses in the Prevention of Injury in Initial Military Training. A Randomized Controlled Trial. The American Journal of Sports Medicine. doi: 10.1177 / 0363546510382852


    Försvarsmakten 2016. Aktuellt. Grundkurs amfibie. Cited 2018-10-12. Available from: https://www.forsvarsmakten.se/sv/aktuellt/2016/02/grundkurs-amfibie-grunden-till-amfibiesoldat/


    Försvarsmakten. Organisation. Andra amfibiebataljonen. Cited 2018-10-12. Available from: https://www.forsvarsmakten.se/sv/organisation/amfibieregementet/krigsforband/andra-amfibiebataljonen/


    Försvarsmakten. Organisation. Amfibieregementet. Cited 2018-10-12. Available from: https://www.forsvarsmakten.se/sv/organisation/amfibieregementet/om-amfibieregementet/


    Försvarsmakten. Utbildning. Grundutbildning. Cited 2018-10-12. Available from:  https://jobb.forsvarsmakten.se/sv/utbildning/grundutbildning/under-utbildningen/


    Försvarsmakten. Verksamhetsområde marinen. Cited 2018-10-12. Available from: https://www.forsvarsmakten.se/sv/var-verksamhet/verksamhetsomraden/marinen/


    Försäkringskassan. 2016. Sjukfrånvarons utveckling 2016. Socialförsäkringsrapport 2016:7. Cited 2018-10-15. Avalible from:https://www.forsakringskassan.se/wps/wcm/connect/a2001891-5c47-4b8a-b47b-64dfbbd48555/socialforsakringsrapport_2016_07.pdf?MOD=AJPERES


    Gottvall M och von Stedingk S. 2017. Neck/shoulder pain limiting work ability in Swedish armed forces marines during the marine training course. Bachelor thesis in physiotherapy. Karolinska institutet.


    Hauret KG, Jones BH, Bullock SH, Canham-Chervak M, Canada S. 2010. Musculoskeletal injuries description of an under-recognized injury problem among military personnel. Am J Prev Med. 2010 Jan;38(1 Suppl):S61-70. doi: 10.1016/j.amepre.2009.10.021


    Jones BH, Cowan DN, Tomlinson JP, Robinson JR, Polly DW, Frykman PN. 1993. Epidemiology of injuries associated with physical training among young men in the army. Med Sci Sports Exerc. 1993 Feb;25(2):197-203


    Kaufman KR, Brodine S, Shaffer R. 2000. Military training-related injuries: surveillance, research, and prevention. Am J Prev Med. 2000 Apr;18(3 Suppl):54-63


    Kucera K, Marshall S, Wolf S, Padua D, Cameron K, Beutler A. 2016. Association of Injury History and Incident Injury in Cadet Basic Military Training. With Sci Sports Exerc. June; 48 (6): 1053-1061.


    Lovalekar M, Abt JP, Sell TC, Lephart SM, Pletcher E, Beals K. 2017. Accuracy of recall of musculoskeletal injuries in elite military personnel: a crossectional study. BMJ Open. 2017;7:e017434. Doi:10.1136/bmjopen-2017-017434


    Monnier A, Larsson H, Djupsjöbacka M, Brodin LÅ, Äng BO. 2015. Musculoskeletal pain and limitations in work ability in Swedish marines: a cross-sectional survey of prevalence and associated factors. BMJ Open. 2015 Oct 6;5(10):e007943. doi: 10.1136/bmjopen-2015-007943.


    Monnier A, Larsson H, Nero H, Djupsjöbacka M, Äng BO. Low back pain in the marine training course: A study of incidence, risk factors and occupational physical activity. Manuscript included in Anderas Monnier’s thesis for doctoral degree (2016) Musculoskeletal disorders in the swedish armed forces marines: Back pain epidemiology and clinical tests. Karolinska institutet.


    Pihlajamäki H, Parviainen M, Kautiainen H, Kiviranta I. 2017. Incidence and risk factors of exercise-related knee disorders in young adult men. doi: 10.1186 / s12891-017-1701-3


    Psaila M, Ranson C. 2017. Risk factors for lower leg, ankle and foot injuries during basic military training in the Maltese Armed Forces. Physical therapy in sport.


    Taanila H, Suni J, Pihlajamäki H, Mattila VM, Ohrankämmen O, Vuorinen P, Parkkari J. 2009. Musculoskeletal disorders in physically active conscripts: a one-year follow-up study in the Finnish Defence Forces. BMC Musculoskelet Disord. 2009 Jul 22;10:89. doi: 10.1186/1471-2474-10-89

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