@SPTSTactical. ! MAJ Rich Westrick, PT, DPT, DSc, OCS, SCS. ! MAJ Sean Suttles, PT, DPT, OCS. ! Firefighter Jacob Morrow, PT, ECS, OCS

2/19/16 Tactical Athlete Special Interest Group Tactical Athletes: Physical Therapists Working with Firefighters, Law Enforcement & Military @SPTSA...
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2/19/16

Tactical Athlete Special Interest Group

Tactical Athletes: Physical Therapists Working with Firefighters, Law Enforcement & Military

@SPTSAPTA @SPTSTactical

Tactical Athlete Special Interest Group

#tacticalathletes

www.spts.org

Tactical Athlete Special Interest Group

Tactical Athlete Special Interest Group

@SPTSTactical

Introduction ! 

MAJ Rich Westrick, PT, DPT, DSc, OCS, SCS " 

SIG Chair: Rich Westrick

! 

Vice Chair: Chuck Rainey

! 

" 

" 

Sports Medicine Program Coordinator, St. Luke’s Health System, Boise, ID U.S Army Veteran

Tyler Christiansen, CSCS*D, USAW, RSCC " 

" 

@SPTSTactical

Beverly Hills Fire Department, Beverly Hills, CA U.S. Army Reserve Physical Therapist

Kyle Sela, PT, DPT, OCS, SCS, CSCS " 

! 

U.S. Army-Baylor DPT Program Internship Site Director, Darnall Army Medical Center, Fort Hood, TX

Firefighter Jacob Morrow, PT, ECS, OCS " 

! 

Deputy Chief, Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA

MAJ Sean Suttles, PT, DPT, OCS " 

www.spts.org Tactical Athlete Special Interest Group

@SPTSTactical

Director, Tactical Strength & Conditioning (TSAC) Program, NSCA, Colorado Springs, CO U.S. Army Veteran

Tactical Athlete Special Interest Group

@SPTSTactical

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Disclosures ! 

Kyle Sela "  " 

! 

Co-founder, Movement Guides, LLC & Inventor of “Squat Guide” Co-owner, Back-to-the-Box, LLC

1. 

Describe the incidence and prevalence of injuries in tactical athlete populations.

2. 

Understand the physical demands of tactical athletes – similarities and differences between “traditional” athletes.

3. 

Understand the impact of musculoskeletal conditions on lost duty time in the tactical athlete population.

4. 

Appreciate the unique rehabilitation considerations for firefighters, law enforcement, and military tactical athletes.

5. 

Understand the benefit of working relationships with TSAC professionals.

Tyler Christiansen " 

! 

Learning Objectives

National Strength & Conditioning Association (NSCA)

Jacob Morrow, MAJ Westrick, MAJ Suttles, " 

No relevant financial relationships

Tactical Athlete Special Interest Group

@SPTSTactical

Tactical Athlete Special Interest Group

Who is the “Tactical Athlete”?

“Tactical Athlete” ! 

Tactical Athlete Special Interest Group

@SPTSTactical

@SPTSTactical

Who is the “Tactical Athlete”?

Tactical Athlete Special Interest Group

@SPTSTactical

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“Tactical Athlete” ! 

“Tactical Athlete”

Who is the “Tactical Athlete”? ! 

! 

A professional in an occupation involving planning and maneuvering to accomplish a purpose; who, as with the professional athlete, is obligated to maintain a certain level of Operational Physical Fitness in order to fulfill that purpose, AND who must maintain that level of fitness as a term of employment. @SPTSTactical

Tactical Athlete Special Interest Group

Tactical Athlete Special Interest Group

“Tactical Athlete” ! 

Scofield & Kardouni, JSCR, 2015

@SPTSTactical

Tactical Athletes!

Scofield & Kardouni, JSCR, 2015

! 

Scofield & Kardouni, JSCR, 2015

•  General Physical Preparedness (GPP) & fitness requirements •  Technical and Tactical Skills (T/TS) •  Strenuous Physical & Mental requirements

Tactical Athlete Special Interest Group

@SPTSTactical

Tactical Athlete Special Interest Group

@SPTSTactical

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Tactical vs Traditional Athletes

Tactical vs Traditional Athletes ! 

Scofield & Kardouni, JSCR, 2015

?

Tactical Athlete Special Interest Group

@SPTSTactical

Why are “Tactical Athletes” important?

Tactical Athlete Special Interest Group

Tactical Athlete Special Interest Group

@SPTSTactical

“Here It’s Not A Game”

@SPTSTactical

Tactical Athlete Special Interest Group

@SPTSTactical

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“Here It’s Not A Game”

Who Ya Gonna Call?

>650,000 911 calls per day @SPTSTactical

Tactical Athlete Special Interest Group

150,560 “Boots on the Ground” Military in Foreign Countries

@SPTSTactical

Tactical Athlete Special Interest Group

50,000 U.S. Army Soldiers Can’t Deploy

>87% musculoskeletal injury Malish, MilMed, 2014

as of October 2015 Tactical Athlete Special Interest Group

OSD Defense Manpower Data Center @SPTSTactical

Tactical Athlete Special Interest Group

@SPTSTactical

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Musculoskeletal Injury Burden

Musculoskeletal Injury Burden

>63%

>51%

Lost duty time due to musculoskeletal injury

Lost duty time due to musculoskeletal injury

Rand 2011

@SPTSTactical

Tactical Athlete Special Interest Group

Jahnke 2013

Tactical Athlete Special Interest Group

The ‘envelope’ changes following MSKI

Tactical Physical Demands & Musculoskeletal Injury Preinjury

Manageable

Tactical Athlete Special Interest Group

S. Dye ‘05

@SPTSTactical

Postinjury

Excessive

@SPTSTactical

Tactical Athlete Special Interest Group

@SPTSTactical

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The ‘envelope’ is not the same for all Athletes

Enhanced Tactical Athlete Physical Health and Readiness Understanding the Population

Tactical Athlete B

Tactical Athlete A

MSKI Decision Aids/ Tools

Rehabilitation

Tactical Strength & Conditioning

Tactical Athlete Special Interest Group

@SPTSTactical

Tactical Athlete Special Interest Group

Enhanced Tactical Athlete Readiness

Screening for MSKI Risk

@SPTSTactical

Tactical Athletes: Physical Therapists Working with Firefighters, Law Enforcement & Military

Tactical Athlete Special Interest Group

@SPTSTactical

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Agenda& Physical&Therapists&Working&with& Military&Tac;cal&Athletes& & CSM&2016& &MAJ&Sean&T.&SuCles&PT,&DPT,&OCS,&CSCS&

•  •  •  •  •  •  •  •  •  • 

Agenda& •  •  •  •  • 

Military&Model&of&Orthopedic&Care& Echelon&of&Care& Treatment&and&Preven;on& Summary& Ques;ons&

Introduc;on& Disclosures& Epidemiology& Financial&Burden& Injury&Details& Tac;cal&Athlete&Defined& Why&the&Term&Fits& Who&is&The&Military&Tac;cal&Athlete?& Why&the&Term&is&Problema;c& Sports&Medicine&Model&

Introduc;on& •  •  •  •  •  •  • 

27yrs&TIS;&17&enlisted;&10&officer& 15yrs&Green&Beret& 17yrs&airborne&status& Staff&PT&in&Lg&Med&Cen&OP&PT&clinic& Stryker&BCT&PT& Special&Forces&PT& Sports&Medicine&Fellow&NFL&(NY&Giants)&

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Disclosures& •  The&Author&is&an&employee&of&the&federal&gov’t& and&the&views&and&opinions&expressed&in&this& presenta;on&are&those&of&the&author&and&do& not&reflect&the&views&or&official&policies&of&the& Dept.&of&the&Army,&The&Dept.&of&Defense,&or& the&U.S.&Government.& •  Dept.&of&Orthopaedics&and&Rehabilita;on,&Carl& R.&Darnall&Army&Medical&Center,&36000&Darnall& Loop,&Fort&Hood,&TX&76544,&USA&

Epidemiology& •  Takehome:& •  MSK&Injury&is&third&leading&cause&of:& –  Total&Medical&Encounters& –  Hospital&Bed&Stays& –  Lost&Duty&Time&

•  #1&cause&of&NBI&evacua;ons&from&OIF/OEF:& –  Sports/PT&related&MSK&Injury&

Other,&0.46%&

Injury&Details& Th p ic&S ac or

•  Most&Commonly&Injured&Regions&Seen&by&PT&in& Units:& Lumbar&Spine,&21.44%&

%& 31 &4. e,

Leg ,&4.6 1% &

in

–  $548&million&annually&in&direct&medical&costs& –  MSK&injury&is/primary&injury&type&associated& with&VA&disability&payouts&–&BILLIONS'

2%& and,&2.5 Wrist/H & .61% w,&2 Elbo %& .72 h,&2 Thig

Financial&Burden& •  Takehome:&

Forearm,&0.21%&

Arm,&0.66%&

Hip,&4 .82%&

Cervical&Spine,&5.92%&

Knee,&17.98%&

Ankle/Foot,&14.32%&

Shoulder,&17.41%&

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m Co aining cal Tr % Physi R3), 2.30 ity, tiv (THO Ac ary ilit 3% n-M 2.6 No

Combat - Battle Injury, 2.02%

MVA, 1.68% Training - Fastrope, 0.55%

Road&Marching,& Injury&Details& 3%&

Injury&Details&

Total'Individuals'Treated'(18'series'vs.'all'others;'n=470)' Total'Injuries'Treated'(18'series'vs.'all'others;'n=543)'

bati

Co m b In at ju N ry, o 2.7 n-B 5% att le

ves

Sports,&9%& , 2.3

5%

•  Most&Common&MOI’s&for&MSK&Injuries:& Un kn

ow

Physical Training (Individual), 19.79%

n, 3

.43 PT&(other),&12%& %

Training - Field Exercise, 3.63%

•  Occupa;ons& –  Amaroso,&1997& all&others&

Other, 4.64% Gradual Onset, 13.63%

Running,&76%&

Training - Schools, 5.14%

Recreational Sports, 6.45% Physical Training (Unit), 11.54%

Training - Airborne Operations, 8.43%

Insidious Onset, 9.04%

Tac;cal&Athlete&Defined& •  Tac;cal&defined:&& –  of,&rela;ng&to,&or&used&for&a&specific&plan&that&is& created&to&achieve&a∥cular&goal&in&war,& poli;cs,&etc.&(Webster’s)& –  rela;ng&to∾ons&occurring&at&the&baClefront&to& gain&a&military&end&&

18&series& (49.79%)&

18&series& all&others& •  (50.21%)& The&men&in&MOS&11B&(Infantrymen)&have&the&highest& 50%& (50.64%)& (49.36%)& hospitaliza;on&rates&for&both´&injuries&and& 50%& 51%& 49%& musculoskeletal&condi;ons.&& •  For&women,&the&highest&rate&of&musculoskeletal& hospitaliza;ons&was&among&Lightqwheeled&Vehicle& Mechanics,&MOS&63B&& •  Detailed&occupa;on&specific&physical&demand&analysis& beyond&the&scope&of&this&20min&talk.&

Tac;cal&Athlete&Defined& •  Athlete&defined:& –  a&person&who&is&trained&or&skilled&in&exercises,& sports,&or&games&requiring&physical&strength,& agility,&or&stamina&(Webster)&

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Tac;cal&Athlete&Defined& •  What&is&a&Tac;cal&Athlete?& –  Any&professional&in&an&occupa;on&involving& planning&and&maneuvering&to&accomplish&a& purpose;&who,&as&with&the&professional&athlete,&is& obligated&to&maintain&a&certain&level&of& Opera;onal&Physical&Fitness&in&order&to&fulfill&that& purpose,&AND&who&must&maintain&that&level&of& fitness&as&a&term&of&employment.&&

Why&the&Term&Fits& •  Jus;fica;on&for&use&of&the&term,&“Military&Tac;cal& Athlete”:& –  Majority&of&MSK&injuries&experienced&by&military& service&members&are&related&to∥cipa;on&in&sports,& recrea;on,&and&physical&training& –  Military&members&as&a&whole&are&at&substan;ally& increased&risk&for&MSK&injuries&commonly&seen&in& sports&athletes&and&managed&in&sports&medicine& clinics&compared&to&general&popula;on.&&

Tac;cal&Athlete&Defined& –  Tac;cal&Athlete& –  Key&term:& –  Opera;onal&Physical&Fitness&& –  (strength,&power,&agility,&&&stamina&to&operate& successfully&within&a&given&occupa;onal¶digm)& –  Occupa;onal&tasks&+&Physical&Fitness&required&for& maneuvering&vs.&Occupa;onal&tasks&alone&

Why&the&Term&Fits& •  Further&jus;fica;on&for&use&of&the&term,& “Military&Tac;cal&Athlete”:& –  Army'physical'readiness'is'the'ability'to'meet'the' physical'demands'of'any'combat'or'duty' situaJon,'accomplish'the'mission'and'sJll'have'a' reserve'of'strength.'(FM'25P101,'Training&the& Force,&BaCleqFocused&Training)&&

& &&&&(Cameron,&2014)&

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Why&the&Term&Fits& •  Further&jus;fica;on&for&the&use&of&the&term,&“Military&Tac;cal& Athlete”:&

–  “Military&leaders&have&always&recognized&that&the&effec;veness&of& figh;ng&men&depends&to&a&large°ree&upon&their&physical&condi;on.& War&places&a&great&premium&upon&the&strength,&stamina,&agility,&and& coordina;on&of&the&soldier&because&victory&and&his&life&are&so&owen& dependent&upon&them.&To&march&long&distances&with&full&pack,& weapons,&and&ammuni;on&through&rugged&country&and&to&fight& effec;vely&upon&arriving&at&the&area&of&combat;&to&drive&fastqmoving& tanks&and&motor&vehicles&over&rough&terrain;&to&make&assaults&and&to& run&and&crawl&for&long&distances,&to&jump&into&and&out&of&foxholes,& craters,&and&trenches,&and&over&obstacles;&to&liw&and&carry&heavy& objects;&to&keep&going&for&many&hours&without&sleep&or&rest&–&all&these& ac;vi;es&of&warfare&and&many&others&require&superbly&condi;oned& troops.”&(FM&21q20,&Physical&Training,&January&1946)&&

Who&is&the&Military&Tac;cal&Athlete?& •  Navy:&& –  Seals&& –  SBU’s&

•  Airforce:&& –  Pararescue&(PJ’s)&& –  Combat&Controller&(CCT)&

Who&is&the&Military&Tac;cal&Athlete?& •  Special&Opera;ons&(closest&resemblance&to&elite& athlete):& –  Recruited&from&top&2%&of&military& –  Special&vexng&

•  Higher&APFT&requirements&at&entrance&level& •  Higher&marksmanship&requirements& •  Higher&intelligence&requirements&(minimum&ASVAB>&score& 110)& •  Greater&psychological&hardiness&(Bartone)& •  Greater&self&efficacy&(Bartone)& •  Embedded&mul;qd&performance/medical&staff&(RAND,& SuCles,&Goss)&

Who&is&the&Military&Tac;cal&Athlete?& •  Army:& –  Delta& –  Special&Forces& –  Rangers& –  Special&Opera;on&Avia;on&Regiment&(SOAR)& –  Special&Warfare&Center&and&School&(SWCS)&

•  Marines:&& –  Recon&

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Who&is&the&Military&Tac;cal&Athlete?& •  US&Army&Special&Opera;ons&Command& (USASOC)&Combined&Aggregate:& –  Mean&age:&&

Who&is&the&Military&Tac;cal&Athlete?& •  Conven;onal&Military& –  More&difficult&to&define&than&in&SOF& –  Ac;ve&Duty&All&Branches&(Cameron,&2014)& •  1.4&million&AD;&enlisted:officer&5:1& •  50%&of&enlisted&≤&25y/o& •  70%&≤&30y/o& •  85.5%&male&

•  Overall&(SOF,&Ranger,&SOAR,&SWCS&combined):&31.1& •  18&series&(Special&Forces):&33.7& •  Non&18&series&assigned&to&USASOC&units:&29.9&

–  Mean&yrs&TIS:&6.6& –  Mean&yrs&;me&in&SOF:&3.7&

Military&Tac;cal…..Athlete?&

&

(Cameron,&2014)&

Why&the&Term&is&Problema;c& •  Key&differences&between&pro&athletes&and& military&personnel:& –  Gene;c/biomechanical&preqdisposi;on& –  Specificist&vs.&Generalist& –  Sports&medicine&model&vs.&Orthopedic&care&for& athletes&

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Why&the&Term&is&Problema;c& •  No&professional&coaches&in&the&ranks& –  Those&who&run&PRT&lack&educa;on&or&exper;se& •  Everyone&thinks&they’re&an&expert&on&adult&fitness& •  Shake&and&bake&training&(MFT)& •  SME’s&(see&one,&do&one,&teach&one)&

–  PRT&has&to&be&performed&as&a&group& •  No&;me&or&personnel&to&conduct&personalized& assessments&or&develop&individualized&exercise& progressions&

Sports&Medicine&Model& •  Sports&medicine&model&of&care:& –  Mul;qD&

•  First&responder&thru&surgeon&+&referral&specialists&in&house& •  All&lanes&involved&throughout&echelon&of&care& •  Physician/Ortho&Surgeon&at&point&of&injury&

VS.&

–  Need&for&PT&as&MSK&diagnos;cian&minimal&

•  Immediate&or&same&day&access&to&advanced&imaging& •  Priori;za;on/Alloca;on&of&care&(starter&vs.&nonqstarters)& –  Related&to&$$$$&invested&in&the&athlete& »  Combat&vs.&combat&support&special;es?& »  SOF&vs.&conven;onal&forces?& »  Dependents?& »  Re;rees?&

Why&the&Term&is&Problema;c& •  Two&key&factors&that&significantly&impact&HPO& as&IP:& –  No&season& •  Periodiza;on&is&an&impossible&pipe&dream&(OPTEMPO)& •  Training&monotony&& •  No&off&season&

–  Exposure&to&physical&demand& •  IntermiCent& •  Unpredictable&

Sports&Medicine&Model& –  Sports&medicine&model&of&care:& •  Owen&biased&toward&early&as&possible&surgery&vs.&focus& on&early&rehab& –  Favors&rapid&return&to&physical&performance&(return&to&play)& over&longterm&func;onal&outcomes&

•  Rehab&conducted&oneqonqone& •  Rehab&includes&in&house:& –  Rehab&to&performance&bridging& –  “Return&to&play”/”Prepare&to&play”&performance&progression& u;lizing&sport&specific&tasks,&loads,&volumes,&and&sexngs&

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Sports&Medine&Model& –  Sports&medicine&model&of&care&cont’d:& •  Training&room&(career&sparing)&opera;ons& –  Daily&management&of&chronic&condi;ons& –  Immediate&and&daily&management&for&minor&injuries¬& requiring&an&appointment&with&a&provider& –  Walkqin&availability&of&recovery&procedures& »  Ice&&&compression& »  Contrast&tubs& »  Foam&rolling& »  Compression&(eg.&Normatec&pants)& »  Sow&;ssue&mobes/manual&stretching& »  Heat&packs&

Military&model&of&Orthopedic&Care& –  Provider&finally&refers&soldier&to&PT& •  Soldier&waits&another&2q4&week&to&be&evaluated& •  Soldier&now&chronically&s;ff&and&painful&

–  Soldier&receives&HEP&due&to&accessibility&issues&or& receives&biw&therex&in&clinc& –  Soldier&fails&to&progress&awer&6wks&and&is& discharged;&referred&back&to&PCM&for&permanent& profile& –  If&lucky&the&PT&orders&imaging&to&r/o&fracture&or& ligamentous&injury&

Military&model&of&Orthopedic&Care& •  Typical&ankle&sprain&case& –  Report&to&sick&call&and&sit&for&several&hours&while& ankle&baloons&up& –  Provided&limited&duty&profile&and&NSAIDs&w/o&f/u& care&planned& •  Worse&case:&soldier&is&seen&by&an&unskilled&provider& who&immobilizes&them&

–  Soldier&receives&no&rehab&for&a&month&and&doesn’t& get&beCer&

Military&model&of&Orthopedic&Care& –  If&there&are&imaging&findings&soldier&receives& rou;ne&referral&to&ortho&or&podietry& –  Awer&wai;ng&2q4&weeks&Soldier&is&screened&by& ortho&service&PA& –  Soldier&waits&another&2q4&weeks&to&consult&with& surgeon& –  Soldier&receives&surgery&for&ligamentous&rupture& one&month&later&(Soldier&is&now&2q4&months&post& original&injury)&

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Echelon&of&Care&

Treatment&&&Preven;on&for&Military& Tac;cal&Athletes& •  Occupa;on/”Sportqspecific”&rehabilita;on& focus&(Infantry,&Armor,&Support,&etc)& –  Regardless&of&their&specialty&the&process&is&the& same& –  You&always&treat&the&impairments&you&find&and&try& as&best&as&you&can&to&keep&your&processes&within& the&context&the&pa;ent&works&in& &

Treatment&&&Preven;on&for&Military& Tac;cal&Athletes& •  “Finishing&Rehab”& –  Restoring&func;on&and&returning&to&preqinjury& level&of&capability&is&likely¬&enough&for& preven;on&of&subsequent&injury&(Wilk&JOSPT&14)&

Treatment&&&Preven;on&for&Military& Tac;cal&Athletes& •  Determining&“Return&to&Duty”& –  Understanding&physical&demands& –  Running& –  Comba;ves,&handqtoqhand/MMA&

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Summary& •  Athlete&is&an&assump;on&in&many&cases&

–  We&have&to&decide&who&in&our&popula;on&are&the& “Tac;cal&Athletes”&and&who&are¬& –  Many&MOS’s&have&lower&physical&demands&and&can& tolerate&limited&physical&capability& –  Permanent&limited&duty&profiling&will&bar&combat&arms& MOS&soldiers&from&con;nuing&to&serve& –  Care&on&all&fronts&should&be&priori;zed&to&combat& arms&soldiers&for&that&reason&

•  As&many&visits&generated&by&nonqathle;c,&nonq combat&arms&soldiers&as&combat&arms&soldiers&

Summary& •  Sports&medicine&model&a&must&in&order&to& properly&care&for&tac;cal&athletes&as&if&they&are& athletes&

–  Training&room&sexng&w/daily&recovery&and&“career& sparing”&treatments&necessary&& –  Full&return&to&play&rehab&workups&necessary& –  Streamlined/priori;zed&access&to&surgical&consults&a& must&&

•  Without&these&we&are&simply&providing& outpa;ent&orthopedic&care&to&our&soldiers&the& same&way&we&would&for&anybody&else&

Ques;ons?& &

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Tactical Athlete Symposium Working with Firefighters Jake Morrow MPT, ECS, OCS MAJ, SP, USAR, Evans Army Community Hospital Firefighter Truck 4C Beverly Hills Fire Department

Who are Firefighters •  1.2 million •  30,052 US Departments •  31% (345,600) Career •  69% (786, 150) Volunteer •  73% of career firefighter work in areas with population >25,000

Objectives • Who is the tactical firefighter • What do they do • What challenges do they face • How and why do they get hurt • How do they return to duty • Tactics to stay fit to fight

Who are Firefighters Age • 16-19 (3%) • 20-29 (21%) • 30-39 (28%) • 40-49 (26%) • 50-59 (16%), • 60 and over (6%)

Demographics • Male 95% • Female 5% • White 82% • African American 8% • Hispanic 10%

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What We Do

Occupational Challenges

Other?

Physical Challenges Turnouts – Coat, Pants, Helmet, Boots, Hood

•  Positional challenges •  Turnouts •  Self contained breathing apparatus (SCBA)

•  Environmental conditions

•  Average 30lbs •  Tools average 5-10lbs •  Withstands 500 F •  Modified movement patterns •  Now carry tools, hose, and ladders o

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Physical Challenges

External Factors/Loads

• Throwing ladders - 42 - 127lbs distributed over 14’-20’

Self Contained Breathing Apparatus

•  Average 35lbs •  Positive pressure •  Increases ventilation rate, O2 consumption, and heart rate

•  Reduces tidal volume

External Factors/Loads • Charged hose line • 100’ of 1.75” hose • 12.5 gallons of water • 104lbs • Nozzle Reaction force • 30-95lbs

External Factors/Loads • Tools and equipment aloft • Rescues • Search and evac

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Physiologic Stresses

Physiologic Stresses Cardiovascular and Thermal Strain

•  •  •  • 

Core body temperature increases 2.5oF in 20 min With sustained work to over 102oF Profuse sweating Prolonged periods of near maximum heart rate

Clinical Effects

Cardiovascular and Thermal Strain

•  • 

Stroke volume decreases

•  • 

Decrease plasma volume (15% in 20 min)

High blood pressure that rapidly drops with cessation of work

Hemoconcentration causes changes in blood electrolytes and platelet aggregability

Internal Risk Factors You are most likely seeing this...

• Lee et al, 2013 • Increased VO2 30% • Rapid increase in HR • Increased RPE • Time to fatigue was 50% faster

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Internal Risk Factors •  50% between age 30-50 •  BMI – 80% overweight or obese •  CDC fitness recommendations

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