A systematic literature review of evidence for the use of assistive exoskeletons in defence and security use cases.

Advances in assistive exoskeleton technology, and a boom in related scientific literature, prompted a need to review the potential use of exoskeletons in defence and security. A systematic review examined the evidence for successful augmentation of human performance in activities deemed most relevant to military tasks. Categories of activities were determined a priori through literature scoping and Human Factors workshops with military stakeholders. Workshops identified promising opportunities and risks for integration of exoskeletons into military use cases. The review revealed promising evidence for exoskeletons' capacity to assist with load carriage, manual lifting, and working with tools. However, the review also revealed significant gaps in exoskeleton capabilities and likely performance levels required in the use case scenarios. Consequently, it was recommended that a future roadmap for introducing exoskeletons to military environments requires development of performance criteria for exoskeletons that can be used to implement a human-centred approach to research and development.

We assessed the state-of-the-art for the use of wearable assistive exoskeletons in UK defence and security use cases. A full systematic review of the literature was undertaken, informed by use cases developed in military stakeholder workshops. Clear gaps in exoskeleton capability and use case requirements were identified, leading to recommendations for future work.

Development of physical employment standards of specialist paramedic roles in the National Ambulance Resilience Unit (Naru).

AIM: To develop evidence-based role-specific physical employment standards and tests for National Ambulance Resilience Unit (NARU) specialist paramedics. METHODS: Sixty-two (53 men, 9 women) paramedics performed an array of (1) realistic reconstructions of critical job-tasks (criterion job performance); (2) simplified, easily-replicable simulations of those reconstructions and; (3) fitness tests that are portable and/or practicable to administer with limited resources or specialist equipment. Pearson's correlations and ordinary least products regression were used to assess relationships between tasks and tests. Performance on reconstructions, subject-matter expert and participant ratings were combined to derive minimum acceptable job performance levels, which were used to determine cut-scores on appropriate correlated simulations and tests. RESULTS: The majority of performance times were highly correlated with their respective simulations (range of r: 0.73-0.90), with the exception of those replicating water rescue (r range: 0.28-0.47). Regression compatibility intervals provided three cut-scores for each job-task on an appropriate simulation and fitness test. CONCLUSION: This study provides a varied and easily-implementable physical capability assessment for NARU personnel, empirically linked to job performance, with flexible options depending on organisational requirements.

A job task analysis to describe the physical demands of specialist paramedic roles in the National Ambulance Resilience Unit (NARU).

BACKGROUND: The National Ambulance Resilience Unit (NARU) works on behalf of each National Health Service (NHS) Ambulance Trust in England to strengthen national resilience and improve patient outcome in challenging pre-hospital scenarios. OBJECTIVE: To conduct a Job Task Analysis and describe the physical demands of NARU roles. METHODS: A focus group was conducted to describe the physically demanding tasks performed by NARU personnel. Subsequently, the physical demands of the identified tasks were measured in 34 NARU personnel (29 male and 5 female). RESULTS: Eleven criterion tasks were identified; Swift Water Rescue (SWR), Re-board Inflatable Boat (RBIB), Set up Decontamination Tent (SDT), Clinical Decontamination (CD), Movement in Gas Tight Suits (MGTS), Marauding Terrorist Fire Arms (MTFA), Over Ground Rescue (OGR), Unload Incidence Response Unit Vehicle (UIRUV), Above Ground Rescue (AGR), Over Rubble Rescue (ORR) and Subterranean Rescue (SR). The greatest cardiovascular strain was measured during SWR, MGTS, and MTFA. The most thermally challenging tasks were the MTFA, CD, SR and OGR. The greatest muscular strength requirements were during MTFA and OGR. CONCLUSIONS: All five components of fitness (aerobic endurance, anaerobic endurance, muscular strength, muscular endurance and mobility) were required for successful completion of the physically demanding tasks performed by NARU personnel.

Energy balance and physical demands during an 8-week arduous military training course.

This study assessed soldier's physical demands and energy balance during the Section Commanders' Battles Course (SCBC). Forty male soldiers were monitored during the 8-week tactics phase of the SCBC. Energy expenditure was measured using the doubly labeled water method. Cardiovascular strain (heart rate) and physical activity (using triaxial accelerometer) were also monitored. Average sized portions of meals were weighed, with all recipes and meals entered into a dietary analysis program to calculate the calorie content. Energy expenditure averaged 19.6 ± 1.8 MJ · d(-1) in weeks 2 to 3 and 21.3 ± 2.0 MJ · d(-1) in weeks 6 to 7. Soldiers lost 5.1 ± 2.6 kg body mass and body fat percent decreased from 23 ± 4% to 19 ± 5%. This average weight loss equates to an estimated energy deficit of 2.69 MJ · d(-1). The Army provided an estimated 14.0 ± 2.2 MJ · d(-1) in weeks 2 to 3 and 15.7 ± 2.2 MJ · d(-1) in weeks 6 to 7. Although this provision adheres to the minimum requirement of 13.8 MJ · d(-1) set by Army regulations, soldiers were in a theoretical 5.6 MJ · d(-1) energy deficit. The physical demands of SCBC were high, and soldiers were in energy deficit resulting in loss in body mass; primarily attributed to a loss in fat mass.

Relationship between the 2.4-km run and multistage shuttle run test performance in military personnel.

In the United Kingdom, all branches of the armed forces use 2.4-km run time and/or the 20-m multistage shuttle run test (MSRT) to assess the aerobic fitness of their personnel. This study quantified the relationship between these two tests in 156 army recruits and officer cadets (100 men and 56 women) to ensure equivalence in the required aerobic fitness standards. The 2.4-km run was performed on surfaced roads and tracks around the training establishment and the MSRT in a gymnasium. Ordinary least product regression was used to describe the relationship between average 2.4-km running speed (km · h(-1)) and the total number of shuttles completed on the U.K. version of the MSRT (r = 0.91, p < 0.01), showing MSRT shuttles = (9.708×2.4-km run speed) - 52.56, with a standard error of prediction of approximately 8 shuttles or 0.8 km · h(-1). The British Army 2.4-km run biannual fitness assessment standard for young men of 10:30 min:s equates to a MSRT score of 82 shuttles (level 10 and 1 shuttle) and for young women of 13:00 min:s equates to 56 shuttles (level 7 and 6 shuttles), with a standard error of estimate of approximately 8 shuttles.

Physiological responses of Police Officers during job simulations wearing chemical, biological, radiological and nuclear personal protective equipment.

The aim of this study was to quantify the physiological responses of Police Officers wearing chemical, biological, radiological and nuclear personal protective equipment (CBRN PPE) during firearms house entry (FE) unarmed house entry (UE) and crowd control (CC) simulations. Participants volunteered from the UK Police Force [FE (n = 6, age 33 ± 4 years, body mass 85.3 ± 7.9 kg, (·)VO2max 53 ± 5 ml · kg⁻¹ · min⁻¹), UE and CC (n = 11, age 34 ± 5 years, body mass 88.5 ± 13.8 kg, (·)VO2max 51 ± 5 ml · kg⁻¹ · min⁻¹)]. Heart rate reserve (HRR) during FE was greater than UE (74 ± 7 vs. 62 ± 6%HRR, p = 0.01) but lower in CC (39 ± 7%HRR, p < 0.01). Peak core body temperature was greater during FE (39.2 ± 0.3°C) than UE (38.9 ± 0.4°C, p < 0.01) and CC (37.5 ± 0.3°C, p < 0.01), with similar trends in skin temperature. There were no differences in the volume of water consumed (1.13 ± 0.44 l, p = 0.51) or change in body mass (-1.68 ± 0.65 kg, p = 0.74) between simulations. The increase in body temperature was a primary physiological limitation to performance. Cooling strategies and revised operating procedures may improve Police Officers' physical performance while wearing CBRN PPE. PRACTITIONER SUMMARY: In recent years, the likelihood of Police Officers having to respond to a chemical, biological, nuclear or radiological (CBRN) incident wearing personal protective equipment (PPE) has increased. Such apparel is likely to increase physiological strain and impair job performance; understanding these limitations may help improve Officer safety and operational effectiveness.

Comparison of the physical demands of single-sex training for male and female recruits in the British Army.

This study compared the physical demands and progression of basic training for male and female British Army recruits in single-sex platoons. Thirty male and 30 female recruits were monitored for energy expenditure (EE) (doubly labeled water), physical activity (3-dimensional accelerometry) and cardiovascular strain (percent heart rate reserve) during 6 weeks over the 14-week course. First time pass rate was similar for male (60%) and female (57%) recruits. Average daily percent heart rate reserve (female 31 +/- 4%; male 32 +/- 5%), physical activity levels (female 2.2 +/- 0.2; male 2.3 +/- 0.2) and percentage improvements in 2.4-km run time (female 10 +/- 4%; male 10 +/- 5%) were similar for both sexes (p > 0.05), although male recruits had 12% higher physical activity counts (p < 0.01). Although the absolute physical demands of basic training were greater for male recruits, the relative cardiovascular strain experienced was similar between sexes.

Injuries and injury risk factors among British army infantry soldiers during predeployment training.

PURPOSE: This prospective cohort study examined injuries and injury risk factors in 660 British Army infantry soldiers during a predeployment training cycle. METHODS: Soldiers completed a questionnaire concerning physical characteristics, occupational factors, lifestyle characteristics (including physical training time) and previous injury. Direct measurements included height, body mass, sit-ups, push-ups and run time. Electronic medical records were screened for injuries over a 1-year period before operational deployment. Backward-stepping Cox regression calculated HR and 95% CI to quantify independent injury risk factors. RESULTS: One or more injuries were experienced by 58.5% of soldiers. The new injury diagnosis rate was 88 injuries/100 person-years. Most injuries involved the lower body (71%), especially the lower back (14%), knee (19%) and ankle (15%). Activities associated with injury included sports (22%), physical training (30%) and military training/work (26%). Traumatic injuries accounted for 83% of all injury diagnoses. Independent risk factors for any injury were younger age (17-19 years (HR 1.0), 20-24 years (HR 0.71, 95% CI 0.55 to 0.93), 25-29 years (HR 0.89, 95% CI 0.66 to 1.19) and 30-43 years (HR 0.41, 95% CI 0.27 to 0.63), previous lower limb injury (yes/no HR 1.49, 95% CI 1.19 to 1.87) and previous lower back injury (yes/no HR 1.30, 95% CI 1.03 to 1.63). CONCLUSION: British infantry injury rates were lower than those reported for US infantry (range 101-223 injuries/100 soldier-years), and younger age and previous injury were identified as independent risk factors. Future efforts should target reducing the incidence of traumatic injuries, especially those related to physical training and/or sports.

Health, fitness, and responses to military training of officer cadets in a Gulf Cooperation Council country.

OBJECTIVE: To quantify the health, fitness, and physiological responses to military training of Officer Cadets from a Gulf Cooperation Council country. METHODS: One hundred and nineteen Officer Cadets volunteered; body composition, core body temperature, aerobic fitness, hydration status (urine osmolality), cardiovascular strain, physical activity (3-dimensional accelerometry), and energy expenditure (doubly labelled water) were measured over 5-days of Basic Training (BT), Army Training (AT), Navy Training (NT), and Air Force Training (AFT). RESULTS: There were no differences between courses for body mass index (mean all courses: 24.1 +/- 4.1 kg x m2) or peak core body temperature (mean all courses: 38.1 +/- 0.4 degrees C) (p > 0.05). AT body fat (19.8 +/- 3.6%) and BT VO2 max (36.8 +/- 11.6 mL x kg(-1) x min(-1)) were lower than the other courses (BT, 26.1 +/- 8.1; NT, 26.0 +/- 6.0; AFT, 24.7 +/- 6.1%) and (AT, 44.8 +/- 9.6; NT, 45.0 +/- 7.5; AFT, 44.6 +/- 5.2 mL x kg(-1) x min(-1)), respectively (p < 0.05). NT urine osmolality (979 +/- 90 mOsmol x kg(-1)) was similar to BT (946 +/- 181 mOsmol x kg(-1) p > 0.05) but lower in AT (868 +/- 144 mOsmol x kg(-1), p < 0.05) and AFT (883 +/- 121 mOsmol x kg(-1), p < 0.05). Cardiovascular strain during NT (22 +/- 5% HRR) was lower than other courses (range, 25 +/- 4-29 +/- 3% Heart Rate Reserve) (p < 0.05). Physical activity level during AFT (1.70 +/- 0.18 AU) was lower than other courses (range, 1.86 +/- 0.21-1.92 +/- 0.18 AU) (p > 0.05). CONCLUSION: Positive developments were apparent from BT leading into other courses. Potential exists to increase physical training volume on all courses, which may improve participants' aerobic fitness, body composition, and health.

Influence of hydration volume and ambient temperature on physiological responses while wearing CBRN protective clothing.

This study examined a low (L; 5 ml/kg per h) and high (H, 10 ml/kg per h) rate of fluid replacement in moderate (18°C) and hot (30°C) conditions on physiological responses while wearing personal protective equipment (PPE). PPE included the gas-tight suit (GTS), the powered respirator protective suit (PRPS) and the civil responder 1 (CR1). Relative to the moderate condition, physiological responses were greater in the hot condition. The percentage change in body mass was different (p < 0.05) between L and H in the hot (L vs. H, GTS: -0.83 vs. -0.38%; PRPS: -1.18 vs. -0.71%; CR1: -1.62 vs. -0.57%) and moderate conditions, although in GTS and CR1 body mass increased (L vs. H, GTS: -0.48 vs. 0.06%; PRPS: -0.66 vs. -0.11%; CR1: -0.18 vs. 0.67%). Fluid replacement strategies for PPE should be adjusted for environmental conditions in order to avoid >1% body mass loss and/or net body mass gain. STATEMENT OF RELEVANCE: Currently, the UK Emergency Services do not have specific evidence-based fluid replacement guidelines to follow when wearing chemical, biological, radiological and/or nuclear (CBRN) PPE. Although ad libitum fluid replacement is encouraged (when breathing apparatus permits), recommendations from evidence-based findings specific to different PPE and to different environmental conditions are lacking. This study provides novel evidence supporting the need to develop fluid replacement strategies during CBRN deployments in both moderate and hot environmental conditions for CBRN PPE.

Gender differences in the physical demands of British Army recruit training.

This study examined gender differences in the physical demands of British Army recruit training in 3 platoons with different gender compositions. Subjects wore heart rate monitors to measure cardiovascular strain and accelerometers to measure physical activity during weeks 1, 6, and 9 of the 12-week program. There was no difference in physical activity between platoons or genders (p > 0.05). In the mixed gender platoon, males operated at a lower cardiovascular strain than females (24 +/- 2 vs. 33 +/- 2% heart rate reserve (HRR), p < 0.001), probably because of their greater aerobic fitness (p < 0.001). Males in the mixed gender platoon experienced lower cardiovascular strain than the male-only platoon (24 +/- 2 vs. 33 +/- 2% HRR, p < 0.001). Females experienced the same degree of cardiovascular strain, irrespective of platoon (33 +/- 2 vs. 33 +/- 3% HRR, p = 0.814). The additional cardiovascular strain experienced by female recruits may increase fatigue and predisposition to overuse musculoskeletal injury.

Development of an operational fitness test for the Royal Air Force.

Since 2002, the Royal Air Force (RAF) has been working towards developing role-related physical tests for use as an operational fitness test (OFT). The purpose of this study was to establish reliability of the OFT (comprising four tests), investigate gym-based tests as predictors of performance and establish performance standards. Fifty-eight RAF personnel performed the OFT on three occasions. A separate cohort carried out fitness and anthropometric tests before performing the OFT, by way of establishing performance predictors. Documented evidence and views of an expert panel were used to determine OFT standards. Reliability ranged from moderate to good for three tests, with one test (Dig) showing poor reliability. The 95% limits of agreement for the prediction models ranged from good to poor (6.7-34.2%). The prediction models were not sufficiently accurate to estimate confidently OFT performance, but could be used as a guide to quantify likely outcome and training needs.

The effect of cool water ingestion on gastrointestinal pill temperature.

UNLABELLED: Telemetric gastrointestinal (GI) temperature pills are now commonly used to measure core body temperature and could minimize the risk of heat illness while maximizing operational effectiveness in workers subject to high levels of thermal strain. PURPOSE: To quantify the effect of repeated cool water ingestion on the accuracy of GI pill temperature. METHODS: Ten operational firefighters ingested a pill to measure GI temperature (T1int) before overnight sleep. Two hours following breakfast and 11.5 h after ingesting T1int, the firefighters ingested a second pill (T2int) before performing 8.5 h of intermittent activity (repetitive cycles of 30 min of seated rest followed by 30 min of general firefighter duties). During the first 2 min of each 30-min rest period, the firefighters consumed 250 mL of chilled water (5-8 degrees C). RESULTS: Water ingestion had a highly variable effect both within and between subjects in transiently (32 +/- 10 min) reducing the temperature of T2int in comparison with T1int. In general, this transient reduction in T2int became progressively smaller as time following ingestion increased. In some firefighters, the difference between T1int and T2int became negligible (+/- 0.1 degrees C) after 3 h, whereas in two others, large differences (peaking at 2.0 degrees C and 6.3 degrees C) were still observed when water was consumed 8 h after pill ingestion. CONCLUSION: These results show that a GI pill ingested immediately prior to physical activity cannot be used to measure core body temperature accurately in all individuals during the following 8 h when cool fluids are regularly ingested. This makes GI temperature measurement unsuitable for workers who respond to emergency deployments when regular fluid consumption is recommended operational practice.

A physical demands analysis of the 24-week British Army Parachute Regiment recruit training syllabus.

This study assessed the physical demands of the 24-week Combined Infantryman's Course (CIC) for Parachute Regiment (Para) recruits and developed physical selection standards for applicants. Fifty recruits were monitored over five separate periods (35 d in total during weeks 1-2, 5, 9, 15 and 19-20). Energy expenditure (doubly labelled water), physical activity (accelerometry) and cardiovascular strain (% heart rate reserve) were measured. There was no overall progression in both the levels of physiological stress (physical activity counts and energy expenditure) and resultant cardiovascular strain during the first nine weeks of training. Applicants' 2.4 km run time and static lift strength measured at selection predicted 10 mile loaded march performance at the end of CIC Para. The introduction of job-related selection procedures and a more progressive approach to training has reduced the incidence of medical discharge from 14.4% to 5.1% and increased overall pass rates from 43% to 58%.

Risk factors for training injuries among British Army recruits.

This study aimed to identify risk factors for training injuries resulting in referral to a remedial instructor (RI) or medical discharge (MD) among British Army recruits undertaking initial training. Physical performance and anthropometric data for 11,937 male and 1,480 female recruits were examined as potential risk factors for RI referral and MD, using Cox regression. There was a trend showing that female recruits' MD rates were higher than male recruits' rates (p = 0.096), and RI referral rates were significantly greater for women than for men (p = 0.041). The independent risk factors for MD were 2.4-km run time, ethnicity, and Army training regiment attended (p < 0.001), and those for RI referral were 2.4-km run time, ethnicity, Army training regiment attended, and body mass index (p < 0.001). Gender was not an independent risk factor for injury, suggesting that lower levels of aerobic fitness are the primary cause of the greater incidence of injury among female recruits during British Army initial training.

Can simple anthropometric and physical performance tests track training-induced changes in load-carriage ability?

The objective of this research was to determine whether tests of strength, endurance, and anthropometry could be used to assess training-induced changes (delta) in load-carriage performance. Eighty-four British Army recruits completed a 10-week training program. Strength, endurance, body composition, and 3.2-km load carriage with 15 kg and 25 kg were assessed before and after training. Training significantly increased load-carriage performance (7-16%), back extension and dynamic lifting strengths, endurance and fat-free mass, and reduced body fat. Statistically significant regression models (adjusted R2 of 0.063-0.797) were produced that predicted delta load-carriage performance. However, the 95% limits of agreement between observed and predicted delta load-carriage data showed margins of error (11-15%) comparable to the average training-induced gains in performance. Training-induced changes in load-carriage performance appear to be highly specific, which suggests that both training and testing procedures should also be specific to load-carriage performance.

Training diagnosis for a load carriage task.

To explore the possibility of training diagnosis for a 3.2-km loaded march with a 25 kg load, 50 men trained for 10 weeks using either running, marching, and endurance-based circuit training (Circuits), or running, marching, and resistance training (Resistance). The march was performed before and after training, and other measurements related to loaded marching were conducted before training only. Each group was ranked by improvement in the loaded march, and divided into significantly different subgroups of 'good' and 'poor' responders (improvements of approximately 20% vs. 10%). For Circuits, there were significant differences between good and poor responders to training in the pretraining ratios of shuttle run: isometric lift strength (p = 0.031) and shuttle run: isometric back extension strength (p = 0.033). Stronger subjects with lower endurance responded better to Circuits. Resistance tended to show the opposite effect (p < 0.2). These are the first objective data on which to prescribe training for load carriage on an individual basis.

Venous obstruction in healthy limbs: a model for chronic compartment syndrome?

PURPOSE: Chronic exertional compartment syndrome (CECS) in the anterior tibial (AT) compartment is generally believed to be the result of reduced venous blood flow caused by restrictive compartments and increased intramuscular pressures. If this is so, then restricting venous flow in the muscles of healthy subjects during exercise should mimic CECS. METHODS: This hypothesis was tested in 10 control subjects (aged 19-41 yr, five males) with and without external venous occlusion induced by a sphygmomanometer cuff fitted just below the knee and inflated to 80 mm Hg. Twenty CECS patients (20-39 yr, 16 males) were studied without external occlusion. Subjects performed intermittent, isometric maximal voluntary contractions (MVC) of the AT for 20 min (1.6-s contractions, 0.5 duty cycle). MVC, tetanic force (2 s at 50 Hz), muscle thickness (ultrasound imaging), and pain were measured during exercise and 10 min of recovery. RESULTS: Venous occlusion in the controls induced greater pain, fatigue, and increase in muscle thickness (P < 0.01). Initially the patients fatigued more slowly than the occluded controls, but at the end of exercise, the fatigue and pain were similar in these two groups. The controls showed a greater increase in muscle size (P = 0.01). Recovery was similar in all three groups, although the size of the patients' muscles recovered rather more slowly. CONCLUSION: External venous occlusion of the AT muscles in control subjects induces changes very similar to those of CECS patients, although the different time courses indicate that different processes are involved. The AT compartment of CECS patients is capable of distension.

Chronic exertional compartment syndrome: muscle changes with isometric exercise.

UNLABELLED: Chronic exertional compartment syndrome (CECS) is a well-documented cause of lower leg pain in active individuals. The pathophysiology is unclear, although it is generally believed to be associated with increased intramuscular pressure, but there is very little information about muscle function in relation to the onset of pain. PURPOSE: To investigate strength, fatigue, and recovery of the anterior tibial muscles in CECS patients and healthy subjects during an isometric exercise protocol. METHODS: Twenty patients and 22 control subjects (mean age 27.6 yr and 33.0 yr, respectively) performed a 20-min isometric exercise protocol consisting of intermittent maximal voluntary contractions (MVC). Central fatigue was evaluated by comparing changes in electrically stimulated (2 s at 50 Hz) and voluntary contraction force before and during the exercise, and then throughout 10 min of recovery. Muscle size was measured by ultrasonography. Pain and cardiovascular parameters were also examined. RESULTS: The absolute MVC forces were similar, but MVC:body mass of the patients was lower (P < 0.05) as was the ratio of MVC to muscle cross-sectional area (P < 0.01). The extent of central and peripheral fatigue was similar in the two groups. The patients reported significantly higher levels of pain during exercise (P < 0.05 at 4 min) and after the first minute of recovery (P < 0.001). An 8% increase in muscle size after exercise was observed for both groups. There were no differences in the cardiovascular responses of the two groups. CONCLUSIONS: CECS patients were somewhat weaker than normal but fatigued at a similar rate during isometric exercise. Patients reported higher pain than controls despite comparable changes in muscle size, suggesting that abnormally tight fascia are not the main cause of CECS symptoms.