Response and clarification of: ‘There is a knowledge mobilization gap in musculoskeletal injury research in the military context’

Dear Editors,

We hope this message finds you well. We are writing to discuss the July 1, 2024, Journal of Military, Veteran, and Family Health (JMVFH) Perspectives article “There Is a Knowledge Mobilization Gap in Musculoskeletal Injury Research in the Military Context” by Dr. Edwards.¹

There is consensus within the medical, therapeutic, and research communities on the critical importance of evidence-based practice (EBP) and knowledge mobilization for managing musculoskeletal injuries (MSKI). The Canadian Forces Health Services (CFHS) supports Dr. Edwards’ recommendations for enhancing knowledge translation and research efforts within the organization. We have been successful in ensuring public awareness of our contributions in this domain, as evidenced by our efforts to present, publish, and maintain an active presence in the national and international MSKI research community

Managing MSKI in a military context is notably complex and requires specialized research and EBPs tailored to the unique demands of military populations. These demands include the diverse environments of the Canadian Armed Forces (CAF) — such as land, sea, air, and special operations forces — along with varying occupations, gender and diversity considerations, and an aging population. Although there are similarities between military populations and sporting populations, military personnel face additional occupational stress factors not commonly encountered in sports settings.

The CFHS recognizes the importance of conducting MSKI research specifically for the military context to support the health and wellness of CAF members. As per the 2019 CAF Health Survey, MSKI represent the leading barrier to deployment, affecting 32.6% of personnel. Additionally, 17.7% of respondents indicated that repetitive strain injuries have affected their military careers, and 26.3% reported that serious acute injuries have had a significant effect on their careers.² Addressing these issues through targeted research and practice is vital for improving the overall health and operational readiness of CAF members.

In the spirit of that dialogue, we would like to provide diverging evidence on several criticisms made by the author, notably about EBP and health professional involvement, occupational demands analysis information, qualification of personnel, military awareness, injury surveillance, and the use of an overall MSKI framework with a specific implementation step.

First, the author wrote, “Beyond including leadership in MSKI research diffusion, rarely are physical training professionals or health services personnel responsible for the delivery of EBP included in the presentation of findings [emphasis added] (e.g., scientific conferences and meetings, research report presentations).”^{1(p. 181)} CFHS acknowledges that not every clinician at the tactical level may be fully aware of all ongoing research in this field and recognizes the need for continuous improvement in this area. However, the author references a 2015 report,³ prepared in collaboration with Defence Research and Development Canada, that demonstrates the CAF’s commitment to addressing MSKI. In the nearly 10 years since the publication of that report, significant strides have been made to enhance knowledge mobilization within the CAF. Contrary to Dr. Edwards’ assertion, health professionals have made substantial contributions to MSKI research andhave disseminated this work through national and international presentations and publications. The referenced and current clinicians, experts, and scientists working with the CAF could have provided additional insight into this progress, as evidenced by the more than 160 references published in association with the Defence Team since 2011 (see the Appendix for the Supplementary Bibliography). For example, physical training professionals from Personnel Support Programs (PSP) and CFHS professionals have been actively involved in conducting and presenting research at recent conferences, such as the Canadian Institute of Military and Veteran Health Research (CIMVHR), International Congress on Military Medicine (ICMM), International Congress on Soldiers’ Physical Performance, Aerospace Medicine Association Annual Scientific Meeting, and NATO Ramstein Aerospace Medicine Summit. Notably, the 2023 CIMVHR Banting-Award-winning research on evidence-based MSKI prevention was a collaborative effort between CFHS and PSP.⁴ Although the primary focus of most clinicians is on providing care rather than conducting research, there are numerous instances of CFHS clinicians contributing to the field through publications and presentations.

Over the past decade, CFHS physical rehabilitation clinicians have published more than 35 articles in peer-reviewed journals, presented more than 30 posters, and delivered more than 35 podium presentations at conferences. These publications cover a wide range of topics, including MSKI prevention and training, loaded marching, prosthetics and amputations, neurophysiology, neuromuscular training programs, gait and posture, low back pain, osteoarthritis, and tendinopathies. Additionally, many papers and presentations have specifically addressed strategies for effective knowledge translation within CFHS. These efforts highlight the active engagement of CFHS clinicians with civilian collaborators, leading to significant collaborations and contributions to the field. This body of work underscores the recognition among clinicians of the importance of research and EBP, as well as the unique environmental and occupational demands faced by CAF members. This work has been translated into MSKI prevention programs delivered by PSP and demonstrates effective knowledge mobilization.

Second, the author states,

“To create an effective training program, a needs-based analysis informed by occupational demands (e.g., unit, trade, tasks) and common injuries within that population is performed [emphasis added]. Unfortunately, this process is impeded by the lack of published literature pertaining to specific military occupation specialties.”^{1(p. 182)}

In 2012, a team of seven from Human Performance Research and Development partnered with the Directorate of Medical Policy, Directorate of Military Career Administration, Directorate of Personnel Generation and Requirements, and other defence stakeholders to investigate and determine the physical, medical, and psychological demands of all occupations in the CAF. This group has continued to advise on standards and training and to inform CFHS, PSP, and CAF of the intricate requirements of each occupation. These requirements are part of the occupational specifications for every Military Occupational Structure Identification code.⁵

In addition, the cited statement also included the notion that

another consideration must be the qualifications of practitioners. In the CAF, for example, fitness delivery is conducted by fitness and sport instructors, a role for which, according to the career recruiting platform …^[6] qualifications do not include a university degree or research literacy. While these individuals might be excellent at motivating service members, their ability to discern quality or applicable research findings cannot be assumed. If EBPs are to be implemented, direct communication between the researchers and physical training personnel is therefore critical.^{1(p. 182)}

The PSP staff who most often deliver fitness programs to CAF personnere fitness and sports instructors and reconditioning staff. Many hold relevant degrees aligned with job requirements. Current data show that of 167 fitness and sports instructors, 157 possess a university degree or college diploma with relevant experience. This suggests a strong capability to read, understand, and apply research and evidence-based programming. Additionally, fitness and sports instructors need to successfully complete two CAF-specific training programs that focus on fitness within the context of the CAF, ensuring that an evidence-based approach is used to improve operational performance and that injury prevention strategies are applied.⁷

Furthermore, 65 PSP reconditioning staff positions require a bachelor’s degree and clinical exercise physiologist certification from the Canadian Society of Exercise Physiology as a prerequisite to employment. Reconditioning staff work alongside CFHS, health promotion, and other key stakeholders in supporting CAF members as they recover from illness or injury or if they require a specialized exercise program. For example, physiotherapy (PT) and PSP staff including, physical exercise specialists, reconditioning managers, reconditioning specialists, and fitness sports and physical exercise specialists have been collaborating for more than 15 years in various formats. Practical examples include: transitioning members care from rehabilitation clinicians (PT, OT) to PSP with directions on rehabilitation precautions to progress them through rehabilitation from injury, collaboration through programs such as Sports as a Laboratory Assessment Model (SLAM) for patients with a mild traumatic brain injury, Rehabilitation for Performance (R4P) which is a staged exercise program with a focus on injury prevention and performance. These programs have been presented at conferences such as CIMVHR, and the references are provided in the supplementary bibliography.

Third, the author observes,

Civilian clinicians play important roles in caring for military members and are the primary health providers for Veterans. That said, many of these practitioners are from general population communities, can lack awareness of military culture or the CAF organizational structure, and are faced with a dearth of CAF-specific literature to guide diagnostic screening questions or treatment plans [emphasis added].^{1(p. 182)}

CFHS recognizes the importance of military-specific knowledge for civilian clinicians. It is also essential to note that the care of CAF members is managed by the CFHS Centres across Canada, where clinicians can apply medical employment limitations for occupational impacts from a health condition. When CAF members are referred by CFHS clinicians to external health care providers for specific conditions or services, it is for their expertise in these areas rather than their military-specific knowledge.

Health care providers can use various military resources to enhance their expertise in occupational and operational medicine. For instance, the Canadian Forces Environmental Medicine Establishment and CFHS Gp produce documents such as flight surgeon guidelines, aerospace medicine authority policies, and undersea medicine policies. These documents provide comprehensive guidance on screening, diagnosis, required labs and imaging, treatment, consultations, return-to-work considerations, and medical employment limitations, tailored to the unique needs of the CAF population. These resources are open source and accessible to clinicians across Canada via a smartphone app (Div Surg) and the Aerospace Medicine website and the 1 Canadian Air Division Surgeon Sharepoint site.⁸ Military expertise also plays a crucial role in customizing physical rehabilitation programs. External physical rehabilitation providers receive annual updates advising them to consult with the local physical rehabilitation team lead and informing them about available local resources for facilitating the return-to-duty process, such as R4P, PSP reconditioning, and group exercise programs. Moreover, many civilian clinicians working alongside CFHS Gp demonstrate a deep understanding and integration of military culture, often stemming from prior military service or extensive experience supporting CAF members. These backgrounds and ongoing relationships significant enhance their contributionto the organization’s mission.

Although operational security considerations may limit the availability of certain studies, most research produced by CFHS is publicly accessible. In addition to the extensive supplementary bibliography previously noted, initiatives such as the Surgeon General Health Research Program are actively working to bridge knowledge gaps through ongoing education and collaboration. Various committees also facilitate interactions among scientists, practitioners, and leaders. Furthermore, practitioners can consult national subject matter experts listed in internal resources, including specialists in sports medicine, physiotherapy, injury prevention, and active living.

In a fourth comment, the author states that

ultimately, military injury surveillance framework and research programs could be more successful if communication was improved by [emphasis added] 1) engaging leadership at each step, 2) translating and disseminating findings directly to support personnel (e.g., health care professionals, physical training staff), and 3) presenting and discussing findings with service members to educate them and to interpret results.^{1(p. 182)}

For decades, the CAF has systematically collected, analyzed, and utilized a range of injury statistics from various sources, including the Recruit Health Questionnaire, the CAF Health Survey (and its predecessor, the Health and Lifestyle Information Survey), the Disease and Injury Surveillance System during deployments, and safety incident reports.⁹ The findings from these sources have been extensively disseminated within both the scientific community and the Defence Team.

In recent years, efforts to enhance injury surveillance have intensified. The Strengthening the Forces (STF) health promotion program within the Directorate of Force Health Protection (DFHP) has expanded with a newly established Injury Surveillance System (ISS). The ISS extracts data on injury consultations from electronic medical records, and its reports are refined through discussions at local bases and wings, as well as with a national advisory committee that includes health professionals, CAF personnel, leaders, and scientists. These discussions focus on educating, interpreting, and addressing MSKI. The ISS will be featured at the ICMM in October 2024, and updates on injury surveillance have been presented at local conferences and published in the JMVFH.⁹

Furthermore, more than 65 STF-PSP health promotion delivery staff are trained to work with leadership, health care providers, and CAF personnel across Canada to implement injury reduction strategies based on best practices and aligned with North Atlantic Treaty Organization (NATO) recommendations.¹⁰ The NATO HFM 283 report emphasizes the importance of a multidisciplinary approach, leadership involvement, education, surveillance, adequate resources for program evaluation, and research — elements already incorporated into the CAF Injury Prevention Program. Another example of knowledge mobilization is NATO HFM RTG 252,¹¹ with a focus on aircrew neck pain prevention. Following the recommendations of that NATO report, CFHS Gp partnered with PSP and DRDC to develop and implement the evidence-based RCAF Aircrew Conditioning Program (RCAF ACP). A concurrent research study demonstrated that the RCAF ACP improves performance in aircrew; in 2025 this program transitioned from research to enduring program and is now being delivered at 6 different locations across Canada.

CAF personnel, fitness instructors, health professionals, and leaders have access to an injury prevention workshop and associated shorter briefings designed by STF-DFHP.¹² These sessions cover injury prevention statistics, the specific context of the CAF, evidence-based medicine, and the role of leadership in implementing and monitoring injury prevention strategies. In fiscal year 2023–24, the course reached 140 CAF personnel, and briefings reached 1,614 CAF members and 243 other Defence Team members. These training sessions are often delivered in collaboration with STF-PSP health promotion staff, physiotherapists, and other stakeholders. Additionally, STF-DFHP produces knowledge translation webinars, briefings, and articles available to the Defence Team (searching the Maple Leaf with the search term strengthening will pull many of those articles).¹³ Increased investment in DFHP epidemiology, health services, and PSP monitoring and evaluation has led to research presentations at CIMVHR conferences and publications in journals such as JMVFH and many others.

Knowledge mobilization is integrated into occupational-specific training programs across different branches of the CAF, for example, the Royal Canadian Air Force (RCAF). Initial aeromedical training at the Canadian Forces School of Survival and Aeromedical Training in Winnipeg provides aircrew with education on health, lifestyle, and injury prevention. Recognizing the need for ongoing education, the RCAF Neck Strain Mitigation Working Group — composed of health care providers, scientists, engineers, human factors professionals, fitness professionals, and RCAF aircrew — has identified the necessity for continued MSKI education and training at multiple points throughout aircrew career progression. This group is collaborating with 2 Canadian Air Division (Air Force Training) and 1 Canadian Air Division (Fleet Readiness) to deliver tailored education and training on musculoskeletal and kinetic injuries. In the Canadian Army, the value of PSP-led training is well documented in the scientific literature and has led to specific directives for training school commandants to implement EBP aimed at reducing injuries.¹⁴ Personnel support programs and DFHP work together to identify high-risk training courses and have positioned specialized strength and conditioning specialists at Canadian Army bases in Gagetown, New Brunswick, and Borden, Ontario. These specialists ensure that fitness training programs are aligned with the demands of these courses, thereby enhancing injury prevention and performance.

A fifth statement from the author suggests a solution: “a five-step system for injury prevention in the military proposed by Jones et al. … which includes a step called program implementation [emphasis added].”^{1(p. 181)} One of the CAF’s notable strengths, particularly compared with other nations, lies in its comprehensive implementation of programs designed to enhance performance and reduce injuries. Key examples include the Generating Resilience to Injury Through Training program, the RCAF Aircrew Conditioning Program, the Basic Training/Canadian Forces Leadership and Recruit School (CFLRS) Program, the Women’s Wellness Program, and the Peri-natal and Postpartum Program. Evidence-based group exercise programs have also been developed and successfully implemented at the Canadian Army base in Valcartier, Quebec, as detailed in a recent article published in the Journal of Orthopaedics & Sports Physical Therapy.¹⁵ Furthermore, since 2022, PSP fitness professionals have been embedded in the military chain of command at key operational units such as the CFLRS, Combat Training Center, and CFHS Training Centre.

A notable achievement includes the support provided by STF experts and clinicians in modifying physical activities, such as the adjustments made to the Iron Warrior event.¹⁶ These changes led to a sixfold reduction in reported injuries, inspired modifications to other events, and earned STF staff an Award of Excellence for their contributions.

In conclusion, we have provided substantial evidence that the Defence Team adheres to EBP for MSKI in knowledge generation, knowledge mobilization, and collaboration with stakeholders, including practitioners aligned with CFHS modernization.¹⁷ Our MSKI-related staff are highly trained professionals who benefit from access to internal experts, CAF-specific publications, and data to inform their practices. Although we acknowledge that there is always room for improvement, we remain dedicated to continuous quality improvement initiatives. We understand that the author may not have had access to some of the information included in this letter, and we encourage future collaboration with CFHS research authors. Such collaboration will foster cooperative efforts and enhance the delivery of services to CAF members.

Considering these clarifications, we respectfully invite the author to re-evaluate her statements to better reflect the tremendous and collaborative efforts and contributions of PSP, CAF leadership, and CFHS teams. We believe that a more accurate portrayal will enhance the ongoing dialogue and foster greater understanding and cooperation within the community.

Thank you for your attention to this matter. We look forward to continuing our collaborative efforts to advance research and practice in this field.

Appendix. Supplementary Bibliography

Included here are some of the latest publications and presentations from Canadian Forces Health Services/Canadian Forces Morale and Welfare Services since 2011 regarding evidence-based musculoskeletal injury prevention, treatment successes, and knowledge transfer.