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Neuromuscular Research Laboratory University of Pittsburgh
Exposure-Related Differences on Neck and Trunk Musculoskeletal Characteristics in
US Army Helicopter Pilots
Nagai T*, Abt JP*, Sell TC*, Lovalekar M*, Smalley BW†, Wirt MD‡, Lephart SM**
Warrior Human Performance Research Center, Neuromuscular Research Laboratory, University of Pittsburgh, Pittsburgh, PA*
US Army School of Aviation Medicine, Fort Rucker, AL† US Army Institute of Surgical Research, Fort Sam Houston, TX‡
College of Health Sciences, University of Kentucky, Lexington, KY**
Neuromuscular Research Laboratory University of Pittsburgh
Disclosure Information 86th Annual Scientific Meeting
Takashi Nagai
Funding: the U.S. Army Medical Research and Materiel Command: W81XWH-11-2-0097. Opinions, interpretations, conclusions, and recommendations are those of the author and are not necessarily endorsed by the U.S. Army
I have no financial relationships to disclose I will not discuss off-label use and/or investigational use in my
presentation
Neuromuscular Research Laboratory University of Pittsburgh
Introduction: High Prevalence of Neck Pain and Low Back Pain in US Army Helicopter Pilots
1yr self-reported NP/LPB among the US Army Helicopter Pilots
Prevalence of NP: 37/123 (30.1%) • 78 Young Pilots: 16/78 (20.5%) • 32 Senior Pilots: 14/32 (43.8%) • 13 Master Pilots: 8/13 (61.5%)
Prevalence of LBP: 69/123 (56.1%) • 78 Young Pilots: 41/78 (52.6%) • 32 Senior Pilots: 18/32 (56.3%) • 13 Master Pilots: 11/13 (84.6%)
AR 600-105: 2010: Senior (7yr/1000hr) & Master (15yr/2000hr)
Neuromuscular Research Laboratory University of Pittsburgh
Vicious Cycle of NP/LBP in Helicopter Pilots
NP Potential Risk Factors • Previous injuries/NP
LBP Potential Risk Factors • Previous injuries/LBP
Neuromuscular Research Laboratory University of Pittsburgh
Vicious Cycle of NP/LBP in Helicopter Pilots
NP Potential Risk Factors • Previous injuries/NP • Total flight-hours/NVG-
hours • Exposure to whole-
body vibration
LBP Potential Risk Factors • Previous injuries/LBP • Total flight-hours • Exposure to whole-body
vibration
Neuromuscular Research Laboratory University of Pittsburgh
Vicious Cycle of NP/LBP in Helicopter Pilots
NP Potential Risk Factors • Previous injuries/NP • Total flight-hours/NVG-
hours • Exposure to whole-
body vibration • Fatigue
LBP Potential Risk Factors • Previous injuries/LBP • Total flight-hours • Exposure to whole-body
vibration • Psychosocial factors • Fatigue
Neuromuscular Research Laboratory University of Pittsburgh
Vicious Cycle of NP/LBP in Helicopter Pilots
NP Potential Risk Factors • Previous injuries/NP • Total flight-hours/NVG-
hours • Exposure to whole-
body vibration • Fatigue • Altered
musculoskeletal characteristics / posture
Salmon 2011
LBP Potential Risk Factors • Previous injuries/LBP • Total flight-hours • Exposure to whole-body
vibration • Psychosocial factors • Fatigue • Altered musculoskeletal
characteristics/posture Gaydos 2012
Neuromuscular Research Laboratory University of Pittsburgh
Vicious Cycle of NP/LBP in Helicopter Pilots
Non-Specific Neck Pain /
Low Back Pain
Total Flight / NVG Hours
Fatigue/Altered Proprioception
Altered Neuromotor
Control
NP Potential Risk Factors • Previous injuries/NP • Total flight-hours/NVG-
hours • Exposure to whole-
body vibration • Fatigue • Altered
musculoskeletal characteristics/ posture
Salmon 2011
LBP Potential Risk Factors • Previous injuries/LBP • Total flight-hours • Exposure to whole-body
vibration • Psychosocial factors • Fatigue • Physical fitness,
BMI/obesity • Altered musculoskeletal
characteristics/posture Gaydos 2012
Potential for Interventions / Modifications – STOP THE BLEEDING!!!
Neuromuscular Research Laboratory University of Pittsburgh
Investigating the Musculoskeletal, Proprioception, and Posture Characteristics
Pilots with NP History • The NP pain group had significant
reductions in cervical extension and rotation range-of-motion (ROM)
• No differences in neck strength, upper quadrant posture, and neck proprioception
Nagai 2014
Neuromuscular Research Laboratory University of Pittsburgh
Investigating the Musculoskeletal, Proprioception, and Posture Characteristics
Pilots with NP History • The NP pain group had significant
reductions in cervical extension and rotation range-of-motion (ROM)
• No differences in neck strength, upper quadrant posture, and neck proprioception
Nagai 2014
Pilots with LBP History • The LBP group had significantly lower
trunk extension strength and trunk extension/flexion strength ratio
• The LBP group had less lumbar spine lateral flexion ROM and greater ROM asymmetry on lumbar spine lateral flexion and rotation
Nagai 2015
Neuromuscular Research Laboratory University of Pittsburgh
Non-Specific Neck Pain /
Low Back Pain
Total Flight / NVG Hours
Fatigue/Altered Proprioception
Altered Neuromotor
Control
Problem Statement • Few studies have evaluated
the musculoskeletal characteristics and compared them among groups of pilots with different flight-hours
Neuromuscular Research Laboratory University of Pittsburgh
Purpose Statement
• The purpose of the study was to examine and compare the neck/trunk strength, ROM, and posture among pilots with different total flight-hours
Neuromuscular Research Laboratory University of Pittsburgh
Clinical/Tactical Significance
• It is clinically significant to understand general patterns of the decrement of musculoskeletal characteristics so that clinicians and pilots can be aware of potential changes and participate intervention programs to reverse the trend
• Maintaining adequate strength, flexibility, and posture is essential to protect the spine so that a prevalence of NP/LBP or early progression of OA will be mitigated
• Experienced pilots play essential role in critical missions – their musculoskeletal characteristics can directly influence flight performance and readiness
Neuromuscular Research Laboratory University of Pittsburgh
Methods Subjects
• Helicopter pilots from the 101st Combat Aviation Brigade were recruited
• 115 male pilots participated in laboratory testing
• They were divided into 5 groups based on their total flight-hours 1. 0-999: n = 61 2. 1000-1999: n = 22 3. 2000-2999: n = 17 4. 3000-3999: n = 8 5. 4000+: n = 7
Laboratory Testing One-time visit (~2hr testing) • Neck strength (normalized to body weight) • Trunk strength (normalized to body weight) • Neck active range-of-motion • Lumbar spine range-of-motion • Hip rotation range-of-motion • Forward head posture • Forward shoulder posture • Pectoralis minor tightness
Statistical Analyses • Normality tests • One way ANOVA or Kruskal-Wallis • Post-hoc analyses for each group comparisons
Neuromuscular Research Laboratory University of Pittsburgh
Results: Demographics / APFT 0-999 1000-1999 2000-2999 3000-3999 4000+ p
Age (yr) 28.3 ± 3.8 34.6 ± 4.2 37.5 ± 4.9 40.3 ± 4.7 40.9 ± 5.8 0.001
Height (cm) 179.0 ± 8.0 177.5 ± 5.5 174.8 ± 6.4 177.2 ± 5.7 177.4 ± 5.4 0.480
Weight (kg) 82.9 ± 11.4 81.7 ± 10.8 85.6 ± 10.4 90.1 ± 7.1 88.8 ± 15.8 0.242
BMI 25.8 ± 3.1 25.8 ± 2.9 28.0 ± 3.3 28.6 ± 1.8 28.0 ± 3.8 0.010
APFT 266.2 ± 30.1 269.6 ± 23.7 255.0 ± 45.1 254.5 ± 35.9 271.5 ± 32.0 0.763
Total Flight-hrs 408.1 ± 252.1 1345.1 ± 285.4 2404.1 ± 339.7 3293.8 ± 302.9 4707.1 ± 809.5 0.001
NVG Flight-hrs 77.5 ± 62.9 375.1 ± 180.7 576.2 ± 304.8 664.4 ± 409.1 1195.0 ± 424.4 0.001
12-mon Flight-hrs 148.7 ± 98.4 177.6 ± 182.6 243.4 ± 254.5 253.2 ± 115.2 273.4 ± 174.0 0.047
Neuromuscular Research Laboratory University of Pittsburgh
Results: Demographics / APFT 0-999 1000-1999 2000-2999 3000-3999 4000+ p
Age (yr) 28.3 ± 3.8 34.6 ± 4.2 37.5 ± 4.9 40.3 ± 4.7 40.9 ± 5.8 0.001
Height (cm) 179.0 ± 8.0 177.5 ± 5.5 174.8 ± 6.4 177.2 ± 5.7 177.4 ± 5.4 0.480
Weight (kg) 82.9 ± 11.4 81.7 ± 10.8 85.6 ± 10.4 90.1 ± 7.1 88.8 ± 15.8 0.242
BMI 25.8 ± 3.1 25.8 ± 2.9 28.0 ± 3.3 28.6 ± 1.8 28.0 ± 3.8 0.010
APFT 266.2 ± 30.1 269.6 ± 23.7 255.0 ± 45.1 254.5 ± 35.9 271.5 ± 32.0 0.763
Total Flight-hrs 408.1 ± 252.1 1345.1 ± 285.4 2404.1 ± 339.7 3293.8 ± 302.9 4707.1 ± 809.5 0.001
NVG Flight-hrs 77.5 ± 62.9 375.1 ± 180.7 576.2 ± 304.8 664.4 ± 409.1 1195.0 ± 424.4 0.001
12-mon Flight-hrs 148.7 ± 98.4 177.6 ± 182.6 243.4 ± 254.5 253.2 ± 115.2 273.4 ± 174.0 0.047
Neuromuscular Research Laboratory University of Pittsburgh
Results: Neck and Trunk Strength (%BW) 0-999 1000-1999 2000-2999 3000-3999 4000+ p
Neck Flexion 17.8 ± 3.9 16.3 ± 3.9 18.8 ± 4.1 16.1 ± 3.6 20.0 ± 3.1 0.092
Neck Extension 31.5 ± 5.8 34.3 ± 3.0 31.8 ± 3.3 27.4 ± 7.2 32.0 ± 7.4 0.036
Neck Latflex R 25.4 ± 5.0 27.5 ± 3.2 26.3 ± 3.7 22.0 ± 3.6 25.6 ± 5.0 0.049
Neck Latflex L 26.8 ± 5.3 28.5 ± 4.6 26.9 ± 4.1 23.4 ± 4.0 26.3 ± 6.1 0.207
Neck Rot R 20.5 ± 3.5 22.5 ± 4.0 21.6 ± 3.6 18.3 ± 4.4 19.9 ± 4.2 0.051
Neck Rot L 21.2 ± 3.8 22.8 ± 5.1 22.2 ± 4.2 19.5 ± 4.4 21.4 ± 5.6 0.367
Trunk Flexion 249.3 ± 53.5 254.8 ± 32.8 245.8 ± 38.6 246.4 ± 43.1 246.6 ± 53.6 0.979
Trunk Extension 381.5 ± 94.7 389.6 ± 69.3 396.6 ± 63.3 331.7 ± 64.4 357.2 ± 94.6 0.400
Trunk Flex/Ext Ratio 67.4 ± 14.7 66.9 ± 12.3 63.5 ± 13.6 74.8 ± 6.1 73.1 ± 22.2 0.340
Trunk Rot R 147.1 ± 30.9 154.1 ± 21.9 153.9 ± 23.6 138.3 ± 23.8 150.7 ± 29.8 0.601
Trunk Rot L 141.3 ± 30.3 152.4 ± 21.8 147.6 ± 24.1 136.0 ± 14.2 146.4 ± 32.5 0.456
Trunk Rot R/L Ratio 104.7 ± 10.8 101.5 ± 8.2 105.0 ± 11.1 101.0 ± 9.6 104.1 ± 13.0 0.652
Neuromuscular Research Laboratory University of Pittsburgh
Results: Neck and Trunk Strength (%BW) 0-999 1000-1999 2000-2999 3000-3999 4000+ p
Neck Flexion 17.8 ± 3.9 16.3 ± 3.9 18.8 ± 4.1 16.1 ± 3.6 20.0 ± 3.1 0.092
Neck Extension 31.5 ± 5.8 34.3 ± 3.0 31.8 ± 3.3 27.4 ± 7.2 32.0 ± 7.4 0.036
Neck Latflex R 25.4 ± 5.0 27.5 ± 3.2 26.3 ± 3.7 22.0 ± 3.6 25.6 ± 5.0 0.049
Neck Latflex L 26.8 ± 5.3 28.5 ± 4.6 26.9 ± 4.1 23.4 ± 4.0 26.3 ± 6.1 0.207
Neck Rot R 20.5 ± 3.5 22.5 ± 4.0 21.6 ± 3.6 18.3 ± 4.4 19.9 ± 4.2 0.051
Neck Rot L 21.2 ± 3.8 22.8 ± 5.1 22.2 ± 4.2 19.5 ± 4.4 21.4 ± 5.6 0.367
Trunk Flexion 249.3 ± 53.5 254.8 ± 32.8 245.8 ± 38.6 246.4 ± 43.1 246.6 ± 53.6 0.979
Trunk Extension 381.5 ± 94.7 389.6 ± 69.3 396.6 ± 63.3 331.7 ± 64.4 357.2 ± 94.6 0.400
Trunk Flex/Ext Ratio 67.4 ± 14.7 66.9 ± 12.3 63.5 ± 13.6 74.8 ± 6.1 73.1 ± 22.2 0.340
Trunk Rot R 147.1 ± 30.9 154.1 ± 21.9 153.9 ± 23.6 138.3 ± 23.8 150.7 ± 29.8 0.601
Trunk Rot L 141.3 ± 30.3 152.4 ± 21.8 147.6 ± 24.1 136.0 ± 14.2 146.4 ± 32.5 0.456
Trunk Rot R/L Ratio 104.7 ± 10.8 101.5 ± 8.2 105.0 ± 11.1 101.0 ± 9.6 104.1 ± 13.0 0.652
Neuromuscular Research Laboratory University of Pittsburgh
Results: Spine Range of Motion 0-999 1000-1999 2000-2999 3000-3999 4000+ p
Neck Flexion 58.7 ± 9.1 57.3 ± 10.2 56.4 ± 10.3 60.7 ± 5.0 61.9 ± 6.1 0.641
Neck Extension 70.8 ± 8.9 68.4 ± 6.5 62.3 ± 10.3 64.5 ± 5.3 63.1 ± 7.9 0.002
Neck Latflex R 53.5 ± 8.4 49.9 ± 5.7 46.0 ± 10.9 45.9 ± 11.7 50.4 ± 6.1 0.023
Neck Latflex L 55.2 ± 9.2 51.1 ± 6.6 48.1 ± 10.1 50.2 ± 11.2 50.3 ± 7.2 0.031
Neck Rot R 73.9 ± 8.5 71.8 ± 6.7 69.5 ± 11.4 68.6 ± 3.6 67.1 ± 7.1 0.085
Neck Rot L 73.4 ± 7.6 71.8 ± 6.5 68.6 ± 11.4 69.7 ± 3.6 68.7 ± 12.8 0.173
Back Flexion 20.4 ± 8.8 19.7 ± 8.4 19.0 ± 8.8 19.9 ± 8.4 15.4 ± 9.7 0.711
Back Extension 50.3 ± 7.9 48.2 ± 8.4 43.4 ± 8.2 42.7 ± 9.4 40.4 ± 7.2 0.001
Back Latflex R 25.8 ± 5.0 23.7 ± 5.5 24.2 ± 6.1 18.8 ± 4.5 20.3 ± 4.6 0.002
Back Latflex L 26.3 ± 5.2 24.9 ± 5.2 25.3 ± 5.7 21.5 ± 5.1 21.6 ± 3.4 0.040
Back Rot R 10.4 ± 3.9 11.8 ± 1.8 11.7 ± 3.9 11.1 ± 5.2 9.8 ± 2.9 0.159
Back Rot L 10.2 ± 3.4 11.4 ± 2.7 10.0 ± 3.1 11.4 ± 5.2 9.1 ± 3.0 0.372
Neuromuscular Research Laboratory University of Pittsburgh
Results: Spine Range of Motion 0-999 1000-1999 2000-2999 3000-3999 4000+ p
Neck Flexion 58.7 ± 9.1 57.3 ± 10.2 56.4 ± 10.3 60.7 ± 5.0 61.9 ± 6.1 0.641
Neck Extension 70.8 ± 8.9 68.4 ± 6.5 62.3 ± 10.3 64.5 ± 5.3 63.1 ± 7.9 0.002
Neck Latflex R 53.5 ± 8.4 49.9 ± 5.7 46.0 ± 10.9 45.9 ± 11.7 50.4 ± 6.1 0.023
Neck Latflex L 55.2 ± 9.2 51.1 ± 6.6 48.1 ± 10.1 50.2 ± 11.2 50.3 ± 7.2 0.031
Neck Rot R 73.9 ± 8.5 71.8 ± 6.7 69.5 ± 11.4 68.6 ± 3.6 67.1 ± 7.1 0.085
Neck Rot L 73.4 ± 7.6 71.8 ± 6.5 68.6 ± 11.4 69.7 ± 3.6 68.7 ± 12.8 0.173
Back Flexion 20.4 ± 8.8 19.7 ± 8.4 19.0 ± 8.8 19.9 ± 8.4 15.4 ± 9.7 0.711
Back Extension 50.3 ± 7.9 48.2 ± 8.4 43.4 ± 8.2 42.7 ± 9.4 40.4 ± 7.2 0.001
Back Latflex R 25.8 ± 5.0 23.7 ± 5.5 24.2 ± 6.1 18.8 ± 4.5 20.3 ± 4.6 0.002
Back Latflex L 26.3 ± 5.2 24.9 ± 5.2 25.3 ± 5.7 21.5 ± 5.1 21.6 ± 3.4 0.040
Back Rot R 10.4 ± 3.9 11.8 ± 1.8 11.7 ± 3.9 11.1 ± 5.2 9.8 ± 2.9 0.159
Back Rot L 10.2 ± 3.4 11.4 ± 2.7 10.0 ± 3.1 11.4 ± 5.2 9.1 ± 3.0 0.372
Neuromuscular Research Laboratory University of Pittsburgh
Results: Hip Range of Motion and Forward Head/Shoulder Posture
0-999 1000-1999 2000-2999 3000-3999 4000+ p
Hip Int Rot R 48.0 ± 9.0 45.0 ± 9.7 40.7 ± 6.9 42.2 ± 5.2 39.9 ± 9.4 0.009
Hip Int Rot L 47.7 ± 8.8 44.7 ± 8.5 37.4 ± 8.8 41.5 ± 2.6 37.6 ± 8.1 0.001
Hip Ext Rot R 60.7 ± 8.6 57.8 ± 6.7 59.6 ± 9.4 58.0 ± 7.9 57.6 ± 6.8 0.598
Hip Ext Rot L 60.9 ± 9.3 59.1 ± 6.6 61.3 ± 11.3 58.0 ± 7.0 59.1 ± 4.8 0.816
Hip Int/Ext Rot R 108.7 ± 14.6 102.8 ± 10.4 100.3 ± 14.9 100.2 ± 8.0 97.5 ± 13.6 0.043
Hip Int/Ext Rot L 108.5 ± 15.0 103.8 ± 10.6 98.7 ± 17.8 99.5 ± 8.1 96.8 ± 9.9 0.033
Fwd Head Posture 21.6 ± 1.3 21.8 ± 1.2 22.4 ± 1.4 22.3 ± 0.8 22.6 ± 2.7 0.118
Fwd Shld R 16.2 ± 2.2 16.3 ± 1.8 16.7 ± 1.9 17.8 ± 2.2 17.7 ± 2.1 0.152
Fwd Shld L 15.7 ± 2.1 15.3 ± 1.9 16.4 ± 1.8 17.5 ± 2.8 16.6 ± 2.5 0.177
Pec Min R 6.8 ± 1.5 6.7 ± 1.5 7.0 ± 1.8 7.4 ± 1.5 7.4 ± 1.1 0.522
Pec Min L 6.3 ± 1.2 5.7 ± 1.3 6.9 ± 1.5 6.8 ± 1.2 7.3 ± 1.2 0.005
Neuromuscular Research Laboratory University of Pittsburgh
Results: Hip Range of Motion and Forward Head/Shoulder Posture
0-999 1000-1999 2000-2999 3000-3999 4000+ p
Hip Int Rot R 48.0 ± 9.0 45.0 ± 9.7 40.7 ± 6.9 42.2 ± 5.2 39.9 ± 9.4 0.009
Hip Int Rot L 47.7 ± 8.8 44.7 ± 8.5 37.4 ± 8.8 41.5 ± 2.6 37.6 ± 8.1 0.001
Hip Ext Rot R 60.7 ± 8.6 57.8 ± 6.7 59.6 ± 9.4 58.0 ± 7.9 57.6 ± 6.8 0.598
Hip Ext Rot L 60.9 ± 9.3 59.1 ± 6.6 61.3 ± 11.3 58.0 ± 7.0 59.1 ± 4.8 0.816
Hip Int/Ext Rot R 108.7 ± 14.6 102.8 ± 10.4 100.3 ± 14.9 100.2 ± 8.0 97.5 ± 13.6 0.043
Hip Int/Ext Rot L 108.5 ± 15.0 103.8 ± 10.6 98.7 ± 17.8 99.5 ± 8.1 96.8 ± 9.9 0.033
Fwd Head Posture 21.6 ± 1.3 21.8 ± 1.2 22.4 ± 1.4 22.3 ± 0.8 22.6 ± 2.7 0.118
Fwd Shld R 16.2 ± 2.2 16.3 ± 1.8 16.7 ± 1.9 17.8 ± 2.2 17.7 ± 2.1 0.152
Fwd Shld L 15.7 ± 2.1 15.3 ± 1.9 16.4 ± 1.8 17.5 ± 2.8 16.6 ± 2.5 0.177
Pec Min R 6.8 ± 1.5 6.7 ± 1.5 7.0 ± 1.8 7.4 ± 1.5 7.4 ± 1.1 0.522
Pec Min L 6.3 ± 1.2 5.7 ± 1.3 6.9 ± 1.5 6.8 ± 1.2 7.3 ± 1.2 0.005
Neuromuscular Research Laboratory University of Pittsburgh
Discussion: Strength • Neck extension and lateral
flexion strength had a significant group difference
• Pilots in the 1000 group were stronger than those in the 3000-3999 group
• Early Retirement / Dropouts due to NP?
• No other strength variables were significant
Normalized Strength (based on the 0-999 group)
Neuromuscular Research Laboratory University of Pittsburgh
Discussion: Neck Range of Motion • Neck extension and lateral flexion
ROM had a significant group difference • Decreased neck extension ROM was
associated in the pilots with NP • Pilots in the 0-999 group were more
flexible than those in the 2000+ group • Early retirement/dropouts due to NP?
Neuromuscular Research Laboratory University of Pittsburgh
Discussion: Back Range of Motion
• Back extension and lateral flexion ROM had a significant group difference
• Pilots in the 0-999 group were more flexible than those in the 2000+ group
• Greater magnitude of decrement • Early retirement/dropouts due to
LBP?
Neuromuscular Research Laboratory University of Pittsburgh
Discussion: Hip Range of Motion
• Hip IR/ER ROM had a significant group difference
• Pilots in the 0-999 group were more flexible than those in the 2000+ group
• Early retirement/dropouts due to LBP / sciatic nerve involvement?
Neuromuscular Research Laboratory University of Pittsburgh
Discussion: Posture
• Pectoralis minor tightness on the left shoulder had a significant group difference
• Pilots in the 1000-1999 group were less tight than those in the 2000+ group
• Only on the left shoulder? – Halo Hunch
Neuromuscular Research Laboratory University of Pittsburgh
Recommendations
• Routine flexibility/ROM exercises pre/post flight
• Strengthening focusing neck/back extensors and lateral flexors
• Proper posture and stretching pec minor muscle
• Flexibility/ROM have downward trends throughout their career while strength may vary
Neuromuscular Research Laboratory University of Pittsburgh
Immediate Cares and Prehab
Anti-WBV / NVG Countermeasures
No Fatigue / No Pain / Good
Proprioception
Build the Body: Smart and
Specific
STOP THE BLEEDING!!!
SOF Truth: “Humans are more important than hardware”
Neuromuscular Research Laboratory University of Pittsburgh
Take Home Messages
1. Suboptimal musculoskeletal characteristics exhibited by the experienced pilots resemble those exhibited by the pilots with a history of NP/LBP
2. It is clinically important for pilots to focus on pre-flight warm-up and post-flight cool-down (stretching)
3. Scientifically designed and validated programs do work in our previous study (101st Div – ETAP), and similar programs should be implemented to reduce the NP/LBP burden among helicopter pilots
Neuromuscular Research Laboratory University of Pittsburgh
Questions?
Collaborative Opportunities?
Takashi Nagai University of Pittsburgh