Defining the magnitude of the problem: U.S. military injury surveillanceMusculoskeletal Injuries: Description of an Under-Recognized Injury Problem Among Military Personnel
Introduction
Injuries are recognized as a leading health problem in the U.S.1, 2 In 2002, some 161,269 people died as the result of injuries (unintentional and intentional).3 Fatal unintentional injuries (n=106,742) constituted the 5th leading age-adjusted cause of death but were the leading cause for those aged between 1 and 45 years.3 Fatal intentional injuries from suicide and homicide ranked 11th and 14th, respectively.3 Each year, an estimated 1.5 million people with injuries are discharged from hospitals, representing the 2nd most common discharge diagnosis,2 and 30 million people are treated for injuries in hospital emergency departments, accounting for 30% of all emergency department visits.2, 4
Data for the military services similarly demonstrate the magnitude of the injury problem within the U.S. Department of Defense (DoD). In 2003, unintentional injury was the leading cause of death, representing 44% of fatalities among active duty military personnel.5 Combat injuries accounted for 22% of deaths, while intentional deaths from suicides and homicides accounted for an additional 16% of fatalities. In 2003, there were more hospitalizations for injury among active duty personnel (n=9605) than for any other diagnosis category except pregnancy-related conditions.6 In 2004, 555,393 injuries were treated in ambulatory clinics throughout DoD.5
Even though these data clearly demonstrate that injuries are a leading health problem, some civilian and military injury experts believe these data markedly underestimate the actual magnitude of the injury problem.7, 8, 9 Injury is typically defined as “bodily harm” resulting from acute exposure to external forces or substances (i.e., mechanical, thermal, electrical, chemical, or radiant) or from absence of such essentials as heat or oxygen caused by a specific event.4 Using this definition for nonfatal injuries, only acute traumatic injuries having relatively sudden discernible effects are included in injury reports.4, 10, 11 These injuries are classified in Chapter 17 (Injury and Poisoning) of the ICD-9-CM. However, many injuries that commonly occur in recreation, sports, and the workplace are not classified as traumatic injuries and, consequently, are not included in the injury estimates. Examples of common injuries not included are (1) meniscal tears and other internal derangements of the knee, (2) recurrent shoulder dislocations, (3) rotator cuff tendinitis and tears, (4) Achilles tendinitis, (5) stress fractures, and (6) injury-related cervical and lumbar strains (with or without neurologic involvement). These injuries are classified in Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue) of the ICD-9-CM.
The Barell Injury Diagnosis Matrix is often used in civilian and military injury surveillance to categorize traumatic injuries (Chapter 17, ICD-9-CM).12, 13 By categorizing injuries by their type and body region, the matrix allows injury experts to recognize the degree to which specific injuries contribute to the overall injury problem and identify focus areas for prevention. Adding to its utility, the matrix allows comparison of injuries over time and between different populations. However, since the matrix includes acute traumatic injuries, but not injury-related musculoskeletal conditions, it under-represents the magnitude of the injury problem.
Injury experts in sports and occupational medicine have developed expanded injury definitions that encompass the full array of injuries common in these fields. In addition to the traumatic injuries represented in the Barell Matrix, these definitions include a subset of musculoskeletal conditions (Chapter 13, ICD-9-CM) that is injury-related in the population of interest.14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 To reinforce the importance of these injury-related musculoskeletal conditions in sports, inclusion of these injuries has become standard in many well-accepted sports-injury surveillance systems, including those maintained by the National Collegiate Athletic Association (NCAA) and international governing bodies for many sports, including soccer and rugby.28, 29, 30, 31, 32
Although acute trauma may be a factor in some cases, many of the injury-related musculoskeletal conditions result from the cumulative effects of smaller amplitude (micro-traumatic) forces. These forces occur with overtraining, overexertion, repetitive movements and activities, forceful actions, vibratory forces, extreme joint positions, and prolonged static positioning.15, 16, 17, 18, 19, 21, 33, 34, 35, 36, 37, 38, 39, 40 These forces, and the injuries they cause, are common in many types of physical activity (i.e., leisure activities, exercise, recreation, and sports)26, 27, 33, 35, 41, 42, 43, 44, 45 and in many occupational settings, including the military.36, 37, 38, 39, 46, 47, 48, 49, 50, 51, 52, 53
During 2001 and 2002, three groups within DoD worked independently to develop a comprehensive list of injury-related diagnosis codes that could be used for injury surveillance in the military services. These groups were the (1) Army Medical Surveillance Activity, (2) DoD Military Injury Metrics Working Group, and (3) Injury Prevention Program, U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM). The groups realized the importance of expanding the injury case definition that included only traumatic injuries to also include the subset of musculoskeletal conditions that are typically injury-related in the military population. The combined efforts and products of these groups contributed to DoD's acceptance of a broader injury definition that includes both types of injury for surveillance, analysis, and reporting.54, 55
The purpose of this analysis was to (1) describe the process used by USACHPPM to select a standardized set of injury-related musculoskeletal conditions to be used for injury surveillance, (2) describe the development of a matrix to classify injury-related musculoskeletal conditions by injury type and body region, (3) report the musculoskeletal injury incidence and rate among the combined military services (DoD) for calendar year (CY) 2006, and (4) present the DoD musculoskeletal injuries for 2006 using the matrix.
Section snippets
Methods
A team of injury epidemiologists, physicians, and physical therapists at USACHPPM identified the subset of musculoskeletal conditions (Chapter 13, ICD-9-CM) that would be included when describing the burden of injury in the predominantly young and physically active military population. The team reviewed data from (1) established army surveillance systems, (2) field investigations, (3) extensive medical record reviews (more than 8000 medical records), and (4) peer-reviewed scientific literature.
Results
Overall, there were 743,547 injury-related musculoskeletal conditions (injuries) in 2006 among active duty, nondeployed service members (Air Force, Army, Marines, and Navy), including primary and secondary diagnoses from medical encounters. The injury rate was 628 injuries per 1000 person-years.
The injury-related musculoskeletal matrix provides frequencies of these injuries categorized by injury type and body region. Table 2 is the simplified matrix in which body region subcategories were
Discussion
This paper offers the first description and implementation of a matrix to categorize injury-related musculoskeletal conditions by injury type and body region. The injuries included in the matrix are the subset of musculoskeletal conditions from Chapter 13, ICD-9-CM, that are injury-related for active duty military personnel. Similar to the Barell Injury Diagnosis Matrix, this matrix allows injury experts to recognize the degree to which injury-related musculoskeletal conditions, categorized by
Conclusion
In 2006, there were 743,547 injuries (including primary and nonprimary diagnoses) among nondeployed military services members that involved injury-related musculoskeletal conditions selected from Chapter 13, ICD-9-CM (rate: 628 injuries per 1000 person-years). To recognize the full extent of the active duty DoD injury problem, however, this injury incidence must be added to the traumatic injury (Chapter 17, ICD-9-CM) incidence. Combined, the overall injury incidence would be almost 1.6 million
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